IMPLEMENTING THE PLAN
The nurse should continue to assess the skills of patients who have had diabetes for many years, because it is estimated that up to 50% of patients may make errors in self-care. Assessment of these patients must include direct observation of skills, not just their self-report of self-care behaviors. In addition, these patients must be fully aware of preventive measures related to foot care, eye care, and risk factor management. If patients are experienc-ing long-term diabetic complications for the first time, they may go through the grieving process again. Some of these patients may have a renewed interest in diabetes self-care in the hope of delay-ing further complications. Other patients may be overwhelmed by feelings of guilt and depression. The patient is encouraged to discuss feelings and fears related to complications; the nurse meanwhile provides appropriate information regarding diabetic complications.
Insulin injections are administered into the subcutaneous tissue with the use of special insulin syringes. A variety of syringes and injection-aid devices are available. Chart 41-7 provides important information to include and evaluate when teaching patients about insulin. Basic information includes explanation of the equipment, insulins, syringes, and mixing insulin.
Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solu-tion into a syringe or a pen.
Whether insulin is the short- or long-acting preparation, the vials not in use should be refrigerated and extremes of tempera-ture should be avoided; insulin should not be allowed to freeze and should not be kept in direct sunlight or in a hot car. The insulin vial in use should be kept at room temperature to reduce local irritation at the injection site, which may occur when cold insulin is injected. If a vial of insulin will be used up in 1 month, it may be kept at room temperature. Patients should be instructed to always have a spare vial of the type or types of insulin they use (ADA, Insulin Administration, 2003). Spare vials should be refrigerated.
Insulin bottles should also be inspected for flocculation, which is a frosted, whitish coating inside the bottle of intermediate- or long-acting insulins. This occurs most commonly with human insulins that are not refrigerated. If a frosted, adherent coating is present, some of the insulin is bound and should not be used.
Syringes must be matched with the insulin concentration (eg, U-100). Currently, three sizes of U-100 insulin syringes are available:
• 1-mL (cc) syringes that hold 100 units
• 0.5-mL syringes that hold 50 units
• 0.3-mL syringes that hold 30 units
The concentration of insulin used in the United States is U-100; that is, there are 100 units per milliliter (or cubic cen-timeter). Syringe size varies. Small syringes allow patients who re-quire small amounts of insulin to measure and draw up the amount of insulin accurately. Patients who require large amounts of insulin would use larger syringes. Although there is a U-500 (500 units/mL) concentration of insulin available by special order for patients who have severe insulin resistance and require mas-sive doses of insulin, it is rarely used. (Individuals who travel out-side of the United States should be aware that insulin is available in 40-U concentration to avoid dosing errors.)
Most insulin syringes have a disposable 27- to 29-gauge nee-dle that is approximately 0.5 inch long. The smaller syringes are marked in 1-unit increments and may be easier to use for patients with visual deficits or patients taking very small doses of insulin. The 1-mL syringes are marked in 2-unit increments. A small dis-posable insulin needle (29- to 30-gauge, 8 mm long) is available for very thin patients and children.
When rapid- or short-acting insulins are to be given simultane-ously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before use. There is some question as to whether the two insulins are stable if the mixture is kept in the syringe for more than 5 to 15 minutes. This may depend on the ratio of the insulins as well as the time between mixing and injecting. When regular insulin is mixed with long-acting insulin, there is a bind-ing reaction that slows the action of the regular insulin. This may also occur to a greater degree when mixing regular insulin with one of the Lente insulins. Patients are advised to consult their health care provider for advice on this matter. The most impor-tant issue is that patients be consistent in how they prepare their insulin injections from day to day.
While there are varying opinions regarding which type of insulin (short- or longer-acting) should be drawn up into the syringe first when they are going to be mixed, the ADA recom-mends that the regular insulin be drawn up first. The most impor-tant issues are, again, that patients be consistent in technique so as not to draw up the wrong dose accidentally or the wrong type of insulin, and that patients not inject one type of insulin into the bottle containing a different type of insulin (ADA, Insulin Administration, 2003).
For patients who have difficulty mixing insulins, two options are available: they may use a premixed insulin, or they may have prefilled syringes prepared. Premixed insulins are available in sev-eral different ratios of NPH insulin to regular insulin. The ratio of 70/30 (70% NPH and 30% regular insulin in one bottle) is the most common and is available as Novolin 70/30 (Novo Nordisk) and Humulin 70/30 (Lilly). Other ratios available in-clude 80/20, 60/40, and 50/50. The ratio of 75% NPL and 25% insulin lispro is also available (ADA, Insulin Administration, 2002). NPL is used only to mix with Humalog; its action is the same as NPH. The appropriate initial dosage of premixed insulin must be calculated so that the ratio of NPH to regular insulin most closely approximates the separate doses needed.
For patients who can inject insulin but who have difficulty drawing up a single or mixed dose, syringes can be prefilled with the help of home care nurses or family and friends. A 3-week supply of insulin syringes may be prepared and kept in the refriger-ator. The prefilled syringes should be stored with the needle in an upright position to avoid clogging of the needle (ADA, Insulin Administration, 2003).
Most (if not all) of the printed materials available on insulin dose preparation instruct patients to inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn. The rationale for this is to prevent the formation of a vacuum in-side the bottle, which would make it difficult to withdraw the proper amount of insulin. Some nurses who specialize in diabetes report that some patients (who have been taking insulin for many years) have stopped injecting air before withdrawing the insulin. These patients found that the extra step was not necessary for ac-curately drawing up the insulin dose. Most patients find it easier to withdraw the insulin by eliminating the step and report no dif-ficulty in preparing the proper insulin dose.
Eliminating this step (or alternating it by, for instance, inject-ing a syringe full of air into the vial once per week) facilitates the teaching process for some patients learning to draw up insulin for the first time. Some patients become confused with the sequence of steps involved in injecting air into two separate bottles in two different amounts before drawing up a mixed dose. For many in-dividuals, including elderly ones, simplifying the procedure for preparing insulin injections may help them maintain indepen-dence in daily living.
As with other variations in insulin injection technique, the most important factors are that the patient maintain consistency in the procedure and that the nurse be flexible when teaching new patients or assessing the skills of experienced patients.
The four main areas for injection are the abdomen, arms (poste-rior surface), thighs (anterior surface), and hips (Fig. 41-7). In-sulin is absorbed faster in some areas of the body than others. The speed of absorption is greatest in the abdomen and decreases pro-gressively in the arm, thigh, and hip.
Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy). In addition, to promote consistency in insulin absorption, patients should be encouraged to use all available in-jection sites within one area rather than randomly rotating sites from area to area (ADA, Insulin Administration, 2002). For ex-ample, some patients almost exclusively use the abdominal area, administering each injection 0.5 to 1 inch away from the previ-ous injection. Another approach to rotation is always to use the same area at the same time of day. For example, patients may in-ject morning doses into the abdomen and evening doses into the arms or legs.
A few general principles apply to all rotation patterns. First, patients should try not to use the same site more than once in 2 to 3 weeks. In addition, if the patient is planning to exercise, in-sulin should not be injected into the limb that will be exercised, because it will be absorbed faster, and this may result in hypo-glycemia.
In the past, patients were taught to rotate injections from one area to the next (eg, injecting once in the right arm, then once in the right abdomen, then once in the right thigh). Patients who still use this system must be taught to avoid repeated injec-tions into the same site within an area. However, as previously stated, it is preferable for the patient to use the same anatomic area at the same time of day consistently; this reduces day-to-day variation in blood glucose levels because of different absorption rates.
Use of alcohol to cleanse the skin is not recommended, but pa-tients who have learned this technique often continue to use it. They should be cautioned to allow the skin to dry after cleansing with alcohol. If the skin is not allowed to dry before the injection, the alcohol may be carried into the tissues, resulting in a localized reddened area.
There are varying approaches to inserting the needle for insulin injections. The correct technique is based on the need for the in-sulin to be injected into the subcutaneous tissue. Injection that is too deep (eg, intramuscular) or too shallow may affect the rate of absorption of the insulin. Aspiration (inserting the needle and then pulling back on the plunger to assess for blood being drawn into the syringe) is generally not recommended with self-injection of insulin. Many patients who have been using insulin for an ex-tended period have eliminated this step from their insulin injec-tion routine with no apparent adverse effects.
Adherence to the therapeutic planis the most important goal of self-care the patient must master. Patients who are having difficulty adhering to the diabetes treatment plan must be approached with care and understand-ing. Using scare tactics (such as threats of blindness or ampu-tation if the patient does not adhere to the treatment plan) or making the patient feel guilty is not productive and may inter-fere with establishing a trusting relationship with the patient. Judgmental actions, such as asking the patient if he or she has “cheated” on the diet, only promote feelings of guilt and low self-esteem.
If problems exist with glucose control or with the develop-ment of preventable complications, it is important to distinguish among nonadherence, knowledge deficit, and self-care deficit. It should not be assumed that problems with diabetes management are related to nonadherence. The patient may simply have for-gotten or never learned certain information. The problem may be correctable simply through providing complete information and ensuring that the patient comprehends the information. Chart 41-8 details how to evaluate the effectiveness of self-injection of insulin.
If knowledge deficit is not the problem, certain physical or emotional factors may be impairing the patient’s ability to per-form self-care skills. For example, decreased visual acuity may impair the patient’s ability to administer insulin accurately, measure the blood glucose level, or inspect the skin and feet. In addition, decreased joint mobility (especially in the elderly) im-pairs the ability to inspect the bottom of the feet. Emotional factors such as denial of the diagnosis or depression may impair the patient’s ability to carry out multiple daily self-care mea-sures. In other circumstances, family, personal, or work prob-lems may be of higher priority to the patient. The patient facing competing demands for time and attention may benefit from assistance in establishing priorities. It is also important to assess the patient for infection or emotional stress that may lead to el-evated blood glucose levels despite adherence to the treatment regimen.
The following approaches by the nurse are helpful for pro-moting self-care management skills:
• Address any underlying factors (eg, knowledge deficit, self-care deficit, illness) that may affect diabetic control.
• Simplify the treatment regimen if it is too difficult for the patient to follow.
• Adjust the treatment regimen to meet patient requests (eg, adjust diet or insulin schedule to allow increased flexi-bility in meal content or timing).
• Establish a specific plan or contract with the patient with simple, measurable goals.
• Provide positive reinforcement of self-care behaviors per-formed instead of focusing on behaviors that were neglected (eg, positively reinforce blood glucose tests that were per-formed instead of focusing on the number of missed tests).
• Help the patient to identify personal motivating factors rather than focusing on wanting to please the doctor or nurse.
• Encourage the patient to pursue life goals and interests; dis-courage an undue focus on diabetes.
As discussed, continuing care of the patientwith diabetes is critical in managing and preventing complica-tions. The degree to which the client interacts with health care providers to obtain ongoing care depends on many factors. Age, socioeconomic level, existing complications, type of diabetes, and comorbid conditions all may dictate the frequency of follow-up vis-its. Many patients with diabetes may be seen by home health nurses for diabetic education, wound care, insulin preparation, or assistance with glucose monitoring. Even patients who achieve excellent glucose control and have no complications can expect to see their primary health care provider at least twice a year for ongoing evaluation.
In addition to follow-up care with health professionals, par-ticipation in support groups is encouraged for those who have had diabetes for many years as well as those who are newly diag-nosed. Such participation may assist the patient and family in coping with changes in lifestyle that occur with the onset of diabetes and with its complications. Those who participate in support groups often have an opportunity to share valuable in-formation and experiences and to learn from others. Support groups provide an opportunity for discussion of strategies to deal with diabetes and its management and to clarify and verify infor-mation with the nurse or other health care professionals. Partici-pation in support groups may help patients and their families to become more knowledgeable about diabetes and its management and may promote adherence to the management plan. Another very important role of the nurse is to remind the patient about the importance of participating in other health promotion activ-ities and recommended health screening.