Pharmacology Diabetes meds #11

Question

The nurse instructs a patient on self-administration of NPH insulin and regular insulins through patient teach-back and demonstration. The nurse knows the patient understands the instruction through demonstration of which action?

Answers

  1. The patient withdrew 20 Units NPH insulin first then regular insulin next
    • Rationale:

      This answer is not correct because regular, clear insulin should be withdrawn from the insulin bottle first. Then, the prescribed amount of NPH, cloudy insulin secondly.

  2. The patient withdrew 10 Units regular first, followed by 20 Units NPH insulin
    • Rationale:

      This answer is correct because when 10 Units of regular, clear insulin and 20 Units of NPH, cloudy insulin are ordered to be mixed with these specific steps, this is the correct method:
      Air is pulled up into the syringe for the 20 Units NPH, cloudy insulin and 20 units of air only placed into the NPH bottle; the needle is withdrawn;
      Air is then pulled up into the syringe for the 10 Units of regular, clear insulin and 10 Units of air placed into the regular insulin bottle; the needle remains in the bottle;
      The 10 Units of regular, clear insul

  3. The patient withdrew 20 Units NPH insulin in one syringe and 10 Units regular insulin in a second syringe
    • Rationale:

      This answer is not correct because NPH and regular insulin can be mixed in the same syringe if done according to the correct, evidence-based methods. This decreases the number of required needle sticks to the patient.

  4. The patient withdrew 30 Units glargine insulin and stated glargine is to never be mixed.
    • Rationale:

      This answer is not correct because glargine insulin is not prescribed in this scenario. It is a long-acting insulin and is not appropriate to give at this time. It is correct that glargine insulin should be given in a separate insulin, if prescribed.

Overview

Teaching and assurance of understanding by the patient regarding the correct method of self-administration of various prescribed insulins is the responsibility of the nurse. Return demonstration and verbalization will show the patient understands properly.

Explanation

When mixing cloudy (NPH or Humulin N) and clear (Regular or Humulin R), the clear must be withdrawn from the insulin bottle FIRST and cloudy next. Air is withdrawn and placed into the cloudy first, then air into the clear. After the air is placed into the clear, withdraw the clear unit dosage followed by the cloudy. Some use the mnemonic of Cloudy to Clear (AIR Draw)…then Clear to Cloudy (MED DRAW). Another is RN when drawing up insulin: Draw up R, then Draw up N. Do not draw up N (cloudy into the syringe first. Two syringes are not necessary. While Lantus is not routinely mixed with another insulin, the question indicates Humulin N and Humulin R will be used.

Learning Outcomes

Teaching and assurance of understanding of methods of how to self-administer insulins is the responsibility of the nurse. Patient’s should understand how to mix insulin when prescribed NPH and regular insulins. When mixing insulins NPH and Regular:

  1. Air is pulled up into the syringe for the correct amount “Y” Units of NPH, cloudy insulin and “Y” units of air only placed into the NPH bottle; the needle is withdrawn
  2. Air is pulled up into the syringe for the correct amount of “X” units of regular, clear insulin and “X” Units of air placed into the regular insulin bottle; the needle remains
  3. The “X” Units of regular, clear insulin is pulled up into the syringe; the needle is now withdrawn and placed in the NPH bottle;
  4. The “Y” Units of NPH, cloudy insulin is then pulled up into the syringe to make the syringe have a total of “X” Units  + “Y” Units*  
  5. *Note that the total units of all insulin should equal the regular, clear insulin units plus the NPH, cloudy insulin units after the correct amount of NPH is pulled up. 

Test Taking Tip

When mixing the appropriate insulins, remember this to help you remember which insulin is actually pulled up first into the syringe: It is always, “Clear before cloudy”.

Video Rationale