Over 4 million people have diabetes in the UK, which is 6 per cent of the total population (Diabetes UK, 2020a), and more than 400,000 people in the UK were injecting insulin for diabetes in 2010 (Holden et al., 2014). Insulin can be injected using a needle and syringe or via an insulin pen. When using a needle and syringe, the patient has to draw up the correct dose of insulin from a vial before injecting it. By comparison, using an insulin pen will allow the patient to inject themselves quickly and easily. Many patients find insulin pens to be more convenient than using a syringe and vial. Insulin pens may also reduce the stigma associated with injecting in public places (Browne et al., 2014).

It is important never to use an insulin syringe to withdraw insulin from a disposable pen: insulin concentrations vary and the result could be a life-threatening overdose (NHS Improvement, 2016).

There are two types of insulin pen: disposable and reusable. Disposable insulin pens are preloaded with insulin and can be thrown away when empty. Reusable insulin pens have cartridges that can be replaced once empty.

When deciding what equipment to use for injection of insulin, the healthcare professional and the patient will need to consider several factors, including:

• What types of insulin are available in the different types of pen;• How much insulin the pen will hold;• How much insulin the pen can inject at one time; • How easy it is to read the display that shows the size of the dose (some pens have a magnified display which is useful for people with visual impairment);• Whether the patient has any problems with dexterity that will affect their ability to self-administer insulin with the equipment selected; and• How environmentally sustainable the pen is: reusable pens create less plastic waste.

This procedure shows how to demonstrate the correct method for using a reusable insulin pen to a patient. Also see the other clinicalskills.net procedures in the Diabetes Care category, including “Demonstrating how to use a disposable insulin pen”.

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SOLUTION SALINESOLUTION SALINANOT FOR HUMAN USENICHT ZUR ANWENDUNG AN MENSCHENBESTIMMTNON PER USO UMANO

NES PAS UTILISER CHEZ HUMMENO USAR EN HUMANOSSodium chloride, 9 mg, Metacresol, 2.5 mg;

Water for injection qs 1 ml. Hydrochloricacid and/or sodium hydroxide adj. pH

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SOLUTION SALINESOLUTION SALINANOT FOR HUMAN USENICHT ZUR ANWENDUNG AN MENSCHENBESTIMMTNON PER USO UMANONES PAS UTILISER CHEZ HUMMENO USAR EN HUMANOSSodium chloride, 9 mg, Metacresol, 2.5 mg;Water for injection qs 1 ml. Hydrochloricacid and/or sodium hydroxide adj. pH

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Diabetes CareAdults

Demonstrating how to use a reusable insulin pen

Demonstrated by Helen Church, Lead Diabetes Specialist Nurse, Hounslow and Richmond Community Healthcare NHS Trust, and Nina Garrett, Diabetes Specialist Nurse, Frimley Park Hospital NHS Foundation Trust

©2020 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Insulin pens are about the size of a large marker pen. While the cartridges available for reusable pens normally contain 150 or 300 units of insulin, disposable pens normally hold 300 units of insulin. The types of pens available to your patient will vary according to local policy. For most patients with diabetes, the recommended length of needle is 4 mm (Frid et al., 2016).

Equipment Demonstrate the equipment to the patient

Browne, J. L., Ventura, A., Mosely, K., & Speight, J. (2014). 'I'm not a druggie, I'm just a diabetic': a qualitative study of stigma from the perspective of adults with type 1 diabetes. BMJ open, 4(7), e005625. https://doi.org/10.1136/bmjop-en-2014-005625

Decontaminate your hands before proceeding with the demonstration. Explain the advantages and disadvantages of the different devices available to the patient and demonstrate their use. Encourage the patient to handle the device. Ask the patient if they have any concerns about using insulin (Diabetes UK, 2020b). It is important to inspect the patient’s injection sites when they attend for review and to discuss the importance of rotating sites (TREND UK, 2019).

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Demonstrate the pen to the patient (a) (b)

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Top of pen barrel

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Subcutaneous injection sites Reusable pens

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Assemble the pen (a) (b)

If you and the patient have decided that a reusable pen is the best option, proceed to demonstrate this type of pen to the patient. Identify the components of the pen. Check the expiry date on the cartridge (inset).

Unless this is the first time the patient has injected insulin, they are likely to be familiar with the correct sites for subcutaneous injection of insulin. Repeatedly injecting at the same site can cause lipohypertrophy, which may affect insulin absorption (TREND UK, 2019). Use of a pen may make it easier for the patient to reach those sites that would otherwise be more difficult to reach, such as the buttocks.

Following the manufacturer’s instructions, show the patient how to check how many units the pen contains, and how to to control the number of units of insulin required. The mechanism may differ from that shown, depending on the make of pen.

Explain when and how to agitate the pen in order to ensure that the insulin is uniformly resuspended. This step is not needed for clear insulins. If this step is required, the patient should gently move the pen as shown or roll the pen between the hands, according to the manufacturer’s instructions.

Insert the cartridge into the graduations holder. Connect the holder and cartridge to the barrel of the pen.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

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3636, 3637, 3638, 3639, 3640 The nondispos-able pen3642, 43, 44, 45, 46 assemble the pen3628, 3629, 3630, 3631 Check the expiry date on the pen3632, 3633, 34, 35, check the expiry date on the barrel3658, 3659, 60, 61, 62, 63, 64 unwrap a needle and apply it to the pen3665, 66, 67, 68, 69 Remove the second protective cap3670, 3671, 72, 73, 74, 75, 76, 77, 78, 79, 80 expel two unit test shots, each time the pen is used3681, 3682, set the dose to 10 units3683, 3684, 3685, 86, 87 inject into the thigh...3695, 96, 97, 98, 99, 3700, 701, 02, 03, 04...or the arm3705, 706, 07, 08, 09 10, 11, 12, 13, 14 after the injection, check if there are more than 2 drops on the needle3615, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 removal of the needle by a nurse

Demonstrating how to use a reusable insulin pen Page 2

Patient Notes ? X

OK Cancel

General Notes

Ms Sweetman has demonstrated that she understands how to use an insulin pen.

Allergy Notes

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Expel a test shot Inject the medication

Check the needle for leakage of insulin Dispose of the needle

Documentation Ensure the patient has written information

At this point, the patient will be ready to inject the medication into a suitable injection site, after first checking that the skin is clean. The patient must insert the needle at a 90° angle. The patient needs to wait for 10 seconds after pushing the plunger, to ensure that the full dose is delivered (FIT, 2016).

Explain to the patient that it is important to check the needle after the injection in case there are more than two drops on the needle; if this happens, the patient needs to leave the needle inserted for slightly longer on subsequent injections, to ensure that the full dose is administered.

Remove the needle and dispose of it safely, either into a sharps container or using a needle clipper device. Dispose of all other equipment according to local policy and decontaminate your hands.

Complete documentation and arrange the patient’s follow-up appointment.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

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Ensure that the patient has written information on: the action profile of the insulin; how to recognise and deal with hypoglycaemia; and driving with diabetes (see Key reading for useful patient resources). Also provide the patient with a medical alert identification card, as well as contact details for the diabetes specialist nurse or community team.

Attach the needle to the pen, remove the cap (see inset, above) and dial up 2–4 units, as recommended by the manufacturer; expel these to remove any air. Then dial up the required dose.

Demonstrating how to use a reusable insulin pen Page 3