Insulin: Types, Functions, and Clinical Uses

Synthetic Insulin and Functions

• Synthetic insulin is used to regulate blood glucose levels in individuals who have diabetes.
• Natural insulin promotes protein synthesis.
• Natural insulin controls the storage and utilization of amino acids and fatty acids.
• Insulin facilitates the conversion of glucose to glycogen for storage in the liver.
• Insulin helps glucose enter cells, effectively removing it from the bloodstream.

Properties of Insulin

• Onset refers to when the medication starts working.
• Peak refers to the maximum strength of the medication.
• Duration refers to how long the insulin lasts in the system.

Clinical Uses of Insulin

• Insulin is used to control type 1 and type 2 diabetes.
• It's administered in cases of severe diabetic ketoacidosis.
• Insulin, in combination with glucose, treats hypokalemia (low potassium levels).

Adverse Reactions to Insulin

• Hypoglycemia is low blood sugar, which can occur if insulin lowers blood sugar too much.
• Hyperglycemia is high blood sugar, which can occur if the insulin is not effective.
• Hypokalemia is low potassium levels.
• Allergic reaction: Hypersensitivity to insulin, often due to pork derivatives in some formulations.

Contraindications and Precautions

• Insulin is contraindicated in clients with hypersensitivity to it, especially pork-derived insulin.
• It is contraindicated in clients with existing hypoglycemia.
• Use insulin cautiously in clients with renal and hepatic impairment, during pregnancy, and during lactation.

Hypoglycemia: Recognition and Treatment

• Hypoglycemia is defined as blood glucose levels less than 70 mg/dL.
• Mnemonic: TIRED
• Tremors
• Irritability
• Restlessness
• Excessive hunger
• Diaphoresis (or depression)
• "Cool and clammy, need some candy" is a helpful phrase to remember the symptoms.
• With suspected hypoglycemia, check blood sugar levels immediately.
• Treat suspected hypoglycemia promptly, even before obtaining a glucose reading.

Hyperglycemia: Recognition and Management

• Hyperglycemia is defined as excessively high blood glucose levels, but the specific range varies by facility.
• The normal blood glucose range is generally 70 to 110 mg/dL, but it can also vary by facility.
• Symptoms of hyperglycemia include hot, flushed skin, fruity breath, polyuria (excessive urination), loss of appetite, and polydipsia (excessive thirst).
• "Hot and dry, sugar too high" is a helpful phrase to remember the symptoms.
• Check blood glucose levels and address hyperglycemia according to doctor's orders or established parameters.

Documentation and Assessment Before Insulin Administration

• Document the type and dose of insulin used.
• Record the type of diabetic diet the client is following.
• Document average glucose results in the client's chart to track trends.
• Note the history of the client's diabetic course of action, including how long they have been diabetic and their treatment history.
• Evaluate past compliance with prescribed therapy.

Hemoglobin A1c (HbA1c)

• HbA1c provides an accurate picture of a client's diabetes control and compliance over time.
• A good HbA1c range is typically 2.5% to 6%.
• An HbA1c higher than 10% indicates poor glucose control.
• Clients with very high HbA1c levels (e.g., 12%) may be asymptomatic due to their bodies acclimating to chronically high glucose levels.
• HbA1c is a blood test that can be taken at any time, without fasting.
• It reflects the average glucose levels over the past three months.

Monitoring During Insulin Therapy

• Assess for signs/symptoms of hypoglycemia and hyperglycemia throughout insulin therapy.
• Be aware of the Somogyi effect, also known as rebound hyperglycemia.
• Low blood sugar triggers the release of glucagon and epinephrine.
• The liver converts glycogen to glucose, raising blood sugar levels.
• The body overcompensates, leading to hyperglycemia after hypoglycemia.
• Often observed in the early morning hours in individuals managing their blood sugar.
• Management requires careful monitoring to avoid overcorrection.

Insulin Administration: Sliding Scale

• Insulin dosage is based on blood glucose readings.
• Blood glucose 145 mg/dL: No insulin if the scale indicates no insulin is needed for 70-150 mg/dL.
• Blood glucose 155 mg/dL: 2 units of insulin if the scale indicates 2 units are needed for 151-200 mg/dL.
• Facilities may have specific protocols for blood glucose levels above 400 mg/dL, potentially involving a set insulin dose and a call to the doctor.
• Healthcare facilities always have specific protocols.

Best Practices for Insulin Administration

• Administer the correct amount prescribed, typically based on a sliding scale.
• Pinch up subcutaneous tissue.
• Inject insulin using a two-handed technique.
• Release the skin and push down with the opposite hand.
• Read all labels carefully when preparing insulin.
• Ensure it's the correct insulin.
• Verify the expiration date.
• Pull up the correct amount of units before administering.

Insulin Interactions

• Insulin's effects can be influenced by various medications and substances, either increasing or decreasing its hypoglycemic effect.
• Increased Hypoglycemic Effect (Risk of Low Blood Sugar):
• Aspirin
• Anticoagulants
• Alcohol
• Beta-blockers
• Oral hypoglycemics
• MAOIs (Monoamine Oxidase Inhibitors - antidepressants)
• Tricyclic antidepressants
• Tetracycline
• Decreased Hypoglycemic Effect (Risk of High Blood Sugar):
• Thiazide diuretics
• Glucocorticoids
• Oral contraceptives
• Thyroid drugs
• Smoking

Lipoatrophy and Lipohypertrophy

• Lipoatrophy and lipohypertrophy are insulin interactions affecting subcutaneous tissue, potentially interfering with insulin absorption.
• Lipoatrophy: Atrophy of subcutaneous fatty tissue.
• Lipohypertrophy: Lumpy, hardened subcutaneous fat.
• Both conditions can interfere with insulin absorption.
• Rotate injection sites.
• Rotate use of different areas of the abdomen, documenting each injection site (e.g., right, left, upper, lower).
• Maintain at least an inch between injection sites.

Insulin Preparation and Administration: Key Considerations

• Insulin cannot be given orally; administer the medicine via subcutaneous injection.
• Insulin should be at room temperature before injection to help prevent lipodystrophy.
• Always check the expiration date before use; insulin is typically viable for only 28 days after opening.
• Roll mixed insulins gently to mix.
• Clear insulins do not need to be mixed; warming or tilting is acceptable.
• Never shake insulin, as it can break down the enzymes.
• Verify the prescribed order for the type and amount of insulin before administration.
• Ensure the correct syringes are used to match the units being administered (e.g., U-100 or U-500).

Types of Insulin and Mixing Guidelines

• Premixed insulins often combine long-acting or intermediate-acting insulin with short-acting insulin; some may include rapid-acting insulin.
• Do not mix or dilute insulin glargine (Lantus) or detemir (Levemir) with any other insulin or solution, as it can compromise glucose control.

Dual Sign-Off for Insulin Administration

• Insulin administration requires a dual sign-off process involving two nurses to ensure accuracy and safety.
• One nurse draws up the insulin and a second nurse verifies the blood glucose level and the correct insulin dosage.
• Both nurses sign off on the medication administration record.
• This enhances patient safety by reducing the risk of medication errors.

Insulin Storage

• Insulin should typically be stored in the refrigerator to maintain its viability.
• Once opened, insulin can be stored at room temperature, but it must be used within 28 days.

Insulin Injection Technique

• Inject insulin into the subcutaneous tissue.
• Pinching the skin helps to lift the subcutaneous tissue away from the muscle.
• Use the appropriate angle of injection based on the amount of subcutaneous tissue.
• Use a two-handed technique for stability and accuracy.
• Release the pinched skin after injecting the insulin.
• Push down with the opposite hand to ensure the insulin is delivered into the subcutaneous tissue.

Additional Considerations

• Educate patients on proper insulin storage, administration, and site rotation techniques.
• Regularly monitor blood glucose levels to adjust insulin dosages as needed.
• Educate patients on the signs and symptoms of hypoglycemia and how to treat it.
• Educate patients on the signs and symptoms of hyperglycemia and when to seek medical attention.
• Obtain a thorough medical history, including medications and allergies, before administering insulin.
• Tailor insulin therapy to meet the individual needs of each patient.

Insulin Mixing: Step-by-Step

• Check compatibility to confirm that the insulins are compatible for mixing.
• Draw air into syringe equal to the dose of the first insulin before injecting air into the vial and removing the syringe.
• Draw air into the syringe again equal to the dose of the second insulin.
• Inject the air into the vial of the second insulin and immediately draw up the correct dose of the second insulin.
• Insert the syringe into the vial of the first insulin and draw up the correct dose.
• Ensure the final dose in the syringe is the combined total of both insulins.
• Administer the mixed insulin immediately after preparation.

Lipodystrophy Prevention

• Systematically rotate injection sites within the same area (e.g., abdomen) to avoid repeated injections in the same spot.
• Ensure each injection site is at least one inch away from the previous site.
• Keep a record of injection sites to track rotation and avoid overuse of specific areas.
• Use the correct injection technique, including pinching the skin and injecting at the appropriate angle.
• Inject insulin at room temperature to reduce the risk of lipodystrophy.

Managing Hypoglycemia

• Symptoms: shaky, sweating, confusion, and dizzy.
• If suspecting hypoglycemia, check blood glucose levels immediately.
• Administer a fast-acting carbohydrate source, such as glucose tablets, juice, or regular soda if blood glucose is low.
• Recheck blood glucose levels after 15 minutes and repeat treatment if necessary.
• Provide a longer-acting carbohydrate source, such as a snack with protein and carbohydrates, once blood glucose levels are stable.
• For severe hypoglycemia, glucagon may be necessary; educate family members on how to administer glucagon.
• Advise patients to wear a medical alert bracelet or carry identification indicating they have diabetes.

Managing Hyperglycemia

• Symptoms: increased thirst, frequent urination, blurred vision, and fatigue.
• If hyperglycemia is suspected, check blood glucose levels immediately.
• Administer insulin as prescribed by the healthcare provider, following the sliding scale or individualized insulin plan.
• Encourage the patient to drink plenty of water to help flush out excess glucose.
• Check urine or blood for ketones, especially if blood glucose levels are very high.
• If hyperglycemia persists or ketones are present, seek medical attention.

Insulin Syringes and Concentrations

• U-100 Insulin: The most commonly used insulin concentration, containing 100 units of insulin per milliliter.
• U-500 Insulin: A more concentrated insulin for patients who require very high doses of insulin.
• Insulin syringes are marked in units, not milliliters.
• Use the correct syringe for the insulin concentration (e.g., U-100 syringe for U-100 insulin).
• Low-dose syringes are available for patients who require small doses of insulin.

Patient Education: Key Points

• Store insulin properly, typically in the refrigerator until opened.
• Demonstrate and explain the correct insulin administration technique.
• Emphasize the importance of rotating injection sites to prevent lipodystrophy.
• Teach patients how to monitor their blood glucose levels and interpret the results.
• Educate patients on the signs and symptoms of hypoglycemia and hyperglycemia and how to manage them.
• Provide guidance on meal planning and carbohydrate counting.
• Encourage regular physical activity as part of a healthy lifestyle.
• Stress the importance of adhering to the prescribed insulin regimen.
• Emphasize the need for regular follow-up appointments with the healthcare provider.
• Advise patients to carry a medical alert bracelet or identification and to have a glucagon kit available for severe hypoglycemia.

Mixing Insulin (NPH and Regular)

• Insulin can lose its effectiveness if left standing for an extended period, therefore, administer regular and NPH insulin immediately after mixing.

Injection Techniques and Site Rotation

• 45-degree angle for non-obese individuals.
• 90-degree angle for obese individuals.
• Rotate injection sites to avoid lipohypertrophy.
• Plan injection sites carefully, maintaining a distance of 1 to 1.5 inches between sites.
• Document the injection site in the client's care plan.
• Record the injection site after administration and note any inflammation or skin reactions.
• Report any allergic reactions, inflammation, or skin changes to the healthcare provider.

Subcutaneous Injection Sites

• Inject two inches away from the navel.
• Note that the upper arms and anterior thighs are also suitable.
• Abdomen: Fastest absorption rate.
• Upper Arm: Intermediate absorption rate.
• Thigh: Slowest absorption rate.
• Prioritize using the fastest absorption rate area whenever possible.

Components of the MAR

• Specifies the type of insulin (e.g., Novolin R - Regular insulin).
• Includes a sliding scale for dosage based on blood glucose levels.
• Example Sliding Scale:
• 0-200 mg/dL: 0 units of insulin.
• 201-300 mg/dL: 2 units of insulin.
• Document if insulin was not administered and the reason (e.g., blood glucose less than 200 mg/dL).
• Record the injection site and units administered only when the injection is given.

Methods of Insulin Delivery

• Jet Injection System:
• Uses pressure to deliver a fine stream of insulin below the skin.
• Disposable Needle and Syringe:
• Standard needle and syringe combination.
• Insulin Pens:
• Pre-filled syringes with a dial to select the dose.
• Disposable.
• Insulin Pump:
• Delivers regular insulin continuously via a needle inserted into subcutaneous tissue.
• Mimics the body's normal pancreatic function.
• Battery-powered.
• Needle changed every 1-3 days, with site rotation.
• U500 Insulin Pen:
• Compact and useful for visually impaired patients due to a magnified window.

Hypoglycemia and Hyperglycemia: Monitoring and Management

• Never administer oral fluids or substances to treat hypoglycemia if the patient's swallowing reflexes are absent; administer an injection of glucagon if the patient is not alert.
• Continuously assess for signs of hypoglycemic reactions throughout the day.
• Can occur in cases of eating too little food, incorrect insulin dosage (too much insulin), or increased physical activity.
• Patients should monitor their glucose before, during, and after exercise, and avoid injecting insulin into the body part where they are exercising.
• Hyperglycemia can occur in cases of eating too much food, too little or no insulin, or because of emotional stress, infection, surgery, pregnancy, or acute illnesses.

Recording Insulin Administration on the MAR

• Insulin Type: Clearly indicates the type of insulin being administered (e.g., Novolin R).
• Sliding Scale: Provides a reference table for dosage adjustments based on blood glucose levels.
• Dosage: Specifies the amount of insulin to be given according to the sliding scale.
• Administration Time: Records the exact time the insulin was administered.
• Injection Site: Documents the location of the injection.
• Documentation Guidelines:
• For administered insulin:
  • Record the date and time of administration and document the exact dose administered (in units).
  • Specify the injection site.
• For withheld insulin:
  • Document the date and time and indicate that the insulin was "not needed" or "withheld".
  • Provide a clear explanation, such as "BG < 200 mg/dL" (blood glucose less than 200 mg/dL).
• If at 0730, the patient's blood glucose was less than 200 mg/dL, document "Insulin not needed, BG < 200 mg/dL."
• if at 2100, the patient's blood glucose was 124 mg/dL, document "Insulin not needed, BG 124 mg/dL."

Practical Aspects of Insulin Delivery

• Jet Injection System:
• Mechanism: Uses high pressure to deliver a fine stream of insulin through the skin, eliminating the need for a needle.
• Considerations: May cause bruising or discomfort at the injection site.
• Disposable Needle and Syringe:
• Components: Consists of a standard insulin syringe and a separate needle.
• Usage: Insulin is drawn from a vial into the syringe, and the injection is administered subcutaneously.
• Insulin Pens:
• Design: Pre-filled with insulin and equipped with a dial to select the desired dose.
• Advantages: Convenient, portable, and easy to use, especially for patients with dexterity issues.
• Types: Available in disposable and reusable models.
• Insulin Pump:
• Components: A small, battery-powered device connected to a thin, flexible tube (catheter) inserted under the skin.
• Function: Delivers a continuous, controlled dose of insulin throughout the day and night.
• Insulin Type: Uses only regular insulin.
• Site Rotation: The infusion site should be changed every 1-3 days to prevent skin irritation and infection.
• U500 Insulin Pen:
  • Special Feature: Designed with a magnified window to enhance visibility of the dose, making it suitable for visually impaired patients.
  • Concentration: Contains a higher concentration of insulin (500 units/mL), requiring careful dose measurement.

Comprehensive Approach to Managing Hypoglycemia and Hyperglycemia

• Hypoglycemia Management:
• Swiftly administer a source of glucose administering either glucose tablets/gel, fruit juice, regular (non-diet) soda, or hard candies.
• If unconscious, immediate administer a prescribed glucagon injection.
• Recheck blood glucose levels every 15 minutes until they return to a safe range.
• Hyperglycemia Management:
• Assessment: Determine the underlying cause administering the prescribed insulin, encouraging fluid intake to prevent dehydration, and continuously monitoring blood glucose levels frequently.
• The underlying causes could be a missed insulin dose, overeating, infection or illness, or stress.
• If hyperglycemia is severe or persistent, seek medical attention.
• Patient Education:
• Provide self-monitoring techniques instructing teaching the patient how to monitor their blood glucose levels.
• Provide instructions on proper injection sites, balanced diet, excercise, how to prevent hypoglycemia, how to manage diabetes during illness, proper foot-care, continuous instruction on medication, and regular follow-ups.

Factors Influencing Blood Glucose Levels

• Dietary Factors:
• The amount and type of carbohydrates consumed have a direct impact on blood glucose levels.
  • Meal timing and consistent carbohydrate intake can help stabilize blood glucose levels. -Insulin Therapy:
• The correct insulin dosage is essential for maintaining target blood glucose levels administering at the appropriate time in relation to meals. Physical Activity:
• Physical activity can lower blood glucose levels by increasing insulin sensitivity and glucose uptake by muscles. -The intensity and duration of exercise can affect blood glucose levels differently, but must be taken before, after, and during. Stress:
• Stress can trigger the release of hormones and cause coping mechanisms to disrupt blood glucose control. Illness:
• Infections can increase blood glucose levels due to the body's stress response and certain medications can also raise blood glucose levels. Hormonal Changes:
• Fluctuations during the menstrual cycle can affect blood glucose levels in women with diabetes as pregnancy can cause insulin resistance, leading to higher blood glucose levels.

Injection Site Rotation

• Lipohypertrophy:
• Lipohypertrophy is the abnormal buildup of fat under the skin at the injection site due to repeated injections in the same area.

Rotation Technique:

• Use a systematic approach to rotate injection sites within a designated area, divide the injection area into a grid pattern and track your records.
• Space injection sites at least one inch apart with each injection, rotating the administration site and avoiding spots filled with the effects of lipohypertrophy and other infections. Patient Education:
• It is key for patients to see this in action and learn, assess, and develop.

Insulin Storage Guidelines

• Store unopened insulin vials and pens in the refrigerator (36°F to 46°F or 2°C to 8°C) and discard any expired insulin.
• Opened Insulin: -Insulin can be stored for 28 to 30 days at room temperature but avoid extreme temperatures, direct sunlight, or freezing.
• General Guidlines:
• Keep insulin safe from kids, pets, and inspect it, especially when traveling or requiring a backup supply.

Insulin Types and Their Action Profiles

• Rapid-Acting Insulin: -Taken before meals to cover carbohydrate intake in about 3-5 hours in under an hour.
• Short-Acting Insulin (Regular Insulin): -Taken before meals and intravenously in emergency situations that takes over 5-8 hours after 30 minutes. Intermediate-Acting Insulin (NPH Insulin): -Provides background insulin coverage for about half a day in about 12-18 hours for half a day starting in 1-2 hours.
• Long-Acting Insulin: -Provides basal insulin coverage for a full day with minimal peak in about an hour. Premixed Insulin:
• Provides both mealtime and basal insulin with composition that is a rapid/short and intermediate-acting insulin.

Patient Education: Key Components

• Through self-monitoring, medication management, providing aid, consistent exercises, and consistent medical checkups can help support and improve patient performance for effective and reliable diabetes treatment,
• Remember to check blood glucose, manage medications, keep follow-up appointments and emphasize the importance of all parts of these steps.

Potential Complications of Insulin Therapy

• Potential Complications:
  • Make sure to be aware of the signs of hypoglycemia and hyperglycemia and how to respond to them with fast-acting ccarbohydrates or a dose management of the insulin.
  • Lipohypertrophy is an abnormal fat production under the skin while an allergic reaction could cause various problems with the sking on all parts of the body.
  • Make sure to keep constant checkups of blood pressures, side-effects, and follow-up dosages to maintain stability.

Special Considerations

• Be mindful of your patients and their physical needs providing different assistance when the following cases present while in therapy and with medication.
  • Preganancy
  • Elderly People
  • Patients with renal/hepatic/cognitive/visual/dexterity impairment
• Ensure the patients understand everything being done and work with the healthcare team to provide assistance during their treatments.

Insulin and Excercise: Key Considerations

• Key components to focus on include constant monitoring with a goal range; the correct insulin amount, and knowledge of how all of this will effect you as an individual.

Conclusion

• In summary, the effective, consistant management of insulin is the best method to make sure all symptoms can be treated and managed; it is up to the patient to make sure all the details can be provided so a healthcare assistant can provide all the necessary skills.