Endocrine Lecture 2

1. Endocrine Lecture 2 Part 3

2. Mixing Insulin – How it #1 Assemble equipment • Insulin • Syringe • Alcohol swab • MD order

3. Mixing insulin – How it #2 Check MD order for dose and types

4. Mixing insulin – How it #3 Roll the bottle of intermediate acting insulin (DO NOT SHAKE)

5. Mixing insulin – How it #4 Wipe the top of both vials with alcohol swab

6. 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

7. 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

8. Mixing insulin – How it #7 Draw up the correct amount of clear/regular insulin.

9. Mixing insulin – How it #8 Double check with another nurse if this is the institutions policy.

10. Mixing insulin – How it #9 Remove the syringe and insert into the cloudy vial. Carefully draw up the correct amount of insulin.

11. Mixing insulin – How it #10 Double check with another nurse before removing the syringe from the vial

12. What do you do if you draw up too much intermediate acting insulin with mixing? • Push it back into the vial and re-draw up the correct amount. • Waste the med and start over with the same syringe. • Waste the med and start over with a clean syringe. • Who cares, a little extra never hurt anyone! Just give it to the patient.

13. What do you do if you draw up too much Regular/clear insulin when mixing? • Push it back into the vial and re-draw up the correct amount. • Waste the med and start over with the same syringe. • Waste the med and start over with a clean syringe. • Who cares, a little extra never hurt anyone! Just give it to the patient.

14. How would you do it? Give 8u Humulin R and 12u NPH sub-q, qAM.

15. 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

16. 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

17. Questions for 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 • If FSBS 189 how much insulin would you give? • If FSBS 309, how much insulin would you give? • If FSBS 120, how much insulin would you give? • If FSBS 60, how much insulin would you give?

18. 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

19. Insulin regiments • Vary • Usually combo • Goal is to mimic normal pancreas • Patient adjust

20. Syringe Types • Insulin syringe • 27-29 gauge • Various units • Must match insulin concentrations

21. Route (Self Administration) • Subcutaneous tissue • If you can “pinch an inch” • 90 degree angle • If you can’t “pinch an inch” • 45 degree angle

22. Area’s of injection • Abdomen • Arm • Thigh • Hips

23. Factors affecting absorption rates • Quickest • Abdomen • Exercise • Increases absorption rate

24. Lipodystrophy • Atrophy of subcutaneous fat • Do not use these sites! • Causes • Non-human insulin • Alcohol • Rotate site

25. Self-Injection Techniques • No need to aspirate • Through clothing  OK • Skin prep with alcohol not recommended • Reuse needles • Disposal

26. Flocculation • Check for flocculation • Frosted, whitish coating inside the bottle) • Caused by extreme heat • Do not use

27. Insulin Storage • Vial NOT being used refrigerate • Vial in use  room temperature • Storage life un-refrigerated = 1 month • Remember: date all vials when opened

28. Pre-mixed insulin • NPH + Regular • Novolin 70/30 • 70% NPH • 30% regular

29. 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

30. Insulin Pens - Disadvantages • $$$$ • Some insulin wasted • Not all insulin's available • Can’t mix • Only for self-injection

31. Nurses pre-filled syringes • Up to 3 weeks supply • Kept in frig • Store with needles in upright position • Mix thoroughly before injecting

32. What would you do? Which of the following is frequently best to teach / do first when doing initial diabetic training? • How & where to purchase insulin • Preparation & storage of insulin • Mixing insulin with return demonstration • Self-injection of insulin • Learning O-P-D of insulin types

33. Insulin Pumps • Portable infusion pump • Subcutaneous needle • Continuous/basal rate • Additional bolus if needed • Change site q24-48 hours

34. Insulin Pumps • S/E - risks • Hypoglycemia • FSBG at 3AM /wk • Infection • Hyperglycemia • Occlusion • Battery

35. Teacher mistakes insulin pump for cell phoneAP: 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.

36. 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.”

37. Inhaled insulin • “Exubera” • Type 2 DM • Pre-meal dose • Not basal insulin

38. Insulin Therapy Complications • Hypoglycemia • Insulin Shock • Causes • Too much insulin • Too little food • Extreme exercise

39. S&S of Hypoglycemia • Neuro • Dizzy / faint • Nervous • Irritability • Blurred vision • Numb tongue or lips • C/O Headache • Stupor

40. S&S of Hypoglycemia • Cardiovascular • Full bounding pulse • Respiratory • Shallow breathing • Gastro-intestinal • Polyphagia

41. S&S of Hypoglycemia • Genital-urinary • No polydipsia • Skeletal/muscular • Weak • Trembling / tremor • Integumentary • Perspiring • Moist • Pale

42. Hyper or Hypoglycemia??? • How come they are not all opposite S&S? • Why are some so similar? • Which symptoms are different?

43. Insulin Therapy Complications • Local allergic reaction • Redness, swelling, tenderness, induration • First start taking insulin • No alcohol prep

44. Insulin Therapy Complications • Insulin Resistance • Decreases sensitivity to insulin • d/t obesity • Lypodystrophy • Do not use site

45. Small group Questions • When is a sliding scale commonly used? • A tuberculin syringe is also calibrated in units. Is it OK to use a TB syringe to draw up insulin? • What route is insulin administered? • Compare the signs and symptoms of hyper and hypoglycemia

46. 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

47. 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?

48. Insulin Therapy ComplicationInsulin waning • Progressive rise in blood glucose from bedtime to morning

49. Insulin Therapy ComplicationInsulin waning • Progressive rise in blood glucose from bedtime to morning

50. Insulin Therapy ComplicationInsulin waning - Treatment • Increase evening dose of intermediate insulin • Or institute a dose of insulin before evening meal