By the end of the presentation, nurses will understand diabetes and insulin therapy. They will know the criteria for diagnosing diabetes, the different types of insulin and regimens, proper administration and storage techniques, and how to use insulin devices. The document discusses myths about insulin, outlines the types and classification of diabetes, and covers topics like symptoms, goals of treatment, insulin types and regimens, administration techniques, storage, and more. Nurses will gain knowledge on properly managing diabetes with insulin.

2. By the end of the presentation
Nurses could be able to
 Know about diabetes and its criteria for diagnosis.
 Different types of insulin and its regimen.
 Administration and storage.
 Use insulin devices.

3. What would you prefer when you suffer from diabetes?
Oral drugs
Or
Insulin
????????????????????

4. Myth about Insulin
 Is the last option ( where no any oral medication
works then only insulin is given.)
 Once used should have to use life long so better not to
use rather I will have take 4-5 oral drugs.
 Should have to refrigerate insulin so its a burden.
 I feel hesitation when someone sees me injecting
insulin.

5. GOSPEL TRUTH ABOUT DIABETES
• Every
• 10 seconds 1 diabetics dies and
in that 10 seconds 2 new
diabetics are detected.
• 12 minutes one stroke
• 19 minutes one myocardial
infarction
• 19 minutes one major
amputation
• 60 minutes a new case of
dialysis
• 90 minutes a new case of
blindness
Liebl et al DMW

6. Diabetes
 a chronic disease associated with abnormally high
levels of the sugar (glucose )in the blood.
 Diabetes is due to one of two mechanisms:
 Inadequate production of insulin (which is made by
the pancreas and lowers blood glucose), or
 Inadequate sensitivity of cells to the action of insulin.

7. Etiological Classification of Diabetes Mellitus
I. Type 1 diabetes* - previously known as
juvenile diabetes
insulin-dependent diabetes mellitus (IDDM)
II. Type 2 diabetes* - previously known as
adult-onset diabetes
non-insulin-dependent diabetes mellitus (NIDDM)
III. Other specific types (includes Secondary Diabetes)
IV. Gestational diabetes mellitus (GDM)
*Patients with any form of diabetes may require insulin
treatment at some stage of their disease. Such use of insulin
does not, of itself, classify the patient.
American Diabetes Association: Clinical Practice Recommendations, updated
annually and published as a supplement to Diabetes Care and at
http://care.diabetesjournals.org/

8. Symptoms of diabetes
 Polyuria
 Polydipsia
 Polyphagia
 Fatigue
 Skin infections
 Impotence
 Tingling, numbness sensation

9. Medical consequences of insulin deficiency
 Hyperglycemic emergencies
 Diabetic ketoacidosis (DKA)
• Chronic complications
– Neuropathy
– Microangiopathy
Retinopathy
Nephropathy
Foot ischemia
– Macroangiopathy - Atherosclerosis
Risk of cardiovascular death in type 1 diabetics vs. nondiabetics:
>5X higher in males, 7X higher in females

10. Poor glycemic control leads to long-
term complications…
Diabetic nephropathy
Proliferative
diabetic retinopathy
Sections through an artery
Atherosclerosis
Diabetic foot

11. Diagnostic Criteria
FPG=fasting plasma glucose; IFG=impaired fasting glucose;
IGT=impaired glucose tolerance; 2-hour PG=postprandial glucose (PPG) **HbA1c
based on the 2-hour PPG challenge with 75-gram glucose load. NGSP 2010
ADA. Diabetes Care. 2002;25(suppl 1):S5–S20; WHO 1999.
Normoglycemia Type 2 Diabetes
IFG
FPG (mg/dl) <110 110 and <126 126
(mmol/l) <6.1 6.1 and <7.0 7.0
IGT
2-h PG (mg/dl) <140 140 and <200 200
(mmol/l) <7.8 7.8 and <11.1 11.1

12. Goals of Glucose Management
Targets for glycemic control
American Diabetes Association. Diabetes Care. 2006;29(suppl 1):S4-S42. Implementation Conference for ACE
Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement at
http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January
6, 2006. AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.
ADA AACE
A1c (%) <7* ≤6.5
Fasting (preprandial)
plasma glucose
90-130 mg/dL <110 mg/dL
Postprandial plasma
glucose
<180 mg/dL <140 mg/dL
*<6 for certain individuals

13. Leonard Thompson

14. Discovery and characterization
 In October 1920, Frederick Banting & Charles
Best: called isletin ( Insulin)
 On January 11, 1922, Leonard Thompson, a
fourteen-year-old diabetic, was given the first
injection of insulin

16. Ala
Tyr
Leu
Glu
Thr
Lys
Thr
Tyr Phe Phe Gly Arg
Glu
Gly
Cys
Val
Leu
Val
Leu
His
Ser
Gly
Cys
Leu
His
Gln
Asn
Val
Phe
B1
Asn Cys
Tyr
Asn
Glu
Leu
Gln
Tyr
Leu
Ser
Cys
Ile
Ser
Thr
Cys
Cys
Gln
Glu
Val
Ile
Gly A21
B30
Pro
Structure & Synthesis of Insulin

17. Insulin
Insulin is a naturally occurring hormone secreted by
the beta cells of the islets of Langerhans in the
pancreas in response to increased blood glucose
levels.1
Insulin regulates the blood glucose level and stores
excessive glucose for energy.2
1. Ehrlich RA. Patient care in radiography: With an introduction to medical imaging, 8th ed. Missouri:Elsevier Mosby; 2013. P. 470.
2. Mayo Clinic. Diabetes treatment: Using insulin to manage blood sugar [Internet]. 2015 [cited 2015 Oct 9]. Available from: www.mayoclinic.org/diseases-conditions/diabetes/in-
depth/diabetes-treatment/art-20044084
3. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2004;27(Suppl 1):s15–s35.
4. Kimball DM. Perceived knowledge of the registered nurse in managing hyperglycemia according to evidence-based practice in the acute care settings. Boca Raton: Florida

18. Pharmacologic treatment of type 2 diabetes [Internet]. 2015 [cited 2015 Oct 9]. Available from: www.columbia.edu/itc/hs/medical/clerkships/primcare/case/diabetes/diabetes01_07.html
Normal Insulin Secretion
The pancreas is constantly secreting basal insulin, which provides 50% of the body’s
requirement.
After a meal, the pancreatic beta-cells secrete bolus insulin in response to meals,
which supplies the body’s other 50% requirement.

19. Precautions for Storing Insulin Pens
1. GOSH NHS UK. Insulin: safe administration of [Internet]. 2015 [cited 2015 Sept 28]. Available from: http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/insulin-safe-
administration.
2. Kalra S, et al. Forum for injection techniques, India: The first Indian recommendations for best practice in insulin injection technique. Indian J Endocr Metab 2012;16:876–85.
Should be refrigerated initially (2-8°C).1
Once the pen is in use there is no requirement for
refrigeration, but do not store above 30°C.1
Pens should never be stored with needles attached.2
If using mixed insulin, i.e., cloudy insulin, before using
the pen for the first time, the pen should be rolled
between the palms about 10 times.1
Thereafter, only turn the pen up and down prior to use
and do not shake.1
Analogues such as insulin Glulisine and insulin Glargine
do not need to be rolled.1

20. Different types of Insulin
Insulin Onset of action Peak of Action Duration ofAction
Short acting (RHI)
( Human insulin, Insuman)
30-60 min 2-4 h 6-8 h
Rapid acting analogue
Lispro ( Humalog) 15 min 1-2 h 2-5 h
Aspart ( Novorapid) 10-20 min 1-3 h 3-5 h
Glulisine ( Apidra ) 10-20 min 1-2 h 3-4 h
Intermediate Insulin
NPH ( Neutral protamine
hegedron )
1-3 h 5-7 h 13-16 h
LongActing Insulin analogue
Glargine ( Lantus) 1-2 h peakless 24 h
Premix Insulin
Insulin lispro 25/75 ( Humalog
Mix)
10 min 1-4 h 10-20 h
Insulin Aspart 30/70 ( Novo
Mix)
10 min 1-4 h 16-20 h

22. •Basal Insulins
•NPH
•Glargine (Lantus)
•Bolus Insulin
•Short acting insulin -Regular Insulin
• Rapid acting analog
•Lispro
•Aspart
•Glulisine

23. Once-daily Dosing Regimen
1. Diapedia. Insulin regimens [Internet]. 2015 [cited 2015 Oct 13 ]. Available from: http://www.diapedia.org/management/insulin-regimens
2. Levich BR. Diabetes management: optimizing roles for nurses in insulin initiation. J Multidiscip Healthc. 2011;4:15–24.
A single dose of insulin given each day.1,2
Long-acting insulin is given, mostly in the evening (for 24-hour
coverage). However, it can be given in the morning as well.1,2

24. Taken twice daily before breakfast and dinner to provide 24-hour
coverage
Also called biphasic because a fixed mixture of a short-acting insulin
and a long-acting insulin taken at each injection.
Twice-daily (Mixed-Insulin) Dosing Regimen
Diapedia. Insulin regimens [Internet]. 2015 [cited 2015 Oct 13]. Available from: http://www.diapedia.org/management/insulin-regimens

25. Basal–Bolus Dosing Regimen
1. NHS Lanarkshire. Basal bolus regimen insulin adjustment (multiple daily injection) [Internet]. 2013 [cited 2015 Oct 12]. Available from:
www.nhslanarkshire.org.uk/Services/Diabetes/Documents/Diabetes%20-%20Basal%20Bolus%20Regimen%20Insulin%20Adjustment.pdf
2. Dunning T. Care of people with diabetes: A manual of nursing practice, 4th ed. Sussex: John Wiley & Sons; 2013.
Basal insulin helps in maintaining the basic amount of insulin needed by the body at all
times by controlling the amount of glucose released. Basal insulin is long-acting insulin or
intermediate insulin as it needs to act over a relatively long period of time.1
Bolus Insulin helps in keeping blood glucose levels under control post-meal (mimics
pancreas role). Bolus insulin is either short-acting insulin or rapid-acting insulin as it
needs to act quickly.1
Basal-bolus regimen involves taking a long-acting insulin at bedtime to supply the basal
insulin requirements through periods of fasting and separate bolus injections of rapid- or
short-acting insulin are given before each meal to prevent blood glucose levels from
rising post-meals.2

27. Insulin Administration
Primarily, there are primarily two routes of insulin administration:
1. Subcutaneous injection using:
 Syringe
 Insulin pen
 Insulin pump
2. Intravenous infusion

28. Delivery devices

29. Delivery devices
Disposable insulin injection pen
Refillable insulin injection pen

30. Injection sites include the subcutaneous tissue of:1
the upper arm and the anterior and lateral portion
of the thigh
buttocks (slowest absorbing)
abdomen (fastest absorption) (except a 2-inch
radius around the navel).
Avoid the lateral portion of arm in small children with
little subcutaneous fat.2
Rotation of the injection site (recommended within
one area but at least 1 cm apart) is important to
prevent lipohypertrophy or lipoatrophy.1,2
Intramuscular injection is not recommended for
routine injections.1,2
1. American Diabetes Association. Insulin Administration. Diabetes Care. 2003; 26(Suppl 1):s121–4.
2. GOSH NHS UK. Insulin: safe administration of [Internet] . 2015 [cited 2015 Sept 28]. Available at: http://www.gosh.nhs.uk/health-
professionals/clinical-guidelines/insulin-safe-administration
Abdomen Upper arm
Anterior
thighs
Posterior
thighs Buttocks
Where to Inject the Insulin?

31. Insulin should be injected at 90° to the
skin using a two-finger ‘pinch-up’
technique.1
Do not aspirate for blood return when
giving insulin.2
Holding of the skin fold should be
maintained until the needle has been
withdrawn at the same angle from the
skin.1,2
For thin individuals or children, use short
needles or pinch the skin and inject at a
45° angle to avoid intramuscular
injection.3
Injection Procedure
Lifted skin fold No lifted Skin fold

32. Needle Length & Technique
Nurses should choose the correct needle length and injection
technique

33. Intravenous Insulin Infusion
Intravenous insulin is used in clinical settings to manage
hyperglycaemia.1
In the critical care setting, intravenous insulin infusion is
the most effective method for attaining glycaemic
targets.1
Indications for intravenous insulin infusion include:2
Critical care illness
Diabetic ketoacidosis
Myocardial infarction or cardiogenic shock
The post-operative period following heart surgery

35. Precautions for Storing Insulin Vials
Nurses should take the following precautions for storing insulin vials:
Vials not in use should be refrigerated at 4-8°C, but not frozen.1,2
If refrigerated, then should be taken out and kept at room temperature
for at least 30 minutes before injecting.2
Avoid extreme temperatures (<2 or >3°C; e.g., direct sunlight, kitchen,
on top of electronics) and excess agitation to prevent loss of potency,
clumping, frosting, or precipitation.1,2
Keep insulin at room temperature (15-25°C) to limit local irritation at
the injection site, which may occur when cold insulin is used.1
Use an opened insulin vial within 1 month, after which there might be a
loss in potency.1
When insulin is used for the first time, ensure a label is used to note the
date and time of opening.3
If a refrigerator is not available, the vial can be labeled using water
proof stickers and placed in an water-filled earthen pitcher.2

36. Precautions for Storing Insulin Pens
Should be refrigerated initially (2-8°C).1
Once the pen is in use there is no requirement for
refrigeration, but do not store above 30°C.1
Pens should never be stored with needles attached.2
If using mixed insulin, i.e., cloudy insulin, before using
the pen for the first time, the pen should be rolled
between the palms about 10 times.1
Thereafter, only turn the pen up and down prior to use
and do not shake.1
Analogues such as insulin Glulisine and insulin Glargine
do not need to be rolled.1

37. Enjoy with Insulin
Thank You