Blood Sugar Coverage...Did I do the right thing?

Freedom42 · Aug 20, 2010

The patient's order should stipulate which insulin to hold and under what circumstances, including a specific blood sugar level. If the order didn't include that when written, I would have asked for clarification before varifying it so that you would not have found yourself in that position. If I were you, and the order was not so detailed, I would have called the physician to ask for instructions and clarify the order for future use.

chloecatrn · Aug 20, 2010

...or the wrong thing?
Pt has Accucheck and coverage AC and HS. HS BS level was 50. Rechecked and it was 68. Gave OJ and Applejuice. Notified Charge RN. Rechecked 30min later and it was 150. Charge RN said to give the insulin coverage and give juice after wards and to hold the Lantus.
My gut feeling was that I should have held the short acting insulin and given the Lantus. The pt was sleepy, but drank sips of the juice when I gave it to her (which had some added sugar too).
Anyway, I told another coworker (staff RN) about the situation and the RN had the same idea I did: hold the short acting, give the Lantus. But instead I followed the charge RN's suggestion since...she had more experience and was the charge nurse. So I held the Lantus and wrote in it "held since pt did not eat dinner"...the pt only had 20% of her meal.
I'm up late and just worried about the pt. I guess 68 isn't horribly low, but it's still low. What should I have done?

First off, your order should have had hold parameters. I would broach this with your management staff.

Secondly, the action is typically to hold your Regular or Log coverage and give the Lantus or Levemir, especially if there wasn't a change in the patient's oral intake status (i.e.: the patient wasn't going to be NPO overnight). Lantus provides basal coverage throughout the whole day, and isn't responsible for lows, for the most part. It has a tiny little hump of a peak in some people, but not too terribly much of one. Lantus is the insulin that keeps the patient's blood sugar steady throughout the day.

Regular insulin and the Logs (Novolog/Humalog) are the ones you want to hold with a meal. They're the more rapid onset insulins that are meant to correct meal carbohydrate intake. I would be curious to see what the patient's Accucheck was after her insulin peaked. You don't say how much was given, but if it were a large dose, that could possibly lead to profound hypoglycemia, which would cause some tail chasing with blood sugars all night. This is an excellent example of why it's best not to guess. DEFINITELY, if you're not sure, call the doc. Don't try to put a few heads together to get an answer.

txspadequeenRN, BSN, RN · Aug 20, 2010

i would have done just as you thought held the regular and given the lantus.

Little_Mouse · Aug 20, 2010

I gave the 2 units of Novolin R coverage for the 150.

And surprisingly, the pt did not have any parameters regarding a blood sugar

chloecatrn · Aug 20, 2010

Eh. Could be worse than 2 units of R for 150. That being said, it still doesn't change my original answer. I almost always, unless there's some underlying reason why NOT to, give the Lantus and hold the short acting.

twinmommy+2, ADN, BSN, MSN · Aug 20, 2010

Just to go through the event with you and bear with me I'm at the end of a night shift. You are finding a person who's glucose is low, and you correctly, rechecked it which was 68. The actions you take at this time are to correct the low glucose, and again you did that, bringing it up to 150. After that don't cover the glucose you just brought up. When you bring up a glucose by giving them sugared up orange juice, it only brings up the glucose for a short time so you may be covering something that won't be there long, see what I'm saying? (I might be rambling) Feed them, give them the lantus and if concerned later recheck fsbs.

Little_Mouse · Aug 20, 2010

twinmommy-- it totally makes sense. I'm up late too and I should be getting sleep since I have work 11 hours from now. That's what my coworker brought up--why cover a blood sugar that you just brought up? I feel like a complete idiot now for not trusting my own gut instinct and I'll pray that my pt is ok...

twinmommy+2, ADN, BSN, MSN · Aug 20, 2010

I'm sure everything came out ok and don't we just beat ourselves up for everything, if you don't sleep you can't take care of the next batch of hypoglycemic needy patients lol:redpinkhe

AirforceRN, RN · Aug 20, 2010

I think the lessons here are:

1) Don't hold Lantus as a general rule.

2) Charge nurses are not infallible. If something seems off or you disagree...double check with someone else.

classicdame, MSN, EdD · Aug 20, 2010

I hate it when we make decisions "by committee". That should have been the call of the MD if there was no specific order on how to handle such situations. Next time call the MD. But I agree, holding the rapid acting makes sense. Chart why of course.

morte, LPN, LVN · Aug 20, 2010

1) Check your P+P for default parameters.

2) Giving sugared juice is not current thought.

3) 68 really isnt that low, but remember to nurse the patient, not the number.

4) Don't cover a "contrived/created" elevated BS.

5) Don't hold Lantus, or other basal insulins.

6) Assess the why of this patient having this reading at this time, ?didn't eat last meal or snack, etc.