Was I taught the wrong thing in school?

If the patient has type 1 diabetes, holding insulin is just asking for DKA. The ideal situation is to have coverage for high glucose and meal coverage calculated separately, plus a set dose of basal coverage. The tough calls of giving SSI when hyperglycemic and not eating are very hard and shouldn't need to me made.

An ideal plan is set long acting dose (Lantus or Levemir) that's given regardless.

Then a set dose for meals (either set dose, or calculated based on how much is eaten).

Finally, a sliding scale of sorts that is given on top the meal dose for hyperglycemia. This could also be given if the patient isn't eating.

The reality of it is, the majority of hospitalized patients that get insulin aren't needing it long term and therefore this is overly labor intensive for little added benefit. That is why sliding scale remains popular. And will continue to be so.

A patient with a BG over 300 definitely needs insulin and I don't agree with holding the dose. I would have called the doctor and asked how much insulin they wanted for the 304 and if they wanted ketones tested.

A hospitalized patient who's body just needs help preventing hyperglycemia should probably just be getting corrections based on BG that are given regardless of eating for simplicity. Possibly a sliding scale with orders to give half dose if patient not eating.

Patients with long term insulin reliance should really be on a top of plan I described above, in my opinion.

I agree 100%.

I would have given the insulin, 3u can cause a drop in BG but the patient has a history of taking higher doses at home. A big factor to consider is if there is any IVF infusing & if there is Dextrose in it?? That alone is a source of nutrition. Though it is a good critical thinking measure to hold insulin for short-term NPO, with a BG level greater than 300 I would want to intervene and get that level down.

A doctor must be contacted if your going against his/her orders!!! Cover your butt at all times and document the outcome it's a pain, but that's what were paid to do.....

GOOD LUCK!!!

I have to agree with the post above. What if the pts is on IVF? Dextrose? In our hospital regardless of NPO status any sugar higher than 300 needs to be called to the PA/MD/NP even if it says to give for example 8units. Still call. Some pt can hadle a sugar that high without any sx but some can't and if they are NPO. That sugar can keep rising. Remember the body under stress will try to fix it self but side effect of the hormones that are being release to help a sick pt will increase the sugar.
What was your preceptor thinking ????

I just came across that issue not too long ago.. my patient was having surgery in the morning and their HS blood sugar was in the 200's. I asked the charge nurse and she said to cover it. I would think 300 would be way too high to leave! Besides like someone else said most people don't eat after their HS dose anyway, and with the infection and stress I would think it could stay up and put more stress on their body while they are already having to have surgery. I talked to a nurse who said that they "new information that's out" is coverage is pretty much always needed and it's strongly recommended not to hold it but I don't remember what her source was.

I agree that you should have called the doctor. The insulin needed to be given . Was the patient on an IV? I would think so as he was NPO plus had an infection?