International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Pressure Application to Prevent Bruising in Subcutaneous Heparin

Injection
Nuran ÇİT1, Leman ŞENTURAN2
1
İstinye State Hospital, Istanbul, Turkey;
İstinye Caddesi No:98 34465 İstinye - Sarıyer – İstanbul
2
Assoc. Prof, Biruni University, Health Science Faculty, Nursing Department, Istanbul, Turkey
10. Yıl Caddesi Protokol Yolu No: 4534010 Topkapı / İstanbul
Corresponding Author: Nuran ÇİT

ABSTRACT

Objective: Bruising that result from heparin injections increases patients’ anxiety and reduces their
confidence in nurses’ efficiency, resulting in refusal to further injections This undesired effect can be
diminished using the proper technique and taking a few simple measures. This study aimed to
examine the effect of applying pressure for a minute on bruising in subcutaneous heparin injection.
Methods: The study, experimental study with a control group, was conducted at an orthopedic clinic.
The sample consisted of 49 patients who agreed to participate in this study and to whom heparin was
injected subcutaneously. Experimental and control practices were performed on the abdominal area of
the same patient using the same amount of heparin. The study data were collected using an
information form, subcutaneous heparin observation form, and Opsite Flexigrid assessment tool. The
data analysis was performed using percentage distribution, chi-square test, and Fisher’s exact test.
Results: This study found that bruising occurred significantly (p < 0,05) less in the area on which
pressure was applied for a minute using dry cotton compared with the area where pressure was
applied for a short time.
Conclusions: Applying pressure on the injection area for a minute following a subcutaneous heparin
injection reduced the development rate of bruising. Thus, the study concluded that this method was
effective in preventing the formation of bruising in subcutaneous heparin injection practices.

Keywords: pressure, bruising, subcutaneous heparin injection, nursing

INTRODUCTION requires making use of the proof and guides,

The administration of medication is and conducting studies to improve
one of the basic nursing practices, and administration.
perhaps the first skill related to nursing by Subcutaneous injection is a method
the society. The preparation and of parenteral injection that is used to
administration of the medication, and the administer certain substances including
evaluation of their effects are among the vaccines, insulin, hormone, and heparin.
goals in patient safety. Nurses are Heparin is one of these anticoagulant
responsible for effectively administering substances that reduce the rate of
medicines, minimizing their harmful effects, coagulation and can be administered orally
and ensuring the positive effects they could or parenterally. [4] Heparin is used very
lead to. [1-3] The scope of this responsibility commonly in treating diseases and as a
is quite broad. In addition to preparation, protective intervention for people facing
administration and evaluation, it also thromboembolism risk because it prevents

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 Nuran ÇİT et al. Pressure Application to Prevent Bruising in Subcutaneous Heparin Injection

the development of thrombus and Applying pressure on the injection area

[1,4-6]
thromboembolic complications. following the subcutaneous heparin
Although it has different forms, heparin injection reduces the development rate of
with low molecular weight (HLMW), bruising due to its indirect effect on the
administered subcutaneously, is used more physiologic process. [1,2,17,19]
frequently in the clinics. [2,7] In addition to The injection area should not be
the desired systemic effect, complications or massaged following the heparin injection
problems such as bruising, hematoma, and since massaging alters the normal
pain may emerge following subcutaneous absorption speed of the medicine and causes
heparin injections. [1,5,8,9] bleeding and bruising. [2,8,18,19] The
Bruising is the bluish purple or black absorption speed varies by the injection area
patch on the skin that occurs as a result of as well. It is fastest in the abdominal area,
blood flowing through the tissue. [10] moderate in the arms, and slower on the
Bruising, which is an undesired condition front side of femur and upper side of back
developing after the subcutaneous heparin and hips. The upper abdominal area is the
injection applications and due to the best place for heparin injection for thin
injection method in general, affects patients people since they do not have sufficient
and practitioners negatively since it has an amount of subcutaneous tissues for
unpleasant appearance. [8,9] Other than the subcutaneous injection. [2,19]
cosmetic appearance, heparin injection Different studies on preventing
restricts the application area since this bruising are available in the relevant
procedure requires changing the application literature. [1,5,9,11,13,14] Some of these studies
site and maintains it in rings. [1,11] are related to the duration of injection, and
Bruising that results from heparin these durations range between 5 and 30
injections increases patients’ anxiety and seconds. [1,13,20] However, there are study
reduces their confidence in nurses’ results indicating that the duration of
efficiency, resulting in refusal to further heparin injection should be at least 10
injections. [12-14] This undesired effect can seconds, which reduces the possibility for
be diminished using the proper technique the development of bruising. [5,11,14] All
and taking a few simple measures. The these studies indicate that pressure should
formation period of bruising and hematoma be applied, without massaging, to the
(due to heparin injection) varies, but it heparin injection area following the
reaches the most distinctive level in the 48th procedure. However, recommendations
h after the injection and begins to fade no regarding how long the pressure should be
later than the 72the h. [1,15,16] applied are quite different. [2,5,11,14,18]
The method to be followed in Medicinal prospectuses do not contain any
heparin injections is not different from the instructions regarding this issue. [21]
standard procedure to be used in Bruising due to heparin injection is
subcutaneous injection. considered to be a problem for both patients
Needle-entry angle: The needle-entry angle and nurses because it is an important factor
in heparin injection is recommended to for changing and adjusting clinical
range between 45° and 90° based on the performance. [22]
volume of subcutaneous tissue and patients’ Considering the previous studies and
age, weight, and muscular characteristics. researchers’ needs during the clinical
[2,17,18]
practices, this study aimed to examine the
Protection from trauma: Interstitial needle effect of applying pressure for a minute on
movement should be minimized to prevent the development of bruising following the
injection-based trauma. Administering subcutaneous heparin injection in
heparin with a slow and constant pressure orthopedic patients.
prevents tissue damage and discomfort.

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MATERIALS AND METHODS committee. The injections performed in

This is an experimental study with a accordance with the clinical routines
control group which was conducted at the consisted of the routine practices. The plan
orthopedic clinic of a state hospital operated generated for the study was followed for the
by the Ministry of Health. experimental practice. Heparin injections
Sample were administered to both sides of the
This study sample included 49 abdominal area during both experimental
patients who agreed to participate, met the and control practices. The left abdominal
inclusion criteria, and experienced area of the patient was used for the control
subcutaneous heparin injection following practice, while the right side was used for
the commencement date. Both experimental the experimental practice. Standard
and control practices were performed on one injectable injectors with 1.26-cm needle,
study sample. Specific references were 4000 IU of HLMW, and air bubble were
determined for the inclusion criteria. These used. [21] The injections were performed at
criteria were as follows: 21.00 o’clock in accordance with the
 No history of coagulopathy. (The clinical routines. All injections were
reference range of the laboratory where performed with size measurement of
the study was conducted was used for bruising and post-injection observations in
the prothrombin time, and similar values mind. The body mass index (BMI) of the
were considered for inclusion.) patient was evaluated using the BMI =
 Receiving heparin treatment with low weight (kg)/height2 (m2) formula, using the
molecular weight. classification by World Health Organization
 No communication difficulties for (WHO). [23] The patients were classified as
obtaining consent. follows:
 No scar tissue, incision, or injection If the index is lower than 18.50 kg/m2,
mark on the abdominal area where the underweight
injection was performed. If it is between 18.5 and 24.99 kg/m2,
 No history of allergy. normal
Data Collection If it is between 25 and 29.99 kg/m2,
The data were collected using the overweight
information form, subcutaneous heparin If it is between 30 and 34.99 kg/m2, obese
observation form, Opsite Flexigrid class I
measurement tool, and acetate pen. If it is between 35 and 39.99 kg/m2, obese
Introduction form: It is an eight-question class II
form about patients’ age, gender, height and If it is over 40 kg/m2, morbid obese class III
weight, smoking habit and chronic diseases, The following procedure was applied in
and medicines they used. each practice until the injector was
Subcutaneous heparin observation form: It extracted:
was prepared by the researchers to indicate  Before administering the medicine, the
the development and size of bruising. area was wiped using an alcohol-
Opsite Flexigrid measurement tool: It is a containing cotton with circular
transparent assessment tool used to perform movements from the center to outside at
millimetric measurements for the size of a 5-cm area.
bruising in the injection area. It was  The practice started after the tissue was
supported with a transparent acetate held, and the tissue was not released
facilitate the assessment. Acetate pen is during the practice.
used to define the borders of bruising.  The injection was performed at 45° on
The study commenced after the those whose BMI was normal or less
permissions and consent were obtained from than normal holding the administration
the relevant institution and ethics

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 Nuran ÇİT et al. Pressure Application to Prevent Bruising in Subcutaneous Heparin Injection

area. For the overweight/obese obtained from those who agreed to

individuals, the injection was performed participate.
at 90° holding the tissue. Statistical Analysis:
 The medicine was administered in 20 s, The data analysis was performed using
and the injector was extracted at the SPSS 15.0 for Windows. The details
same angle after administering the regarding the demographic data were
medicine. presented in frequency and percentage
 In the control practice, the pressure was tables. The chi-square test was used to
applied for 3 or 4 s using dry cotton examine the relationships between the
after the injector was extracted in variables. The Fisher’s exact test was used
accordance with the clinic routine. as a continuity correction factor when the
 In the experimental practice, the value in the tables with four cells was
pressure was applied for 60 s using dry smaller than 5. The significance level was
cotton after the injector was extracted. accepted as p < 0.05 in the analyses.
The injection was performed using
the following method by the same RESULTS
Table 1. Characteristics of patients (n=49)
researcher at the same hour. The injection Characteristics Groups n %
was administered on the right abdominal Age 45-64 16 32,7
65-84 33 67,3
area on the first day (experimental practice), Gender Women 43 87,8
on the left abdominal area on the second day Men 6 12,2
(control practice), on the right abdominal BMI underweight /normal 4 8,2
Overweight / obese 45 91,8
area on the third day (experimental
practice), and on the left abdominal area on Table 2. Distribution of the development of bruising (n=49)
the fourth day (control practice). Thus, the First Practice
Hour Control Practice Experimental Practice
experimental and control practices were Present Absent Present Absent
performed every other day. The injection n % n % n % n %
24 th 22 44,9 27 55,1 18 36,7 31 63,3
areas were changed by rotation, and the X2=0,676 ; p=0,411
injection was performed at least 2.5 cm 48th 24 49 25 51 19 38,8 30 61,2
further from the previous spot in the X2=1,036; p=0,309
72nd 24 49 25 51 18 36,7 31 63,3
following subcutaneous injections. The X2=1,500 ; p=0,221
development and size of bruising in the Second Practice
Control Practice Experimental Practice
injection area were evaluated in the 24th, Hour Present Absent Present Absent
48th, and 72th hours after each injection. n % n % n % n %
24 th 23 46,9 26 53,1 11 22,4 38 77,6
The borders of bruising area (if emerged) X2=6,485 ; p=0·011*
were marked using an acetate pen. The 48 th
24 49 25 51 12 24,5 37 75,5
Opsite Flexigrid measurement tool was X2=6,323 ; p=0,012*
72nd 25 51 24 49 12 24,5 37 75,5
placed on the acetate, and its size was X2=7,338 ; p=0,007*
measured in millimeter square and defined The chi-square test
in three groups: a small bruising with a
diameter smaller than 2 mm as pinpoint Of the patients, 67,3% (n = 33) were aged
needle tip, a moderate-sized bruising with a between 65 and 84 years, and their mean
diameter ranging between 2 and 10 mm, and age was 68,5 ± 9.5 years; 87,8% were (n =
a large bruising with a diameter greater than 43) female; and 91,8% (n = 45) were
10 mm. [24] overweight/obese (Table 1). Following the
Ethical Considerations: first injection practices, no significant
The approval of the ethics committee of the difference was present in the development
Halic University was obtained before the of bruising observed at all hours between
study (consent date-number: 11/12/2013 - the experimental and control practices (p >
86). Permission was taken from the hospital 0,05). Following the second practice,
administrator. Later, informed consent was significant differences were found in the

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development rates of bruising between the practice, this rate was 50% in the control
experimental and control practices (p <0.05) practice. The development rate of moderate-
(Table 2). sized bruising was 72% in the experimental
The sizes of bruising were practice and 36% in the control practice.
examined, and no significant difference was Although large bruising developed in all
found between the experimental and control hours of the control practice within the first
practices. However, the sizes of the practice, they did not develop in the
numerical values were found to range experimental practice. Regarding the second
(Table 3). Although small bruising practice, the development rate of large
developed in 28% of the patients in the bruising seen in the control practice was
experimental practice 24 h after the first found to be higher (Table 3).

Table 3. Distribution and relationship of the size of bruising (N=49)

First Practice
Control Practice Experimental Practice
Hour Small Moderate Large Small Moderate Large
n % n % n % n % n % n %
24 th 11 50 8 36,4 3 13,6 5 27,8 13 72,2 - -
X2=6,716 ; p=0,082*
48th 4 16,7 16 66,7 4 16,7 4 21,1 15 78,9 - -
X2=4,487 ; p=0,213*
72nd 3 12,5 15 62,5 6 25 6 33,3 12 66,7 - -
X2=7,597 ; p=0,055*
Second Practice
Control Practice Experimental Practice
Hour Small Moderate Large Small Moderate Large
n % n % n % n % n % n %
24 th 5 21,7 17 73,9 1 4,3 4 36,4 6 54,5 1 9,1
X2=7,622 ; p=0,055*
48th 3 12,5 19 79,2 2 8,3 2 18,2 9 81,8 1 9,1
X2=6,427 ; p=0,093*
72nd 4 16 18 72 3 12 2 16,7 8 66,7 2 16,7
X2=6,267 ; p=0,099*
The chi-square test * The Fisher’s exact test

DISCUSSION experimental practice was not significant in

The effect of developments seen in the first practice, and the development rate
science and technology also reflects on of bruising was higher in the experimental
nursing practices. This reflection is effective practice than in the control practice. The
when nurses use their knowledge and skills decrease in the development rate of bruising
together rather than using them separately. in this practice supported the significant
Nurses support the developments in science difference in the second practice, although
and technology with the evidence-based the decrease in the development rate was
practices they perform and also support the not significant. The findings in this study
development of nursing. Subcutaneous were consistent with those in previous
HLMW injection practices facilitate good studies [1,2,16,17,19] indicating that the pressure
nursing practices for patients. They increase applied to the injection area following the
nurses’ responsibilities regarding subcutaneous heparin injection reduced the
complications. Incorrect or incomplete development rate of bruising, and also
practices cause pain to patients, besides the revealed the effect of the duration for which
development of bruising with an undesired the pressure was applied. Several previous
appearance. In a study that examined the studies have included the study outcomes
effect of applying pressure for 60 s on the related to various pressure durations.
development of bruising, the development Yıldırım’s study (1999) suggested that
rate of bruising significantly diminished in bruising developed in patients on whom
the experimental practices within the second pressure was applied for 5–10 s. [25] In a
practice (Table 2). The decrease in the study conducted to determine the effect of

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the duration of pressure (10 or 60 s) applied heparin injections was effective in

on the development of bruising following preventing the development of bruising.
the subcutaneous heparin injection, Zaybak However, further studies comparing
(2008) suggested that no significant different durations of applying pressure are
difference (p > 0,05) in the development of still needed.
bruising was observed between the
experimental and control practices, which ACKNOWLEDGMENTS
was in contrast with the former study. This research did not receive any
However, in a study conducted by Zaybak specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
and Khorşit (2008) to examine the effect of
This research was conducted as a master's thesis
applying pressure (for 30 and 10 s) on the at Halic University. The authors thank Ayça
development of bruising in the injection Pamukçu for her support in statistical analysis.
area, it was found that applying pressure for
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How to cite this article: ÇİT N, ŞENTURAN L. Pressure application to prevent bruising in
subcutaneous heparin injection. Int J Health Sci Res. 2018; 8(4):159-165.

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