What action should the nurse have taken before administering the insulin?
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Citation Text: Modic MB, Albert NM, Sun Z, et al. Does
an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314. Copy Citation Download Citation April 20, 2016 Modic MB, Albert NM, Sun Z, et al. J Nurs Adm. 2016;46(3):154-60. Insulin
is a high-risk medication, and The Joint Commission and Institute for Safe Medication Practices recommend that hospital insulin administration be double-checked by nurses. This randomized trial found that double-checking insulin can result in fewer
administration errors. Save Save to your library Print Cite Citation Citation Text: Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314. Copy Citation Download Citation
Insulin is the cornerstone of therapy in the management of type 1 diabetes. Insulin therapy also has a clear role in type 2 diabetes mellitus in patients with long-standing or poorly controlled disease. [1] Since the discovery of insulin approximately 80 years ago, insulin therapy has undergone various changes in formulations with different pharmacokinetics. In the 1930s, protamine zinc insulin, the first long-acting preparation, was introduced. In the 1950s, the neutral protamine hagedorn (NPH) and insulin zinc (lente) were introduced. [2] Newer formulations have since been developed, allowing insulin to be provided in more physiologically appropriate ways. These provide more flexibility in dosing, mimic endogenous production of insulin, and lower the incidence of nocturnal hypoglycemia. [3, 4, 5] When used as monotherapy, oral hypoglycemic drugs generally lower glycated hemoglobin (HgbA1C) by only 0.5%-1.5%. Most patients with type 2 diabetes eventually require multidrug therapy or insulin. Some guidelines encourage early use of insulin if HgbA1C remains poorly controlled on maximal-dose, single-drug therapy. Insulins have varying pharmacokinetics that allow for specific products from which to choose. Table 1 provides a comparison between insulins for onset of action and duration of action. Table 2 provides a list of combination insulin products. Table 1. Insulin Pharmacokinetics (Open Table in a new window)
Table 2. Insulin Combination Products (Open Table in a new window)
Rapid-acting insulins with a short duration of action include insulin aspart (NovoLog), insulin lispro (Humalog), and insulin glulisine (Apidra). Their onset of action is approximately 5-15 minutes, peak action is between 30 and 90 minutes, and duration of action is approximately 4-6 hours. Regular insulin (Humulin R, Novolin R) is categorized as short-acting with a short duration of action and regular onset of action. Regular insulin's onset is 30-60 minutes, peak is 2-3 hours, and duration of action is approximately 8-10 hours. In general, insulin lispro, insulin aspart, and insulin glulisine are slightly more effective than regular insulin in decreasing HgbA1C, with less nocturnal hypoglycemia. [6] In September 2017, Fiasp (insulin aspart injection) was approved by the US Food and Drug Administration (FDA) to improve glycemic control in adults with type 1 (T1D) and type 2 diabetes (T2D). This rapid-acting human insulin analog can be dosed at the start of a meal or within 20 minutes after starting a meal. Fiasp is formulated with niacinamide, which helps increase the speed of the initial insulin absorption. A pharmacokinetics study of adult patients with type 1 diabetes showed that Fiasp appeared in the circulation in approximately 2.5 minutes after administration. The time to maximum insulin concentrations was achieved in roughly 63 minutes after administration. [7] In the manufacturing of regular insulin, zinc atoms are added, causing the formation of hexamers. [2] Because they are larger molecules, they diffuse slowly into the circulation. On the other hand, insulin lispro has lysine and proline inverted at the B28 and B29 position and insulin aspart has the proline at position 28 replaced by aspartic acid. [2] These changes in structure reduce the formation of dimers and hexamers, and they are rapidly absorbed. The short-acting insulins typically are used as bolus insulin given premeal. The rapid-acting insulins are administered immediately before a meal, whereas regular insulin is administered 30 minutes before a meal. [8] Insulin NPH (Humulin N, Novolin N) is an intermediate-acting insulin that is a suspension of crystalline zinc insulin combined with the positively charged polypeptide protamine. Unlike the shorter-acting insulins, NPH has a longer duration of action, yet not as long as the newer long-acting insulins. Insulin NPH's onset of action is 2-4 hours, peak action is 4-10 hours, and duration of action is approximately 12-18 hours. NPH insulin is also available in combination with regular insulin (insulin isophane human/insulin regular human). They are in a fixed combination of either 70% or 75% of NPH and 25% or 30% of regular insulin. These are marketed as Humulin 70/30 or Novolin 70/30. It is also available with NPH and a rapid-acting insulin combination. NPH/lispro mixtures are Humalog Mix 50/50, Humalog Mix 50/50 KwikPen, Humalog Mix 75/25, and Humalog Mix 75/25 KwikPen. NPH/aspart mixtures are marketed as NovoLog Mix 70/30 and NovoLog Mix 70/30 FlexPen. These combinations are a good option for patients who may be noncompliant, those who want to reduce theirnumber of self-injections, and those who are unable to use more sophisticated regimens. On the other hand, it is hard to manipulate the dosing because they are in a fixed combination. The long-acting insulin analogs were made with recombinant DNA technology. Insulin glargine (Lantus) is made by replacing the asparagine by glycine in the A-chain and adding 2 arginines at the C-terminus of the B-chain. When injected into subcutaneous tissue, this forms microprecipitates, which then delays absorption from the injection site. Insulin detemir (Levemir) is manufactured by elimination of the amino acid threonine at position B30 and the addition of a 14-carbon fatty acid chain at position B29. Insulin detemir is also slowly absorbed from the injection site; in addition, it is also reversibly bound to albumin in the blood, which further prolongs its action and clearance. [2] Of the two that are currently available, insulin glargine is considered long-acting, and insulin detemir is considered intermediate-to-long acting. Insulin detemir may have to be given twice a day because it may wear off before the subsequent dose. [9] The long-acting insulins, in addition to having a long duration of action, do not have a pronounced peak effect. Some European studies have shown an association of increased risk of cancer with insulin glargine, as opposed to other insulins. [10] Although this may be alarming, these studies have not been convincing. Once-weekly injectable insulin is being studied in patients with type 2 diabetes. Phase 2 data show that it is comparable in efficacy and safety to insulin glargine. [11] When insulin therapy is initiated in a patient who is already on oral medication, a basal (long- or intermediate-acting) rather than short-acting or premeal insulin should be chosen. Basal insulin helps improve nocturnal and fasting blood glucose levels, whereas premeal bolus insulin decreases postprandial glucose elevations. When choosing a basal insulin and drug cost is not a barrier, insulin glargine or detemir may be a better option than NPH insulin because they do not have a peak and therefore have a lower risk of nocturnal hypoglycemia. In all patients with type 1 diabetes and in patients with type 2 diabetes with elevated levels of postprandial blood glucose, a bolus premeal insulin should be given. All patients with type 1 diabetes and patients on oral medications may be started on basal insulin. For basal insulin, either the intermediate-acting or the long-acting insulins are used, and, for bolus or preprandial insulin, the short-acting insulins are used. What should a nurse check before administering insulin?Perform a physical assessment to establish a baseline before beginning therapy. Assess skin lesions; orientation and reflexes; blood pressure, pulse, respiration and adventitious breath sounds which could indicate a response to high or low glucose levels and potential risk factors in giving insulin.
What are the nursing interventions for insulin?Interventions. Ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking.. Give maintenance doses subcutaneously, rotating injection sites regularly to decrease incidence of lipodystrophy; give regular insulin IV or IM in severe ketoacidosis or diabetic coma.. |
