Teaching Self-Injection of Insulin and Other Injectable Diabetes Medications

EQUIPMENT

• Prescribed bottle of insulin or insulin pen or other injectable diabetes medication

• Disposable insulin syringe and needle or pen injection device and pen needle

• Cotton ball and alcohol or alcohol wipe (only in the institutionalized setting, not required for most patients at home)

PROCEDURE

Nursing Action

Rationale

To inject insulin using a syringe

1. Give the patient the syringe or insulin pen device containing the prescribed dose of insulin.

1. Patient must see stoma site to learn care.

2. Have patient select a clean area of skin.

2. Preparation with alcohol is not necessary, but if used must completely dry before injection to reduce pain.

3. Instruct the patient to hold the syringe as he or she would a pencil or a dart.

3. Helps to accurately target the injection site.

4. Show the patient how to select an area of skin from the anterior thighs and form a skin fold by picking up subcutaneous tissue between the thumb and forefinger if the patient is thin. The skin fold should not be squeezed so tight that it would cause pain or blanching of the area.

4. Using a skin fold and injecting at a 45-degree angel is recommended for thin people; injecting at a 90-degree angle into taut skin is recommended for heavier people. Avoid pinching the skin tightly to avoid pain, bleeding, and trauma.

5. Select areas of upper arms, abdomen, and upper buttocks for injection after patient becomes proficient with needle insertion (see figure).

5. The skin is loose and there is more subcutaneous fat in these areas. Systematic rotation of sites will keep the skin supple and favor uniform absorption of insulin. Use of the same body part for each time of day dosage will make absorption more consistent.

Rotate sites within each body part and use the same body part for the same injection time each day. Absorption is quicker from the abdomen and arms than the thighs and buttocks. Exercising a body part will hasten insulin absorption, so exercise should be consistent.

6. Assist the patient to insert the needle with a quick thrust to the hub at a 45- to 90-degree angle to the skin surface.

6. The needle is inserted into deep subcutaneous tissue.

7. Inject the insulin slowly and then withdraw the needle from the skin.

7. The insulin is injected into the subcutaneous tissue and the risk of bruising is reduced.

8. Instruct the patient to release the skin fold and dispose of the needle safely.

To inject insulin/other DM medication using a pen device

All non-insulin-injectable diabetes medications are only available in prefilled pen devices.

1. Pen devices must be primed according to manufacturer’s instructions before use. Once primed, the desired dose should be dialed.

1. Ensures no obstruction and clears any air in the needle.

2. Inserting the pen needle into the skin is the same procedure used for inserting a needle of a syringe and is described above.

2. 90 degree angle for most individuals.

3. Once the needle is inserted into the skin up to the hub, the patient will administer the medication by pushing the thumb button at the end of the pen device.

4. After completely pushing the thumb button, the patient will continue to hold the needle in place for a slow count of 10 before withdrawing the needle.

4. Unlike when using a syringe, the full dose takes longer to be fully dispensed from a pen device.

5. Remove the needle from the pen and dispose of it safely.

5. Leaving the needle attached to the pen will allow for air and possibly other contaminants to enter the cartridge or for the medication to leak out.

To load the syringe

1. If insulin is in a suspension (NPH), gently rotate or roll the insulin bottle to mix well.

1. Vigorous shaking may result in air bubbles, so rotating or rolling is preferred.

2. Do not instruct the patient to wipe off the top of the vial with alcohol; instead, make sure that the vial is stored in its original carton and is kept clean.

2. Wiping with alcohol is not necessary as risk of infection is small.

3. Inject approximately the same volume of air into the insulin vial as the volume of insulin to be withdrawn.

3. Air is injected into the vial to keep its contents under slight positive pressure and to make it easier to withdraw the insulin.

4. If insulin pen device is being used, follow manufacturer’s instructions for dialing the dosage and changing cartridges (if not using a prefilled pen device).

4. Most pen devices now available are prefilled and disposable, eliminating the need to change cartridges.

To fill a syringe with NPH and short-acting or rapid-acting insulin mixture

1. Inject air equal to the number of units to be injected into each vial. Use the same sequence each time, for example, always NPH insulin first.

1. Creates positive pressure in vial so that insulin will be withdrawn from each vial without mixing.

2. After injecting air into the second vial, keep needle in vial and withdraw prescribed amount of that type of insulin, then withdraw needle.

2. There is no real benefit to withdrawing either type of insulin first, as the risk of mixing insulins in the second vial is minimal. It is more important not to switch vials and draw up the wrong dose, so the sequence should always be the same.

3. Withdraw prescribed amount of insulin from the second vial.

3. Positive pressure already created in that vial will make withdrawal of insulin easy.

DRUG ALERT Lantus and Levemir insulins must never be mixed with any other insulin in the same syringe.

Evidence Base Frid, A., Hirsch, L., Gaspar, R., et al. (2010). New injection recommendations for patients with diabetes. Diabetes and Metabolism, 36(Suppl. 2), S3-S18.

Hanson, B., & Matytsina, I. (2011). Insulin administration: Selecting the appropriate needle and individualizing the injection technique. Expert Opinion on Drug Delivery, 8(10), 1395-1406.