Melissa O’Donovan

Lark Hunter-Bonnah

Insulin is a protein in the

human body that plays a

major role in decreasing the

levels of glucose in the blood

and regulating the metabolism

of glucose, fats, and proteins.

• The human body wants blood glucose (blood sugar)

maintained in a very narrow range.

• The main function of the pancreas is to produce insulin,

glucagon, digestive enzymes, and other hormones.

• Both insulin and glucagon are referred to as pancreatic

endocrine hormones.

• Insulin is synthesized in the beta cells of the pancreas in the

Islets of Langerhans through a glucose transporter by means

of facilitated diffusion.

• The secretion of insulin is controlled by the

glucose concentrations in the blood stream.

• As the level of glucose rises in the blood, the

insulin levels also increase.

• Following a meal, the carbohydrates or sugars

are absorbed by the intestines during digestion

and enter the bloodstream, which raise blood

glucose levels.

• The beta cells in the islets of Langerhans of the

Pancreas respond to this increase in blood

glucose levels.

• When the levels of glucose in the blood rise, membrane

depolarization of the beta cells occurs, causing

extracellular calcium to rush into the cell.

• This influx of extracellular calcium stimulates the export

of secretory granules, which contain insulin, out of the

cell and into the blood stream.

• The insulin is circulated through out the body where it

enables the glucose to be taken up and used by cells as

an energy source and this causes the blood glucose

levels to decrease.

Diagram of the insulin and glucose regulation model

Most cells through out the body have insulin

receptors to which insulin binds, and these cells in

turn activate other receptors designed to absorb the

glucose from the blood stream.

To elevate the glucose levels in the beta cells,

calcium-independent pathways are triggered by these

receptors.

When glucose levels fall below normal range due to a

lack of insulin, glycogen synthesis in the liver ceases

and the enzymes responsible for the breakdown of

glycogen become active.

Without insulin, many of the cells in the body would

not be able to take up glucose and would have to

resort to alternative fuel sources such as fatty acids

for energy.

Analogue - A man-made substance resembling insulin in which the molecular structure has been altered for a more desirable effect.

Basal – insulin that controls blood glucose levels between meals and over night.

Bolus - a burst of insulin that is delivered by the pancreas, injection or by insulin pump

Prandial – insulin pertaining to before or during a meal or a snack

Rapid acting

Short acting

Intermediate acting

Long acting

Insulin Type/Action (Appearance)

Brand names(Generic Name)

Basal or Bolus Dosing Schedule

Rapid acting analogue (clear)Onset: 10-15 minutesPeak:1-2 hoursDuration: 3-5 hours

Apidra (insulin glulisine)Humalog (insulin lispro)NovoRapid (insulin aspart)

Bolus Usually taken right before eating or to lower high blood glucose levels

Short-acting (clear)Onset: 30 minutesPeak: 2-3 hoursDuration: 6.5 hours

Humulin-RNovolin ge (Toronto)

Bolus Taken about 30 minute before eating or to lower high blood glucose levels

Intermediate –Acting (cloudy)Onset: 1-3 hoursPeak: 5-8hoursDuration: up to 18 hours

Humulin-NNovolin ge NPH

Basal Often taken at bedtime or twice a day (morning and bedtime)

Long-acting basal insulin analoguesOnset: 90 minutesPeak: not applicableDuration: up to 24 hours(Lantus 24 hours, Levemir 16-24 hours)

Lantus (insulin glargine)Levemir (insulin detemir)

Basal Usually taken once or twice a day

Premixed (cloud)A single vial contains a fixed ratio of insulin (the numbers refer to the ratio of rapid or short-acting to intermediate acting insulin in a vial)

Humalog Mix 25Humalog Mix 25, 50NovoMix 30Humulin (30/70)Novolin ge (30/70, 40/60, 50/50)

   

Insulin delivery refers the routes that insulin is introduced into the body when insulin cannot be produced by the pancreas, as with most people with Type 1 Diabetes.

Examples of Insulin delivery are:Subcutaneous Injections Insulin Pens Insulin Pumps Inhaled Insulin (Just Recently approved by the FDA in the US)

• Resemble a large pen which makes them portable and easy to

handle

• Replace vials and syringes, which is helpful to people with poor

eyesight, and also helps avoid over- or under-dosing.

• Use insulin cartridges and disposable needles.

• Can select (dial) the proper dose, which is displayed in the

pen’s window.

• Some models allow you to reselect the dose if a mistake is

made.

• Needles simply screw into place and are easily removed

Insulin pumps are becoming more widely used and are a good therapy option for people with diabetes who have difficulty controlling blood glucose by other means (by using a syringe or pen)

Some insulin pumps are computerized / motorized and can even be flexible use devices, while there are others that serve as a glucose monitor and insulin pump combined.

The pump is filled with rapid or short-acting insulin which is administered into the body before each meal, and there is also a small amount of insulin delivered for 24 hours. 

The patient calculates how much insulin is needed based on the carbohydrate content (grams) of the meal or snack.  Since it is programed into the pump it helps to prevent overdosing.

The catheter is implanted in the patient’s abdomen beneath skin and fatty layers and the pump is attached to the catheter when needed. 

The pump can be attached to different areas of the body, but is most commonly placed on the waist.

Mrs. Smith has orders for her insulin to be administered at 0800. The doctors orders state that she is to receive 5 units Regular and 10 units NPH before breakfast.

How do you mix both types of insulin in one syringe?

AIR AIR DRAW DRAW

Cloudy Clear Clear Cloudy

N R R N

Use the RN MnemonicRegular then NPH

Cloudy Clear Clear Cloudy

1. First, Wash your hands and make sure to follow the 6 R’s2. Mix insulin (roll vials upright between palms)3. Clean tops of both vials with alcohol swab4. Open syringe and needle (Assemble if necessary)5. Draw air into syringe equivalent to the Total dose (units)

of insulin to be given (both kinds)6. Insert needle into N vial and express air equal to only

the required dose of N insulin into the N vial and remove.

7. Insert needle into the R vial and express remaining air left in the syringe into the vial. This should equal the amount of R insulin to be given

8. Leave needle inside the R vial and turn the R vial upside down with the needle still inserted. Check for bubbles.

9. Withdraw required amount of insulin from the R vial and remove needle.

10. Put needle into N vial and turn vial upside down11. Withdraw the required amount of N insulin and remove

needle. 12.Total insulin in syringe should be equal to the total

amount of air placed in both vials.13.Replace cap on needle for transport to patient bedside

using the scoop method (scoop cap up with needle tip not with fingers to prevent stick injury)

14. Wash your hands when entering room15. Administer insulin to patient16. Wash your hands when leaving the room17. Document

Mr. G. is a 50 year old gentleman who was admitted to the floor last night at 1900 for an infection in his right big toe. He has type 1 diabetes and hypertension. You are just beginning your shift and it is 0700. Meals are served @ 08, 12, 17 with HS snack @ 2100.

The doctors orders for Mr. G are as follows:

Vitals (protocol), Amoxicillin 500 mg IV q8h, CBC, Chem. 1

CBG AC, AM, and HS, 10 units NPH SC, Regular insulin SC

Sliding Scale (dose based on blood glucose)If CBG = >24 =32 u 20-23.9 =28 u 17-19.9 =24 u 14-16.9 =20 u 11-13.9 =16 u 8-10.9 =12 u 5-7.9 = 8 u 3- 4.9 = 4 u

Cox, H., Hinz, M., Lubno, M., Scott-Tilley, D., Newfield, S., Slater, M., & Sridaromont, K.(2002).

Clinical Applications of Nursing Diagnostics. Philadelphia, PA: F.A Davis Company.

Day, R., Paul, P., Williams, B., Smeltzer, S., & Bare, B. (2007). Textbook of Medical Surgical Nursing.

Philadelphia, PA: Lippincott Williams & Wilkins.

Doenges, M., Moorhouse, M., & Murr, A. (2006). Nurses Pocket Guide: Diagnoses, Prioritized

Interventions and Rationales. Philadelphia, PA: F.A. Davis Company

Kozier, B., Erb, G., Berman, A., Burke, K., Bouchal, D., & Hirst, S. (2004). Fundamentals of Nursing:

The Nature of Nursing Practice in Canada. Toronto, ON: Pearson Education Canada Inc.

Wilson, B., Shannon, M., Shields, K., & Stang, C. (2008). Prentice Hall Nurse's Drug Guide 2008.

Upper Saddle River, New Jersey: Pearson Education Canada Inc.