The subcutaneous layer protects the body and keeps it warm. It provides insulation and protection for vital tissues such as muscles, bones, blood vessels, and organs.
This article looks at subcutaneous tissue, its functions, and conditions that can affect this essential skin layer.
Subcutaneous tissue is the deepest skin layer that lies closest to the muscle. This layer has other names, including superficial fascia, hypodermis, subcutis, and tela subcutanea.
The skin consists of layers called the epidermis, dermis, and hypodermis. The epidermis is the outermost layer, and the hypodermis, or subcutaneous layer, is the innermost layer.
The subcutaneous layer consists mainly of fat. The fat forms a layer that insulates the body from cold and helps absorb shock and damage to the internal organs. It also provides structural support for the skin.
Share on PinterestThe skin is made up of multiple layers: the epidermis, the dermis, and the subcutaneous layer, which includes fat and important connective tissue.
The body stores fat in the subcutaneous layer. Other components include collagen-rich connective tissue and a network of blood vessels and nerves.
In the body’s abdominal area, which often has more fat, the subcutaneous layer reaches up to 3 centimeters in depth. The thickness depends on someone’s overall body fat composition.
In other areas, such as the eyelids, the subcutaneous layer has no fat and may be as thin as 1 millimeter.
The crucial functions of the subcutaneous layer are due to the significant amount of fat it holds. These functions include:
Insulation
The subcutaneous layer consists primarily of fat, allowing it to act as the body’s insulator. It regulates the body’s internal temperature independent of the surrounding environment.
Thermoregulation
The blood vessels in the hypodermis dilate to cool the body down. When blood vessels dilate, they open up or enlarge, allowing more blood to flow into the area. The blood flows away from warmer areas of the body toward cooler regions. The heat radiates away from the body into the environment and cools the body down.
Shock absorption
Besides insulation, the large proportion of fat in the subcutaneous layer also helps with shock absorption. When someone falls or experiences an impact, the fat layer limits the damage to the body’s bones and internal organs.
Structural support
The subcutaneous layer connects the skin with the fibrous tissue of the bones and muscles underneath.
Energy reserve
The body can convert fat stored in the subcutaneous layer to energy if it needs an energy boost.
The subcutaneous layer also produces hormones such as leptin. These hormones send a signal to the body to tell it that it has eaten enough, which helps regulate energy.
Subcutaneous fat is the fat located in the subcutaneous layer. Adipocytes, or fat cells, hold the fat in specialized connective tissue called adipose tissue.
The rest of the body’s fat stores reside in the spaces surrounding organs such as the liver and intestines. This fat is called visceral fat.
A subcutaneous injection is an effective method of injecting medications. People use injection sites on the outer surface of the upper arm, top of the thigh, and the area of the abdomen surrounding the belly button to administer subcutaneous injections.
Anyone administering a subcutaneous injection must avoid placing the needle into the muscle.
Injecting into the subcutaneous layer allows the body to absorb the drug slowly. The slow absorption rate is because compared with muscle, the subcutaneous tissue has far fewer blood vessels. Any substance injected into this layer is absorbed far slower than if someone injected it into the muscle.
A slower absorption rate is beneficial for drugs that require continuous absorption, including:
- allergy shots
- blood thinners such as heparin
- epinephrine
- fertility drugs
- insulin
- morphine
Any medicine injected using the subcutaneous route must be a water-soluble, non-irritant drug administered in small quantities of up to 2 milliliters.
Subcutaneous injections have some drawbacks. People may experience abscesses, which are areas of pus under the skin. Anyone who needs frequent injections may experience an accumulation of fat under the skin called lipohypertrophy. People can avoid this by varying the injection site, as it typically happens when an individual has multiple injections in the same area.
Anything that penetrates the upper layers of skin can damage the subcutaneous layer. As the subcutaneous layer is the deepest skin layer, conditions that damage it can sometimes be severe.
Burns
Burns have different classifications according to how deeply they penetrate. The two classifications of burns that affect the subcutaneous layer are third degree and fourth degree burns.
Third degree burns destroy the entire epidermis and dermis and may impact the subcutaneous tissue. These burn sites may appear either white or blackened.
Fourth degree burns enter the subcutaneous layer and may go even deeper. These types of burns may involve the bones and muscles. Since this burn type destroys all the nerve endings in the subcutaneous layer, a person does not have feeling at the burn site.
Abscesses
An abscess is a pocket of pus that can form anywhere in the body, often in the subcutaneous layer of skin. If a germ enters the skin, the person’s immune system attempts to contain it, and white blood cells (WBCs) flood into the area. Pus forms from fluid, WBCs, debris, and dead bacteria. The surrounding area becomes swollen, inflamed, and painful.
Pressure ulcers
If someone has prolonged pressure on their skin due to lying in bed or using a wheelchair, they could develop a pressure ulcer. These skin injuries, also called pressure sores or bedsores, can affect the skin and potentially the subcutaneous layer if they are severe.
Tumors
People can develop a tumor, such as a sarcoma, in the subcutaneous layer if there is an uncontrolled growth of cells.
Unlike many other types of tumors, people can easily see these masses, and doctors can examine them to see how firm and mobile they are, which helps with diagnosis. These tumors can be benign or malignant.
Panniculitis
Panniculitis is an umbrella term for a variety of diseases concerning subcutaneous tissue. The signs of panniculitis include inflammation in the subcutaneous layer and possible scarring of the subcutaneous tissue. This condition is most often associated with autoimmune disorders. It can also be caused by infection and trauma.
The subcutaneous layer is located underneath the dermis and is one of the three layers of the skin. It is the deepest skin layer, composed of fat cells, collagen, blood vessels, and nerves.
The subcutaneous layer has many functions, including insulation, thermoregulation, shock absorption, structural support, and energy storage.
Possible damage to the subcutaneous layer includes third or fourth degree burns, abscesses, pressure ulcers, tumors, and panniculitis.
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The intramuscular (IM) injection route is used to place medication in muscle tissue. Muscle has an abundant blood supply that allows medications to be absorbed faster than the subcutaneous route.
Factors that influence the choice of muscle to use for an intramuscular injection include the patient’s size, as well as the amount, viscosity, and type of medication. The length of the needle must be long enough to pass through the subcutaneous tissue to reach the muscle, so needles up to 1.5 inches long may be selected. However, if a patient is thin, a shorter needle length is used because there is less fat tissue to advance through to reach the muscle. Additionally, the muscle mass of infants and young children cannot tolerate large amounts of medication volume. Medication fluid amounts up to 0.5-1 mL can be injected in one site in infants and children, whereas adults can tolerate 2-5 mL. Intramuscular injections are administered at a 90-degree angle. Research has found administering medications at 10 seconds per mL is an effective rate for IM injections, but always review the drug administration rate per pharmacy or manufacturer’s recommendations.
Anatomic Sites
Anatomic sites must be selected carefully for intramuscular injections and include the ventrogluteal, vastus lateralis, and the deltoid. The vastus lateralis site is preferred for infants because that muscle is most developed. The ventrogluteal site is generally recommended for IM medication administration in adults, but IM vaccines may be administered in the deltoid site. Additional information regarding injections in each of these sites is provided in the following subsections.
Ventrogluteal
This site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children because it provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat. To locate the ventrogluteal site, place the patient in a supine or lateral position. Use your right hand for the left hip or your left hand for the right hip. Place the heel or palm of your hand on the greater trochanter, with the thumb pointed toward the belly button. Extend your index finger to the anterior superior iliac spine and spread your middle finger pointing towards the iliac crest. Insert the needle into the “V” formed between your index and middle fingers. This is the preferred site for all oily and irritating solutions for patients of any age. See Figure 18.31 for an image demonstrating how to accurately locate the ventrogluteal site using your hand.
Figure 18.31 Locating the Ventrogluteal SiteThe needle gauge used at the site is determined by the solution of the medication ordered. An aqueous solution can be given with a 20- to 25-gauge needle, whereas viscous or oil-based solutions are given with 18- to 21-gauge needles. The needle length is based on patient weight and body mass index. A thin adult may require a 5/8-inch to 1-inch (16 mm to 25 mm) needle, while an average adult may require a 1-inch (25 mm) needle, and a larger adult (over 70 kg) may require a 1-inch to 1½-inch (25 mm to 38 mm) needle. Children and infants require shorter needles. Refer to agency policies regarding needle length for infants, children, and adolescents. Up to 3 mL of medication may be administered in the ventrogluteal muscle of an average adult and up to 1 mL in children. See Figure 18.32 for an image of locating the ventrogluteal site on a patient.
Vastus Lateralis
The site is commonly used for immunizations in infants and toddlers because the muscle is thick and well-developed. This muscle is located on the anterior lateral aspect of the thigh and extends from one hand’s breadth above the knee to one hand’s breadth below the greater trochanter. The outer middle third of the muscle is used for injections. To help relax the patient, ask the patient to lie flat with knees slightly bent or have the patient in a sitting position. See Figure 18.33 for an image of the vastus lateralis injection site.
Figure 18.33 Vastus Lateralis SiteThe length of the needle used at the vastus lateralis site is based on the patient’s age, weight, and body mass index. In general, the recommended needle length for an adult is 1 inch to 1 ½ inches (25 mm to 38 mm), but the needle length is shorter for children. Refer to agency policy for pediatric needle lengths. The gauge of the needle is determined by the type of medication administered. Aqueous solutions can be given with a 20- to 25-gauge needle; oily or viscous medications should be administered with 18- to 21-gauge needles. A smaller gauge needle (22 to 25 gauge) should be used with children. The maximum amount of medication for a single injection in an adult is 3 mL. See Figure 18.34 for an image of an intramuscular injection being administered at the vastus lateralis site.
Deltoid
The muscle has a triangular shape and is easy to locate and access. To locate the injection site, begin by having the patient relax their arm. The patient can be standing, sitting, or lying down. To locate the landmark for the deltoid muscle, expose the upper arm and find the acromion process by palpating the bony prominence. The injection site is in the middle of the deltoid muscle, about 1 inch to 2 inches (2.5 cm to 5 cm) below the acromion process. To locate this area, lay three fingers across the deltoid muscle and below the acromion process. The injection site is generally three finger widths below in the middle of the muscle. See Figure 18.35 for an illustration for locating the deltoid injection site.
Figure 18.35 Locating the Deltoid Injection SiteSelect the needle length based on the patient’s age, weight, and body mass. In general, for an adult male weighing 60 kg to 118 kg (130 to 260 lbs), a 1-inch (25 mm) needle is sufficient. For women under 60 kg (130 lbs), a ⅝-inch (16 mm) needle is sufficient, while for women between 60 kg and 90 kg (130 to 200 lbs) a 1-inch (25 mm) needle is required. A 1 ½-inch (38 mm) length needle may be required for women over 90 kg (200 lbs) for a deltoid IM injection. For immunizations, a 22- to 25-gauge needle should be used. Refer to agency policy regarding specifications for infants, children, adolescents, and immunizations. The maximum amount of medication for a single injection is generally 1 mL. See Figure 18.36 for an image of locating the deltoid injection site on a patient.
Description of Procedure
When administering an intramuscular injection, the procedure is similar to a subcutaneous injection, but instead of pinching the skin, stabilize the skin around the injection site with your nondominant hand. With your dominant hand, hold the syringe like a dart and inject the needle quickly into the muscle at a 90-degree angle using a steady and smooth motion. After the needle pierces the skin, use the thumb and forefinger of the nondominant hand to hold the syringe. If aspiration is indicated according to agency policy and manufacturer recommendations, pull the plunger back to aspirate for blood. If no blood appears, inject the medication slowly and steadily. If blood appears, discard the syringe and needle and prepare the medication again. See Figure 18.37 for an image of aspirating for blood. After the medication is completely injected, leave the needle in place for ten seconds, then remove the needle using a smooth, steady motion. Remove the needle at the same angle at which it was inserted. Cover the injection site with sterile gauze using gentle pressure and apply a Band-Aid if needed.
Z-track Method for IM injections
Evidence-based practice supports using the for administration of intramuscular injections. This method prevents the medication from leaking into the subcutaneous tissue, allows the medication to stay in the muscles, and can minimize irritation.
The Z-track method creates a zigzag path to prevent medication from leaking into the subcutaneous tissue. This method may be used for all injections or may be specified by the medication.
Displace the patient’s skin in a Z-track manner by pulling the skin down or to one side about 1 inch (2 cm) with your nondominant hand before administering the injection. With the skin held to one side, quickly insert the needle at a 90-degree angle. After the needle pierces the skin, continue pulling on the skin with the nondominant hand, and at the same time, grasp the lower end of the syringe barrel with the fingers of the nondominant hand to stabilize it. Move your dominant hand and pull the end of the plunger to aspirate for blood, if indicated. If no blood appears, inject the medication slowly. Once the medication is given, leave the needle in place for ten seconds. After the medication is completely injected, remove the needle using a smooth, steady motion, and then release the skin. See Figure 18.38 for an illustration of the Z-track method.
Figure 18.38 Z-track MethodSpecial Considerations for IM Injections
- Avoid using sites with atrophied muscle because they will poorly absorb medications.
- If repeated IM injections are given, sites should be rotated to decrease the risk of hypertrophy.
- Older adults and thin patients may only tolerate up to 2 milliliters in a single injection.
- Choose a site that is free from pain, infection, abrasions, or necrosis.
- The dorsogluteal site should be avoided for intramuscular injections because of the risk for injury. If the needle inadvertently hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.
IM injection Ventrogluteal Site
The gluteus medius and minimus muscle is the safest intramuscular injection site for adults and children because it provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat.
A muscle located on the anterior lateral aspect of the thigh and extends from one hand’s breadth above the knee to one hand’s breadth below the greater trochanter.
Commonly used for intramuscular vaccinations in adults because it has a triangular shape and is easy to locate and access.
A method for administering intramuscular injections that prevents the medication from leaking into the subcutaneous tissue, allows the medication to stay in the muscles, and minimizes irritation.