Insulin Awareness and Injection technique
for People who have Diabetes
Reference Number
3.21
Version
1
Name of responsible (ratifying) committee
Nursing and Midwifery Advisory Committee
Date ratified
10.03.2011
Document Manager (job title)
Lead Inpatient Diabetes Specialist Nurse
Date issued
10.03.2011
Review date
March 2013
Electronic location
Corporate Policies
Related Procedural Documents
See section 8 of this policy
Key Words (to aid with searching)
Insulin; injection; diabetes
Insulin Awareness and Injection technique for People who have Diabetes. Issue 1. 10.03.2011
(Review date: March 2013)
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CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 4
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
PROCESS ................................................................................................................................... 7
TRAINING REQUIREMENTS ...................................................................................................... 9
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 9
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS .............................................................................................................................. 9
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QUICK REFERENCE GUIDE
This guideline must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. To recognise the differences between insulin types
2. To understand why it is important to assess injection sites before administering insulin
3. To have an awareness of how absorption of insulin varies
4. To be able to administer insulin using the correct technique
5. To be able to store insulin safely
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1. INTRODUCTION
A recent audit showed that nearly 17% of inpatients at QAH have diabetes. Anecdotally it is
very likely that there is at least one person with diabetes in all wards and departments every
day.
Administration of insulin varies depending on the insulin to be delivered and the individual
characteristics of the patient but in any case, it must be delivered into subcutaneous fat to
ensure relatively predictable absorption of the insulin. Incorrect injection techniques can result
in the insulin being administered intramuscularly or intradermally. Injections of this nature may
either speed or slow down absorption, adversely affecting glycaemic control and so correct
injection technique is important.
2. PURPOSE
This guideline has been developed to assist the RGN and medical staff in making appropriate
decisions regarding insulin administration. They will understand how physiological insulin
relates to manufactured insulin and will be educated on the correct injection technique. Insulin
injections will be required by Type 1 patients, and if dietary modifications and oral diabetes
agents are not sufficient, a person with Type 2 diabetes may also require insulin.
This guideline is not designed to inform staff on initiating, adjusting or converting insulin.
3. SCOPE
This guideline is aimed at all registered nursing staff and clinicians working within PHT who are
involved in the care of people who have diabetes. It applies to adult inpatients who have Type
1 diabetes or those with Type 2 diabetes requiring insulin therapy and includes all clinical
settings where insulin is administered such as outpatient clinic settings, community based
patients and pregnant ladies.
This guideline should be used in conjunction with:
o
Blood Glucose Monitoring For Inpatients
o
DIPPIE (Diabetes InPatient Pathways for Increased Effectiveness).
Found on: Intranet / Departments / Diabetes
o
Insulin reference chart
For a copy please ask Anita Thynne, diabetes centre, ext 6260 or 5378
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Type of Diabetes
Type 1 diabetes is an autoimmune disease characterised by hyperglycaemia resulting from
absolute deficiency of insulin affecting a heterogeneous group of people.
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Type 2 diabetes is a metabolic disease characterised by hyperglycaemia resulting from relative
insulin deficiency and insulin resistance affecting a heterogeneous group of people (1).
The Pancreas and Insulin
There are approximately 1 million islets of Langerhans in a normal adult pancreas and these
constitute just 1-2% of the glands mass. There are four main cell types in the islets but it is the
predominant beta cells that produce insulin. The principal physiological stimulus for insulin
release is the blood glucose concentration, although numerous other metabolites, hormones
and neural factors also modulate this process. Glucose concentrations of >5 mmol/l stimulate
insulin release. Insulin cannot be taken in oral form as it is easily degraded by gastric juices.
Therefore insulin replacement must be administered via injection into the subcutaneous tissues
(2).
Physiological Insulin
Insulin is a hormone that is made in the pancreas and like many hormones, insulin is a protein.
Insulin regulates carbohydrate, fat and protein metabolism
Physiological insulin is released in two phases:
o
o
First Phase - Following a meal blood glucose levels rise and stimulate insulin secretion
Second Phase - In the fasting state insulin secretion falls, enabling maintenance of
glucose levels (1)
Manufactured insulin
Manufactured insulin (human insulin and human analogue insulins) are laboratory
manufactured to replace physiological insulin. Manufactured insulins come in several different
forms of action.
Bovine and Porcine insulin are now rarely used and so not discussed (1)
Insulin Allergy
True insulin allergy is extremely rare and often those cases showing a local reaction do not
have any clinical significance (3).
Subcutaneous Injection
Insulin can only be given by injection as it is broken down by enzymes in gastric fluids and so
can not be administered tablet form. Currently intravenous or subcutaneous injection is the
only method of administration for insulin.
Insulin injections will be required by people who have Type 1 diabetes, and if dietary
modifications and oral diabetes agents are not sufficient, a person with Type 2 diabetes may
also require insulin (1)
Injection technique
Using the correct technique to insert the insulin needle into the skin to ensure insulin is
delivered into the subcutaneous tissue
Type of Insulin
o
Short-acting insulins – Soluble insulin is a short-acting insulin which peaks between 2 4 hours after administration and disappears approximately 6 - 8 hours after. It is usually
administered 20-30 minutes before a meal. For example: Humulin S or Insuman Rapid.
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o
Rapid-acting analogue insulins – Rapid insulin peaks between 1 - 2 hours after
administration and disappears approximately 3 - 4 hours after. It is usually administered
immediately before a meal. For example: Humalog or Novorapid.
o
Intermediate-acting insulins – Intermediate insulin has a longer duration of action and
peaks between 4 – 12 hours after administration and disappears approximately 16 – 24
hours after. It is usually administered once (early morning or late evening) or twice daily
(prior to breakfast and evening meal). For example: Humulin I or Insulatard.
Long-acting analogue insulins – Long insulin has a prolonged duration of action and
peaks between 3 – 14 hours and disappears approximately 22 – 24 hours after. It is
usually administered once daily although may be twice daily. For example: Glargine or
Levemir.
o
o
o
Biphasic Isophane insulin – Biphasic insulins are essentially a mixture of soluble insulin
combined with intermediate insulin. Peaks and durations are as above. It is usually
administered 20-30 minutes before breakfast and evening meal. For example: Humulin
M3 or Insuman comb 25
Biphasic insulin analogue – Biphasic analogues are essentially a mixture of rapid
analogue insulin combined with intermediate insulin. Peaks and durations are as
above. It is usually administered immediately before breakfast and evening meal. For
example: Humalog Mix 25 or Novomix 30 (1)
Insulin Regimens
There are three common insulin regimens although these are not exclusive (1)
o
o
o
Once daily or twice daily (either early morning or/and late evening) – Intermediate-acting
or long-acting analogues are administered, usually in conjunction with Oral
Hypoglycaemic Agents in the person with Type 2 diabetes
Twice daily (prior to breakfast and evening meal) – Biphasic Isophane and Biphasic
Isophane analogues are administered. These may be in conjunction with a Biguanide in
the person who has Type 2 diabetes
Multiple injection therapy – Soluble or rapid analogue insulins are administered prior to
each meal of the day and an Intermediate or long-acting analogue insulin is
administered once (early morning or late evening) or twice (early morning and evening)
daily. These may be in conjunction with a Biguanide in the person who has Type 2
diabetes
Insulin regimen choice depends on many factors including patient lifestyle, eating and activity
habits, age and health
Insulin delivery systems
Although syringes are still commonly used by district nurses and hospital staff, it is uncommon
to see people using syringes in their home environment. Insulin pen devices have been
specifically designed to deliver insulin and patients are encouraged to bring these into hospital
and continue using them. There are a number of different pen devices and are designed to
accommodate a particular insulin brand.
Insulin pens and insulin brands are not
interchangeable.
5. DUTIES AND RESPONSIBILITIES
All registered nurses, midwifes and clinicians should understand the correct injection technique
and management of insulin to ensure knowledge and skills are passed on to other staff and
appropriately educated to patients.
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6. PROCESS
ACTION
Injection sites
o
Identify appropriate injection sites to
ensure administration is directed into
the subcutaneous tissue layer
enabling reliable absorption of insulin
RECOMMENDATIONS
Recommended sites
o
o
o
o
Abdomen. Not too close to umbilicus and
avoiding the extreme flanks
Buttocks, upper external quarter
Anterior or Lateral aspect of thighs
Upper, lateral aspect of arms
See below, but site will also depend of fat deposition
Subcutaneous Tissue
Insulin must be injected into subcutaneous tissue as:
o
o
o
IM injections can accelerate insulin absorption
and initially provoke hypoglycaemia followed by
hyperglycaemia
Intra-dermal injections can lead to leakage, pain
or an enhanced immune reaction.
Acknowledge
differences
in Rates of absorption
absorption rates as achieving a
Different injection sites may lead to varying absorption
steady absorption rate will optimize
rates
glyaeamic control. Consider whether
o The abdomen has a fast absorption rate
the patient is due to have physio as
o The arms a medium rate
this may influence your injection site
o Thighs and buttocks have a slow absorption
choice
rate
Injection times
It may be appropriate to inject in the same site at the
same time of day to ensure absorption rates are
consistent
o
Lypohypertrophy and Lypoatrophy
The injection site must be free from
evidence of lypohypertrophy or Sites displaying lumps or pitting caused by repeated
lypoatrophy so choose site wisely injections into the same site must be avoided as
absorption will be ineffective and unpredictable
and rotate injection site.
Needle choice
Choose appropriate needle length
considering patient size to ensure
injected needle enters the subcutaneous
tissue only.
A new needle should be used with each
injection to prevent blockage and
increased risk of lyphypertrophy
Fat distribution
o
o
Males do not deposit fat well in their thighs and
so may be more muscular
Fat distribution must be considered for all
patients as despite a large waistline arms and
legs can be much thinner
Needle Length
o
4mm needles may be used at any
recommended body site
o
5 and 6mm needles are suitable for most
people bit you may need to apply a skin fold lift
Insulin Awareness and Injection technique for People who have Diabetes. Issue 1. 10.03.2011
(Review date: March 2013)
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if injecting into arms and thighs
o
8mm and 12mm needles for insulin pen
devices are now rarely used but if used a skin
fold lift technique must be adopted
See below for skin fold lift technique
Resuspending Insulin
Cloudy insulins will separate when left still
and so will need resuspension prior to
administration. To do this roll or invert the
insulin vial or pen device until the insulin is
thoroughly mixed / resuspended. Do not
shake as potency can be lost.
o
Insulin should be checked for
clumping, frosting or precipitation.
Short-acting insulin’s and analogue
insulins should be clear in
appearance. Intermediate-acting
insulin’s should be cloudy in
appearance.
Skin Lift
A skin fold should be lifted when:
o
5 and 6 mm needles are injected into
arms and thighs
o
8 and 12 mm needles are used
NB: avoid use of 8 and 12 mm needles in
arms and thighs
Skin Lift technique
The skin (dermis and subcutaneous
tissue) is lifted up between thumb and
forefinger prior to insertion of the needle
to ensure it is injected into subcutaneous
tissue and minimise the risk of injecting
into the muscle. The skin should not be
released until the needle has been
removed from the skin.
Injecting Insulin
Insert needle into the skin at a 900 angle
and depress the plunger of the syringe or
pen device slowly and steadily. The
speed at which the insulin is delivered
will depend on the bore of the needle
Removal of needle
Needles should be left in the skin after
depressing the plunger for 10 seconds to
ensure all insulin is administered
/injected
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(Review date: March 2013)
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Sharp Disposal
Needles should be immediately disposed
of in an appropriate sharp disposal bucket
Storage of Insulin
o
o
o
o
o
Unopened insulin will last until its
expiry date if stored correctly.
Insulin should be stored in a fridge.
Once opened it will last three months
in the fridge or once month at room
temperature
It should never be frozen, packed
next to a frozen container or put in
direct sunlight. Insulin will deteriorate
more readily in bright light than when
in the dark.
Pen devices may crack if stored in a
fridge. These should remain with the
patient
Insulin should be labeled for the
individual patient and dated as to
when it was opened.
Ref (4)
7. TRAINING REQUIREMENTS
All staff involved in the administration of insulin should have read this guideline and may have
further educational input via DIPPIE. PHT staff will be informed of this guideline and may
cascade down to junior staff and students
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1)
2)
3)
4)
British National Formulary 60. Section 6.1, Drugs Used In Diabetes
English P and Williams G (2001). Type 2 Diabetes. Martin Dunitz Ltd, London
Connor H and Boulton A (1992). Diabetes in Practice. John Wiley & Sons, Chichester
BD Diabetes (Becton Dickinson) (2011) [online]. www.bd.com/uk/diabetes / Diabetes
Information Centre
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
The details of the monitoring to be considered include:
 Routine daily ward visits will allow for checking of insulin storage and discussions with
patients as to how their insulin is managed.
 Specialist diabetes team will discuss unfavorable insulin management issues with staff
during ward rounds or via adverse incident reporting
 Annual diabetes audits will capture insulin management. Results of the audit will be
considered by the specialist diabetes team and any educational needs will be identified.
Insulin Awareness and Injection technique for People who have Diabetes. Issue 1. 10.03.2011
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