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  • 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
  • 2. UNIVERSAL SYMBOL FOR DIABETES
  • 3. INSULIN Increases glucose transport into cells and promotes conversion of glucose to glycogen, decreasing serum glucose levels.
  • 4. 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.
  • 5. INDICATION •Clients with type 1 DM and Type 2 DM •Clients with uncontrolled blood glucose levels with oral hypoglycemic agents
  • 6. TIME ACTIVITY OF PHARMACOCLOGICAL INSULIN
  • 7. 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
  • 8. 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
  • 9. PREPARATION BRAND ONSET (Hr) PEAK (Hr) DURATION (Hr) LONG -ACTING INSULIN INSULIN GLARGIN INJECTION LARTUS 2-4 NONE 24
  • 10. INSULIN INJECTION SITES
  • 11. a. The main areas of injections are – Abdomen – absorbed more rapidly and evently Arms (posterior surface) Thighs (anterior surface) Hips
  • 12. •Systemic rotation with in one anatomical area – prevents lipidodyastrophy •Injections should be 1½ inches apart with in the anatomical area.
  • 13. 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
  • 14. Injection into scar tissue may delay absorption of insulin
  • 15. STORING OF INSULIN
  • 16. •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
  • 17. ADMINISTRATION OF INSULIN
  • 18. 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)
  • 19. Subcutaneous injections Watch the video
  • 20. 1. Prevention of dosage errors 2. Insulin syringe 3. Procedure of administration 4. Insulin I/V infusion
  • 21. NOTE …… “Insulin glargine” cannot be mixed with any other types of insulin
  • 22. 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)
  • 23. Insulin syringe •Usual range of needles- 27-29 gauge •½ inches long
  • 24. Before use - Swirl vial gently or rotate – between palms Don’t shake it vigorously – may cause bubbles
  • 25. 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.
  • 26. •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.
  • 27. 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
  • 28. Inject air equal to regular dose into a regular vial Invert regular insulin vial and withdraw the dose
  • 29. Note …. Regular insulin is the only type of insulin that can be administered intravenously
  • 30. 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
  • 31. Monitor – •Vitals, potassium, glucose, urinary out put, signs of fluid overload, signs of increased ICP •If potassium falls, IV administration of potassium
  • 32. 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
  • 33. SPECIAL INSULIN CONSIDERATIONS
  • 34. TPN and insulin
  • 35. Insulin may be added to control the blood glucose level because of the high concentration of glucose in Parenteral nutrition
  • 36. Use of insulin in children
  • 37. •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
  • 38. Insulin and surgery
  • 39. •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
  • 40. Glucose monitoring
  • 41. 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
  • 42. 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
  • 43. •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.
  • 44. 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.
  • 45. 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.
  • 46. Instruct the client that the test may take 3 to 5 hours requires I/V or oral administration of glucose, and multiple blood samples.
  • 47. Self monitoring of blood glucose (SMBG)
  • 48. To maintain good glycemic control Used with caution in patients with diabetic neuropathy
  • 49. Instructions for self monitoring Use proper procedure Wash hands before and after Check expiration dates of the strips
  • 50. Candidates Unstable diabetes Tendency for severe ketosis and hypoglycemia Hypoglycemia with out warning symptoms
  • 51. Frequency of SMBG Usually 4 times daily – before meals and bed time
  • 52. Frequency of SMBG For patients who take insulin before each meal At least three times a day
  • 53. Frequency of SMBG For patients who not receiving insulin At least 3-4 times a week
  • 54. The procedure Watch the video
  • 55. 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%
  • 56. COMPLICATIONS OF INSULIN THERAPY
  • 57. 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
  • 58. 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
  • 59. Lipoatrophy
  • 60. Lipohypertrophy
  • 61. Insulin resistance Development of immune antibodies that bind insulin Prevention / treatment – Administer pure preparations
  • 62. 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
  • 63. 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
  • 64. Questions
  • 65. 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
  • 66. Ans Small dose of regular insulin subcutaneously with self administration of additional dose before each meal
  • 67. 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
  • 68. Ans I need to stop insulin Do not stop insulin Have plenty of water, notify physician look for ketonurea