胰岛素注射规范.ppt

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Master text styles,Second level,Third level,Fourth level,Fifth level,BD 2011,*,2011,版糖尿病药物注射技术指南,目录,第一章：医护人员的职责,第二章：注射前的心理准备,第三章：注射治疗的教育,第四章：注射药物,第五章：注射装置,第六章：注射技术,第七章：皮下脂肪增生与其他并发症,第八章：胰岛素注射相关问题,第九章：规范胰岛素注射标准,0,步骤（胰岛素笔）,第十章：注射部位规范检查,3,要素,2011,版中国糖尿病药物注射技术指南,注射技术篇,注射技术是糖尿病注射治疗的三大关键因素之一,注射技术：,注射部位的选择,注射部位的轮换,注射部位的检查和消毒,选择是否捏皮,选择进针角度,针头留置时间,注射器材的废弃,针头重复使用的危害,关于注射部位选择的推荐：,注射餐时胰岛素等,短效胰岛素,，最好,选择腹部,1-7,A1,希望胰岛素的吸收速度较缓时，可以选择臀部,。,臀部注射可以最大限度地降低注射,至肌肉层,的,风险,8,9,A1,给少儿患者注射,中,效,或者长效胰岛素时,，最好选择,臀部或者大腿,10,A1,Frid,A,Gunnarsson,R,G,ntner,P,Linde,B.Effects of accidental,intramuskul,r,injection on insulin absorption in IDDM.Diabetes Care 1988;11:41-45.,Frid,A&B,Linde,(1993)Clinically important differences in insulin absorption from the abdomen in IDDM.Diabetes Research and Clinical Practice:,Vol,21.No 2-3.137-141.,Frid,A,Lind,n B.Intraregional differences in the absorption of unmodified insulin from the abdominal wall.,Diabet,Med 1992;9:236-9.,Annersten,M,Willman,A.Performing subcutaneous injections:a literature review.Worldviews,Evid,Based,Nurs,2005;2:122-30.,Zehrer,C,Hansen R,Bantle,J.Reducing blood glucose variability by use of abdominal insulin injection sites.Diabetes,Educ,1985;16:474-7.,Henriksen,JE,Djurhuus,MS,Vaag,A,Thye-Ronn,P,Knudsen D.,Hother,-Nielsen O,et al.Impact of injection sites for soluble insulin on,glycaemic,control in type 1(insulin-dependent)diabetic patients treated with a multiple insulin injection regimen.,Diabetologia,1993;36:752-8.,Sindelka,G,Heinemann L,Berger M.,Frenck,W,Chantelau,E.Effect of insulin concentration,subcutaneous fat thickness and skin temperature on subcutaneous insulin absorption in healthy subjects.,Diabetologia,1994;37:377-40.,Ahern J&ML Mazur(2001)Site rotation.Diabetes Forecast:,Vol,54.No 4.66-68.,Wood L,Wilbourne,J,Kyne-Grzebalski,D,et al.administration of insulin by injection.Practice Diabetes International 2002;19(Suppl 2-1):S1-S2.,Smith CP,Sargent,MA,Wilson BP,Price DA.Subcutaneous or intramuscular insulin injections.Arch,Dis,Child 1991;66:879-82.,腹部,以肚脐为中心，半径,2.5cm,外的距离。越靠近腰部两侧（即使是肥胖患者），皮下组织的厚度也会变薄，因此容易导致肌肉注射。,根据可操作性,/,神经血管距离,/,皮下组织状况：适合注射的部位,上臂,上臂侧面或者后侧部位；皮下组织较厚，导致肌肉注射的概率较低。,臀部,臀部上端外侧部位；即使是少儿患者还是身材偏瘦的患者，该部位的皮下组织仍然丰富，最大限度降低肌肉注射的危险性。,大腿,大腿外侧；皮下组织较厚，离大腿血管和坐骨神经较远，针头导致外伤的概率较低。,推荐的注射部位,关于注射部位轮换的推荐：,一种已经证实有效的注射部位轮换方案：将注射部位分为,四个,等分区域,（大腿或臀部可等分为两个等分区域），每周使用一个,等分区域,并始终,按顺时针方向进行轮换,1,2,A3,在任何一个等分区域内注射时，每次的注射点都应,间隔至少,1cm,，以避免重复的组织损伤,A3,从注射治疗一开始，就应教会患者掌握一套简单易行的注射部位轮换方案,3,A2,每次患者就诊时，医护人员都应检查患者轮换方案的执行情况,A3,Diagrams courtesy of Lourdes,Saez,-de Ibarra and Ruth Gaspar,Diabetes Nurses and Specialist Educators from La Paz Hospital,Madrid,Spain.,Lumber T.Tips for site rotation.When it comes to insulin.where you inject is just as important as how much and when.Diabetes Forecast 2004;57:68-70.,Thatcher G.Insulin injections.The case against random rotation.Am J,Nurs,1985;85:690-2.,注射部位的轮换：不同注射部位之间的轮换,午餐前,晚餐前,不同注射部位之间的轮换：,“每天同一时间注射同一部位，每天不同时间注射不同部位”,早餐前,午餐前,晚餐前,早餐前,睡前,一天注射三次：,一天注射四次：,注射部位的轮换：左右轮换,注射部位左右轮换：,左边一周，右边一周，部位对称轮换,左边一次，右边一次，部位对称轮换,注射部位的轮换：同一注射部位内的轮换,同一注射部位内的轮换：,每次注射时离上次注射点之间距离至少间隔,1cm,关于注射部位检查和消毒的推荐：,患者应于,注射前,检查注射部位,1,2,A3,一旦发现注射部位若出现脂肪增生、炎症或感染，应更换注射部位,3-10,A2,注射时，应保持注射部位的清洁,11,A2,当注射部位,不洁净,，或者患者处于感染已于传播的环境（如：医院或疗养院），,注射前应消毒注射部位,2,12,16-18,A3,Danish Nurses Organization.Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus,2nd edition,December 2006.,Association for,Diabetescare,Professionals(EADV).Guideline:The Administration of Insulin with the Insulin Pen.September 2008.,Johansson U.,Amsberg,S,Hannerz,L,Wredling,R,Adamson U,Arnqvist,HJ&P,Lins,(2005)Impaired Absorption of insulin,Aspart,from,Lipohypertrophic,Injection Sites.Diabetes Care:,Vol,28,No 8,2025-2027.,Ariza-Andraca,CR,Altamirano,-Bustamante E,Frati-Munari,AC,Altamirano,-Bustamante P,Graef,-Sanchez A.Delayed insulin absorption due to subcutaneous edema.Arch Invest Med 1991;22:229-33.,Saez,-de Ibarra L,Gallego,F.Factors related to,lipohypertrophy,in insulin-treated diabetic patients;role of educational intervention.,Pract,Diabetes,Int,1998;15:9-11.,Young RJ,Hannan,WJ,Frier,BM,Steel JM,Duncan LJ.Young RJ,Hannan,WJ,Frier,BM,Steel JM Diabetic,lipohypertrophy,delays insulin absorption.Diabetes Care 1984;7:479-80.,Chowdhury,TA,Escudier,V.Poor,glycaemic,control caused by insulin induced,lipohypertrophy,.BMJ 2003;327:383-4.,Johansson UB.Impaired absorption of insulin,aspart,from,lipohypertrophic,injection sites.Diabetes Care 2005;28:2025-7.,Overland J,Molyneaux,L,Tewari,S.,Fatouros,R,Melville P,Foote D,et al.,Lipohypertrophy,:Does it matter in daily life?A study using a continuous glucose monitoring system.Diabetes,Obes,Metab2009;11:460-3.,Frid,A,Linden B.Computed tomography of injection sites in patients with diabetes mellitus.Injection and Absorption of Insulin.Stockholm:Thesis,1992.,Gorman KC.Good hygiene versus alcohol swabs before insulin injections(Letter).Diabetes Care 1993;16:960-1.,Schuler G,Pelz,K,Kerp,L.Is the reuse of needles for insulin injection systems associated with a higher risk of,cutaneous,complications?Diabetes Res,Clin,Pract,1992;16:209-12.,Workman B.Safe injection techniques.,Nurs,Stand 1999;13:47-53.,Bain A,Graham A.How do patients dispose of syringes?,Pract,Diabetes,Int,1998;15:19-21.,Chantelau,E,Schiffers,T,Schutze,J,Hansen B.Effect of patient-selected intensive insulin therapy on quality of life.Patient,Educ,Couns,1997 Feb;30(2):167-73.,Le,Floch,JP,Herbreteau,C,Lange F,Perlemuter,L.Biologic material in needles and cartridges after insulin injection with a pen in diabetic patients.Diabetes Care 1998;21:1502-4.,McCarthy JA,Covarrubias B,Sink P.Is the traditional alcohol wipe necessary before an insulin injection?Dogma disputed(Letter).Diabetes Care 1993;16:402.,Swahn,A.,Erfarenheter,av,94000,osterilt,givna,insulininjektioner,(Experiences from 94000 insulin injections given without skin swab).,Sv,Lakaresallskapets,Handlingar,Hygiea,1982;92:160(3O).,关于捏皮的推荐：,所有患者在起始胰岛素治疗时就应,掌握捏皮的正确方法,A3,捏皮时力度不得过大导致皮肤发白或疼痛,A3,不能用整只手来提捏皮肤,，以避免将肌肉及皮下组织一同捏起,最佳的注射步骤为：,捏起皮肤形成皮褶,和皮褶表面呈,90,角进针后，缓慢推注胰岛素,当活塞完全推压到底后，针头在皮肤内停留,10,秒钟（采用胰岛素笔注射）,拔出针头,松开皮褶,A3,正确的捏皮手法,错误的捏皮手法,Clauson,PG,Linde,B.Absorption of rapid-acting insulin in obese and,nonobese,NIDDM patients.Diabetes Care 1995;18:986-91.,Jamal R,Ross SA,Parkes,JL,Pardo,S,Ginsberg BH.Role of injection technique in use of insulin pens:prospective evaluation of a 31-gauge,8mm insulin pen needle.,Endocr,Pract,1999;5:245-50.,Birkebaek,N,Solvig,J,Hansen B,Jorgensen C,Smedegaard,J,Christiansen J.A 4mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults.Diabetes Care.2008 Sep;22(9):e65.,Gibney,MA,Arce,CH,Byron KJ,Hirsch LJ.Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections:Implications for needle length recommendations.,Curr,MedRes,Opin,2010;26:1519-30.,Hirsch L,Klaff,L,Bailey T,Gibney,M,Albanese J,Qu,S,et al.Comparative,glycemic,control,safety and patient ratings for a new 4 mm32G insulin pen needle in adults with diabetes.,Curr,Med Res,Opin,2010;26:1531-41.,Kreugel,G,Keers,JC,Jongbloed,A,Verweij-Gjaltema,AH,Wolffenbuttel,BHR.The influence of needle length on,glycemic,control and patient preference in obese diabetic patients.Diabetes 2009;58:A117.,Kreugel,G,Beijer,HJM,Kerstens,MN,ter,Maaten,JC,Sluiter,WJ,Boot BS.Influence of needle size for SC insulin administration on metabolic control and patient acceptance.,Europ,Diab,Nursing 2007;4:1-5.,Van,Doorn,LG,Alberda,A,Lytzen,L.Insulin leakage and pain perception with,NovoFine,6 mm and,NovoFine,12 mm needle lengths in patients with type 1 or type 2 diabetes.,Diabet,Med 1998;1:S50.,Solvig,J,Christiansen JS,Hansen B,Lytzen,L.,Localisation,of potential insulin deposition in normal weight and obese patients with diabetes using,Novofine,6 mm and,Novofine,12 mm needles.Meeting Federation European Nurses in Diabetes,Jerusalem,Israel,2000(Abstract).,Schwartz S,Hassman,D,Shelmet,J,Sievers,R,Weinstein R,Liang J,Lyness,W.A multicenter,open-label,randomized,two-period crossover trial comparing,glycemic,control,satisfaction,and preference achieved with a 31 gauge x 6mm needle versus a 29 gauge x 12.7mm needle in obese patients with diabetes mellitus.,Clin,Ther,2004;26:1663-78.,Frid,A,Lindn,B.Where do lean diabetics inject their insulin?A study using computed tomography.BMJ 1986;292:1638.,关于进针角度的推荐：,使用较短（,4mm,或,5mm,）的针头时，大部分患者,无需捏起皮肤，并可,90,进针,1-9,A1,使用较长（,8mm,）的针头时，,需要捏皮或,45,角,以降低肌肉注射风险,10,11,A1,针头留置时间,药液的流速还与注射笔针头的内径有关，注射笔针头的内径越大，其药液流速更快。目前，临床上有采用“薄壁”设计的针头，在同等外径的情况下内径更大，在降低注射引起不适感的同时保证胰岛素的流速，更利于机体对胰岛素的吸收,*Frid A.New injection recommendations for patients with diabetes.Diabetes&Metabolism 36(2010)S3-S18,*,A3,关于注射器材废弃的推荐,医护人员和患者必须熟知国家有关,医疗废弃物处理的相关规定,1,A3,所有医护人员从注射治疗的开始，就应教会患者如何正确废弃注射器材,2,A3,医护人员应向患者说明可能发生于患者家人（如刺伤儿童）和服务人员（如垃圾收运工和清洁工）的不良事件,A3,任何情况下都,不能将注射器材丢入公共垃圾桶或者垃圾场,A3,Workman B.Safe injection techniques.,Nurs,Stand 1999;13:47-53.,Bain A,Graham A.How do patients dispose of syringes?,Pract,Diabetes,Int,1998;15:19-21.,注射器材的规范废弃,胰岛素注射笔针头的废弃,胰岛素专用注射器的废弃,废弃针头或者注射器的最佳方法是，,将注射器或注射笔针头放入专用废弃容器内再丢弃。,如果没有专用废弃容器，,也可使用加盖的硬壳容器。,针头重复使用有危害,注射笔针头应一次性使用,1-7,A2,Chantelau,E,Lee DM,Hemmann,DM,Zipfel,U,Echterhoff,S.What makes insulin injections painful?British Medical Journal 1991;303:26-27.,Strauss K,De,Gols,H,Letondeur,C,Matyjaszczyk,M,Frid,A.The second injection technique event(SITE),May 2000,Barcelona,Spain.,Pract,Diabetes,Int,2002;19:17-21.,Danish Nurses Organization.Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus,2nd edition,December 2006.,Association for,Diabetescare,Professionals(EADV).Guideline:The Administration of Insulin with the Insulin Pen.September 2008.,Schuler G,Pelz,K,Kerp,L.Is the reuse of needles for insulin injection systems associated with a higher risk of,cutaneous,complications?Diabetes Res,Clin,Pract,1992;16:209-12.,Maljaars,C.,Scherpe,studie,naalden,voor,eenmalig,gebruik,Sharp study needles for single use;Diabetes and,Levery,2002;4:36-7.,Torrance T.An unexpected hazard of insulin injection.,Pract,Diabetes,Int,2002;19:63.,重复使用注射笔针头的常见原因,知识缺乏,不了解重复使用针头的危害,经济条件,太贵了，不能承受,个人经验,多次重复使用未感到风险,风险教育,教育者没有提过,其他,中华现代护理杂志,2010,16(14):1631-1632.,358,例使用胰岛素注射笔的糖尿病患者，年龄,1982,岁，以问卷形式进行调查其胰岛素笔用针头安全使用情况。,重复使用注射笔针头具有多重风险之一：,影响注射剂量的准确性,注射漏液,药液流失,温度降低时,胰岛素体积收缩导致空气进入笔芯，产生气泡,导致注射时间的延长产生漏液现象,温度升高时,胰岛素体积膨胀而从笔芯泄漏,浪费胰岛素,改变混合胰岛素的浓度,重复使用注射笔针头具有多重风险之二：,针头断裂或针管堵塞,重复使用注射笔针头具有多重风险之三：,疼痛增加,新针头,多次使用后的针头,（高倍电子显微镜下的针头形状）,1.Bangstad H-J.ISPAD Clinical Practice Consensus Guidelines,2009 Compendium.Pediatric Diabetes 2009:10(Suppl.12):82-99.,2.,Chantelau E,et al.What makes insulin injections painful?,British Medical Journal 1991;303:26-27.,重复使用注射笔针头具有多重风险之四：,导致皮下脂肪增生和硬结,下腹部皮下脂肪增生,上腹部皮下脂肪增生,腹部两侧皮下脂肪增生,Diabetes&Metabolism 36(2010)S3-S18,注射相关问题,皮下脂肪营养障碍与其他并发症,皮下脂肪营养障碍,疼痛,出血和淤血,胰岛素的贮存,胰岛素的混匀,特殊人群的胰岛素注射,儿童,妊娠,皮下脂肪营养障碍,左侧：,正常的部位捏起皮肤较薄,右侧：,发生皮下脂肪营养障碍的部位，,捏起皮肤较厚,每次注射前都应检查注射部位，尤其是对已经出现皮下脂肪增生的患者,推荐方法：不仅需要视诊而且需要触诊。正常皮肤能被紧紧的捏在一起，而发生皮肤硬结的皮肤却不能,判断并避开出现疼痛、皮肤凹陷、皮肤硬结、出血、瘀斑、感染的部位,如发现皮肤硬结，请确认出现硬结的部位及大小，避开硬结进行注射,关于皮下脂肪营养障碍的推荐,：（一）,患者（尤其是已经出现皮下脂肪营养障碍的患者）每次就诊时，医护人员应对其注射部位进行检查。每个注射部位,至少每年检查一次,（儿童患者最好每次就诊时都检查）。医护人员应教会患者自己检查注射部位，并培训他们如何发现皮下脂肪增生,1,2,A2,用墨水笔在皮下脂肪营养障碍部位的两端，即正常皮肤与“橡皮样”病变的,交界处做标记,，测量并记录病变的大小以便,长期随访,。若病变部位肉眼可见，应同时拍照以便长期随访,A3,Seyoum,B,Abdulkadir,J.Systematic inspection of insulin injection sites for local complications related to incorrect injection technique.,Trop,Doct,1996;26:159-61.,Teft,G.,Lipohypertrophy,:patient awareness and implications for practice.J,Diab,Nursing 2002;6:20-3.,关于皮下脂肪营养障碍的推荐,：（二）,病变组织,恢复正常通常需要数月至数年,，在此之前，不得在此部位进行注射,1,2,A2,注射部位由病变组织转换至正常组织时，通常需要减少胰岛素的注射剂量。注射剂量的实际变化因人而异，并在频繁血糖监测的指导下进行,2,3,A2,目前，,预防和治疗皮下脂肪营养障碍的策略,包括：使用纯化的人胰岛素，每次注射时规范检查注射部位，选择注射部位时范围更广，不重复使用注射笔针头,4-9,A2,Hambridge,K.The management of,lipohypertrophy,in diabetes care.Br J,Nurs,2007;16:520-4.,Jans,M,Colungo,C,Vidal M.Actualizaci,n sobre t,cnicas y sistemas de administraci,n de la insulina(II).,Update on insulin administration techniques and devices(II).Av,Diabetol,2008;24:255-69.,Saez,-de Ibarra L,Gallego,F.Factors related to,lipohypertrophy,in insulin-treated diabetic patients;role of educational intervention.,Pract,Diabetes,Int,1998;15:9-11.,Teft,G.,Lipohypertrophy,:patient awareness and implications for practice.J,Diab,Nursing 2002;6:20-3.,Nielsen BB,Musaeus,L,Gde,P.Attention to injection technique is associated with a lower frequency of,lipohypertrophy,in insulin treated type 2 diabetic patients.,Diabetologia,1998;41(suppl1):A251(Abstract 970).,Vardar B,Kizilci,S.Incidence of,lipohypertrophy,in diabetic patients and a study of influencing factors.Diabetes Res,Clin,Pract,2007;77:231-6.,Ampudia-Blasco,J,Girbes,J,Carmena,R.A case of,lipoatrophy,with insulin,glargine,.Diabetes Care 2005;28:2983.,De Villiers FP.,Lipohypertrophy,-a complication of insulin injections.S,Afr,Med J 2005;95:858-9.,Hauner,H,Stockamp,B,Haastert,B.Prevalence of,lipohypertrophy,in insulin-treated diabetic patients and predisposing factors.Exp,Clin,Endocrinol,Diabetes 1996;104:106-10.,关于疼痛的推荐：,减轻注射疼痛,的方法包括：,室温保存正在使用的胰岛素,如果使用酒精对注射部位进行消毒，应于酒精彻底挥发后进行注射,避免在体毛根部注射,选用直径较小、长度较短的注射笔针头,每次注射使用新针头,1-5,A2,Bohannon NJ.Insulin delivery using pen devices.Simple-to-use tools may help young and old alike.,Postgrad,Med 1999;106:57-8.,Dejgaard,A,Murmann,C.Air bubbles in insulin pens.Lancet 1989;334:871.,Danish Nurses Organization.Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus,2nd edition,December 2006.,Association for,Diabetescare,Professionals(EADV).Guideline:The Administration of Insulin with the Insulin Pen.September 2008.,Chantelau,E,Lee DM,Hemmann,DM,Zipfel,U,Echterhoff,S.What makes insulin injections painful?BMJ 1991;303:26-7.,注射过程多种情况引发疼痛增加,因注射疼痛导致的不愿进行胰岛素治疗的比例达,50.8%,温度较低的胰岛素诱发疼痛和不适感,消毒皮肤的酒精未干会从针眼带到皮下引起疼痛,体毛根部附近神经末梢丰富,直径较小、长度较短的注射笔针头具有较好的安全性和耐受性,注射笔针头重复使用后卷边反刺，针头表面润滑层发生脱落，增加患者疼痛,低温,胰岛素,消毒酒精,未干,注射在体毛根部,针头的直径和长度,针头重复,使用,关于出血和淤血的推荐：,应使患者放心，注射部位局部出血或淤血并不会给胰岛素的吸收或者糖尿病的整体管理带来不良的临床后果,A2,有时注射时针头会触到血管，导致局部出血或淤血。更换注射笔针头的长度或者改变其他注射参数，似乎并不能改变出血或淤血的发