BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

LEARNING POCKET DESCRIPTION

-This learning packet discusses the importance of blood glucose monitoring. It also
includes the types and methods of blood glucose monitoring. More importantly,
it discusses the proper procedure of obtaining blood glucose.

LEARNING OUTCOMES

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After this lesson, the students will be able to:

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1. Understand the importance of blood glucose monitoring.
2. Perform proper procedure on obtaining blood glucose level.
3. Define insulin and identify its role to metabolism.
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4. Identify the different insulin injection sites.
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Topic 1

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

BLOOD GLUCOSE MONITORING

Blood Glucose monitoring is a cornerstone of diabetes management.

The process observes for patterns in the fluctuation of blood glucose (sugar)
levels that occur in response to diet, exercise, medications, and
or pathological processes associated with blood glucose fluctuations.
Unusually high or low blood glucose levels can potentially lead to acute and
or chronic, life-threatening conditions.

WAYS OF MONITORING BLOOD GLUCOSE

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1. Self-Monitoring of Blood Glucose (SMBG)

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-it can be done randomly
-Using frequent SMBG and learning how to respond to the results enable people with
diabetes to adjust their treatment regimen to obtain optimal blood glucose control.

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-This allows for detection and prevention of hypoglycemia (low blood glucose level)
and hyperglycemia (high blood glucose level) and plays a crucial role in normalizing
blood glucose levels. rep
- NORMAL VALUE: Less than 140mg/dL (7.8 mmol/L)

*Glucometer – also known as glucose meter

-highly sophisticated, requiring only a
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single drop of blood, and are
conveniently sized and portable
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- small enough to take with you on-the-

go, and based on your comfort level, can
be used anywhere at any time
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Methods of SMBG

a. Most involve obtaining a drop of blood from the fingertip, applying the blood to a
special reagent strip, and allowing the blood to stay on the strip for the amount of
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time specified by the manufacturer ( usually 5 to 30 seconds).

b. Some meters are biosensors that can use blood obtained from alternative test
sites, such as the forearm. They have a special lancing device that is useful for
patients who have painful fingertips or experience pain with fingersticks.

c. Some meters can be used by patients with visual impairments. They have audio
components that assist the patient in performing the test and obtaiņing the result.

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

FREQUENCY OF MONITORING
 For patients who require insulin
 2 – 4 times daily ( usually before meals and at bedtime)
 For patients who take insulin before each meal
 At least 3 times daily before meals
 Patients not receiving insulin
 At least 2-3 times per week

2. Continuous Glucose Monitoring System

- a device worn for 72 hours that continuously monitors blood glucose
levels; the data are downloaded and analyzed for blood glucose
patterns for that time period; presently used diagnostically to elicit
patterns and tailor treatment

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3. Glycated hemoglobin (glycosylated hemoglobin, Hgb A1C or A1C):

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- a long-term measure of glucose control that is a result of glucose attaching to
hemoglobin for the life of the red blood cell (120 days).

-Normal Value: less than 6%

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4. Fasting plasma glucose (FPG) / Fasting Blood Sugar (FBS)
-blood glucose determination obtained in the laboratory after fasting for more than 8
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hours
-Normal Value: 70 – 110 mg/dL (3.9 - 5.6 mmol/L)
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BLOOD GLUCOSE MONITORING

Equipment
• Antiseptic swab
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• Cotton ball
• Sterile lancet or blood-letting device
• Paper towel
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• Blood glucose meter (e.g., OneTouch,

Freestyle)
•Blood glucose reagent strips (brand
determined by meter used)
• Clean gloves
PROCEDURE
Assessment
1. Assess understanding of procedure and purpose. Determine whether patient with diabetes
mellitus understands how to perform test and realizes importance of glucose monitoring.
• Data set guidelines for nurse to develop teaching plan.

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

2. Determine whether specific conditions need to be met before or after sample collection
(e.g., with fasting, after meals, after certain medications, before insulin doses).
• Dietary intake of carbohydrates and ingestion of concentrated glucose preparations alter blood
glucose levels.

3. Determine whether risks exist for performing skin puncture (e.g.,low platelet count,
anticoagulant therapy, bleeding disorders).
• Abnormal clotting mechanisms increase risk for local ecchymosis and bleeding.

4. Assess area of skin that you will use as puncture site. Inspect the patient’s fingers, toes,
and heel. Alternative sites are the palm, arm, and thigh. Avoid areas that have bruises and
open lesions.
• Sides of fingers, toes, and heels are commonly selected because they have fewer nerve endings.

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• Measurements at alternative sites are meter specific and may be different from measurements at

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traditional sites (Corbett, 2008).
•The puncture site should not be edematous, inflamed, or recently punctured because these factors
cause increased interstitial fluid and blood to mix and also increase the risk for infection.

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5. Review health care provider’s order for times and frequency of measurement.
• Health care provider determines test schedule on basis of patient’s physiological status and risk for
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glucose imbalance.

6. If diabetic patient performs test at home, assess patient’s ability to handle skin-puncturing
device. If patient chooses, he or she may wish to continue self-testing while in hospital.
• Patient’s physical health may change (e.g., vision disturbance,fatigue, pain, disease process),
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preventing patient from performing test.
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Expected Outcomes
Expected outcomes after completion of procedure:
 Puncture site shows no evidence of bleeding or tissue damage.
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 Blood glucose level is normal.

 Patient demonstrates procedure.
 Patient explains test results.
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Planning
Explain procedure and purpose to patient or family, or both. Offer patient and family opportunity to
practise testing procedures.Provide resources and teaching aids for patient.Such explanations
promote understanding and cooperation.
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Implementation
1. Perform hand hygiene before procedures.
• Hand hygiene reduces transfer of microorganisms.

2. Instruct patient to perform hand hygiene with soap and warm water, if patient is able.
• Instructions promote skin cleansing and vasodilation at selected puncture site. Hand washing
establishes practice for patient when test is performed at home. Because of its ability to remove food
residue from the hands and fingers, hand washing is superior to the use of alcohol pads to cleanse
the test site.
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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

3. Position patient comfortably in chair or in semi-Fowler’s position in bed.

• This position ensures easy accessibility to puncture site. Patient will assume position when self-
testing.

4. Remove test strip from container, then tightly seal cap. Check the code on the test strip
vial.
• Sealing cap protects unused strips from accidental discoloration caused by exposure to air or light.
Code on test strip vial must match code entered into the glucose meter.

5. Turn on glucose meter, if necessary.

• Turning on activates meter.
•Some monitors are activated when the test strip is inserted and therefore do not have a specific on-

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off switch.

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6. Insert strip into glucose meter (refer to manufacturer’s directions), and make necessary
adjustments

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• Some machines must be calibrated; others require zeroing of timer. Each meter is adjusted
differently.
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7. Remove unused glucose test strip from meter and place on paper towel or clean, dry
surface with test pad facing up(see manufacturer’s directions).
• Moisture on strip can alter accuracy of final test results.
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8. Apply disposable gloves.
• Wearing gloves reduces risk for contamination by blood.
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9. Choose puncture site. Puncture site should be vascular. In adults, select lateral side of
finger; be sure to avoid central tip of finger, which has more dense nerve supply.
• Vascularity ensures free flow of blood after puncture.
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10. Hold the finger that you will puncture in dependent position while gently massaging finger
toward puncture site.
• Massage increases blood flow to area before puncture.
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11. Clean site with antiseptic swab, and allow it to dry completely.
• The site must be allowed to dry because alcohol can cause blood to hemolyze.
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12. Remove cover of lancet or blood-letting device. Hold lancet perpendicular to puncture
site, and pierce finger or heel quickly in one continuous motion (do not force lancet).
• Cover keeps tip of lancet or needle sterile.

13. Some employers use lancet devices with an automatic blade retraction system. This
reduces the possibility of self-sticks, preventing exposure to blood-borne pathogens. Place
bloodletting device firmly against side of finger and push release button, causing needle to
pierce skin
• Blood-letting devices are designed to pierce skin to specific depth, ensuring adequate blood flow.

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

Perpendicular position ensures proper skin penetration.

14. Wipe away first droplet of blood with cotton ball.

• First drop of blood may contain more serous fluid than blood cells.

15. Lightly squeeze puncture site (without touching) until a second large droplet of blood has
formed. Repuncturing is necessary if large enough drop does not form to ensure accurate
test results.
• Adequate-sized droplet is needed to activate monitor and obtain accurate results. Excessive
squeezing of tissues during blood sample collection may contribute to pain, bruising, scarring, and
hematoma formation (Pagana & Pagana, 2007).

16. Obtain test results.

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• Exposure of blood to test strip for prescribed time ensures proper results.

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A. Be sure meter is still on. Bring test strip in the meter (in this example, an Accu-Check) to the
drop of blood.The blood will be absorbed into the test strip
• Blood is absorbed into strip, and glucose device will show message on screen to signal that

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enough blood is obtained.
B. The blood glucose test result will appear on the screen. Some devices beep when
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is completed.

17. Turn meter off. Dispose of test strip, lancet, and gloves in proper receptacle.
• Meter is battery powered. Proper disposal reduces risk for needle stick injury and spread of
infection.
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18. Discuss test results with patient.

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Evaluation
1. Re-inspect puncture site for bleeding or tissue injury.
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• Site is possibly a source of discomfort and infection.

2. Compare glucose meter reading with normal blood glucose levels and previous test
results.
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• Comparison helps determine whether glucose level is normal.

3. Ask patient to discuss procedure.

• Discussion validates patient’s level of learning.
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4. Ask patient to explain test and results.

• Results of test may cause anxiety. Patient may misunderstand specific step of procedure.

Unexpected Outcomes
1. Puncture site bruised and continues to bleed
• Apply pressure.
• Elevate hand above level of heart
• Notify health care provider.

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

2.Blood glucose level above or below target range

• Continue to monitor patient.
• Check for medication orders regarding deviations in glucose level.
• Administer insulin or carbohydrate source as ordered, depending on glucose level.
• Notify health care provider.

3. Glucose meter malfunction

• Review instructions for troubleshooting glucose meter.
• Repeat test.
• Call the company phone number found at the back of every BG testing meter.

4. Patient misunderstanding of procedure and results

• Repeat instructions to patient.

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• Have patient demonstrate procedure.

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Recording and Reporting
 In nurses’ notes or special flow sheet, record procedure, glucose level, and action taken for
abnormal range.

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 Describe response, including appearance of puncture site, in nurses’ notes.
 Record and report abnormal blood glucose levels.
 Stress importance of timing the testing of blood glucose levels, particularly in patients with
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diabetes mellitus.
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https://www.youtube.com/watch?v=ZgM0t_tymm8
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Topic 2

INSULIN

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

This is a hormone produced by the eta cells of the pancreas. A major action of insulin
is to lower blood glucose by permitting entry of glucose into the cells of the liver, muscle, and
other tissues, where it is either stored as glycogen or used for energy. Insulin also promotes
the storage of fat in adipose tissue and the synthesis of protein s in various body tissues.

Insulin Therapy

Insulin therapy is a treatment approach designed to keep your blood sugar levels
closer to the levels of someone who doesn't have diabetes. This treatment requires close
monitoring of blood sugar levels and one or multiple doses of insulin

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Insulin Regimens
An insulin regimen is how much insulin a patient gets (dosage) and how often they
get it (frequency). Depending on the patient’s needs there are different insulin regimens
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including multiple daily injections (MDI), three-times-a-day (TID) insulin routine, and twice-a-
day (BID) insulin routine
Types of Insulin Regimen

1. Conventional Regimen
 In this type of simplified regimen (eg, one or more injections of a mixture of short-
acting
and intermediate-acting insulins per day), the patient should not vary meal
patterns and activity levels.
 The simplified regimen would be appropriate for the terminally ill, the frail elderly
with limited self-care abilities, or patients who are completely unwilling or unable

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

to engage in the self-management activities that are part of a more complex

insulin regimen.

2. Intensive Regimen
 This approach to uses a more complex insulin regimen to achieve as much
control over blood glucose levels as is safe and practical.
 A more complex insulin regimen allows the patient more flexibility to change the
insulin doses from day to day in accordance with changes in eating and activity
patterns, with stress and illness, and as needed for variations in the prevailing
glucose level.

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Insulin Injection Methods

Learning about Syringes
1. Syringes
Syringes vary by the amount of insulin
they

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hold and the size of the needle. They’re made of plastic and should be discarded after one
use.

2. Insulin Pens
Insulin pens use small (150- to 300-unit)
prefilled insulin cartridges that are loaded into a
pen like holder. A disposable needle is attached
to the device for insulin injection. Insulin is

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delivered by dialing in a dose or pushing a button

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for every 1- or 2-unit increment administered.

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Learning About Insulin Pens

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3. Jet Injectors
As an alternative to needle injections, jet injection devices deliver
insulin through the skin under pressure in an extremely fine stream.
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4. Insulin Pumps
Continuous subcutaneous insulin infusion involves the use
of small, externally worn devices (insulin pumps) that
closely mimic the functioning of the normal pancreas (ADA,
2009b). Insulin pumps contain a 3-mL syringe attached to a
long (24- to 42-in), thin, narrow-lumen tube with a needle or
Teflon catheter attached to the end (Fig. 41-4). The patient
inserts the needle or catheter into subcutaneous tissue

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 BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

(usually on the abdomen) and secures it with tape or a transparent dressing. The needle or
catheter is changed at least every 3 days. The pump is then worn either on a belt or in a
pocket.

INJECTION SITES

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DRAWING AND INJECTING ONE INSULIN
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https://www.youtube.com/watch?v=C0coWZbO-_E

Mixing, Drawing and Injecting Insulins

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https://www.youtube.com/watch?v=0siAYIk8muc

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BLOOD GLUCOSE MONITORING AND INSULIN SITE INJECTION

PREPARING AND INJECTING WITH A REUSBALE INSULIN PEN

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PREPARING AND INJECTING WITH A DISPOSABLE INSULIN PEN

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https://www.youtube.com/watch?v=ZofLlDgUSgw

ACTIVITY

To be posted in google classroom.

REFERENCES:

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Smeltzer, D., Bare, B., et.al.,(2008). Brunner & Suddarth’s Textbook of Medical-Surgical

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Nursing,11th edition, p1389- 1398.

Potter, P., Perry, A., et.al..,(2018).Fundamentals of nursing, 9th edition, p1094- 1097.

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https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulin-
therapy/art-20043866
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https://www.aboutkidshealth.ca/Article?contentid=1736&language=English#:~:text=An%20
insulin%20regimen%20is%20how,day%20(BID)%20insulin%20routine.
https://www.healthline.com/health/diabetes/insulin-injection#injection-location
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https://kidshealth.org/en/teens/injection-graphic.html
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