The patient is a 91-year-old female with a 10-year history of type 2 diabetes.
Two years ago, despite use of multiple oral hypoglycemic agents, her glycated hemoglobin (HbA1c) remained at 9.2% (77 mmol/mol) and her home glucose levels were in the mid-200 mg/dL (approximately 11.1 mmol/L) range. Her caretaker was educated on how to administer insulin glargine using a pen device. On 10 units of insulin glargine per day, the patient’s glucose levels were in the low 100 mg/dL (approximately 5.5 mmol/L) range and her HbA1c remained at 7% (53 mmol/mol). At her recent visit, the morning and afternoon glucose levels were elevated to the mid-200 mg/dL range (11 mmol/L).
Although the first instinct was to increase the insulin dose, it was noted that the patient had a new caretaker. On questioning, the caretaker described giving the insulin appropriately. To double-check, the caregiver was given an insulin pen and asked to demonstrate what she had been doing. The caregiver put a needle on the pen, dialed to 10 units, pushed the needle into the injection pad and then proceeded to dial back to zero. When hired, the new caregiver had told the patient and the patient’s family that she was experienced with assisting diabetes patients with insulin injections. No one actually assessed her actual knowledge or technical abilities.
Even though someone says they have experience, and tells you what they are doing, you still need to watch the person’s technique, including injecting the patient. If it is correct, praise them and tell them so. If it is not correct, you need to demonstrate the correct technique. Then, the person needs to perform a return demonstration as many times as it takes until he or she has perfected their technique.
Look at it this way: it’s a great time to teach how to correctly inject insulin, which also includes other tips such as near-painless injections, rotating sites, and safe sharps’ disposal.
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