What Is Therapeutic Communication?

Therapeutic communication is a collection of techniques that prioritize the physical,

mental, and emotional well-being of patients opens in new window. Nurses provide
patients with support and information while maintaining a level of professional distance
and objectivity. With therapeutic communication, nurses often use open-ended
statements and questions, repeat information, or use silence to prompt patients to work
through problems on their own.

Therapeutic Communication
Techniques
There are a variety opens in new windowof therapeutic communication techniques
nurses can incorporate into practice opens in new window.

Using Silence
At times, it’s useful to not speak at all. Deliberate silence can give both nurses and
patients an opportunity to think through and process what comes next in the
conversation. It may give patients the time and space they need to broach a new topic.
Nurses should always let patients break the silence.

Accepting
Sometimes it’s necessary to acknowledge what patients say and affirm that they’ve been
heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to
simply make eye contact and say “Yes, I understand.” Patients who feel their nurses are
listening to them and taking them seriously are more likely to be receptive to care.

Giving Recognition
Recognition acknowledges a patient’s behavior and highlights it without giving an overt
compliment. A compliment can sometimes be taken as condescending, especially when
it concerns a routine task like making the bed. However, saying something like “I
noticed you took all of your medications” draws attention to the action and encourages it
without requiring a compliment.

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Offering Self
Hospital stays can be lonely, stressful times; when nurses offer their time, it shows they
value patients and that someone is willing to give them time and attention. Offering to
stay for lunch, watch a TV show, or simply sit with patients for a while can help boost
their mood.

Giving Broad Openings

Therapeutic communication is often most effective when patients direct the flow of
conversation and decide what to talk about. To that end, giving patients a broad opening
such as “What’s on your mind today?” or “What would you like to talk about?” can be a
good way to allow patients an opportunity to discuss what’s on their mind.

Active Listening
By using nonverbal and verbal cues such as nodding and saying “I see,” nurses can
encourage patients to continue talking. Active listening involves showing interest in
what patients have to say, acknowledging that you’re listening and understanding, and
engaging with them throughout the conversation. Nurses can offer general leads such as
“What happened next?” to guide the conversation or propel it forward.

Seeking Clarification
Similar to active listening, asking patients for clarification when they say something
confusing or ambiguous is important. Saying something like “I’m not sure I understand.
Can you explain it to me?” helps nurses ensure they understand what’s actually being
said and can help patients process their ideas more thoroughly.

Placing the Event in Time or Sequence

Asking questions about when certain events occurred in relation to other events can
help patients (and nurses) get a clearer sense of the whole picture. It forces patients to
think about the sequence of events and may prompt them to remember something they
otherwise wouldn’t.
Making Observations
Observations about the appearance, demeanor, or behavior of patients can help draw
attention to areas that might pose a problem for them. Observing that they look tired
may prompt patients to explain why they haven’t been getting much sleep lately; making
an observation that they haven’t been eating much may lead to the discovery of a new
symptom.

Encouraging Descriptions of Perception

For patients experiencing sensory issues or hallucinations, it can be helpful to ask about
them in an encouraging, non-judgmental way. Phrases like “What do you hear now?” or
“What does that look like to you?” give patients a prompt to explain what they’re
perceiving without casting their perceptions in a negative light.

Encouraging Comparisons
Often, patients can draw upon experience to deal with current problems. By
encouraging them to make comparisons, nurses can help patients discover solutions to
their problems.

Summarizing
It’s frequently useful for nurses to summarize what patients have said after the fact. This
demonstrates to patients that the nurse was listening and allows the nurse to document
conversations. Ending a summary with a phrase like “Does that sound correct?” gives
patients explicit permission to make corrections if they’re necessary.

Reflecting
Patients often ask nurses for advice about what they should do about particular
problems or in specific situations. Nurses can ask patients what they think they should
do, which encourages patients to be accountable for their own actions and helps them
come up with solutions themselves.

Focusing
Sometimes during a conversation, patients mention something particularly important.
When this happens, nurses can focus on their statement, prompting patients to discuss
it further. Patients don’t always have an objective perspective on what is relevant to
their case; as impartial observers, nurses can more easily pick out the topics to focus on.

Confronting
Nurses should only apply this technique after they have established trust. It can be vital
to the care of patients to disagree with them, present them with reality, or challenge
their assumptions. Confrontation, when used correctly, can help patients break
destructive routines or understand the state of their situation.

Voicing Doubt
Voicing doubt can be a gentler way to call attention to the incorrect or delusional ideas
and perceptions of patients. By expressing doubt, nurses can force patients to examine
their assumptions.

Offering Hope and Humor

Because hospitals can be stressful places for patients, sharing hope that they can
persevere through their current situation and lightening the mood with humor can help
nurses establish rapport quickly. This technique can keep patients in a more positive
state of mind.

Venipuncture technique.
Wash your hands.
Before beginning this procedure perform a thorough hand wash.

Identify | Explain | Consent

If you have not yet done so, introduce yourself to the patient and ensure you
have their correct identity. Ask for first and last name as well as date of birth
checking against their ID bracelet.

Explain the procedure to the patient.

Tell them the short version before you do it and tell them long version as you are
doing it (more on this important skill here).
Make sure you also tell them exactly why they need to have blood drawn, what
 tests are going to be run and roughly how long the results will take to come back.
Finally, ask them if they have any questions.

Having the patient extend their arm or begin squeezing their fist etc is considered
an implied consent for this procedure but it is preferable to ask them specifically
for permission or simply ask “are you OK with that?”

If you have some form of electronic ID label generator, print them out at this time
and check against patients ID. Set them aside ….close by.
You should never stick the patient ID labels to the pathology tubes until
they are filled with blood. This increases the risk of errors.
You should also never carry blood filled tubes across to the printer or set them
down unattended.

To recap:

1. print out the labels.

2. check against patient ID.
3. fill the tubes.
4. then attach the labels and complete any additional documentation.

Position | Planning | Preparation.

Ensure the patient is in a comfortable position and that their arm is supported
and sloping downwards if possible.

Always ask yourself: if this patient were to have a vasovagal response during the
procedure (or otherwise collapses) are they safe from harm? For example: sitting
a big beefy tattoo covered man upright on a stool whilst you draw his blood is
probably an unwise strategy in my experience.

Importantly, make sure you will also be comfortable during the procedure. Being
bent over or at an uncomfortable angle during the draw will decrease your
likelihood of success.

Check to see exactly which blood tests have been ordered.

Assemble your equipment and blood tubes taking into consideration:

 Which tube should you use first?

See: Order of draw
 Blood cultures require additional actions, and again there is a specific order in
which they should be drawn.
See: Blood cultures.
 Other special orders such as venous gas samples or blood alcohol collection.

Take time to properly set up your equipment for venipuncture as per your
hospital protocol.

PPE.
Don your personal protective equipment (PPE).

Namely, gloves and eye protection.

If your patient has been given chemotherapy within the last 7 days further
precautions should be used (consult your local policy for advice on this).

Tip: I tend to opt for gloves that are a size smaller than I would usually wear to
ensure the glove stretches tight across my fingertips. I find this gives me a better
touch sensitivity when palpating the vein. Check for wrinkles on the gloves
across your fingertips as these can misleadingly feel like a vein during palpation.

And yes, you should always be wearing additional eye protection during
venipuncture.
Prescription glasses are NOT enough. I have had blood flick up under my
glasses and directly into me eyes on two occasions. I now always wear a full face
shield when drawing blood (Which I often wear upside down when not using
much to the amusement of my colleagues).

Performing the venipuncture.

Select your target vein.

Apply the disposable tourniquet firmly but not too tight (reusable tourniquets are
an infection control risk and should not be used)
A good light source will help to visualise your vein but it is your sense of touch
that will be most useful. Palpate for the unique ‘spongey firmness’ that a good
vein has. You will also want to palpate above and below to get an idea of the
direction of that vein so your needle does not enter across it and out the other
side.
Here are some tips to help you when you just can’t find that vein.

As featured in the above video, many hospitals recommend using some sort
of vaccuette system consisting of a needle and a plastic tube holder.

Personally, I would recommend using a butterfly needle (and I usually use an

18fr or green for most adults) attached to the tube holder. I find that if you use a
standard needle the movement caused by removing a blood tube from the holder
and re-loading a new tube often moves the needle tip out of the vein resulting in
a failed venipuncture..

During my preparation I grab a small 3cm length of Transpore tape which I

temporarily place on the tourniquet (within easy reach) once it has been applied
to the patients upper arm.
During insertion I place the tube holder in the palm of my dominant hand whilst
holding the actual butterfly needle between the thumb and first fingers.

The needle enters through the skin bevel up at about a 15-30 degree angle. Let
the patient know there is about to be a sharp push. Be confident.
 Once I have confirmed the butterfly is in the vein (by seeing a flash-back of blood
in the proximal butterfly needle tubing) I grab the tape and gently lay it across the
wings of the butterfly, temporarily holding it in place.

Letting go of it with my fingers, I now have the tube holder in my dominant hand
and my other hand is free to attach and remove the required blood tubes as they
fill. This avoids movement of the needle tip in the vein.

Two caveats to this technique. So use caution:

1. Butterfly needles cause a high number of occupational exposure injuries. They

tend to spring and bounce around on their tubing if not removed carefully.
2. There is extra air in the tubing of the butterfly which will enter the first tube filled
and may affect some tests. For example, it could lead to under-filling of
coagulation tubes (where correct volume is important) or introduce extra air into
an anaerobic blood culture bottle.

Some people hold the butterfly needle by the wings , others prefer holding it back
behind the wings. This is personal preference, but I find holding the wings leads
to the fingers obscuring your view of blood flashback in the tubing).

Sharps management:
Always have a sharps bin within easy reach during this procedure. The
needle must go directly from the patient into the sharps bin.
NEVER place a needle down on to any other surface. Even if you think you will
pick it up again in just a second. Never.

Also remember that the vacuette collection tube also contains a needle (although
this one is often hidden under a rubber coating) that can easily lead to an
exposure injury if you inadvertently place your finger over the lip. Again, directly
into the sharps bin.

Puncture site care .

Apply direct sustained pressure to the site once you have removed the needle. If
the patient is able, they can assist with this once you have demonstrated how to
do it.

Don’t let the patient ‘bend their arm’ to apply pressure as this usually leads to a
bigger haematoma at the puncture site.
 Obviously if the patient is on anticoagulant therapy they may need pressure to be
applied for a longer time.

Care of blood tubes:

After collecting blood most tubes should be inverted gently 6-8 times to mix with
any anticoagulant, antiglycolytic or clot activators present in the
tube. An inversion is one complete turn of the wrist, 180 degrees, and
back.

Only after the specimen has been collected should any patient identification
information be attached. Re-confirm this information before doing so.

Documentation :
Remember to correctly complete all documentation relevant to this blood draw
including pathology forms, labelling and signing of tubes and completing an entry
in the patients notes confirming the venipuncture was attended.

Injection technique 2: administering drugs via

the subcutaneous route



 COMMENT

Part 2 of this two-part series on injection techniques

describes the evidence base and procedure for
administering a subcutaneous injection

Abstract
The subcutaneous route allows drugs such as insulin and heparin to be
absorbed slowly over a period of time. Using the correct injection technique
and selecting the correct site will minimise the risk of complications. This is
the second article in a two-part series on injection techniques. Part 1covers the
intramuscular route.
 Citation: Shepherd E (2018) Injection technique 2: administering drugs via
the subcutaneous route. Nursing Times [online]; 114: 9, 55-57.

Author: Eileen Shepherd is clinical editor at Nursing Times.

 This article has been double-blind peer reviewed

 Scroll down to read the article or download a print-friendly PDF here (if the PDF
fails to fully download please try again using a different browser)
 Read part 1 of this series here

Introduction
Drugs administered by the subcutaneous route are deposited into
subcutaneous tissue (Fig 1); small volumes (up to 2ml) of non-irritant, water-
soluble drugs can be administered by subcutaneous injection (Dougherty and
Lister, 2015).

Unlike muscle, subcutaneous tissue does not have a rich blood supply, and
absorption of drugs delivered via that route is therefore slower than via the
intramuscular route (see part 1) (Dougherty and Lister, 2015). This slower rate
of absorption is beneficial when continuous absorption of a drug is required;
for example, with insulin or heparin (Hunter, 2008).

Factors affecting blood flow to the skin, including exercise and changes in
environmental temperature, can affect drug absorption. The subcutaneous
route may be unreliable in patient with conditions that result in impaired blood
flow, such as circulatory shock (Dougherty and Lister, 2015).

It is often suggested that the subcutaneous route is relatively pain free (Zijlstra
et al, 2018; Srivastava and Robson, 2012) but the evidence supporting this
assertion is poor and further research is required. A Cochrane review in 2017
looked at the duration of pain and bruising after subcutaneous heparin
injection and reported that a slow injection – taking 30 seconds to administer –
may reduce pain but there is no difference in bruising compared with a fast
injection (Mohammady, 2017). The researchers noted that the evidence was
oComplications associated with subcutaneous
injections include abscesses and, in patients
who require frequent injections, there is a risk of
lipohypertrophy; this is characterised by an
accumulation of fat under the skin.
Lipohypertrophy occurs when multiple injections
are repeatedly administered into the same area
of skin. It can be painful and unsightly, and affect
drug absorption, but can be prevented by
rotating injection sites (Down and Kirkland,
2012).

Preparation
Site selection
Recommended sites for subcutaneous injection
include the lateral aspects of the upper arm and
thigh, and the umbilical region of the abdomen
(Ogston-Tuck, 2014; Hunter, 2008). The back
and lower loins can also be used (Fig 2).
 Injection sites should be:
 Clean;
 Free of infection, skin lesions, scars, birthmarks, bony prominences, and large
underlying muscles, blood vessels or nerves (Dougherty and Lister, 2015).
As the amount of subcutaneous fat varies
between patients, individual patient assessment
is vital before carrying out the procedure. It is
important to avoid inadvertently injecting the
drug into muscle, as intramuscular injection can
affect drug absorption; for example, inadvertent
administration of insulin into the muscle can lead
to accelerated insulin absorption and lead to
hypoglycaemia (Down and Kirkland, 2012).

A lifted skinfold technique (pinching or bunching

the skin) can be used to lift the subcutaneous
layer away from the underlying muscle (Down
and Kirkland, 2012) (Fig 3). This method reduces
the risk of inadvertent intramuscular injection
when undertaken correctly; however, releasing
the skin too quickly before the injection is
completed or lifting it incorrectly can increase
that risk (Down and Kirkland, 2012).
Needles
Safety needles should be used for subcutaneous
injections to reduce the risk of needle- stick
injury (Health and Safety Executive, 2013).
Some drugs such as heparin come in a pre-
loaded syringe and patients prescribed insulin
may use insulin delivery devices.
Needle size is measured in gauges (diameter of
the needle) – a 25G is commonly used for
subcutaneous injections (Dougherty and Lister,
2015; Public Health England, 2013). Needle size
depends on the viscosity of the liquid being
injected (Dougherty and Lister, 2015).

Needles need to be long enough to inject the

drug into the subcutaneous tissue. They come in
lengths of 5cm, 6cm and 8cm. Dougherty and
Lister (2015) suggest the required needle length
can be estimated by pinching the skin using the
lifted skinfold technique (Fig 3) and selecting a
needle that is 1.5 times the width of the skinfold.

Skin preparation
There is debate around the use of alcohol-
impregnated swabs to clean injection sites. The
World Health Organization (2010) suggested that
if a patient is physically clean and generally in
good health, swabbing of the skin before
injection is not required. This was supported by
Hicks et al (2011) in the First UK Injection
Technique Recommendations.
In older patients and those who are
immunocompromised, skin preparation using an
alcohol-impregnated swab (70% isopropyl
alcohol) may be recommended (Dougherty and
Lister, 2015). The patient’s condition should be
individually assessed and local policies should
be followed.

Aspiration
It is common practice to draw back on a syringe
after the needle has been inserted to check
whether it is in a blood vessel. This is not
recommended for subcutaneous injections, as
there are no major blood vessels in the
subcutaneous tissue and the risk of inadvertent
intravenous administration is minimal (Public
Health England, 2013).

Gloves
The WHO (2010; 2009) stated that gloves need
not be worn for this procedure if the skin of both
health worker and patientis intact. It also notes
that gloves do not protect against needlestick
injury. Nurses need to assess risk in each
individual patient (Royal College of Nursing,
2018) and be aware of local policies for glove
use.

Angle of injection
It is recommended that subcutaneous injections,
particularly of insulin, are administered at a 90-
degree angle to ensure that the medication is
delivered into the subcutaneous tissue (Down
and Kirkland, 2012; Hunter, 2008). However,
patient assessment is vital – patients who are
cachectic and therefore have minimal amounts
of subcutaneous tissue may require injections to
be delivered at a 45-degree angle.

PHE (2013) recommends that subcutaneous

vaccinations are given with the needle at a 45-
degree angle to the skin and the skin should be
pinched together (PHE, 2013).

Equipment
 Needles (one of which should be a safety-engineered device) and syringe or
prefilled syringe.
 Drug for administration.
 Medicines administration chart/prescription.
 Receiver or tray to carry the drug.
 Sharps container.

Procedure
1. Explain the procedure to the patient and gain consent.
2. Screen the patient to ensure privacy during the procedure.
3. Check whether the patient has any allergies.
4. Check the prescription is correct and follow the ‘five rights’ of medicines
administration (Box 1) and local medicines administration policy to reduce the
risk of error.
5. Wash and dry hands to reduce the risk of infection.
6. Assemble the syringe and needle and then draw the required amount of drug
from the ampoule. Some drugs are available in pre-filled syringes and
manufacturer’s instructions should be followed.
7. Disperse any air bubbles from the syringe.
8. Change the needle to ensure that the one you are about to use for injecting
the drug is sharp, thereby reducing pain (Agaç and Günes, 2011). To reduce
the risk of sharps injury, a safety-engineered needle should be used for
injection.
9. Dispose of the needle used to draw the drug in a sharps container according
to local policy.
10. Place the injection in a tray and take it to the patient, along with a
sharps bin so the used needle can be disposed of immediately after the
procedure.
11. Check the patient’s identity according to local medicines management
policy.
12. Position the patient comfortably with the selected injection site exposed
(Fig 2).
13. Check the site for signs of oedema, infection or skin lesions. If any of
these are present, select a different site.
14. Wash and dry hands.
15. If gloves are considered necessary following risk assessment, put
gloves on.
16. Ensure the skin is clean or follow local policy on skin cleansing.
17. If skin cleansing is considered necessary, swab for 30 seconds with
isopropyl alcohol and then allow to dry for 30 seconds (Dougherty and Lister,
2015).
18. Inform the patient that you are going to carry out the injection. Use
distraction and relaxation techniques to reduce anxiety if needed.
19. Hold the syringe and needle in your dominant hand and pinch the skin
together using the non-dominant hand to lift the tissue away from underlying
muscle (Fig 3) (Dougherty and Lister, 2015).
20. Insert the needle at the required angle (usually 90 degree) using a dart-
like action. Aspiration to check whether the needle is in a blood vessel is not
necessary (PHE, 2013).
21. Depress the plunger and inject the drug slowly over 10-30 seconds
(Dougherty and Lister, 2015).
22. Wait 10 seconds before withdrawing the needle (Down and Kirkland,
2012) – this will prevent backtracking of the drug (Hunter, 2008) – and then
withdraw the needle. Do not massage the area, as this can lead to bruising
following administration of heparin (Ogston-Tuck, 2014) and speed up
absorption times with insulin (Down and Kirkland, 2012).
23. Release the lifted skinfold (Down and Kirkland, 2012).
24. Dispose of sharps directly into the sharps bin and dispose of the syringe
according to local policy.
25. Ensure the patient is comfortable and wash hands.
26. Record administration on the prescription chart. Also record
administration site so that the same site is not repeatedly used. This is to
avoid lipohypertrophy.
27. Monitor the patient for any effects of the prescribed medicine and any
problems with the injection site.
28. Patients receiving injection in a health centre or outpatient department
may need to wait for a period of time to monitor for any reaction to the drug.
Local policies should be followed.
Box 1. ‘Five rights’ of medicines administration

 Right patient
 Right drug
 Right time
 Right dose
 Right route
f low quality.