Do YOU know the Standard Technique To giving a Heparin Injection

2. PICO Question: For adults 18 and older receiving subcutaneous heparin therapy, does rotating sites, duration of injection, pre and post application of ice reduce the side effects of bruising, pain, and hematomas at the injection site compared with the standard technique?

3. Defining Terms: Standard Technique: Cleaning the skin with alcohol, choosing and area of subcutaneous fat (arm, thigh, or abdomen), pinch the skin, inserting the needle at a 45 to 90-degree angle, no aspiration, remove needle and dispose into biohazard container.

4. Defining Terms: Heparin: Including both Low-Molecular Weight Heparin (LMWH) and Unfractionated Heparin (UFH) used for anticoagulant therapy in the prevention and/or treatment of deep vein thrombosis (DVTs), pulmonary embolisms (PEs), and numerous cardiac diseases.

5. Problem: Lack research-based knowledge Nursing text books Side-Effects

6. Statistics: 200,000-400,000 people suffer from a DVT. 100,000-200,000 people suffer from a PE About 2.2 mil people suffer from atrial-fib Estimated $304.6 billion cost for health care services, medications and lost of productivity due to heart disease for 2009.

7. Comparison

8. Study #1 *Ross & Soltes The study looked at the pre and post application of ice in order to reduce discomfort and hematoma formation in adults.

9. Study #1 Results: Did not support reducing the formation of hematomas. Did promote in minimizing patient discomfort.

10. Study #2 *Zeraatkari, et al. The study compared the effects of different areas of injection monitoring the bruising and pain intensity.

11. Study #2 Results: The preferred site of administration is the abdomen. It shows the least amount of bruising and pain intensity.

12. Study #3 *Chan The study evaluated the effects of 10-second and 30-second injection durations on site pain intensity and bruising.

13. Study #3 Results: 30-second duration injection administration resulted in decrease site-pain intensity and bruising

14. Study #4 *Beyea & Nicoll This is a systematic review in which several scholarly researches were reviewed for their statistical significance.

15. Study #4 Results: In conclusion, using a 25-guage needle, 3mL syringe, abdomen, thigh, or arm for site of insertion, bunch skin, insert at 45 to 90-degree angle, inject slowly, remove needle slowly, and apply gentle pressure to site is suggested.

16. Synthesis of Data: The studies show pre and post application of ice reduces pain perception. Rotating sites within the abdomen reduced the site-pain intensity. Increasing the injection duration to 30-seconds decreases the incidence of bruising, hematoma and pain intensity.

17. Pros and Cons of Implementation Pros: Decrease pain, bruising and hematomas Increase Patient Compliance Decrease hospital length of stay Decrease re-hospitalization Strengthening Nurse-Patient Relationship

18. Pros and Cons of Implementation Cons: Cost of implementation Resistance to change

19. Recommended Protocol: Choose a needle size based on the patient’s body mass, preferably a 25-guage. Use a 3 mL syringe, preferably. Choose an area of subcutaneous fat: preferably the abdomen, 2” away from the umbilicus. Apply cold/ice treatment for 2-5 minutes pre injection and dry area. Clean the site of injection with an alcohol swab in a circular fashion and allow to dry. Pinch the skin and insert the needle at a 90-degree angle. Use a 45-degree angle if the needle size is too long.

20. Recommended Protocol: Inject medication slowly over a rate of 30-seconds. Withdraw the needle slowly at the same angle of insertion. If bleeding is present apply gentle pressure with gauze and apply bandage. Reapply cold/ice treatment for 2-5 minutes post injection and dry area. Dispose of needle into biohazard container. Re-asses site for any tissue injury and note any findings.

21. Evaluation Methods: Formal: Research Study Informal: Patient and Staff Survey

22. Suggestions for New Research: Research Recommendations: Needle Gauge Angle of Insertion Research Designs Suggestions: Randomization Larger and More Representative population

23. References: Baglin, T., Barrowcliffe, T., Cohen, A., & Greaves, M. (2006). Guidelines on the Use and Monitoring of Heparin. British Society for Haematology , 19-34.   Beyea, S. C., & Nicoll, L. H. (1996). Subcutaneous Administartion of Heparin: An Integrative Review of the Research. The Online Journa of Knowledge Synthesis for Nursing , 3 (1), 1-5.   Center for Disease Control and Prevention. (n.d.). Deep Vein Thrombosis: Health Care Professionals: Data and Statistics. Retrieved April 10, 2009, from cdc.gov: http://www.cdc.gov/ncbddd/dvt/hcp_data.htm Center for Disease Control and Prevention. (n.d.). Heart Disease Facts and Statistics. Retrieved April 10, 2009, from cdc.gov: http://www.cdc.gov/heartdisease/statistics.htm Center for Disease Control and Prevention. (2003, February 21). MMWR Weekly. Retrieved April 10, 2009, from cdc.gov: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5207a2.htm

24. References: Chan, H. (2000). Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin. Issues and Innovations in Nursing Practice , 882-892. Hunter, J. (2008). Subcutaneous Injection Technique. Nursing Standard , 22 (21), 41-44. Perry, A. G., & Potter, P. A. (2006). Clinical Nursing Skills & Techniques. St. Louis, Missouri, USA: Elsevier Mosby. Ross, S., & Soltes, D. (1995). Heparin and haematoma: does ice make a difference? Journal of Advanced Nursing , 21, 434-439. Zeraatkari, K., Karimi, M., Shahrzad, M., & Changiz, T. (2005). Comparison of heparin subcutaneous injection in thigh, arm, and abdomen. Canadian Journal of Anesthesia , 52 (A60), 1.