Dr Praveen Ramachandra
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INSULIN ADMINISTRATION

Steps to follow while administering insulin injection

  •        Hand wash: Wash hands with warm, soapy water using plenty of friction.

  •        Clean the site:  Make sure the injection site is cleansed with soap and water or an alcohol/spirit pad. The area should be dry before injecting. 

  •        Numbing the area: This is usually not necessary but sometimes helps children feel better about a forthcoming shot. One can numb the area with ice; (never put cold objects directly on the skin, wrap them in a hand towel or wash cloth). Numbing creams that contain lidocaine are expensive and have some side effects and are not recommended for multiple daily injections. Cold insulin right from the refrigerator can causes stinging when injected. It is fine to let your pen, or syringe warm up for 5 minutes, or, even the bottle of insulin for 5-10 minutes.

  •        Pinch up a fold of skin: Pinch up a fold of skin surrounding the site you've selected. Hold it firmly with one hand. One can inject insulin into muscle, but it is more painful. Inject into fat when possible. 

  •        Inserting the needle:  Inserting faster is better, inserting slowly will cause more pain. Try inserting the needle almost like you would toss a dart. 

  •        Needle angle:  For adults or those with good fatty tissue, insert at a 90° angle. Thin adults and children may need to inject at a 45° angle. Try to get the needle all the way into fatty tissue below the skin, but not so deep that it hits the muscle below. 

  •        Injecting the insulin: Push the syringe plunger all the way in with a slow steady motion or firmly press the insulin pen injection button. Wait ten seconds before removing the needle. Let go of the skin. 

  •        Remove the needle by pulling straight out: Twisting or shifting the needle's position will cause pain. You may gently press on the injection site with your finger for a couple seconds. Do not rub or massage the skin where the insulin is injected; it can affect how fast the insulin is absorbed and acts within the body. 

  •        Dispose: Dispose the syringe in a hard plastic container.

Rotating Injection Sites

Injecting in the same place much of the time can cause hard lumps or extra fat deposits to develop. These lumps are not only unsightly; they can also change the way insulin is absorbed, making it more difficult to keep the blood glucose on target.

Follow these two rules for proper site rotation:

  •        Same general location at the same time each day.
  •        Rotate within each injection site.

Same Time, Same General Location:

Insulin is absorbed at different speeds depending on where you inject, so it's best to consistently use the same part of the body for each of your daily injections. For example, do not inject your lunch bolus dose in the abdomen on Monday and in the thigh on Tuesday. If you have picked the thigh for your evening injection, then continue to use the thigh for all of your evening injections.

Most insulin enters the blood:  

·        Fastest from the abdomen (stomach)

·        A little slower from the arms

·        Even slower from the legs

·        Slowest from the buttocks

 Inject your mealtime bolus doses into the abdomen. Insulin is absorbed fastest when injected into this area. Fast absorption is needed at mealtimes to cover the carbohydrates you are about to eat.

Long-acting insulin could be injected into the thigh or buttocks.

If you mix two types of insulin in one shot, you can inject into the abdomen, arm, thigh, or buttocks.

Rotate Within an Injection Site:

To avoid developing hard lumps and fat deposits, it is important to inject in different spots within a general part of the body.

  •        Change sides within an area. For example, if you inject your evening insulin in the thigh, try using the right thigh one evening and the left thigh the next evening.

  •        You might find it useful to picture the face of a clock on your abdomen. That helps you to keep each of your injections at least one finger’s width from the last injection.

  •     Ask the patient to examine their abdomen and picture “Noon” below your belly button. Place the first injection at Noon, your second injection at 1 o’clock, the third injection at 2 o’clock, and the fourth injection at 3 o’clock. The patient will not come back to the “Noon” spot again until day 4, which gives that spot a chance to rest.

Smart Tips for Site Rotation

Work with your doctor and track your blood glucose levels carefully when you begin practicing site rotation. Over time, you and your doctor will learn which injection sites give you the best blood glucose control at different times of day.

  •       Do not inject close to the belly button. The tissue there is tougher, so the insulin absorption will not be as consistent.

  •       For the same reason, do not inject close to moles or scars

  •        If you inject in the upper arm, use only the outer back area (where the most fat is). It is hard to pinch the upper arm when you are injecting yourself. Try pressing your upper arm against a wall or door.

  •       If you inject in the thigh, stay away from the inner thighs. If your thighs rub together when you walk, if might make the injection site sore.

  •        Do not inject in an area that will be exercised soon. Exercising increases blood flow, which causes long-acting insulin to be absorbed at a rate that’s faster than you need.

  •        Do not become a creature of habit. It might seem easier to find a spot that does not hurt and inject there all of the time. However, the result could be unpleasant swelling and lumps.

  •        Move to a new injection site every week or two.

o   Inject in the same area of the body, making sure to move around within that area with each injection, for one or two weeks.

o   Then move to another area of your body and repeat the process.

o   Use the same area for at least a week to avoid extreme blood sugar variations.

  •        Rotate the sides (right, left) of your body where you inject within your injection sites.

Injection Site Selection

The most common injection site is the abdomen (or stomach). The back of the upper arms, the upper buttocks or hips, and the outer side of the thighs are also used. These sites are the best to inject into for two reasons:

  •        They have a layer of fat just below the skin to absorb the insulin, but not many nerves - which means, that injecting there will be more comfortable than injecting in other parts of your body.

  •        They make it easier to inject into the subcutaneous tissue, where insulin injection is recommended. Depending on your body type, you'll find that certain injection sites work better than others.

  •        Some people, for example, prefer injecting in the abdomen because the insulin absorbs well there.

  •        Injecting in the abdomen isn't right for everyone, especially young children or people who are so thin and/or heavily muscled that they can't pinch up a half-inch of fat.

Fig 1: Selection of injection sites for Insulin

Insulin and Insulin Analogues Table

Insulin Preparation

Onset of action

Peak

Duration of Action

Comments

Rapid-acting Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

5 to 15 minutes

1 to 2 hours

4 to 5 hours

 

Short-acting Regular (recombinant) (Humulin R) (Novolin R)

20 to 60 minutes

2 to 4 hours

8 to 10 hours

Inject 30 min prior to meal

Intermediate-acting Isophane (NPH) (Humulin N) (Novolin N)

1 to 2 hours

4 to 8 hours

10 to 20 hours

 

Long-acting Detemir (recombinant) (Levemir)

 Glargine (Lantus)

1 to 2 hours

 

 

 

1 to 2 hours

Relatively flat

 

 

 

Relatively flat

12 to 20 hours

 

 

 

20 to 24 hours

Administered once to twice daily (12 hours apart), can be kept w/o refrigeration up to 42 days

Usually administered once daily

Mixed

Multiple preparations NPH/Regular mixHumulin 70/30 Novolin 70/30 Aspart Protamine/ AspartNovolog Mix 70/30Lispro Protamine/Lispro Humalog Mix 75/25

20 to 60 minutes

 

 

 

 

 

 5 to 15 minutes

Dual peak (short & intermediate up to 12 hrs)

 

 

 

Dual peak (fast & intermediate)

Dual duration (8 to up to 20 hours)

 

 

 

 

Dual duration-up to 24 hours

Glycemic control

may not be as tight with mixed insulins as the ratio of the two

preparations cannot be altered

Administer twice

daily at breakfast and dinner

Individuals who do not have regular

access to food will be at a higher risk for

significant

hypoglycemia

 

Storage and Handling Insulin

Always read the instructions that come with your insulin. Bottles of insulin, either open or unopened, generally last for one month when stored at room temperature (59 to 86°F). A bottle is considered open if its seal has been punctured. If you remove the cap but don't puncture the seal, the bottle is still considered unopened.

If stored in a refrigerator, unopened bottles are good until the expiration date printed on the bottle. Opened bottles that are stored in a refrigerator should be used within one month of being opened. Many people store their unopened bottles in the refrigerator and keep open bottles at room temperature because they find it uncomfortable to inject cold insulin.

Don't use bottled insulin past the expiration date printed on the label. And no matter what the expiry date is, throw away a bottle one month after you open it. To help you keep track, write the date that you opened the bottle on the bottle's label.

With insulin pens and their cartridges, storage life ranges from ten days to one month. Check the chart below for shelf life details on popular brands.

Length of time an insulin pen can be at room temperature

Insulin

Time (days)

Novolin R

28

Novolin N

14

Novolin70/30

10

Novolog

28

Humalog

28

Lantus

28

Levemir

42

 

 Steps to follow when using insulin syringe to administer insulin

For those with diabetes, an insulin shot delivers medicine into the subcutaneous tissue -- the tissue between your skin and muscle. Subcutaneous tissue (also called "sub Q" tissue) is found throughout your body.

Gather Insulin Supplies

Select a clean, dry work area, and gather the following insulin supplies:

  •       Bottle of insulin
  •       Sterile insulin syringe (needle attached) with wrapper removed
  •       Two alcohol wipes (or cotton balls and a bottle of rubbing alcohol)
  •       One container for used equipment (such as a hard plastic or metal container with a screw-on or tightly secured lid or a commercial "sharps" container)
  •      Wash hands with soap and warm water and dry them with a clean towel.

Prepare the Insulin and Syringe

  •        Remove the plastic cap from the insulin bottle.
  •        Roll the bottle of insulin between your hands two to three times to mix the insulin. Do not shake the bottle, as air bubbles can form and affect the amount of insulin withdrawn.
  •        Wipe off the rubber part on the top of the insulin bottle with an alcohol pad or cotton ball dampened with alcohol/spirit.
  •        Set the insulin bottle nearby on a flat surface.
  •        Remove the cap from the needle.

If you've been prescribed two types of insulin to be taken at once (mixed dose), skip to the instructions in the next section.

  •       Draw the required number of units of air into the syringe by pulling the plunger back. You need to draw the same amount of air into the syringe as insulin you need to inject. Always measure from the top of the plunger.
  •       Insert the needle into the rubber stopper of the insulin bottle. Push the plunger down to inject air into the bottle (this allows the insulin to be drawn more easily). Leave the needle in the bottle.
  •       Turn the bottle and syringe upside-down. Be sure the insulin covers the needle.
  •       Pull back on the plunger to the required number of units (measure from the top of the plunger).
  •      Check the syringe for air bubbles. Air bubbles in the syringe will not harm you if they are injected, but they can reduce the amount of insulin in the syringe. To remove air bubbles, tap the syringe so the air bubbles rise to the top and push up on the plunger to remove the air bubbles. Recheck the dose and add more insulin to the syringe if necessary.
  •       Remove the needle from the insulin bottle. Carefully replace the cap on the needle.

How to Measure a Mixed Dose of Insulin

Your doctor may prescribe two types of insulin to be injected at once for diabetes. This mixed dose may provide better blood sugar control for some people.

Steps to be followed when injecting a mixed dose of insulin:

  •       Follow the preparation steps described above for both bottles of insulin.
  •     Draw the required number of units of air into the syringe by pulling the plunger back. Draw air into the syringe equal to the amount of cloudy (intermediate or long-acting) insulin needed. Always measure from the top of the plunger (the edge closest to the needle).
  •     Insert the needle into the rubber stopper of the cloudy insulin bottle. Push the plunger down to inject air into the bottle (this allows the insulin to be drawn more easily). Do not withdraw the insulin into the syringe at this time. Take the needle out of the bottle.
  •     Draw the required number of units of air into the syringe by pulling the plunger back. Draw air into the syringe equal to the amount of clear (short-acting) insulin needed. Always measure from the top of the plunger.
  •     Insert the needle into the rubber stopper of the clear insulin bottle. Push the plunger down to inject air into the bottle (this allows the insulin to be drawn more easily).
  •     Turn the bottle and syringe upside-down. Be sure the insulin covers the needle.
  •     Pull back on the plunger to the required number of units of clear insulin needed (measure from the top of the plunger, the edge closest to the needle).
  •     Check the syringe for air bubbles. Air bubbles in the syringe will not harm you if they are injected, but they can reduce the amount of insulin in the syringe. To remove air bubbles, tap the syringe so the air bubbles rise to the top and push up on the plunger to remove the air bubbles. Recheck the dose and add more insulin to the syringe if necessary.
  •     Remove the needle from the clear insulin bottle and insert it into the rubber stopper of the cloudy insulin bottle.
  •     Turn the bottle and syringe upside-down. Be sure the insulin covers the needle.
  •        Pull back on the plunger to the required number of total units of insulin needed (measure from the top of the plunger).

Important:This must be an exact measurement. If you withdraw too much cloudy insulin, the total dosage in the syringe must be discarded. Be careful not to push any of the clear insulin from the syringe into the cloudy insulin. If there are large air bubbles after mixing the insulin in the syringe, discard this dosage and start the procedure again. Do not push the insulin back into the bottle.

Rotate Insulin Injection Sites

Because you will be injecting insulin on a regular basis for diabetes, you need to know where to inject it and how to rotate (move) your injection sites. By rotating your injection sites, you will make your injections easier, safer, and more comfortable. If the same injection site is used over and over again, you may develop hardened areas under the skin that keep the insulin from being used properly.

Important: Only use the sites on the front of your body for self-injection. Any of the sites may be used if someone else is giving you the injection.

Follow these guidelines:

  •             Ask your doctor, nurse, or health educator which sites you should use.
  •        Move the site of each injection. Inject at least 1 1/2 inches away from the last injection site.
  •        Try to use the same general injection area at the same time of each day (for example, use the abdomen for the injection before lunch). Note: The abdomen absorbs insulin the fastest, followed by the arms, thighs, and buttocks.
  •        Keep a record of which injection sites you have used.

Select and Clean the Injection Site

·        Choose an injection site for your insulin shot.

·        Do not inject near joints, the groin area, navel, the middle of the abdomen, or near scars.

·        Clean the injection site (about 2 inches of your skin) in a circular motion with an alcohol wipe or a cotton ball dampened with rubbing alcohol. Leave the alcohol wipe or cotton ball nearby.

Fig 2: Steps to follow while administering insulin (vial)

 

Inject the Insulin

Using the hand you write with, hold the barrel of the syringe (with the needle end down) like a pen, being careful not to put your finger on the plunger.

  •        Remove the needle cap.
  •        With your other hand, gently pinch a two- to three-inch fold of skin on either side of the cleaned injection site.
  •        Insert the needle with a quick motion into the pinched skin at a 90-degree angle (straight up and down). The needle should be all the way into your skin.
  •        Push the plunger of the syringe until all of the insulin is out of the syringe.
  •        Quickly pull the needle out. Do not rub the injection site. You may or may not bleed after the injection. If you are bleeding, apply light pressure with the alcohol wipe. Cover the injection site with a bandage if necessary.

Dispose of the Syringe and Needle

Do not cap the needle. Drop the entire syringe and needle into your container for used "sharps" equipment. When the container is full, put the lid or cover on it and throw it away with the trash.

Do NOT put this container in the recycling bin. Some communities have specific disposal laws. Check with your local health department for specific disposal instructions in your community.