[2bnp2006]

I am a new nurse on Med/surg floor.I need to know some easy to learn info about administration of insulin. I don't know when I have to hold insulin based on pt meal time. I hold Insulin Novolog 12 units before dinner last night for my patient because her BS was 175 and she was on sliding scale insulin too,I gave her 10 units regular and hold novolog. The Dr. was so mad and told me that you shouldn't hold it. I checked with another experienced nurse and she told me to hold it. Please tell me how I can determine when to hold and when not to hold.

[neverlandlpn2001]

Novolog is another name for humalog that type of insulin should be given right as the patient is eating because it is so fast acting. i usually give it right before i give them their tray to eat.

[Myxel67]

Just make sure you read about each type of insulin in your med book or a PDR. Never give a med you don't understand.

Humalog and Novolog are both fast acting insulin analogs, but they are not the same. Humalog (lispro) lasts for a slightly shorter time. Novolog (aspart) has a slightly longer tail and stays in the system about 30 minutes longer. Either is normally given 5 to 15 minutes before a meal. However, if the pt has a BG of 200 or higher, the insulin may be given earlier to give it time to start working. Even though the plasma peak is in 45 minutes to an hour, the pt generally won't feel the full physiologic effect of the insulin for 2.5 to 3 hours--this is when the risk for low BG is highest. You may see or hear of another insulin analog--Apidra (glulising). Their pitch is that it can be given up to 20 minutes after start of a meal.

Usually a hospital will have one or the other on its formulary and will give the nonformulary only if the doc specifies "medically necessary." However, if a pt takes a prescription for Humalog to a pharmacy, the pharmacist must dispense Humalog.

Many nurses (and doctors too) are afraid of insulin and choose to hold (or under-prescribe) much too often. If a pt is about to eat & has a BG of 50, you still should not hold the insulin. Recommended procedure in this case would be to start the meal with a fast acting carbohydrate, and give the insulin in the middle or at the end of the meal.

Many nurses also have problems with Lantus as well. Lantus is a nearly peakless insulin that generally lasts 24 hours. It provides basal insulin only and does not provide any coverage for meals. Therefore, you would not hold if pt is NPO. This is especially important if pt is a true type 1 diabetic (not just a type 2 who has reached the point that he/she now requires insulin.) Since a person with type 1 DM produces no insulin, holding the Lantus (or Levemir, or NPH) can cause a dangerous increase in BG and put the pt at risk for DKA. If pt is on NPH, which has a pronounced peak, the dose might be decreased.

Remember that food is only one source of carbohydrate that will raise blood glucose. The liver also releases glucose into the bloodstream--especially if person skips meal (NPO). You might notice that some of your pts who are NPO continue to have high BG. Sliding scale insulin is intended to lower BG from a high level. It is not intended to cover the meal. Therefore, fast acting sliding scale insulin should not be held if pt is NPO. You would hold any scheduled mealtime insulin though. Ideally, the pt should have long-acting insulin )for basal needs), scheduled fast acting insulin to cover the meal, and sliding scale to correct a high BG.

Watch your pts who have only sliding scale insulin. If they have a fairly good fasting BG (say, 120, which is below the level of the SS) no insulin is given with breakfast. Usually, the ac lunch BG will be well over 200. The pt needs schedule pre-meal insulin to have a chance at getting good control in the hospital.

[Myxel67]

Originally Posted by np2006

I am a new nurse on Med/surg floor.I need to know some easy to learn info about administration of insulin. I don't know when I have to hold insulin based on pt meal time. I hold Insulin Novolog 12 units before dinner last night for my patient because her BS was 175 and she was on sliding scale insulin too,I gave her 10 units regular and hold novolog. The Dr. was so mad and told me that you shouldn't hold it. I checked with another experienced nurse and she told me to hold it. Please tell me how I can determine when to hold and when not to hold.

Pt really needed both--sliding scale to reduce high (before meal target BG is 110 or lower), and premeal insulin (12 units Novolog) to cover the carb content of meal.

If pt is on mealtime Novolog, sliding scale should be Novolog too. Often, these orders are written by different doctors, so they don't match. Novolog can be given 5 to 15 minutes before a meal, but regular insulin should be given 30 to 45 minutes before a meal, so it doesn't make sense to use both. Always encourage docs to use Novolog if you are taking orders. When regular insulin isn't given early enough, it won't have the desired effect.

Premixed insulin (Novolin or Humulin 70/30, Novolog Mix 70/30 & Humalog Mix 75/25 are given before breakfast and dinner. But if the doc orders Novolog (or Humalog, or Regular) and NPH separately, The ac breakfast dose can be mixed, but the second NPH dose should be given at bedtime. One of the main drawbacks of premixed insulin is that the NPH in the dinner dose may peak between midnight and 2 am and produce low BG when pt is sound asleep and less likely to wake up. If given at bedtime, peak is closer to 5 or 6 am and pt is more likely to wake up and be able to treat the low.