Help when calling the md - page 2

I'm a new lpn. I just have a question. This hasn't happened to me yet but when it does I want to be prepared. At our facility it says if a pt BS is over 350 call MD. If their BS is below 70 hold... Read More

  1. by   Julius Seizure
    Quote from iwannabeanursee
    Yes I work in a ltc facility. So if the BS is really high would I still give the novolog and lantus or just give the novolog first retest in 15 min then give lantus? Just give her water. That's what I'm worried I don't want to do something Call the doc tell him what I did, what if I was wrong?
    This isn't directly answering your question, but lets talk about insulin for a minute. I didn't understand it well when I was a new nurse, so don't feel bad about any confusion. And if you already have all this down, congratulations on being smarter than I was as a new grad!

    There are basically three categories of insulin:
    • Rapid/Fast acting
    • Intermediate acting
    • Long acting

    This patient is on Novolog and Lantus. Novolog is a fast-acting insulin, and Lantus is a long-acting insulin. This is a pretty typical regimen: a long or intermediate-acting insulin, plus a fast-acting one. It is called basal-bolus therapy, and their insulin levels will look like this over the course of a 24 hour day:

    3093_1-jpg

    So if you hold the Lantus (long-acting), is that going to do much to fix abnormal blood sugar? Not really. Lantus doesn't start taking effect for about 1.5 hours after you give it anyway, and by then hopefully you have already done something else to raise your patients blood sugar, right? The long-acting insulin is there to provide just a baseline level of insulin in the body all the time. That's why you usually still give it even if a patient is NPO...their body will still need a low level of insulin in the body at all times. (Always confirm with the provider, of course.)

    The short-acting insulin is what you are giving to actually adjust their glucose level when they eat meals and snacks - it takes effect in about 15 minutes. That is what you will hold or adjust the dose of based on your fingerstick glucose checks. This is why your Novolog dose sometimes changes based on the glucose level, but the Lantus does doesn't change.

    In the scenario that you presented, you asked if you should just give the Novolog and then recheck in 15 minutes before giving the Lantus. So, based on what we just went over, does it matter if you give them both at once or if you hold the Lantus? Will the Lantus change anything for that 15 minute recheck?

    I suggest that you check your facility policy on whether they expect you to hold all the insulin until you speak to the provider, or to give what is ordered and then call to ask if they would like additional insulin given as well. And don't feel bad about being nervous calling the provider, it can be an intimidating thing at first but it gets easier as time goes on!

    Check out this great thread on tips for new nurses when calling providers.
  2. by   iwannabeanursee
    Quote from KelRN215
    Does the order specifically say to hold the lantus when blood glucose is < 70? Lantus is a basal insulin, holding it will most likely lead to an increase in blood sugars for the next day and requiring higher doses of short acting insulin. I've never worked anywhere where lantus would be held.
    I follow what's on the computer screen. It says hold if less than 70 both lantus and novolog.
  3. by   djh123
    If, as in your example, someone is 500 and has Novolog AND Lantus scheduled simultaneously (this is probably either early morning or at HS), then yes, I'd go ahead and give it, and call the dr. if the order says to call if they're above 350. Another tip that I've found some nurses don't know: if there is any food or drink on their finger, it can affect the # and give you a false result, even if you just kind of lightly cleaned the fingertip with an alcohol wipe. If you have any doubt at all about whether a # is 'real' - because so-and-so is almost never above 200, or say, they have a bag of Cheetos on their nightstand :^) - try the other hand, and clean it real well before checking again.
    Because you don't want to get a false reading of let's say 350, when in reality they're really at 210 and there is some food residue on the finger, then you give them enough Novolog to cover the 350, and then they may start going hypoglycemic.
  4. by   Julius Seizure
    Quote from djh123
    If, as in your example, someone is 500 and has Novolog AND Lantus scheduled simultaneously (this is probably either early morning or at HS), then yes, I'd go ahead and give it, and call the dr. if the order says to call if they're above 350. Another tip that I've found some nurses don't know: if there is any food or drink on their finger, it can affect the # and give you a false result, even if you just kind of lightly cleaned the fingertip with an alcohol wipe. If you have any doubt at all about whether a # is 'real' - because so-and-so is almost never above 200, or say, they have a bag of Cheetos on their nightstand :^) - try the other hand, and clean it real well before checking again.
    Residual rubbing alcohol on the finger can also affect the glucose reading, for that matter. That is part of the reason for wiping away the first drop of blood after pricking the finger.
  5. by   nursinghealth
    You sound very new. That's ok, we all were at one time. A few things:

    1. Get to know your insulins. You need to understand how insulin works before deciding whether or not you should hold it. Lantus is long-acting, whereas Novolog is fast-acting. You need to consider this when deciding whether or not to "hold" something.

    2. Don't hold anything without MD approval, either by direct order or medical directive. If the MAR or a Medical Directive says to hold the Novolog, great - hold the Novolog. If the MAR or Medical Directive doesn't say to hold the Novolog, but you think you should hold it based on your understanding of the med and the patient's presentation - call the MD and ask if they want to hold it. If they say yes, bingo - you have an order to hold it.

    3. Get to know your medical directives. I can't stress how important this is. If you haven't already, ask where you can find your agencies policies and medical directives.
    Last edit by nursinghealth on Jan 7
  6. by   djh123
    Quote from Julius Seizure
    Residual rubbing alcohol on the finger can also affect the glucose reading, for that matter. That is part of the reason for wiping away the first drop of blood after pricking the finger.
    Right... actually what I do is clean w/alcohol wipe first, then a 2x2.
  7. by   nursinghealth
    Quote from iwannabeanursee
    At our facility it says if a pt BS is over 350 call MD. If their BS is below 70 hold novolog and lantus. Let's say their BS is 500 and they're on Novolog 6u and Lantus 12u. What should I say to the doctor when it's high?
    Based on what you learned from the responses in this thread, what do you think you would say?

    Quote from iwannabeanursee
    Do I have to hold anything?
    Based on what you learned from the responses in this thread, do you think you would want to hold something in this scenario? If so, what?

    I'd be curious to see you work through this yourself based on the knowledge you've acquired.
  8. by   KelRN215
    Quote from iwannabeanursee
    I follow what's on the computer screen. It says hold if less than 70 both lantus and novolog.
    That's an order that I would question or at least seek clarification on. It makes no sense to hold lantus based on a single low blood sugar value that you're going to (presumably) give carbs to correct. Lantus is the basal insulin that is needed. If values are consistently trending low the dose may need to be adjusted but, in general, it should not be held.
  9. by   BostonFNP
    You don't have to be nervous, though it is natural to be. This is a basic part of your job. Your responsibility is to the patient and in this case your patient needs a new plan.

    As someone who gets these call often, here are a few things to remember.

    Always give an SBAR. When I am on call coverage I am covering for nearly 20 providers and chances are I will not have ever seen this patient nor do I know anything about this patient. Use your SBAR! If you are nervous, write it down before have and use it as a script.

    Talk slow and clear. Depending on when you call you could be getting someone that is out at dinner or shopping, at home with yelling kids, just been awoken from sleep, etc.

    Have the relevant information. Make sure you have: 1. assessed the patient yourself, 2. know their meds, 3. know their allergies, 4. know the timing and amount of their last doses, and 4. know of any pertinent information regarding how the patient has responded in the past.

    Advocate for your patient. If you feel like something isn't right then speak up and make sure it is clearly known.


    "Boston, this is is iwannabe calling from Good Ole LTC. I am the nurse taking care of Patient X this evening. Patient X is a 89 year old woman with basal-bolus insulin-dependent diabetes, afib, and vascular dementia. Her blood sugar was checked tonight and it was 450. She is asymptomatic. She was checked at lunch and her blood sugar was 250 and she was given 8units of humalog. Her dinnertime sliding scale goes up to 10units at 350. She rarely has hypoglycemic episodes. Would you like to have me give her a larger dose of insulin?"
  10. by   jodispamodi
    OP, it also matters if the patient is aymptomatic or symptomatic. So when calling the doc, revert back to your SBAR (this was the exact reason it was brought into healthcare to facilitate communication between doctor and nurse as we tend to have different communication styles so for example:
    Hi Doc, this is D. Mellilitus LPN at Old Peoples Home. My number is xxx-xxx-xxxx,
    (Situation) I am calling on Hi Sugar room 320-A, (In ltc you don't really need the room number) we just checked his blood sugar and it is 500. I notice he has 6 units of novolog, and 12 units of lantus due with no sliding scale.
    (Background) he has a R BKA, esrf, dialysis patient, and diabetic retinopathy.
    (assessment) he is asymptomatic at the moment, aox 4, his VS are..., he denies hunger, thirst, shakes, (hyperglycemia sxs, etc)
    (Recommendation) I see he doesn't have a sliding scale ordered, and I'm not sure if you want me to give him his current insulins or possibly adjust the dose? Please call me back at xxx-xxx-xxxx with any orders. Thank you,
    That isn't exactly how the conversation would go but hopefully you get the idea. ALWAYS have all your info in front of you before you make the call. Be succinct, don't be afraid, and if need be write out what you are going to say. Also look back over the past few days and see where patients sugars have been, very important to communicate that with the doctor. Good luck.
    Last edit by jodispamodi on Jan 8 : Reason: I felt the need to edit
  11. by   cyc0sys
    Before you call the Doc, get a set of vitals. Try to figure out what the likely outcome would be. If the VS are WNL, the options are give more insulin and/or continue to monitor. Since hyperglycemia isn't going to kill your patient, at least not quickly, the Doc is probably not going to send them out. He may want to order labs or a dietary consult.

    Unless the Medical Director wrote the facility policies, I'd stick to the parameters of the order and notify the Doc. Policies change all the time in the LTC world, unlike hospitals. If you need clarification regarding the parameters or absence there of, ask the Doc who wrote the order. Then write a clarification T.O. so the next person isn't in the same situation. Docs often make a lot of assumptions regarding Rx parameters. It is our job to catch this kind of stuff, e.g. adding NTE 3gm APAP x 24hrs for Norco.

    If you're working 3-11 or 11-7 at an LTC you're probably not going to have a nursing manager/ADON on shift. If you're at a small facility, you'll probably just have the DON to call. I wouldn't get in the habit of calling any of them. It makes you look incompetent and incapable of critical thought.

    Doc is running the show, not the NM/ADON or DON. If his Pt has a condition change, he needs to be the first to know anyway. He/she may not be happy about getting that 0'dark thirty call but that's why they make the big money.

    Never hold a medication w/o an order unless the Doc is unreachable and giving the med may kill your Pt. Think bp meds, digoxin, morphine etc... If Doc is unreachable and VS are heading south, call EMS. If it was heart burn and not an MI, so be it. Remember, when your Pt becomes unstable in the LTC, You don't have the tools or staff to deal with an emergent condition. Even if you have the experience and training, you're most likely going to send them out.
  12. by   Oldmahubbard
    Great answers here, and just remember, 100% of all people in practice today were once brand new, first day on the job.

    Your most valuable experience will happen when some prescriber gets irritable, angry, or maybe even explosive, despite your sincere intentions and preparations.

    And you live through it, and understand it was never about you, but all about the patient.
  13. by   Here.I.Stand
    Quote from iwannabeanurse
    Let's say their BS is 500 and they're on Novolog 6u and Lantus 12u. What should I say to the doctor when it's high? Do I have to hold anything?
    Why would you hold insulin for hyperglycemia? What happens to the BG if insulin is withheld?

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