INSULIN BY PEN 12/2008

Goal: Optimal Student Health and Learning Accurate and timely insulin dosing is a vital piece of a comprehensive plan. This training component is one of thirteen components created specifically for school nurses and non-medical school personnel who perform diabetes care tasks at school. These components are: • Diabetes Basics • Diabetes Medical Management Plan • Hypoglycemia • Hyperglycemia • Blood Glucose Monitoring • Glucagon Administration • Insulin Basics • Insulin by Syringe and Vial • Insulin by Pen • Insulin by Pump • Ketones • Nutrition and Physical Activity • Legal Considerations This unit is Insulin by Pen.

Learning Objectives Participants will be able to understand: Types of insulin pens Where on the body to inject insulin Preparation steps for insulin pen injection Participants will be able to demonstrate: How to dose with an insulin pen How to inject with an insulin pen Participants will be able to understand: Types of insulin pens Where on the body to inject insulin Preparation steps for insulin pen injection Participants will be able to demonstrate: How to dose with an insulin pen How to inject with an insulin pen In addition to understanding insulin dosing and delivery using an insulin pen, it is important school staff who administers insulin to a student or assists a student with insulin administration understand the fundamentals of insulin action, dosing and delivery. These general concepts are covered in the unit entitled “Insulin Basics.”

Insulin Pens Techniques for dosing and insulin delivery are similiar for both types of pen devices: Prefilled pens Reusable (cartridge) pens Both long-acting or basal insulin and rapid-acting or bolus insulin are available in pens Most students will only take rapid-acting or bolus insulin in school Regardless of whether a student uses a pre-filled or a reusable pen design, the techniques for dose preparation and insulin delivery are generally similar. Pre-filled pens Pre-filled pens contain a built-in, insulin cartridge. Because this device requires no loading by the student/parent/guardian, it is especially convenient and easy to use. Reusable pens With the reusable pen, an insulin cartridge is inserted into the pen's delivery chamber. Check the package insert for the specific guidelines for product expiration, as pens vary from vials. Injection basics with a pen: Once a disposable needle is screwed on to the pen and the pen is primed, pen is dialed to the appropriate dose, which can be seen in the device's display window and can be heard as audible clicks in many pen devices. The needle is inserted subcutaneously, and the plunger injection button is depressed to deliver the dose. The pen needle should remain in the subcutaneous tissue for 5 seconds after complete depression of the plunger.

Where to Give Insulin: On Target! Insulin works best when it is injected into a layer of fat under the skin, above the muscle tissue Rotating sites is important to insulin absorption Common preferred sites are the abdomen, thighs, buttocks, and upper arms Student should help choose injection site Inject into fat layer under skin Rotate sites Student should choose site Common sites: abdomen, thigh buttocks, upper arms 5

Insulin Pen: Preparation 1. Gather supplies. Verify insulin type pen device (with cartridge) pen needle alcohol wipe sharps container 2. Wash hands 3. Apply gloves 4. Have student chose injection site 5. Clean injection site 6. Screw on pen needle Here are the steps for administering insulin with an insulin pen device: Gather supplies: You will need the pen device (with insulin cartridge), pen needle, alcohol wipe, sharps container Wash hands Apply gloves Chose injection site Clean the area where you plan to give the injection Screw the pen needle onto the pen device

Insulin Pen: Dosing 7. Prime: Dial “2” units. If the pen is being used for the first time, prime 4-6 units as per manufacturer’s instruction 8. Hold upright. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows at end of needle 9. Dial number of units to be administered as per DMMP 7. Dial “2” units 8. Holding the pen upright, needle end up, press the plunger at the base or bottom of the pen to remove air until a few drops of insulin come out of the end of the needle 9. Dial number of units to be administered as per DMMP Note: A brand new pen will need to be “primed” with 4-6 units until a few drops of insulin come out of the needle. The purpose of priming is to clear any air out of the syringe that could affect dosing. Priming should be done into the air and not at the student.

Insulin Pen: Injecting 10. Pinch up the skin 11. Push the needle into the skin at 90 12. Release pinched skin 13. Push down on the plunger 14. Count to “5” 15. Remove and dispose of pen needle 16. Document time, dose, site, and blood glucose value 10. Pinch up the skin 11. Push the needle into the skin at 90 into the chosen injection site 12. Release pinched skin 13. Push down on the plunger at the base or bottom of the pen 14. Count to “5” 15. Remove and dispose of pen needle 16. Document time, dose, site, and blood glucose value The needle should be removed after each dose to prevent leakage of insulin from the pen. School personnel should allow the child to remove the needle if s/he is deemed competent to do so according to care plan agreements with the parent/guardian, student, and school nurse. If school personnel remove the needle, caution should be taken to carefully replace the outer cap of the needle without touching the outer cap itself.