[nptobee]

It also depends on the type of diabetic that they are. In the type 1 diabetic, who has an absolute insulin deficiency you never want to hold basal insulin as they can go into DKA.

[Tweety]

Originally Posted by SandySummers

I beg to differ. We are ethically and legally bound to deliver the best possible care to our patients and advocate for them as we would if we were lying in the bed ourselves. We do not give medications just because some physician prescribes them. We give them because they would benefit the patient. We do not work for physicians. We work for our patients.

We are autonomous professionals, duty-bound to protect our patients over the objections of any physician or administrator, and are held to this standard in a court of law.

Thanks for the ethics lesson.

However, nothing in there convinced me that I am allowed to hold a medication and not notify the MD that I held it, if there are no parameters pre-written or no hospital policy pre-written.

Let me put it this way. For an accucheck of 20 I would autonomously and ethically decide to hold the insulin and not endanger the patient by giving it.

This is not where my duties stop. I am also bound by my lack of medical license to prescribe medications to notify the MD that I held the dose and obtain further instructions.

Giving any insulin to a patient with a blood sugar of 20 is a very bad idea. If the blood sugar is 20, then I question why this nurse would be in the mode of passing medications in the first place--we should be working vigorously to correct the blood sugar to a normal level before resuming medication administration duties. Once the blood sugar is repaired, we should examine how it got that way in the first place and consider whether or not the patient needs a dosage adjustment, and if so, negotiate with the physician or nurse practitioner for a more fitting dose.

You begged to differ, but essentially you were agreeing with the mode of action I proposed. Assess the situation with critical thinking first, hold the dose and collaborate with the MD (or NP, sorry didn't mention that one, old habits).

[SandySummers]

Originally Posted by nptobee

It also depends on the type of diabetic that they are. In the type 1 diabetic, who has an absolute insulin deficiency you never want to hold basal insulin as they can go into DKA.

Nobody is going to go into DKA with a blood sugar of 20! Nursing is an ongoing professional service, where we monitor people over time and intervene as appropriate--hopefully not a once-per-shift service--though I know in this age of short-staffing it can often feel that way...

The common sense way to proceed is to get the patient's blood sugar back up to normal before even considering administering any insulin at all. Once it's normal, then start thinking about the patient's previous day(s) and any intervening factors that might have made her blood sugar drop. This might make you rethink the patient's insulin dose over the 24 hours instead of just blindly proceeding on with physician prescriptions regardless of what the patient really needs...

[SandySummers]

Originally Posted by Tweety

Nurses are not licensed to hold drugs without an MD or parameters.

Originally Posted by Tweety

However, nothing in there convinced me that I am allowed to hold a medication and not notify the MD that I held it, if there are no parameters pre-written or no hospital policy pre-written.
...
I am also bound by my lack of medical license to prescribe medications to notify the MD that I held the dose and obtain further instructions.

You said that nurses can't hold drugs without an MD or parameters. That is plainly wrong--as your own care plan acknowledged. We can and must withhold drugs that are dangerous for patients--whether or not we have an advanced provider agreeing with us. Of course we tell them about it, I was never suggesting we keep it a secret. Professionals working on the same patient should all know what the other is doing.

[Tweety]

Originally Posted by SandySummers

You said that nurses can't hold drugs without an MD or parameters. That is plainly wrong--as your own care plan acknowledged. We can and must withhold drugs that are dangerous for patients--whether or not we have an advanced provider agreeing with us. Of course we tell them about it, I was never suggesting we keep it a secret. Professionals working on the same patient should all know what the other is doing.

You're correct. I apologize for the misunderstanding and appreciate the clarification, as I worded what I was thinking incorrectly.

I certainly didn't mean that we were to blindly give meds just because the doctor ordered it, or that we have to have an MD order to hold the med.

We're educated professionals with common sense for heaven's sakes.

I meant to say, that we don't hold the meds without ultimately collaborating with the MD and letting them know we held the medication. It is wrong to hold the med and go about your business.

I think ultimately we are in agreement. BTW I wrote a paper on automony. I've been to your referenced website before. It's awesome.

[nptobee]

Originally Posted by SandySummers

Nobody is going to go into DKA with a blood sugar of 20! Nursing is an ongoing professional service, where we monitor people over time and intervene as appropriate--hopefully not a once-per-shift service--though I know in this age of short-staffing it can often feel that way...

The common sense way to proceed is to get the patient's blood sugar back up to normal before even considering administering any insulin at all. Once it's normal, then start thinking about the patient's previous day(s) and any intervening factors that might have made her blood sugar drop. This might make you rethink the patient's insulin dose over the 24 hours instead of just blindly proceeding on with physician prescriptions regardless of what the patient really needs...

Of course you treat the hypoglycemia first. You are correct that you have to look at the factors that contributed to the episode. The doctor may want to modify the dose if there is a trend. But again I say you never withold basal insulin for a type 1. Basal insulin is required to control hepatic glucose output even when fasting.

[SandySummers]

Originally Posted by Tweety

I think ultimately we are in agreement.

Good, I'm glad.

Originally Posted by Tweety

BTW I wrote a paper on automony. I've been to your referenced website before. It's awesome.

Thank you Tweety. We work hard on it...

[CHATSDALE]

interesting thread. i hope that we are being the educators that our patients require when they are sent home

as for the nurse that routinely gives 2 units when has been ordered she is playing with fire and with her license...how does the nurse working the next day know what has been given..if she gives the prescribed dose of regular dose and the patient bottoms out

[AdelaideChic]

Just another point to consider -
Diabetics on an insulin pump can go into DKA approx 4 hours after the insulin is stopped. So say, they go in the shower and disconnect the pump and forget to put it back on, 4 hours after disconnecting and they could be in DKA, even if their BSL was 20mgdl before the shower. Insulin pumps require a different mindset to be adapted. If a client had a pump, and a BSL of 20, stopping the insulin being administered from the pump will not help raise their sugars in the short-term, but in the longer-term (when the insulin would have peaked 30min-2 hours later).

[Myxel67]

Originally Posted by nptobee

Of course you treat the hypoglycemia first. You are correct that you have to look at the factors that contributed to the episode. The doctor may want to modify the dose if there is a trend. But again I say you never withold basal insulin for a type 1. Basal insulin is required to control hepatic glucose output even when fasting.

This point is so true, and it underscores the importance of knowing whether your pt has type 1 or type 2 DM. In our hospital a few years ago, there was the case where a woman with type 1 DM had her surgery delayed 2 days by a doctor's order: NPO after midnight Hold all insulin. The nurse followed the doctor's order. Pt's BG in a.m, was >500 so anesthesiologist cancelled surgery. Same procedure was repeted that night with same results in the a.m. It took the third try for someone to let the doctor know what the problem was.

Lantus insulin acts very slowly--starts about 2 hrs after injection and lasts about 24 hrs in most people. The Lantus insulin can still be given safely to a person with type 2 DM who is NPO. However, if it is withheld for type 2, the results are not so drastic because with type 2 there is still some indogenous insulin present.