Presentation on theme: "Adult Subcutaneous Insulin Pump On Line Resource"— Presentation transcript:
1Adult Subcutaneous Insulin Pump On Line Resource Catherine Lai RN-BCCN III ProjectMary M. Sullivan RN, MSN, ANP-BC, CDEDiabetes CNS
2What is an Insulin Pump ?A subcutaneous insulin pump is a battery – operated device,designed to deliver insulin into the user’s body 24 hrs a dayaccording to a preset program.The insulin pump continuously delivers a small amount of rapidacting insulin Aspart or Lispro at a basal rate to help the bodyto utilize the glucose that is in the blood stream at the time.A “bolus dose” of insulin can be given to cover the glucose thatcomes from the carbohydrates that the patient eats and/or to covera high blood glucose level.
3What is an Infusion Set ?The infusion set is a connection between the body and the insulin pump.The infusion set is composed of a cannula or needle, adhesive dressing,tubing and a connector to the pump cartridge.The infusion set is inserted subcutaneously.The infusion set is usually inserted in the abdomen, but can be placed inother locations, e.g. thigh, back of the arms or the upper buttocks.
5An insulin pump and infusion set. The infusion set is shown loaded into a spring-loaded insertion device (the blue object). A reservoir of insulin is shown attached to the set..
6supplied by UCSF hospital pharmacy Insulin for PumpRapid acting insulinsupplied by UCSF hospital pharmacyLispro InsulinAspart Insulin
7Critical PointsBecause the pump uses a rapid acting insulin analogue (lispro or aspart),the patient is at risk for developing diabetic ketoacidosis if:the pump malfunctionsthe set dislodges or kinksthe reservoir becomes emptyThe blood glucose level should be monitored:the patient is eating (before meals, bedtime, 2 am)The insulin pump should be disconnected from the infusion set for: Mammograms - Bone density tests- Radiation treatment CT scan- MRI - X-raysThe infusion set can remain in place provided it is not metal.The Sure-T and the Detach Infusion set contain metal andmust be removed prior to MRI.
8Physicians Responsibilities The Primary team must contact Endocrine service, for aninsulin pump plan evaluation.A patient may only use their own insulin pump if they are cognitivelyintact, demonstrate knowledge about pump operation and have beenevaluated by Endocrine service.Endocrine service will give the patient form # ( ).ADULT GUIDELINES FOR USING YOUR SUBCUTANEOUS INSULIN PUMP WHILE IN THE HOSPITAL.The team will write orders on form # ( ).ADULT SUBCUTANEOUS INSULIN PUMP ORDER SET.
9Insulin Pump Instructions: MD writes an order for:Insulin Pump Instructions:Insulin typeBasal rateCarbohydrate ratioHigh glucose correction
10Patient’s Responsibility The patient will need to supply his own infusion sets, reservoirs /cartridges and pump batteries.The patient must change and fill the pump reservoir and infusion set toinsulin supplied by Hospital.The patient must change the infusion set every 72 hours or sooner ifdislodged, if redness develops at the insertion site, or if unexplainedhyperglycemia occurs (BG >300 mg/dL) x 2.The patient must not change pump settings without MD direction.The patient must not give boluses without RN supervision.
11Adult Guidelines for Using Your Subcutaneous Insulin Pump While in Hospital form (107-0033). Endocrine service will give patient this form.
12Pharmacy Responsibilities Pharmacy will supply the vial of LISPRO or ASPART insulin.
13RN Responsibilities Procedure Check infusion site for redness or dislodgement of the infusioncatheter every shift.2. Verify and document the pump’s basal rate, carbohydrate ratio, andcorrectional insulin dose in U care.
14RN Responsibilities continued: Documentation in UCARE
15If the patient is unable to show the RN: the basal rate RN Responsibilities continued:If the patient is unable to show the RN: the basal rate carbohydrate ratio high glucose correction on the pumpIt is inappropriate for the patient to be on an insulin pump at this time.The team must be contacted to write appropriate orders to switchpatient to Subcutaneous insulin or intravenous insulin infusion.
16to change reservoir syringe if necessary. RN Responsibilities continued:4. Verify the pump reservoir has enough insulin for 24 hours, the patientto change reservoir syringe if necessary.5. Supervise boluses of insulin given via insulin pump by patient.2 RN’s to check insulin vial supplied by hospital pharmacy.Primary RN will observe patient draw up insulin using a new reservoir syringe/set.2 RN’s to check with any changes to pump settings ordered by MD.6. Prevent Diabetic Ketoacidosis on the pump:BG >300 mg/dL x 2Notify MDAsk the patient to change his infusion set.
177. Managing hypoglycemia on the Insulin Pump: RN Responsibilities continued:7. Managing hypoglycemia on the Insulin Pump:BG < 70mg/dL.Notify MDCheck BG Q15 minutes and repeat treatment until BG is > 100mg/dL.Patient is alert and can take PO: Give 20 grams of oral fast acting carbohydrate per patient preference:e.g. 4 glucose tablets (5 grams glucose/tablet) or 6 oz fruit juice.Patient is not able to take PO but is alert: Give 25ml of D50W IV push.Patient is incoherent/unconscious: Give 25ml D50W IV push. Temporarily disconnect pump tubing from the infusion setor turn off pump.8. If insulin pump is discontinued, notify Endocrine Service at
18Guidelines for transferring patient off insulin pump Contact Endocrine Service atBefore taking a patient off an insulin pump the following must occur:Obtain an order for Subcutaneous insulin or Intravenous insulin infusion.The patient is at risk for DKA if the patient does not receiveanother source of insulin before pump is discontinued.
19Risks of Pump TherapySigns and symptoms of Diabetic Ketoacidosis and HypoglycemiaDiabetic KetoacidosisHypoglycemiaBG > 300Ketones in urine, bloodDrowsinessNauseaAbdominal PainDry mouthFlushed skinKussmaul respirationsPolydipseaPolyureaBG < 70SweatingShakingIrritabilityHeadachePalenessConfusionSeizure
20Troubleshooting Hyperglycemia/hypoglycemia on pump therapy Causes:Actions:Insulin Pump:- Basal rate incorrect- Pump malfunction, suspended- Nurse to check rate and time, always reviewbasal rate after any changes madeReservoir Syringe/cartridge- Empty cartridge- Leakage at luer lock- Not primedPatient to fill new cartridge,Patient to tighten connectionsPatient to prime infusion setInfusion Site:- Redness, irritation, inflammation, pain- Scar tissue- Nurse to check infusion sitePatient to change infusion site if redness orirritation notedInfusion set:- Needle dislodged or cannula kinked- Air in infusion set or tubingBlood in infusion set- Patient to change infusion set and siteNurse to check for air in tubingPatient to disconnect from pump and prime airout of tubingInsulin:- Expired, cloudy- Lost potency- Obtain new insulin vial and changereservoir/cartridge
21Carbohydrate Counting and Determining Insulin Dose Involves computing the number of carbohydrategrams in a given meal or snack.Allows patients on an insulin pump to calculatethe right amount of insulin to counteract thecorresponding blood glucose rise from their meal.To determine the amount of carbohydrate in a meal plan:Contact the dietitian to write the carbohydrateamount on patient menu.Look at the label for total carbohydrate andserving size.
22Menu listing carbohydrate amount on each food items.
23Calculate Insulin Dose for Carbohydrates Patient is on a carbohydrate ratio of 1 unit per 15 grams carbohydrates.Dietary department indicates on the patients food tray the amount ofcarbohydrates for each food item:1 cup of rice 45 grams of carbohydrates1 milk carton 15 grams How much insulin does patient need for his carbohydrates?Total the amount of carbohydrates and divide by 15. answer is 60/15 = 4 units for his carbohydrates..
24Review Questions1. A patient arrives on your unit wearing an insulin pump, he is on a PCA pump and is drowsy and is not able to show the nurse his current pump settings. Can he/she continue to wear his pump?No, because the patient is not alert. The patient must demonstrate ability tomanage his insulin doses on his insulin pump independently.Contact Endocrine to switch off pump and to get insulin plan set upfor patient.2. Which service needs to be contacted when a patient wearing an insulinpump arrives on your floor?Endocrine Service,3. How frequently does the patient have to change his infusion set?Every 72hr or sooner if patient has high blood glucose > 300mg/dL x 2,redness develops at insertion site or dislodgement of infusion catheter.4. Where do you obtain pump supplies?Patient must provide own pump supplies.UCSF Hospital Pharmacy provides the vial of Lispro / Aspart Insulin.
25References Information Source: Mary M. Sullivan, RN, MSN, ANP-BC, CNS DiabetesAdditional Detailed Reference:UCSF Medical Center Nursing procedure – Use of Subcutaneous Insulin Pump (Adult)Author: Mary Sullivan, RN, MSN,CNS Diabetes – originated 07/08UCSF Medical Center (Adult Subcutaneous Insulin Pump Order Set) , (Rev 01/09).(Adult Guidelines for Using Your Subcutaneous Insulin Pump While in the Hospital) , (Rev 12/08).