How to administer third party insulin injections safely with a pen device, safety pen needle and syringe 1 Hand washing It takes at least 15 seconds to wash your hands. This is about how long it takes to sing happy birthday twice. How to wash your hands: Wet hands with water Apply enough soap and hand wash to cover all hand surfaces Rub hands palm to palm Right palm over the other hand with interlaced fingers and vice versa Palm to palm with fingers interlaced Backs of fingers to opposing palms with fingers interlocked Rotational rubbing of left thumb clasped in right palm and vice versa Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa Rinse hands with water Dry thoroughly with towel. Duration of procedure: At least 15 seconds Acknowledgement goes to WHO for use of their hand washing technique 2 How to inject with an insulin pen and (in this case branded) safety pen needle (BD Auto Shield Duo ). Note: There are multiple safety engineered products on the market, please always refer to and follow manufacturer s instructions for safety engineered devices and pen devices Keeping injection sites healthy 1. Wash your hands 2. Wear a plastic apron to minimise risk of cross infection 3. The site should always be inspected prior to the injection 4. Avoid injecting into sites with lipohypertrophy, oedema, inflammation or signs of infection (refer to DITAS Learning Module 1 & 2) 5. If required cleanse the site with soap and water and dry with paper towel 6. Inject only into a clean site with properly washed gloved hands a. The use of surgical or latex type gloves is strongly recommended as it has properties which can reduce infection risk by wiping the needle during puncture b. It is recommended that you do not use examination gloves or gloves designed only for general or cleaning duties as they lack the wiping properties of gloves described above 7. If required to do so cleanse injection site with alcohol swab and allow to dry before injecting 8. Always rotate sites, try to spread the time between a single injection site as much as
possible, use body maps to record site time and date of injection How to inject with an Insulin Pen Device and Safety Pen Needle no lifted skin fold 9. Wash your hands 10. Inspect the injection site to be used if unhealthy mark using skin safe pen and with patient consent and avoid injecting into unhealthy area (refer to DITAS Learning Module 1 & 2) 11. Check the insulin for expiry date and that it is contaminant free and that it has been stored properly 12. Check to make sure that the pen is the correct pen for the patient and that the insulin corresponds to that prescribed for the patient 13. Select a new safety pen needle 14. Check the seal is intact and that it is in date 15. Remove the outer tear drop seal 16. Screw the pen needle onto the pen in a straight line not at an angle (see manufacturer s instructions for use) 17. Do not over tighten the needle 18. Remove the outer cap 19. If the insulin is the cloudy or mixed type invert 10 times and roll 10 times to fully re-suspend a. Check the insulin is fully suspended and evenly cloudy 20. Perform a test dose a. Dial 2 units and with the needle tilted away from you but still clearly visible press the dose button and observe for a bead of insulin at the needle tip 21. If no insulin appears repeat the test dose 22. Set the dose to be administered 23. Hold the pen in your fist 24. Keep your thumb away from the dose button 25. With the pen at 90 degrees to the skin surface gently push the pen needle into the injection site 26. Ensure the guard has fully retracted 27. Ensure the needle is in the tissues and remains in the tissues for the full duration of the injection 28. Place your thumb on the dose button and push down slowly all the time observing closely the guard and needle ensuring the guard is retracted and needle is in the tissues for the full duration of the injection 29. When zero is reached on the pen dose dial and the dose is fully dispensed count to ten slowly 30. Gently and in a straight line remove the pen needle from the skin 31. The patient end of this type of needle will automatically activate the guard 32. Unscrew the pen from the needle, the cartridge end of this type of needle will automatically activate the guard a. Then immediately dispose of the needle into a sharps container which is close to hand How to inject with an Insulin Pen Device and Safety Pen Needle with a lifted skin fold 33. Wash your hands 34. Wear a plastic apron to minimise risk of cross infection 35. The site should always be inspected prior to the injection 36. Avoid injecting into sites with lipohypertrophy, oedema, inflammation or signs of infection 37. Inspect the injection site to be used if unhealthy mark using skin safe pen and with patient consent and avoid injecting into this area (refer to DITAS Learning Module 1 & 2) 38. If required cleanse the site with soap and water and dry with paper towel 39. Inject only into a clean site with properly washed gloved hands a. The use of surgical or latex type gloves is strongly recommended as it has
properties which can reduce infection risk by wiping the needle during puncture b. It is recommended that you do not use examination gloves or gloves designed only for general or cleaning duties as they lack the wiping properties of gloves described above 40. If required to do so cleanse site with alcohol swab and allow to dry before injecting 41. Always rotate sites, try to spread the time between a single injection site as much as possible, use body maps to record site time and date of injection Practice lifted skinfold technique before committing to the injection 42. Practice how to lift a skin fold 43. Start with your index and second finger opposed to your thumb, tuck remaining fingers into your palm 44. Spread your fingers and thumb to at least 7.5cm apart, push down onto the patients tissues where the injection is to be given 45. Draw your fingers and thumb together a. At the same time lifting up a skinfold which contains ample subcutaneous fat tissue to accommodate the length of the needle being used b. Avoid drawing up muscle or too little subcutaneous fat so that the risk of an intramuscular injection is minimised 46. Keep fingers and thumb at least 2.5cm apart a. Do not draw your fingers and thumb closer together than 2.5cm to minimise the risk of through and through needle stick injury Once practice skinfold is completed successfully start the injection procedure 47. Check the insulin for expiry date and that it is contaminant free and that it has been stored properly 48. Check to make sure that the pen is the correct pen for the patient and that the insulin corresponds to that prescribed for the patient 49. Select a new safety pen needle 50. Check the seal is intact and that it is in date 51. Remove the outer tear drop seal 52. Screw the pen needle onto the pen in a straight line not at an angle 53. Do not over tighten the needle 54. Remove the outer cap 55. If the insulin is the cloudy or mixed type invert 10 times and roll 10 time to fully re-suspend 56. Check the insulin is fully re-suspended and evenly cloudy 57. Perform a test dose dial 2 units and with the needle tilted away from you but still clearly visible press the dose button and observe for a bead of insulin at the needle tip 58. If no insulin appears repeat the test dose 59. Set the dose to be administered 60. Hold the pen in your fist 61. Keep your thumb away from the dose button 62. Lift the skinfold as practiced earlier 63. With the pen at 90 degrees to the skin surface gently push the pen into the lifted skinfold apex which now forms the injection site 64. Ensure the guard has retracted 65. Ensure the needle is in the tissues for the full duration of the injection 66. Place your thumb on dose button and push down slowly all the time observing closely the guard and needle ensuring the guard is retracted and needle is in the tissues for the full duration of the injection 67. When zero is reached and the dose is fully dispensed count to ten slowly 68. Gently and in a straight line remove the pen needle from the patient s tissues 69. Once the pen needle is fully withdrawn release the lifted skinfold 70. Unscrew the pen from the needle and then immediately dispose in sharps container which
is close to hand How to inject with syringe Keeping injection sites healthy 71. Wash your hands 72. Wear a plastic apron to minimise risk of cross infection 73. The site should always be inspected prior to the injection 74. Avoid injecting into sites with lipohypertrophy, oedema, inflammation or signs of infection (refer to DITAS Learning module 1 & 2) 75. If required cleanse the site with soap and water and dry with paper towel 76. Inject only into a clean site with properly washed gloved hands a. The use of surgical or latex type gloves is strongly recommended as it has properties which can reduce infection risk by wiping the needle during puncture b. It is recommended that you do not use examination gloves or gloves designed only for general or cleaning duties as they lack the wiping properties of gloves described above 77. If required to do so cleanse site with alcohol swab and allow to dry before injecting 78. Always rotate sites, try to spread the time between a single injection site as much as possible, use body maps to record site time and date of injection One insulin Step one check the syringe packaging intact and in date, check that it is correct type and unit gradation for patient and insulin being used - check the vial (see how to check insulin above) Step two - if insulin is cloudy type fully re-suspend prior to use - invert vial through 180 degrees ten times and roll in palm of hands 10 times
Step three draw up the same number of units of air as units of insulin to be injected inject the air into the insulin vial Step three continued - drawing up the insulin invert the vial so that the stopper is pointing towards the floor and needle tip is pointing skywards draw back on the syringe plunger to withdraw insulin from the vial draw back slowly and deliberately to minimize ingress of air into syringe barrel drawback a few more units of insulin than is required if air is in the barrel a few sharp taps should make the air bubble rise to the needle end of the barrel next expel extra insulin and air back into vial and ensure that syringe plunger stops exactly at the prescribed dose of insulin
Step four - giving the injection Insulin Syringes are manufactured with 6mm, 8mm and 12.7mm length needles only. Some syringes are fitted with active type guards or safety engineered devices and some with a passive type guards or safety engineered devices. Always refer to manufacturer s instructions for use regardless of type of syringe used. Note: The shortest currently available syringe needle length in the UK is 8mm. This presents a significant risk of accidental intramuscular deposition of insulin. If using a syringe with >6mm it is recommended to use correct lifted skinfold technique (see above). Step four continued - To give the injection of insulin using a syringe now smoothly and gently push the needle into the skin at 90 degrees to the skin surface with the needle inserted into the subcutaneous fat layer, push the plunger down slowly when the plunger is fully compressed and the dose has been delivered the needle can be carefully withdrawn from the skin unlike the pen devices and pen needles there is no need with a syringe to hold for 10 seconds Mixing insulin Sometimes patients need to mix cloudy longer acting insulin with clear short acting insulin the following instructions will guide you on how to mix insulin correctly NOTE: Never mix analogue insulin mixing analogue insulin will result in denaturing of the insulin molecules and lead to significant glycaemic control issues Step one when mixing clear and cloudy insulin ensure that the cloudy type is fully re-suspend prior to use invert vial through 180 degrees ten times and roll in palm of hands 10 times Step two Draw up the same number of units of air as the total units of both clear and cloudy insulin to be injected inject the exact number of cloudy insulin units of air into the cloudy insulin vial withdraw the needle and inject the exact number of clear insulin units of air into the clear insulin vial leave the needle in the clear vial and invert proceed to step three below
Step three - Drawing up the insulin Clear First Cloudy Second Draw up clear insulin first, invert the vial so that the stopper points towards the floor and needle tip is pointing skywards draw back on the syringe plunger to withdraw insulin from the vial draw back slowly and deliberately to minimize ingress of air into syringe barrel drawback a few more units of insulin than is required if air is in the barrel a few sharp taps should make the air bubble rise to the needle end of the barrel next expel extra insulin and air back into vial and ensure that syringe plunger stops exactly at the prescribed dose of insulin Draw up the cloudy insulin second, insert the syringe needle into the cloudy insulin vial stopper and invert the vial so that the stopper is pointing towards the floor and needle tip is pointing skywards draw back on the syringe plunger to withdraw insulin from the vial draw back slowly and deliberately to minimize ingress of air into syringe barrel drawback the units of insulin that have been prescribed, try not to draw back more insulin than is required this will minimize the pushing back into the vial the now mixed insulin if air is in the barrel a few sharp taps should make the air bubble rise to the needle end of the barrel next expel extra insulin and air back into vial and ensure that syringe plunger stops exactly at the prescribed dose of insulin Step four - Giving the injection Insulin Syringes are manufactured with 6mm, 8mm and 12.7mm length needles only. The shortest available syringe needle length in the UK is 8mm. This presents a significant risk of accidental intramuscular deposition of insulin. Minimize this risk by using correct lifted skinfold technique (see above) now smoothly and gently push the needle into the skin at 90 degrees to the surface with the needle inserted push the plunger down slowly when the plunger is fully compressed and the dose is delivered, the needle can be carefully withdrawn from the skin unlike the pen device and pen needle there is no need with a syringe to hold for 10 seconds