Insulin Delivery System and Self Monitoring Blood Sugar (SMBG ) Leyden V. Florido, RN, MAN

Management of Diabetes Mellitus Pharmacological Glucose Lowering Agents/Oral Antidiabetes Drug/Oral Hypogycemic Agent Insulin Others Non-pharmacologic Nutrition Physical Activity Stress Management Self-monitoring Blood Glucose (SMBG)

Objectives At the end of the session, participants will be able to: Recognize the practical skills and issues associated with insulin therapy and selfmonitoring blood sugar Enumerate different barriers in insulin therapy initiation Discuss the different insulin delivery devices available in the Philippines Discuss the insulin injection technique

Objectives State the Blood Glucose Targets/Goals Explain the frequency of SMBG Enumerate common barriers and errors in glucose monitoring

INSULIN TREATMENT Lifestyle intervention: diet, exercise Medication includes 1) oral and/or 2) insulin

Types of insulin and its action Onset Peak Duration

INSULIN Type 1 For Survival Type 2 For Better Glucose Control

Barriers to Insulin Use: Patients and Providers Concerns Insulin equates to worse diabetes Personal failure, poor selfefficacy about using insulin Inconvenience (perceived loss of control over one s life) Clinicians fear of extra time for education and management Responses Diabetes is a progressive disease: early intervention critical Discuss personal beliefs, obstacles, fears, restore sense of control New delivery systems (pens, pumps) and insulins increase flexibility

Insulin Delivery

Insulin Delivery Syringes U100 Needle length: ½ (mm), 5/16 (mm) 1cc, ½ cc, 3/10 cc 28, 29, 30, 31 gauge Pens and pen needles Magnifying devices Aids for the blind

Pen Delivery of Insulin Multiple-dose insulin therapy Convenience Flexible schedule Reduce insulin waste May improve accuracy

Insulin Pump

Patient Education Insulin Administration Abdomen preferred injection site Insulin analog within 15 minutes before meals, regular insulin 30 45 minutes before meals When to self-monitor blood glucose 4 times per day (pre-meals) Intermittent 1 2 hours post-meal to adjust insulin analog Occasional 3 AM glucose How to recognize, treat and prevent hypoglycemia and hyperglycemia Time action of insulin

Factors influencing the effect of Insulin Factors Influencing The Effect Of Insulin Subcutaneous blood flow Exercise/massage of the site Subcutaneous fat thickness Insulin concentration Injection site and depth Injection technique Becton Dickinson, 2004

Avoiding Insulin Errors Know the insulin Correct insulin from pharmacy Regular and rapid-acting insulin should be clear. NPH and premixed insulin should be cloudy. Action curves and absorption variables Do not use insulin if you see any flakes, clumps, or other pieces floating in it. Deliver correct dose at correct time Correct syringe size and technique Able to see insulin in vial, syringe and pen Mixing insulins (Lantus can not be mixed) Proper storage

Storage of Insulin Storage Of Insulin - Can be damaged by heat and freezing Ideal temperature 2 to 8 C Don t put the insulin too close to the freezing compartment Insulin loses effect above 25 C Vials of insulin than are in use may be kept at room temperature for 25 to 30 days, and those that are not in use should be refrigerated. Becton Dickinson, 2004

General Rules for the Care of Injection Site Exercise increases insulin absorption up to 7 fold. The only assurance of subcutaneous injection is to do a pinch-up. Do not mix site and time to reliably predict the effect of insulin dose. Observe proper site rotation, moving by about a finger-breadth from the last site of injection. Becton Dickinson, 2004

Injection Sites Subcutaneous injection and needle length. Absorption variables and site rotation.

Injection Site Becton Dickinson, 2004

Subcutaneous injection Techniques Used To Perform Subcutaneous Injection Becton Dickinson, 2004

Correct Pinch-up Correct Pinch-up It should be done only with the thumb and index/middle finger. The pinch-up should take the dermis and subcutaneous tissue but leave the muscle behind. Becton Dickinson, 2004

Recommendation Why Is The Abdomen Preferred? There is usually abundant subcutaneous fat. It is easier to do a pinch-up. The fastest absorption is from abdomen. Inject a hand s breadth from the umbilicus and the SQ narrows on the lateral aspect. Why Is The Arm The Least Preferred Site? There is usually a thin layer of subcutaneous fat. A pinch-up is absolutely necessary for each injection. Becton Dickinson, 2004

Medical risks in reusing needles Are There Medical Risks In Reusing Needles? With reuse, the tip bends into the form of a hook. It lacerates the tissue causing microtrauma. Local growth factors are released to form lumpy nodules called lipodystrophy. Becton Dickinson, 2004

What Are The Consequences Of These Nodules? Lipodystrophy nodules are disfiguring. People often prefer injecting into them because it is less painful. BUT insulin absorption from these nodules is erratic and can compromise glucose control. Becton Dickinson, 2004

What Happens When Needles Are Reused? Injection sites begin to bleed or leave unsightly bruises. The dulled tip can force the needle to bend, sometimes breaking off during the injection. Insulin remaining in the needle shaft may crystallize and block the flow of the next injection. The tips dulls, twists, and can break off and stay inside the patient. The lubricant is removed and shots become painful. Becton Dickinson, 2004

How Much Reuse Is Needed Before Tip Damage Occurs? Excessive reuse is often associated with breaking off of the microscopic end of the needle tip. Significant tip damage can occur after only ONE injection.

Insulin Injection

Insulin Injection using the pen* Remove the pen cap. Check the insulin (amount and appearance). Clean the injection site with alcohol swab. Attach a needle to insulin pen by screwing the needle straight onto the cartridge holder until it is firmly attached and remove both caps. Prime the pen. *BD Diabetes.com

How to inject* Squeeze a couple of inches of skin between your thumb and two fingers, pulling the skin and fat away from the underlying muscle. (If you use a 5 millimeter mini-pen needle to inject, you don't have to pinch up the skin when injecting at a 90 angle; with this shorter needle, you don't have to worry about injecting into muscle.) Insert the needle. Hold the pinch so the needle doesn't go into the muscle. Push the button to inject the insulin. Release the grip on the skin fold. Count 5 to 10. Remove the needle from the skin. Do not swab the skin. *BD Diabetes.com

Insulin Pen Precautions* Before using an insulin pen, read the manufacturer's instructions to learn any specific safety precautions that they recommend. Carrying an insulin pen with the needle attached can alter the accuracy of your insulin dose. Keep pens and needles separate until you're ready to inject After injecting, remove the needle immediately. *BD Diabetes.com

Insulin Shrinkage* Carrying an insulin pen from a warm place to a cold place (for example, from the warmth of outdoors to an air-conditioned building in the summer, or from a warm house to a cold car in the winter) causes the insulin in the cartridge to shrink. When you carry the pen with needle attached, air goes into the cartridge through the needle, into the space where the insulin had been before (and this will happen even if the needle is capped). *BD Diabetes.com

Disposal of syringes and sharps

Disposal Of Syringes And Sharps In Hospital Setting Recapping of needles is very risky and can lead to accidental needle sticks. All sharps should be disposed of in specific containers.

Disposal Of Syringes And Sharps In Home Setting Clip off the needle with a safety clip or put the used syringe/pen needle into a sealable sharps container. Keep out of reach of children. Follow local disposal guidelines where applicable.

Give a man a fish And he will not go hungry for a day But teach him how to fish And he will survive for the rest of his life.

The Evolution of Blood Glucose Meters

SMBG can aid in diabetes control by: facilitating the development of an individualized blood glucose profile guide health care professionals in treatment planning for an individualized diabetic regimen; giving people with diabetes and their families the ability to make appropriate day-to-day treatment choices Diet physical activity insulin or other agents Clinical Diabetes 20:45-47, 2002 American Diabetes Association, Inc., 2002

SMBG can aid in diabetes control by: improving patients recognition of hypoglycemia or severe hyperglycemia enhancing patient education and patient empowerment regarding the effects of lifestyle and pharmaceutical intervention on glycemic control. Clinical Diabetes 20:45-47, 2002 American Diabetes Association, Inc., 2002

Frequency of SMBG When to monitor: There is no absolute recommendation varies from person to person frequency and timing of glucose monitoring should be dictated by the needs and goals of the individual patient Diabetes Care 25:S97-S99, 2002 2002 by the American Diabetes Association, Inc.

Blood glucose testing Using meters Advantages: reliable fast portable more acceptable and convenient Disadvantages: more expensive for some pricking finger sometimes painful Most meters have memories and can be downloaded to computers either at home or in the pharmacy, doctor s office or diabetes clinic

Blood glucose testing Details to be learned How well did the last medication work? When did each insulin dose or tablet have the most or least effect? How did the food eaten affect levels? What was the benefit of physical activity?

Keeping a diary (diabetes education) Explain how to keep a blood glucose diary Give reasons for keeping a diary Emphasize importance of entering ALL results Encourage comments when daily activity is different than usual

See the Pattern, Solve the Problem What is the problem? What could be the cause? What are the possible solutions?

Pattern Management Assumes food/carbohydrate intake and activity are similar each day

Barriers to increasing use of SMBG Cost of testing Inadequate understanding (myths and facts) Health beliefs Patient psychological and physical discomfort Inconvenience of testing

Common problems in blood sugar monitoring Blood glucose levels do not coincide with how one feels Not enough blood on strip Finger prick may be painful Incorrect preparation

Future Developments Several companies are developing new continuous glucose monitoring systems (CGMS) An artificial pancreas created by an implantable pump with a continuous glucose monitoring is in development Several companies are working on noninvasive blood glucose monitoring devices

Limitations Of Conventional Finger Sticks

Summary SMBG and A1C are now routinely incorporated into the treatment plans Checking blood glucose levels and making appropriate adjustments can help optimize glycemic control Reduced risk of diabetes-related complications

Summary There are numerous options for SMBG available to fit patient s needs Manufacturers have added their product lines and refined functionality Pattern management can be important for therapy adjustment and lifestyle changes Insulin injection: Survival for T1DM and blood glucose control for T2DM

Summary Right technique is important for both insulin injection and monitoring As a nurse it is our duty to give outmost care to clients through education