Needle Change and Heparin Injections 1 Running Head : NEEDLE CHANGE AND HEPARIN INJECTIONS The Effect of Needle Change on Bruising after Subcutaneous Heparin Injections

Evaluation of bruises and areas of induration after two techniques of subcutaneous heparin injection Judith Belinda Wooldridge, RN, MNEd and Jayne Gosnell Jackson, RN, MN, Columbia, SC Subcutaneous administration of heparin occurs daily in the acute care setting. Bruises may occur after the injections. Injection technique is frequently suggested as contributing factor to the development of bruises. The purpose of this study was to compare the number and sizes of bruises and indurations associated with two accepted subcutaneous heparin injection protocols that differed in four elements. Variables investigated were syringe size, use of air bubble, needle change after drawing heparin into the syringe and type of sponge applied to the injection site. The hypothesis was that applying Technique A, using a 3 mL syringe, an air bubble, a needle change and a sterile dry sponge applied post-injection would be less traumatic to the tissue and result in fewer and smaller bruises and indurations than Technique B, that used a smaller syringe, no air bubble, no needle change and an alcohol sponge applied post injection. The study concluded that Technique A resulted in smaller areas of bruising and induration, and fewer indurations, but not a statistically significant lower number of bruises. Needle Change and Heparin Injections 4 Bruising and indurations are not only unsightly and painful, they also prevent future use of the site. Employing a less preferred site may have unwanted medication absorption and/or comfort issues for the client. Given these concerns it is interesting to note that many of the suggestions made about the best way to perform a subcutaneous heparin injection are not based in research, and instead rely upon methods developed through tradition and accepted practices. The investigators selected four variables with the intent of reducing force, preventing leakage, eliminating superficial tracking/residue and eliminating alcohol as a potential source of vasodilation. The fifty patient participants were screened for a normal platelet count, no known clotting disorders and adequate abdominal surface area. The study does not make clear what conditions were considered “known clotting disorders”. Coagulation tests such as aPTT, PT and INR were not reported in the literature, suggesting these tests were not done to screen the participants. It is possible that study participants could have been taking prescription medications with the expressed or unintended effect of increased clotting times. Similarly, participants could have been taking over the counter medications or herbal supplements such as garlic and ginkgo in sufficient concentrations to impact clotting times prior to the heparin injection(s). Both of these conditions could have predisposed participants to bruise formation after a needle stick of any kind, unrelated to the injection technique. The multiple grouped variables included in this study make it difficult, if not impossible to determine which variables are crucial and which may be trivial. The conclusions, then, apply only to the injection technique and not its individual elements. For this reason, application of Technique A to administer subcutaneous heparin in the clinical setting may be most helpful when a practicing nurse integrates the recommended variables on a case-by-case basis, as long as Needle Change and Heparin Injections 5 they do not contradict agency policy. For example, if a patient reports stinging during the heparin injection, the nurse may elect to change the needle after draw up for all subsequent injections and note this in the chart for others to implement. Similarly, a gauze sponge could be used instead of an alcohol pad if a patient reports post injection stinging. Integrating them as responses to individual patient’s conditions alters the rationale from preventive to reactive, which seems to be at odds with the author’s original intent of prevention. From a personal perspective, I have observed no needle changes after heparin draw up during my clinical rotations although the policy clearly states a needle change step prior to injection. Using a gauze sponge or an alcohol wipe appears to be a nursing judgment, perhaps related to the nurse’s assessment of his/her own injection skill or experience with the extent of bleeding after subcutaneous injections, although this hospital’s policy indicates an antiseptic pad should be used. This study has implications for acute and long term subcutaneous administration of heparin. It is important to minimize trauma to the injection site to reduce patient anxiety and distress, lessen physical discomfort and preserve the integrity and availability of the injection site for future use. Attempting to evaluate four independent variables within the context of one field study, while ambitious, is the major weakness of this study for the reason mentioned above. The authors acknowledge this when stating “. future investigation will need to be done to determine whether any one of the four variables investigated made the difference” (p.481). It was also interesting to note that not all subjects developed bruises. 18% of the patients treated using Technique A and 6% of the patients treated using Technique B remained bruise free. This suggests that bruising after heparin injection is avoidable for some patients although the exact method through which to achieve this, if it exists, remains unspecified. Needle Change and Heparin Injections 6