The Basics ofInsulin Pump Therapy

Diabetes Care CenterPatty Lord, RN,BSN, CDE

Joyce Jones, RN,BSN,CDE

Revised 8/2012

Insulin Pump Therapy

This course is designed to provide you with the basic skills and information to help take care of your patient with an insulin pump.

Insulin Pump

Insulin Pump Therapy:Use of Continuous Insulin Infusion (CSII) in the hospitalized patient

CSII is an alternative method of insulin delivery for patients with either Type1 or Type 2 diabetes. Some advantages in the hospitalized patient include:

Provides a consistent source of basal insulin with greater flexibility to make changes

Less variation in insulin absorption as compared to multiple daily injections (MDI)

Greater flexibility to manage variable eating patterns

Common Features

Computerized, programmable, external About the size of a cell phone or pager 24hr tech support #1-800 (on back of pump) Supplies are ordered from pump company Shock resistant Water resistant Costly, approx $5000 for pump Holds 180-300 units of insulin in a cartridge/reservoir

which the patient fills with a syringe and vial Reservoir and insertion set need to be changed every

2-3 days

Types of Insulin used in pumps

Rapid acting insulin is the only type of insulin used in pumps:

Humalog Novolog Apidra Please note: When patients need to refill insulin in the

reservoir, the insulin needs to be ordered from our Pharmacy. If patients want to use their own insulin from home, the vial needs to be sent to Pharmacy to be checked prior to patient use.

Pump Terms:

Basal Insulin : A continual dose of insulin based on individual need previously determined by the physician and the patient. This is also referred to as the “background” insulin. The patient may have multiple basal rates per day.

With any stress, surgery, infection or steroid use, patients will have increased insulin needs and rates may need to be adjusted on the pump.The physician will order the rate change and the patient will change their own rates.

Bolus Insulin doses: These doses are programmed by the patient and given as needed prior to meals, snacks and occurrences of hyperglycemia.

More pump terms:

Target Blood Glucose

ISF: Insulin Sensitivity Factor or Correction Bolus Dose

Insulin to Carbohydrate Ratio

The patient knows the above information and is to fill out the 24 Hour Insulin Pump Flowsheet using these numbers on a daily basis. This is important so we have documentation of how much insulin the patient is self administering via the pump.

Where is the pump at on a patient?

Most patients put their insertion sites in the abdominal area. It can go anywhere there is adequate adipose tissue. Insulin is delivered SQ through a needle or catheter connected to the syringe by flexible tubing. They change the insertion set/ site about every 2-3 days.

Important Points to Remember:

The patient who comes in with an insulin pump, is a highly motivated individual who has gone through

extensive training in self-management skills related to diabetes management and insulin pump therapy. The patient will, if physically and mentally capable, perform

all necessary skills needed to self-manage insulin pump therapy while at Lake Health.

Insulin Pump

Now that you know how the pump works.

What do you do when you get a patient with a pump?

3 forms to use when your patient has an insulin pump

Place the Physician Orders for Insulin Pump (order #4823) on chart for the physician to sign. This is a 2 page form. Insulin rates that are used at home from their managing pump physician are to be ordered by the hospital physician. This information is obtained from the patient.

When admitting a patient with an insulin pump the admitting nurse reviews the Insulin Pump Management Guidelines (#4013) with the patient. This form explains the responsibilities of the patient and the nurse when caring for insulin pumps. Both the patient and the nurse sign.

Place the 24Hour Insulin Pump Flow sheet (#4824) at the bedside for the patient to complete. This is where the patient documents the basal rates and bolus doses that they are self-administering. A new flowsheet is given daily. Both the patient and nurse sign.

Staff Responsibilities at a Glance

Assess patient’s mental, physical, and cognitive capabilities to self manage the pump. Refer to our Insulin pump policy and procedure, located under Diabetes Care Center on the intranet.

Assess that the insulin pump is functioning, infusion site is securely in place without s/s of leakage or infection. Document on the 24 hr flowsheet.

Verify basal and bolus doses with patient using the 24 hr flowsheet.

Obtain physician orders for insulin doses, target glucose values and frequency of glucose testing using Physician Orders. The insulin doses are written on this form from the information the patient provides.

Note: for additional information see Insulin Pump Management Guidelines (#4013)

Patient Responsibilities at a Glance:

Must supply adequate supplies, including infusion sets, reservoirs, batteries, specific tapes or dressing.

Provide programming information (insulin doses, targets and ratios)

Chart insulin doses on 24Hour Insulin Pump Flow sheet (#4824)

Inform staff of hypoglycemia symptoms Trouble shoot alarms

Note: for additional information see Insulin Pump Management Guidelines (#4013)

When to remove an Insulin Pump ?

If a patient is unable to manage pump because of Diabetic Ketoacidosis (DKA), altered mental status, or other circumstances, remove the pump and notify physician IMMEDIATELY to obtain alternative insulin delivery orders. This is especially important with patients with Type1, who have no insulin production.

When to temporarily disconnect a pump?

Instruct the patient to disconnect pump for MRI, CT scan, X-rays or any procedure anticipated to take longer than 1 hour and do the following:

Obtain blood glucose accucheck Notify physician to obtain an order for an alternative insulin dose

to be given prior to the procedure. Recheck blood glucose upon return to room and prior to patient

reconnecting pump. Patients can only be disconnected only for up to 1 hour without

needing insulin. If more than 1 hour, it is imperative that SQ or IV insulin be initiated.

IV drip can be started at time CSII is stopped.

Managing Hypoglycemia

If hypoglycemia occurs, treat per hypoglycemia orders and DO NOT STOP PUMP. Follow the Physician Orders for Hypoglycemia. If pump is stopped, rapid or short acting insulin must be given. An IV insulin infusion can be started immediately after pump is stopped.

Managing Hyperglycemia

Unexplained high blood sugars requires having the patient troubleshoot their pump, infusion set, and site. The patient should be able to do this on their own.

If there is a logical cause for the high BG, have the patient follow their course of corrective action. Examples of logical causes include: Patient forgot to bolus for last meal or their infusion set is dislodged. The action plan for the patient includes checking the blood glucose, giving a bolus dose or changing the infusion site.

The hospital glucometer will be used for insulin doses and hypo/hyperglycemia and for documentation.Patients can check their own glucoses using their own glucometer from home.

Always Remember

When admitting a patient with an insulin pump, the diabetes educators receive an automatic referral through Soarian when the admitting nurse checks off “insulin pump”. We will come to assist the nurse with what is needed when taking care of patients with pumps. We also talk with the patient to assess their ability to self manage the pump.

The diabetes educators can also be reached via Vocera, if assistance is needed at any time!!!

We are here to help you, help our patients keep their pumps on during hospitalization for improved outcomes and increased patient satisfaction.

THANK YOU

Please feel free to contact Patty Lord, Joyce Jones or the Diabetes Care

Center with questions or concerns.

QUESTIONS

1. Novolog, Humalog and Apidra are types of insulin used in pumps True False Answer: true 2. If a patient is unable to self manage the pump, it is the nurse’s responsibility to do it for them True False Answer: false 3. If a patient becomes hypoglycemic, remove the pump and treat for hypoglycemia True False Answer: false 4.There are 3 insulin pump forms to be used with patients with pumps, these are: Insulin Pump Management Guidelines, Physician Orders for Pumps and 24 Hr

Insulin Pump Flowsheet True False Answer: true

5. It is imperative that the patient record all insulin doses on the 24 hr flowsheet on a daily basis True False Answer: true 6. If a patient runs out of pump supplies, you can order from the stockroom True False Answer: false 7. When a physician writes an order, “patient may use pump from home”, this is NOT acceptable, the nurse needs to place Physician Orders for Insulin Pump on the

chart True False Answer :true