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1. Medical assistant
2. Electronic records
3. Medical terminology and anatomy
4. The fundamentals of infection control
5. Introduction to vital signs
6. The patient interview and history
7. The physical examination
8. Appointment scheduling
9. Insurance billing
10. Diagnostic coding and the ICD-10-CM System
11. Procedural coding
12. Medical billing and reimbursement essentials
13. Assisting with medical specialties
14. Assisting with the musculoskeletal system
15. Assisting with the cardiovascular system
16. Assisting with the respiratory system
17. Assisting with the nervous system
18. Anatomy and physiology of the urinary system
19. Assisting in obstetrics and gynecology
20. Assisting in endocrinology
21. Assisting in ophthalmology & otolaryngology
22. Assisting in gastroenterology
23. Assisting in the immune & lymphatic systems
24. Assisting in pediatrics: the developmental stages and care
25. The medical assistant’s role in caring for the older patient
26. The role of the medical assistant in physical therapy examination and assessment
27. Preparing for minor surgery: room, solutions, and supplies
28. Introduction to the clinical laboratory
29. Urinalysis
30. Blood collection
31. Analysis of blood
32. Electrocardiography and heart structure
33. The principles of pharmacology
34. Essential calculations and measurement systems
35. Solid, liquid, & solutions medication doses
36. Administering medications
36.1 Administering medications
36.2 Administering vaccines
36.3 Routes of medication
36.4 Intradermal injections and tuberculin testing
36.5 Needles and syringes
36.6 Reconstitution, mixing, and general injection guidelines
36.7 Subcutaneous and intramuscular injections
37. Metabolism and core nutrient roles
38. Medical emergencies in the healthcare setting
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36.7 Subcutaneous and intramuscular injections
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36. Administering medications
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Subcutaneous and intramuscular injections

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Subcutaneous injections

Subcutaneous (SUBQ) injections involve placing medication into the subcutaneous layer under the dermis. The subcutaneous layer has fewer blood vessels than the muscles do. The medication absorbs more slowly in the subcutaneous layer compared with medications injected into the muscles. The patient may complain of discomfort or pain with a subcutaneous injection. Subcutaneous tissue contains pain receptors.

Common medications given via the subcutaneous route include several vaccines (e.g., MMR, varicella, and polio), enoxaparin (Lovenox), heparin, and insulin.

Abbreviations for subcutaneous injections

There have been many abbreviations for subcutaneous injections over the years. Some may still be used in practice, although they are not recommended. The Institute for Safe Medication Practices (ISMP) discourages the use of SC, SQ, and sub q. Healthcare professionals should use SUBQ or subcutaneously. For more information, refer to the ISMP website at www.ismp.org/recommendations/error-prone-abbreviations-list.

Administration techniques

When a SUBQ injection is given, the angle depends on the needle length. If a 5⁄8-inch needle is used, the medical assistant should use a 45-degree angle. If a 1⁄2-inch needle is used, a 90-degree angle should be applied. It is important to pinch up the tissue with the index finger and thumb of the nondominant hand. This ensures that the injection is given in the subcutaneous tissue.

Aspiration

Aspiration is used to check if the needle is in a blood vessel. This is done once before the medication is given. (The aspiration technique will be discussed in detail in the Intramuscular Injections section, presented later in the chapter.) With SUBQ injections, the aspiration should be done if the medication manufacturer recommends it. It should also be done if it is part of the facility’s policy.

Insulin is not aspirated. SUBQ immunizations do not need to be aspirated, as recommended by the CDC. Anticoagulants, such as enoxaparin and heparin, are administered in the abdomen. They are not aspirated, as specified by the manufacturers.

Subcutaneous sites

Typically, three SUBQ sites are used in ambulatory care:

  • Abdominal site: Have the patient remove the clothing in that area. Provide a drape sheet if needed to protect the patient’s modesty. The site is located below the costal margins to the iliac crests. Stay 2 inches away from the umbilicus. It is important to stay away from the waistline and any scars. The patient may have more discomfort if the injection is given at the waistline due to the rubbing of clothing.
  • Outer posterior aspect of the upper arm: Expose the arm. The outer posterior site extends from 3 inches above the elbow to about 3 fingerbreadths below the acromion process. It is important to stay away from the shoulder area.
  • Anterior aspect of the thigh: Place one hand above the knee and the other hand below the greater trochanter. The site is the middle one-third of the thigh. The site extends from the front midline to the back midline, wrapping around the outer thigh. Usually, only the middle one-third—from the front midline to the outer thigh—is used. Injections are not done on the back of the leg because sitting would irritate the injection site.

Subcutaneous injections

  • Medication injected into subcutaneous layer; slower absorption than IM
  • Common meds: insulin, heparin, enoxaparin, some vaccines (MMR, varicella, polio)
  • Contains pain receptors; may cause discomfort

Abbreviations for subcutaneous injections

  • Use “SUBQ” or “subcutaneously”
  • Avoid: SC, SQ, sub q (ISMP discouraged)

Administration techniques (SUBQ)

  • 5⁄8-inch needle: 45-degree angle; 1⁄2-inch needle: 90-degree angle
  • Pinch up tissue to ensure correct placement

Aspiration (SUBQ)

  • Aspirate only if manufacturer or facility policy requires
  • Do not aspirate insulin, SUBQ immunizations, or anticoagulants (enoxaparin, heparin)

Subcutaneous sites

  • Abdominal: below costal margins to iliac crests, 2 inches from umbilicus, avoid waistline/scars
  • Outer posterior upper arm: 3 inches above elbow to 3 fingerbreadths below acromion
  • Anterior thigh: middle one-third, front midline to outer thigh

Intramuscular injections

  • Medication injected into muscle; faster absorption than SUBQ
  • Common meds: vaccines (hep A/B, Td, TDaP, influenza, meningococcal), antibiotics, Depo-Provera
  • Aqueous meds: higher gauge needle; oil-based: lower gauge

Administration techniques (IM)

  • 90-degree angle; flatten/stretch skin
  • Ensure correct site, minimize pain, maintain asepsis

Aspiration (IM)

  • Aspirate before injecting (except immunizations per CDC)
  • Pull back plunger 5 seconds; if blood appears, discard and restart

Air lock technique (IM)

  • Add 0.2–0.5 mL air after measuring medication
  • Air follows medication, seals in muscle, prevents tracking

Z-track technique (IM)

  • Pull skin laterally, inject, release after withdrawing needle
  • Used for irritating meds, especially at ventrogluteal site

Intramuscular sites

  • Site selection varies by age and medication
  • Deltoid: not for infants; for small volume aqueous meds, vaccines (teens/adults)
  • Vastus lateralis: preferred for infants/children, also adults; middle third of thigh
  • Ventrogluteal: preferred for oil-based/irritating meds; side-lying position, use opposite hand to locate

Patient coaching

  • Some liquid meds contain alcohol; important for recovering alcoholics/diabetics
  • Teach patients to check ingredients; communicate concerns to provider

Legal and ethical issues

  • Scope of practice for injections varies by state
  • Medical assistants must know and follow local regulations

Patient-centered care

  • SUBQ and IM thigh sites overlap in small children
  • Secure child’s body and limbs; use one-handed technique for injections
  • Two assistants may be needed for multiple injections

Professional behaviors

  • Attention to detail critical; report medication errors immediately
  • Notify provider and supervisor; complete incident report
  • Patient typically not charged for error; supervisor may file additional reports

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Subcutaneous and intramuscular injections

Subcutaneous injections

Subcutaneous (SUBQ) injections involve placing medication into the subcutaneous layer under the dermis. The subcutaneous layer has fewer blood vessels than the muscles do. The medication absorbs more slowly in the subcutaneous layer compared with medications injected into the muscles. The patient may complain of discomfort or pain with a subcutaneous injection. Subcutaneous tissue contains pain receptors.

Common medications given via the subcutaneous route include several vaccines (e.g., MMR, varicella, and polio), enoxaparin (Lovenox), heparin, and insulin.

Abbreviations for subcutaneous injections

There have been many abbreviations for subcutaneous injections over the years. Some may still be used in practice, although they are not recommended. The Institute for Safe Medication Practices (ISMP) discourages the use of SC, SQ, and sub q. Healthcare professionals should use SUBQ or subcutaneously. For more information, refer to the ISMP website at www.ismp.org/recommendations/error-prone-abbreviations-list.

Administration techniques

When a SUBQ injection is given, the angle depends on the needle length. If a 5⁄8-inch needle is used, the medical assistant should use a 45-degree angle. If a 1⁄2-inch needle is used, a 90-degree angle should be applied. It is important to pinch up the tissue with the index finger and thumb of the nondominant hand. This ensures that the injection is given in the subcutaneous tissue.

Aspiration

Aspiration is used to check if the needle is in a blood vessel. This is done once before the medication is given. (The aspiration technique will be discussed in detail in the Intramuscular Injections section, presented later in the chapter.) With SUBQ injections, the aspiration should be done if the medication manufacturer recommends it. It should also be done if it is part of the facility’s policy.

Insulin is not aspirated. SUBQ immunizations do not need to be aspirated, as recommended by the CDC. Anticoagulants, such as enoxaparin and heparin, are administered in the abdomen. They are not aspirated, as specified by the manufacturers.

Subcutaneous sites

Typically, three SUBQ sites are used in ambulatory care:

  • Abdominal site: Have the patient remove the clothing in that area. Provide a drape sheet if needed to protect the patient’s modesty. The site is located below the costal margins to the iliac crests. Stay 2 inches away from the umbilicus. It is important to stay away from the waistline and any scars. The patient may have more discomfort if the injection is given at the waistline due to the rubbing of clothing.
  • Outer posterior aspect of the upper arm: Expose the arm. The outer posterior site extends from 3 inches above the elbow to about 3 fingerbreadths below the acromion process. It is important to stay away from the shoulder area.
  • Anterior aspect of the thigh: Place one hand above the knee and the other hand below the greater trochanter. The site is the middle one-third of the thigh. The site extends from the front midline to the back midline, wrapping around the outer thigh. Usually, only the middle one-third—from the front midline to the outer thigh—is used. Injections are not done on the back of the leg because sitting would irritate the injection site.
Key points

Subcutaneous injections

  • Medication injected into subcutaneous layer; slower absorption than IM
  • Common meds: insulin, heparin, enoxaparin, some vaccines (MMR, varicella, polio)
  • Contains pain receptors; may cause discomfort

Abbreviations for subcutaneous injections

  • Use “SUBQ” or “subcutaneously”
  • Avoid: SC, SQ, sub q (ISMP discouraged)

Administration techniques (SUBQ)

  • 5⁄8-inch needle: 45-degree angle; 1⁄2-inch needle: 90-degree angle
  • Pinch up tissue to ensure correct placement

Aspiration (SUBQ)

  • Aspirate only if manufacturer or facility policy requires
  • Do not aspirate insulin, SUBQ immunizations, or anticoagulants (enoxaparin, heparin)

Subcutaneous sites

  • Abdominal: below costal margins to iliac crests, 2 inches from umbilicus, avoid waistline/scars
  • Outer posterior upper arm: 3 inches above elbow to 3 fingerbreadths below acromion
  • Anterior thigh: middle one-third, front midline to outer thigh

Intramuscular injections

  • Medication injected into muscle; faster absorption than SUBQ
  • Common meds: vaccines (hep A/B, Td, TDaP, influenza, meningococcal), antibiotics, Depo-Provera
  • Aqueous meds: higher gauge needle; oil-based: lower gauge

Administration techniques (IM)

  • 90-degree angle; flatten/stretch skin
  • Ensure correct site, minimize pain, maintain asepsis

Aspiration (IM)

  • Aspirate before injecting (except immunizations per CDC)
  • Pull back plunger 5 seconds; if blood appears, discard and restart

Air lock technique (IM)

  • Add 0.2–0.5 mL air after measuring medication
  • Air follows medication, seals in muscle, prevents tracking

Z-track technique (IM)

  • Pull skin laterally, inject, release after withdrawing needle
  • Used for irritating meds, especially at ventrogluteal site

Intramuscular sites

  • Site selection varies by age and medication
  • Deltoid: not for infants; for small volume aqueous meds, vaccines (teens/adults)
  • Vastus lateralis: preferred for infants/children, also adults; middle third of thigh
  • Ventrogluteal: preferred for oil-based/irritating meds; side-lying position, use opposite hand to locate

Patient coaching

  • Some liquid meds contain alcohol; important for recovering alcoholics/diabetics
  • Teach patients to check ingredients; communicate concerns to provider

Legal and ethical issues

  • Scope of practice for injections varies by state
  • Medical assistants must know and follow local regulations

Patient-centered care

  • SUBQ and IM thigh sites overlap in small children
  • Secure child’s body and limbs; use one-handed technique for injections
  • Two assistants may be needed for multiple injections

Professional behaviors

  • Attention to detail critical; report medication errors immediately
  • Notify provider and supervisor; complete incident report
  • Patient typically not charged for error; supervisor may file additional reports

More from Administering medications

  • Administering medications
  • Administering vaccines
  • Routes of medication
  • Intradermal injections and tuberculin testing
  • Needles and syringes