We recently had a very undernourished gentleman admitted to the hospital with multiple problems, one of them, a new diagnosis of diabetes with no detectable c-peptide. He was started on basal bolus insulin appropriately and the blood glucose control was leveling off reasonably. I was at the nurses’ pod reviewing his notes, when I was tapped on the shoulder and a student nurse asked if I could help her figure out where to give his insulin injections. He was so thin that she was having difficulty finding any subcutaneous tissue. We discussed optional locations, the 45 degree angle for the injections and she went into the patient room to help with the shot. I decided to take a look at the one-use needles we were using, and noted they were 8 mm needles. I was surprised to find out it was all we stocked! In further investigation I learned some parents of the children bring in their own pen needles due to the child’s discomfort when injected with the hospital needles, not to mention their inappropriateness. Not exactly a good protocol in the hospital – but hats off to the parents finding a way to minimize the discomfort for their child.
In all the concern over the change in policy, nursing education, changing IV drip to subcutaneous insulin equations, writing insulin pump protocols, I have missed a simple change that could make a difference not only in comfort, but in the successful delivery of insulin in most patients.
So I am once again reminded of how important it is to remember the simple things in this complex and relentless disease. To review on a consistent basis the things we have learned about taking care of persons requiring insulin that may make a difference.
I pulled out an article I had cut and saved “Translating the Research in Insulin Injection Technique: Implications for Practice” in the October 2012 issue of The Diabetes Educator and reread it. Research that investigated injection technique, teaching insulin administration, and of length of the insulin needles and reviewed it for clarity.
So along with needle length – here are a few simple reminders when reviewing insulin administration with patients, nurses, and care providers:
1. Check needle length, 4-5 mm is enough – there are still some folks with 12 mm needles – in fact I was horrified last year to see some had been shipped to kids’ camp!
2. Only individuals who are very thin need to have any skin pinched up when using smaller needles
3. Absorption rate of insulin analogs does not appears to be site dependent
4. Insulin leakage can occur and is reported more frequently with pen use – suggest holding the needle in the skin for a longer period (10 seconds) before removing to prevent leakage
5. Clean skin does not need to be cleansed with alcohol – which may actually dry out the skin with repeated use
6. Discuss the risks and benefits of insulin therapy on occasion and review symptoms and treatment for low blood glucose
7. And it is good to remind us all periodically – that the discovery and use of this drug is a wonderful and life-saving treatment that can be embraced rather than avoided.
As we work with our patients, both inpatient and outpatient – it is often the little things we can forget. Appropriate needle length is just one of those details and an easy thing miss when there is so much work to be done to help take care of our patients. Needless to say, we are already working to resolve this issue!