Skill 5-9

Administering a Continuous Subcutaneous Infusion: Applying an Insulin Pump

Some medications, such as insulin and morphine, may be administered continuously via the subcutaneous route. Continuous subcutaneous insulin infusion (CSII, or insulin pump) allows for multiple preset rates of insulin delivery. These delivery systems consist of a small pump with a reservoir that delivers insulin through infusion tubing to a small plastic cannula or needle (Figure 1) or a wireless patch-pump system, which uses wireless communication to control insulin delivery into the subcutaneous tissue (Nimri et al., 2020) (Figure 2). Pumps can be programmed to deliver a continuous dose of insulin (basal) and on-demand (bolus) administration as needed for meals or an elevation in blood glucose. The settings may be adjusted as needed for things such as exercise and illness. This type of insulin administration more closely mirrors the body's normal function and promotes better blood glucose control, increases quality of life, and reduces potential microvascular and macrovascular complications of diabetes (ADCES, 2021; Nimri et al., 2020). Many insulin pumps are waterproof and interface with a smartphone. It is recommended that the site is changed every 2 to 3 days according to the manufacturer's recommendations to prevent tissue damage or absorption problems (ADCES, 2021).

Another example of a medication given via continuous subcutaneous infusion is morphine. Subcutaneous morphine infusion can be used for palliative dyspnea and pain management. Advantages of continuous subcutaneous medication infusion include the sustained rate of absorption via the subcutaneous route and convenience for the patient.

The following skill outlines steps in applying an insulin pump utilizing infusion tubing and a small needle-insertion device. There are many different manufacturers of insulin pumps.

Nurses need to be familiar with the particular pump in use by their patient and to refer to the specific manufacturer's recommendations for use.

Delegation Considerations

The administration of a continuous subcutaneous infusion using an insulin pump is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the management of an insulin pump in some settings may be delegated to licensed practical/vocational nurses (LPN/LVNs) who have received appropriate training. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Insulin pump
Pump syringe and vial of insulin or prefilled cartridge, as ordered
Sterile infusion set
Insertion (triggering) device
Needle (24- or 22-gauge, or blunt-ended needle)
Antimicrobial swabs
Sterile nonocclusive dressing
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)
Disposable gloves
Additional PPE, as indicated

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check the expiration date. Assess the infusion site. Typical infusion sites include those areas used for subcutaneous insulin injection. Assess the area where the pump is to be applied. Do not place the pump on skin that is irritated or not intact. Assess the patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about it. Assess the patient's blood glucose level as appropriate or as ordered. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Risk for medication side effect
Hyperglycemia

Outcome Identification and Planning

The expected outcomes to achieve are that the device is applied successfully using aseptic technique, the medication is administered correctly, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of the rationale for the pump use and mechanism of action, the patient's skin remains intact, and the patient does not experience unstable blood glucose levels or adverse effect.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. If using a prepackaged insulin syringe or cartridge, remove from packaging. Follow Skill 5-4 to prepare insulin from a vial, if necessary. Prepare enough insulin to last the patient 2 to 3 days, plus 30 units for priming tubing.	Patient will wear pump for up to 3 days without changing syringe or tubing.
10. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
11. Label the syringe/cartridge with the medication's name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021).
12. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
13. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
14. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
15. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
16. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
17. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
18. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of the medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, and reduces anxiety.
19. Scan the patient's bar code on the patient's identification band, if required (The Joint Commission, 2021) (Figure 3).	This provides an additional check to ensure that the medication is given to the right patient.
20. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
21. Put on gloves.	Gloves prevent contact with blood and body fluids.
22. Remove the cap from the syringe or insulin cartridge (Figure 4). Attach sterile tubing to the syringe or insulin cartridge. Open the pump and place the syringe or cartridge in compartment according to the manufacturer's directions (Figure 5). Close the pump.	Tubing must be attached correctly, and the syringe must be placed in pump correctly for insulin delivery.
23. Initiate priming of the tubing, according to the manufacturer's directions. Program the pump according to the manufacturer's recommendations following prescribed insulin regimen (Figure 6).Check for any bubbles in the tubing.	Removing all the air from the tubing and correct programming of pump ensures the patient receives the correct dose of insulin.
24. Activate the delivery device. Place the needle between prongs of the insertion device with the sharp edge facing out. Push the insertion set down until a click is heard.	To ensure correct placement of insulin pump needle, an insertion device must be used.
25. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape, as needed, to expose only the site area to be used.	Using the appropriate site and appropriate positioning prevents injury. Draping maintains privacy and warmth.
26. Identify the appropriate landmarks for the site chosen.	Good visualization is necessary to establish the correct site location and to avoid complications (Taylor et al., 2023).
27. Cleanse the site with an antimicrobial swab while wiping with a firm, circular motion and moving outward from the injection site (Figure 7). Allow the skin to dry.	Pathogens on the skin can be forced into the tissues by the needle. Moving from the center outward prevents contamination of the site. Allowing the antimicrobial solution to dry completely ensures complete antimicrobial effectiveness (Gorski et al., 2021; Slater et al., 2018), and prevents introducing alcohol into the tissue, which can be irritating and uncomfortable.
28. Remove paper from adhesive backing. Remove the needle guard. Pinch skin at the insertion site, press the insertion device on the site, and press the release button to insert the needle. Remove the triggering device. Alternatively, if a needle was used to introduce a subcutaneous catheter and then withdrawn, engage the safety shield or needle guard.	To ensure delivery of insulin into subcutaneous tissue, a skin fold is made with a pinch before insertion of the medication. Safety shield or needle guard prevents accidental needlestick.
29. Apply a sterile occlusive dressing over the insertion site, if not part of the insertion device (Figure 8). Attach the pump to patient's clothing, as desired.	Dressing prevents contamination of site. The pump can be dislodged easily if not attached securely to patient.
30. Remove gloves and perform hand hygiene. Assist the patient to a position of comfort.	Removing gloves and performing hand hygiene reduces the risk of contamination of other items and the spread of microorganisms. Assisting the patient to a position of comfort promotes patient comfort.
31. If a needle was used to introduce a subcutaneous catheter and then withdrawn, discard the needle and syringe in the appropriate receptacle, such as a sharps receptacle.	Proper disposal of the needle prevents injury.
32. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
33. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
34. Evaluate the patient's response to the medication within the appropriate time frame. Monitor the patient's blood glucose levels, as appropriate, or as ordered.	The patient needs to be evaluated to ensure that the pump is delivering the drug appropriately. The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the device was applied successfully, the medication was administered correctly, the patient has experienced the intended effect of the medication, the patient has verbalized an understanding of the rationale for the pump use and mechanism of action, the patient's skin remained intact, and the patient did not experience unstable blood glucose levels or adverse effect.

Documentation

Guidelines

Document the application of the pump, the type of insulin used, pump settings, insertion site, and any teaching done with the patient on the eMAR/MAR or record using the required format, including date, time, and the site of administration, immediately after administration. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

After the pump is attached to the patient, a large amount of air is noted in tubing: Remove the pump from the patient. Obtain a new sterile tubing with insertion needle. Prime the tubing and reinsert.
Patient must rotate site more frequently than every 2 to 3 days due to insulin usage: Check the manufacturer's recommendations. Most pumps are initially set in a smaller mode but can be changed for a larger amount of insulin delivery.
Patient expresses unwillingness to rotate site at least every 3 days: Inform the patient that absorption of medication decreases after 3 days, which may increase their need for insulin. Rotating sites prevents this decrease in absorption from developing. In addition, site rotation reduces risk of infection at the site.
You note that the insertion site is now erythematous: Remove the stylet, obtain a new pump setup, and insert at a different site at least 1 inch from the old site.
Occlusive dressing will not stick due to perspiration: Apply a skin barrier around the insertion site but not over the insertion site.

Special Considerations

General Considerations

The U.S. FDA has approved an insulin pump that responds to sensor data to adjust basal rates, suspend on low or impending low rates, and give automatic correction bolus doses when glucose is approaching predetermined targets (ADCES, 2021).
Assess infusion site areas routinely for inflammation, allergic reactions, infection, and lipodystrophy (ADCES, 2021).
Good hygiene and frequent catheter site changes reduce the risk of site complications. Change the catheter site every 2 to 3 days (ADCES, 2021).
Adverse cutaneous reactions, such as contact dermatitis and allergic contact dermatitis, are sometimes an issue with insulin pumps (Herman et al., 2020). Routine assessment of insertion and pump sites is important for early detection and intervention (Ahrensbøll-Friis et al., 2021; Herman et al., 2020).
In an in-patient setting, insulin self-administered by the patient through the insulin pump should be communicated to the nurse at the time of administration. This allows for accurate documentation of insulin requirements.
Patient and family/caregiver education should include information about the technical components of the insulin pump, including how to insert/change the battery, filling and inserting the insulin cartridge/reservoir, how to insert/change the infusion set and tubing (if applicable), how to input information for the pump to calculate appropriate insulin dosages, noting program basal rate changes, how to review the pump history, and how to troubleshoot to solve potential problems with the pump (ADCES, 2021).
Ongoing assessment is an important part of nursing care for both evaluation of patient response to administered medications and early detection of adverse reactions. If an adverse effect is suspected, withhold further medication doses and notify the health care team. Additional intervention is based on type of reaction and patient assessment.

Community-Based Care Considerations

Encourage patients to consult the policies of their local government regarding contaminated and sharps waste disposal.
The U.S Food & Drug Administration (FDA, 2021) recommends a two-step process for properly disposing of used needles and other sharps by patients, family members and caregivers. (1) Needles and other sharps should be placed in a sharps disposal container immediately after they have been used to reduce the risk of needle sticks, cuts, and punctures from loose sharps. (2) Used sharps disposal containers should be disposed of according to community guidelines; guidelines and disposal programs vary depending on location. Patients should consult local trash removal services and the local health department to identify available disposal methods. Never use glass containers.
Sharps disposal methods (depending on community location) include drop boxes or supervised collection sites, household hazardous waste collection sites, mail-back programs, and residential special waste pick-up services (FDA, 2021).
If a patient, family member, or caregiver does not want to purchase a sharps container, an empty laundry detergent or bleach bottle may be used; it must be a strong plastic container with a screw-on lid, not an empty plastic water or soda bottle or other type of thin plastic container (SafeNeedleDisposal.org, 2021). Label the container as sharps and not for recycling. The screw-on top should be used to close the container for disposal, and containers should be sealed with strong tape (e.g., duct tape) (SafeNeedleDisposal.org, 2021).
Sharps disposal containers should be kept out of reach of children and pets (FDA, 2021).
The Safe Needle Disposal resource page provides information on needle disposal takeback programs and an interactive tool to locate state waste links (FDA, 2021; SafeNeedleDisposal.org, 2021).

EVIDENCE FOR PRACTICE

Continuous Subcutaneous Insulin Infusion (CSII)

Association of Diabetes Care & Education Specialists (ADCES). (2021, March). ADCES practice paper. Continuous subcutaneous insulin infusion (CSII) without and with sensor integration. https://www.diabeteseducator.org/docs/default-source/default-document-library/continuous-subcutaneous-insulin-infusion-2018-v2.pdf?sfvrsn=4

This practice paper provides information to support maintaining a high level of expertise in patient care and education for health care professionals who include insulin pump and sensor training in their professional practice. The paper also outlines topics that should be covered by diabetes care and education specialists when teaching people with diabetes and their family/caregivers. These guidelines are directed to diabetes nurse educators but provide best-practice guidelines for all nurses caring for patients with diabetes considering or using continuous subcutaneous insulin infusion (CSII).

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Skill 5-9

EVIDENCE FOR PRACTICE