Small changes in clinicial practice make a big difference

• Free from lipohypertrophy?
• Free from lipoatrophy?
• Free from oedema?
• Free from Inflammation and / or infection?
• Consider amount of subcutaneous tissue at injection site, is it sufficient for the needle length being used?

Lipohypertrophy or other lesion found by observation and palpation

Support patient to:

• Avoid injecting into lipo areas
• Monitor blood glucose levels frequently
• Reduce insulin dose as required to avoid hypoglycaemia
• Properly rotate injection sites
• Use shortest needle length (4mm) to minimise risk of intramuscular injection
• Use each needle once
• Inspect injection sites regularly (at least annually) to detect lipo early

• Cloudy insulin mixed correctly?
• Needle attached to pen correctly?
• All pen needle caps removed?
• Pen needle primed correctly?
• Dose dialled correctly?
• Injecting at 90°?
• Button fully depressed?
• Needle held in skin for at least 10 seconds
• Short needle length used for a subcutaneous injection?

Optimise injection technique (use image on FIT wheel)

• Teach correct injection technique- encourage correct rotation of sites
• Use 4mm pen needle
• Use lifted skin fold if necessary to avoid accidental intramuscular injection

• Is insulin within expiry date?
• Is insulin in pen out of fridge for less than 28 days? (or within manufacturers recs)
• Clear insulin completely clear?
• Cloudy insulin free from particulate before and after re-suspension?
• Insulin stored at correct temperature?

Insulin no longer viable

• Dispose of all date expired or poorly stored insulin
• Replace expired or poorly stored insulin with new viable insulin

Pen device

• Pen working correctly?
• Correct manufacturer’s reusable pen and insulin cartridge being used?
• Insulin appears at needle tip when primed?

Pen needle

• Using a new pen needle for each injection?

Check injection equipment (use image on FIT wheel)

• Replace reusable pen device with new fully functioning device
• Match cartridge with correct pen
• Advise single use only for pen needles

• Syringe new?
• Syringe being pre-filled?
• Cloudy insulin fully re-suspended in vial?
• Clear and cloudy insulin correctly mixed?

Check syringe

• Use new syringe for every injection
• Teach correct re-suspension of cloudy insulin
• Teach correct technique for mixing clear and cloudy insulin

• Monitor calibrated and working correctly?
• Correct in date test strips being used? Access to control solution?

Check blood glucose monitor

• Replace blood glucose meter with new fully functioning device
• Replace test strips with new compatible in date strips
• Provide access to control solution

Food & Activity

• Missing or delayed meals?
• Eating less than normal
• Gastrointestinal disturbance?
• Unplanned activity?

Insulin

• Missed insulin dose?
• Second dose of insulin in error?
• Incorrect dose of insulin?

Other

• Alcohol consumption?
• Recreational drug use?
• Stress

If you have been unable to find any issues, seek specialist help.

Food and Activity

• Review ratios and correction doses
• Support patient with advice on all aspects of daily life and diabetes management and refer for specialist advice from diabetes specialist team as appropriate