INSULIN Flashcards
When mixing meds from vial and ampule, what order?
Vial, then ampule
–> put on filter needle for ampule
If not sure about med compatibility when mixing, what to do?
- Check med compatibility chart
- Phone pharmacist
What kind of vessel does insulin come in?
Vials
What to do with intermediate acting insulins prior to administering them?
Roll gently to re-suspend (cloudy)
*What to do with insulins prior to administering?
- Check expiry date
- Check compatibility
- Back check with doctor’s orders! and MAR
- Do insulin research
If mixing insulins, which is drawn up first?
Basic procedure for this?
Rapid or short-acting first, then intermediate
Air into cloudy, air into clear, draw up clear, draw up cloudy
Can other diluents or meds be mixed with insulins?
No other diluent or med should be mixed with any other inslin product unless approved by the prescriber
Which insulins can’t be mixed?
Do NOT mix inulin glargine (Lantus) or insulin detemir (Levemir) with any other types of insulin and do not admin IV
If mixing rapid acting with NPH, when is the insulin given?
Within 15 mins before meal
How many checks by nurses is required for insulins?
2
What to do if too much insulin in drawn up from second vial?
discard
*Assessments prior to insulin admin?
- Hypo/hyperglycemia
-
Signs and symptoms of hypoglycemia
Neurogenic (Autonomic) - Trembling - Palpitations - Sweating - Anxiety - Hunger - Nausea - Tingling Neuroglycopenic: - Difficult concentrating - Confusion - Weakness - Drowsiness - Vision changes - Difficulty speaking - Headache - Dizziness - Tiredness
Which s&s can be from both hyper and hypoglycemia?
Tachycardia, delirium, sweating
When does first check of insulin take place?
As remove from med cart - compare label with MAR
Ensure to do what to vials prior to injecting blunt needle into insulin vials?
clean with alcohol swab
Is the procedure during mixing parenteral meds considered sterile?
No, aseptic technique is used
Is long acting insulin clear or cloudy?
Clear
Which is the long acting insulin?
Glargine (Lantus)
When should a second nurse verify the insulin?
After withdrawing first (clear) and after second
When is second check of accuracy done when mixing insulins?
After both drawn up - compare MAR with prepared med and labels on vials
Third check is done where?
At patient’s bedside
WHere to store vials of insulin?
In refrigerator, not the freezer. Keep vials currently being used at room temp.
Is it ok to inject insulin straight from the fridge?
NO! Do not inject cold insulin!!!
What should insulin vials be inspected for prior to use?
Changes in appearance: clumping, frosting, precipitation, change in clarity or colour)
–> indicative of lack of potency
Can you interchange insulin types?
No, not unless indicated by prescriber
Where is preferred injection site for insulin/
Abdomen, avoid 5cm (2in) radius around umbilicus
- Or outer aspect of thighs
When do children generally start self-administering?
By adolescence
If patient can self-admin, should you do it for them?
Have pt self-admin whenever possible!
What should those who self admin insulin keep with them at all times?
At least 15g CHO
- 4 oz fruit juice or pop, 8 oz skim milk, 6-10hard candies
According to P&P, is rotation of insulin sites necessary?
No, because insulins now carry very low risk of hypertrophy
- Just pick an area and rotate within it, to keep absorption consistent
Where is insulin absorption rate fastest? Slowest?
Fastest: abdomen
Slow: in thighs
Primary treatment for Type 1 DM?
Insulin
Broad term for insulin + oral hypoglycemics collectively?
Antidiabetic drugs
When are type 2 diabetes prescribed insulin?
ONly when lifestyle changes and oral drug therapy no longer drug tx nolonger provide adequate management
Or if experience adverse from oral
Normoglycemic aka?
Euglycemic
Two sources of current insulin?
Extracted from domesticated animals or synthesized in labs using recombinent DNA technology (using bacteria or yeast for replication)
- Beef-derived insulin original source but no longer made in Canada (but can be imported from the UK)
- Porcine also has been replaced by DNA tech
By how many amino acids does porcine insulin differ from human?
1 amino acid
Do exogenous insulins act like endogenous insulins?
Yes!
If Type 2 is receiving insulin, do they require oral as well?
Yes
Worst case scenario with overdose of insulin
Extreme hypoglycemia leading to shock and possible death
Which symptoms could either be a result of hypo or hyperglycemia?
Tachycardia, delirium, sweating…
so check blood glucose first!
Which drugs can act as antagonists to insulins?
- Result in elevated glucose levels
B-blockers, chlorthalidone, corticosteroids, diazoxide, epinephrine, furosemide, niacin, thyroid hormones, etc…
Names of rapid-acting insulins?
Aspart (Novorapid)
Glulisine (Apidra)
Lispro (Humalog)
Peak, onset + duration of:
1) Rapid acting insulins
2) Humulin R (human regular)
3) Human NPH (Humulin N, NPH)
4) Lantus
1) Onset = 10-15mins
Peak = 60-90mins
Duration = 305hrs
2) 30 mins
Peak = 2-3hrs
Duration = 6.5hrs
3) Onset 1-3hrs
Peak = 5-8hrs
Duration = up to 18hrs
4) Onset = 90 mins
Peak = None
Duration = 24hrs
Common adverse effects of insulin?
Tachycardia, palpitations
Headache, lethargy, tremors, weakness, fatgue, delirium, sweating
Hypoglycemia
Blurred vision, dry mouth, hunger, nausea, flushing, rash, urticaria, anaphylaxis
Primary treatment for gestational diabetes?
Insulin
4 major classifications of insulins?
1) Rapid-acting
2) Short-acting
3) Intermediate-acting
4) Long-acting
When are porcine products used?
(not typically d/t risk of allergy)
May be used if have intolerance to other insulins or achieve better glycemic control with them
Which insulins are clear?
regular insulin insulin glulisine (Apidra) Lispro (Humalog) Glargine (Lantus) * All rapid or short-acting + Lantus (long)
Which insulins are cloudy/opaque?
NPH (Humulin N, Novolin ge NPH)
*ALl intermediate acting
For which two groups are insulin calculated based on weight?
Pregnant + children
Insulin protocol for BG of 2.8-3.9mmol/L (mild-moderate)
1) Give 15mg CHO (3 tablets)
2) Repeat BG in 15 mins
3) Repeat 1 and 2 until BG >4.0mmol/L
4) Give snack or meal
5) Inform physician
6) Document incidence of hypoglycemia
If a meal is more than 1 hour away when responding with hypoglycemic protocol (mild-moderate or sever conscious), what should you do?
Give snack in form of diabetes reaction kit
***Snack should include 15g CHO and a protein sources
Insulin protocol for BG of
1) Give 20mg CHO (4 tablets)
2) Repeat BG in 15 mins
3) Repeat 1 and 2 until BG >4.0mmol/L
4) Give snack or meal
5) Inform physician
6) Document incidence of hypoglycemia
Insulin protocol for BG of
1) IV glucose 25g given as 50mL of D50W over 1-3minutes
OR
1mg glucagon subcut or IM
(Call 911 if in community)
2) IV or glucagon can be repeated after 10min (if BG less than 4.0mmol/L)
3) Inform physician ASAP
4) Document
How many glucagon injections can be given?
2 max
Where are diabetes reaction food kits available?
In nursing medication fridge (regular and dysphagia versions)
In order to make glucose tablets more tolerable, what can you do?
Cut into quarters or crush and mix with water
For VIHA, what are you supposed to do (according to subcut insulin clinical order set) if patient becomes NPO or develops nausea and vomitting?
Call the doctor
What is a requirement of subcut insulin clinical order set for VIHA? (Which patients can be taking s/c insulin?
Must be taking solid food orally or intermittend tube feeding. May be on TPN
How often does blood glucose monitoring take place?
QID
If BBG is less than 4mmol/L, what to do for VIHA?
Initiate glycemic protocol
If BBG is
Call the physician managing diabetes
If new to insulin, what is the usual starting daily insulin requirement according to VIHA protocol?
0.5 unit/kg/day
Suggested daily initial insulin radio is:
1 (prandial breakfast), 1 (prandial lunch), 1 (prandial supper), 2 (basal bedtime)
What is the “prandial insulin”?
Short acting (given before meals)
What is “basal insulin”
Long acting
When are basal insulin doses typically given?
Breakast, supper, and/or bedtime (not typically at lunch)
When is prandial insulin typically not given?
bedtime
What kind of symptoms occur with mild hypoglycemia according to VIHA?
autonomic syntoms (trembling, palpitations, sweating, anxiety, hunger, nausea, tingling) \+ person has ability to self treat
What kind of symptoms occur with moderate hypoglycemia according to VIHA?
autonomic and neuroglycopenic symptoms (includes difficulty [ ]ing, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness, tiredness )
+ person has ability to self-treat
What constitutes “severe” hypoglycemia according to VIHA?
Person requires the assistance of another person and may be unconscious
If a patient has had ____ or more incidents of hypoglycemia during their hospitalization, ____ should happen.
3
Phyisician must be informed verbally or by telephone
How much fruit juice/drink makes up 10-15g CHO?
4 oz
If a patient has issues (dysphagia, dentition issues) that prevents intolerance to glucose tablets, what can be given?
1 tube glucose gel (provides approx 20g CHO) can be administered and MUST BE SWALLOWED
A snack (of 15g CHO and protein) is recommended if? (in hypoglycemic protocol)
Next meal is more than 1 hour away and in the absence of complications.
What should be given to an emaciated or undernourished pt’s or those with uremia, or hepatic disease in severe (unconscious) hypoglycemic protocol? Why?
Glucagon NOT effective in these patients
Give IV glucose (50mL of D50W)
Does taking glucose tablets or glucose gel compromise NPO status?
No, even with small amount of water.
In patient that is NPO with naso-gastric tube, admin what?
1 tube glucose gel orally
In pre=op patients who are NPO, how should hypoglycemia be treated?
Eitehr with glucose tablets or gel (if dysphagia)
