Insulin administer time on dementia/poor appetite pts

  1. I am a bit confused with insulin administer time because the nature of pts we have on medicine floor.

    I understand different kinds of insulins, including their onset, peaks, and duration. I was taught in school to give regular insulin 20-30 minutes before eating, and according to our hospital policy insulin premix 30/70 (30 regular 70 NPH) is also given 30 minutes before eating.

    Now the problem is, a lot of pts are confused and dont eat much at all! I can take the BS at 0730, gave the scheudled regular @ 0740 and BRFT comes at 0800 but they tell me "I dont want to eat." or they ate couple spoons and stopped. I do encourage the diabtic pts to eat and drink more, sometimes i say "Okay you can leave the toast and egg, but you gonna finish the chocolate milk/boost so you are not dehydrated and you just had the insulin" (half of the time they dont understand what im saying), also another disadvantage is that 0700-1000 is the busiest time for me, not only that i had to finish my vitals, med pass, assessments and am care but also set up/feed the pts and have my 30 minutes break. In fact, I cant really force them to eat because not eating much is fairly common among such population, as their activity level is not high during the day either.

    I see some practice is...

    1) give the sliding scale: regular, rapid, or premix (regular and NPH, rapid and regular) in front of the tray and watch pt start eating. Give the NPH a bit earlier before eating.
    2) give the sliding scale and premix after eating. Give the NPH in front of tray.

    Now my problem is:

    they ate, only couple spoons. Now what? Gave the needles? So far I have not seen any hypoglycemia related to sliding scale or scheduled insulin during day shift yet, but i have seen rebound hypoglycemia at 0100 on one pt who totally lost consciousness and was bubbling. She had glucacon and d50w and then transferred to ICU.

    Plz help, thanks!
    Last edit by Joe V on Aug 13, '12 : Reason: spacing
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  3. by   Double-Helix
    This needs to be discussed with the resident's doctor and the resident should be switched in an insulin scale with a correction factor and carb count ratio for insulin dosing. That way you would be giving insulin to correct the pre-meal blood sugar and giving extra insulin in proportion to the carbohydrates consumed.

    When we have young children on insulin, we can't predict how much they are going to eat. So we take their blood glucose right before they start eating, and then give them a set period of time (20-30 minutes) to eat the meal. When they are done, we count the carbohydrates they ate and give both the correction factor dose (based on their pre-meal sugar) and their carbohydrate dose (based on how much/what they ate) after the meal. This policy is per our endocrinologists and diabetes educators. I imagine a patient with dementia, whose food intake is unpredictable, should be managed similarly.
  4. by   whitebunny
    very rationale answer. thanks for your reply, i will keep that in mind
  5. by   Double-Helix
    You might also want to ask this in the LTC forum. There tends to be more traffic over there than in this forum.