INSULIN:

I. Rapid Acting Insulin ( Clear ) = gives midmorning weakness /trembling-*Covers Insulin Needs for Meals Eaten = at the Same Time as the Injection. 1. Lispro ( Humalog) = SQ Rapid Acting O = Onset : 5 15 min. ( rapid onset = administer immediately before meals) P = Peak : 1 3 hours D = Duration : 3 - 5 hours

2. Aspart ( Novolog) = SQ Rapid Acting O = Onset : 5 15 min. ( rapid onset = administer immediately before meals) P = Peak : 1 3 hours D = Duration : 3 - 5 hours

3. Apidra ( Glulisine) = SQ Rapid Acting O = Onset : 5 15 min. ( rapid onset = administer immediately before meals) P = Peak : 1 3 hours D = Duration : 3 - 5 hours

Nursing Care = Because Quick Onset of Action = Client Must Eat Immediately.Mix only with = NPH ( Humulin-N) or Ultralente ( Humulin-U)/If Mixing = Rapid Acting: Lipsro/Aspart/Apidra : Drawn Up into Syringe 1st & Administer Immediately.

II. Short Acting Insulin ( Clear) *Covers Insulin Needs for Meals Eaten = within 30 60 minutes. Regular Insulin ( Humulin R , Novolin R) = SQ, IV Short-Acting O = Onset : 30 min. 1 hr ( administer = 30 60 min. before meals) P = Peak : 2 4 hours D = Duration : 6 8 hoursNursing Care = Only Regular Insulin can be Given IV*.Regular = Can be Mixed with All Insulin.If Mixing = Short Acting: Regular Drawn Up into Syringe 1st & Give Immediately

III. Intermediate-Acting Insulin ( Cloudy) = gives early evening fatigue.*Covers Insulin Needs for about = Half the Day or Overnight.1. NPH ( Humulin N , Novolin N) = SQ Intermediate Acting2. Lente ( Humulin L , Novolin L) = SQ Intermediate Acting O = Onset : 1 2 hours. (administer = 30 60 min. before meals) P = Peak : 6 - 12 hours D = Duration : 18 24 hoursNursing Care = Hypoglycemia Tends to Occur in Mid-to-Late Afternoon.NPH & Lente = Can be Mixed with Regular / Lispro / Aspart / Apidra.IV. Long Acting Insulin ( Cloudy) = gives early morning headache & confusion*Covers Insulin Needs for about = One Full Day. Ultralente (Humulin U ) = SQ Long Acting O = Onset : 3 6 hours. P = Peak : 12 16 hours D = Duration : 24 36 hoursNursing Care = Slow Onset : m.b. require readjustment of carbohydrate intakeProlonged Action: m.b. require more between meal & bedtime snacks. Ultralente = Can be Mixed with Regular Insulin.-Give Once a Day = at The Same Time Each Day .

V. Long-Acting Insulin ( Clear)*Covers Insulin Needs for about = One Full Day1. Lantus ( Glargine) = SQ Long Acting2. Levemir ( Detemir) = SQ Long Acting

O = Onset : 1 - 2 hours. P = Peak : Peakless* D = Duration : 24 hoursNursing Care = Dont Mix with Any Insulin!*-Give Once a Day = at The Same Time Each Day : ( with evening meal or bedtime)

VI. Combination Insulin : NPH + Regular ( Cloudy) = give midmorning reactions*These Products = Give Twice a Day Before Mealtime.1. NPH ( 70U) + Regular ( 30U) = ( Humulin 70/30 , Novolin 70 / 30) = SQ2. NPH ( 50U) + Regular ( 50U) = ( Humulin 50/50) = SQ

O = Onset : 30 min. 1 hr P = Peak : 4 12 hours D = Duration : 24 hoursNursing Care = Dont Give IV* Eliminates Problem of Mixing Different Types.

Side Effects of Insulin:-Hypoglycemia* = blood glucose drops < 50 mg/dl: Headache /Fatigue /Changes in Vision / Dizziness/ Drowsiness/ Confusion / Coma ( coma related to = insulin overdose, caused by inadequate food intake, excessive exercise, excessive insulin administration)-Redness/ Swelling / Itching / Mild Pain = at the Injection Site-Allergic Reactions = Rash /Hives/ Difficulty Breathing / Tightness of Chest

Insulin Uses:a) Short Acting = DKA / During = Surgery, Infection, Trauma / Poor-Controlled DM To Supplement Longer-Acting Insulinb) Intermediate - Acting =Maintenance Therapyc) Long-Acting = Maintenance Therapy in Clients who Experience Hyperglycemia during the Night with Intermediate-Acting Insulin.

*insulin preparations consist mixture of = beef & pork insulin / pure beef / pure pork / human insulin ( purest insulin = low antigenic effect)

Insulin Delivery Devices= Pens Injector/ Jet Injectors / Pumps / Implantable Devicesa) External SQ Insulin Infusion Pump:are small , externally worn pagersize programmable device : continuous subcutaneous insulin delivery system.1) Contain = a 3 ml Syringe Attached to a Long ( 42-inch), Narrow-Lumen Plastic Tubing with either a Needle or Teflon Catheter at the End.2) The Needle or Teflon Catheter is Inserted into SQ Tissue ( usually on the abdomen) & Secured with Tape or a Transparent Dressing.3) The Needle or Teflon Catheter Changed = Every 3 days 4) The Pump is Worn either on a Belt or in a Pocket = Uses Only Regular Insulin. ( lipsro m.b. prescribed)5) Pump Delivers: a) Continual ( Basal Rate ) Infusion of Insulin by Rate: 0.5 2 U /hr = delivered continuously throughout the day & night. b) Additional Low Doses of Insulin (Bolus Doses) , which are Administered by a Patient Prior to Each Meal (injected prior to eating = by a series of button pushes).6) The Pump Provides = Flexibility for the Patient. The Pump is Worn Continuously & is Not Disconnected for > than 1 hr at a Time.7) Most Pumps are Now Waterproof & Can be Worn during Showers & Swimming. 8) Only Short-Acting ( Regular Insulin) or Rapid-Acting ( Lispro, Aspart, Apidra) Can be Used in the Pumps.b) Jet Injectors:1) High-Pressure Jet Injection of Insulin into the Skin = to Avoid Needle Injection2) Used = in Cases of Needle Phobia3) Problems with Jet Injectors = Variable Depth of Penetration, Bruising, Variable Absorption of Insulinc) Insulin Pen Injector 1) Contain Insulin = in Prefilled Cartridges, designed to make injection easier & more flexible/ eliminate needs for drawing up insulin from a vial/ special pen injection needles of small size = less discomfort2) Useful for Insulin Administration = Away from Home. Useful in Children on Multiple Injection Regimen.Administration of insulin

Injections by syringe are usually given into the deep SC tissue through a two-finger pinch of skin at a 4590 angle The pinch of skin is used to avoid the risk of administering insulin IM The SC fat layer should be thicker than the needle length. Very short needle lengths (e.g. 5 or 8 mm) are now available in some countries and they are particularly useful for young, slim children All suspensions of insulin (e.g. NPH, IZS, pre-mixes) must be resuspended before injection by rolling or inverting the vial or pen injector device (10 times) so that the cloudy suspension mixes thoroughly and uniformly Pen injector technique requires careful education including the need to ensure that no airlock or blockage forms in the needle; a wait of 510 seconds after pushing in the plunger helps to ensure complete expulsion of insulin through the needle Self-injectionMost children over the age of 10 years either administer their own injections or help with them Younger children sharing injection responsibility with a parent or other care provider may help to prepare the device or help push the plunger and subsequently under supervision be able to perform the whole task successfully Younger children on multiple injection regimens may need help to inject sites that are difficult to reach (e.g. buttocks) to avoid lipohypertrophSelf-mixing of insulinWhen a mixture of two insulins is drawn up = it is most important that there is no contamination of one insulin with the other in the vials. To prevent this the following principles apply:clear insulin (short-acting) is drawn up into the syringe before cloudy insulin (intermediate- or long-acting) If the cloudy insulin is lente type, the mixture must be administered immediately otherwise the short-acting component interacts NPH and lente insulins should never be mixed Rapid-acting insulin analogs may be mixed in the same syringe as NPH or lente Insulin syringesNeedle Gauge = 25 26 Syringes are available in a variety of sizes in different countries and should enable accurate dose delivery, but it is desirable for small dose, 1 unit per mark syringes (e.g. 0.3 ml) to be available for small children Plastic fixed-needle syringes are designed for single use Insulin syringes must have a measuring scale consistent with the insulin concentration (e.g. U 100 syringes) Syringes must never be shared with another person because of the risk of acquiring blood-borne infection (e.g. hepatitis, HIV)

Injection Sites = SQ (upper arms/ thighs / abdomen ) & IV ( only regular)a) Rotate Injection Sites = to Prevent Lypodystrophy ( Tissue Atrophy & Hypertrophy)b) Insert Needle = at 45 or 90 degree angle ( depending on amount of adipose tissue)Storage of Insulin :-Store Unopened Vials = in Refrigerator-Store Opened Vials = at Room Temperature for 1 month Label Vial with Date & Time Opened or due to Expiration Date -Should be at Room Temperature = Before Injection.

Complications of Insulin:1. Hypoglycemia = Caused by Insulin Overdose. Treatment = Administer Glucagon.2. Lypodystrophy ( Tissue Atrophy & Hypertrophy) , Caused by: a) Administration of Cold Insulin b) from Poor Rotation of Injection Sites

3. Somogyi Effect: physiologic effect.-occurs when a person takes long-acting insulin.- when blood glucose drops during sleep ( at night) = that cause release of hormones: growth hormone, cortisol & catecholamines =they trigger the liver to release of glucose into the blood stream = to elevate blood glucose level. the body overcompensate = releasing a large amount of glucose , which cause rebound effect = causing hyperglycemia in the morning.a) Nighttime Hypoglycemia , which Leads to = Rebound Hyperglycemia in the Early Morning Hours. This may Happen Anytime during Sleep, but Low Blood Glucose: Hypoglycemia Usually Occurs = around 2 - 3 AM , Followed Hyperglycemia : Elevation of Blood Glucose = in the Morning. Cause = Having Too Much Insulin in the Body Before Bedtime /Long Acting Insulin/ Not Having a Bedtime Snack / Low Blood Sugar at Night . SS = Night Sweats / Insomina / Morning Headacheb) Treatment = Adjusting the Insulin Dose by Decreasing the Evening Insulin* / Increasing the Bedtime Snack*(protein snack: toast with peanut butter,cottage cheese) Instruct Patient = Check Blood Glucose at Night: between 2- 3 AM*Top of FormBottom of Form4. Dawn Phenomena : physiologic effect-results due to reduce tissue sensitivity to insulin. ( increase resistance to insulin)a) Prebreakfast Hyperglycemia* =Elevation of Early Morning Blood Glucose between 2 8 AM due to Nocturnal Release of GH ( trigger the liver to release of glucose into the blood stream & elevate blood glucose level) -blood glucose steadily elevates through the night=between 2 -3 AM & time to wake upb) Treatment = Administer an Evening Dose of Intermediate-Acting Insulin at 10 PM*./ Use Insulin Pump: to Administer Extra Insulin during Early Morning Hours* / Limit of Bedtime Snack*( eat protein snacks & limit carbohydrates) / Exercise Later in the Day/ Increase Dose of Oral Hypoglycemic Drugs ( Type-2) or Insulin ( Type-1) Instruct Patient = Check Blood Glucose at Night : between 2- 3 AM*#If the Blood Glucose Level is Low at 2 3 AM = Somogyi Effect# If the Blood Glucose Level is Normal or High at 2 3 AM = Dawn Phenomen#Difference Dawn Phenomen from Somogyi Effect that = Hyperglycemia is Not Triggered by Overnight Hypoglycemia.** When Administering Any Insulin = Hypoglycemic Reaction is Most Likely Occurs During Peak Action Hours*. A Snack will Prevent a Hypoglycemic Reaction.**Hormone that Counteract Insulin = Glucagon / Epinephrine / Cortisol / GH (Growth H)5. Insulin Resistance = Pt develops Immune Antibodies that Bind the Insulin Treatment = Administer Purer Insulin ( ex = human)

**How to Draw Up & Administer a Mixed Dose of Insulin ( Regular + NPH):#Use Insulin = at Room Temperature (Avoid Administer Cold Insulin)#Draw Up Insulin = Using Sterile Technique***When Drawing Up Both : Regular ( R) & Intermediate ( N) Insulin = Draw up into the Syringe the Regular 1st ** If Intermediate ( N) Acting Insulin is Ever Injected into the Vial of Regular ( R) Insulin = the Entire Vial Needs to be Discarded! -Before Administering Insulin = Ensure that Patient Blood Glucose is Appropriate to the Insulin Dose to be Administered.-Check the Label of Insulin Vials/Confirm Dose of Both Types/ Check Expiration Date. 1. Wash Hands 2. Mix Long-Acting Insulin = Gently Roll Vial of NPH Insulin Between Palms of Hands or Gently Invert (Turn) Bottle Slowly Up & Down (Dont Shake ) 3. Cleanse the Tops (Rubber Stopper) of Both Insulin Vials= with Alcohol Pads, Let Dry 4. Draw Up Air into the Syringe, Equivalent the Amount of Long-Acting Insulin ( NPH) to be Administered & Inject Air into the Long-Acting Insulin ( NPH) Vial . 5. Draw Up Air into the Syringe, Equivalent the Amount of Short -Acting Insulin(Regul) to be Administered & Inject Air into the Short-Acting Insulin(Regular ) Vial. 6. Turn Bottle Upside Down = Make Sure Needle is Covered with Insulin. Draw Up Regular Insulin into the Syringe 7. Check for & Remove Any Bubbles from Regular Insulin = by Tapping Syringe & Injecting Air Back into Vial. 8. Then =Withdraw the Needle & Carefully Insert the Needle into Long-Lasting ( NPH) Vial (make sure needle is covered with insulin)& Draw Up NPH Insulin into Syringe. 9. Choose & Cleanse the Injection Site with Alcohol . Gently Pinch Up Tissue = to Pull Fat Away from Muscle.10. Insert Needle ( Full Length ) at 45 90 degree angle into SQ Tissue. (45 degree = for thin patients, 90 = for thick patients.) Inject Slow, Release the Pinched Skin & Remove Needle ( pull the needle straight out by holding the syringe by the barrel) 11. Apply Gentle Pressure = Dont Massage the Site