Insulin Therapy Patient Education

Many individuals are reluctant to initiate insulin therapy. Openly discussing their concerns prior to technical training is of prime importance. In particular, a common fear is that the injections will be painful or complex. Discussing up front the convenience of modern injection systems, and injecting the patient with saline to show the painlessness of the needle may be all that is needed to gain his trust and acceptance. Common concerns and issues are discussed below.

• Needle phobias are common at any age. Ask about previous injection experiences patients may have had, or observed. Inform the patient that—unlike intramuscular (i.m.) injections, which are painful—subcutaneous (s.q.) insulin injections with today's syringes and pens are generally painless. Insulin doesn't sting (glargine occasionally causes minor local reactions because of its acidic buffer), but using of alcohol for skin cleansing can sting and is not necessary. Also, injection-assistance devices may help in extreme cases (discussed later).

• There may be concerns that insulin therapy is the treatment of last resort, and is permanent. Patients may view themselves as failures or struggle to accept that they cannot avoid insulin or diabetes self-care any longer.

• Patients may have memories of family members or friends who suffered complications or death that they associate with having started insulin. Their own use of insulin may trigger fears that they will have a similar fate. It is helpful to point out that insulin therapy is effective, relatively inexpensive, and generally well tolerated. Also, emphasize the patient's current lack of optimal glycemic control and the risk of microvascular complications that it creates, plus the ability to "fine-tune" insulin doses and regimens to exactly meet the patient's needs in order to maximize the benefits and minimize the difficulties.

• Many people fear that the inconvenience of carrying supplies and taking the time to prepare and administer insulin will be a major barrier. Reviewing with patients their lifestyle and schedule, and pointing out the relevant issues, will help them in choosing equipment and an insulin regimen that meets their needs.

• Most patients (whether they admit it or not) will have some anxiety about injecting themselves for the first time, which hinders them from thinking about much else. Preparing a saline injection and having them self-inject

as the first part of the teaching session can alleviate their anxiety, and allow them to concentrate on the information that must be learned when beginning insulin therapy.

Patients should never be expected to self-teach injection technique at home. Written literature and training tapes should be used only to complement, not replace, individualized live instruction. Referral to a trained diabetes educator is encouraged when first beginning insulin. If not possible, office staff should be formally trained in the proper techniques of injection, mixing, and self-blood-glucose monitoring; current equipment; detection, prevention, and treatment of hypoglycemia; sharps disposal; and insulin storage.

Patients already taking insulin who have an unexplained change in their blood glucose values or difficulty in attaining stable glycemia should be asked to demonstrate their syringe preparation and injection techniques, to describe their insulin storage practices, and to show their injection sites. This often uncovers problems, especially in self-taught or inadequately educated individuals and the elderly.

Syringes

Gone are the days when patients boiled their glass syringes and needles, sharpened the needles with a whetstone, ran them through cotton to detect burrs, soaked everything in alcohol, and finally gave painful intramuscular injections. Now a variety of insulin-delivery systems exist that use disposable, wire-thin needles that have been laser-sharpened and silicon-coated so that injections are usually painless.

Today's disposable syringes come in multiple sizes (0.3 cc [doses up to 30 units], 0.5 cc [up to 50 units], and 1 cc [up to 100 units], needle thicknesses (28 to 30 gauge), and needle lengths (5/16" and V2"). Insulin in the United States is standardized to a concentration of 100 units per cc (U100), with syringes to match. However, some other parts of the world use other concentrations (mostly U40). Occasionally, foreign visitors call local pharmacies, physicians, or emergency departments because they have run out of insulin syringes. The concentration of their insulin needs to be determined. U40 syringes are available in the United States by special order, or U100 insulin may need to be given along with syringes. The 5/16" needles are appropriate for children (unless obese) or, as a rule, individuals with a body mass index < 27 kg/m2. Use in larger individuals can result in back-leakage and loss of insulin at injection sites, which can cause erratic or elevated blood glucose levels. Useful practices: blood glucose should be checked more frequently when changing syringes or needle lengths to make sure there is no deterioration in glycemic control; patients should be cautioned to check markings when changing syringes to avoid medication errors; be sure to order syringes that are large enough to hold increased or mixed doses.

Reuse and Disposal

Although syringe manufacturers recommend one-time usage of syringes, reuse is common and safe for most individuals if basic guidelines are followed. Immunocompromised patients or those with open wounds, poor hygiene, or acute concurrent illness should not reuse. It is generally recommended that syringes be used no more than three or four times (occasionally patients report longer usage without complaint or apparent problem), and that they be discarded if they come in contact with anything but skin, Recap the needles until the next use. Don't wipe the needle with alcohol; it results in a duller needle by removing the silicon coating faster. Patients who mix insulins dull their needles more quickly because of the puncturing of the rubber vial caps. Discuss needle reuse with your patients so you know exactly what they are doing.

Discarded sharps should be contained in a puncture-free container. Check with the local waste agency for specific instructions.

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