Diabetes
Education &
Care Program
Diabetes Professionals
Pages-Checklist for Patients Using Insulin
Pages-Checklist for Patients Using Insulin
home page / information / financial assistance / eye care / foot care / fitness / pharmacies / diabetes professionals pages: Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada / Flow Sheet for Patients with Diabetes / Checklist for Patients Using Insulin: Insulin Types & Delivery Devices / Insulin Administration / Hypoglycemia / Driving
Types
Manufacturer
Rapid Acting
Fast Acting
Intermediate Acting
Long Acting
Pre-Mixed
Pre-Mixed Analog
NovoRapid: __Cartridge __Vial
Toronto (R): __Cartridge __Vial
NPH (N): __Cartridge __Vial
Novolin 30/70: __Cartridge __Vial
Other Mix ____: __Cartridge __Vial
Humalog: __Cartridge __Vial
Regular: __Cartridge __Vial
NPH (N): __Cartridge __Vial
UltraLente: __Vial
Humulin 30/70: __Cartridge __Vial
Other Mix ____: __Cartridge __Vial
Humalog Mix 25: __Cartridge __Vial
• Keep manufacturer consistent if using more than one type of insulin.
• All intermediate, long acting and pre-mixed insulins require mixing prior to injection due to separation. It is recommended that the pen device be turned up and down at least 20 times.
• Ensure the pen is primed prior to each injection.
• Storage of insulin: Avoid extreme temperatures (<2 or >30 degrees C). If kept at room temperature, it is stable for 28 days, regardless if insulin has been used or not. If unopened and kept refrigerated (2 to 10 degrees C), it is stable until date of expiration marked on package.
• Pen needle cap should be removed prior to storing pen to avoid leakage of insulin.
INSULIN DELIVERY DEVICE
Manufacturer
Pens
Pen/Meter System
Syringes
Pen Needles
Also Available
Novolin Pen 3 __
Novolin Junior (0.5 increments) __
Innovo __
Induo __
Novo Fine Pen Needles:
12 mm__
8 mm __
6 mm __
Magnifier
Needle Remover
(*both available free at Diabetes Education Centre)
Humapen Ergo __
Latitude __
12.7 mm __
8 mm __
BD Pen Needles
12.7 mm __
8.0mm __
5 mm __
BD Magnifier
BD Inject Ease (automatic injector)
12.7 mm __
8 mm __
Unifine Pen Tips
12 mm __
8 mm __
6 mm __
• Novofine pen needles are recommended for use with Novolin Pen systems.
• BD and Autocontrol needles are compatible with all insulin delivery systems.
• For best insulin absorption:
average adult - 8 mm, no pinch
very lean adult - 8 mm with pinch or, 5mm/6mm, no pinch
very obese adult - 12 mm, no pinch
INSULIN ADMINISTRATION
Sites:
Insulin is absorbed most rapidly from the ABDOMEN
followed by the ARMS
followed by the THIGHS
followed by the BUTTOCKS
• Injecting into a site near an exercising muscle just prior to exercise will cause an increased rate of absorption.
Recommendations (Teaching Tips)
• The ABDOMEN gives the fastest and most CONSISTENT absorption, therefore, is the preferred site of injection.
• Rotation of sites is very important to give consistent absorption (giving insulin into the same site can cause lipohypertrophies which cause slow erratic absorption leading to increasing daily requirements of insulin - if the injection is then given into normal subcutaneous tissue HYPOGLYCEMIA can occur.)
* recommended to inject into the same site only once per month *
See example in chart below.
Insulin Injection Chart - Abdomen
1
17
9
25
17
9
25
1
17
9
25
17
9
25
2
18
10
26
18
10
26
2
18
10
26
18
10
26
3
19
11
27
19
11
27
3
19
11
27
19
11
27
4
20
12
28
20
12
28
4
20
12
28
20
12
28
5
21
13
29
21
13
29
5
21
13
29
21
13
29
6
22
14
30
22
14
30
6
22
14
30
22
14
30
7
23
15
31
23
15
31
7
23
15
31
23
15
31
8
24
16
32
24
16
32
8
24
16
32
24
16
32
Navel
Right
17
1
25
9
1
25
9
17
1
25
9
1
25
9
18
2
26
10
2
26
10
18
2
26
10
2
26
10
19
3
27
11
3
27
11
19
3
27
11
3
27
11
20
4
28
12
4
28
12
20
4
28
12
4
28
12
21
5
29
13
5
29
13
21
5
29
13
5
29
13
22
6
30
14
6
30
14
22
6
30
14
6
30
14
23
7
31
15
7
31
15
23
7
31
15
7
31
15
24
8
16
8
16
24
8
16
8
16
Morning & Lunch Injections - use darker number according to day of the month.
Supper & Evening Injections - use lighter numbers according to day of the month.
Procedure
• The pen needle / syringe needs to be left in skin for 6 - 10 seconds following the delivery of insulin to ensure that the full dose is received (i.e.: have the patient count to 10 prior to removing the needle).
RE-USE OF PEN NEEDLES / SYRINGES
The trauma of blunt, re-used needles can cause lipohypertrophies leading to slow, erratic absorption.
Re-use is generally not recommended.
MIXING CLEAR INSULIN AND CLOUDY INSULIN
1) Clean top of both insulin bottles with alcohol swab.
2) Mix cloudy insulin well.
3) Put air (same as number of units of insulin needed) in cloudy vial and remove needle.
4) Put air (same as number of units of insulin needed) into clear vial.
5) Pull number of units of clear insulin needed into syringe and remove needle.
6) Put needle into cloudy vial.
7) Pull number of units needed into syringe. You have to stop at the right amount. Do not push any insulin back into the cloudy vial.
8) Take needle out of the cloudy vial.
9) Give injection right away. If using Ultralente, do not let sit for more than one minute.
PRE-LOADED SYRINGES
• Pre-filled syringes should be placed in a vertical position with the needles pointing upward to prevent the suspended insulin particles from clogging the needle bore.
• Pre-drawn syringes with an R + NPH mix are stable in syringe for 21 days. Pre-drawn syringes need to be stored in refrigerator.
• The mixed insulin must be resuspended by rolling the barrel of the syringe between the palms before use.
DISPOSAL OF SHARPS
The Department of Public Works and Transportation has opened their new Household Special Waste (HSW) Facility at 115 Industrial Park Crescent (turn off Great Northern Road across from Esquire Honda).
The facility is open every Friday and Saturday from the beginning of April until the end of October each year, between the hours of 8:00 a.m. and 4:00 p.m.
All sharps should be properly containerized in a hard plastic bottle (i.e. Javex, Downey, Liquid Laundry Detergent) and sealed.
Sharp containers that are brought to the HSW Depot will be properly disposed through a pathological waste contractor instead of at our local landfill. This is the preferred way to dispose of your sharps.
Sharps will still be accepted with the regular curbside garbage collection if properly containerized.
If you have any questions or concerns, do not hesitate to call the Department of Public Works and Transportation at 759-5201
Finding it difficult to bring your sharps to the Household Special Waste Facility Depot?
Your local Sault Ste. Marie & District Branch of the Canadian Diabetes Association (CDA) located at 677 MacDonald Avenue; Unit #2 would be pleased to help. Drop off your sharps (properly containerized) and at the same time become familiar with the services your branch office has to offer. Call the CDA office at 759-1233 if you require further information.
HYPOGLYCEMIA
Causes:
1) Too much insulin injected.
2) Insulin has been injected, but the meal has been delayed or interrupted.
3) After drinking alcohol.
4) During or after exercise.
Symptoms:
Sudden tiredness
Vomiting
Fast heart rate
Dizziness
Frequent sighing
Nausea
Confusion
Headache
Tingling
Numbness-lips
Silliness
Hunger
• (BS from 3.0-4.0) Mild to moderate hypoglycemia should be treated with 15 g of carbohydrate, preferably as glucose or sucrose tablets. In smaller children, 10 g of glucose may be used initially.
• (BS below 3.0) Severe hypoglycemia in a conscious person should be treated with 20 g of carbohydrate, preferably as glucose tablets or equivalent. Retreat with another 15 g glucose if blood glucose remains <4.0 mmol/L after 15 minutes.
The items in the table below are listed in order of the quickest to slowest acting carb.
4 BD Glucose Tablets
1-1/2 Tbsp. Honey
12 Lifesavers
8 ounces (250 mL) Unsweetened Fruit Juice
8 ounces (250 mL) Regular Pop
4 tsp. White Sugar
3 BD Glucose Tablets
1 Tbsp. Honey
8 Lifesavers
6 ounces (200 mL) Unsweetened Fruit Juice
6 ounces (200 mL) Regular Pop
3 tsp. White Sugar
• Once hypoglycemia is reversed, the person should have their usual meal or snack. A snack including 15 g of carbohydrate and a protein source is recommended, i.e. crackers, cookies, bread with meat, cheese or peanut butter, if a meal is more than 1 hours away and in the absence of complicating factors.
Avoid high fat carbohydrate foods for treatment of low sugars as the fat slows the digestion and you won’t get quick results. For example—chocolate bars, cookies, ice cream, etc.
• Severe hypoglycemia in an unconscious person in the home situation should be treated with 1 mg glucagon subcutaneously. In children 5 years of age or younger, a dose of 0.5 mg should be used.
• For severe hypoglycemia with unconsciousness, IV glucose, 10 to 25 g (20 to 50 cc D50W) given over 1 to 3 minutes, is the standard medical paramedical treatment.
• A PRN order for glucagon should be considered for any hospitalized patient at risk for severe hypoglycemia.
ALCOHOL
• Alcohol can cause low blood sugar as it blocks the release of sugar from the liver.
• When consuming alcohol in moderation, always combine with meal or snack.
• Alcohol may have a delayed effect (i.e. if you drink in the evening, you may experience low blood sugar through the night). Test blood sugars regularly.
• Alcohol may mask your usual signs of hypoglycemia.
• Alcohol blocks the effect of Glucagon.
OTHER MEDICATIONS
Other regular medications, such as Beta Blockers (blood pressure & heart medication) can mask the usual signs of hypoglycemia.
DIABETES AND DRIVING... YOUR RESPONSIBILITIES
Driving is a privilege. Everyone who applies for a driver’s license must prove they are going to be responsible behind the wheel.
When you have diabetes this means your diabetes must be in good control. Take an active role in your diabetes management by maintaining medical records and using blood glucose logs.
• If you are taking insulin or diabetes pills you should have the following supplies close at hand in your vehicle . . .
~ Self monitoring equipment--one that is calibrated correctly preferably with meter downloading capabilities.
~ A source of rapidly absorbable sugar like juice or glucose tablets or LifeSavers, and a snack (protein/starch choice).
• You should check your blood sugar immediately before driving and then approximately every four hours after that. Do not drive if blood sugar level is <4.0 mmol/L.
• If your blood sugar is between 4.0 and 5.0 mmol/L driving should be stopped and not resumed until your blood sugar level increases by eating food.
• If you feel symptoms of a reaction starting, pull over immediately. Turn the ignition off and remove the keys. Test your blood sugar and treat your low blood sugar. You should not drive until at least 45 to 60 minutes after effective treatment of mild to moderate hypoglycemia. Re-check your blood sugar before you start driving again.
• You should limit driving to a maximum of 12 hours during the day. You should not have more than 6 consecutive hours between your meals.
• If you are a commercial driver your physician will help devise a work schedule that is compatible with your insulin routine.
~ If on insulin, blood sugar must be tested within 1 hour before driving and approximately every 4 hours while driving.
~ Driving should be stopped if blood glucose levels fall below 6.0 mmol/L and should not be resumed until blood glucose level has risen >=6.0 mmol/L after food ingestion.