Insulin question

[nurse4theplanet, RN]

Pretty much every patient that I have taken care of has been on sliding scale insulin or an insulin gtt. So I completely understand checking the BS before injections or according to protocol, then administering appropriate units/adjust the gtt rate accordingly, and holding the insulin if BS is WNL or too low...etc.

I was charge the other day during our last clinical. One of my students had a pt that was getting scheduled insulin that morning, and he had SSI AC/HS. I can't remember which type of insulin was his scheduled insulin was...sorry but I am sure it was not regular, and it wasn't Lantus, maybe an intermediate acting insulin. I should have paid more attention. Anyway, his scheduled insulin was not on the floor yet. The student checked the BS and it was 85. Held the Reg SSI and the pt ate breakfast. At 9 or so the scheduled insulin came up and she administered that. Before lunch she rechecked his sugar and it was 45 but was not showing any clinical signs of hypoglycemia. We alerted the real nurse, got some crackers and juice, and then I went and got my instructor. He seemed to be fine, instructor said no need for D50, rechecked the BS p 30min and it was 150.

I didn't think to ask these questions then, but after I got home I started wondering. If a pt is getting scheduled insulin, you still check the BS right and hold only if the pt's BS is lower than 70? or would you hold if the BS was WNL as well? Did the pt's blood sugar drop because he had already eaten...i didn't think that intermediate insulin would peak that quickly? And my last thought, is perhaps she didn't wipe away enough of the alcohol...I didn't watch her take the BS. Could that have produced a false low, since the patient was not showing any s/sx if hypoglycemia. Would you have rechecked it to make sure it was accurate?

Sorry if these are dumb questions. :monkeydance:

[cardiacRN2006, ADN, RN]

I always recheck a low blood sugar-always.

It really depends on what the insulin was and how many units were scheduled. But for me, as a new nurse, I always want to know what the BS is prior to giving insulin.

What if they didn't really eat any breakfast?

[lsyorke, RN]

It's hard to make the call on this without knowing what kind of insulin the patient is on. If it was humalog you wouldn't hold the insulin for a "normal" blood sugar, since that humalog would cover the calories from the meal.

[zacarias, ASN, RN]

Look at your hospital's policy. At my hospital, we check the blood sugar twice if it's low or above 400 to verify. Also, the scheduled long-lasting insulin (lispro or aspart) can be given without regard to meals generally. But since he did get low later, it is possible that his SS needs to be adjusted.

[SharonH, RN]

I didn't think to ask these questions then, but after I got home I started wondering. If a pt is getting scheduled insulin, you still check the BS right and hold only if the pt's BS is lower than 70?

It depends on the ordered parameters. In case there are no parameters and if it is a fasting blood sugar and the patient has a pattern of blood sugars in the 60s in the morning and 200+ at lunch, then I would probably administer it. Unless of course, the patient was symptomatic.

or would you hold if the BS was WNL as well?

NO

Did the pt's blood sugar drop because he had already eaten...i didn't think that intermediate insulin would peak that quickly?

It's hard to say but I suspect that the patient either didn't eat as much breakfast as you thought, or I wouldn't be surprised if he was on a combination insulin i.e. 70/30 which has a faster onset and a quicker peak. Or it was some other combination of factors.

And my last thought, is perhaps she didn't wipe away enough of the alcohol...I didn't watch her take the BS. Could that have produced a false low,

NO

since the patient was not showing any s/sx if hypoglycemia. Would you have rechecked it to make sure it was accurate?

I would have rechecked it anyway and most places have a standing policy in place for hypoglycemia and for most of them, they would require a lab draw to confirm a blood sugar of 45.

[SuesquatchRN, BSN, RN]

We had no policy in place in my last facility except OJ and hold insulin for 450.

We got it clarified, finally, and it depended on the patient. ALWAYS give Lantus. DON'T give regular. Recheck in an hour after giving OJ or SSI.

I certainly would have done a finger stick for your patient and asked if he was WNL. Depending on how brittle someone is, and the nurses there know that, your would give or hold, depending.

[CarVsTree]

What did the Sliding Scale say? In my hospital, sliding scales generally do not require a dose until over 140.

Why did the student give it based on a post meal sugar? Or did they just give it because the pt ate. Sounds like the SS is based on fasting BG.

It's hard to answer your questions without knowing the orig. order.

As for being asymptomatic, I had a pt. who was 39 and asymptomatic. I re-checked via glucometer, drew a stat glucose for the lab, administered D50, then checked the glucose lab result and the glucometer was correct.

Even with alcohol or a dilute sample, you usu won't drop more than a few points.

[nurse4theplanet, RN]

What did the Sliding Scale say? In my hospital, sliding scales generally do not require a dose until over 140.

Why did the student give it based on a post meal sugar? Or did they just give it because the pt ate. Sounds like the SS is based on fasting BG.

It's hard to answer your questions without knowing the orig. order.

As for being asymptomatic, I had a pt. who was 39 and asymptomatic. I re-checked via glucometer, drew a stat glucose for the lab, administered D50, then checked the glucose lab result and the glucometer was correct.

Even with alcohol or a dilute sample, you usu won't drop more than a few points.

The SSI insulin was held. The accucheck was before breakfast. The pt ate 100% of his tray. The scheduled insulin was given at 9 without checking the BS again. The next AC check was done before lunch...that was the low BS.

I should have paid more attention to what type of insulin the scheduled insulin was. I should have made sure the student checked the BS before giving the scheduled dose. If it was below normal limits, then I should have made sure it was held. I should have made her double check the sugar while I notified the nurse/CI/got juice and crackers. I guess I just took for granted that this NS has had a high performance and knew what she was doing. Lesson learned.

Thanks for all the replies.

[SuesquatchRN, BSN, RN]

Shoulda, woulda, coulda - you're a student, and learning. And you did.

:)

[marilynmom, LPN, NP]

Definatly always recheck a very low or very high BS. I have checked mine before and it would show something like 60, an I could tell I wasn't at a 60, I rechecked it like 1 min later and it was actually at like 120 which is good.

Those glucose machines can sometimes blip like that.

Also some people are just asymptomatic with low BS, my dads BS can get down to around 30 and he is asymptomatic. I actually start having low symptoms around 90 sometimes.

You can still give Lantus during a low but no way would I give anything else if the patients BS is low because it's going to bring it down too much, I had a nurse actually do that to me one time and I ended up passing out with a BS of 20.

And don't be so hard on yourself or the other students--your just a students right?!

[JoycMarr]

As someone said above, you should always recheck a low blood sugar. False lows may come from not having enough blood on the strip also.

[mel1977]

we are getting rid of the SS where I work-but from the few we do have. Depends. If they get a scheduled, we give it no matter what unless the bg is too low-or we'll give it during the meal. Then if it is high and requires the SS we'll give the additional insulin. Many times we just make it a judgement call on how low it is. If you held it until they ate, you'd have to make sure they ate a good meal and most of it or you could bottom them out if one assumes they ate and then the didn't still getting the insulin.