test 4

Why monitor blood glucose?

Diabetes or risk for developing, Adrenal gland problems, Liver disease, Taking meds that can raise blood sugar levels, serious infections can raise blood sugar levels, recovering from major trauma or surgery can raise blood sugar levels

Hypoglycemia

• <70 mg/dL (for diabetics)

• hunger/nausea, shaking/trembling, headache, sweating, paleness, nervousness, disorientation/confusion/slurred speech

Hyperglycemia

• >180 mg/dL (for diabetics)

• frequent urination, increased thirst, hunger, blurred vision, hot/dry skin, flushed, feeling weak or unusually tired

A fasting blood glucose level of _ is considered normal

70-99 mg/dL

If fasting blood glucose is _ or higher on two separate tests, indicative of diabetes

126 mg/dL

Intradermal injections (ID)

• injected just beneath the epidermis into the dermis layer (used for sensitivity tests, ie., allergies Tuberculosis test)~ 10-15°

• targets antigen presenting cells of the immune system that play a vital role in immune responses

• dosages very small

• common locations: inner forearm, upper back

Subcutaneous injections (SubQ)

go into the 3rd layer of the integumentary system, the subcutaneous fat layer. Absorbed into the bloodstream more slowly than IM injections~ 45-90°

Intramuscular injections (IM)

• needle inserted through all three layers of the integumentary system and into muscle. Then medication is injected into the muscle.~90°

• gradually adsorbed into the bloodstream via capillaries

• absorbs IM injections more rapidly than subq injections because of the greater concentration of capillaries in muscle tissue

• given into healthy muscle tissue for proper absorption to occur

• some IM meds are thick/viscous~ harder to withdraw from vial and inject

Intradermal Injection Sites (ID)

• most commonly used for psych techs = inner forearm~ upper back/upper chest

• inner forearm used for TB testing

• other uses: Allergy testing, vaccine

Subcutaneous Injection Sites (SubQ)

• most commonly used sites in healthcare settings: back of upper arm, abdomen~ Ventral Gluteal, Deltoid Muscle, Vastus Lateralis Muscle

• commonly used for insulin, heparin, Lovenox

Factors for Choosing Injection Site

• choose according to ordered route of injection being given: ID, SubQ, IM

• choose a site free from infection, scar tissue, necrosis, bruising, wounds, etc

• volume of medication being given

• pain (the ventrogluteal site is the least painful site for an IM injection)

• rotate sites

TB Testing details

• site: left or right anterior forearm (FA). region beginning 2-3 inches below elbow

• angle: 10-15 degrees

• amount: 0.1mL

• Needle: 27g; ½ inch

• bevel: up

• slowly inject to create wheal, instruct pt to return in 48-72 hours to have test read, don’t insert all the way

Tuberculin Skin Test

• terms: Mantoux Skin Test, Purified Protein Derivative (PPD) Test, Tuberculin Skin Test (TST)

• test pt for current or prior tuberculosis infection

• completed annually or for newly admitted pt in a facility

• intradermal injection of mycobacterial antigens, if current or prior tb, immune system recognize antigen and the response is an induration (raised hardened area).

What is Tuberculosis?

• highly contagious infectious disease caused by the bacteria Mycobacterium tuberculosis

• affects respiratory tract/lungs~ systemic= kidney, brain, spinal cord

• Active: symptomatic and can spread disease

• Latent: asymptomatic; cannot spread

• spread by inhalation of infected droplets from a person with active TB~ isolation precautions are airborne

Deltoid-upper arm (IM)

• locate acromion process, 2-3 fingers down, triangle below

• needle: 22-25G x 5/8-1in

• volume: 0.5-2mL

• ex: vaccinations for adults

• not used for children under 3

Ventrogluteal-side of hip (IM)

• palm over greater trochanter, middle finger pointing towards posterior superior iliac crest, pointer finger towards anterior superior iliac spine

• needle: 18-22G x 1-1 ½in

• volume: 2.5mL

• preferred site~ safer/least pain

• side-lying, prone, or supine

• fat layer thinner, gluteal muscle is thicker

Vastus Lateralis-side of thigh (IM)

• hand under the greater trochanter, hand above knee, in the middle

• needle: 18-22G x 1-1 ½ in

• volume: up to 3ml

• used for IM injections in infants and children younger than 3

• little risk of injury

IM Sites No Longer Recommended

• Dorsogluteal- back of hip; risk for sciatic nerve injury and its proximity to major blood vessels

• Rectus Femoris-anterior thigh; risk of damage to lateral femoral artery and femoral nerve

Aspiration with IM injections

• once a needle is inserted, pull back on plunger slightly and check for blood in syringe

• purpose: to ensure that the needle tip is not located in a blood vessel prior to medication injection

• if blood, remove needle and prepare new syringe/needle

• vaccinations→ preferred site is Deltoid, aspiration not necessary

• ventrogluteal and vastus lateralis~ may require aspiration and do need z-track

Z- track method (zig zag)

• useful for medications that may be irritating or staining to the skin’s dermal and subcutaneous layers, larger volgume injections, long-acting injection

• zig-zag track line helps prevent medication from leaking from muscle tissue

• ventrogluteal, vastus lateralis,

• deltoid-varies~ not necessary for vaccines, meds that are: irritating, viscous, staining, long acting psych meds

Info r/t IM injections

• inject drug slowly to reduce pain.~ inject no quicker than 1 mL per 10 sec

• needle too long= penetrate beyond target muscle/hitting bone. needle too short= fail to reach muscle and medication will be injected into subq tissue

• don’t massage~ may force medication from the muscle into the integumentary layers, reducing the absorption of the drub, bruising

Reducing pain

• never reuse needles, skin dry fully, injection area warm and relaxed, break through skin quickly, pull straight out,

• when using ztrack, hold until injection is complete and needle is removed

Vaccines

given IM:

• common site: deltoid

• vastus lateralis in children under 3

• often require a consent and a patient questionnaire filled out

Needlestick injuries

• exposes worker/pt to bloodborne pathogens~ HIV/AIDS, Hepatitis B, Hepatitis C

• blood tests for worker/pt immediately

• Encourage the wound to bleed gently by holding it under running water, lots of soup and running water, do not scrub, dry the wound and cover with waterproof bandage, seek medical attention, report injury

Reconstitution

• medications that are not stable in liquid form

• must be reconstituted with appropriate diluent (liquid) as noted on the vial~ sterile water, sterile saline, liquid lidocaine

• once diluent is added; gently roll or swirl the vial until powder is dissolved; then medication is ready to draw up and admin

Ampule

• tamper proof

• better storage for some unstable elements

• has score mark where top is to be broken off using an ample breaker, gauze, or alc wipe~ break away from you

• must use filter needle (filter straw) to draw up to prevent any glass particles from being drawn into syringe

• remove filter straw and apply needle for administration

Carpuject syringe system

• reusable autoclave plastic holder/disposable, prefilled medication cartridge

• advantages: provides precise, tamper-evident delivery system, has luer-lock tip for use wit IM or IV administration

• check directions regarding whether to expel air from cartridge or to shake/rotate cartridge prior to administration

What is Insulin?

• insulin is a hormone made by the beta cells of the pancreas

• key to open channels in the cell walls so that glucose can move blood from blood to the cells where it can be used as fuel

• w/o insulin, glucose remains in the blood and cannot be used by cells

Diabetes Mellitus

a metabolic condition involving elevated levels of glucose in the blood

Type 1 Diabetes

• autoimmune process; destruction of beta cells in pancreas~ cannot produce insulin

• lifelong insulin administration will be necessary

• most common onset in young people and onset is typically rapid

Type 2 Diabetes

• insulin resistance: the body does not use insulin properly

  • this is the most common cause (rusty locks)

• beta cells in the pancreas do not function properly; too little/excess insulin

• may be a combination of both causes

• most common onset in adults over 45 and onset is typically gradual

• can be managed with a combination of all or some of the following; insulin, oral medications, diet, exercise

Gestational diabetes

Hormones made by the placenta make the mother’s body resistant to insulin, BG increases to the point of needing insulin

3 P’s of Diabetes

• polyuria- increased urination

• polyphagia- increased appetite

• polydipsia- increased thirst

Hormone Replacement Therapy

• need to “replace” the hormone insulin that the patient is unable to make for themselves

• replacement hormones (“exogenous”

  • several types, new products are more effective, fewer allergic properties, vary onset/peaks/duration

Insulin = High Alert Med

• errors in dosing, timing, or administration carry a heightened risk of causing life-threatening harm

• Severe hypoglycemia: too much insulin can cause blood sugar to drop rapidly, which can lead to brain damage or death

  • brain/heart would eventually give up after not having enough fuel~ panic for resources

• margin between therapeutic dose and dangerous dose is very small

Rapid-acting insulin

• lispro (Humalog), aspart (Novolog), glulisine (Apidra)

• onset: 15 min, peak: 30-90 min, duration: 2-4 hours

• often given on a sliding scale with food

Long-acting insulin

• glargine (Lantus)

• onset: 1-2 hours (up to 5), peak: none, duration: 24 hours

• usually given once per day

Insulin Sliding Scales

• pt may be prescribed sliding scale insulin that they will receive before each meal and sometimes at bedtime

• rapid-acting insulin prevents blood sugar spikes and allows the food the person eats to be metabolized correctly

• a pt’s blood sugar is taken just prior to administration, then the scale is used to determine pre-meal dose using the patient’s current FSBG

• differs between pts

• imperative that the patient eat their meal after receiving this; part of nursing care is to assess whether the patient ate post administration

Insulin mimics the body’s normal insulin spikes w/ meals

• rapid acting: administered near meal times; mimics insulin spikes from the pancreas triggered by eating

• long acting: mimics the baseline insulin in the bloodstream to manage baseline glucose

Care of Insulin

• deteriorates when exposed to heat, cold, light, agitation

• keep in refrigerator before use

• can be kept in room temp once opened. good for 28 days once opened & in use (or per manufacturer guidelines). Facility insulin must be labeled with open and expiration dates.

• good insulin clear or milky white depending on type (only NPH= milky)

• NOT GOOD: frosting/coating on bottle, does not easily re-suspend

Insulin Pens

• convenient, portable form of insulin. a new subcutaneous needle is attached for each dose, and the dose is set via a dial

• reusable: types of pens contain cartridges that are switched out with a new one when empty or after 28-32 days. The outside pen is reused.

• disposable: types of pens are discarded when empty or 28-32 days of first use (depending on insulin type) and replaced with a new pen

Insulin is not for sharing

• clearly labeled with patient ID

• insulin pens are never shared

Rotate sites

• prevents tissue damage

• ensures predictable absorption

After injection, count 5-10 seconds with needle still in (or per manufacturer guidelines)

• unique to subq injections

• prevent the medication leaking out with such a shallow injection and thin medication

• if leak, hold for 15 or 20 seconds~ pens/syringes