Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Name of Student: _________________________________ Grade: _________

Year & Section: ___________________________________ Date: __________

PROCEDURE CHECKLIST
INSULIN ADMINISTRATION WITH PEN DEVICE
Instruction: Below is the grading scale which will be used in rating your performance.
5 Excellent 95 - 100
4 Very Satisfactory 88 - 94
3 Satisfactory 82 – 87
2 Fair 76 – 81
1 Needs Practice 70 – 75

PURPOSES
• To know how to properly prepare and administer Insulin
• To understand the importance of Insulin therapy
• To evaluate the effectiveness of insulin after administration

ASSESSMENT
Before administration of Insulin, determine:
o The policies and procedures for the facility
o The client’s understanding of the procedure
o Assess the client’s skin at the puncture site to determine if it is intact and the
circulation is not compromised. Check color, warmth, and capillary refill.
o Review the client’s record for medications that may prolong bleeding such as
anticoagulants, or medical problems that may increase the bleeding response.

PLANNING

EQUIPMENT
 Gloves, Insulin pen, Insulin cartridge (if needs to be changed), Pen needle, Alcohol
wipes, Cotton ball, Medication Tray and Sharps container.

IMPLEMENTATION

PREPARATION

PROCEDURE DONE NOT

DONE

1 Prior to performing the procedure, introduce self and

verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it is
necessary, and how he or she can participate.

2 Perform hand hygiene and observe other appropriate

infection prevention procedures.
3 Provide for client privacy.
4 Prepare the equipment: gloves, insulin pen, insulin
cartridge (if needs to be changed), pen needle, alcohol
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

wipes, cotton ball, and sharps container.

5 Verify the doctor’s orders. Check the insulin bottle

label and verify the expiration date. Make sure it is the
right insulin. Make sure it is not expired.
6 Put gloves on.
7 If using cloudy insulin, rolls and rotate pen 10 times.
8 Loads insulin cartridge (if needed), wipe insulin pen top
with alcohol wipe. Attach needle onto end of insulin
pen. Remove cap, sets outer cap on flat surface.

9 Prime the needle by dialing pen to 2 units. Push the

plunger until a small drop or stream of insulin is seen,
and repeat as needed.
10 Turn the dose knob to the dose ordered.

11 Assist the patient to select an appropriate injection

site.
12 Clean the skin with alcohol wipe or swab. If the skin is
visibly dirty, clean it with soap and water.
16 Pinch the skin and put the needle in at a 45 degree
angle. If the skin tissues are thicker, you may be able
to inject straight up and down. Check with your
provider before doing this.
17 Push the needle all the way into the skin. Let go of the
pinched skin. Inject the insulin slowly and steadily until
it is all in. Leave the syringe in place for 5 seconds
after injecting.
18 Pull the needle out at the same angle it went in.
Dispose the pen needle in sharps container.
19 Document dose and administration site appropriately.

EVALUATION
• Evaluate the effectiveness of the Insulin Therapy after its administration.
• Conduct appropriate follow-up such as asking patient’s understanding about the
importance of insulin administration.
• Prepare the client for self-administration of Insulin at home.

REMARKS:__________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Date/Time:__________________________
Clinical Instructor: ____________________