INSULIN ADMINISTRATION

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2. 2 Overall Goal: Student Health and Learning The training component is one of eight components created specifically for school nurses and non-medical school personnel who perform diabetes care tasks at school. These components include: Diabetes Basics Hypoglycemia and Hyperglycemia Blood Glucose Monitoring Insulin Administration Glucagon Administration Ketone Testing Nutrition and Exercise Legal Considerations This unit is Insulin Administration. The training component is one of eight components created specifically for school nurses and non-medical school personnel who perform diabetes care tasks at school. These components include: Diabetes Basics Hypoglycemia and Hyperglycemia Blood Glucose Monitoring Insulin Administration Glucagon Administration Ketone Testing Nutrition and Exercise Legal Considerations This unit is Insulin Administration.

3. 3  Participants will learn: Types of insulin Insulin delivery basics Vial and syringe administration Pen device administration Pump basics Our learning objectives include the following: Types of Insulin Insulin delivery basics Vial & syringe administration Pen device administration Pump basics Our learning objectives include the following: Types of Insulin Insulin delivery basics Vial & syringe administration Pen device administration Pump basics

4. 4 Insulin in Schools Today Many students need to take insulin in school Insulin regimens vary Need for assistance will vary. GOAL: Maintenance of blood glucose target range Not very many years ago, few students with diabetes took insulin injections at school. But now many physicians prescribe intensive insulin therapy for children that requires multiple daily injections to enable students to maintain blood glucose levels in target range. This is because studies have shown that this intensive treatment prevents or delays long-term complications of diabetes. Today many students will take insulin at lunch. Or when blood glucose levels are above target range. Regardless of when they need to take insulin, many students will need accommodations. Most older or more experienced students are capable of self-administration although some may want a private place to inject. Others will need full assistance in drawing out, dosing, and injecting. The student’s Diabetes Medical Management Plan (DMMP) will state what accommodations are needed. Not very many years ago, few students with diabetes took insulin injections at school. But now many physicians prescribe intensive insulin therapy for children that requires multiple daily injections to enable students to maintain blood glucose levels in target range. This is because studies have shown that this intensive treatment prevents or delays long-term complications of diabetes. Today many students will take insulin at lunch. Or when blood glucose levels are above target range. Regardless of when they need to take insulin, many students will need accommodations. Most older or more experienced students are capable of self-administration although some may want a private place to inject. Others will need full assistance in drawing out, dosing, and injecting. The student’s Diabetes Medical Management Plan (DMMP) will state what accommodations are needed.

5. 5 Insulin Types Rapid-acting – Humalog ®, Novolog ® Short-acting - Regular Intermediate - Lente, NPH Long-acting - Ultralente, Glargine (Lantus) Storage: Refrigeration or store at room temperature as specified by DMMP. Rapid-acting insulins act quickly within 10-15 minutes and are used primarily to treat a high blood sugar level and to “match” or “cover” a rise in blood glucose levels following food intake. Many students require rapid acting insulin before meals and snacks. Note, hypoglycemia can occur if meal or snack is delayed for than 15 minutes after injection of rapid-acting insulin. Rapid-acting insulin is frequently referred to as bolus insulin. Short-acting insulins are used like rapid-acting insulins, but have a longer duration of action and a delayed peak. Short-acting insulin is also referred to as bolus insulin. Intermediate- and long-acting insulins provide basal insulin concentrations and doses are adjusted based on the student’s pattern of blood glucose. They are not used for acute treatment of high blood glucose levels and are not generally given before meals eaten at school. Intermediate and long-a acting insulins are referred to as basal insulin. Basal insulin controls the blood glucose in the fasting state, when you’re not eating. Typically 50% of daily insulin dose.Rapid-acting insulins act quickly within 10-15 minutes and are used primarily to treat a high blood sugar level and to “match” or “cover” a rise in blood glucose levels following food intake. Many students require rapid acting insulin before meals and snacks. Note, hypoglycemia can occur if meal or snack is delayed for than 15 minutes after injection of rapid-acting insulin. Rapid-acting insulin is frequently referred to as bolus insulin. Short-acting insulins are used like rapid-acting insulins, but have a longer duration of action and a delayed peak. Short-acting insulin is also referred to as bolus insulin. Intermediate- and long-acting insulins provide basal insulin concentrations and doses are adjusted based on the student’s pattern of blood glucose. They are not used for acute treatment of high blood glucose levels and are not generally given before meals eaten at school. Intermediate and long-a acting insulins are referred to as basal insulin. Basal insulin controls the blood glucose in the fasting state, when you’re not eating. Typically 50% of daily insulin dose.

6. 6 Delivery Methods Insulin Syringe Insulin Pen Insulin Pump Jet Injector No longer do all students take their insulin by using a vial and syringe. Many do. But an increasing number of students are using other methods, especially pens and pumps. Insulin pens offer the convenience of carrying insulin in a discreet way. An insulin pen looks like a pen with a cartridge. Some pens use replaceable cartridges of insulin; other pen models are totally disposable. A fine needle, similar to the needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin. The insulin pump is about the size of a pager, weighs about 3 ounces, and can be worn on a belt or in a pocket. The pump connects to narrow, flexible plastic tubing that ends with a needle inserted just under the skin in the abdomen, buttocks, or thigh. Users set the pump to give a steady trickle or "basal" amount of insulin continuously throughout the day. Pumps release "bolus" doses of insulin (several units at a time) at meals and at times when blood sugar is too high based on the user’s programming. Insulin jet injectors send a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles. This training contains a review of the basics of insulin delivery for students who use syringes, pens, or pumps. Since each pump or pen is somewhat different than the others, further training will be needed on specific technology that is used by students in your school. Training videos are generally available from the manufacturers. Additionally, most of the companies now post their product manuals online as PDF files, so that you can print a copy of a pump or pen device manual to keep in the health office for training and troubleshooting.No longer do all students take their insulin by using a vial and syringe. Many do. But an increasing number of students are using other methods, especially pens and pumps. Insulin pens offer the convenience of carrying insulin in a discreet way. An insulin pen looks like a pen with a cartridge. Some pens use replaceable cartridges of insulin; other pen models are totally disposable. A fine needle, similar to the needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin. The insulin pump is about the size of a pager, weighs about 3 ounces, and can be worn on a belt or in a pocket. The pump connects to narrow, flexible plastic tubing that ends with a needle inserted just under the skin in the abdomen, buttocks, or thigh. Users set the pump to give a steady trickle or "basal" amount of insulin continuously throughout the day. Pumps release "bolus" doses of insulin (several units at a time) at meals and at times when blood sugar is too high based on the user’s programming. Insulin jet injectors send a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles. This training contains a review of the basics of insulin delivery for students who use syringes, pens, or pumps. Since each pump or pen is somewhat different than the others, further training will be needed on specific technology that is used by students in your school. Training videos are generally available from the manufacturers. Additionally, most of the companies now post their product manuals online as PDF files, so that you can print a copy of a pump or pen device manual to keep in the health office for training and troubleshooting.

7. 7 When to Give Insulin Administer as specified by DMMP: Generally: Before meals For blood glucose levels significantly above target range For increased ketones Insulin must be administered as specified in the student’s DMMP. The DMMP specifies the orders of the student’s health care provider. Generally insulin will be given: Before meals or some snacks, depending on DMMP recommendations For blood glucose levels significantly above target range For increased ketones Insulin must be administered as specified in the student’s DMMP. The DMMP specifies the orders of the student’s health care provider. Generally insulin will be given: Before meals or some snacks, depending on DMMP recommendations For blood glucose levels significantly above target range For increased ketones

8. 8 Dosing Many students do not take the same amount of insulin every day. Insulin dose will vary, depending upon: blood glucose readings food availability/preference activity level age and body weight See student’s DMMP for specific instructions. Many students do not take the same amount of insulin every day. Insulin dose will vary, depending upon: blood glucose readings food availability/preference activity level age and body weight See student’s DMMP for specific instructions.

9. 9 Dosage Specifications The DMMP should specify a insulin to carbohydrate ratio specific dose to cover meals and or snacks and a specific correction dose to treat hyperglycemia that is predetermined by student’s health care provider and parent/guardian. Definitions: Insulin to Carbohydrate Ratios – specifies how much carbohydrate one unit of insulin (rapid or short-acting insulin) will cover or match. For example if your insulin to carbohydrate ratio is 1:10 you will then need 1 unit of rapid or short-acting insulin to cover every 10 grams of carbohydrate. The ratio will vary from student to student. The more insulin sensitive a child or teen is the larger the ratio. Overweight children and teens will need more insulin to cover or match their carbohydrates. Correction Dosage – The amount of insulin to correct a blood glucose level above the student’s target range. Once again, this will vary from student to student. The DMMP should specify a insulin to carbohydrate ratio specific dose to cover meals and or snacks and a specific correction dose to treat hyperglycemia that is predetermined by student’s health care provider and parent/guardian. Definitions: Insulin to Carbohydrate Ratios – specifies how much carbohydrate one unit of insulin (rapid or short-acting insulin) will cover or match. For example if your insulin to carbohydrate ratio is 1:10 you will then need 1 unit of rapid or short-acting insulin to cover every 10 grams of carbohydrate. The ratio will vary from student to student. The more insulin sensitive a child or teen is the larger the ratio. Overweight children and teens will need more insulin to cover or match their carbohydrates. Correction Dosage – The amount of insulin to correct a blood glucose level above the student’s target range. Once again, this will vary from student to student.

10. 10 Insulin Syringes Sizes – 30, 50, 100 units Disposal- Insulin syringes Different size syringes are available: 1/3 cc (30 units), ½ cc (50 units), and 1 cc (100 units). Each horizontal marking indicates 1 unit on 30 and 50 unit syringes and 2 units on 100 unit syringes. Needles and syringes should be disposed of in a manner consistent with Universal Precautions and local waste disposal laws. Insulin syringes Different size syringes are available: 1/3 cc (30 units), ½ cc (50 units), and 1 cc (100 units). Each horizontal marking indicates 1 unit on 30 and 50 unit syringes and 2 units on 100 unit syringes. Needles and syringes should be disposed of in a manner consistent with Universal Precautions and local waste disposal laws.

11. 11 Syringe & Vial: Preparation 1. Get Supplies Insulin (Verify) Syringe Alcohol wipe Disposable gloves Sharps container Method: Syringe and vial 1. Get supplies: insulin, syringe and needle, alcohol wipe, sharps container Method: Syringe and vial 1. Get supplies: insulin, syringe and needle, alcohol wipe, sharps container

12. 12 Syringe & Vial: Preparation 2. Wash hands; apply gloves 3. Clean the insulin vial Method: Syringe and vial 2. Wash hands 3. Clean the rubber top of the insulin vial with an alcohol swab.Method: Syringe and vial 2. Wash hands 3. Clean the rubber top of the insulin vial with an alcohol swab.

13. 13 Syringe & Vial: Preparation 4. Have student select injection site. 5. Clean the injection site Method: Syringe and vial 4. Have student select injection site per DMMP. Common sites are upper arm, thigh, stomach, and buttocks. 5. Clean the injection site and wait to dry.Method: Syringe and vial 4. Have student select injection site per DMMP. Common sites are upper arm, thigh, stomach, and buttocks. 5. Clean the injection site and wait to dry.

14. 14 Syringe & Vial: Preparation 6. Check the insulin dose 7. Remove the cap from syringe. Method: Syringe and vial 6. Check the insulin dose Verify each of the following: student, insulin, where/how delivered, specific dose for conditions Method: Syringe and vial 6. Check the insulin dose Verify each of the following: student, insulin, where/how delivered, specific dose for conditions

15. 15 Syringe & Vial: Dosing 8. Pull the plunger down to number of units to be administered. 9. Inject air into bottle. Method: Syringe and vial 8. Pull the plunger down to the number of units to be administered. 9. Push the needle into the bottle and push the plunger in with the syringe type down. This will inject air into the bottle to prevent the development of a vacuum.Method: Syringe and vial 8. Pull the plunger down to the number of units to be administered. 9. Push the needle into the bottle and push the plunger in with the syringe type down. This will inject air into the bottle to prevent the development of a vacuum.

16. 16 10. Draw out prescribed number of units of insulin as per DMMP. Syringe & Vial: Dosing Method: Syringe and vial 10. With the needle still the in bottle, turn the bottle and syringe upside down and pull the plunger down to prescribed number of units of insulin as per DMMP. Check dose against DMMP specifications. Method: Syringe and vial 10. With the needle still the in bottle, turn the bottle and syringe upside down and pull the plunger down to prescribed number of units of insulin as per DMMP. Check dose against DMMP specifications.

17. 17 Syringe & Vial: Injecting 11. Pinch up the skin. 12. Push needle into skin at 90?. 13. Release pinch. 14. Push the plunger in. 15. Count to “5”. 16. Remove needle and dispose of syringe. Method: Syringe and vial 11. Pinch up the skin 12. Push the needle into the skin at 90?. Do not insert the needle at an angle. 13. Release pinch. 14. Push the plunger in. 15. Count to “5”. 16. Remove needle and dispose of syringe.Method: Syringe and vial 11. Pinch up the skin 12. Push the needle into the skin at 90?. Do not insert the needle at an angle. 13. Release pinch. 14. Push the plunger in. 15. Count to “5”. 16. Remove needle and dispose of syringe.

18. 18 Insulin Pen: Devices Prefilled pens Reusable (cartridge) pens Techniques for dose preparation and insulin delivery are similar for both types of pen devices. Pre-filled pens Pre-filled pens contain a built-in, insulin cartridge. Because this device requires no loading by the student/family, it is especially convenient and easy to use. Reusable pens With the reusable pen, an insulin cartridge is inserted into the pen's delivery chamber. Regardless of whether a patient chooses the pre-filled or the reusable pen design, the techniques for dose preparation and insulin delivery are generally similar. Also, check the package insert for the specific guidelines for product expiration, as pens vary from vials. Once a disposable needle is screwed on to the pen and the pen is primed, the patient simply dials to the appropriate dose, which can be seen in the device's display window and can be heard as audible clicks in many pen devices. The needle is inserted subcutaneously, and the plunger injection button is depressed to deliver the dose. The pen needle should remain in the subcutaneous tissue for 5 seconds after complete depression of the plunger. Pre-filled pens Pre-filled pens contain a built-in, insulin cartridge. Because this device requires no loading by the student/family, it is especially convenient and easy to use. Reusable pens With the reusable pen, an insulin cartridge is inserted into the pen's delivery chamber. Regardless of whether a patient chooses the pre-filled or the reusable pen design, the techniques for dose preparation and insulin delivery are generally similar. Also, check the package insert for the specific guidelines for product expiration, as pens vary from vials. Once a disposable needle is screwed on to the pen and the pen is primed, the patient simply dials to the appropriate dose, which can be seen in the device's display window and can be heard as audible clicks in many pen devices. The needle is inserted subcutaneously, and the plunger injection button is depressed to deliver the dose. The pen needle should remain in the subcutaneous tissue for 5 seconds after complete depression of the plunger.

19. 19 Insulin Pen: Preparation 1. Gather supplies. Verify insulin type. pen device (with cartridge) pen needle alcohol wipe sharps container 2. Wash hands. 3. Chose injection site 4. Clean injection site 5. Screw on pen needle Here are the steps for Administering insulin with an insulin pen device: 1. Gather supplies: You will need the pen device (with insulin cartridge, if requires a), pen needle, alcohol wipe, sharps container 2. Wash hands. 3. Chose injection site. 4. Clean the area where you plan to give the injection. 5. Screw the pen needle onto the pen device.Here are the steps for Administering insulin with an insulin pen device: 1. Gather supplies: You will need the pen device (with insulin cartridge, if requires a), pen needle, alcohol wipe, sharps container 2. Wash hands. 3. Chose injection site. 4. Clean the area where you plan to give the injection. 5. Screw the pen needle onto the pen device.

20. 20 Insulin Pen: Dosing 6. Prime: Dial “2” units. 7. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows. 8. Dial number of units to be administered as per DMMP. 6. Dial “2” units. 7. Holding the pen upright, needle end up, press the plunger at the base or bottom of the pen to remove air until a few drops of insulin come out of the needle. 8. Dial number of units to be administered as per DMMP. Note: A brand new pen will need to be “primed” with 4-6 units until a few drops of insulin come out of the needle.6. Dial “2” units. 7. Holding the pen upright, needle end up, press the plunger at the base or bottom of the pen to remove air until a few drops of insulin come out of the needle. 8. Dial number of units to be administered as per DMMP. Note: A brand new pen will need to be “primed” with 4-6 units until a few drops of insulin come out of the needle.

21. 21 Insulin Pen: Injecting 9. Pinch up the skin. 10. Push the needle into the skin at 90? into the chosen injection site. 11. Release pinched skin. 12. Push down on the plunger at the base or bottom of the pen. 13. Count to “5”. 14. Remove and dispose of pen needle. 9. Pinch up the skin. 10. Push the needle into the skin at 90? into the chosen injection site. 11. Release pinched skin. 12. Push down on the plunger at the base or bottom of the pen. 13. Count to “5”. 14. Remove and dispose of pen needle.

22. 22 Insulin Pump Therapy Based on what body does naturally Small amounts of insulin all the time (basal insulin) Extra doses to cover each meal or snack (bolus insulin) Rapid or Short-Acting Insulin Precision, micro-drop insulin delivery Flexibility Pump therapy is based on what the human body does naturally - deliver small amounts of insulin all the time (basal insulin) - and then when at meals or snacks, a little extra insulin is delivered to cover that amount of food (bolus insulin). The Pump Uses Rapid or Short-Acting Insulin Students who are on injections use both long and short acting insulin. Generally their long-acting insulin will be taken either once or twice daily. Absorption of injected long-acting insulin can be extremely unpredictable. This is a big reason that blood sugar can vary so much from one day to the next. Pumps uses rapid or short-acting insulin which is much more predictable than long-acting insulin. The Pump Delivers Insulin in micro-drops that are continuous and accurate. With injections, the insulin is injected in larger doses. The level of activity directly affects when that insulin goes into the bloodstream. Just sitting at a desk, it will go into a student’s system more slowly. But the student goes for a walk or a run, it will go into her system much more quickly. Pumps continuously send a little bit of insulin every few minutes (like a pancreas) so you don't have this inconsistency problem. Pump therapy is based on what the human body does naturally - deliver small amounts of insulin all the time (basal insulin) - and then when at meals or snacks, a little extra insulin is delivered to cover that amount of food (bolus insulin). The Pump Uses Rapid or Short-Acting Insulin Students who are on injections use both long and short acting insulin. Generally their long-acting insulin will be taken either once or twice daily. Absorption of injected long-acting insulin can be extremely unpredictable. This is a big reason that blood sugar can vary so much from one day to the next.

23. 23 What is an Insulin Pump? Battery operated device about the size of a pager Reservoir filled with insulin Computer chip with user control of insulin delivery Worn 24 hours per day Delivers one type of insulin An insulin pump is an external, battery-powered device that continuously delivers insulin in small doses to the body. It looks very much like a pager and can be attached to a belt or waistband, carried in a pocket, or held with a strap around the arm or thigh. The pump contains a cartridge, or reservoir, of insulin. While the pump contains computer technology, it is not completely automatic. The user still has to decide how much insulin will be given. An insulin pump requires programming, close monitoring, and frequent blood glucose tests. Pump settings are determined by the student, family, and health care provider. An insulin pump is an external, battery-powered device that continuously delivers insulin in small doses to the body. It looks very much like a pager and can be attached to a belt or waistband, carried in a pocket, or held with a strap around the arm or thigh. The pump contains a cartridge, or reservoir, of insulin. While the pump contains computer technology, it is not completely automatic. The user still has to decide how much insulin will be given. An insulin pump requires programming, close monitoring, and frequent blood glucose tests. Pump settings are determined by the student, family, and health care provider.

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25. 25 Insulin Pump Manufacturers Animas Corporation 1-877-YES-PUMP (937-7867) www.animascorp.com Medtronic MiniMed, Inc.1-800-MINIMED (646-4633)www.minimed.com Call pump manufacturer for detailed training on insulin pump therapy. Animas Corporation 590 Lancaster Avenue Frazer, PA 19355 (877) 937-7867 www.animascorp.com   Disetronic Medical Systems, Inc. 5151 Program Avenue St. Paul, MN 55112-5300 1-800-280-7801 www.disetronic-usa.com   MiniMed, Inc. 12744 San Fernando Road Sylmar, CA 91342 1-800-933-3322 www.minimed.com   Deltec Cosmo 1265 Grey Fox Road St. Paul, MN 55112 1-800-826-9703 www.deltec.comCall pump manufacturer for detailed training on insulin pump therapy. Animas Corporation 590 Lancaster Avenue Frazer, PA 19355 (877) 937-7867 www.animascorp.com   Disetronic Medical Systems, Inc. 5151 Program Avenue St. Paul, MN 55112-5300 1-800-280-7801 www.disetronic-usa.com   MiniMed, Inc. 12744 San Fernando Road Sylmar, CA 91342 1-800-933-3322 www.minimed.com   Deltec Cosmo 1265 Grey Fox Road St. Paul, MN 55112 1-800-826-9703 www.deltec.com

26. 26 Pump Supplies at School Infusion set Reservoir Insulin Skin prep items Alcohol wipes Syringe (in case of malfunction) Pump batteries Inserter (if used) Manufacturers manual, alarm card The following supplies should be provided by the parents and kept in a place at school as designated in the DMMP: Infusion set Reservoir Insulin Skin prep items Alcohol wipes to clean top of insulin vial Syringe (in case of malfunction) Pump batteries Inserter (if used) Manufacturers manual, alarm card The following supplies should be provided by the parents and kept in a place at school as designated in the DMMP: Infusion set Reservoir Insulin Skin prep items Alcohol wipes to clean top of insulin vial Syringe (in case of malfunction) Pump batteries Inserter (if used) Manufacturers manual, alarm card

27. 27 Possible Pump Problems Empty insulin reservoir ( syringe ) Clogged infusion set Partially blocked infusion set Leaky infusion set Weak or dead battery Pump malfunction

28. 28 After Giving Insulin Check site for leakage Correction doses: Retest per DMMP Meal/snack doses: Timeliness Supervision of food amount per DMMP A few points to keep in mind after insulin is given, regardless of whether it is by syringe, pen, or pump. Occasionally injection sites or infusion sites will leak when insulin is administered. When correction doses are given to lower blood glucose, a retest should be done, if specified in the DMMP, to determine how well the correction dose worked. When insulin has been given prior to a meal or snack, it is important that the food is eaten soon (beginning within 15 minutes) after the insulin has been taken. If necessary, the student should be moved to the front of a long line, or given milk, juice or some other quick-acting carbohydrate. Younger students may need to be supervised at every meal/snack to be sure the amount of food eaten is appropriate for the insulin given.A few points to keep in mind after insulin is given, regardless of whether it is by syringe, pen, or pump. Occasionally injection sites or infusion sites will leak when insulin is administered. When correction doses are given to lower blood glucose, a retest should be done, if specified in the DMMP, to determine how well the correction dose worked. When insulin has been given prior to a meal or snack, it is important that the food is eaten soon (beginning within 15 minutes) after the insulin has been taken. If necessary, the student should be moved to the front of a long line, or given milk, juice or some other quick-acting carbohydrate. Younger students may need to be supervised at every meal/snack to be sure the amount of food eaten is appropriate for the insulin given.