In a follow-up visit for an insulin-requiring patient with type 2 DM, it was obvious that the management of his DM had deteriorated. According to his girlfriend, this patient ate only 1-2 meals a day, but they tended to be high-carbohydrate meals. We reviewed the patient’s insulin regimen in detail and ascertained that he was using the sliding scale correctly. He stated he rotated his insulin injections throughout his abdomen and his abdominal tissue was soft without swelling or nodules. In reviewing insulin pen procedures, he demonstrated with my saline pen how he would put on a pen needle, prime the pen and dial the appropriate dose. He did state he did not change the pen needle and uses the same one until the pen is finished. After educating him about the importance of pen needle change he stated, “Well, I don’t use that pen needle. I use the one with the shield.”
Now the problem was solved. He had been using a BD Autoshield Duo pen needle, which is a one-time use only and locks after one use. He had been dialing and “delivering” insulin, but since the needle no longer penetrated the skin, no insulin was actually injected. He hadn’t noticed that the insulin was instead running down his abdomen.
As a precaution, insulin doses were decreased to prevent hypoglycemia since he will actually now be getting his insulin dosage with proper pen change technique.
- It’s not always clear to patients that they need to change pen needles. As part of insulin pen teaching, include safe ways of removing, and disposing of, the needle. Always remove the needle, so the patient sees that step.
- When I receive reports of high carb intake, I won’t always rely on what I’m told on the phone. I will request the patient come in to see me sooner so I can assess technique.
- Don’t always blame high carbs for the high glucose levels. There are many reasons for high glucose levels.
Mary Paschal RN,MS,CDE
Joslin Center, Needham, MA
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