Was I wrong to hold Insulin?

[Anne36]

I had a bood sugar check of 75 during the 5:30 check. I was supposed to give 6 units of Novolog and there was no hold order in the MAR. I consulted 2 other Nurses on the floor who agreed the blood sugar was too low and I held it. This is an elderly lady with an unreliable appetite. Later on in the evening I went and checked her blood sugar again and it was 133. (was I even wrong to recheck? mabye) The next time I went into work the care manager for the unit told me that I should have called the Dr if I was going to hold her insulin for under 100. She also said that I should have given her regular Novolog and given her a milk shake. What if she wont drink the milkshake? I dont have time to chase 7 Diabetics all over the place watching everything they eat and drink. I did the check when I was supposed to and it was low, so I held it. What do you think?

[Sun0408, ASN, RN]

Quick question!!

I understand you DO NOT HOLD Lantus for a Blood Sugar of 59.

What about Humulin N ? It is scheduled at 44 units Q am in the wee hours (6:00 am).

Can I simply just Hold Humulin N, chart it as such and tell the oncoming nurse, or do I need to call the Doctor at 6 AM/

Do you not have a hypoglycemic protocol to follow?? I know with all our DM pts or any pt on SS insulin pharmacy adds the hypo protocol, this states what to do if the BS is that low. But to answer your question, yes I would hold and call the PCP if no other protocols to follow were added to the MAR. A BS of 59 is very low and the pt needs further interventions now. Did you treat the low BS??

[Bella RN, BSN, MSN]

I completely agree you did the right thing by using your judgment. I think its ludicrous for your superior to tell you to give a milkshake while giving her the insulin. this is an elderly woman, her body will metabolize things a little slower and eventually it would have caught up with her in a negative way. You were also very smart to recheck it. After the recheck I would have called the Md and said this am she was 75 I with held her insulin waited and now she is at 133 are you okay with her receiving the 6 units after she ate 1/3 of her breakfast. Especially with the elderly we have to be very cautious to how they respond to meds. Kudos to you!

[Pvida]

Thank you Anne36 so much for reminding everyone ...just like a patient is not a room number! :-) They have names and should be used!

[Mudwoman]

As nurses, we think that because we have a brain and we can think, that gives us the right to stretch that line in the sand when it comes to what we can LEGALLY do and what CRITICAL THINKING says we "should" do. The reality is that you do not have the scope of practice to ignore a doctor's order. If your critical thinking skills say that insulin probably should be held, then call the doctor. Only the doctor can give you the order to hold that insulin. I know it is a pain to do that; especially if you are chasing 7 diabetics, but nurses can not decide to hold a medication. There has to be a doctor's order to do so or standing orders from that doctor that if the patient is eating less than "x" % of their meals and their blood sugar is less than "x", hold the insulin. You could get such an order for this patient and save everyone (including the doctor) calls every time someone decides insulin is not such a good idea.

Basal insulins such as Lantus and Levemir are never held.

Treating a low blood sugar requires giving ONLY a food with carbs. Never give any food with fat in it as fat slows the absorption of carbohydrate (glucose). Once a blood sugar is stable, giving a protein with a carb will help keep that blood sugar stabilized.

[solarusmoon]

Holding insulin without an MD order is practicing medicine and outside the scope of practice for an RN. You need to call the provider and either ask MD to hold or ask for a lower dose. What if the patient is Type 1? Also - why would you be giving Humalog at 5:30am? Is that when breakfast is given? Humalog is a rapid acting insulin that should be given when the meal tray is in front of the patient... in my hospital our orders say that if PO intake is uncertain that Humalog can be given at the end of the meal (once you see what patient has eaten)... obviously every hospital is different. Hope that helps... :)

[solarusmoon]

@Mudwoman - This! Great answer!!!! :)

[downsouthlaff, LPN]

Holding insulin without an MD order is practicing medicine and outside the scope of practice for an RN. You need to call the provider and either ask MD to hold or ask for a lower dose. What if the patient is Type 1? Also - why would you be giving Humalog at 5:30am? Is that when breakfast is given? Humalog is a rapid acting insulin that should be given when the meal tray is in front of the patient... in my hospital our orders say that if PO intake is uncertain that Humalog can be given at the end of the meal (once you see what patient has eaten)... obviously every hospital is different. Hope that helps... :)

Not to say your answer is wrong cause it's not. You are technically supposed to have an order to hold any medication. But Im an LTC Nurse and I'm telling you now, I'm not giving anybody rapid acting insulin with a CBG in the range of 70-80. Lessons learned. It's not safe even if there eating a snack. At my facility there are rapid acting Insulins scheduled at 5am on the morning med pass way before breakfast is served at 7:15. In this situation the ideal thing to do is contact an NP or MD. But how many MDs are gonna answer a call from the nursing home at 5am? Truth is not many. There for I will hold the rapid acting insulin, notify the MD later. This is exercising nursing judgement, and being a patient advocate, and is justifiable at a nursing board hearing. If a residents CBG was 68, and you couldn't get in touch with the PCP are you really gonna admin a rapid acting insulin at 5:30am? Technically you had an order to do so with 0 order to hold. There's MD orders and there's nursing judgment. Sometimes in my opinion for patient safety we must use our common sense to keep patients/residents safe but we all practice differently. This is not practice advice to the OP, just insight to how I would do it.

[Mudwoman]

You are confusing holding an insulin vs re-timing an insulin. It is crazy to time a fast acting insulin that has to be given with a meal at 0500 when breakfast is at 0715-0730. You are not holding it when you use judgement to give it with the meal. Surely there is not an order for your fast acting insulin that has no parameters such as "do not give if BG is less than 120 mg/dl". If there are no parameters, that probably should be addressed for all patients in the NH.

"Holding" means that you decide to ignore an order regardless. So, maybe the patient has a blood sugar of 122 mg/dl and there is an order for that patient to receive 2 units of fast acting insulin for that blood sugar with a meal, but you decide that because they can get as low as 80 mg/dl on that and have symptoms of a low blood sugar you are not going to give it at all.

You would not hold a basal insulin such as Levemir or Lantus. That does not mean that the dose should have been adjusted and you are using nursing judgement to hold the dose until you are able to address the need for dose adjustment with the doctor. Surely that would not be necessary at 0500.

[downsouthlaff, LPN]

You are confusing holding an insulin vs re-timing an insulin. It is crazy to time a fast acting insulin that has to be given with a meal at 0500 when breakfast is at 0715-0730. You are not holding it when you use judgement to give it with the meal. Surely there is not an order for your fast acting insulin that has no parameters such as "do not give if BG is less than 120 mg/dl". If there are no parameters, that probably should be addressed for all patients in the NH.

"Holding" means that you decide to ignore an order regardless. So, maybe the patient has a blood sugar of 122 mg/dl and there is an order for that patient to receive 2 units of fast acting insulin for that blood sugar with a meal, but you decide that because they can get as low as 80 mg/dl on that and have symptoms of a low blood sugar you are not going to give it at all.

You would not hold a basal insulin such as Levemir or Lantus. That does not mean that the dose should have been adjusted and you are using nursing judgement to hold the dose until you are able to address the need for dose adjustment with the doctor. Surely that would not be necessary at 0500.

You make a world of sense ! I do get where you coming from. But Retiming a med without an order is the same crime of practicing medicine without a license. If a med is not giving within the time frame it is ordered, hour before, hour after it still constitutes a med error and it goes against the original PO. Look at it this way if a Nurse works 10pm-6am and the rapid acting insulin is scheduled at 5am in accordance with med pass time on the noct. shift the 6am-2pm will not administer another shifts medications at breakfast time. Therefore the logical decision of the night Nurse using judgement is to hold the rapid acting insulin. Then yes of course something will need to be adjusted with the MD orders but I don't think that the night nurse did the wrong thing by using nursing judgement to hold as long as when the MD does call the NH back something can be adjusted of parameters can be given.

[Kooky Korky, BSN, RN]

Giving the insulin and a milkshake sounds goofy.

Should you hold it? Yes, I think so. I like to give insulin AFTER people have eaten, but I know the practice in institutions is usually to give it before they eat.

As for calling at such an early hour - if I were Doc, I would write my orders differently, so as to avoid being called so early for something so routine. Do you know how many calls a doc might get every single morning? Why docs don't write orders that include some self-protection is hard to comprehend.

Depend on Day shift to pass this on to Doc? Only if you want your head whacked off.

[outsidethebox]

So, the ideal answer is indeed not to hold the insulin if the patient is eating. Novolog should be administered to match the carbohydrate intake or to correct hyperglycemia. It is unfortunate that it would be given at any other time. The 6 units is ordered to help with the meal, so if the patient is not eating, there would be no reason to administer 6 units for a FSBG of 75. The doctor should be notified if this was not ordered to match the food intake.

Feeding insulin only results in weight gain. If the patient has type 1 Diabetes, not type 2, then not administering scheduled mealtime insulin could put this patient at risk of DKA, especially if they are already ill. At the very least, the insulin prevents hyperglycemia.

My son has Type 1 Diabetes, and his glucose levels are rarely over 100. However, if he is eating, he always has to take mealtime boluses. This is how we keep his glucose levels under control. If his glucose levels are less than 60, we do subtract 1 unit from his mealtime dose. That would be contacting the physician in a facility for orders.

My son has only been hospitalized for surgeries, and he does get frustrated because nurses do want to hold his insulin. He does not produce insulin. He will get sick, and could die if his insulin is held. It is a very big deal, and he is not afraid to tell his nurses that. Please consider if your patient has type 1 or type 2 before holding insulin. He needs insulin to survive. Additionally, hyperglycemia can be dangerous for both.