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Points to assess during appointments with clients taking insulin:
Name of insulin:___________________ Dose:__________________ Is this being taken consistently at the same time from day-to-day? Is SMBG being done consistently at hs and first thing in the morning? RD to assess dietary intake as for any medication regimen. Assess HS snack practices.
Premixed:
Name of insulin: _________________ Doses: a.m._________ p.m._________ Time of a.m. dose: _________________ Time of p.m. dose: _______________  Ideally b/f and dinner doses should be spaced by 10-12 hrs to ensure adequate basal coverage for 24 hrs How long prior to eating is client administering insulin? ___________________ Humalog Mix 25 and Novomix 30 should be taken about 10 min prior to eating or with food. 30/70 should be taken about 30 min prior to eating. Ensure that client never takes premixed insulin at hs, on an empty stomach, or after eating. Is client resuspending insulin 20 times prior to injecting? Is client consistently SMBG QID: a.c. all meals and at hs daily? RD to assess diet and set initial carbohydrate target for each meal (ideally, lunch should be the smallest meal for this regimen). Then, monitor whether targets can be met from day to day by client and adjust as required (note: this will likely require corresponding insulin adjustments). (For example, are all of client’s various breakfasts meeting 45 g target? If not, can adjustments to diet be made? If not, should CHO target be adjusted? If so, is a corresponding insulin adjustment also required?). Also, assess HS snack practices. Name of basal insulin: __________________ Dose:_____________ Is this being taken consistently at the same time every day? □Yes □No Name of bolus insulin: _________________ Doses: breakfast: __________ How long prior to eating is client administering bolus insulin? _________________ Rapid insulins should be taken about 10 min prior to eating/with food Ensure that client never takes rapid insulin on an empty stomach, at hs, or after eating Is client consistently SMBG QID: a.c. all meals and at hs daily? RD to assess diet and set initial carbohydrate target for each meal (note: bolus insulin should be redistributed according to carbs/meal initially if meal periods will differ greatly in carbohydrate). Then, monitor whether targets can be met from day to day by client and adjust as required (note: this will likely require corresponding insulin adjustments). (For example, are all of client’s various breakfasts meeting 45 g target? If not, can adjustments to diet be made? If not, should CHO target be adjusted? If so, is a corresponding insulin adjustment also required?).
All regimens: Assess physical activity and its impact on client’s blood glucose levels.
Created by Angela Heerema, RN, CDE (Updated: May, 2012) All regimens (Cont’):
e.g. coded correctly, used properly, replaced recently, ideally checked against lab results annually Is pt aware of symptoms of hypoglycemia? Is pt able to identify any contributing factors? Has pt experienced any recent episodes of hypoglycemia? Does pt know how to properly treat hypoglycemia? Do episodes occur consistently at a particular time of day? Is pt familiar with blood glucose target levels? Unawareness of blood glucose targets can lead to many different erroneous self-titration practices. Is pt familiar with how the insulin they are taking works? Examples: many pts do not realize that premixed insulin contains 2 different insulins, therefore, they may not see any risk in taking extra doses. Others may use extra injections of basal insulin to treat hyperglycemia. Others, titrate rapid too aggressively thinking that the doses are so much smaller than their basal dose. Is pt taking insulin as prescribed or self-adjusting dose? If self-adjusting, is this based upon a HCP’s instructions or pt’s own criteria? How often might pt “forget” to take their insulin in an average week? Is it one particular dose that is often missed? What can be done to problem-solve and make it easier to take the frequently missed dose? Does pt know how to check and store their insulin? Opened cartridges can be at room temp for 28 days, unopened ones should be stored in the fridge Clear insulins should always be clear, cloudy ones should always mix evenly with no visible clumps/frosting on glass. Is pt priming pen prior to dialing up their dose? 1-2 units should be primed to dialing dose to ensure that pen is working properly/remove air from needle/cartridge. 4, 5, 6 mm needles are suitable for all people with diabetes regardless of BMI (FIT). Is pt pinching up skin prior to injecting? What injection angle are they using? 4, 5 and 6 mm needles do not generally require the lifting of a skin fold, particularly if using size 4 mm (TITAN/FIT) Injections with shorter needles (4, 5, 6 mm) should be given in adults at 90 degrees to the skin surface (TITAN/FIT) When injecting into limbs or slim abdomens, to prevent IM injections, even 4 and 5 mm needles may warrant use of a skin fold and injections with 6 mm needles should be used either with a skin fold or a 45degree injection angle (TITAN/FIT). Pts using needles ≥8 mm should lift a skin fold and inject at 90 degrees. Slim pts should use both a skin left and inject at 45 degrees. (FIT) Where is pt injecting? Is lipohypertrophy present? (Examine abdomen with pt standing). What method is pt using to rotate sites? The abdomen should be used whenever possible. (Thighs and buttocks may also potentially be considered) (FIT). Use of the arms should be discouraged due to potential for IM injections (FIT) Various methods for site rotation can be taught (e.g. calendar method). Ensure client can identify a clear method to be used prior to leaving. Following injection, does pt hold pen in place for >10 seconds? Does pt check to ensure that pen dial has returned to “0”? Is pt aware of how to proceed if dial shows a result other than “0”?  If cartridge has run out and dial shows a number other than zero, pt needs to insert new cartridge and inject again to administer this remaining Is pt removing and discarding pen needle following each injection? Is pt disposing of pen needles correctly?  Leaving needles on the pen can allow air leakage into insulin cartridge and/or contamination of insulin (and/or distortion of proportion of bolus/basal insulin with pre-mixed insulin).  Pen needles are so fine that they can be easily bent/blocked and may not deliver an accurate dose if used more than once. Does pt have a pattern of high or low blood sugars consistently at a certain time of day?  If factors related to diet, activity, and/or improper insulin administration are not causing this problem, then, an insulin adjustment is required. Is pt also taking Metformin in combination with insulin? If not, why not? In type 2 diabetes pts who are treated with insulin, the combination of insulin and metformin results in superior glycemic control compared with insulin therapy alone, while insulin requirements and weight gain are less. Created by: Angela Heerema, RN, CDE (Updated: May, 2012)

Source: http://www.diabetestoronto.ca/sites/default/files/documents/resources/UNISON-All%2Bsites-Points%2Bto%2Bassess%2Bat%2Ban%2Binsulin%2Bappt_May2012_Unison_%2Blogo.pdf