1&2.

Teach patients and families the safe use of insulin injection equipment including
alternative methods of insulin administration and glucose monitoring.
Identify the onset, peak, duration, usual administration time, mixing compatibility,
nursing implications, and patient teaching of various insulin.
(IGGY Pages 1430-1439, ATI Med Surg Chapt 83 and ATI Endocrine Pharmacology
module)
Inject at 90 degree angle (45 degree if thin) Aspiration for blood is not necessary.
Many factors affect insulin absorption and availability, including injection site; timing,
type or dose of insulin used and physical activity. Injection site area affects the speed of
insulin absorption. Absorption is fastest in the abdomen, followed by the deltoid, thigh,
and buttocks. The abdomen except for a 2 inch radius around the navel is the preferred
injection site area because it provides the most rapid insulin absorption.
Alternative methods of Insulin Administration
Continuous subcutaneous infusion of a basal dose of insulin (CSII) with increases in
insulin at mealtimes is more effective in controlling blood glucose levels than a multiple
injection schedule. Problems with CSII include skin infections that can occur when the
infusion site is not cleaned or the needle is not changed every 2 or 3 days. Removing the
pump for any length of time can result in hyperglycemia. Complications of the insulin
pump are accidental cessation of insulin administration, obstruction of the tubing/ needle,
pump failure, and infection.
Injection devices now include a needless system and a pen-type injector in addition to
traditional insulin syringes. With a needleless device, the needle is replaced by an
ultrathin liquid stream of insulin forced through the skin under high pressure. Insulin
given by jet injection is absorbed at a faster rate and has a shorter duration of action.
Syringes are the most commonly used method of administration. Insulin syringe needles
are measured in 28, 29, and 30, and 31 gauge in lengths from inch to 5/16 inches. Short
needles are not used obese patients because of poor insulin absorption. Only use
disposable needles once. Teach the patient to discard the syringe after one use.
The pen-type injectors hold small, lightweight, prefilled insulin cartridges. The injectors
are easy to carry and make intensive therapy with multiple injections easier. The devices
allow greater accuracy than traditional insulin syringes, especially when measuring small
doses. Pen-type injectors are not designed for independent use by visually impaired
patients or by those with cognitive impairment.
Unopeneded vials of a single type of insulin may be stored in the fridge until their
expiration date. Vials of premixed insulins may be stored up to 3 months. Insulins

premixed in syringes may be kept for 1 to 2 weeks under refrigeration. Keep the syringes
in a vertical position, with the needles pointing up. Prior to administration, the insulin
should be suspended by gently moving the syringe. Store the vial that is in use at room
temperature, avoiding proximity to sunlight and intense heat. Discard after 1 month.
Self Monitoring of Blood Glucose
Assessment of blood glucose levels is very important for these situations;
Symptoms of hypoglycemia/hyperglycemia
Hypoglycemic unawareness
Periods of illness
Before and after exercise
Gastroparesis
Adjustment of diabetes medications
Evaluation of other drug therapies (e.g. steroids)
Preconception planning
Pregnancy
Technique
The finger is pricked, a drop of blood flows over or is drawn into a testing strip or disc
impregnated with chemicals, and the glucose value is displayed in mg/dL or mmol/L.
Most meters display blood glucose results on a screen. For vision-impaired patients
talking meters are available to allow independence in blood glucose monitoring.
Common errors in Self monitoring blood glucose include failure to obtain a sufficient
blood drop, poor storage of test strips, using expired strips, not changing the code number
on the meter to match the strip code on the bottle.
Provide training, explain, demonstrate procedures, assess visual acuity, and check the
patients ability to perform the procedure through a return demonstration. Teach the
patient to calibrate the machine. Blood glucose therapy target goals are set individually
for each patient. Teach the patient to take infection control measures. Not reusing lancets,
not sharing blood glucose monitoring equipment, hand washing. Remind health care staff
who perform blood glucose testing and family members who help with testing to wear
gloves. Alternative site testing allows patients to obtain blood from other sites other than
the fingertip and is available on many meters. However use caution when interpreting
results obtained from alternate sites. Teach patients that there is a lag time for blood
glucose levels between the fingertip and other sites when blood glucose levels are
changing rapidly and that the fingertip reading is the only safe choice at those times.
Advise the client to keep a record of the SMBG that includes time, date, serum glucose
level, insulin dose, food intake, and other events that may alter glucose metabolism, such
as activity level or illness.

Drug Information Table

Insulin lispro (Humalog), regular (Humulin R), NPH (Humulin N), insulin glargine
(Lantus)

Therapeutic Use
Diabetes mellitus (type 1, type
2, gestational)

Administration Health Care

Professional

Administration Patient

Injection considerations
Give subcutaneously (using an
insulin syringe) or IV (Humulin R).
Select an appropriate needle
length for injecting insulin into
subcutaneous tissue versus
intradermal (too short) or
intramuscular (too long).
For insulin suspensions (cloudy
insulins), gently rotate the vial
between your palms to disperse the
particles.
When mixing short-acting insulin
with longer-acting insulin, draw the
short-acting insulin into the syringe
first, then the longer-acting insulin.
Do not mix insulin glargine or insulin
detemir with any other insulin.
Do not administer short-acting
insulins if they appear cloudy or
discolored.
Instruct patients to self-administer
insulin subcutaneously in one
general area for consistent
absorption rates.
Storage of insulin
Keep vials in use at room
temperature for 1 month.
Refrigerate unopened vials of a
single type of insulin until their
expiration date.
Keep insulins premixed in

Instruct on principles of daily

insulin injections.
Draw up prescribed amount of
insulin using insulin syringe
Administer subcutaneously
have patient demonstrate
proper technique.
Rotate injection sites
systematically and space them
1 inch apart.
Do not inject cold insulin. Keep
insulin at room temperature.

syringes for 1 to 2 weeks under

refrigeration and vertical, with the
needles pointing upward. Prior
to administration, resuspend the
insulin via gentle motion.
Expect dosage adjustments in
response to caloric intake, infection,
exercise, stress, growth spurts, and
pregnancy.
Make sure adequate glucose is
available at onset and peak insulin
times.
Side/Adverse Effects

Interventions

Patient Instructions

Hypoglycemia

Monitor for signs of hypoglycemia

(with abrupt onset: tachycardia,
palpitations, diaphoresis, shakiness;
with gradual onset: headache,
tremors, weakness).
Check blood glucose level
to confirm, then give 15 g of
carbohydrate (4 oz fruit juice, 1
tbsp honey, glucose tablets per
manufacturers suggestion to equal
15 g).
For unconscious patients, administer
glucose or glucagon parenterally.

Wear a medical alert bracelet.

Watch for symptoms of
hypoglycemia. Test blood
glucose to confirm, then
consume a snack of 15 to 20 g
carbohydrates, and retest in 15
to 20 min and repeat treatment
if still low.
Carry a carbohydrate snack at
all times.
Report recurring episodes of
hypoglycemia to provider.

Lipohypertrophy

Monitor skin for subcutaneous fat

accumulation.

Rotate injection sites

systematically and space them
1 inch apart.
Do not inject cold insulin.

Hypokalemia

Monitor potassium levels.

Monitor ECG.
Monitor for indications of
hypokalemia.

Report weakness, nausea,

palpitations, or paresthesias.

Contraindications
Hypersensitivity to insulin

Precautions
Older adults
Renal or hepatic dysfunction
Fever
Thyroid disease

Interactions
Sulfonylureas, meglitinides,
beta blockers, salicylates, and
alcohol increase hypoglycemic
effects.
Thiazide and loop diuretics,
sympathomimetics, thyroid
hormones, and glucocorticoids
increase blood glucose
levels, thus counteracting
hypoglycemic effects.
Beta blockers mask

manifestations of hypoglycemia
(tachycardia, tremors).

Classification

Drug

Onset

Peak

Duration

Rapid-acting

Lispro insulin
(Humalog)

Less than 15 min

30 min to 1 hr

3 to 4 hr

Short-acting

Regular insulin
(Humulin R)

30 min to 1 hr

2 to 3 hr

5 to 7 hr

Intermediate-acting

NPH insulin
(Humulin N)

1 to 2 hr

4 to 12 hr

18 to 24 hr

Long-acting

Insulin glargine
(Lantus)

1 hr (2-4 Iggy)

None Levels are

steady

24 hr

Rapid acting insulin is administered before meals to control postprandial rise in blood glucose.
Onset is rapid.
Short-acting insulin is administered before meals to control postprandial hyperglycemia
Intermediate Acting Insulin is administered for glycemic control between meals and at night. Not
administered before meals to control postprandial rise in blood glucose.
Long Acting- Administered once daily, anytime during the day but always at the same time each
day.

3. Provide accurate patient teaching regarding principles of dietary management and

exercise therapy for diabetic patients. (Iggy pages 1438-1444)
The ADA advocates that nutrition therapy focuses on these outcomes:
Achieving and maintaining blood glucose levels in the normal range or as close to normal
as in safely possible.
The dietician develops a meal plan based on the patients usual food intake, weight
management expectations, and lipid and blood glucose patterns. Day-to-day consistency in
the timing and amount of food eaten helps control blood glucose.

Patients receiving insulin therapy need to eat at times that are coordinated with the timed
action of insulin. Teach patients using intense and quality changes in their meal plan.
Carbohydrate recommendation for the patient with diabetes is a diet containing 45% to 65 %
of calories from carbs. With a minimum intake of 130 g carbohydrate a day. Dietary fat and
cholesterol intake for people with diabetes focus on limiting saturated fatty acids, trans fatty
acids, and cholesterol to reduce the risk for cardiovascular disease. Limiting dietary
cholesterol to less than 200 mg a day. Protein intake intake needs to 15%- 20% of daily
calories and fiver with the target of 25 g each day. Teach the patient to select a variety of
fiber-containing foods such as legumes, fiber-rich cereals (more than 5g/serving)
Alcohol consumption can affect blood glucose levels. Levels are not affected by moderate
use of alcohol when diabetes is well controlled. Teach patients with diabetes that two
alcoholic beverages for men and one for women can be ingested with, and in addition to the
usual meal plan. Alcohol raises plasma triglycerides. Because of the potential for alcoholinduced hypoglycemia, instruct the patient with diabetes to ingest alcohol only with or
shortly after meals. Patients using intensive insulin or pump therapies an use CHO
(carbohydrate counting) to determine insulin coverage.
Physical exercise can cause hypoglycemia if insulin is not decreased before activity. For
planned exercise, reduction in insulin dosage is the preferred method for hypoglycemia
prevention. For unplanned exercised intake of additional carbs is usually needed.
Special considerations for type 1 diabetes include developing insulin regimens that conform
to the patients preferred meals routines, food preferences, and exercise patients
Many patients with type 2 diabetes focus on lifestyle changes. Many patients with type 2
diabetes are overweight and insulin resistant. Many patients also have abnormal blood fat
leels and hypertension making reductions of saturated fat, cholesterol, and sodium desirable.
A moderate caloric restriction (250-500 calories less than average daily intake) and an
increase in physical activity improve diabetic control and weight control. Decreases of more
than 10% of body weight can result in significant improvement in HbA1c.
Regular exercise is an essential part of diabetic management. It has beneficial effects on
carbohydrate metabolism and insulin sensitivity. Programs of increased physical acitivity and
weight loss reduce the incidence of type 2 diabetes in patients with impaired glucose
tolerance.
Appropriate exercise results in better regulation of blood glucose levels and lowing of insulin
requriments for patients with type 1 DM. Exercise also increase insulin sensitivity, wihich
enhances ell uptake of glucose and promotes weight loss.

Regular exercise decreases risk for cardio disease. It dereases most blood lipid levels and
increases high-density lipoproteins (HDLs). Regular vigorous physical activity prevents or
delays type 2 DM by reducing body weight, insulin resistance, and glucose intolerance.
Special considerations and adjustments must be made for patients with diabetic retiopathy,
decreased pain sensation in extremities, and history of cardio disease.
Advise people with DM to perform at least 150min of moderate intensive aerobic physical
activity, or 75 min a week of vigorous aerobic physical activity or an equivalent combination
of the two. Resistance exercise is encouraged 3 times a week unless contraindicated. The
ADA recommends that there by no more than 2 consecutive days without aerobic physical
activity.
Teach patients with type 1 diabetes to perform vigorous exercise only when blood glucose
levels are 100 to 250 mg/dL and no ketones are present in the urine.
Instruct patient to wear appropriate footwear, carry a simple sugar to eat during exercise if
symptoms of hypoglycemia occur, to examine his or her feet after exercise, check blood glucose
level more frequently on days that exercise occurs, and not to exercise within 1 hour of insulin
injection or near the time of peak insulin action. Teach the patient to each 15 to 30 g of carbs for
every 30 to 60 minutes of exercise if it is vigorous.
4. Describe pre and post-operative nursing interventions for a patient undergoing surgical
management for diabetes.
(Iggy 1443-1444)
Surgical interventions for diabetes include transplantation of the pancreas. Successful
transplantation improves quality of life by eliminating the need for insulin injections,
blood glucose monitoring, and many dietary restrictions. It can eliminate the acute
complications related to blood glucose control but is only partially successful in reversing
long-term diabetes complications. Pancreatic transplant is successful when the patient no
longer needs insulin therapy and all blood measures of glucose are normal.
Transplantation requires life long therapy to prevent graft rejection. Long term antirejection therapy increases the risk for infection, cancer, and atherosclerosis.
Surgery is a physical and emotional stressor and the patient with diabetes has a higher
risk for complications.
Anesthesia and surgery cause a stress response with release of counter regulatory
hormones that elevate blood glucose. Stress hormones suppress insulin action, increasing
the risk for ketoacidosis and metabolic acidosis. Complications of diabetes increase the
risk for surgical complications.
Patients undergoing major surgery should be admitted to the hospital 2 to 3 days before
surgery to optimize blood glucose control. Second generation sulfonylureas are

discontinued 1 day before surgery. Metformin is stopped 48 hours before surgery and
restarted only after kidney function is normal. All other oral drugs are stopped the day of
surgery. Patients taking long-acting insulin may need to be switched to intermediateacting insulin forms 1 to 2 days before surgery. Preoperative blood glucose levels should
be less than 200 mg/dL. Higher levels can cause neutrophil dysfunction and increased
infection rates. Plan ahead for pain control after surgery. Pain, a stressor triggers the
release of counter regulatory hormones, increasing blood glucose levels and insulin
needs. IV infusion of insulin, glucose, and potassium is stand therapy for perioperative
management of diabetes. The purpose is to keep the glucose level between 140 -180 to
reduce the risks form hyperglycemia. Patients with DM should receive about 5 g of
glucose per hour during surgery to prevent hypoglycemia, ketosis, and protein
breakdown. Monitor the patients temperature. Hypothermia decreases metabolic needs
resulting in high blood glucose levels.
Monitor patient closely after surgery. Hyperglycemia is associated with increased
mortality and morbidity after surgical procedure. Maintain blood glucose levels between
140- 180 in critically ill patients. Short term insulin therapy may be needed after surgery
for the patient uses oral agents.