Question

A nurse is teaching a client who has diabetes Mellitus about mixing regular insulin and NPH insulin. Which of the following statement by the client indicates an understanding of the teaching?

1. I should draw up NPH Insulin before the regular Insulin
2. I should inject air into the vial of regular insulin first
3. I should roll vial of NPH insulin between my hands before drawing it up
4. I should wait 3 minutes after Mixing the insulin to inject it

Answer 1

THE STATEMENT BY THE CLIENT THAT INDICTES A CLEAR UNDERSTANDING OF THE NURSE'S TEACHING IS OPTION C.

Answer :OPTION C:I should roll vial of NPH insulin between my hands before drawing it up .

Explanation:

NPH(neutral protamine Hagedorn) insulin is an isophane suspension of insulin which on resting separates into a lower cloudy part and an upper clear part to make the concentration of insulin in the solution different in the clear and cloudy parts. To ensure uniform distribution of insulin, the vial  has to be gently rolled before injecting. This ensures a proper concentration of NPH insulin being delivered. This can be achieved by slowly rolling the vial of insulin between the palm of the hands till the entire mixture becomes cloudy and there is no cloudy and clear partition visible in the vial. There should be no lumps noticed in the cloudy suspension.It should be uniformly cloudy before injection. If the patient does not mix the insulin by rolling the vial between the hands ,the distribution of insulin in the solution will not be uniform,concentration of insulin will be not correct,dose will change even after drawing the same amount of insulin and the sugar levels will fluctuate considerably .To ensure correctness and the accuracy of the dose of NPH insulin injection, the insulin vial containing NPH insulin has to be gently rolled between the palms of the hands.

Since the client has understood this fact properly, it indicates that the client has understood the fundamentals of rolling of NPH insulin vial before injection.Hence this is the correct option which indicates the right  understanding of the nurse's teaching.

THE STEPS IN THE MIXING OF REGULAR INSULIN WITH NPH INSULIN

1.Verify the dose,the no of units to be drawn,the vials label,drugs expiry.

2.Practice hand hygiene.

3.Inspect Regular insulin for the clarity of the solution.

3.Roll the NPH insulin between the palms of the hands to obtain a uniformly cloudy NPH solution.

4.Clean the top of the vials with a sterile alcohol swab.

5.Using sterile insulin syringe, inject air equal to the dose in the vial of NPH INSULIN FIRST and then withdraw the needle.

6.Then inject air into the vial of Regular insulin,leave the needle inside.

7.Invert the vial and draw REGULAR INSULIN FIRST.Remove airbubbles if any.withdraw the needle

8.Then insert the needle into the vial of NPH insulin and withdraw the units required very slowly without any air bubbles.

9.Administer the injection IMMEDIATELY after appropriate part preparation and discard the syringe,

The reasons why the other options are wrong

explanation

A :I should draw up NPH  insulin before the regular insulin ;incorrect learning

Reasoning:NPH insulin is a cloudy insulin while regular insulin is a clear insulin .Regular insulin is always drawn before NPH insulin as the NPH  insulin loses efficacy if it gets mixed with Regular insulin .so the rule of Insulin administration by mixing in the same syringe is drawing the Regular insulin first and NPH insulin next. This has to be learned by the patient so that there is no mistake in the sequence of withdrawing insulin into the syringe.and the effect required for the control of sugar is achieved.

Since the client says that he/she should draw up the NPH insulin before the Regular insulin it indicates that his or her understanding of the teaching regarding this matter is erroneous.A change in the sequence of drawing the insulins will affect its effects and action and blood glucose control as both insulins have different pharmacokinetics.THE SEQUENCE IS CLEAR FOLLOWED BY CLOUDY.

The Regular and NPH Insulin differ as follows.

Type of insulin	start of action	peak of action	duration of action
Regular insulin(fast acting)	~30mins	~2 hours	-8hours
NPH insulin(intermediate acting)	~2hours	~6-8 hours	~12-16 hours.

B i should inject air into the vial of Regular insulin first:incorrect learning

Reasoning: Since the efficacy of NPH insulin get affected if it gets mixed with Regular insulin, always air has to be injected into the vial of NPH insulin first followed by injection of air into the Regular insulin and drawing up of the Regular insulin into the syringe first,then drawing up of the NPH insulin into the syringe The air bubbles from the regular insulin should be gently removed before drawing up the NPH insulin. if Regular insulin gets injected into the vial of NPH insulin,then the vial has to be discarded.

if that client states that he or she should inject air into the vial of Regular insulin first ,it shows that his or her understanding of the sequence of injecting air into the insulin vials  is incomplete and needs further learning.

D. i should wait 3 minutes after mixing the insulin to inject it:incorrect learning.

Reasoning:It is a regular practice to inject the mixture of Regular insulin with the NPH insulin soon after mixing. that is Immediately the injection has to be administered. the NPH insulin efficacy gets altered with regular insulin. So the injection  has to be injected immediately .

Since the client says that he or she should wait 3 minutes after mixing the insulin to injected it indicates that the teaching of the client in the administration of Regular insulin with the NPH insulin,which has been mixed in the same syringe is incomplete and needs further improvisation.