Drawing up more than one type of insulin

For *short-acting insulins*, the time interval between injecting insulin and eating a meal is

20 to 30 minutes BEFORE a meal.

If insulin has been refrigerated prior to administration.

Bring insulin to room temperature

EXPECTED OUTCOMES

Combined medications equal correct dose. Correct medications are combined. No air bubbles are present in syringe barrel.

3. When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection? A. Insert air into the intermediate-acting insulin. B. Warm the vials to room temperature. C. Shake the vials to disperse the medication within the suspension. D. Withdraw the prescribed amount of short-acting insulin after the intermediate-acting insulin.

Insert air into the intermediate-acting insulin. Rationale: Air is injected into the intermediate-acting insulin before it is injected into the short-acting insulin. Warming the vials to room temperature will enhance patient comfort but will not ensure the effectiveness of the insulin injection. Shaking insulin is not recommended, as it may damage the protein molecules. Short-acting insulin must be drawn up before intermediate-acting insulin.

Supplies

Rapid- or short-acting insulin and longer-acting insulins in multi-dose vials U-100 insulin syringe with preattached needle (29-gauge, ½ inch) Alcohol swabs Tape and permanent marker (if syringe is prepared away from patient's bedside)

4. When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe? A. By noting when 5 units of clear insulin is visible in the syringe B. By noting when 12 units of cloudy insulin is visible in the syringe C. By having another registered nurse verify the presence of 17 units of insulin D. By verifying that the prescription confirms the medication administration record (MAR)

Rationale: Because it is clear, regular insulin will be drawn into the syringe first, so it is the first thing the nurse will verify as she draws the proper dosage. NPH or cloudy insulin is not drawn into the syringe first. While this confirms the correct total insulin volume, it fails to confirm the first step of drawing the clear, regular insulin. Although this confirms the amount of insulin prescribed, which is important, it does not address the amount of insulin in the syringe.

DOCUMENTATION Documentation Guidelines:

Record insulin administration after giving the drug. It is not necessary to document separately the preparation or mixing of insulin. Record blood glucose levels as ordered prior to the administration of insulin. Record the patient's weight in kilograms per the organization's practice Record unexpected outcomes and related nursing interventions

Do not compound IV push medications (combining two or more medications) in a single syringe outside the pharmacy.

TRUE

MONITORING AND CARE

Take the insulin to the patient's bedside for administration. Before administering the insulin to the patient, compare the MAR with the label on the prepared insulin syringe.

what type of syringe is used when administering insulin?

U-100 insulin syringe

NEVER administer insulin with anything but a

U-100 insulin syringe with preattached needle (29-gauge, ½ inch)

Do not mix insulin with any other medication or diluent unless

approved by the health care provider.

NPH or_____ ______ is not drawn into the syringe first.

cloudy insulin

ALWAYS check ________before drawing up 2 types of insulin

compatibility

Shaking insulin is not recommended, as it may

damage the protein molecules.

when combining two or more types of insulin that one that is the longer acting of the two, should be

drawn up last

Warming the vials to room temperature will

enhance patient comfort but will not ensure the effectiveness of the insulin injection.

Always, Check the ________ ____________ on the vials.

expiration date

Short-acting insulin must be drawn up before

intermediate-acting insulin.

The sequence in which vials are prepared or drawn does not matter when mixing two

intermediate-acting insulins in the same syringe.

When mixing medications from two vials, do not contaminate one medication with another. Always draw up the short- or rapid-acting insulin BEFORE the

longer-acting insulin to prevent its being contaminated with the longer-acting insulin.

If insulin is prepared away from the patient's bedside, label the syringe with the

name and volume of each insulin in the syringe.

*Mixed insulins* containing a RAPID-OR-SHORT ACTING insulin should be injected

no earlier than 5 to 15 minutes before a meal.

Remember to do a third accuracy check against the MAR at

the patient's bedside.

Maintain aseptic technique during preparation of insulin for injection. Do not use a single-dose vial more than once. Multiple use of single-dose vials increases

the risk for blood-borne pathogen infections. Use one needle, one syringe, only one time on one patient.

Since insulin is considered a "high-alert" medication, have another registered nurse double-check

the type and amount after it has been draw up into the syringe and before administration.

When mixing *rapid- or short*-acting insulin *with intermediate*-acting insulin, prepare the injection as follows:

1. First calculate the total volume of insulin you will need. 2. Ask another registered nurse to verify the types of insulins and your calculations. 3. Roll the vial between your hands. 4. Wipe off the top of the *rapid- or short-acting* insulin with an alcohol swab. 5. For insulin suspension preparations, roll the vial between your palms to redistribute any medication that settles out. Wipe off the insulin with a new alcohol swab. 6. Pick up the insulin syringe with a preattached needle. 7. Aspirate a volume of air equal to the total amount of intermediate insulin to be administered. 8. Insert the needle of the syringe into the longer-acting insulin. (Do not allow the needle tip to touch the solution in the vial.) 9. Inject a volume of air equal to the amount of intermediate insulin that will be given. 10. Immediately withdraw the needle, without aspirating any medication. 11. Insert the needle of the same syringe into the short- or rapid-acting insulin. 12. Inject the remaining amount of air (equal to the prescribed dose of short-acting insulin) into the vial. 13. *Invert* the vial of the *rapid- or short-acting insulin*, with the needle still inserted, and draw up the ordered amount of the rapid- or short-acting insulin. 14. Remove the syringe from the vial of rapid- or short-acting insulin, eliminating any air bubbles to ensure an accurate dose. 15. Verify the short-acting insulin dosage with the MAR. 16. Show the insulin prepared in the syringe to another nurse to verify that the correct dosage has been prepared. 17. Determine the point on the syringe scale to which the combined units of insulin should reach, by adding the number of units of both insulins together. 18. Verify the combined dose. 19. Place the needle of the syringe back into the vial of intermediate- or long-acting insulin. As you do, be careful not to push the plunger and inject insulin from the syringe into the vial. 20. Invert the vial and carefully withdraw the desired amount of insulin into the syringe. 21. Do not overdraw or push any insulin in the syringe back into the vial. Either of these actions could cause the wrong volume of either insulin to be drawn up. 22. Withdraw the needle, and check the volume in the syringe. 23. Verify the volume with another registered nurse. Keep the needle of the prepared syringe sheathed or capped until you are ready to administer the medication.

For subcutaneous injections, assess the patient's

1. body build 2. muscle size 3. weight.

Visually inspect the insulin vial before administration. Do not use insulin if you note

1. clumping 2. frosting 3. precipitation 4. altered clarity 5. altered color.

Do not mix insulin with any other types of insulin, and do not administer either intravenously.

1. insulin glargine (Lantus®) or 2. insulin detemir (Levemir®)

Know the 1.__________, 2._____________ & 3. ____________ of all insulin given. *Timing* of insulin injection is critical to correct insulin administration.

1. onset 2. peak 3. duration

Document the procedure in the patient's record.

1. type of insulin 2. dose 3. injection site 4. date 5. time 6. your name

what type of needle is used when administering insulin?

29-gauge (0.5inch) IT WILL BE PRE_ATTACHED

Preparation and administration must be timely, taking into consideration mealtimes. Usually the time between injecting a *rapid-acting* insulin and eating a meal is no more than

5 to 15 minutes.

UNEXPECTED OUTCOMES

Air bubbles remain in syringe barrel. Incorrect medications combined. Excess or insufficient volume of medication is prepared.

regular insulin will be drawn into the syringe first, regular insulin should be

CLEAR (as in clarity)

ASSESSMENT AND PREPARATION

Check the accuracy and completeness of each medication administration record (MAR) against the health care provider's medication orders. Confirm the patient's name, the specific type of insulin, the dosage in units, and the time of administration. Clarify incomplete or unclear orders with the health care provider. Note if the patient has allergies. Determine the region where previous insulin injections have been given, and plan to use a different site within the same region. **Obtain the patient's current blood glucose level prior to preparing insulin**. Familiarize yourself with the expected action, onset, peak, and duration of the prescribed insulin(s). Coordinate the administration of rapid- and short-acting insulin with mealtime, Rapid-acting insulin is administered no more than 5 to 15 minutes before a meal. Short-acting insulin is administered no more than 20 to 30 minutes before a meal. Draw up the appropriate dose of insulin into the insulin syringe. Check the label of the insulin and the amount drawn into the syringe against the MAR two times. Check the expiration date on the vial. Verify the patient's actual admission weight in kilograms. Reweigh the patient if appropriate. Roll an insulin suspension preparation between your palms before drawing it up into the syringe.

2. The patient is to receive both Lantus® (insulin glargine) and regular insulin. To ensure the proper action of the insulins, what would the nurse do when preparing these two types of insulin for administration? A. Mix the insulins in one syringe for a single injection. B. Prepare the insulins in two syringes for separate injections. C. Roll each vial between the palms to disperse the medication within the suspension. D. Have another registered nurse verify the dose of the insulins.

Prepare the insulins in two syringes for separate injections. Rationale: Lantus is not to be mixed with other insulins. Separate injections are required. Lantus and regular insulins are solutions and do not settle out. Verifying the dose is important but will not affect the proper action of the insulins.

Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe? A. Draw the intermediate-acting insulin into the syringe first. B. Draw the long-acting insulin into the syringe first. C. Prepare two injections. D. Draw either the intermediate- or the long-acting insulin into the syringe first.

Prepare two injections. Rationale: You never mix long-acting insulin with any other insulins. You would need to prepare two injections because you never mix long-acting insulin with any other insulins.

The nurse is preparing to mix short- and intermediate-acting insulins to administer to a patient. Which action best preserves the insulin's effectiveness? A. Determining the patient's blood glucose level B. Refraining from injecting the intermediate-acting insulin into the short-acting vial C. Applying clean gloves when administering the medication D. Having another registered nurse verify the dose of both types of insulins

Refraining from injecting the intermediate-acting insulin into the short-acting vial Rationale: Refraining from injecting the intermediate-acting insulin into the short-acting vial will prevent the short-acting insulin vial from being contaminated with intermediate-acting insulin. Determining the patient's blood glucose level will not ensure the effectiveness of the insulin. Wearing clean gloves will not ensure the effectiveness of the insulin. Having another nurse verify the dose will not ensure the effectiveness of the insulin.