Applicability of calf subcutaneous tissue to subcutaneous injection in young adults.

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Original rticle

Applicability of calf subcutaneous tissue to subcutaneous injection in

young adults

Serap Torun, Phd., MSc.

a

,

_{Şükriye Deniz Mutluay, Phd., MSc.}

b,

⁎

a

Çukurova University, Faculty of Health Science, Department of Nursing, Adana 01330, Turkey b_{Çukurova University, Faculty of Health Science, Department of Midwifery, Adana 01330, Turkey}

a b s t r a c t

a r t i c l e i n f o

Article history: Received 27 December 2016 Revised 31 January 2017 Accepted 1 February 2017

Aim: The aim of the study is to provide usage of subcutaneous tissue of lateral calf area (region of M. Gastrocnemius) in addition to the existing injection regions and to compare tissue thicknesses of the lateral upper arm, anterior and lateral thigh, anterior abdomen regions and calf regions.

Background: Subcutaneous injection (SC) is an application of 0.5 cc drug with an injection (No. 25 and 8–15–18 mm long) to the connective tissue under the skin. Individuals to which SC injection is frequently applied, should rotate the injection areas.

Methods: This research uses the descriptive method.

One hundred and sixty-one students (aged; 20.09 ± 2.268) were used as test subjects. Demographic data was ob-tained from the students who agreed to participate in the research. Body Mass Index (BMI) was calculated. Skin thickness measured using the Holtain Skinfold Caliper. SPSS 20 package software was used for statistical analysis of the data. For comparison of the tissue thicknesses between genders, the t-test was used for independent groups. In order to determine the interactions between anthropometric measurements within each other and other numer-ical measurements (age, length. BMI, etc.). Pearson Correlation coefﬁcient and related P value was performed. Sta-tistical P value is taken as 0.05.

Results: Consideration of subcutaneous injection applicability of the calf region depended on the injector lengths: 8 mm, 15 mm and 18 mm, 86.3%, 59.6% and 47.8% of the population, respectively were found applicable for this region.

Conclusions: The calf region could be recommended as SC injection region with an 8 mm injector. According to theﬁndings it can be said that the calf region of female genders is more applicable than male genders for SC injection. Calf region could be proposed as anticoagulation treatment.

Subcutaneous injection is the administration of 0.5 cm3

water-solu-ble drug, using a needle (No. 25 and 8–15–18 mm long), to the connec-tive tissue under the dermis (Potter & Perry, 2011; Hall, 2004; Kim, 2005; Gibney et al., 2010; Zeraatkari et al., 2005). Subcutaneous tissue thickness varies by body mass index and several body regions (Smith, Sargent, Wilson, & Price, 1991). Therefore, subcutaneous (SC) injection is administered at a 45–90° angle (Potter & Perry, 2005; Acaroğlu et al., 2008; Ulusoy & Görgülü 2001; Ay, 2007). The angle must be 90° when pen injectors are used (Şenturan, Karabacak, Ecevit Alpar, & Sabuncu, 2008). SC injection of vaccines, hormone replacement, and an-ticoagulant agents requires short- or long-term treatment. For type 1 di-abetes patients it is typically required as a lifelong injection

(Karadakovan & Eti- Aslan, 2011). The injection site is changed by rota-tion in patients administered SC injecrota-tion in order to avoid hematoma, lipohypertrophy, and lipodystrophy (Akp_{ınar, Polat, Yaman, & Özer,} 2010; Akpınar & Çelebioğlu, 2008; Rızalar et al., 2007; Zaybak & Khorshid, 2008; Kuzu, 1999). The most appropriate body regions for self-injection of patients for a SC injection are the outer surfaces of the upper arm, the abdomen region from the lower end of the costae to the iliac processes, and the anterior face of the femurs (Potter & Perry, 2011; Hall, 2004; Kim, 2005; Potter & Perry, 2005; Acaroğlu et al., 2008). The regions over the scapula and the hip can be used as a site for SC injection; however, they fall outside the application area for self-injection. Lipodystrophy, ecchymosis, or hematoma, developing on the injection site despite protective measures, prevents the use of the application area (Akpınar et al., 2010; Akpınar & Çelebioğlu, 2008; Rızalar et al., 2007; Zaybak & Khorshid, 2008; Kuzu, 1999; Zaybak, 2008). This leads to a limited number of injection sites for nurses and self-injecting patients during the rotation. The calf region is important, since it is easy to access and adds extra injection site to the rotation.

Applied Nursing Research 34 (2017) 66–69

⁎ Corresponding author.

E-mail address:dakman@cu.edu.tr(Ş.D. Mutluay).

http://dx.doi.org/10.1016/j.apnr.2017.02.002

Contents lists available atScienceDirect

Applied Nursing Research

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2. Material and method

The study was designed as a descriptive and an anthropometric study aiming to determine the calf region applicability on subcutaneous injection. The universe consisted of 161 young adults were students from Çukurova University, Faculty of Health Science between March 2013 and December 2014.

Students whose measurements were taken are all agreed to partici-pate in the study and were randomly selected. Approval was obtained from the study sites, Çukurova University, Faculty of Health Science and Ethics Committee of Çukurova University, Faculty of Medical School.

2.1. Data and sample

The data were collected by obtaining the demographic character-istics and checking the body mass indexes of young adults who agreed to participate in the study. The skin fold thicknesses of exte-rior arm, anteexte-rior and lateral femur, anteexte-rior abdomen, medial and lateral calf were measured. And with these measurements; the appli-cability of the calf region to subcutaneous injection was compared with the other injection regions (for needle No. 25 and 8–15– 18 mm long). These measurements were taken by using a Holtain skinfold caliper (Picture 1).

The leg length of the young adult was measured by using a measur-ing tape. While the young adult was in the fowler position with a free lower leg; the skin and the subcutaneous tissue on the calf's lateral sur-face (which is approximately 10 cm below the knee's lateral sursur-face) was grab by using the thumb and indexﬁnger, and the thickness of this skin fold was measured by using the skinfold caliper. The measure-ment process was repeated for the outer arm (lateral aspect of the arm, one-third of the landmark between the acromion of the scapula and the head of the radius), anterior femur (anterior aspect of the thigh from the linear line centering the muscle extending from the muscle anterior

quadriceps femur on one-third area), lateral femur (lateral aspect of the thigh from the linear line centering the vastus lateral muscle on 1/ 3 area), anterior abdomen (anterior side to the thickest part of the rec-tus abdominal muscle from the linear line between the anterior superior iliac spine and the umbilicus) and calf (the lateral aspect of the gastroc-nemius muscle) (Picture 1). The measurement was made three times in order to eliminate measurement errors and the arithmetic mean of the results was calculated. The obtained result was considered as subcuta-neous tissue thickness and analyzed statistically.

2.2. Statistical analysis

The statistical analysis of the data was made using SPSS 20 packaged software. Categorical measurements were summarized in numbers and percentages; numerical measurements were summarized in mean and standard deviation (median where required, and min.-max.). The com-parison of tissue thickness measurements between genders was made using t-test in independent groups. The interactions between anthropo-metric measurements within each other and other numerical measure-ments (such as age, length, BMI) were analyzed using Pearson's Correlation coefﬁcient and related P values. Statistical P value was con-sidered 0.05 for all tests.

3. Results

The present study included 161 participants (male: 80, female: 81) with a mean age of 20.09 ± 2.268 years. Body mass index was for females 23, 13 ± 3 5 (17–33) and 23, 17 ± 3, 3 (17–32) for males. All anthropometric measurements were found statistically signi ﬁ-cant when compared with gender (Pb 0.005).

Considering subcutaneous injection applicability of calf (M. gastroc-nemius) region by injector size of 8 mm, 15 mm and 18 mm; 86.3%, 59.6% and 47.8% of the population, respectively were found applicable for this region.

4. Discussion

This study was conducted to compare the tissue thicknesses of the calf versus the outer arm, the anterior femur, lateral femur, and the anterior abdomen. And to determine the applicability of the calf region for subcutaneous (SC) injections, in order to enable the use of subcuta-neous tissue of the lateral calf region in addition to SC injection sites during drug administration. Based on the study data, calf (M. gastrocne-mius) region was found applicable for subcutaneous injections with an 8-mm injector size for 86.3% of the population. Considering the applica-bility for 8-mm and 15-mm injector size, 59.6% and 47.8%, respectively were found applicable for this region. It can be suggested that the calf region of the female population is more applicable for SC injections compared with the male population.

The mean values of subcutaneous tissue thicknesses at the calf, ante-rior abdomen, lateral femur, anteante-rior femur, and outer arm were respec-tively, 23,72 ± 6,95, 23,92 ± 5,36, 29,08 ± 5,93, 29,91 ± 6,05 and

Table 1

The dermographic and anthropometric data by gender. Measuring sites Female (n = 80)

Mean ± SD (mm) (Min-max) Male (n = 81) Mean ± SD (mm) (Min-max) P value Age 20,09 ± 1,7 (18–28) 20,81 ± 2,5 (17–32) BMI 23,13 ± 3,5 (17–33) 23,17 ± 3,3 (17–32) Tissue thickness (mm) Calf 23,72 ± 6,5 (7–40) 12,09 ± 6,4 (5–34) Pb 0005 Anterior abdomen 23,92 ± 5,3 (13–38) 16,93 ± 8,4 (4–37) Pb 0005 Lateral thigh 29,08 ± 5,92 (17–40) 13,88 ± 7,4 (4–37) Pb 0005 Anterior thigh 29,91 ± 6 (3–40) 16,22 ± 7,4 (3–40) Pb 0005 Outer arm 24,87 ± 6,1 (13–39) 14,72 ± 7,6 (1–39) Pb 0005

Picture 1. Measurement side of calf region with caliper.

67 S. Torun,Ş.D. Mutluay / Applied Nursing Research 34 (2017) 66–69

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24,87 ± 6,13 mm for females and 12,09 ± 6,14, 16,93 ± 8,44, 13,88 ± 7,47, 16,22 ± 7,45 and 14,72 ± 7,62 mm for males (Table 1). The subcu-taneous tissue thickness in females was statistically signiﬁcantly higher than that of boys at all sites (Pb 0.001). Similarly, in the report by Gibney et al. who studied with diabetic adults in insulin injection sides, claimed that the subcutaneous tissue in females were thicker than females.

The applicability of regions (calf, anterior abdomen, lateral femur, anterior femur, outer arm) by gender with an 8-mm injector size was found 75.3% for males and 97.5% for females of calf (M. gastrocnemius region), 58.2% for males and 100% for females of anterior abdomen re-gion, 76.5% for males and 100% for females for lateral femur rere-gion, 91.4% for males and 98.8% for females of anterior femur region, and 79% for males and 100% for females of deltoid region. Based on these re-sults; the calf, anterior abdomen, lateral femur and outer arm regions were found completely applicable for females with 8-mm injector use (Table 2). Gibney et al. indicated that injection with 8 mm needles length without lifting skin fold is in the superﬁcial muscle tissue. By

the way, the result would likely differ in patients with lower or higher BMI.

The applicability of regions (calf, anterior abdomen, lateral femur, anterior femur, and outer arm) by gender with a 15-mm injector size was found 27.2% for males and 92.5% for females of calf, 54.3% for males and 97.5% for females of anterior abdomen region, 43.2% for males and 100% for females of lateral femur region, 54.3% for males and 98.8% for females of anterior femur region, and 44.4% for males and 96.2% for females of outer arm region (Table 3).

The lateral femur region shows equal applicability in females for 8-mm and 15-mm injector sizes.

The comparison of the regions' applicability rates with an 18-mm in-jector size revealed that; the injection sites such as anterior abdomen, lateral femur, anterior femur, and outer arm region's were more appli-cable than compared to calf region (M. gastrocnemius region) (Fig. 1). Based on this result, the subcutaneous tissue of the calf (gastrocnemius region) is applicable for SC injections with an 18-mm injector in only 47% of the participants in the population.

All anthropometric measurements were found statistically different when compared with gender (Pb 0.001). It is supposed that, these dif-ferences between genders are due to the variety of the height and weight values.

The correlation test revealed a weak negative correlation between body mass index (BMI) and abdomen measurements (r = 0.233, P = 0.003). Accordingly, the abdomen measurement value increased with increasing BMI value in this study. Therefore, the tissue thickness of the abdomen region increases as the body mass indexes (BMIs) of study participants' increases.

5. Conclusion and suggestions

Based on these results, the use of the calf (M. gastrocnemius) region as a SC injection site with an 8-mm injector is suggested only for antico-agulant treatment purposes and recommended for the usage of; pri-marily by prospective nurses receiving formal education, secondarily by clinician nurses and then by subcutaneously self-injecting patients. For diabetic patients, cardiovascular diseases, lipodystrophy and diabet-ic foot risk should be considered, and it is recommended to conduct a

Table 2

Applicability of 8-mm long needle by gender.

Region Female % Male % P value

Calf 97.5 75.3 Pb 0005 Abdomen 100 85.2 Lateral femur 100 76.5 Anterior femur 98.8 91.4 Outer arm 100 79 Table 3

Applicability of 15-mm long needle by gender.

Region Female % Male % P value

Calf 92.5 27.2 Pb 0005

Abdomen 97.5 54.3

Lateral femur 100 43.2

Anterior femur 98.8 54.3

Outer arm 96.2 44.4

Fig. 1. Bar graph for 18-mm injector length. 68 S. Torun,Ş.D. Mutluay / Applied Nursing Research 34 (2017) 66–69

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broader and radiology-supported experimental study in order to use this region in such patients.

Acknowledgment

This study was supported by Çukurova University SRP Coordination Unit as project no: ASYO 2012BAP1.

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