Endocrine Lecture 2
Part 3
Mixing Insulin – How it
#1 Assemble equipment
• Insulin
• Syringe
• Alcohol swab
• MD order
Mixing insulin – How it
#2 Check MD order for
dose and types
Mixing insulin – How it
#3 Roll the bottle of
intermediate acting
insulin (DO NOT
SHAKE)
Mixing insulin – How it
#4 Wipe the top of both
vials with alcohol
swab
Mixing insulin – How it
#5 Draw up and inject
an amount of air
equal to the dose of
intermediate acting
insulin vial. Then
remove syringe from
the vial
Mixing insulin – How it
#6 Draw up and inject
an amount of air
equal to the amount
of short-acting insulin
into the clear vial.
*Leave syringe in the
vial
Mixing insulin – How it
#7 Draw up the correct
amount of
clear/regular insulin.
Mixing insulin – How it
#8 Double check with
another nurse if this is
the institutions policy.
Mixing insulin – How it
#9 Remove the syringe
and insert into the
cloudy vial. Carefully
draw up the correct
amount of insulin.
Mixing insulin – How it
#10 Double check with
another nurse before
removing the syringe
from the vial
What do you do if you draw up too much
intermediate acting insulin with mixing?
A. Push it back into the vial and re-draw up the
correct amount.
B. Waste the med and start over with the same
syringe.
C. Waste the med and start over with a clean
syringe.
D. Who cares, a little extra never hurt anyone!
Just give it to the patient.
What do you do if you draw up too much
Regular/clear insulin when mixing?
A. Push it back into the vial and re-draw up the
correct amount.
B. Waste the med and start over with the same
syringe.
C. Waste the med and start over with a clean
syringe.
D. Who cares, a little extra never hurt anyone!
Just give it to the patient.
How would you do it?
Give 8u Humulin R and 12u NPH sub-q, qAM.
Sliding Scale
• Used during
– Surgery
– Illness
– Stress
• Determines insulin dose based on FSBG
• Usually regular insulin is used
• FSBS check usually every 4-6 hrs
Sample Sliding Scale
•
•
•
•
•
•
Check FSBS before meals and at HS (2200)
4u Humulin R insulin for glucose 151-200 mg/dL
6u Humulin R insulin for glucose 201-250 mg/dL
8u Humulin R insulin for glucose 251-300 mg/dL
10u Humulin R insulin for glucose 301-350 mg/dL
Call MD for glucose >350 mg/dL
Questions for sliding scale
•
•
•
•
1. If FSBS 189 how much
insulin would you give?
Check FSBS before meals and
at HS (2200)
2. If FSBS 309, how much
4u Humulin R insulin for
insulin would you give?
glucose 151-200 mg/dL
3. If FSBS 120, how much
6u Humulin R insulin for
insulin would you give?
glucose 201-250 mg/dL
4. If FSBS 60, how much
8u Humulin R insulin for
insulin would you give?
glucose 251-300 mg/dL
• 10u Humulin R insulin for
glucose 301-350 mg/dL
• Call MD for glucose >350
mg/dL
Insulin Injections • In general the more
frequent the injections
the better the control.
• Read and study pg.
1394-1395 of text book
for different insulin
regimens
Insulin regiments
• Vary
• Usually combo
• Goal is to mimic
normal pancreas
• Patient adjust
Syringe Types
• Insulin syringe
• 27-29 gauge
• Various units
– Must match insulin
concentrations
Route (Self Administration)
• Subcutaneous tissue
– If you can “pinch an inch”
• 90 degree angle
– If you can’t “pinch an inch”
• 45 degree angle
Area’s of injection
•
•
•
•
Abdomen
Arm
Thigh
Hips
Factors affecting absorption rates
• Quickest
– Abdomen
• Exercise
– Increases absorption
rate
Lipodystrophy
• Atrophy of subcutaneous
fat
• Do not use these sites!
• Causes
– Non-human insulin
– Alcohol
• Rotate site
Self-Injection Techniques
• No need to aspirate
• Through clothing  OK
• Skin prep with alcohol not
recommended
• Reuse needles
• Disposal
Flocculation
• Check for flocculation
– Frosted, whitish coating inside the bottle)
– Caused by extreme heat
– Do not use
Insulin Storage
• Vial NOT being used
refrigerate
• Vial in use  room
temperature
• Storage life un-refrigerated = 1
month
• Remember: date all vials when
opened
Pre-mixed insulin
• NPH + Regular
• Novolin 70/30
– 70% NPH
– 30% regular
Insulin Pens - Advantages
• Portable, discreet,
convenient
• Save time (don’t draw
up insulin)
– Pre-filled insulin
cartridge
• Set accurate dose with
the turn of a dial
Insulin Pens - Disadvantages
• $$$$
• Some insulin wasted
• Not all insulin's
available
• Can’t mix
• Only for self-injection
Nurses pre-filled syringes
•
•
•
•
Up to 3 weeks supply
Kept in frig
Store with needles in upright position
Mix thoroughly before injecting
What would you do?
Which of the following is frequently best to teach / do
first when doing initial diabetic training?
A. How & where to purchase insulin
B. Preparation & storage of insulin
C. Mixing insulin with return demonstration
D. Self-injection of insulin
E. Learning O-P-D of insulin types
Insulin Pumps
•
•
•
•
•
Portable infusion pump
Subcutaneous needle
Continuous/basal rate
Additional bolus if needed
Change site q24-48 hours
Insulin Pumps
• S/E - risks
– Hypoglycemia
• FSBG at 3AM /wk
– Infection
– Hyperglycemia
• Occlusion
• Battery
Teacher mistakes insulin pump for
cell phone
AP: October 5, 2005
CLERMONT — A substitute teacher pulled out a student’s insulin pump
after mistaking it for a cell phone, officials said.
Cliffton Hassam told East Ridge High School officials that his insulin
pump began beeping in class Friday.
Before he could turn it off, substitute teacher Richard Maline ripped
it from his leg, according to the written statement Hassam gave
school officials on Tuesday.
Hassam, a junior, is diabetic and wears the insulin pump to
regulate his blood sugar level.
Maline pulled the pump because he thought the beeping came
from a cell phone, said Russell Anderson, executive director of
human resources for Lake County School District.
“It fell to the floor,” Hassam wrote in his statement to school
officials. “The second time he pulled it the tube came out of
my leg.”
Inhaled insulin
• “Exubera”
– Type 2 DM
– Pre-meal dose
– Not basal insulin
Insulin Therapy Complications
• Hypoglycemia
– Insulin Shock
• Causes
– Too much insulin
– Too little food
– Extreme exercise
S&S of Hypoglycemia
• Neuro
–
–
–
–
–
–
–
Dizzy / faint
Nervous
Irritability
Blurred vision
Numb tongue or lips
C/O Headache
Stupor
S&S of Hypoglycemia
• Cardiovascular
– Full bounding pulse
• Respiratory
– Shallow breathing
• Gastro-intestinal
– Polyphagia
S&S of Hypoglycemia
• Genital-urinary
– No polydipsia
• Skeletal/muscular
– Weak
– Trembling / tremor
• Integumentary
– Perspiring
– Moist
– Pale
Hyper or Hypoglycemia???
• How come they are not all opposite S&S?
• Why are some so similar?
• Which symptoms are different?
Insulin Therapy Complications
• Local allergic reaction
– Redness, swelling, tenderness, induration
– First start taking insulin
– No alcohol prep
Insulin Therapy Complications
• Insulin Resistance
– Decreases sensitivity
to insulin
– d/t obesity
• Lypodystrophy
– Do not use site
Small group Questions
1. When is a sliding scale commonly used?
2. A tuberculin syringe is also calibrated in units. Is
it OK to use a TB syringe to draw up insulin?
3. What route is insulin administered?
4. Compare the signs and symptoms of hyper and
hypoglycemia
– How come they are not all opposite signs and
symptoms?
– Why are some so similar?
– Which symptoms can you look for to tell the
difference between hyper and hypoglycemia? (*)
– Identify the components of a complete
endocrine physical assessment
– What type of insulin is used in an insulin pump?
– What is the biggest risk factor in using an insulin
pump?
– What qualifications would you look for in
recommending a client for using an insulin pump?
Insulin Therapy Complication
Insulin waning
300
250
200
150
100
50
0
60
0
40
0
20
00
24
00
0
22
• Progressive rise in
blood glucose from
bedtime to morning
350
Insulin Therapy Complication
Insulin waning
300
250
200
150
100
50
0
60
0
40
0
20
00
24
00
0
22
• Progressive rise in
blood glucose from
bedtime to morning
350
Insulin Therapy Complication
Insulin waning - Treatment
300
250
200
150
100
50
0
60
0
40
0
20
00
24
00
0
22
• Increase evening dose of
intermediate insulin
• Or institute a dose of
insulin before evening
meal
350
Insulin Therapy Complication
Dawn Phenomenon
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Relatively normal glucose
level until about 3:00 AM,
when the level begins to
rise
Insulin Therapy Complication
Dawn Phenomenon
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Relatively normal glucose
level until about 3:00 AM,
when the level begins to
rise
Insulin Therapy Complication
Dawn Phenomenon - TX
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Change time of injection of
evening intermediate
acting insulin from
dinnertime to bedtime
Insulin Therapy Complication
Somogyi Effect
350
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Normal or elevated glucose
level at bedtime, a
decrease at 2-3AM
(hypoglycemic), increase BS
levels due to “counterregulatory” hormones
Insulin Therapy Complication
Somogyi Effect
350
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Normal or elevated glucose
level at bedtime, a
decrease at 2-3AM
(hypoglycemic), increase BS
levels due to “counterregulatory” hormones
Insulin Therapy Complication
Somogyi Effect - TX
350
300
250
200
150
100
50
0
80
0
60
0
40
0
20
00
24
00
0
22
• Decrease evening or
bedtime dose of
intermediate acting insulin
• Or increase bedtime snack
Ms. Sunshine:
Ms. Sunshine in waking up in the morning with
hyperglycemia. She is taking insulin to control her
diabetes. She takes 15 units of NPH qAM before
breakfast and 15 units q PM before dinner. She is
told to check her blood sugar every hour through the
night. The results are as follows. What would you
expect the doctor to diagnose as the cause? What
changes do you expect the doctor to make in Ms.
Sunshine’s management of diabetes?
Time
FSBS
10:00 PM
152
11:00 PM
143
12:00 AM
148
1:00 AM
131
2:00 AM
107
3:00 AM
76
4:00 AM
51
5:00 AM
101
6:00 AM
187
7:00 AM
219
Mrs. Small:
Mrs. Small in waking up in the morning with
hyperglycemia. She is taking insulin to control her
diabetes. She takes 15 units of NPH qAM before
breakfast and 15 units q PM before dinner. She is
told to check her blood sugar every hour through the
night. The results are as follows. What would you
expect the doctor to diagnose as the cause? What
changes do you expect the doctor to make in Mrs.
Small management of diabetes?
Time
FSBS
10:00 PM
120
11:00 PM
135
12:00 AM
147
1:00 AM
159
2:00 AM
168
3:00 AM
180
4:00 AM
193
5:00 AM
204
6:00 AM
219
7:00 AM
230
Mr. Flush:
Mr. Flush in waking up in the morning with
hyperglycemia. She is taking insulin to control her
diabetes. She takes 15 units of NPH qAM before
breakfast and 15 units q PM before dinner. She is
told to check her blood sugar every hour through the
night. The results are as follows. What would you
expect the doctor to diagnose as the cause? What
changes do you expect the doctor to make in Mr.
Flush management of diabetes?
Time
FSBS
10:00 PM
120
11:00 PM
110
12:00 AM
115
1:00 AM
118
2:00 AM
121
3:00 AM
130
4:00 AM
157
5:00 AM
197
6:00 AM
213
7:00 AM
247