101 Quiz 9

The amount of insulin that an individual with diabetes needs depends on 3 factors:

(1) the type of diabetes, (2) the presence of other diseases or illnesses (3) the individual's body weight.

Pre-Meal Administration of Insulin

*Preferred pre-meal insulin regimens are usually combined with routine doses of long-acting insulin administered once or twice per day.

Intravenous Administration of Insulin

*high risk of adverse reactions treat individuals with extremely high blood glucose levels. Intermediate, long-acting, and mixtures of insulin are not appropriate for intravenous infusions because of their long duration of action, which makes titration of insulin less predictable.

Insulin Orders

1. on a routine or "fixed" schedule 2. to be given before a meal 3. to be given after a meal 4. as a correction dose 5. using a sliding scale 6. using a combination of methods

Insulin Concentration

100 units per mL Only regular (short-acting) insulin comes in two strengths: U-100 and U-500

Regular (short-acting) insulin is available in two strengths:

100 units/mL and 500 units/mL.

Algorithm

A set of rules specifying the instructions for accomplishing a task or achieving a goal.

Hyperglycemia

Abnormally high blood glucose levels.

Hypoglycemia

Abnormally low blood glucose levels.

Administering Insulin Using Syringes and Vials

Administering insulin with a syringe and vial requires the full attention of the nurse. It is easy to make errors when drawing up insulin because insulin doses tend to be small, and some different insulin vials look similar. Always ask another nurse to check the insulin dose for accuracy before administering it.

Postprandial (pc)

After meals

Insulin analog

An altered form of insulin.

Rapid-Acting insulin

Aspart (Novolog) Lispro (Humalog) Glulisine (Apidra) inhalation (Afrezza)

Preprandial (ac)

Before meals

Carbohydrate Counting

Carbohydrate counting requires determining the number of grams of carbohydrates to be eaten during a meal, then injecting a predetermined dose of rapid-acting insulin to metabolize the ingested carbohydrates. Most meals should contain 30 to 60 grams of carbohydrates. An individual using carbohydrate counting should be able to read food labels and accurately calculate the amount of needed insulin.

type 1 diabetes mellitus

Caused by an autoimmune process that destroys the beta cells in the pancreas. Person is unable to produce endogenous insulin, so they must inject exogenous insulin to survive.

Treatment of hypoglycemia

Depends on whether the patient is conscious, is able to eat, or has intravenous access. retest the patient's blood glucose level 15 minutes after providing treatment. Continue the treatment until the blood glucose level is greater than 70 mg/dL

Endogenous

Derived or produced from inside the human body.

Exogenous

Derived or produced from sources outside the human body.

Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that results from impaired pancreatic secretion of insulin and/or defects in the action of insulin inside cells. Managed with diet, exercise, and medications.

25. Only the intermediate- and long-acting types of insulin should be used in intravenous infusions. True/False

False

6. A correction dose of insulin is administered when a patient's blood glucose level is abnormally low. True/False

False

Examples of routine insulin orders include the following:

Insulin glargine (Lantus) 20 units, subcut, every evening • NPH insulin 14 units, subcut, before breakfast • NPH insulin 25 units, subcut, before evening meal • NovoLog Mix 70/30, 18 units, subcut, before breakfast and dinner

Routine Administration (Fixed Schedule)

Intermediate- and long-acting insulin (including mixtures of insulin, such as Humalog Mix 75/25 or NovoLog Mix 70/30) are usually ordered on a routine basis. This regimen provides a slow release of insulin over a relatively long period (called a basal level), which mimics the body's own natural release of insulin throughout the day.

gestational diabetes

Is the presence of diabetes during pregnancy and may be caused by hormonal changes and/or a lack of insulin. Gestational diabetes may disappear after delivery of the baby, although a small percentage of women will continue to have diabetes (usually type 2) after the pregnancy. Other women may develop type 2 diabetes later in life.

Insulin may be ordered on a routine (fixed) schedule, to be administered either before or after meals, as a correction dose, or on a sliding-scale basis.

Most insulin regimens consist of a combination of methods.

NPH insulin

Neutral protamine Hagedorn insulin.

Insulin may be administered intravenously.

Only regular insulin and several of the rapid-acting types of insulin may be given intravenously. Careful attention is needed when titrating an insulin infusion based on the patient's blood glucose level.

Intermediate-acting: NPH insulin/isophane insulin suspension (Novolin N, Humulin N)

Onset: 1-2 hrs. Peak: 4-12 hrs. Duration: 18-24 hrs. Admin: 30-60 ac

Rapid-Acting: Aspart (novoLog)

Onset: 10-20 min Peak: 1-3 hr Duration: 3-5 hr Admin: 5-10 min ac

Inhalation (Afrezza)

Onset: 12-15 min. Peak: 50 min. Duration: 3 hrs. Admin: Beginning of meal

Insulin Mixtures: Insulin aspart protamine suspension/insulin aspart solution (NovoLog Mix 70/30)

Onset: 15 min. Peak: 1-4 hrs. Duration: 18-24 hrs. Admin: up to 15 min. ac

Insulin Mixtures: Insulin lispro protamine suspension/insulin lispro solution (Humalog Mix 75/25, Humalog Mix 50/50)

Onset: 15-30 min. Peak: 2.8 hrs. Duration: 24 hrs. Admin: Up to 15 min. ac

Long Acting: Insulin detemir (Levemir)

Onset: 3-4 hrs. Peak: 3-14 hrs. Duration: 24 hrs. Admin: With evening meal or at bedtime

Long-Acting: Insulin glargine (Lantus, Toujeo)

Onset: 3-4 hrs. Peak: None Duration: 24 hrs. Admin: At same time each day

Insulin Mixtures: NPH/regular insulin mixture (Humulin 70/30, Novolin 70/30)

Onset: 30 min. Peak: 4-8 hrs. Duration: 24 hrs. Admin: 30-60 min.

Short-Acting: Regular Insulin (Novolin R, Humulin R)

Onset: 30-60 min. Peak: 2-4 hrs. Duration: 5-7 hrs. Admin: 15-30 ac

Rapid-Acting: Glulisine (Apidra)

Onset: Less than 15 min. Peak: 1 hr. Duration: 2-4 hrs. Admin: 15min ac within 20 min

Rapid-Acting: Lispro (Humalog)

Onset: less than 15 min. Peaks: 1/2 -1 hr. Duration: 3-4 hrs. Admin: 5-15 min ac

Insulin Cap colors

Orange U-100 Green U-500

Particulates

Particles of solids suspended in a liquid.

Post-Meal Administration of Insulin

Patient who is very ill may not be able to eat well. Giving a routine or standard dose of insulin before a meal may cause the individual to experience hypoglycemia.

Insulin Delivery Systems

Prior to 2006, insulin could be administered into the body only by way of subcutaneous or intravenous injection. Standard insulin preparations taken orally were destroyed by the digestive system before they could reach the bloodstream, rendering them ineffective in reducing blood glucose levels. In 2006, a powdered form of insulin that could be inhaled was introduced to the U.S. market, but production was discontinued after several years because the drug was expensive, few people were using it, and there was concern that the drug might be linked to lung disease. In 2014, the FDA approved a new inhaled powdered insulin Afrezza. Clinical trials are underway for an oral form of insulin.

Carbohydrate counting

Requires determining the number of grams of carbohydrates to be eaten during a meal, then injecting a predetermined dose of rapid-acting insulin to metabolize the ingested carbohydrates. Most meals should contain 30 to 60 grams of carbohydrates. An individual using carbohydrate counting should be able to read food labels and accurately calculate the amount of needed insulin.

Combination of Methods

Some facilities use the medication administration record to accomplish this, while others may use a separate flow sheet

Oral and Injected Antidiabetic Medications

Table 15-1

Basal

The minimum level necessary to sustain life.

type 2 diabetes mellitus

The pancreas may still produce some insulin, but the insulin is not used effectively by the body's cells.

10. NPH insulin (Novolin N) may be mixed with insulin aspart (NovoLog). True/False

True

24. External insulin pumps are a good choice for individuals who are able and willing to check their blood glucose levels often, and are able to make adjustments to their insulin intake. True/False

True

7. U-100 insulin refers to insulin preparations that contain 100 units of insulin per mL. True/False

True

9. Injection pen devices are a good choice for individuals who have poor eyesight. True/False

True

4. Which type of insulin has an onset of 1 to 2 hours, peaks in 4 to 12 hours, and has a duration of action from 18-24 hours? a. NPH insulin (Novolin N) b. insulin glulisine (Apidra) c. insulin detemir (Levemir) d. regular insulin (Humulin R)

a. NPH insulin (Novolin N)

6. Which insulin should be administered 30 to 60 minutes before meals? a. NPH insulin (Novolin N) b. regular insulin (Humulin R) c. insulin aspart (NovoLog) d. insulin lispro (Humalog)

a. NPH insulin (Novolin N)

14. One characteristic of a U-100 insulin syringe that differentiates it from a standard syringe is: a. The cap of the insulin syringe is orange. b. An insulin syringe can hold up to 3 mL of solution. c. The needles on an insulin syringe may be up to 1½ inches long. d. An insulin syringe has the U-250 designation on it.

a. The cap of the insulin syringe is orange.

8. Which insulin is rapid-acting? a. insulin aspart (NovoLog) b. insulin glargine (Lantus) c. regular insulin (Humulin R) d. insulin detemir (Levemir)

a. insulin aspart (NovoLog)

5. Which type of insulin may be given intravenously? a. regular insulin (Humulin R) b. NPH insulin (Novolin N) c. insulin detemir (Levemir) d. insulin glargine (Lantus)

a. regular insulin (Humulin R)

Hypoglycemia

abnormally low blood glucose level, typically below 70 mg/dL.

Oral: Alpha-glucosidase inhibitors

acarbose (Precose), miglitol (Glyset) Delays and reduces carbohydrate absorption in the gastrointestinal tract.

For a patient who is unconscious or unable to eat and does not have intravenous access

administer 1 mg glucagon by subcutaneous or intramuscular injection. Roll the person onto his or her side after administrating the glucagon, since it can cause vomiting. Obtain intravenous access if possible. Once the person is conscious, provide an oral form of carbohydrate if the person is able to eat.

For a patient who is unconscious or unable to eat but has intravenous access

administer 25 mL of dextrose 50% intravenously over 1 to 3 minutes.

Subcutaneous Insulin Delivery Systems

administered periodically or continuously

1. The nurse is to draw up 14 units of insulin lispro (Humalog). Which syringe is the most appropriate to use? a. 1-mL tuberculin syringe b. 0.3-mL/30-unit insulin syringe c. 0.5-mL/50-unit insulin syringe d. 1-mL/100-unit insulin syringe

b. 0.3-mL/30-unit insulin syringe

3. The nurse is to draw up 2 units of regular insulin (Humulin R). Which syringe is the most appropriate to use? a. 1-mL tuberculin syringe b. 0.3-mL/30-unit insulin syringe c. 0.5-mL/50-unit insulin syringe d. 1-mL/100-unit insulin syringe

b. 0.3-mL/30-unit insulin syringe

8. The nurse obtains a fingerstick blood glucose level just before breakfast. It is 108 mg/dL. How many units of insulin should the nurse administer to the patient? a. 0 units b. 1 unit c. 2 units d. 4 units

b. 1 unit

7. Which insulin may be mixed together in the same syringe? a. NPH insulin (Novolin N) and insulin detemir (Levemir) b. NPH insulin (Novolin N) and regular insulin (Humulin R) c. insulin glargine (Lantus) and regular insulin (Humulin R) d. insulin aspart (NovoLog) and insulin lispro (Humalog)

b. NPH insulin (Novolin N) and regular insulin (Humulin R)

11. Just before dinner, the nurse obtains another fingerstick blood glucose level from the patient. It is now 148 mg/dL. Which action should be taken by the nurse? a. administer 0 units of insulin b. administer 1 unit of insulin c. administer 2 units of insulin then call the provider d. call the provider for further orders

b. administer 1 unit of insulin

2. Diabetes mellitus is managed by: a. diet, exercise, and meditation. b. diet, exercise, and medication. c. medication only. d. diet and exercise only.

b. diet, exercise, and medication.

4. Which of the following types of insulin is long-acting? a. insulin aspart (NovoLog) b. insulin glargine (Lantus) c. NPH insulin (Novolin N) d. insulin glulisine (Apidra)

b. insulin glargine (Lantus)

1. Which of the following types of diabetes mellitus is characterized by the complete destruction of beta cells in the pancreas? a. gestational diabetes b. type 1 diabetes c. type 2 diabetes d. type 3 diabetes

b. type 1 diabetes

15. A nurse is preparing to administer an injection of insulin glargine (Lantus) from an unopened vial. The package insert states that insulin glargine may be used for 28 days after it is opened. If the current date is October 3, on which date will this vial of insulin expire (assuming the manufacturer's expiration date has not passed)? a. October 29 b. October 30 c. October 31 d. November 1

c. October 31

12. If the nurse administers the regular insulin injection at 1700 (5:00 p.m.), at what time would the nurse expect the insulin to peak? a. between 1700 (5 p.m.) and 1900 (6 p.m.) b. between 1800 (6 p.m.) and 2000 (8 p.m.) c. between 1900 (7 p.m.) and 2100 (9 p.m.) d. between 2000 (8 p.m.) and 2200 (10 p.m.)

c. between 1900 (7 p.m.) and 2100 (9 p.m.)

5. A provider writes the following order: "Insulin detemir (Levemir) 13 units, subcut, every evening." This order is an example of which type of insulin order? a. sliding-scale order b. pre-meal insulin order c. routine (fixed schedule) order d. correction dose order

c. routine (fixed schedule) order

2. Human insulin refers to: a. insulin collected from a human pancreas. b. insulin collected from a pig's pancreas. c. synthetic insulin that closely resembles insulin produced by humans. d. insulin collected from the pancreas of a cow.

c. synthetic insulin that closely resembles insulin produced by humans.

3. The amount of insulin that an individual needs to maintain normal or near-normal blood glucose levels: a. is the same for everybody. b. varies, depending on the age of the person. c. varies greatly from person to person. d. depends upon the individual's body type.

c. varies greatly from person to person.

substances responsible for increasing blood glucose levels

carbohydrates found in bread, cereal, pasta, and sweets

Administering Insulin Using an External Insulin Pump

contain rapid- or short-acting insulin in prefilled syringes, which is infused though a very thin tube that is inserted into the subcutaneous tissue of the abdomen. programmed to deliver both basal and bolus (mealtimes) doses of insulin best suited to individuals who are willing to check their blood sugar frequently and are able to manage the necessary adjustments to their insulin intake.

2. The nurse is to draw up 78 units of NPH insulin (Novolin N). Which syringe is the most appropriate to use? a. 1-mL tuberculin syringe b. 0.3-mL/30-unit insulin syringe c. 0.5-mL/50-unit insulin syringe d. 1-mL/100-unit insulin syringe

d. 1-mL/100-unit insulin syringe

10. The nurse obtains a fingerstick blood glucose level just before lunch. It is 196 mg/dL. How many units of insulin should the nurse administer to the patient? a. 2 units b. 4 units c. 6 units d. 8 units

d. 8 units

4. Which of these items should the nurse check before withdrawing insulin from a vial? a. the manufacturer's expiration date b. the appearance of the insulin c. the date the vial was opened d. All of the above

d. All of the above

9. According to Table 15-2, what is the recommended time to administer the subcutaneous injection of insulin glulisine (Apidra)? a. 15 minutes before starting a meal b. 30 minutes before starting a meal c. Within 20 minutes after starting a meal d. Both a and c are correct.

d. Both a and c are correct.

10. At lunchtime, the nurse obtains another fingerstick blood glucose level from the patient. It is now 219 mg/dL. What action should be taken by the nurse? a. Administer 2 units of insulin glulisine (Apidra). b. Administer 4 units of insulin glulisine (Apidra). c. Administer 4 units of insulin glulisine (Apidra), then call the provider. d. Call the provider for further orders.

d. Call the provider for further orders.

13. If the nurse administers the regular insulin injection at 1700 (5:00) p.m., at what time would the nurse expect the insulin to lose effectiveness? a. between 1900 (7 p.m.) and 2100 (9 p.m.) b. between 2000 (8 p.m.) and 2200 (10 p.m.) c. between 2100 (9 p.m.) and 2300 (11 p.m.) d. between 2200 (10 p.m.) and 2400 (12 a.m.)

d. between 2200 (10 p.m.) and 2400 (12 a.m.)

1. Diabetes that is present only during pregnancy is called: a. type 1 diabetes. b. type 2 diabetes. c. borderline diabetes. d. gestational diabetes.

d. gestational diabetes.

5. Which insulin has an onset of 3 to 4 hours, does not peak, and has a duration of action of 24 hours? a. NPH insulin (Novolin N) b. insulin glulisine (Apidra) c. regular insulin (Humulin R) d. insulin glargine (Lantus)

d. insulin glargine (Lantus)

9. Which insulin should be injected right before a meal? a. insulin glargine (Lantus) b. insulin detemir (Levemir) c. NPH insulin (Novolin N) d. insulin glulisine (Apidra)

d. insulin glulisine (Apidra)

3. Which of the following types of insulin has an approximate onset of 15 minutes, peaks in 1 hour, and has a duration of action of 3 to 4 hours? a. regular insulin (Humulin R) b. insulin detemir (Levemir) c. NPH insulin (Novolin N) d. insulin lispro (Humalog)

d. insulin lispro (Humalog)

Insulin analogs

different onset, peaks, and durations of action allow individuals with diabetes to have more freedom in planning meals and activities

Individuals with type 2 diabetes who are placed on medium- or high-dose regimens have increased resistance to insulin.

documented in the patient's medical record, taking care to note times and the patient's response to the interventions

Injected (subq): GLP-1 analog (incretin mimetic)

exenatide (Byetta) liraglutide (Victoza) Stimulates release of insulin from the pancreas.

Symptoms of hypoglycemia

feelings of weakness, shakiness, hunger, and anxiety. Patients may complain of a headache, heart palpitations, blurred vision, and sweating. If not treated promptly, hypoglycemia can lead to loss of consciousness, seizures, and possibly death.

Oral: Sulfonylureas

glimepiride (Amaryl), glipizide (Glucotrol), glyburide (Micronase) Stimulates release of insulin from the pancreas. Increases sensitivity to insulin.

Insulin

hormone responsible for allowing the body to utilize and store glucose. Produced in the laboratory using recombinant DNA technology

Bedtime

hs

Diabetes mellitus is a group of metabolic diseases characterized by:

hyperglycemia.

Medications used to treat diabetes

insulin and oral or injected antidiabetic medications

insulin glargine provides the basal amount of insulin

insulin aspart provides the short burst of insulin

Diabetes is managed through a combination of

medications, diet, and exercise.

Oral: Biguanides

metformin (Glucophage) Decreases glucose production in the liver. Decreases intestinal absorption of glucose. Increases sensitivity to insulin.

Oral: Meglitinides

nateglinide (Starlix), repaglinide (Prandin) Stimulates release of insulin from the pancreas.

Oral: Thiazolidinediones

pioglitazone (Actos), rosiglitazone (Avandia) Increases sensitivity to insulin

Injected (subq): Amylin analog

pramlinitide (Symlin) Controls blood sugar levels after meals.

For a patient with hypoglycemia who is able to eat

provide 15 g of a simple carbohydrate in the form of glucose gel (or tablets), 6 ounces of non-diet soda, or 4 ounces of fruit juice.

NPH insulin may be mixed with:

rapid-acting and regular insulin Care must be taken to avoid cross-contaminating the vials of insulin, as this may alter the onset, peak, and duration of action.

Synthetic insulin is available in

rapid-acting, short-acting, intermediate-acting, and long-acting forms.

Oral: DPP-4 Enzyme inhibitors

sitagliptin (Januvia), saxagliptin (Onglyza) linagliptin (Tradjenta) Stimulates insulin release from beta cells. Reduces glucose production in the liver. Slows gastric emptying time.

Insulin may be administered

subcutaneously using a syringe and vial, an insulin pen device, or an external insulin pump.

Insulin is

the hormone, produced in the beta cells of the pancreas, that allows the body to use and store glucose.

Administering Insulin Using an Injection Pen

up to 315 units of insulin allowing for days or weeks of use individuals who have poor eyesight or have difficulty manipulating syringes and vials with their hands