INSULIN ADMINISTRATION

I – DEFINITION

INSULIN THERAPY- Exogenous insulin is needed when insulin production by

the islet cells is insufficient. Because insulin is destroyed in the gastrointestinal
tract, it must be supplied by injection. Insulins are categorized according to their
duration of action.

Considered in light of the normal eating and activity pattern and the response to
therapy:
1. Time of onset

2. Peak action

3. Duration

Regular insulin is a unmodified insulin. Crystalline zinc is a more highly purified

unmodified form of regular insulin. These are used interchangeably when quick
action is needed. They are selected for treatment of ketoacidosis, during an
acute illness, during surgical procedures, or to stabilize a client who is out of
control. Regular or crystalline insulin is the only type that can be given
intravenously.

Regular insulin may be used to bring blood glucose into the control by using it as
a supplement with long-acting or intermediate-acting insulins. This is termed the
“sliding scale” or “rainbow” method. Sliding scale insulin is usually taken before
meals and at bedtime. By this method the client selects a proper regular insulin
dose based on a blood glucose level at that time. The physician has previously
prescribed units of insulin to be given for various ranges in blood glucose or for
results of the glucosuria test. The client measures the blood glucose with
capillary blood and the DEXTRO System (or tests the urine with the glocosuria
test).

Intermediate-acting and long-acting insulins are administered approximately ½

hour before breakfast. The rapid-acting insulins are given 15-30 minutes before
meal. Because their action is coordinated to meals, the nurse should be alert to
the time of administration. When insulin therapy is initiated, clients will notice
some bodily changes that may be distressing. weight gain and blurred vision are
common. The increase in weight does not mean that the client is “cheating” on
the meal plan. Weight stabilizes as metabolic control is reached. Blurred vision
arises from fluctuations in the blood glucose level that cause osmotic changes
within the lens and ocular fluids. As the blood glucose smooth’s out, the ocular
equilibriums restored and vision improves. Clients should be informed that this
may happen and that it will subside in 6-8 weeks.

An allergic reaction at the injection site is not unusual when insulin is first
administered. Itching, redness, and induration develop at the injection site. This
process is self-limiting and subsides spontaneously after 1-2 weeks of therapy.
Impurities in the alcohol used in skin leansing or giving the insulin intradermally
can cause these symptoms. The former is easily relieved by switching skin
preparation to povidone iodine (betadine) solution. The client’s injection
technique should also be evaluated and reteaching instituted as appropriate.

COMPLICATIONS OF INSULIN ADMINISTRATION

Somogyl Effect This phenomenon is the body’s attempt to correct a low blood
glucose caused by administering too much insulin. It is suspected when the client
has wide swings in blood glucose over a short time interval. The hypoglycemia
may not cause any symptoms, and therefore the phenomenon may be
overlooked as the basis for the unregulated blood glucose. The underlying
mechanism is that hypoglycemia activates counter regulation with release of
epinephrine, glucocorticoids, and growth hormone. This stimulates
gluconeogenesis, and the blood glucose climbs.

Hypoglycemia Clients taking insulin can encounter symptoms of insulin

excess. An oversupply of insulin drives glucose into the cells, leaving the blood
itself with a lower than normal amount (hypoglycemia). This is commonly referred
to as an insulin reaction. Ordinarily this hypoglycemia develops rapidly. Because
glucose is the primary nutrient used by the brain, many symptoms are those
associated with cerebral deprivation of glucose.

Insulin reactions develop more slowly with the long and intermediate-acting
insulin’s so that the premonitory sins may go unheeded.

Diabetic ketoacidosis An acute and serious emergency situation is the

development of ketoacidosis in diabetic client. It usually develops slowly,
although the time of onset can vary from client to client. It is characterized by
acidosis, associated with the buildup of ketones and loss of sodium, and
hypovolemia that is secondary to renal fluid losses.

Hyperkalemia is not uncommon in ketoacidosis as a consequence of protein

catabolism, decreased renal excretion, and a shift of intracellular potassium to
the extracellular space. Correction if the ketosis and restoration of the fluid allows
potassium to shift back to the intracellular fluid.

Diabetic control during surgery When the diabetic client undergoes surgery,
special care is needed to avert serious metabolic complications. The
management scheme throughout the operative experience depends largely upon
whether insulin is a usual part of the daily therapy. For non- insulin-dependent
client the possibilities range from being permitted to take the oral antidiabetic
agent on the morning of surgery to receiving intravenous fluids. Undermost
circumstances, insulin is not given to the client controlled by diet alone. If the
therapeutic plan is a combination o diet and an oral agent, an intravenous
infusion is started. Whether the oral agent is taken or insulin is given as
replacement for it depends upon the extent of the procedure. Fluids are
administered intravenously, and insulin is given in low dose by slow continuous
infusion.

Hyperglycemic Hyperosmolar Non - Ketotic coma (HHNK) It develops instead

of ketosis if the client produces insulin that is sufficient to prevent ketone bodies
from forming, but inadequate to reduce the hyperglycemia. The glucose then
accumulates to render the blood hyperosmolar.

Management and monitoring are similar to those for the person in ketosis. The
blood volume is restored, and the osmolarity of the blood reduced. Hypotonic
intravenous fluids are used, and insulin is given sparingly.

Transplantation An approach to keeping the blood glucose at physiologic levels

has been through pancreatic transplantation. Pancreatic transplant from a
nondiabetic donor to a diabetic recipient has been used experimentally.

Insulin delivery devices Research in development of devices that stimulate

pancreatic secretion of insulin to keep the blood glucose in a physiological range
are exciting. Use of these devices in clinical practice has become reality. One
type is the continuous subcutaneous insulin infusion (CSII), which delivers insulin
from an external device via a fine nylon cannula into the subcutaneous tissue.
These devices are equipped to deliver insulin at two rates---one to match the
basal metabolic level and another at a higher rate to cover mealtime or food
intake.

Potential for Injury Several factors contribute to the diabetic’s potential for
injury. Neuropathic changes can diminish sensation, making the client less aware
of injury. Vascular changes can decreased the arterial blood supply, thereby
decreasing the body’s ability to heal.

Differents Tests:

Glycosylated Hemoglubin

Glycosylated hemoglobin is a blood test that reflects average blood glucose

levels over a period of approximately 2 to 3 months. When blood glucose levels
are elevated, glucose molecules attach to hemoglobin in the red blood cells. The
longer the amount of glucose in the blood remains above normal, the more
glucose binds to the red blood cell and higher the glycosylated hemoglobin level.
This complex is permanent and lasts for the life of the red blood cell,
approximately 120 days.

Urine testing for Glucose

The advantages of urine glucose testing are that it is less expensive than SMBG
and it is not invasive. The general procedure involves applying urine to a reagent
strip or tablet and matching colors on the strip with a color chart at the end of a
specified period.

Disadvantages of urine testing include the following:

• Results do not accurately reflect the blood glucose level at the time of the
test

• The renal threshold for glucose is 180 to 200 mg/dl (9.9 to 11.1 mmol/L),
far above target blood glucose levels.

• Hypoglycemia cannot be detected because a “negative” urine glucose

result may occur when the blood glucose level range from 0 to 180
mg/dL (9.9 mmol/L) or higher.

• Patients may have a false sense of being in good control when results are
always negative.

• Various medications may interfere with test results.

• In elderly patients and patients with kidney disease, the renal threshold is
raised; thus, false-negative readings may occur at dangerously elevated
glucose levels.

Testing for Ketones

Ketones (or ketone bodies) in the urine signal that control of type 1 diabetes is
deteriorating, and the risk of DKA is high. When there is almost no effective
insulin available, the body starts o break down stored fat for energy. Ketone
bodies are byproducts of this fat breakdown, and they accumulate in the blood
and urine.

Urine testing is most common method used for self-testing of ketone bodies by
patients. A meter that enables testing of blood for ketones is available but not
widely used.
Urine ketone testing should be performed whenever patients with type 1 diabetes
have glucosuria or persistently elevated blood glucose levels (more than 240
mg/dL or 13.2 mmol/L for two testing periods in a row) and during illness, in
pregnancy with pre-existing diabetes, and in gestational diabetes.

PHARMACOLOGIC THERAPY

Insulin is secreted by the beta cells of the islet of Langerhans and works to lower
the blood glucose level after meals by facilitating the uptake utilization of glucose
by muscle, fat, and liver cells.

Insulin Therapy and Insulin Preparations

Because the body loses the ability to produce insulin in type 1 diabetes,
exogenous insulin must be administered for life.

In type 2 diabetes, insulin may be necessary on a long-term basis to control

glucose levels if diet and oral agents fail.

In addition, some patients in whom type 2 diabetes is usually controlled by diet

alone or by diet and an oral agent may require insulin temporarily during illness,
infections, pregnancy, surgery, or some other stressful event. In many cases,
insulin injection is administered two or more times daily to control the blood
glucose level.

A number of insulin preparation are available. They vary according to three main
characteristics: time course of action, species (source), and manufacturer

II – PURPOSES:

1. to achieve optimal metabolic control

2. to reduce the risk of long – term complications
3. reduce the incidence of hypoglycemia
4. to increase flexibility of lifestyle, especially in terms of amount and
timing of meals and physical activity
5. to improve outcomes for pregnancy,
6. to be more in control and more responsible for own health
7. to improve self-esteem

III – PROCEDURE

1. Storing Insulin
Cloudy insulin’s should be thoroughly mixed by gently inverting the vial or
rolling it between the hands before drawing the solutions into a syringe or
a pen.

Whether insulin is the short- or long-acting preparation, the vials not in use
should be refrigerated and extremes of temperature should be avoided;
insulin should not be allowed to freeze and should not be kept in direct
sunlight or in a hot car. The insulin vial in use should be kept at room
temperature to reduce local irritation at the injection site, which may occur
when cold insulin is injected. If a vial of insulin will be used up in 1 month,
it may be kept at room temperature. Patients should be instructed to
always have a spare vial of the type or types of insulin they use. Spare
vials should be refrigerated.

2. Selecting syringes
Syringes must be matched with the insulin concentration. Currently, 3
sizes of U-100 insulin syringes are available:

• 1 ml (cc) syringes that hold 100 units

• 0.5 ml syringes that hold 50 units

• 0.3 ml syringes that hold 30 units

Small syringes allow patient to require small amounts of insulin to

measure and draw up the amount of insulin accurately. Patients to
required large amounts of insulin would use larger syringes.

Most insulin syringes have a disposable 27-to 29- gauge needle that is
approximately 0.5 inch long. The 1 ml syringes are marked in 2-unit
increments. A small disposable insulin needle (29- to 30- gauge, 8 mm
long) is available for very thin patients and children.

3. Preparing the injection: Mixing Insulins

When rapid- or short-acting insulin’s are to be given simultaneously with

longer-acting insulin, they are usually mixed together in the same syringe;
the longer-acting insulin must be mixed thoroughly before use. There is
some question as to whether the two insulin’s are stable if the mixture is
kept in the syringe foe more than 5 to 15 minutes. This may depend on the
ratio of the insulin’s as well as the time between mixing and injecting.

For patients who have difficulty mixing insulin’s, two options are available
they may use a premixed insulin, or they may have prefilled syringes
prepared.

4. Withdrawing Insulin
 Most (if not all) of the printed materials available on insulin dose
preparation instruct patients to inject air into the bottle of insulin equivalent
to the number of units of insulin’s to be withdrawn. The rationale for this is
to prevent the formation of a vacuum inside the bottle, which would make
it difficult to withdraw that proper amount of insulin.

5. Selecting and Rotating the Injection Site

The four main areas for injection are the abdomen, arms (posterior
surface), thighs (anterior surface), and hips. Insulin is absorbed faster in
some areas of the body than others. The speed of absorption is greatest
in the abdomen and decreases progressively in the arm, thigh, and hip.

Systemic rotation of injection sites within an anatomic area is

recommended to prevent localized changes in fatty tissue (lipodystrophy).

6. Preparing the Skin

7. Inserting the Needle

IV – NURSING CONSIDERATION

1. Provide Instruction on Blood Glucose Monitoring. All clients with

newly diagnosed diabetes mellitus require teaching about blood glucose
monitoring. More accurate blood glucose meters that are easier to use are
constantly being made available.

2. Provide Instruction on Urine Testing. Urine testing for glucose is rarely

done; however, urine can be tested for ketones. These substances appear
in the urine of clients who are fasting, clients with poorly controlled type 1
diabetes, and clients with type 1 or type 2 diabetes who have a secondary
illness. Ketones result from fat metabolism and are therefore present
during fasting. The presence of ketones may indicate the serious
complication of diabetic ketoacidosis.

3. Provide Instruction on Insulin Administration. To administer insulin

properly, the client must be familiar with insulin concentrations, syringes,
storage, preparation for injection, and techniques for self-injection.

4. Insulin Concentration. Insulin is prescribed in units.

5. Insulin Syringes. Insulin syringes are manufactured with capacities of

0.25, 0.30, 0.50, and 1ml.
6. Insulin Storage. Although storing vials of insulin in the refrigerator,
injection more painful. Avoid temperature extremes of less than 36°F or
greater than 86°F. A slight loss of potency may occur after 30 days at
room temperature.

7. Insulin preparation and Injection. Experts once thought that insulin vials
should be rolled between the hands to resuspend the insulin without
creating air bubbles.

8. Prefilled Syringes. Prefilled syringes are chemically stable for up to 3

weeks when stored in refrigerator.

9. Site Selection and Rotation. Insulin absorption varies from side to side.
To avoid possibly dramatic changes in daily insulin absorption, instruct the
client to give injections in one area, about an inch apart, until the whole
area has been used, before changing to another site.

10. Techniques for self-injection. Insulin injections are administered

into the subcutaneous tissue with the use of special insulin syringes. A
variety of syringes and injection and devices are available.