INSULIN THERAPY AND GLUCOSE MONITORING

1. INSULIN THERAPY
AND
GLUCOSE MONITORING
Mr.Prasanth.K
MSc In CARDIOVASCULAR THORACIC NURSING
(NARAYANA HRUDAYALAYA BANGLORE)
SENIOR NURSING TUTOR , ACLS AND BLS INSTRUCTOR
AT SARVODAYA HOSPITALAND NURSING INSTITUTE
FARDABAD

3. UNIVERSAL SYMBOL
FOR DIABETES

4. INSULIN
Increases glucose transport into cells
and promotes conversion of glucose to
glycogen, decreasing serum glucose
levels.

5. Insulin acts in the liver, muscle, and
adipose tissue by attaching to
receptors on cellular membranes and
facilitating the passage of glucose,
potassium and magnesium.

6. INDICATION
•Clients with type 1 DM and Type 2
DM
•Clients with uncontrolled blood
glucose levels with oral hypoglycemic
agents

7. TIME ACTIVITY OF
PHARMACOCLOGICAL
INSULIN

8. PREPARATION BRAND ONSET
(Hr)
PEAK
(Hr)
DURATION
(Hr)
RAPID ACTING
INSULIN
INSULIN ASPART NovoLog 0.25 1-3 3-5
INSULIN GLULISIN Apidra .3 0.5-1.5 3-4
HUMAN LISPRO
INJECTION
Humalog 0.25 0.5-1.5 5
SHORT ACTING
INSULIN
REGULAR HUMAN
INSULIN
INJECTION
Humulin R
Novolin R
0.5
0.5
2-4
2.5-5
5-7
8
HUMULIN R
(CONCENTRATED
U- 500)
Humulin R (U-500) 1.5 4-12 24

9. PREPARATION BRAND ONSET
(Hr)
PEAK
(Hr)
DURATION
(Hr)
INTERMEDIATE-ACTING
INSULIN
ISOPHANE INSULIN NPH
INJECTION
INSULIN DETERMIR
INJECTION
Levemir 1 6-8 5.7-24
70% HUMAN INSULIN
ISOPHANE SUSPENSION/30%
HUMAN INSULIN INJECTION
Humalin 70/30
Novolin 70/30 0.5 1-12 24
50% HUMAN INSULIN
ISOPHANE SUSPENSION /50%
HUMAN INSULIN INJECTION
Humalin 50/50 0.5 3-5 24
70% INSULIN ASPART
PROTAMINE SUSPENSION / 30%
INSULIN ASPART INJECTION
Novolog Mix
70/30
0.25 1-4 24
75% INSULIN LISPRO
PROTAMINE SUSPENSION / 25%
INSULIN LISPRO INJECTION
Humalog mix
75/25
0.25 1-2 24

10. PREPARATION BRAND ONSET
(Hr)
PEAK
(Hr)
DURATION
(Hr)
LONG -ACTING INSULIN
INSULIN GLARGIN INJECTION LARTUS 2-4 NONE 24

11. INSULIN INJECTION
SITES

12. a. The main areas of injections are –
Abdomen – absorbed more rapidly and
evently
Arms (posterior surface)
Thighs (anterior surface)
Hips

13. •Systemic rotation
with in one
anatomical area –
prevents
lipidodyastrophy
•Injections should be
1½ inches apart with in
the anatomical area.

16. CLIENT INSTRUCTION
Not to use one site more than once in
2-3 weeks period
Heat application
Massage
Exercise
Increase absorption rate
May result in
hypoglycemia

17. Injection into scar tissue may delay
absorption of insulin

18. STORING OF INSULIN

19. •No to extreme temperature , no to
freezing , no direct sunlight
•Keep in room temperature before
administering
•Use vial with in 1 month if it is kept at
room temperature
•Otherwise keep it refrigerated

20. ADMINISTRATION
OF
INSULIN

21. Insulin delivering devices
1. Subcutaneous injections- insulin
pens
2. Insulin pumps
3. Jet injectors
4. Implantable and inhalant insulin
delivery ( clinical trials are going
on)

22. Subcutaneous injections
Watch the video

23. 1. Prevention of dosage errors
2. Insulin syringe
3. Procedure of administration
4. Insulin I/V infusion

24. NOTE ……
“Insulin glargine” cannot be mixed with
any other types of insulin

25. Prevent dosage Errors
Be certain that there is a match
between
•Insulin concentration noted on the vial
And
•Calibration of units on the insulin syringe
•Usual concentration – U 100 (100Units/ml)

26. Insulin syringe
•Usual range of needles- 27-29 gauge
•½ inches long

27. Before use -
Swirl vial gently or rotate – between
palms
Don’t shake it vigorously – may cause
bubbles

28. Procedure
1. Inject air into the insulin bottle – vacuum makes it difficult
to draw up the insulin
2. Insulin Mixing
• When mixing insulin draw up the regular insulin (shorter
acting ) first
• Regular insulin may be mixed with NPH or Lente insulin
• Lispro insulin may be mixed with Humulin N or Humulin –
U
• Insulin aspart protamine may be mixed with NPH insulin
only.
• Insulin zinc suspensions may be mixed only with each
other and regular insulin, not with other types of insulin.

29. •Administer to a mixed dose of insulin within 5 -15 minutes of
preparation ; after this time, the regular insulin binds with the
NPH insulin and its action is reduced.
•Aspiration generally is not recommended with self injection
of insulin
•Administer insulin with 45 to 90 degree angle in clients with
normal subcutaneous mass
• 45-60 degree angle in thin persons or those with a
decreased amount of subcutaneous mass.

30. Steps
•Wash hands
•Gently rotate NPH insulin bottle
•Wipe off tops of insulin vials with
alcohol sponge
•Draw back amount of air into the
syringe that equals total dose
•Inject air equal to NPH dose into
NPH vial
•Remove syringe from the vial

31. Inject air equal to regular dose into a
regular vial
Invert regular insulin vial and withdraw
the dose

32. Note ….
Regular insulin is the only type of
insulin that can be administered
intravenously

33. I/V infusion of insulin
•Use regular insulin
•Usually 5-10 units
prescribed before
continuous infusion starts
•Mix in 0.9% to 0.45% NS
•Flush the insulin solution
through the infusion set
•Discard first 50 – 100 ml
•Place with an IV infusion
controller

34. Monitor –
•Vitals, potassium, glucose, urinary out
put, signs of fluid overload, signs of
increased ICP
•If potassium falls, IV administration of
potassium

35. Insulin pump
•Needle or teflon catheter is changed
at every 2-3 days
•Client delivers bolus of insulin before
each meal
• rapid and regular acting insulin are
used

38. SPECIAL INSULIN
CONSIDERATIONS

39. TPN and insulin

40. Insulin may be added to control the
blood glucose level because of the
high concentration of glucose in
Parenteral nutrition

41. Use of insulin in children

42. •Diluted insulin for infants
•Glycosylated hemoglobin – every
3months
•With held in illness, stress, infection
•If not receiving any thing by mouth
verify with the physician
•Instruct for the –I/M inj glucagon – if
hypoglycemic reaction occurs

43. Insulin and surgery

44. •Insulin after a surgery in a diabetic
client may be reduced-
Because clients nutritional intake is
increased
• Need increased when – stress
response and I/V administrations of
glucose solutions

45. Glucose monitoring

46. MEASUREMENT SETTING NORMAL VALUE
Glucose fasting 70-110 mg/dl
Glucose monitoring (capillary
blood)
60-110mg/dl
Glucose tolerance test , oral
Baseline fasting
30-min fasting
60-min fasting
90-min fasting
120-min fasting
70-110mg/dl
110-170 mg/dl
120-170 mg/dl
100-140 mg/dl
7—120 mg/dl
Glucose, 2 hr postprandial <140mg/dl

47. Fasting blood glucose
Glucose levels measured after food
has been with held for at least 8 hours
Norm- <100mg?dl
Significant- 100-125mg/dl
Diabetes – 125mg/dl or more

48. •Instruct the client to fast for 8-12
hours before the test
•Instruct a client with DM to with hold
morning insulin or oral hypoglycemic
medication until after the blood is
drawn.

49. Glucose tolerance test
If glucose levels peak at higher than
normal at 1 -2 hours after injection or
ingestion of glucose and are slower
than normal to return to fasting levels,
then DM is confirmed.

50. Nursing considerations
•Instruct client to eat a high CHO (200-300g)
diet for 3 days before the test
•Instruct the client to avoid alcohol, coffee and
smoking before 36 hours before the test
•Keep a fast for 10 to 16 hours
•With hold insulin and hypoglycemic agents
•Avoid strenuous exercise for 8hrs before and
after the test.

51. Instruct the client that the test may
take 3 to 5 hours requires I/V or oral
administration of glucose, and multiple
blood samples.

52. Self monitoring of blood
glucose
(SMBG)

53. To maintain good glycemic control
Used with caution in patients with
diabetic neuropathy

54. Instructions for self
monitoring
Use proper procedure
Wash hands before and after
Check expiration dates of the strips

55. Candidates
Unstable diabetes
Tendency for severe ketosis and
hypoglycemia
Hypoglycemia with out warning
symptoms

56. Frequency of SMBG
Usually
4 times daily – before meals and bed
time

57. Frequency of SMBG
For patients who take insulin before
each meal
At least three times a day

58. Frequency of SMBG
For patients who not receiving insulin
At least 3-4 times a week

59. The procedure
Watch the video

60. Glycosylated hemoglobin
Average blood glucose levels for a
period of time (2-3 months)
How longer glucose attaches to RBC’s
– and remain an above normal glucose
level
Normal values – 4%- 6%

61. COMPLICATIONS OF
INSULIN THERAPY

62. Local allergic reactions
Redness
Swelling
Tenderness
Indurations or a wheel at the site of injection- 1-2 hrs
Occurs in early stages of insulin therapy
Instruct the client cleanse the skin with alcohol
before injection

63. Insulin lipodystrophy
Lipoatrophy –
Loss of subcutaneous fat-
Prevention – use of human insulin
Lipohypertrophy – fibrous fatty masses
at the injection site
Prevention - Avoid repeated use of
same site

64. Lipoatrophy

65. Lipohypertrophy

66. Insulin resistance
Development of immune antibodies
that bind insulin
Prevention / treatment –
Administer pure preparations

67. Dawn phenomenon
Reduced tissue sensitivity to insulin
Usually develops at 5-8 am ( prebreak
fast hyper glycemia- may be because
of nocturnal release of growth
hormone)
Treatment
Evening dose of intermediate acting
insulin

68. Somogyi effect
Normal / elevated blood glucose levels at
bed time
A decrease at 2-3 AM
And a subsequent increase
( action of counter regulatory hormones)
Treatment –
Predinner or bed time dose of
intermediate acting insulin or increase
bed time snack

69. Questions

70. 1
Function of insulin pump
1. Programmed doses delivered
2. Continuous infusion with self monitoring
3. Surgical attachment to pancreas
4. Small dose of regular insulin subcutaneously
with self administration of additional dose before
each meal

71. Ans
Small dose of regular insulin
subcutaneously with self
administration of additional dose
before each meal

72. 2
A client with DM1 – diarrhea, vomiting
Nothing had by mouth for 24hrs, which
statement shows need of additional
teaching?
1. I need to stop insulin
2. I need to increase fluid intake
3. Monitor glucose every4 hrly
4. Call physician

73. Ans
I need to stop insulin
Do not stop insulin
Have plenty of water, notify physician
look for ketonurea