First of all, I've been out for Medical-Surgical Nursing for so long, please explain to me as if I am a new graduate. Secondly, please excuse the way I'm posting this. I am quite confused. Thanks. =)
So, there is this patient, not known diabetic, pregnant, who is currently on sliding scale every 8 hours on Actrapid. She was endorsed to me with a blood sugar of 297mg/dl (2 hours after receiving her due insulin based on the sliding scale - 0600H).
Because I can still remember in the back of my mind that 297mg/dl is no good, I decided to check her blood sugar again at 0800H and it was at 205mg/dl (still high) I decided to give her her due 10 units of Actrapid after finding out that it's "quite" same as Regular Insulin according to the hospital pharmacist. I intended to recheck her blood sugar after 30 mins.
Questions: Should I have waited for 8 hours to pass before I rechecked her blood sugar? Shouldn't I have check her blood sugar at 0800H? The previous nurse didn't give any insulin for the 297mg/dl reading (she referred it to the resident doctor but there was no order). Are we only suppose to give insulin every 8 hours, just the same time frame as the sliding scale? But aren't we suppose to lower her blood sugar? Was I suppose to give some more time for the Actrapid to work? But they said it's like Regular Insulin and from what I remember in the ER we give another dose of regular insulin as ordered if the reading is still high. Should I have called the doctor regarding her blood sugar instead of relying on the sliding scale?
Back to my patient, I missed rechecking her blood sugar 30 minutes after because I am acting like a new nurse (chaos). Noting the trend of her blood sugar and the patient's "good" general status (that and I started questioning myself if I should only check the blood sugar x 8hrs), I settled with checking her blood sugar at 1200H. It was around 0930H when my LPN asked me if I rechecked the blood sugar (OMG, you remembered and you didn't check!). I said that I'll check later because of the reasons I stated above. Anyway, the patient also requested if we could move the testing later.
Question: Is this poor judgment on my part? I think yes.
After that my senior nurse finally arrived (thank God), they took the blood sugar at 1100H which is 168mg/dl and they wanted me to give the due 4 units of Actrapid. I didn't want to because at this point in time did all those previous questions pop into my head. Also, I'm not really familiar with Actrapid. I was worried about hypoglycemia. I also happened to ask my senior if we could check the blood sugar later 2 hours post-prandial but she said there is no need because the order is q8h. (Then why did you check her blood sugar now? Because I gave insulin? But if I give another dose of insulin, aren't we definitely going to check for her blood sugar later?) My senior said not to worry about giving another dose of Actrapid so soon because it's a short-acting drug. Still I didn't give it, for some reason I am not confident with her explanation. I feel like 168mg/dl is not detrimental compared to 200+ and is still under coverage of the Actrapid that I last gave. Anyway, my break time came, after which, I failed to catch up on that patient (because she's actually assigned to my senior and I only slightly care). In short I forgot about it only to be asked by the LPN if I gave the 4 units Actrapid as we were going home. =O (but I was on an allowed break at that time...) Now it's haunting me.
I just recently checked the internet for my problems but there is no mention of rechecking the blood sugar after the scheduled sliding scale. There is not mention of giving another dose of regular insulin except for "give it some time".
Please educate me. Thank you.
Oct 27, '12
Your post is difficult to follow. Im confused about several things. Did you do a finger stick out of the blue and just decide to give X amount of units on your own or was this a scheduled check... Normally finger sticks coincide with sliding scale; meaning you check q8h and based on those numbers you give the prescribed amount of insulin..
After giving insulin I do not recheck until the next scheduled time unless the pt is acting as tho they are hypoglycemic etc...
Follow the order, if it is confusing call the PCP and get it clarified. Since you are not familiar with this med at all, looking it up would have a been a good thing to do.
Oct 28, '12
i'm sorry for the confusing post. I must say that I am really confused. I did the finger stick on my own and felt weird doing it on my own. So now I am asking, am I suppose to only do glucose checks as ordered?
You said that you only recheck if there is possible hypoglycemia, but what about cases of hyperglycemia? If the patient is still hyperglycemic in between tests/after giving regular insulin as ordered, can I give another dose based on the sliding scale?
Oct 28, '12
Yes, you are only to do checks as ordered UNLESS you feel the pt is showing S&S of going hypo. At that time you would follow your facilities hypoglycemic protocol.
No, the sliding scale is ordered q8h. So you can only give the insulin q8h. If the pt is having uncontrolled levels then the MD needs to be aware and he/she can decide if they want to add levemier or lantus on board in addition to the sliding scale. The MD could also change the sliding scale to q4 or increase the number of units at each FS. We have 3 levels of coverage, low, med and high. Many pts are started on low dose sliding scale and if their levels are still too high we can have the MD change the level to med or high. That only means the pt will get more insulin than originally.
Oct 28, '12
The finger stick times should be on your EMAR or MAR for the due times along with the sliding scale. Pharmacy usually adds this so everyone knows when the finger sticks are due and what the prescribed amount of insulin is. Giving any medication without an order is outside of our scope of practice and can get you in hot water with the facility and the BON. Giving insulin just because her FS was still high is practicing outside your scope. The order is for q8h and that is what we have to follow or get changed.
Oct 28, '12
Follow the rules. CS as ordered. Insulin/med as ordered , at time ordered
Take c/s if pt symptomatic hypoglycemic.
High-report it to MD. MD will decide if pt needs insulin drip then and how often CS will then be (q1 or 2hrs )
Don't take things on that you are not sure of. Go to who knows more. You are learning. Experience in time will teach you. You are not expected to know everything .Meantime,get help if you are unsure of anything.
Be patient with yourself. Your knowledge/skill will grow just by doing.
Oct 28, '12
I just wanted to post a thanks to everyone. It definitely made things clearer. I better review my insulins now
Oct 29, '12
In my state the RN has the freedom to do a fingerstick prn, no medical order required. This is to allow the nurse to assess properly and intervene if needed. Not familiar with the name Actrapid but looked it up and it is the same as Regular Insulin. Sometimes patients on regular insulin get injections of the SAME amount at specific times, or VARYING amounts, depending on glucose reading. Be sure you know which. This insulin peaks in about two hours, so you would expect the glucose level to be the LOWEST in about two hours after an injection. I have checked glucose levels about two hours after insulin injections, just to see what the lowest level is and report to MD. If the patient is chronically hyperglycemic, even after an injection, then the dose might need to be adjusted. Of course, that is an MD decision. This is not an easy disease to get a grip on so you are doing great so far.
Oct 29, '12
Do fingersticks as ordered. Typically they are ordered AC&HS (before meals and at bedtime) but if a patient is NPO, they might be ordered Q6H...or Q4H if they are on TPN. Check your orders. Typically the provider will also write an order to perform a PRN fingerstick if you suspect hypoglycemia, and typically facilities have a hypoglycemia protocol in place that you would follow. For AC&HS checks, typically they are done at 0800, 1200, 1600 and around 2100-2200. Where I work the providers typically have the patients on prandial (meal-time) insulin. The prescriber may also add a correctional dose, which is the sliding scale and of course the sliding scale is dosed base on the patient's blood sugar. Depending on how much the patient eats (or if they eat) and what the blood sugar is, you may have to hold the prandial dose and just give the sliding scale, or hold both. Look at your parameters for your sliding scale doses. You may have to call the MD for a dose adjustment.
I am also unfamiliar with Actrapid but after doing some Googling, it is like regular insulin (short-acting) with an onset of 30min after injection. Peak time is about 2 hours and duration is about 6-8 hours. It is important to know the onset, peak and duration of the different insulins and it is safe practice to know your medications before administering them.