SUBJECT: ADMINISTRATION OF INSULIN This cancels NP 513 dated 3/1/07 1. PURPOSE: COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 513 Effective Date: June 20, 2007 To provide nursing staff with guidelines for the safe and appropriate administration of insulin. 2. AUTHORITY: Title 22, division 6, 80092.8, Lippincott, W& W, Lippincott Manual of Nursing Practice eighth edition. 3. POLICY: Insulin therapy involves the subcutaneous injection of immediate, short, intermediate, or long acting insulin(s) at various times to achieve desired effect and the monitoring of glucose levels prior to the administration of insulin. Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff. The second licensed staff is still required for Individuals who have been approved and assessed to self administer their own insulin (see NP 523). 4. EQUIPMENT: 1. Diabetic Record (MH563) and Continuation (MH5633A) 2. Prescribed vial(s) of insulin 3. Insulin syringe and needle 4. Alcohol swabs 5. Gloves 6. Sharps container 7. Personal Protective Equipment as needed 8. Glucometer, test strips, and lancets 5. METHOD: A. PREPARING MEDICATION: -1-
NURSING ACTION A. Check Diabetic Medication Record and select prescribed insulin(s). Check glucose level prior to administration of insulin as per physician order. B. Verify type and dosage of insulin with another licensed staff member. The second licensed staff member is not required for Individuals who have been approved and assessed to self administer their own insulin (see NP 575). C. Gently roll insulin vial between palms of hands to thoroughly mix. D. Cleanse the rubber stopper on vial with an alcohol swab. E. Inject air into the vial equal to the amount of insulin you are giving. F. Withdraw plunger to required dosage being careful to expel any air bubbles before removing needle from the vial. RATIONALE-PRECAUTIONS A. An open bottle of insulin currently in use can be kept at room temperature, out of direct sunlight. Check vial for expiration date and date vial was opened. Monitoring glucose level prior to administration of insulin for hypoglycemic levels. B. The licensed staff member verifying the dosage shall observe the insulin being drawn from the vial in order to verify the accuracy of the type of insulin and dosage. After verifying accuracy initial below the diagonal line on the Diabetic Medication Record. The staff member who draws-up the insulin initials above the diagonal line. For insulin being self administered the licensed staff member shall observe the insulin being drawn from the vial in order to verify accuracy of type and dose of insulin. After verifying accuracy initial the date and time on the Diabetic Medication Record C. The rolling action mixes the insulin. Never shake the bottle as this causes air bubbles, which could distort the dosage. D. Removes dust and grease but does not sterilize. E. To prevent buildup of negative pressure in the vial when aspirating medication, air must first be injected into the vial. F. Tap side of syringe barrel carefully to dislodge any air bubbles as accumulation of air displaces medication and causes dosage errors. -2-
1. ADMINISTRATION OF INSULIN: NURSING ACTION RATIONALE-PRECAUTIONS A. Perform hand hygiene A. To Maintain proper hygiene. B. Identify Individual (see NP 500) and explain procedure. B. Ensures correct Individual receives the correct medication. Individual teaching assists with minimizing anxiety and gaining cooperation. C. Put on disposable gloves. C. Prevents possible exposure to blood. D. Select site for injection. D. Check injection log on Diabetic Medication Record. Rotate site to prevent induration of tissue. E. Cleanse the skin using a firm circular motion while moving out from the center of selected site. F. Gently stretch the skin taut at the site of injection. Insert the needle quickly and firmly at a 45 to 90 o angle. G. When the needle is in place, release skin tension. H. Depress the plunger, injecting the prescribed dose of insulin. I. Gently withdraw the needle if not a safety syringe. If a safety syringe is used, continue to depress the plunger until the needle retracts into the syringe. J. Properly dispose of syringe in designated Sharps container. E. Friction aids in cleansing the skin. Pathogens present on the skin can be introduced into the tissues by the needle. F. Angle depends on the skin turgor and the amount of subcutaneous fat present. G. Quick firm insertion minimizes discomfort. Tight skin is easier to penetrate then loose skin H. The injection should be completed in 3 to 5 seconds. Avoid moving the syringe. I. This prevents painful pulling of the skin as the needle is withdrawn. Do not massage the site. J. Proper disposal of glass and needle prevents accidental injury. K. Discard all disposable items into K. Controls transmission of infection designated container. L. Perform hand hygiene. L. To maintain proper hygiene C. MIXING OF TWO INSULINS: -3-
NURSING ACTION A. Inject air into the NPH vial equal to the amount of NPH insulin to be given. Remove needle without withdrawing insulin. B. Inject air into the Regular insulin vial equal to the amount of Regular insulin to be given. Then, with needle still in vial, withdraw prescribed units of Regular insulin. C. Using same syringe, insert needle into NPH vial. Do not inject anything. Invert vial and withdraw prescribed units of NPH insulin. D. Administer the two insulins immediately after mixing. RATIONALE-PRECAUTIONS A. It is very important to withdraw Regular insulin (which is a clear solution) first and then withdraw NPH insulin (which is a cloudy solution) so as not to contaminate the Regular insulin vial. B. Always remember: Clear to Cloudy. C. Be careful not to extract more than prescribed amount. Do Not push on plunger. D. NPH insulin will slow down the action of the Regular insulin if mixed over a period of time. Do not allow insulin mixture to stand because unpredictable physical changes may occur. D. DOCUMENTATION: The following information shall be recorded in the Individual s Diabetic Medication Record: -The drug name, dose, time, and route of administration. -The site where the injection was given (injection sites shall be rotated and recorded). -The name, initial and title of the licensed staff administering the medication. -The licensed staff member administering medication shall initial on the Diabetic Medication Record above the diagonal line and the licensed staff member verifying medication shall initial below the diagonal line in the box corresponding to the date and time the medication is given. -Individual fingerstick blood glucose testing shall be recorded on the back of the Diabetic Medication Record. -Any adverse reaction experienced by the Individual will be recorded in the ID Notes along with assessment findings and interventions. The MD (MOC via NOD after hours) will be contacted. -If the insulin is withheld or if the Individual refuses the insulin, circle the time it should have been given on the Diabetic Medication Administration Record. Document the reason it was not given or the reason it was refused in the Wellness and Recovery Notes, and notify the physician. -4-
6. COMPETENCY/TRAINING: Nursing Administration will assure all staff assigned medication room duties is trained and competent in the use of the facility s blood glucose monitor. 7. GENERAL INFORMATION: Insulin injections shall be administered immediately after a syringe is filled. For those Individuals on a diabetic diet as ordered by a physician, dietary intake shall be monitored and documented on the Daily Care Flow Sheet. All orders pertaining to diabetic medication and diabetic care must be re-transcribed by hand onto the Diabetic Medication Record. The Diabetic Medication Record shall be used to document the administration of Diabetic medication. The vial of insulin must be initialed and dated when first opened. The vial may be used for 30 days after opening. The opened vial may be refrigerated or kept at room temperature (less than 86 o F). Return to Pharmacy when it expires. Insulin therapy involves the following insulin preparations: TYPE ONSET HRS PEAK ACTION DURATION IMMEDIATE ACTING Lispro, aspart 0.25 hour 1-2 hour 4 hours SHORT ACTING Regular, semilente 0.5-1 hour 2-4 hours 6-8 hour INTERMEDIATE-ACTING NPH, lente 1-3 hours 6-12 hours 16-24 hours LONG- ACTING Ultralente insulin glargine 4-6 hours 1 hour 8-10 hours none 24-28 hours 24 + hours MIXED Regular 30%, NPH 70% 0.5 hour 2-12 hour 24 hour Regular 50%, NPH 50% 0.5 hour 3-5 hours 24 hours Lispro 25%, NPH 75% 0.25 hour 0.5-1.5 hours 24 hours Aspart 30%, NPH 70% 0.25 hour 1-4 hours 24 hours 8. PRECAUTIONS: A. Short-acting insulin s are to be given 20 to 30 minutes before meals and Intermediate insulin s are usually given once daily before breakfast or in divided doses before breakfast and the evening meal. -5-
B. Give insulin and food on time. Delaying a meal or HS snack may cause an insulin shock, particularly when regular insulin is used. C. Ignorance, neglect of therapy, undercurrent disease, or infection adversely affects the diabetic Individual. Know the signs and symptoms of hypoglycemic reaction (insulin shock), which is clinically more critical and can be fatal, and hyperglycemic reaction (diabetic ketoacidosis) so that prompt medical attention can be provided. If a Individual has symptoms of Hypoglycemic Reaction (insulin shock), check Individual s blood sugar level and take vital signs. Give glucose if Individual has a physician s order for it and meets conditions of the order for administration. Notify physician (MOC via the NOD after hours) of symptoms, vital signs, and interventions by staff. F. The following are signs and symptoms of hypoglycemic reaction (insulin shock) and hyperglycemic reaction (diabetic ketoacidosis): HYPOGLYCEMIC REACTION (insulin shock) -Onset is sudden. -Headache, lightheadedness, weakness -Nervousness, apprehension, anxiety -Tremor -Excess perspiration; cold, clammy skin -Hunger, -Dizziness, faintness, -Tachycardia -Slurred speech -Pallor, -Dilated pupils, double vision -Memory lapse, confusion -Seizures -Blood sugar level < 60 mg/dl HYPERGLYCEMIC REACTION (diabetic ketoacidosis) -Extreme thirst -Polyuria -Fruity breath odor -Kussmaul breathing (deep, rapid, labored, distressing, dyspnea) -Rapid thready pulse -Dry mucous membranes, poor skin turgor -Blood sugar level > 250 mg/dl -Headache, -Nausea, vomiting, abdominal pain, -Dim vision -6-