09.03 Insulin

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Overview

  1. Types of Insulin
    1. Rapid Acting
      1. Aspart (Novolog)
        1. Onset- 10-20 minutes
        2. Peak – 1-3 hours
        3. Duration – 3-5 hours
      2. Lispro
        1. Onset- 5-15 minutes
        2. Peak- 1-1.5 hours
        3. Duration- 3-4 hours
      3. Glulisine- rare
    2. Short Acting
      1. Humulin R and Novolin R
        1. Onset- 30-60 minutes
        2. Peak- 1-5 hours
        3. Duration- 6-10 hours
    3. Intermediate Acting
      1. NPH or Humulin N
        1. Onset- 1-2 hours
        2. Peak- 6-14 hours
        3. Duration- 14-16 hours
    4. Long Acting
      1. Detemir (Levemir)
        1. Peak- 6-8 hours
        2. Duration- 24 hours
      2. Glargine
        1. Peak- 1 hour
        2. Duration- 24 hours

Nursing Care

General

  1. Nursing care focused on safe administration and monitoring for hypoglycemia.

Assessment

  1. Patient may show signs of hyperglycemia prior to administration
    1. Increased thirst
    2. Headaches
    3. Blurred vision
    4. Frequent urination
    5. Confusion
    6. Change in level of consciousness
  2. Look for symptoms of hypoglycemia at peak onset
    1. Shakiness
    2. Dizziness
    3. Sweating
    4. Hunger
    5. Irritability
    6. Anxiety
    7. Headache

Therapeutic Management

  1.  Administration
    1. Rapid acting-
      1. Given SubQ
      2. Aspart should be clear and can be mixed with NPH
      3. Lispro is clear
    2. Short acting
      1. Humulin R or Novolin R
        1. Only insulin that can be given IV and SubQ
        2. Used with patients in DKA (diabetic ketoacidosis) and HHS (hyperosmolar hyperglycemia)
    3. Intermediate acting
      1. NPH or Humulin N
        1. Given SubQ
        2. Cloudy in color
        3. Can be mixed with rapid acting
        4. Draw up CLEAR (rapid insulin) first then draw up CLOUDY (intermediate)
          1. Ways to remember this-
            1. Clear to Cloudy like a weather report!
            2. R.N. – Rapid first then NPH
      2. Long acting
        1. Cannot be mixed with any other insulin
        2. Usually given as one dose per day due to long duration
  2. Make sure patients are ready to eat prior to administration to prevent hypoglycemia.

Nursing Concepts

  1. Glucose metabolism
    1. Insulin is a hormone that helps the body regulate the glucose in the blood.
  2. Pharmacology
    1. Insulin is prescribed to threat hyperglycemia in patients with diabetes.

Patient Education

  1. Patients should be taught about onset and peak times to prevent hypoglycemia.
  2. Patients should be taught to recognize signs of hypoglycemia and what are appropriate ways to eat to raise blood sugar levels if needed.

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Video Transcript

Okay, so, in this video, we gonna talk about the insulin, different types of insulin, what is the peak time, what is the onset of action time and how long they will last. We really need to know all those 3 things only. We don’t really need to go in detail about the mechanism of action because it is at a cellular level. And, as nurses, we don’t really need to know. Now, NCLEX questions on insulin are focused usually on like, let’s say, for example, talk about the rapid acting insulin. If you give this patient rapid acting insulin at 8 o’clock and the onset of action is within 15-20 minutes but its peak time is 1-3 hours after you give. So, when will you look for the hypoglycemia symptoms? So, when you give it at 8 o’clock, look for the hypoglycemia symptoms between 9 o’clock to 11. So, that’s what it actually ask for, doesn’t go in detail. And there’s also one question they like to ask about the insulin is how do you mix a clear insulin and a cloudy insulin, for example, regular insulin and NPH. Regular is clear and NPH is cloudy. And we’ll go in detail about that one too in this video how to mix those. And the only one insulin we cannot mix with any other insulin is the long acting. So, we can’t really mix any any any insulin with long acting or it cannot be mixed with any other as well.

Alright, so, the first one. Rapid Acting. We got three different types of rapid acting insulin. Insulin Aspart, Insulin Lispro and Insulin Glulisine. This one is not really been used very often. I have seen Insulin Aspart and Insulin Lispro all the time, so we gotta cover only those two on this video.

Let’s talk about the Insulin Aspart. Rapid acting insulin. Insulin Aspart, also known as a Novolog. The onset of action is 10-20 minutes and the peak time is 1-3 hours after you give it. So, let’s say you give this medication, this insulin at 9 o’clock to the patient. Then, it will start working from 9:10 to 9:20, anytime between that, and its peak time will be from 10 o’clock to 12 o’clock. So, the symptom for hypoglycemia, as a nurse, you’ll look for, you’ll be looking between 10-12 because its its peak time is between 1-3 hours after you give it. And duration is 3-5 hours it will last. It is clear, so if you have a rapid acting insulin aspart, if it is cloudy, then don’t use it, that’s supposed to be clear. And, it can be mixed with the NPH.

Rapid acting, another type is Insulin Lispro. The onset of action is a little bit faster, Lispro has 5-15 minutes. The peak time which is 1 – 1.5 hours. So, if you give it at 9 o’clock, you’ll be looking for the hypoglycemia symptoms between 10 – 10:30. Okay. Duration is 3-4 hours and the color is clear.

The next category is short acting. It includes the Insulin Regular also known as Humulin R or Novolin R. The onset of action is 30-60 minutes, the peak time is 1-5 hours, so, this is like a little bit long range to look for the hypoglycemic symptoms. So, if you give it at 9 o’clock, you wanna look for signs and symptoms of hypoglycemia between 10 o’clock all the way to (10, 11, 12, 1, 2, 3) so, 1500. I believe so. No, my mistake. 0900 to 1400, because this is 9 o’clock. Could be 10 o’clock and 5 hours will be 1400. So, you’ll be looking for hypoglycemic symptoms in between these hours. And last it a little bit longer, it has a longer duration of action, 6 – 10 hours. It is clear. The only difference with this insulin compared to other ones, this insulin, you can give IV. This is the only insulin you can give in IV. It’s a really important thing to remember. You cannot give any other insulin through IV, only the regular. So, probably, if you have studied about the DKA, diabetes ketoacidosis or hyperosmolar hyperglycemia syndrome, HHS or DKA, blood sugar is really really high like DKA,I believe it’s more than around like 400 – 600. HHS is really even higher like 800 blood sugar. Then, you would start them on IV insulin drip which will be Insulin Regular. Because you cannot give any other insulin by IV, all other insulins are given subq. This one, it can be given as a subq or IV. It’s an important thing to remember. And you can mix it with sterile water and normal saline. So, you will mix it with a normal saline and put in a bag and give as a drip. Okay.

The next one is Intermediate Acting Isophane Suspension also known as NPH or Humulin N. The onset of action is 1-2 hours. The peak time is 6-14 hours, it lasts a little bit longer like 16-14 hours and the color of this insulin is cloudy. This is the difference, okay? Now, as we talk, like NCLEX may ask you a question how to mix. Let’s say you have a, this is a bottle, this is Regular Insulin and this is NPH and you wanna mix regular insulin and NPH. Clear, cloudy, okay? So, how do you mix these? You wanna mix 3 units of regular with 2 units (let’s say, I’m just drawing some numbers) of NPH. How do you mix it? Do you take NPH first and then go to regular or do you take regular first and go to the NPH? Let’s think about it. If you take some insulin out of the NPH, so, you have a cloudy insulin in your syringe, now if you try, and then if you put the same syringe in the regular, try to draw a regular which is clear. What if, by mistake, you draw some cloudy insulin in the regular? The solution will become cloudy. It’s not bad, but it will become cloudy, that means, you cannot use that insulin anymore. That’s why, when you are mixing insulin, you do not want to go from cloudy to clear at all. You wanna go from clear to cloudy. So, let’s talk about mixing 3 units of Regular Insulin with 2 units of NPH. Well, you have a syringe, let’s say this is a syringe, a plunger, now, 5 units (1,2,3,4,5) because you want 3 + 2, 5 units. So, you gonna pull out up to here and have that 5 this much air, you gotta put a needle in the regular insulin, you gonna insert about 3 units of air into this regular unit and draw 3 units out of it. Then you gonna go into NPH, put the remaining 2 units of amount of air and then draw the NPH. So, draw regular first, NPH. So, that’s the order. Like, pull this plunger back up to the 5 units, so, you can put that much here, that’s 3 + 2. Take out, insert air to the regular unit, take out 3 units, go to the NPH and take NPH. Okay, that’s a really important question and have seen NCLEX ask me this question, or generally ask me, like in exams, in nursing school exams. This is an important question to remember.

Then, Rapid Acting is, I think I mix this one right here. We gonna cover on this one like, I think, as we talk about the rapid acting insulin. There are 3 types of insulin, aspart, lispro and glulisine and this is a rapid acting. 15-30 minutes. Peak time is 1 hour. Duration is 3-4 hours. It’s clear. It can be mixed with NPH.

The long acting, the last one, is long acting and it’s Insulin Detemir, also known as Levemir. The peak time is 6-8 hours and duration is up to 24 hours. This one is clear. It cannot be mixed with any other insulin. Long acting insulin cannot be mixed with any other insulin.

There’s another type of insulin, long acting, it’s Insulin Glargine. The onset of action is 1 hour, there’s no peak, just the same level for 24 hours. There’s no peak. Color is clear. And the same, do not mix long acting insulin with any other insulin.

Okay, that was a video about the insulin. If you have any questions about the insulin, let us know and thank you for watching.

Read more

  • Question 1 of 10

A nurse is teaching a newly diagnosed diabetic client about controlling blood glucose levels with short-acting insulin. The nurse is teaching the client how to use an insulin syringe when the client complains “Why do I have to take an injection? Isn’t there any way to take this insulin as a pill?” Which response from the nurse is accurate?

  • Question 2 of 10

The nurse is caring for a client who is experiencing an insulin reaction. Which of the following is a nursing priority?

  • Question 3 of 10

A nurse is caring for a diabetic client who uses an insulin pump. The client is in the hospital for diagnostic testing of kidney disease and the provider has ordered an MRI. Which action of the nurse is most appropriate?

  • Question 4 of 10

An example of a type of long-acting insulin would be:

  • Question 5 of 10

A 35-year-old patient with type 1 diabetes is in the hospital following surgery. The patient has an order for combination insulin therapy to be administered on a sliding scale depending on his blood glucose levels. The nurse uses a rapid-acting insulin to achieve short term control and mixes it with another type. Which type of insulin may be used in combination with rapid-acting insulin for this type of therapy?

  • Question 6 of 10

The nurse is administering a subcutaneous insulin injection after noting a POC glucose check result of 175. The nurse follows which of the following guidelines for administration? Select all that apply.

  • Question 7 of 10

A nurse is assessing a diabetic client at the healthcare clinic who has a log of glucose levels and insulin dosages for the past month. The nurse notes that the client has had high levels of blood glucose every morning, requiring increased dosages of insulin first thing in the morning when compared to other times of day. Which of the following suggestions would most likely assist the client to have better readings of morning blood glucose levels?

  • Question 8 of 10

A nurse is caring for a client that has an order for an insulin drip STAT. What kind of insulin can be safely administered intravenously? Select all that apply.

  • Question 9 of 10

You are planning for your morning medication administration. Which medications do you need to make sure are given right before a meal? Select all that apply.

  • Question 10 of 10

A nurse is preparing to administer insulin to a four year old girl who has high blood glucose levels after being admitted to the hospital. The nurse prepares 4 units of regular insulin to be administered subcutaneously. Which of the following interventions will most likely uphold the safety of this patient when administering the insulin?

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