Insulin Therapy
NURS 108
ECC- Spring, 2008
Majuvy L. Sulse MSN, RN, CCRN
Insulin
 Exogenous substance
Purified insulin prep from beef and pork
Human insulin preparation (synthetic) more rapid onset of action, shorter peak action
 Preferred for pregnant women
 Clients beginning insulin therapy
 clients going for intermittent use only
 Uses of Insulin therapy
Type 1 diabetes
Meet metabolic demands
Oral agents are unable to maintain satisfactory blood
glucose levels
Types
 Types differ in regard to onset, peak action, and
duration
 Available in 100 units/ml or 500 units/ml (500
unit/ml & Lispro needs Rx)
 Combinations are tailored according to blood
glucose level, lifestyle, eating & activity patterns.
Rapid Acting
Short Acting
Intermediate acting
Long Acting
Combination therapy
RAPID-ACTING INSULINS
 Humalog (insulin Lispro, aspart or Novolog), in which a
chemical change has been made to the insulin molecule.
This gives the insulin a very desirable property of
extremely rapid absorption. Onset is 15 minutes
 Peak action of Lispro insulin is about 60-90 minutes after
injection, and insulin levels fall off rapidly after 3 to 4
hours.
 This allows the insulin, if given before the meal, to
control the post-meal rise of glucose much better, and to
reduce the chance of hypoglycemia (because insulin
levels drop faster). This may well be its greatest
advantage.
 It can essentially substitute for any short-acting insulin.
SHORT-ACTING INSULINS
 These include Humulin R (HR), and Novolin Toronto
(also known as regular) insulins.
 Rapid-acting insulins start being absorbed in 30-60
minutes
 Peak action within 2 to 3 hours of injection in most
individuals.
 Duration of action is approximately 4 to 6 hours Shortacting insulins are often used before eating to control the
large rise of blood glucose that often occurs after a meal.
Ideally, short-acting insulin is taken approximately 30-45
minutes before the meal, as it takes up to 2 hours to see
its main effect. However, most people take their insulin
just before eating.
INTERMEDIATE-ACTING INSULINS
 Includes NPH and Lente, start being
absorbed 2-3 hours after injection
Peak action after 6-8 hours.
Duration of action may be as much as 1216 hours after injection. Used in the
morning, its greatest action would be in
the afternoon. One of the best uses is
injection at bedtime to control the morning
glucose of the next day.
LONG-ACTING INSULINS
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Mainly includes the UltraLente insulin.
Onset-2 hours
Peak effect occurring after 16-20 hours
Duration of action may be 24 hours, and vary
occasionally longer. It is not a popular insulin. It is mainly
used in individuals in whom intermediate-acting insulins
taken at bedtime act too quickly, resulting in
hypoglycemic reactions during the night.
 By using a human UltraLente, one can slow down the
peak action by an hour or two, often preventing
hypoglycemia at night, but controlling the fasting sugar of
the next day.
LONG-ACTING INSULINS
 Insulin Gargline (Lantus)-long acting insulin
analog is used for once daily subcutaneous
injection at bedtime to provide basal insulin
coverage
 Cannot be mixed/diluted with other types of
insulin. Mixing may result in a cloudy solution
and an unpredictable alteration in both the onset
of action and time to peak effect
Pharmacokinetics of Insulin
 Injection site-rotation of sites
 Absorption ratelarger doses prolongs absorption,
longer duration of action provides less consistent
absorption
Injection into scar tissue delays absorption
 Injection depth Time of injection Mixing of insulins-mixing different types can change the
timing of peak insulin action
Method of administration
 Subcutaneous
 IV- as a drip or IVP
 MDI-multiple daily insulin injections-uses
immediate and long acting insulin as basal
component together with frequent blood glucose
monitoring
 Insulin pump-continuous subcutaneous injection
in the abdominal wall via a small plastic tube to a
catheter into subcutaneous tissue-tight glucose
control, flexibility & close to normal lifestyle
Insulin Pump
Release an additional bolus from the same
cartridge and via the same infusion set at
mealtimes and to correct the blood sugar
Increase or reduce the basal insulin supply as
needed for a certain period of time without having
to reprogram the basal rate for every hour,
Program / adjust the basal rate himself/herself.
The insulin pump does not measure blood sugar
and also does not react automatically to fluctuations
in blood sugar. The pump user must handle blood
sugar monitoring himself/herself and make any
adjustments to the insulin dosage
Features of an Insulin Pump
Method of administration
New Technology
Nasal spray administered via a nebulizer
Inhalation- regular insulin (U-500) delivered
in an inhaler during inspiration
Transdermal also being tested
Problems associated with Insulin Therapy
 Hypoglycemia
 Allergic reaction-itching, burning, redness around site
 Lipodystrophy lipohypertrophy –increased fat deposits in the skin
 Lipoatrophy-loss of fatty tissue
 Somogyi effect-treat with less insulin
 Dawn Phenomenon-hyperglycemia on awakening due to
release of growth hormones or cortisol levels-treat with
increase insulin for the overnight period or adjust insulin
administration (intermediate) to be given at 10 pm
Patient Diabetic Teaching
Medication
Storage
Dose preparation
Syringes
Blood glucose monitoring
Patient Diabetic Teaching
Medication
 Recognize characteristics, purpose, and
action, dosage, duration, and adverse effects of
medication
Inform the generic and brand names of insulin
Evaluate client’s ability to self administer
medications
Instruct what to do if medication is missed
Instruct client how to mix medications
Patient Diabetic Teaching
 Storage-Store new vials of insulin in the refrigerator.
 The vials you will use within 30 days can be stored at
normal room temperature.
 In case you don't finish a vial within 30 days, keep it in
the refrigerator.
 30 minutes before having a shot, remove the vial from
the refrigerator so the shot will hurt less.
 Put it back in the refrigerator until you use it next time.
 Never store your insulin in the glove compartment of
your car; extremes temperatures can spoil your insulin.
 If it is very cold try to keep your insulin in a pocket close
to your body.
 In hot weather use special bags with an ice pack; insulin
must be kept cool but not frozen.
Patient Diabetic Teaching
Dose Preparation
Inspect the bottle before each use for
changes that may signify loss in potency
(clumping, precipitation, frosting, or
change in color & clarity)
Rapid & short acting should be clear; all
others cloudy
Mixing Different types of Insulin
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Wash hands
Gently rotate NPH insulin bottle
Wife off top of vial with alcohol swabs
Draw back amount of air into the syringe that equals total
dose
Inject air equal to NPH dose into NPH vial
Inject air equal to regular dose into regular vial
Invert regular insulin vial and withdraw regular insulin
dose
Carefully withdraw NPH dose
Patient Diabetic Teaching
 Syringes-marked in
insulin units
 Differs in unit increments
 Insulin syringes comes in
1 ml, 0.5ml, and 0.3 ml
 reuse of syringes for same
client does not increase
rate of infection at site
Patient Diabetic Teaching
Injection
Rotating sites-abdomen, arms, thigh, buttocks
90 or 45 degree angle subcutaneously
90 degree angle if able to grasp a fold of skin
45 degree if individual is thin to avoid IM injections
Aspiration for blood is not necessary
Sites of Administration
Blood Glucose monitoring
Cornerstone in diabetes management
Detects hyper and hypoglycemic episodes
Enables patient to make decisions
regarding diet, exercise and medications
Frequency of testing depends
Pt. glycemic goals
Type of diabetes
Pt ability to perform test
Willingness to test
Patient Teaching Guide
Wash hands in warm water
Let hands hang in dependent position or
warm hands in warm water if unable to
obtain adequate blood sample
Use side of finger rather than the center
Deep punctures unnecessary and causes
pain & bruising