PREPARED BY:

LIMJOCO, Rochelle May

LOPEZ, Janine
LOSTICO, Rowena
MALIT, Jeziemin
MALLARI, Alison Gail
MANANGHAYA, Melissa
MARTEJA, Mark Anthony
MARTIN, Abigail
MENDOZA, James Edward
 PRESENTED TO:
Ms. Frances Elaine Sioco

Mrs. Amy Santos

- Exogenous insulin is needed when insulin
production by the islet cells is insufficient.
Because insulin is destroyed in the
gastrointestinal tract, it must be supplied by
injection. Insulins are categorized according
to their duration of action.
Considered in light of the normal eating and
activity pattern and the response to therapy:

1. Time of onset

2. Peak of action

3. Duration
Regular insulin is a unmodified insulin. Crystalline
zinc is a more highly purified unmodified form of
regular insulin. These are used interchangeably
when quick action is needed. They are selected
for treatment of ketoacidosis, during an acute
illness, during surgical procedures, or to stabilize
a client who is out of control. Regular or
crystalline insulin is the only type that can be
given intravenously.
 Regular insulin may be used to bring blood
glucose into the control by using it as a
supplement with long-acting or intermediate-acting
insulins. This is termed the “sliding scale” or
“rainbow” method. Sliding scale insulin is usually
taken before meals and at bedtime. By this
method the client selects a proper regular insulin
dose based on a blood glucose level at that time.
The physician has previously prescribed units of
insulin to be given for various ranges in blood
glucose or for results of the glucosuria test. The
client measures the blood glucose with capillary
blood and the DEXTRO System (or tests the urine
with the glocosuria test).
 Intermediate-acting and long-acting insulins are
administered approximately ½ hour before
breakfast. The rapid-acting insulins are given 15-30
minutes before meal. Because their action is
coordinated to meals, the nurse should be alert to
the time of administration. When insulin therapy is
initiated, clients will notice some bodily changes
that may be distressing. weight gain and blurred
vision are common. The increase in weight does
not mean that the client is “cheating” on the meal
plan. Weight stabilizes as metabolic control is
reached. Blurred vision arises from fluctuations in
the blood glucose level that cause osmotic changes
within the lens and ocular fluids. As the blood
glucose smooth’s out, the ocular equilibriums
restored and vision improves. Clients should be
informed that this may happen and that it will
subside in 6-8 weeks.
 An allergic reaction at the injection site is not
unusual when insulin is first administered. Itching,
redness, and induration develop at the injection
site. This process is self-limiting and subsides
spontaneously after 1-2 weeks of therapy.
Impurities in the alcohol used in skin cleansing or
giving the insulin intradermally can cause these
symptoms. The former is easily relieved by
switching skin preparation to povidone iodine
(betadine) solution. The client’s injection
technique should also be evaluated and
reteaching instituted as appropriate.
Preparation Agent Common name Appearance Approximate Peak Hours Approximately When to Compatible Indication
Time of onset Duration Hours anticipate Mixed with
hours Hypoglycemia

Rapid-acting Used for rapid

reduction of
Insulin injection glucose level, to
Lispro (Humalog) Regular insulin Clear 1 2-4 5-7 Before lunch All preparation treat postprandial
Injection USP Aspart (Novolog) hyperglycemia,
(insulin made from Regular Clear 1 2-4 5-7 Before lunch All preparation and/or to prevent
zinc insulin nocturnal
crystals) hypoglycemia

Prompt insulin zinc

suspension USP
Semilente insulin Cloud 1 2-4 12-16 Before lunch All lente
Intermediate- preparation
acting

Isophane insulin NPH (neutral Late afternoon and Regular Insulin Usually taken after
suspension USP protamine NPH insulin during night food
Hagedorn) isophane insulin Cloudy 2 6-12 24-28
(Humulin N, lletin
Insulin zinc
II Lente, lletin II
suspension USP
NPH, Novolin L
(Lente) Lente Late afternoon and
Globin zinc insulin
Insulin during night Regular Insulin and
injection USP
Cloudy 2 6-12 24-28 semilente insulin
Globin insulin Late afternoon and
Long-acting
during night Regular Insulin and
Cloudy 2 6-8 18 semilente insulin
Protamine zinc
insulin suspension
USP
Novolin N (NPH) During night
Ultralente (“UL”) Protamine Regular insulin
Extended insulin
Zinc Used primarily to
zinc suspension
Insulin Cloudy 7 14-24 36+ control fasting
USP
glucose level

During night
Ultralente Regular insulin
insulin And semilente
Cloudy 7 18-24 36+ insulin
Somogyl Effect.

This phenomenon is the body’s attempt to

correct a low blood glucose caused by
administering too much insulin. It is
suspected when the client has wide swings
in blood glucose over a short time interval.

Hypoglycemia.
Clients taking insulin can encounter
symptoms of insulin excess. An oversupply of
insulin drives glucose into the cells, leaving
the blood itself with a lower than normal
amount.
Diabetic KetoAcidosis.
It is characterized by acidosis, associated with the
buildup of ketones and loss of sodium, and
hypovolemia that is secondary to renal fluid losses.

Hyperkalemia.
It is not uncommon in ketoacidosis as a
consequence of protein catabolism, decreased
renal excretion, and a shift of intracellular
potassium to the extracellular space.
Hyperglycemic Hyperosmolar Non -
Ketotic coma (HHNK)

It develops instead of ketosis if the client

produces insulin that is sufficient to prevent
ketone bodies from forming, but inadequate to
reduce the hyperglycemia.
Potential for Injury.

Neuropathic changes can diminish

sensation, making the client less aware of
injury. Vascular changes can decreased
the arterial blood supply, thereby
decreasing the body’s ability to heal.
Glycosulated Hemoglubin

a blood test that reflects average blood glucose

levels over a period of approximately 2 to 3
months. When blood glucose levels are
elevated, glucose molecules attach to
hemoglobin in the red blood cells.
 Urine testing for Glucose
Advantage:

 Less expensive than SMBG

 It is not invasive.
 involves applying urine to a
reagent strip or tablet and matching
colors on the strip with a color chart
at the end of a specified period.
 Disadvantage:

 Results do not accurately reflect the blood glucose

level at the time of the test.

 The renal threshold for glucose is 180 to 200 mg/dl

(9.9 to 11.1 mmol/L), far above target blood glucose
levels.

 Hypoglycemia cannot be detected because a

“negative” urine glucose result may occur when the
blood glucose level range from 0 to 180 mg/dL (9.9
mmol/L) or higher.
 Patients may have a false sense of being in good
control when results are always negative.

 Various medications may interfere with test results.

 In elderly patients and patients with kidney disease,

the renal threshold is raised; thus, false-negative
readings may occur at dangerously elevated glucose
levels.
Testing for Ketones

Urine ketone testing should be performed

whenever patients with type 1 diabetes have
glucosuria or persistently elevated blood glucose
levels (more than 240 mg/dL or 13.2 mmol/L for
two testing periods in a row) and during illness, in
pregnancy with pre-existing diabetes, and in
gestational diabetes.
Insulin delivery devices
The continuous subcutaneous insulin
infusion (CSII), which delivers insulin from
an external device via a fine nylon cannula
into the subcutaneous tissue. These
devices are equipped to deliver insulin at
two rates---one to match the basal
metabolic level and another at a higher
rate to cover mealtime or food intake.

Transplantation.
An approach to keeping the blood glucose at
physiologic levels has been through pancreatic
transplantation.
Insulin is secreted by the beta cells of the
islet of Langerhans and works to lower the
blood glucose level after meals by
facilitating the uptake utilization of glucose
by muscle, fat, and liver cells.
NOTE:
Because the body loses the ability to produce
insulin in type 1 diabetes, exogenous insulin must
be administered for life.

In type 2 diabetes, insulin may be necessary on

a long-term basis to control glucose levels if diet
and oral agents fail.
In addition, some patients in whom type 2 diabetes
is usually controlled by diet alone or by diet and an
oral agent may require insulin temporarily during
illness, infections, pregnancy, surgery, or some
other stressful event. In many cases, insulin
injection is administered two or more times daily to
control the blood glucose level.
A number of insulin preparation are available.

They vary according to three main characteristics:

1. time course of action

2. species ( source)
3. manufacturer
 to achieve optimal metabolic control

 to reduce the risk of long term complications

 reduce the incidence of hypoglycemia

 to increase flexibility of lifestyle, especially in

terms of amount and timing of meals and physical
activity.
 to improve outcomes for pregnancy.

 to be more in control and more responsible

for own health

 to improve self - esteem

Cloudy insulin’s should be thoroughly mixed by
gently inverting the vial or rolling it between the
hands before drawing the solutions 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 temperature
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. Spare vials
should be refrigerated.
Syringes must be matched with the insulin
concentration. Currently, 3 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

1 ml (cc)
syringes
that hold
100 units
0.5 ml syringes that hold 50 units
 Small syringes allow patient to require small
amounts of insulin to measure and draw up the
amount of insulin accurately. Patients to required
large amounts of insulin would use larger syringes.

Most insulin syringes have a disposable 27-to

29- gauge needle that is approximately 0.5 inch
long. The 1 ml syringes are marked in 2-unit
increments. A small disposable insulin needle
(29- to 30- gauge, 8 mm long) is available for
very thin patients and children.
 When rapid- or short-acting insulin’s are to be
given simultaneously with longer-acting insulin,
they are usually mixed together in the same
syringe; the longer-acting insulin must be mixed
thoroughly before use. There is some question as
to whether the two insulin’s are stable if the
mixture is kept in the syringe foe more than 5 to
15 minutes. This may depend on the ratio of the
insulin’s as well as the time between mixing and
injecting.
 For patients who have difficulty mixing
insulin’s, two options are available they may
use a premixed insulin, or they may have
prefilled syringes prepared.
 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’s
to be withdrawn. The rationale for this is to
prevent the formation of a vacuum inside the
bottle, which would make it difficult to
withdraw that proper amount of insulin.
 The four main areas for injection are the
abdomen, arms (posterior surface), thighs
(anterior surface), and hips. Insulin is absorbed
faster in some areas of the body than others. The
speed of absorption is greatest in the abdomen
and decreases progressively in the arm, thigh,
and hip.
Systemic rotation of injection sites within
an anatomic area is recommended to
prevent localized changes in fatty tissue
(lipodystrophy).
Provide Instruction on Blood Glucose
Monitoring.

All clients with newly diagnosed diabetes mellitus

require teaching about blood glucose monitoring.
More accurate blood glucose meters that are
easier to use are constantly being made available.
Provide Instruction on Urine Testing.

Urine testing for glucose is rarely done;

however, urine can be tested for ketones.
These substances appear in the urine of
clients who are fasting, clients with poorly
controlled type 1 diabetes, and clients with
type 1 or type 2 diabetes who have a
secondary illness. Ketones result from fat
metabolism and are therefore present during
fasting. The presence of ketones may indicate
the serious complication of diabetic
ketoacidosis.
Provide Instruction on Insulin
Administration

To administer insulin properly, the client must

be familiar with insulin concentrations,
syringes, storage, preparation for injection,
and techniques for self-injection.
Insulin Concentration.

Insulin is prescribed in units.

Insulin Syringes.

Insulin syringes are manufactured with

capacities of 0.25, 0.30, 0.50, and 1ml.
Insulin Storage.

Although storing vials of insulin in the

refrigerator, injection more painful. Avoid
temperature extremes of less than 36°F or
greater than 86°F. A slight loss of potency
may occur after 30 days at room
temperature.
Insulin preparation and Injection.

Experts once thought that insulin

vials should be rolled between the
hands to resuspend the insulin
without creating air bubbles.
Prefilled Syringes.

Prefilled syringes are chemically stable for

up to 3 weeks when stored in refrigerator.
Site Selection and Rotation.

Insulin absorption varies from side to side. To

avoid possibly dramatic changes in daily insulin
absorption, instruct the client to give injections
in one area, about an inch apart, until the whole
area has been used, before changing to another
site.
Techniques for self-injection.

Insulin injections are administered into the

subcutaneous tissue with the use of
special insulin syringes. A variety of
syringes and injection and devices are
available.
 - is a surgical opening in the chest wall and
inserting. A thoracostomy tube
(chest catheter) is inserted into the chest wall
above the area of the second
or third rib. A local anesthetic (xylocaine 1% or
2%) is administered and an
incision is then made into the pleural space of
the chest wall. The tube is
inserted, positioned, and clamped, and silk
sutures are use to secure the chest tube in
place.
 known as the water-seal drainage.
 use to restore the negative pressure that
has been lost inside the pleural space owing
to pneumothorax, and to prevent additional air
and fluid from entering the pleural cavity.
 It provides water-seal gravity drainage.
The gravity system allows the flow of air or
water into the bottle when the pressure in
the pleural space is sufficient to displace the
water in the glass rod.
 it is sometimes called suction –
breaking bottle
 It involves the addition of a suction source and a
suction-control bottle. These are added if gravity is
not sufficient to clear the air or fluid from the chest.
 Failure of the breaker bottle to bubble means
that the desired amount of suction has not been
reached. The reasons for this should be
investigated. Causes may include a leak within
the bottle and tube system, an inadequate
suction source, and a serious air leak into the
pleura from ruptured bronchus or bronchopleural
fistula.
 It involves the addition of a separate
collection bottle so that the drainage may
be separate collection bottle so that
drainage may be measured and inspected
as it comes from the chest.
 It is a commercially available product
incorporating all the features all ready discussed. It
is a single light weight unit which indicates the
amount of air bubbling through the suction chamber
from the atmosphere. It calibrates the exact amount
of negative pressure in the pleural space and has a
client leak air flow meter to indicate the amount of
air coming from the individual.
 Remove excess air, blood, or fluid from the
pleural cavity.

 Reduce the size of the pleural space, and

restore negative intrapleural pressure to promote
lung expansion.

 Remove tumors of the lung, bronchus or chest

wall
 Repair or reverse structures contained in the
thorax such as open heart surgery or repair of a
thoracic aneurysm.

 Repair trauma to the chest or chest wall, such

as penetrating chest wounds or crushing chest
injuries

 Sample a lesion for biopsy.

 Measure and document the amount of
drainage coming from the pleural space in
the collection chamber. This record helps
determine the amount of blood loss and flow
rate of drainage from the pleural space.
Notify the surgeon if:

the drainage remains frankly bloody for

longer than the first few postoperative hours
bleeding recurs after it has slowed
there are any other manifestation of
hemorrhage.
 A water seal provides a one-way valve
between atmospheric pressure and sub-
atmospheric (negative) intrapleural pressure. It
allows air and fluid to leave the intrapleural
space but prevents the back-flow of atmospheric
air into the chest.
 When tidaling is occurring, the drainage tubes
are patent and the apparatus is functioning
properly. Tidaling stops when the lung has re-
expander or if the chest drainage tubes are
kinked or obstructed.

If Tidaling doest not occur:

Check to make sure the tubing is not kinked or

compressed.
Change the client’s position.
Have the client deep breath and cough.
If indicated, milk the tube If these measures do
not restore tidaling, notify the surgeon. (Note:
Tidaling may not occur or may be minimal in
systems not using suction.)
 Rapid bubbling in the absence of an air leak
indicates considerable loss of air, as from an incision
or tear in the pulmonary pleura.

When this occurs, notify the physician

immediately so that appropriate measures can
be taken to prevent collapse of the lung or
mediastinal shift, such as;

application of suction
increase in the amount of suction
thoracotomy
Suction at 10 to 20 cm H2O may be applied to a
chest drainage system if gravity drainage is not
adequate or if a client’s cough or respirations are
too weak to force air and fluid out of the pleural
space through the chest catheters.
Because most suction regulators can create
potentially damaging amounts of suction, the
amount of suction in the system must be
controlled. Proper functioning of a wet
suction control compartment is indicated by
continuous bubbling in the suction control
chamber.
Possible reasons for malfunction of a
mechanical suction apparatus include :

large amounts of air leaking into the pleural

space or into the drainage apparatus
mechanical problems in the regulator (suction
power source).
the most serious problem is air leaking into the
pleural space.
Closed-chest drainage systems must always
be placed lower (preferably 1 to 2 feet) than
the client’s chest. Drainage by gravity is thus
maintained, and fluid is not forced back into the
pleural space. Chest drainage systems must
be placed upright on the floor or hung from the
foot of the bed.

Provide thorough instruction and preparation
or hospital discharge:
Surgical wound and chest tube insertion site Wound care varies according to condition of
care
Continuation of exercise program
Precautions regarding activity and
environmental irritants
Clinical manifestations to be reported to
health care professionals
Importance of regular follow-up care.
Community agencies that can provide
resources, as needed.
RATIONALE:
Thorough understanding promotes
compliance and enhances self-care
capabilities.
incision and client.
Continued exercise increases activity
tolerance and prevents complications
Heavy lifting should be avoided. Return to
work depends on clients condition and type of
job. However, it is usually possible to return
to work within 4 to 6 weeks. Environmental
irritants can cause severe coughing episodes.
Evidence of infection, deteriorating
respiratory status, or other complications
should be reported promptly.
The client should be monitored closely for
manifestations or surgical complications,
recurrence of malignancy and metastasis.
Community resources can facilitate home
management.