I NSULI N SELF- ADMI NI STRATI ON TECHNI QUE W I TH DI SPOSABLE SYRI NGE AMONG
PATI EN TS W I TH DI ABETES MELLI TUS FOLLOW ED BY THE FAMI LY HEALTH STRATEGY
Thaís Sant os Guer r a St acciar ini1 Ana Em ilia Pace2 Van der lei José Haas3 St acciarini TSG, Pace AE, Haas VJ. I nsulin self- adm inist rat ion t echnique w it h disposable syringe am ong pat ient s w it h Diabet es Mellit us follow ed by t he fam ily healt h st r at egy. Rev Lat ino- am Enfer m agem 2009 j ulho- agost o; 1 7 ( 4 ) : 4 7 4 - 8 0 .
This cr oss- sect ional st udy aim ed t o descr ibe t he m ost com m on cor r ect and incor r ect self- adm inist r at ion t echniques f or in su lin u sin g disposable sy r in ges by pat ien t s car ed f or by t h e Fam ily Healt h St r at egy ( FHS) , r elat e t h e findings t o sociodem ogr aphic var iables and also ident ify t he pr ofessional r esponsible for t eaching t his t echnique. A t ot al of 169 pat ient s w er e select ed by sim ple r andom sam pling in 37 FHS unit s in a cit y in t he st at e of Minas Ger ais, Br azil fr om August t o Oct ober 2006. The r esult s ident ified er r or s in all t he st eps r ecom m ended by t he Am er ican Diabet es Associat ion and Br azilian Diabet es Associat ion for t he safe adm inist r at ion of insulin, fr om hand w ashing t o com pr ession on t he inj ect ion sit e. The FHS favor s t he developm ent of int er vent ions focused on t he needs of t he client ele r egist er ed at t he unit , st im ulat ing self- car e. Result s fr om t his st udy can cont r ibut e t o t he planning of t hese int er v ent ions.
DESCRI PTORS: diabet es m ellit us; insulin; self car e; nur sing; fam ily healt h
TÉCNI CA DE AUTO APLI CACI ÓN DE I NSULI NA CON JERI NGAS DESECHABLES ENTRE
USUARI OS CON DI ABETES MELLI TUS ACOMPAÑADOS POR LA ESTRATEGI A
SALUD DE LA FAMI LI A
Se t r at a de un est udio seccional que t uvo com o obj et ivó descr ibir los er r or es y los acier t os m ás com unes de la t écnica de aut o aplicación de insulina, con j er ingas desechables, por los usuar ios, acom pañados por la Est r at egia Salud de la Fam ilia ( ESF) , así com o r elacionar lo encont r ado a las v ar iables sociodem ogr áficas e ident ificar al pr ofesional r esponsable por las or ient aciones. Par t icipar on 169 usuar ios, seleccionados por m edio de un m uest r eo aleat or io sim ple, en 37 unidades de la ESF, de un m unicipio del Est ado de Minas Ger ais, ent r e agost o y oct ubr e de 2006. Los r esult ados ident ificar on er r or es en t odos los pasos r ecom endados por la Asociación Am er icana de Diabet es y la Sociedad Br asileña de Diabet es par a la aplicación segur a de la insulina, desde el lav ado de las m anos hast a la com pr esión del local de aplicación. La ESF favor ece el desar r ollo de int er venciones con foco en las n ecesid ad es d e la clien t ela ad scr it a, est im u lán d ola p ar a el au t o cu id ad o, y los r esu lt ad os d el p r esen t e est udio podr án cont r ibuir par a la planificación de esas int er v enciones.
DESCRI PTORES: diabet es m ellit us; insulina; aut ocuidado; enfer m er ía; salud de la fam ilia
TÉCNI CA DE AUTOAPLI CAÇÃO DE I NSULI NA COM SERI NGAS DESCARTÁVEI S ENTRE OS
USUÁRI OS COM DI ABETES MELLI TUS, ACOMPANHADOS PELA ESTRATÉGI A
SAÚDE DA FAMÍ LI A
Est udo seccional que obj et iv ou descr ev er os er r os e os acer t os m ais com uns da t écnica de aut oaplicação de in su lin a, com ser in gas descar t áv eis, pelos u su ár ios, acom pan h ados pela Est r at égia Saú de da Fam ília ( ESF) , assim com o r elacion ar esses ach ados às v ar iáv eis sociodem ogr áf icas e iden t if icar o pr of ission al r espon sáv el pelas or ient ações. Par t icipar am 169 usuár ios selecionados por m eio de am ost r agem aleat ór ia sim ples, em 37 unidades da ESF, de um m unicípio do Est ado de Minas Ger ais, ent r e agost o e out ubr o de 2006. Os r esult ados iden t if icar am er r os em t odos os passos r ecom en dados pela Associação Am er ican a de Diabet es e Sociedade Br asileir a de Diabet es par a a aplicação segur a da insulina, desde a lav agem das m ãos at é a com pr essão do local de aplicação. A ESF fav or ece o desenv olv im ent o de int er v enções cent r adas nas necessidades da client ela adscr it a, est im u lan do- a par a o au t ocu idado, e os r esu lt ados do pr esen t e est u do poder ão con t r ibu ir par a o p lan ej am en t o d essas in t er v en ções.
DESCRI TORES: diabet es m ellit us; insulina; aut ocuidado; enfer m agem ; saúde da fam ília
1M.Sc. in Nur sing, RN, Univer sidade Federal do Tr iângulo Mineir o, Brazil, e- m ail: t hais.st acciar ini@t er ra.com .br ; 2Ph.D. in Nur sing, Associat e Pr ofessor, Escola
de Enferm agem de Ribeirão Pret o, Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil, e- m ail: aepace@eerp.usp.br;
3Ph.D. in Sciences, Colaborat ing Pr ofessor, Escola de Enfer m agem de Ribeir ão Pr et o, Univ er sidade de São Paulo, WHO Collabor at ing Cent r e for Nur sing
Resear ch Developm ent , Brazil, e- m ail: haas@eer p.usp.br.
I NTRODUCTI ON
T
h e n e e d t o u s e e x o g e n o u s i n s u l i n t o m aint ain good m et abolic cont rol has been increasingly ack n ow led g ed as a t h er ap eu t ic op t ion f or d iab et es m ellit us t ype 2 ( DM2)( 1) in addit ion t o being a classical indicat ion for diabet es m ellit us t ype 1 ( DM1) . Mult iple d aily d oses of in su lin n eed t o b e in j ect ed in t o t h e su b cu t a n e o u s t i ssu e t o a ch i e v e g l y ce m i c co n t r o l , w hich has been show n t o be an essent ial condit ion t o p r e v e n t a cu t e a n d ch r o n i c co m p l i ca t i o n s o f t h i s d isease( 2 ).T h e m o s t u s e d i n s t r u m e n t a m o n g t h e sev er al av ai l ab l e i n t h e Br azi l i an m ar k et t o i n j ect i n s u l i n i n t o t h e s u b c u t a n e o u s t i s s u e i s t h e d isp osab le sy r in g e d u e t o it s low cost , easy access, h ealt h p r of ession als’ f am iliar it y( 3 ) w it h it s u se an d also b ecau se it is f r eely d ist r ib u t ed b y g ov er n m en t in st it u t ion s accor d in g t o t h e Fed er al law n ° 1 1 . 3 4 7 f r om Sep t em b er 2 7 , 2 0 0 6( 4 ).
Fo r g l y cem i c co n t r o l d o n e t h r o u g h i n su l i n t h e r a p y w i t h d i sp o sa b l e sy r i n g e s t o b e e f f e ct i v e , sev er al t hings need t o be lear ned( 3,5- 6). Am ong t hem is t he adm inist rat ion t echnique, considered one of t he f act or s in f lu en cin g t h e ef f ect iv en ess of in su lin :( 5 , 7 ) inadequat e and unsafe pract ices in t he adm inist rat ion of in su lin can in t er fer e in t h e m et abolic con t r ol an d consequent ly lead t o t he dev elopm ent of DM chr onic com plicat ions( 8 - 9 ).
Due t o t he incr eased num ber of people w it h D M u si n g i n su l i n i n r ecen t y ea r s, m o r e em p h a si s s h o u l d b e g i v e n t o t h e s t a n d a r d i z a t i o n a n d i m p r o v e m e n t o f i n su l i n a d m i n i st r a t i o n t e ch n i q u e , focusing on pr oper ly t eaching t his t echnique so t hat people becom e aw ar e of t heir r esponsibilit y and m ake less m ist ak es dur ing insulin adm inist r at ion( 3).
Ev en t h ou gh som e st u dies h av e focu sed on t h e m a n y v a r i a b l e s r e l a t e d t o t h e i n s u l i n adm inist r at ion( 3, 5- 6), t her e is a need t o int r oduce t he pr ocess of insulin self- adm inist r at ion w it h disposable syringes in t he current cont ext of healt h policies, t hat is, in t he Fam ily Healt h St rat egy ( FHS) cont ext .
Be ca u se t h e FHS a i m s t o r e o r g a n i ze t h e d e l i v e r y o f p r i m a r y h e a l t h ca r e a n d e n su r e t h a t in div idu als w it h DM r eceiv e in t egr al, equ it able car e w it h case- r esolu t ion ab ilit y, in t er v en t ion s in h ealt h should be dev eloped w it h an adequat e k now ledge of people’s cont ext so t o favor t he est ablishm ent of goals a n d p r a ct i ce s t h a t e f f e ct i v e l y m e e t t h e n e e d s o f p op u lat ion s.
Ba sed o n t h e a b o v e, t h i s st u d y a i m ed t o i d e n t i f y t h e m o st co m m o n i n co r r e ct a n d co r r e ct procedures in t he insulin self- adm inist rat ion t echnique w i t h d i s p o s a b l e s y r i n g e s , r e l a t e t h e f i n d i n g s t o s o c i o d e m o g r a p h i c v a r i a b l e s a n d i d e n t i f y t h e pr ofessional r esponsible for pr ov iding inst r uct ions on how t o self- adm inist er insulin.
METHOD
Th is q u alit at iv e, cr oss- sect ion al st u d y w as ca r r i e d o u t i n 3 7 FHS u n i t s b e t w e e n Au g u st a n d Oct ober 2006 in t he m et r opolit an ar ea of a cit y t hat is con sider ed an im por t an t econ om ic cen t er an d poin t of r efer en ce in t h e ar eas of h eat h an d edu cat ion in t he st at e of Minas Ger ais, Br azil
Th e p o p u l a t i o n b a se co m p r i se d 7 8 1 FH S ser v ice u ser s w it h DM t ak in g in su lin . Th e f ollow in g inclusion crit eria w ere considered: 18 years of age or older, r egist er ed at t he FHS, t ak ing insulin for m or e t han one year, being r esponsible for t he adm inist rat ion of insulin and using disposable sy r inges.
According t o t he est ablished inclusion crit eria, 231 pat ient s w er e not included in t he st udy: 100 did not self- adm inist er insulin, 31 w er e y ounger t han 18 y ear s of age, 8 2 w er e adm in ist er in g in su lin for less t han one year, 12 w er e r egist er ed for less t han one year at t he FHS and four used t he insulin pen inj ect or. Th u s, t h e st u d y p o p u l at i o n w as co m p o sed o f 5 5 0 pat ien t s.
A list w it h t he nam es of t he 550 indiv iduals dist r ibut ed in t he 37 FHS unit s w as developed, aim ing t o d r a w t h e i r n a m e s t h r o u g h a s i m p l e r a n d o m sam pling using t he St at ist ical Pack age for t he Social Scien ce ( SPSS) v er sion 1 5 . 0 . I n or d er t o calcu lat e t h e s a m p l e s i z e , a p r e v a l e n c e o f 5 0 % o f s e l f -adm inist r at ion, confidence int er val of 95% and sam ple loss of 15% w er e consider ed.
Th u s , t h e s a m p l e w a s c o m p o s e d o f 1 8 6 in d iv id u als. Sev en t een in d iv id u als w er e lost d u r in g t he st udy due t o t he follow ing r easons: 11 w er e not found at hom e aft er t hr ee visit s, one w as hospit alized, t hr ee died and t w o r efused t o par t icipat e in t he st udy, t ot aling a final sam ple of 169 indiv iduals.
s c h o o l i n g , d u r a t i o n o f d i a b e t e s a n d o f i n s u l i n t r eat m en t ) , d escr ip t ion of st ep s f or p r ep ar in g an d inj ect ing insulin accor ding t o t he Am er ican Diabet es Associat ion ( ADA)( 7) and t he Diabet es Brazilian Societ y ( SBD)( 8 ) an d a list of p r of ession als r esp on sib le f or providing orient at ion for t he insulin self- adm inist rat ion t ech n iq u e.
D e p e n d i n g o n t h e v a r i a b l e s’ n a t u r e , t h e y w er e pr esent ed in t ables of absolut e fr equencies ( n) a n d r e l a t i v e f r e q u e n ci e s ( % ) o r t h r o u g h ce n t r a l t e n d e n ci e s ( a v e r a g e a n d m e d i a n ) a n d v a r i a b i l i t y m e a s u r e s ( m i n i m u m , m a x i m u m a n d s t a n d a r d dev iat ion - sd) . Associat ions bet w een t he dependent var iables w er e elabor at ed: per cent age of cor r ect st eps p e r f o r m e d i n t h e i n s u l i n p r e p a r a t i o n a n d adm inist r at ion t echnique w it h independent v ar iables: g en d er, ag e r an g e ( ad u lt s an d eld er ly ) , sch oolin g , dur at ion of t he disease and of t he insulin t r eat m ent , w er e analyzed t hr ough t he follow ing t est s: t he Mann-Wh i t n ey t est an d Kr u sk al l , Wal l i s an d Sp ear m an ’s cor r elat ion . Ty pe I er r or of 5 % w as adopt ed in t h e st at ist ical analy sis for all t est s.
Th e FHS coor din at ion in t h e cit y w h er e t h e st u dy w as car r ied ou t an d t h e Com m it t ee on Et h ics a n d Re se a r ch w i t h Hu m a n Be i n g s a t t h e Fe d e r a l Un iv er sit y of Tr iân g u lo Min eir o ap p r ov ed t h e st u d y ( Pr ot ocol No. 5 2 7 ) . Par t icip an t s sig n ed a f r ee an d in f or m ed con sen t agr eem en t , w h ich per m it t ed dat a collect ion and t he use of dat a t her ein.
RESULTS
Sociodem ogr aph ic an d clin ical v ar iables
Accor d in g t o sociod em og r ap h ic an d clin ical v ar iables, 120 pat ient s ( 71% ) ar e w om en, 93 ( 55% ) ar e 60 year s old or older and 146 ( 86.4% ) have less t h an eigh t y ear s of edu cat ion , t h e av er age t im e of schooling w as six years ( sd 3) . I t is w or t h highlight ing t hat 38 ( 22.5% ) had no for m al educat ion.
I n t er m s of t im e of t h e d isease d iag n osis, t h e a v er a g e w a s 1 3 y ea r s ( sd 8 ) , m ed i a n o f 1 2 , m axim um of 40 and m inim um of one year. Regar ding t he durat ion of t he insulin t reat m ent , t he aver age w as sev en y ear s ( sd 5 ) , m edian of six , m ax im u m of 3 0 and m inim um of one year.
Th e d a t a a n a l y s i s o f t h e i n s u l i n s e l f -ad m in ist r at ion t ech n iq u e b ased on t h e ADA( 8 ) an d SBD( 9) r ecom m endat ions w as divided in t hr ee st ages:
hand w ashing, insulin pr epar at ion and adm inist r at ion; t h ose st ep s t h at can in t er f er e w it h t h e saf et y an d efficacy of t he insulin adm inist rat ion w ere highlight ed. Dat a ar e pr esent ed in Table 1.
The self- adm inist r at ion t echnique of a m ix ed dose of insulin in t he sam e syringe is not analyzed in t his st udy because none of t he pat ient s follow ed such a p r a ct i ce , e v e n t h o se w h o e x cl u si v e l y u se d t h e sy r inge at t ached t o a needle ( 53.8% ) .
n o i t a r t s i n i m d a -f l e s n i l u s n I e u q i n h c e t s y a w l
A Sometimes Never
N % N % N %
g n i h s a w d n a
H 150 88.8 9 5.3 10 5.9
n il u s n i e h t e v r e s b O s c it s i r e t c a r a h
c 154 91.1 3 1.8 12 7.1
t i g n i k a h s t u o h t i w n il u s n i x i
M 101 59.8 1 0.6 67 39.6
n il u s n i e h t f o p o t r e b b u r e h t e p i W % 0 7 t a l o h o c l a h t i w e lt t o
b - - - - 169 100
e lt t o b n il u s n i e h t o t n i r i a t c e j n
I 44 26 10 6 115 68
e g n i r y s e h t m o r f s e l b b u b e v o m e
R 153 90.5 3 1.8 13 7.7
n il u s n i f o y t it n a u q e h t p u w a r D e h t e t e l p m o c o t y r a s s e c e n e s o d d e b i r c s e r p 4 5
1 91.1 3 1.8 12 7.1
e h t o t p u e l d e e n e h t p a c e R n o it a r t s i n i m d a f o t n e m o
m 14 8.3 - - 155 91.7
t a l o h o c l a h t i w n i k s e h t s n a e l C y r d o t t i s w o ll a d n a % 0
7 - - - - 169 100
n i k s f o d l o f a h c n i
P 130 77 10 5.9 29 17.1
e e r g e d -0 9 a t a e l d e e n e h t t c e j n I e l g n
a 80 47.3 17 10.1 72 42.6
o t e g n i r y s o t n i k c a b d i u lf e t a r i p s A n r u t e r d o o l b r o f k c e h
c 50 29.6 6 3.6 113 66.8
e h t w a r d h t i w o t s d n o c e s e v if t i a W e l d e e
n 23 13.6 3 1.8 143 84.6
t u o h t i w n i k s e h t s s e r p m o C t i g n i g a s s a
m 83 49.1 15 8.9 71 42
Tab le 1 – Nu m er ical an d p er cen t ag e d ist r ib u t ion of people w ho self- adm inist er insulin and ar e car ed for in t h e FHS u n it s ( N= 1 6 9 ) , accor d in g t o t h e in su lin adm inist r at ion t echnique, 2 0 0 7
I t is w or t h m ent ioning t hat 59.8 and 78.7% of t he pat ient s w ipe t he r ubber t op of t he insulin bot t le an d clean t h e sk in , r esp ect iv ely, w it h alcoh ol of a concent r at ion less t han 70% ( t hey use or dinar y alcohol sold in su per m ar k et s) . All t h ose w h o clean t h e sk in pr efer t o w ait for t he alcohol t o dr y.
t h e n u t r i t i o n i st . I n a d d i t i o n t o i n f o r m a t i o n t h e y r eceived fr om pr ofessionals, four ( 1.9% ) r epor t ed t hey al so h av e o b t ai n ed i n f o r m at i o n i n m ag azi n es. We highlight t hat 43 ( 20.8% ) pat ient s r epor t ed t he need for for m al or ient at ion on t his t echnique.
Th e f o l l o w i n g r e su l t s w e r e o b t a i n e d a f t e r analysis of t he st eps of t he insulin self- adm inist rat ion t ech n iq u e r ecom m en d ed b y t h e ADA( 8 ) an d SDB( 9 ): 35% w as t he m inim um per cent age of st eps cor r ect ly p e r f o r m e d , m a x i m u m o f 9 4 % , a v e r a g e o f 6 1 % , st andar d dev iat ion of 10% and m edian of 65% . The angle of needle dur ing adm inist r at ion and aspir at ion aft er punct ur e w as consider ed cor r ect based on body m ass index ( BMI ) , as t he needle pr ovided by t he FHS is 13m m long.
We o b s e r v e d t h a t 6 3 ( 3 7 . 3 % ) p a t i e n t s pr esent ed BMI≤25 and used a 13m m needle . Of t hese, 36 ( 57.1% ) inj ect ed t he needle at a 90- degr ee angle and 41 ( 65.1% ) did not dr aw back t he syr inge plunger t o check for blood r et ur n.
When t hese scor es ar e r elat ed t o gender, age an d edu cat ion , n o st at ist ically sign if ican t dif f er en ce w as found bet w een m en and w om en ( Mann- Whit ney t est , p= 0532) , bet w een pat ient s older t han 60 y ear s of ag e ( Man n - Wh it n ey t est , p= 0 . 2 3 4 ) n or b et w een pat ient s w it h no form al educat ion, less t han eight years of ed u cat ion an d n in e or m or e y ear s of ed u cat ion ( Kr usk al- Wallis t est , p= 0. 356) .
No st at ist ically sig n if ican t d if f er en ces w er e found in t he av er age of t im e fr om t he DM diagnosis ( Spear m an’s cor r elat ion, p= 0 . 1 8 ) or du r at ion of t h e t r e a t m e n t w i t h i n s u l i n ( Sp e a r m a n ’ s c o r r e l a t i o n , p= 0.46) in r elat ion t o t he av er age of st eps cor r ect ly per for m ed in t he self- adm inist r at ion t echnique.
DI SCUSSI ON
Th e t h er apeu t ic su ccess of in su lin does n ot depend only on it s t ype and dose prescribed but also on how it is adm inist ered. Thus, t he recom m endat ions provided by t he ADA( 8) and SBD( 9) on t he preparat ion an d ad m in ist r at ion of in su lin in v olv in g con secu t iv e st ages can cont ribut e, when properly followed, t o safe pract ice and achieving t reat m ent goals and prevent ing or delay in g acu t e an d ch r on ic com plicat ion s du e t o poor m et abolic cont r ol. For t hat , healt h pr ofessionals also n eed t o m ak e a d et ailed ev alu at ion of v isu al, m o t o r o r n e u r o l o g i ca l d e f i ci t s o f p a t i e n t s b e f o r e providing t hem t he sequent ial st eps of t his t echnique( 11).
I n t he analy sis of t he fir st st age of t he self-a d m i n i s t r self-a t i o n t e c h n i q u e , t h e p r o c e d u r e h self-a n d w ashing, w e found t hat 88.8% of t he par t icipant s used w at er and soap or liquid det er gent befor e pr epar ing an d adm in ist er in g t h e in su lin . Han d w ash in g bef or e ad m in ist er in g in su lin is a n ecessar y st ep t o av oid con t am in at ion of m at er ial an d con sequ en t ly pr ev en t infect ion in t he sit e of applicat ion( 8- 9).
The second and t hird st eps of t he insulin self-a d m i n i st r self-a t i o n t e ch n i q u e i n v o l v e p r o ce d u r e s w i t h consecut ive st eps, w hich m eans t hat expect ed r esult s w i l l b e a c h i e v e d o n l y i f a l l s t e p s a r e p r o p e r l y follow ed( 8 ).
I n t h e an aly sis of t h e secon d st age of t h is t ech n i q u e, i n su l i n p r ep ar at i o n , w e f o u n d t h at t h e m aj or it y ( 9 1 . 1 % ) follow ed it s fir st st ep, w h ich is t o o b s e r v e t h e i n s u l i n c h a r a c t e r i s t i c s b e f o r e i t s a d m i n i st r a t i o n . I n su l i n ’ s p h y si ca l ch a r a ct e r i st i cs d ep en d on it s classif icat ion , f or in st an ce, NPH an d r eg u lar in su lin u n if or m ly p r esen t clou d y an d clear aspect s, r espect iv ely( 8 - 9 ).
Hen ce, in case t h e in su lin appear s t o h av e lu m ps or f lak es or if it becom es opaqu e, t h e bot t le h as t o b e d i scar d ed( 8 - 9 ). Th e f act o r s t h at al t er i t s char act er ist ics ar e r elat ed t o ex cessiv ely shak ing t he bot t le, exposing it t o t em per at ur es under 2°C or ab ove 30º C and w hen opened insulin r eaches it s expir at ion dat e( 8- 9). The NPH insulin in use can be st or ed eit her in t h e r ef r ig er at or or at r oom t em p er at u r e f or on e m ont h( 8- 9).
When t he insulin is st ored in t he refrigerat or, it has t o st ay far fr om t he fr eezer or cooling plat es. The door is not an adequat e st or age opt ion because i t p r esen t s a h i g h er v ar i at i o n o f t em p er at u r e an d m ov es t h e bot t le each t im e it is open ed. Th u s, t h e ideal place t o st ore t he insulin bot t le is t he veget ables draw er or t he first shelf closest t o it( 8- 9).
Not obser v in g t h ese r ecom m en dat ion s m ay alt er t h e pot en cy of in su lin . We n ot e t h at w h ile t h e m aj or it y ( 9 1 . 1 % ) of p ar t icip an t s ob ser v ed w h et h er t h e i n su l i n p r e se n t e d p h y si ca l a l t e r a t i o n s b e f o r e adm inist er ing it , m any did not adopt act ions t o pr event t hem . One exam ple is t he fact t hat only 59.8% of t he par t icipan t s m ix t h e in su lin gen t ly r ollin g t h e bot t le b et w een h a n d s a n d a r e ca r ef u l t o n o t v i g o r o u sl y shake it( 8- 9).
b ot t le, m in im izin g p ot en t ial cu t an eou s in f ect ion s on t h e s i t e , e s p e c i a l l y a m o n g p a t i e n t s w h o r e u s e d i sp o sab l e sy r i n g es( 8 - 9 ). Ho w ev er, p a r t i ci p a n t s d i d n ot r ep or t t h e u se of alcoh ol at 7 0 % an d all t h ose ( 5 9 . 8 % ) w h o p er f or m an t i sep si s of t h e r u b b er l i d u se t h e co m m o n a l co h o l f o u n d i n su p e r m a r k e t s, w h ich is ch eap an d easy t o access.
The pr ocedur e of dr aw ing air int o t he syr inge in volum e equal t o t hat of t he insulin t o be aspirat ed an d t u r n in g t h e b ot t le u p sid e d ow n aim t o av oid b u b b l es i n t h e sy r i n g e( 8 - 9 ). Al t h o u g h m a n y o f t h e p ar t icip an t s d id n ot f ollow t h ese r ecom m en d at ion s, 90.5% r epor t ed t hey elim inat e bubbles in t he syr inge. The lit t le bubbles do not cause any har m w hen inj ect ed but t heir pr esence r educes t he quant it y of insulin t o be adm inist er ed( 8- 9).
Reca p p i n g t h e n eed l e a f t er p r ep a r i n g t h e i n su l i n u p t o t h e m o m en t o f i t s a d m i n i st r a t i o n i s r e co m m e n d e d t o a v o i d t h e n e e d l e t o u ch i n g a n y s u r f a c e o t h e r t h a n t h e s k i n , w h i c h c a n c a u s e c o n t a m i n a t i o n a n d l e a d t o p o t e n t i a l c u t a n e o u s com plicat ions w hen inj ect ed int o t he skin, t hough only 8. 3% of t he par t icipant s r epor t ed t his pr ocedur e.
I n t h e t h i r d s t e p o f t h e i n s u l i n s e l f -adm in ist r at ion t ech n iqu e, t h e in su lin -adm in ist r at ion t echnique in relat ion t o t he skin ant isepsis, all ( 78.7% ) t h o se w h o r e p o r t e d su ch p r o ce d u r e s, o p t t o u se com m on alcohol found in super m ar ket s inst ead of t he alcoh ol at 7 0 % , t h e con cen t r at ion r ecom m en ded by t he ADA( 8) e SBD( 9).
The st ep of allow ing t he alcohol t o dr y so it does not penet rat e t he punct ure m inim izes pain at t he m om ent of applying t he insulin. There are ot her sm all p r e c a u t i o n s t h a t m i n i m i z e p a i n d u r i n g t h e s e l f -adm inist rat ion procedure: not applying t he insulin while it is cold, elim inat ing bubbles in t he syringe, relaxing m uscles dur ing insulin inj ect ion, r apidly inser t ing t he needle int o t he skin, not m oving t he needle during t he applicat ion and not reusing needles( 8- 9)”.
I n relat ion t o t he rout ine procedure of pinching a fold of skin before inj ect ing t he insulin, 77% of t he par t icipant s r epor t ed it should be done and t he pinch r eleased befor e t aking t he needle out . This st ep aim s t o ensur e t he needle goes t hr ough t he subcut aneous t issue inst ead of t he m uscle( 8- 9,12).
Th e l i t e r a t u r e r e co m m e n d s i n se r t i n g t h e needle at a 90- degr ee angle, t hat is, per pendicular t o t he skin( 8- 9). How ever, an angle sm aller t han 90 degr ees m ig h t b e n ecessar y in case of ch ild r en an d p eop le
w i t h BMI sm al l er o r eq u al t o 2 5 w h en n eed l es o f 1 2 . 7 m m or lon g er ar e u sed t o av oid in j ect in g t h e i n su l i n i n t o t h e m u scl e( 1 2 ). W i t h t h a t i n m i n d w e ob ser v ed t h at 3 6 ( 5 7 . 1 % ) p at ien t s m ad e m ist ak es t hat can cause insulin t o be inj ect ed int o t he m uscle, w hich causes episodes of hy pogly cem ia( 1 2 ).
Th e sa m e h a p p en s w i t h t h e p r o ced u r e o f pulling t he plunger back so as t o v er ify blood r et ur n before t he insulin applicat ion. This is not a necessary pr ocedur e as long as all devices adequat e t o t he BMI( 8-9,12)
ar e used. How ever, as t he FHS unit s do not have needles of differ ent lengt hs av ailable, t he v er ificat ion of blood r et ur n is necessar y at least in pat ient s w it h BMI≤ 25 and w ho r epor t inser t ing t he needle at a 90-d e g r e e a n g l e , p e r p e n 90-d i c u l a r t o t h e s k i n( 1 2 ). We o b ser v ed t h at 4 1 ( 6 5 . 1 % ) p at i en t s ar e at r i sk o f inj ect ing t he insulin int o t he m uscle.
The pr ocedur e of w ait ing five seconds befor e r em ov in g t h e n eedle is per f or m ed by 1 3 . 6 % of t h e p at i en t s. Th i s p r oced u r e av o i d s l eak ag e of i n su l i n ensur ing t hat t he adm inist er ed dose is equiv alent t o t he pr escr ibed dose( 8- 9).
Th e r e co m m e n d a t i o n a f t e r r e m o v i n g t h e n eedle is t o com pr ess t h e locale w h er e in su lin w as inj ect ed from five t o eight seconds wit hout m assaging it . Massaging t he sit e alt er s t he m edicat ion’s t im e of act ion. Thus, physicians and nurses should pay attention to this orientation because 42% of the study participants m assage the site instead of com pressing it(8-9).
Ev e n t h o u g h t h e r e w a s n o a s s o c i a t i o n bet w een gender, age and educat ion w it h t he average of cor r ect st eps per for m ed in t he self- adm inist r at ion t echnique, it is acknow ledged t hat healt h int ervent ions ar e ham per ed w hen educat ive act ions do not consider pat ient s’ indiv idual differ ences( 1 3 ).
Th e r e su l t s a n a l y si s sh o w s t h e n e e d f o r p r of ession als at t h e FHS u n it s t o t ak e ear ly act ion r egar ding t he det er m inant s t hat hinder t he pr ocedur e b e i n g p e r f o r m e d a s r e c o m m e n d e d , t o p l a n t h e acqu isit ion of m at er ial accor din g t o t h e popu lat ion ’s c h a r a c t e r i s t i c s ( i . e . n e e d l e l e n g t h a n d t y p e o f s y r i n g e )( 3 ) a n d a l s o t o s h a r e r e s p o n s i b i l i t y a n d st r e n g t h e n b o n d s w i t h p a t i e n t s a n d t h e i r f a m i l y m em b er s so as t o en cou r ag e t h eir p ar t icip at ion in t h eir self - car e.
t h e self - ad m in ist r at ion t ech n iq u e an d also a lar g e n u m b er of m ist ak es w er e f ou n d in t h e p er f or m an ce of t h ese st ep s.
Ev en t h ou gh n u r ses’ t ech n ical an d scien t ific k now ledge of t he adm inist r at ion of m edicat ion( 14) put t hem in a st r at egic posit ion t o or ient t he pr ocess of i n su l i n a d m i n i st r a t i o n a t t h e p a t i e n t s’ h o m e , t h e par t icipat ion of n u r ses w as less ex pr essiv e ( 2 2 . 2 % ) w hen com par ed t o t hat of phy sicians ( 41.5% ) .
I t is w or t h h ig h lig h t in g t h e p ar t icip at ion of o t h e r p r o f e s s i o n a l s i n o r i e n t i n g p e o p l e i n s e l f -a d m i n i s t r -a t i o n t e c h n i q u e s u c h -a s d e n t i s t s , p h a r m a ci st s, n u t r i t i o n i st s a n d b i o p h y si ci a n s. Th e inclusion of ot her pr ofessionals at t he FHS unit s w as est ablished as a r esour ce t o link differ ent sour ces of k n ow led g e d u e t o t h e com p lex it y h ealt h p r ob lem s im pose, how ev er, each pr ofessional should be awar e o f t h e l i m i t s a n d p o t e n t i a l o f t h e i r r o l e s a n d b e r esponsible for pr oviding guidance appr opr iat e t o each field of k now ledge( 15).
Th e r e f o r e , t h e r o l e o f p r o f e ssi o n a l s i s t o iden t ify st r at egies t o dev elop safe self- car e abilit ies of people w it h DM an d t h eir fam ily m em ber s based on scien t if ic ev iden ce sin ce t h e daily adm in ist r at ion of ex ogenous insulin is essent ial t o m aint ain nor m al g ly cem ic lev els.
Th e g u i d e l i n e s g o v e r n i n g t h e FHS p e r m i t closer proxim it y and int eract ion bet w een professionals an d p at ien t s, en ab lin g t h e est ab lish m en t of t r u st , com m unicat ion and bonds, so t hat bot h find solut ions t h a t b e t t e r m e e t t h e n e e d s o f p a t i e n t s a n d t h e com m u n it y.
CONCLUSI ONS
All pat ient s com m it t ed er r or s in som e st ep of t he insulin self- adm inist rat ion t echnique and t he m ain p r o f e ssi o n a l r e sp o n si b l e f o r t e a ch i n g t h e i n su l i n p r ep ar at i o n an d ad m i n i st r at i o n t ech n i q u e w as t h e ph y sician ( 4 1 . 5 % ) .
Th e a v e r a g e s c o r e o f s t e p s c o r r e c t l y p e r f o r m e d d u r i n g t h e i n s u l i n p r e p a r a t i o n a n d adm inist r at ion t echnique w as 61% ( sd 10% ) and no st at ist ically significant associat ion w as found bet w een t h is av er age an d t h e sociodem ogr aph ic an d clin ical v ar i ab l es.
FI NAL CONSI DERATI ONS
B e c a u s e d i s p o s a b l e s y r i n g e s a r e f r e e l y d i st r i b u t e d b y t h e g o v e r n m e n t , w e h i g h l i g h t t h e im port ance of healt h professionals t o be fam iliar w it h it s use m et hods as w ell as w it h t he com plicat ions t hat m ight ar ise if it is inappr opr iat ely used.
Th e p a t i en t s’ a d o p t i o n o f i n a d eq u a t e a n d u n saf e pr act ices r epr esen t s a w eak n ess in t h e FHS d e l i v e r y o f i n t e g r a l c a r e t o D M p a t i e n t s , w h i c h consequent ly hinder s t he deliver y of good qualit y car e w it h case- r esolu t ion abilit y. On t h e ot h er h an d, w e believe t hat under st anding t hese gaps can enable t he FHS t o pr opose act ion s f ocu sed on in div idu als’ r eal n eeds, t h u s, pr ov idin g saf et y an d en cou r agin g self -car e an d at t h e sam e t im e st r en g t h en in g t h e FHS capabilit y for case r esolut ion pr oposal.
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