INFECTION CONTROL

INTRODUCTION:

There are important concepts regarding infection prevention and control measures that have been clarified over
the past decade. In the health care setting infection can easily spread from person to person. A client may be
infected while receiving care. A health worker may be infected while carrying out their duties. People who
work or interact with clients in a health care setting may be infected.

This transmission of infection is called cross infection. It is essential to understand the way infection is
controlled in any health care setting including hospitals, residential aged care, community services, dental
practices, mortuaries or alternative health care services.

DEFINITION:

An invasion and multiplication of micro organisms in body tissues, as in an infectious disease. The infectious
process is similar to a circular chain with each link representing one of the factors involved in the process. The
mere presence of micro organisms without reaction is not evidence of infection.

-MedicineNet.com

OR

Clients in all health care settings are at risk for acquiring infections because of lower resistance to infectious
micro organisms, increased exposure to numbers and types of disease causing micro organisms and invasive
procedures. In acute ambulatory are facilities, clients can be exposed to pathogens. Some of which may be
resistant to most antibiotics. By practicing infection prevention and control techniques, the nurse can avoid
spreading micro organisms to clients. Client teaching should include information concerning infections, mode
of transmission and methods of prevention.

-Potter Perry

Infection control is the discipline concerned with preventing nosocomial or healthcare-associated infection, a
practical (rather than academic) sub- discipline of epidemiology. It is an essential, though often under-
recognized and under-supported, part of the infrastructure of health care. Infection control and hospital
epidemiology are akin to public health practice, practiced within the confines of a particular health-care delivery
system rather than directed at society as a whole.

-www.enotes.com

PURPOSE:

 The purpose of infection control is to reduce the occurrence of infectious diseases. These diseases are
usually caused by bacteria or viruses and can be spread by human to human contact, animal to human
contact, human contact with an infected surface, airborne transmission through tiny droplets of
infectious agents suspended in the air, and, finally, by such common vehicles as food or water.
 Diseases that are spread from animals to humans are known as zoonoses; animals that carry disease
agents from one host to another are known as vectors.
TRANSMISSION:

Micro organisms are transmitted in health care settings by several routes, and the same micro organism may be
transmitted by more than one route. There are five main routes of transmission: contact, droplet, airborne,
common vehicle, and vector borne.

a) Contact transmission, the most important and frequent mode of transmission of health care associated
infections (HAI), is divided into direct and indirect contact transmission. Direct contact transmission
involves a direct body surface-to-body surface contact and physical transfer of micro organisms between
an infected or colonized person, such as occurs when a health care provider turns a client, gives a client a
bath, or performs other client care activities that require direct personal contact.

b) Droplet transmission, theoretically, is a form of contact transmission. However, the mechanism of

transfer of the pathogen to the host is quite distinct from either direct or indirect contact transmission.
Droplets are generated from the source person primarily during coughing, sneezing, and talking, and during
the performance of certain procedures such as suctioning and administering nebulized medications.

c) Airborne transmission occurs by dissemination of either airborne droplet nuclei (small particle residue
[five mm or smaller in size] of evaporated droplets containing micro organisms or dust particles containing
the infectious agent.

d) Common vehicle transmission applies to micro organisms transmitted by contaminated items such as
food, water and medications to multiple hosts and can cause explosive outbreaks. Control is through using
appropriate standards for handling food and water and preparing medications.

e) Vector borne transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin
transmit micro organisms; this route of transmission is of less significance in health care facilities in Canada
than in other settings.

INFECTION CONTROL TEAM:

i) The Infection Control Team are:-

1. Senior Nurses, Infection Control Nurses, Nurse Consultant and Infection Control Specialist Advisor
2. Infection Control Doctors (Medical Microbiologists)/Infection control officer
3. Biomedical scientists
4. Administrative staff

ii) Responsibilities of the Infection Control Team:

• Advise staff on all aspects of infection control and maintain a safe environment for patients and staff.
 Advise management of at risk patients.
 Carry out targeted surveillance of hospital acquired infections and act upon data obtained e.g.
investigates clusters of infection above expected levels.
 Provide a manual of policies and procedures for aseptic, isolation and antiseptic techniques.
 Investigate outbreaks of infection and take corrective measures.
 Provide relevant information on infection problems to management.
 Assist in training of all new employees as to the importance of infection control and the relevant
policies and procedures.
 Have written procedures for maintenance of cleanliness.
 Surveillance of infection, data analyses, and implementation of corrective steps. This is based on
reviews of lab reports, reports from nursing in charge etc.,
 Waste management.
 Supervision of isolation procedures.
 Monitors employee health program.
 Addresses all requirements of infection control and employee health as specified by NABH, state and
local laws.

iii) INFECTION CONTROL OFFICER (ICO)

The Infection Control Officer is usually a medical microbiologist or any other physician with an interest
in hospital associated infections. The Pathologists serves as Infection Control Officer. The ICO
supervises the surveillance of hospital acquired infection as well as preventive and corrective
programmes.

Functions:

• Secretary of Infection Control Committee and responsible for recording minutes and arranging
meetings;
• Consultant member of ICC and leader of ICT;
• Identification and reporting of pathogens and their antibiotic sensitivity;
• Regular analysis and dissemination of antibiotic resistance data, emerging pathogens and unusual
laboratory findings;
• Initiating surveillance of hospital infections and detection of outbreaks:
• Investigation of outbreaks, and
• Training and education in infection control procedures and practice.

iv) INFECTION CONTROL DOCTOR (ICD)

The ICD must be a registered medical practitioner. In the majority of countries, the role is performed
either by a medical microbiologist or hospital epidemiologist. Hospital consultants in other disciplines
(e.g. infectious diseases) may be appointed. Irrespective of their professional background, the ICD
should have knowledge and experience in asepsis, hospital epidemiology, infectious disease,
microbiology, sterilization and disinfection, and surveillance. It is recommended that one ICD is
required for every 1,000 beds.

The role and responsibilities of the ICD are summarized as follows:

• Serves as a specialist advisor and takes a leading role in the effective functioning of the ICT.
• Should be an active member of the hospital Infection Control Committee (ICC) and may act as its
Chairman.

v) INFECTION CONTROL NURSE (ICN)

Duties of Infection Control Nurse: The duties of the ICN are primarily associated with ensuring the
practice of infection control measures by nursing and house -keeping staff.

Functions:
• Serves as a specialist advisor and takes a leading role in the effective functioning of the ICT.
• Should be an active member of the hospital ICC.
• Assists the hospital ICC in drawing up annual plans and policies for infection control.
• Provides specialist nursing input in the identification, prevention, monitoring, and control of infection
within the hospital.
• Participate in surveillance, investigation, and control of infection in the hospital.
• Identify, investigate and monitor infections, hazardous practice and procedures.
• Advice to the contracting departments, participating in the preparation of documents relating to
service specifications and quality standards.
• Ongoing contribution to the development and implementation of infection control policy and
procedure, participating in audit, and monitoring tools related to infection control and infectious
diseases.
• Presentation of educational programmes and membership of relevant committees where infection
control input is required.

HOSPITAL INFECTION CONTROL PROGRAMME:

Hospital infection control program is dedicated to assisting the Public Health Services, State and Local
Health Departments, Hospitals and other professional organizations in the prevention and control of
nosocomial infections.
To be effective the infections control programme should include the following.

1. Organised surveillance and control activities

2. One infection control practitioner for every major Health Facility.
3. A Trained Hospital Epidemiologist
4. A system for reporting surgical wound infection rates and other infection back to the practicing
surgeons and physicians.

GUIDELINES AND RECOMMENDATIONS:

* Hand washing and Hospital Environmental Control

* Immunization
* Infectious Diseases Control
* Intravascular Device-Related Infections and its control
* Isolation Precautions
* Long-Term Care Facilities
* Guidelines for Infection Control in Health Care Personnel
* Surgical Site Infections Control
* Urinary Tract and Respiratory Tract Infections Control
* Ordering and Preparing Guidelines appropriately
* Home care
* Hospital Construction
* Sterilization / Disinfection

TIPS TO PREVENT INFECTION IN HOSPITALS:

The following are 5 tips that a hospital can keep in mind when preventing infection:

1. Wash your hands

The most effective was to protect a hospital from spreading infection is to enforce strict hand-washing
protocol. All physicians should clean their hands before treating any patient so it doesn't hurt to ask
them to do it in front of you. Hospitals should consider placing alcohol-based hand cleaners in each
room, or in close proximity of rooms to keep harmful bacteria off the hands that will be touching sick,
weakened patients.

2. Keep equipment clean

Stethoscopes are commonly contaminated with Staphylococcus aureus and other bacteria. A central line
catheter that is antibiotic-impregnated or silver- chlorhexidine coated can reduce chance of infection. It
is also important to keep bodily fluids intact by covering the mouth and nose when sneezing or
coughing.

3. Keep the sick away from the healthy

If a patient's sickness is infectious, it is important to keep them quarantined or separate from other
patients and employees, especially those whose immune system is weakened. Consider investing in
single-patient rooms or better air- ventilation systems.

4. Constantly change IVs

Patient IVs should be changed constantly, at a pace of every 3 to 4 days. Make sure that the IV is
inserted and removed under clean conditions, and that the attending nurse or physician is wearing clean
gloves.

5. Encourage patients to prevent infection

Patients are as much in control of their infection as the hospitals that treat them. Help the patient to
understand the importance of washing their hands, covering the mouth and nose, avoiding close contact
with others, and possibly getting vaccinated.

Precautions for infection control

 There is a two-tier approach to management of cross infection: Standard precautions and Additional
precautions.

i) Standard precautions:”

Standard precautions include the following five procedures:

➤ Hand washing,
➤ Use of personal protective equipment,
➤ Correct handling and disposal of waste,
➤ Appropriate cleaning of client care equipment, and
➤ Hygienic environmental control.

Standard precautions apply whenever you may come in contact with the following four bodily
substances:

• Blood (including dried blood),

• All body substances, secretions and excretions (excluding sweat), regardless of whether or not they
contain visible blood,
 Non-intact skin, and
 Mucous membranes.

A) HAND WASHING:

Hand washing is the single most effective way to reduce the number of micro- organisms on the surface
of the skin. It should always be performed:

1. Before and after contact with a client

2. Before and after eating,
3. After using the toilet,
4. Before and after using gloves,
5. After contact with used equipment, and
6. Immediately following contact with bodily fluids.

Standard hand washing procedure:

 Remove jewellery.
 Wet hands thoroughly all over.
 Use pH neutral soap.
 Lather soap all over hands.
 Rub hands together vigorously for 15-20 seconds. Pay particular attention to the fingertips, thumbs,
wrists, finger webs and the backs of the hands.
 Rinse under running water.
 Pat hands dry with paper towels.
 Barrier creams
 The best protection against bacteria is intact skin, so each time you wash your hands you should
apply barrier cream. Take care when cutting your finger nails and pay attention to maintaining intact
cuticles. Any wound or abrasion should be covered using a waterproof dressing.

Waterless hand washing:

There are waterless alcohol based hand wash solutions that are as effective as soap and water hand
washing. These preparations should only be used when there is no visible soiling of the hands. If there is
visible soiling, then soap and water hand washing should be used. These waterless preparations contain
an emollient and aid in reducing damage to the hands.
• Gloves do not replace hand washing; it is an additional protective measure to hand washing. Hands
should be washed before and after using gloves.

b) Respiratory Protection:

Masks are worn to protect you from the environment in which you are working, and infection from
clients. They are also worn to protect the client from you if you are infectious. The correct mask must be
worn depending on the situation at hand.

Type of protective Type of use Correct usage

equipment

1. Paper Mask Wear in areas where droplet Cover the nose and mouth.
infection of the client is a concern. Secure correctly behind
Wear when the worker has a cold. your ears with elastic
Cannot be worn for extended fastenings.
periods.

2. Surgical mask Wear in areas where droplet Cover the nose and mouth.
infection of the client is a concern. Secure correctly behind the
Can be worn for extended periods. ears with tape fastenings.

3. Specialised Wear to protect from droplet Cover the nose and mouth.
particulate infection from active pulmonary Secure correctly behind
respiratory filter tuberculosis clients. your ears with elastic
mask fastenings.

4. Respiration mask Wear when there are noxious fumes, Has an inbuilt filtration
harmful dusts, sprays, vapours and system. Cover the nose and
mists. mouth. Secured correctly
behind the ears by straps.
c) Foot Protection:

Appropriate footwear should be worn at all times for your own safety and to prevent the spread of
infection.

Type of protective Type of use Correct usage

equipment

1. Shoe covers Wear to protect from contamination Cover shoe completely and
when entering an area of infection. tie securely. Made from
Wear to prevent contamination from polypropylene. Discard
spreading. after use.
2. Enclosed, Wear at all times to reduce contact Upper section of footwear
waterproof footwear with blood, bodily secretions, should cover all of the
with non-slip soles excretions, disinfectants, chemicals. upper foot and be made of
waterproof material. Soles
should be made of a
substance that reduces the
chance of slipping. Shoes
should be flat, with a heel
of not more than 2.5 cm.

3. Protective Wear to protect from splashes, drips, Footwear with a steel

footwear and the dropping or rolling of heavy toecap, a heavy duty upper
objects. and rubber soles.

d) Body Protection:

Gowns and clothes such as overalls will reduce the possibility of contact with hazardous or
contaminated substances. They also protect from contact with micro organisms.

Type of protective Type of use Correct usage

equipment

1. Fabric or paper Wear to protect self from infectious Has ties at the neck and at
gown client. Wear to protect client from the waist. Both sets of ties
possible exposure to micro need to be tied securely.
organisms. Discard paper gown after
use. Wash fabric gown. If
infectious, place in correct
linen bag and secure.
Change between clients.

2. Plastic Apron Wear to reduce contact with blood, Has ties at the neck and at
bodily secretions, excretions, the waist. Both sets of ties
disinfectants, chemicals. need to be tied up. Clean
and store dry between
 uses. Change between
clients.

3. Overalls Wear when there is a risk of Change if overalls become

splashing from corrosive materials contaminated. Wash after
use. Disposable overalls
should be correctly
discarded after use.

e) Eye Protection:

Eyewear provides the worker or client with protection from splashes. Splashes may be from bodily fluids,
chemicals spray or splash, dust or particles.

Type of protective Type of use Correct usage

equipment

1. Safety spectacles Wear when there is the risk of eye May look like normal
injury from splashing. glasses or may have side
shields. Cannot wear
glasses underneath. Clean
after use.

2. Goggles Wear if required when using Have a larger area of

potentially dangerous equipment. coverage. May wear
Wear when handling dangerous glasses underneath. Clean
substances such as chemicals Wear after use.
instead of safety spectacles if you
wear glasses.

f) Head Protection:

Protection of the head is important in many areas. It is also important as a means of preventing
contamination.

Type of protective Type of use Correct usage

equipment

1. Hairnet/Cover Wear to prevent contamination from Hair should be tied up and

falling hair. completely tucked into
cover.

2. Hard Hat Wear when there is a danger of Should be correct type of

falling objects hat for different work areas
 g) Ear Protection:

Ear protection is necessary when there is a risk of auditory damage.

Type of protective Type of use Correct usage

equipment

1. Ear Plugs Wear to reduce harm from noise. Roll the ear plugs until
they are thin and then
place them into your ear
canal where they will re-
expand to the shape of the
canal

Wear when operating loud Place them firmly over

2. Ear Muffs machinery. your ears so that your
entire ear is covered. The
strap sits across the centre
of your head joining the 2
ear pads.

h) Sharps Management:

Sharps are any item that has the possibility to puncture or penetrate. They include:Needles, scissors,
scalpels, razors, or anything that could constitute a danger of penetration such as a sharp piece of metal, broken
glass or a sharp piece of plastic. Contaminated sharps have a high risk of transmitting blood-borne diseases.

Methods to reduce the incidence of needle stick injuries and contamination include:

 Safe work practices and on going training,

 The development and use of retractable needles and syringes and needle- free IV delivery systems,
 Rigid sharps disposal containers placed strategically in all work and clean up areas, and
 The correct use of personal protective equipment where possible to reduce injury, eg; heavy-duty
leather gloves for maintenance personnel.

II) ADDITIONAL PRECAUTIONS:

Additional precautions are put into place when there is a higher level of protection required to prevent
the transmission of infectious diseases. They are used in addition to standard precautions.
Additional precautions may include the following five procedures:
 Client isolation,
 The use of gloves and gowns, where the protective equipment is removed and discarded into the waste
bin in the room prior to exiting,
 Hands are washed before and after glove use,
 Equipment stays in the room rather than going back into general population use, and
 There is specialized equipment cleaning and disinfection of both the equipment and the environment.

WASTE MANAGEMENT:

Waste management practices must meet national and local requirements; the following principles are
recommended as a general guide.
Principles of Waste management of hospital waste include:

• Generation.
• Segregation/separation,
•Collection,
• Transportation,
• Storage,
• Treatment,
• Final disposal.

Develop a waste management plan that is based on an assessment of the current situation and minimizes
the amount of waste generated. Waste is divided into three categories; general, biomedical and
pathological. Legislation requires that biomedical waste be handled and disposed of in such a way as to
avoid transmission of potential infections.

ΒΙΟ ΜEDICAL WASTE MANAGEMENT:

The most obvious biomedical waste generated in a long term care facility, health office or community
health agency is sharps. Use puncture resistant sharps containers to remove, store and dispose of used
sharps such as needles, blades, razors and other items capable of causing punctures.

If your practice generates large quantities of bio-hazardous waste, you may have to partner with a
medical waste management company in order to dispose of the waste safely. Bio-hazardous waste
includes both anatomical and non anatomical waste. Hazardous anatomical waste includes human
tissues, blood, and body fluids but excludes teeth, hair, nails, urine and feces. You may throw out a
diaper in the regular waste, for example. This means that bio-hazardous waste must be transported and
disposed of properly.

Protection from Bio-medical Waste:

Wash your hands with soap and warm water after handling biomedical waste. Also, wash all areas of
your body with soap and water that you think may have come into contact with biomedical waste, even
if you are not sure your body actually touched the biomedical waste.

• Keep all sores and cuts covered.

• Immediately replace wet bandages with clean, dry bandages.
• Wear disposable latex gloves when handling biomedical waste. Discard the gloves immediately after
use.
• Wear an apron or another type of cover to protect your clothes from contact with the waste. If your
clothes become soiled, put on fresh clothes, and take a shower, if possible.
• Launder or throw away clothes soiled with biomedical waste.
• Promptly clean and disinfect soiled, hard-surfaced floors by using a germicidal or bleach solution and
mopping up with paper towels.
• Clean soiled carpets. First blot up as much of the spill as possible with paper towels and put the soiled
paper towels in a plastic lined, leak-proof container. Then try one of the following:
• Steam cleans the carpet with an extraction method.
• Scrub the carpet with germicidal rug shampoo and a brush. Soak the brush used for scrubbing in a
disinfectant solution and rinse the brush. Let the carpet dry, and then vacuum it.
• Never handle syringes, needles, or lancets with your hands. Use a towel, shovel, and/or broom and a
dustpan to pick up these sharp objects. Dispose of them in a plastic soda pop bottle with a cap. Tape
down the bottle cap. Then throw the bottle in the trash.

CONCLUSION:
It is the responsibility of all health care providers to enact principles of care to prevent health care
associated infections, though not all infections can be prevented. Nurses can reduce the risk for
infection. Proper use of personal protective barriers and proper hand hygiene is paramount to reducing
the risk of exogenous transmission to a susceptible patient. For example, micro organisms have been
found in the environment surrounding a patient and on portable medical equipment used in the room..

Health care workers should be aware that they can pick up environmental contamination of micro
organisms on hands or gloves, even without performing direct patient care.

Nursing has many complicated scopes of practice, which challenge time management, priority setting,
and efficiency of practice. Although system and administrative support is beneficial to supporting
aspects of nursing care, direct care is performed by individuals.
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BLOOD GLUCOSE MONITORING

INTRODUCTION:

Regular blood sugar monitoring is the most important thing we can do to manage type 1 or type 2 diabetes.
You’ll be able to see what makes your numbers go up or down, such as eating different foods, taking your
medicine, or being physically active. With this information, you can work with your health care team to make
decisions about your best diabetes care plan. These decisions can help delay or prevent diabetes complications
such as heart attack, stroke, kidney disease, blindness, and amputation.

Blood glucose monitoring involves the use of test methods to determine the concentration of glucose in the
body; it helps to determine individual trend/patterns and changes in glucose level. On the condition where the
patient has all the equipment this test can be performed at home, office, hospitals, clinics and even when
travelling.

DEFINITION:

► Blood glucose monitoring is a method of assessing the concentration of glucose in the blood.

► Tests are performed rapidly and easily by using a reagent strip (e.g Glucostix) where a minute drop of
capillary blood is obtained from the client's digits (finger or toe), earlobe or heel

OR

Measuring the blood glucose level with the help of a portable glucometer.
 OR

A blood sugar test is a procedure that measures the amount of sugar or glucose in the blood that help to
diagnose the diabetes.

RISK FACTORS FOR DIABETES:

 45 years or older age

 Overweight
 Have high blood pressure, high triglycerides or low good cholesterol level
 Don’t exercise much
 A history of gestational diabetes
 History of insulin resistance
 History of stroke or hypertension
 Family history of diabetes.

IMPORTANCE OF MONITORING GLUCOSE AT THE BEDSIDE :

1. Routine bedside testing helps to guide treatment decisions maintaining blood glucose level with an
appropriate range.
2. Routine BG testing helps prevent hypoglycemia (i.e. less than 70 mg/dl) and hyperglycemia (i.e. more
than 140 mg/dl)
3. It is helpful to determine the life threatening conditions and is essential to maintaining a high quality of
life and increasing life expectancy in patients.
4. Severe hyperglycemia (i.e. BG level more than 240mg/dl can lead to diabetic ketoacidosis (DKA) and
hyperglycaemic hyperosmolar nonketotic syndrome(HHNS).
5. Hypogylcemic can lead to unconsciousness if the brain does not receive sufficient glucose to function.
6. Severe hypoglycaemic (i.e. BG level less than 40mg/dl can lead to seizures, coma and death.
PURPOSE:

 To obtain base line data

 For diagnostic purposes
 To determine high risk patients for diabetic complications
 As a prerequisite to commencing diabetic regimens
 To guide emergency interventions for insulin coma, diabetic coma, hyperglycemia or hypoglycemia
 To direct or redirect pre-diabetic and diabetic management e.g guides decisions on exercise pattern,
meal types/patterns, oral anti- diabetic and insulin doses
 To determine if previous diabetic management modalities has been effective

INDICATIONS :
  Diabetic patient on insulin therapy Etc.
 Persons with characteristic signs/symptoms of Type 1 or type 2 diabetes mellitus, gestational diabetes,
poor wound healing Etc
 Client/patient with family history of Diabetes Mellitus (part of routine health assessment before
admission)
 Client or patient with signs of Hypoglycemia (Fatigue, perspiration, confusion, shakiness, palpitations,
anxiety, lightheadedness, hunger and irritability)
 Pancreatic disorders and other related diseases
 Starvation
 Shock
 Insulin overdose

METHODS OF BLOOD GLUCOSE MONITORING:

1. Glucose strip test (Glucostix);

This method involves applying a drop of blood or dipping strip in urine or into a specially prepared
chemical reagent and the color change on the strip is compared with a color chart E.g Chemostrip BG,
Glucostix. This method may require blood or urine as directed by the strip manufacturer.

2. Glucometer:

E.G (Ames), Accu Check II, glucoscan 3000 (Life Scan) and one touch (Life scan): This method involves the
use of a glucometer also called a glucose meter (a mini electronic device with a mini-monitor and a strip
insertion point. The strip is inserted in the strip holder on the glucometer, the strip sensor point is then pegged
with blood from the finger tip to determine blood glucose level which appears on the glucometer.

3. Oral Glucose tolerance test:

This method requires that the client or patients fasts for at least 8-12 hours before the first glucose reading is
taken; thereafter, a high glucose containing drink is given (75grams), 2 hours after taking glucose drink
subsequent blood samples are taken and glucose level determined.

4. Continues Glucose Monitoring;

This method requires that a sensor strip is inserted into the patients skin around the abdomen or arm, the sensor
strip determines glucose level within the fluids in the interstitial space and transmits signals to the glucose
monitor which the patient keeps. Glucose reading is taken and transmitted every 5 minutes and indicated on the
monitor. This method determines sugar trend/pattern overnight or over a certain period of time. The CGM unit
alerts clients by beeping when blood glucose level is above or below normal.

5. Glycatedhemoglobin (HbA1c);

This is a laboratory method to determine the amount of glucose bound to hemoglobin. This method use blood
samples put through certain laboratory methods and the quantity of glucose attached to hemoglobin is
determine. This method provides insight to what the average blood glucose level has been over the last 2- 3
months.
Note: In clinical situations the following terms may be used when referring to blood glucose tests

1. Fasting plasma glucose or Fasting blood sugar/glucose: blood glucose test done at least 10-16
hours after last meal. The patient is asked to fast overnight until after blood sugar reading is taken.
2. Random plasma glucose or Random blood sugar/glucose; in this case blood glucose test is taken
at any period in time i.e at random intervals regardless of when the individual had a meal.

RBS RANGE:

 Less than 140mg/dl (7.8mmol/l) -----Normal

 Between 140 to 199 mg/dl (7.8-11.0 mmol/l)-----Prediabetes
 RBS above 200 mg/dl (11.1mmol/l) Diabetic

FBS RANGE:

 Less than (100mg/dl)-------Normal

 Between (100-125mg/dl)-----Prediabetic
 FBS above 126mg/dl (7mmol/l) taken on 2 separate occasions-Diabetic

REQUIREMENTS:

A tray containing,

 Antiseptic or alcohol swab or wet swap in a galipot

 Dry cotton balls swap in a galipot
 Sterile lancet or blood-letting device
 Paper towel
 Blood glucose meter or
 Blood glucose reagent strip (specific meters have specific strips)
 Gloves
PROCEDURE:

s.no. ACTION RATIONALE

1. Explain Action and gain consent Promotes understanding and
cooperation
2 Perform hand hygiene before Action Reduces transfer of micro
organisms
3 Instruct patient to perform hand hygiene with soap and warm Promotes skin cleansing and
water if able vasodilatations at selected puncture
site. Hand hygiene establishes
practice for patient when test is
performed at home.
4 Position patient comfortably in a chair or in Semi Fowler's Ensure easy accessibility to
position puncture site.

5 Apply clean gloves Reduces risk of contamination of

blood
6 Remove reagent strip from the container and replace the cap Protects strip in the container from
immediately. Accidental discoloration due to
exposure to air or light.
7 Check the code on the test strip Code on vial test strip must match
code entered into the glucose meter
8 Turn on glucose meter if necessary N/B: Some monitors are Activates meter
activated when the reagent strip is inserted and therefore do not
have on or off switch.
9 Insert strip into glucose meter (Refer to manufacturer's Some machines must be calibrated,
directions) and make necessary adjustments others require zeroing of timer.
Each meter is adjusted differently.
10 Remove unused reagent strip from meter and place on paper Moisture on strip can alter accuracy
towel or clean dry surface with test pad facing up (See of final test results.
manufacturer's directions).
11 Choose puncture site. Puncture site should be vascular. In adult, Ensures free flow of blood
select lateral side of finger, be sure to avoid central lip of following puncture.
 fingers which has more dense nerve supply.
12 Hold finger you will puncture in dependent position while Increase blood flow to area before
gently massaging finger toward puncture site. puncture

13 Clean site with antiseptic swab and allow it to dry complete Alcohol can cause blood to
haemolyze
14 Remove cover of lancet or blood-letting device. Hold lancet Cover keeps tip of lancet sterile
perpendicular to puncture site, and pierce/prick finger or heel
quickly in one continuous motion (do not force lancet)
15 Some agencies use lancet devices with an automatic blade Position the skin properly for the
refraction system. This reduces the possibility of self-sticks penetration
injury and preventing exposure to blood borne pathogens. Place
blood-letting device firmly against side of finger and push
release button, causing needle to pierce skin.
16 Wipe away first droplet of blood with dry cotton ball. (See First drop of blood may contain
manufacturer's direction for meter used) more serous fluid than blood cells.
17 Lightly squeeze puncture site (without touching) until large Adequate size is needed to activate
droplet of blood has formed. Hold finger in dependent position monitor and obtain accurate result.
before puncturing to improve blood flow. Excessive squeezing of tissue
during blood sample collection may
contribute to pain, bruising scaring
and hematoma formation.
18 Repuncturing is necessary if large enough drop does not form. Diabetic patients have peripheral
(See manufacture's direction on blood application). vascular disease making it difficult
to obtain a large drop of blood after
a finger stick.
19 Ensure that the meter is still on. Bring test strip in the meter e.g. Blood enters strip and glucose
ACCU-CHEK to the drop of blood. The blood will be wicked device will show message on the
on to the test strip (See manufacture's instruction). screen to signal enough blood is
obtained.
20 Do not scrap blood onto the test strip or apply to wrong side of This prevents inaccurate glucose
test strip. measurement.
21 Take reading, note reading Exposure of blood to test strip for
prescribed time ensures accurate
result. N/B: Some meters such as
(One Touch Life Scan) require
blood sample to be applied to test
strip already in the meter. Once the
drop of blood is applied, the meter
automatically calculates the
reading.
22 Turn meter off. Dispose test strip, lancet and gloves in the Meter is battery powered. Proper
proper receptacle disposal reduces risk for needle
stick injury and spread of infection.
23 Discuss test result with patient Promotes participation and
compliance with therapy.
24 Document findings, report findings as applicable Serves as baseline or reference
information
25 Offer patient and family opportunity to practice testing action. Serves as baseline or reference
information
26 Provide resources or teaching aids for the patient To facilitates learning.
Common Errors in Blood Glucose Monitoring:

1. Dropping a very small amount of blood

2. Inappropriate timing (the test is usually performed before meals and at bedtime, or whenever
hypoglycemia or hyperglycemia occurs)
3. Squeezing the puncture site too hard allowing tissue fluids to mix with the sample
4. Improper maintenance of glucometers (dust or blood accumulation on the digital display)

SPECIAL CONSIDERATIONS:

 Check the test/ regent strips for expiration before using protect the strips from light, heat and
moisture.Avoid selecting cold, cyanotic and swollen puncture site to ensure adequate blood sample.
 When using blood from refrigerated sample allow the blood to return to room temperature before testing
it.

INSULIN ADMINISTRATION
DEFINITION:

Insulin is a drug that is used to control glucose in patients with diabetes mellitus. It is the only
parenteral antidiabetic agent available for exogenous replacement of low levels of insulin.

PURPOSE:

 To assure proper administration of subcutaneous and intramuscular insulin.

  To define the guidelines for administration of constant infusion Insulin therapy on the general care units
when no Intensive Care Unit bed is available.

POLICY:

1. Syringe Use: All insulin shall be drawn up with an insulin syringe.

2. 2nd Nurse Verification: Two licensed personnel shall verify the following prior to administration: the
physician’s order, type of insulin, dosage, route, time, and content. The 2nd Nurse verification shall be
documented in the MAK System. On non-MAK units the 2nd Nurse verifying the information shall
initial on the MAR, on the line, 2nd verification nurse. Nurses in the clinics shall document the 2nd nurse
verification as designated by the department.
3. Different types of insulin are :
A. Rapid Acting (Humalog, Novolog, and Apidra)
B. Short Acting (Regular)
C. Intermediate Acting (NPH)
D. Long Acting (Lantus, Levemir)
E. Premixed Insulins
4. Labeling: The nurse shall label the insulin bottle with a date and initials upon opening. Insulin may be
kept refrigerated or stored at room temperature.
5. Discarding: The nurse shall dispose of the insulin bottle after 28 days from the date labeled on the
bottle.

ROUTES OF ADMINISTRATION:
A. Subcutaneous Insulin Injections:

1. Sites for subcutaneous injections of routine insulin are shown in the diagram below.

2. Recent research indicates that insulin injections into the abdomen give the most consistent absorption rate,
and the abdomen is the site of choice if the person is going to be exercising the extremity.

3. Vigorous exercise of the extremity leads to increased blood flow through the site, which results in more rapid
absorption and shorter duration of action of the insulin.

NOTE: Routine subcutaneous insulin injections should not be given into the deltoid area because in the average
sized to thin person this would result in an intramuscular injection.
B. Intramuscular Injections:
1. Occasionally the physician may order an IM insulin injection in order to increase the absorption rate of the
insulin.

2. REGULAR INSULIN is the ONLY insulin that shall be given IM. Unless the person is thin, it is doubtful
that the use of the insulin syringe and needle will result in an IM injection. (Insulin syringe needle length is
1/2").

3. Since the length of the needle on an insulin syringe is not sufficient to administer insulin intramuscularly, the
following procedure shall be utilized:

a. Draw up insulin in an insulin syringe in the correct amount.

b. Transfer the insulin to a tuberculin syringe, and attach a 5/8" to 1" needle. (The needles on insulin syringes
are not removable because they are attached directly to the syringe to eliminate the dead space in the needle
hub).

c. 1. When transferring the insulin from the insulin syringe to the tuberculin syringe with a detachable needle
that has a needle hub space, it is important to have enough air in the syringe to clear the hub of the needle.

2. The needle hub and needle hold from 3-5 units of insulin. Once the insulin is transferred to the tuberculin
syringe, pull down on the plunger so that when the insulin is injected, the air will clear the needle and needle
hub and all the insulin will be injected.

d. IM insulin can be injected into the deltoid muscle or another IM site.

C. Constant Insulin IV Infusion: (Regular Insulin):

1. REGULAR INSULIN is the ONLY insulin that shall be given IV.

2. Constant IV Insulin infusions shall not be placed on the general care units if a bed is available in an
appropriate Intensive Care Unit.
3. The physician shall notify the Unit Manager/Administrative House Manager of the need for placement
of a patient on a continuous insulin infusion on a general care unit while awaiting transfer to an ICU.
4. A patient with a constant Insulin IV infusion shall have a written a physician’s order as well as a
separate specific order for each rate change based on laboratory results.
5. A patient with a constant insulin infusion shall have blood glucose monitoring at least every hour with
the medical staff assuming responsibility for blood glucose monitoring and lab work required more
frequently than every two hours.
6. The RN shall assess the patient with a constant insulin infusion at least every two hours for:
a. Level of consciousness (LOC),
b. Signs and symptoms of hypo-hyperglycemia and
c. To assure blood glucose monitoring is completed appropriately.
7. The medical staff shall be responsible for documentation of information relative to the administration of
constant Insulin infusion.
8. Continuous Insulin IV infusions shall be administered via a volumetric infusion pump at all times.
9. The Pharmacy shall be responsible for mixing Insulin IVPB’s. The standard mixture shall be as follows
unless otherwise ordered by the physician:
 Adult 100 Units Regular Insulin/100cc Normal Saline
 Pediatric 10 Units Regular Insulin/100cc Normal Saline.
 Exception: Nurses in the ECC and the ICUs may mix the insulin in urgent and emergent situations.
 Insulin Reference Guide

Insulin Type Onset Peak Duration

Novolog (aspart) Rapid Acting 5-15 minutes 1-2 hours 4-6 hours

Humalog (lispro) Rapid Acting 5-15 minutes 1-2 hours 4-6 hours

Apidra (glulisine) Rapid Acting 5-15 minutes 1-2 hours 4-6 hours

Humulin R (human Short Acting 30-60 minutes 2-4 hours 6-10 hours
regular)

Novolin R (human Short Acting 30-60 minutes 2-4 hours 6-10 hours
regular)

Reli-On R (human Short Acting 30-60 minutes 2-4 hours 6-10 hours
regular)

Humulin N (NPH) Intermediate Acting 1-2 hours 10-18 hours

4-8 hours

Novolin N (NPH) Intermediate Acting 1-2 hours 10-18 hours

4-8 hours

Reli-On N (NPH) Intermediate Acting 1-2 hours 10-18 hours

4-8 hours

Lantus (glargine) Long Acting 1-2 hours no peak up to 24 hours

Levemir (detemir) 1-2 hours no peak up to 24 hours

MIXED INSULINS

Humulin 70/30=70% NPH (intermediate-acting insulin) +30% Regular Insulin

Novolin 70/30=70% NPH (intermediate-acting insulin) +30% Regular Insulin

Reli-On 70/30=70% NPH (intermediate-acting insulin) + 30% Regular Insulin

Humalog 75/25= Humalog protamine that is 75% intermediate-acting insulin +25% Humalog (lispro)

Novolog Mix 70/30 = Novolog protamine that is 70% intermediate-acting insulin + 30% Novolog (aspart)

Reference: AADE Diabetes Education Curriculum

PROCEDURE OF INSULIN ADMINISTRATION:

 Filling the Syringe - one Type of Insulin

To fill a syringe with one type of insulin:

 Wash your hands with soap and water. Dry them well
 Check the insulin bottle label. Make sure it is the right insulin. Make sure it is not expired.
 The insulin should not have any clumps on the sides of the bottle. If it does, throw it out and get another
bottle.
 Intermediate-acting insulin (N or NPH) is cloudy and must be rolled between your hands to mix it. Do
not shake the bottle. This can make the insulin clump.
 Clear insulin does not need to be mixed.
 If the insulin vial has a plastic cover, take it off. Wipe the top of the bottle with an alcohol wipe. Let it
dry. Do not blow on it.
 Know the dose of insulin you are going to use. Take the cap off the needle, being careful not to touch
the needle to keep it sterile. Pull back the plunger of the syringe to put as much air in the syringe as the
dose of medicine you want.
 Put the needle into and through the rubber top of the insulin bottle. Push the plunger so the air goes into
the bottle.
 Keep the needle in the bottle and turn the bottle upside down.
 With the tip of the needle in the liquid, pull back on the plunger to get the right dose of insulin into the
syringe.
 Check the syringe for air bubbles. If there are bubbles, hold both the bottle and syringe in one hand, and
tap the syringe with your other hand. The bubbles will float to the top. Push the bubbles back into the
insulin bottle, then pull back to get the right dose.
 When there are no bubbles, take the syringe out of the bottle. Put the syringe down carefully so the
needle does not touch anything.

Filling the Syringe - two Types of Insulin

To fill a syringe with two types of insulin:

 Never mix two types of insulin in one syringe unless you are told to do this. You will also be told which
insulin to draw up first. Always do it in that order.
 Your doctor will tell you how much of each insulin you will need. Add these two numbers together. This
is the amount of insulin you should have in the syringe before injecting it.
 Wash your hands with soap and water. Dry them well.
 Check the insulin bottle label. Make sure it is the right insulin.
 The insulin should not have any clumps on the sides of the bottle. If it does, throw it out and get another
bottle.
 Intermediate-acting insulin (N or NPH) is cloudy and must be rolled between your hands to mix it. Do
not shake the bottle. This can make the insulin clump.
 Clear insulin does not need to be mixed.
 If the vial has a plastic cover, take it off. Wipe the top of the bottle with an alcohol wipe. Let it dry. Do
not blow on it.
 Know the dose of each insulin you are going to use. Take the cap off the needle, being careful not to
touch the needle to keep it sterile. Pull back the plunger of the syringe to put as much air in the syringe as
the dose of the longer-acting insulin.
 Put the needle into the rubber top of that insulin bottle. Push the plunger so the air goes into the bottle.
Remove the needle from the bottle.
 Put the air in the short-acting insulin bottle the same way as the previous two steps above.
 Keep the needle in the short-acting bottle and turn the bottle upside down.
 With the tip of the needle in the liquid, pull back on the plunger to get the right dose of insulin into the
syringe.
 Check the syringe for air bubbles. If there are bubbles, hold both the bottle and syringe in one hand, and
tap the syringe with your other hand. The bubbles will float to the top. Push the bubbles back into the
insulin bottle, then pull back to get the right dose.
 When there are no bubbles, take the syringe out of the bottle. Look at it again to make sure you have the
right dose.
 Put the needle into the rubber top of the longer-acting insulin bottle.
 Turn the bottle upside down. With the tip of the needle in the liquid, slowly pull back on the plunger to
exactly the right dose of long-acting insulin. Do not draw extra insulin in the syringe, since you should
not push the mixed insulin back into the bottle.
 Check the syringe for air bubbles. If there are bubbles, hold both the bottle and syringe in one hand, and
tap the syringe with your other hand. The bubbles will float to the top. Remove the needle from the bottle
before you push out the air.
 Make sure you have the right total dose of insulin. Put the syringe down carefully so the needle does not
touch anything.

GIVING THE INJECTION

 Choose where to give the injection. Keep a chart of places you have used, so you do not inject the
insulin in the same place all the time. Ask your doctor for a chart.
 Keep your shots 1 inch (2.5 centimeters, cm) away from scars and 2 inches (5 cm) away from your
navel.
 Do not put a shot in a spot that is bruised, swollen, or tender.
 Do not put a shot in a spot that is lumpy, firm, or numb (this is a very common cause of insulin not
working the way it should).
 The site you choose for the injection should be clean and dry. If your skin is visibly dirty, clean it
with soap and water. Do not use an alcohol wipe on your injection site.
 The insulin needs to go into the fat layer under the skin.
 Pinch the skin and put the needle in at a 45º angle.
 If your skin tissues are thicker, you may be able to inject straight up and down (90º angle). Check
with your provider before doing this.
 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.
 Pull the needle out at the same angle it went in. Put the syringe down. There is no need to recap it. If
insulin tends to leak from your injection site, press the injection site for a few seconds after the
injection. If this happens often, check with your provider. You may change the site or the injection
angle.
 Place the needle and syringe in a safe hard container. Close the container, and keep it safely away
from children and animals. Never reuse needles or syringes.
 If you're injecting more than 50 to 90 units of insulin in one injection, your provider may tell you to
split the doses either at different times or using different sites for the same injection. This is because
bigger volumes of insulin may get weakened without being absorbed. Your provider may also talk to
you about switching to a more concentrated type of insulin.
 AFTER CARE:-
• Check site for leakage
• Correction doses: - Retest as per medical practitioner to check effectiveness.
• Meal/snack doses: - Timeliness in relation to eating
• Supervision of food amount per medical practitioner.

SUMMARY:
The injection of insulin is essential for management of patients with type 1 diabetes and may be needed by
patients with type 2 diabetes for intermittent or continuous glycemic control. The species and dosage of insulin
used should be consistent, and the patient’s injection technique should be reviewed periodically with the
diabetes care team. The effective use of insulin to obtain the best metabolic control requires an understanding of
the duration of action of the various types of insulin and the relationship of blood glucose levels to exercise,
food intake, inter-current illness, certain medications, and stress; SMBG; and learning to adjust insulin dosage
to achieve the individualized target goals established between the patient, family, and diabetes care team.
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