Lantus part II, oh how I want to scream! - page 2

So I had a pt last night that had just had a very minor procedure and was npo. Had a FS at 1800 and it was 80....lantus due at 2200 and 50 units.. my charge nurse wanted me to hold the lantus. I gave... Read More

  1. by   marilynmom
    Quote from lsyorke
    As a wife of a 40 year diabetic on Lantus, you CAN shock out on Lantus alone if NPO for a long enough time period.

    Do NOT assume that Lantus is always given regardless of blood sugar. Consistently low blood sugars mean that the Lantus dose should be adjusted.
    I absolutly agree!! I can't tell you how many times we had to call 911 for my diabetic father who went into a freakin diabetic coma thanks to the RN who told us to always give Lantus no matter what the blood sugar, especially with regards with NPO and overnight for some. A lot of diabetics just the fact that they can't eat will significantly lower their BS to dangerous levels, Lantus can make that even worse.

    Every diabetic reacts differently to NPO.
  2. by   veronica butterfly
    Quote from evans_c1
    yea, i guess i was kind of harsh..but it did make me mad bc I felt some of the nurses were ganging up on me or something bc I did give it. I really don't understand their raionale (yes, even if they were npo)...they kept saying "we don't want her to be in the 40's at 5am" and I felt like saying maybe the day shift nurse doesn't want the BS to be 350 at 10 am the next morning. I don't think they are analyzing the whole situation..they seem to be taking a couple bad experiences and applying it to all patients.
    No prob, I'm a new nurse too, on a medsurg floor, and the worst part of my shifts are when the nurses turn on each other...

    I think our presurgical protocol says something about giving only 1/2 the normal dose of insulin the morning before surgery when someone has been npo since midnight.
  3. by   RedSox33RN
    Quote from marilynmom
    I absolutly agree!! I can't tell you how many times we had to call 911 for my diabetic father who went into a freakin diabetic coma thanks to the RN who told us to always give Lantus no matter what the blood sugar, especially with regards with NPO and overnight for some. A lot of diabetics just the fact that they can't eat will significantly lower their BS to dangerous levels, Lantus can make that even worse.

    Every diabetic reacts differently to NPO.
    Same here. I'm on a pump now, but was on Lantus from the time it was approved, for about 18 months. I could easily get a peak with Lantus, and it was found I metabolized it too quickly. Same with other insulins, hence the pump.

    I would have clarified the order with the MD also, and withheld it until I knew. As rotten as a hypoglycemic pt is for the nurse, it's a million times worse for the pt.
  4. by   SportyNurse
    Quote from nursenatalie
    I personally agree with your charge nurse. If the patient is not eating then you are probably giving them sliding scale as well as the lantus, right? I would prefer to manage them on an as needed basis than give a long acting drug that could bottom them out. Face it Lantus lowers blood sugar, did it need to be much lower? Scary thing to know their blood sugar could bottom at 2 am and you may think they are sleeping peacefully while they slip into a diabetic coma. You wont convince me this patient needed lantus. Ultimately clarify order now that pt is npo but dont care who ordered it, the md is not going to be the one monitoring the pt through the night...I would not give it with that blood sugar.
    You never hold Lantus. Typically when nurses are "doing the right thing and you won't change my mind", and they hold that 40-80 units of Lantus, guess what... usually the next day, no one can figure out why their BGs are so high and nothing can get it down. I work on the renal floor and all we deal with is DM every day. Our endocrinologists and nephrologists have all made a big point with the staff that if you think you want to hold Lantus, call them so they can tell you not to, otherwise they'll have your butt.

    Not getting Lantus is like not getting your blood pressure pills for a day. The next day you're all out of control and out of whack. We have had inservice after inservice on this and there are still nurses who have the "well I'm the one who has to deal with them when they're in a coma, I'm not giving it" attitude.

    In addition to that, each area you inject into metabolizes differently depending on the amount of fat and muscle composition. So yes, it is possible to peak someone on Lantus... that's why you regularly give it in the same general area. New insulins do not cause the tissue damage that the old ones used to, so rotating sites is more dangerous because of the absorption.
    Last edit by SportyNurse on Aug 15, '06
  5. by   evans_c1
    Quote from suemom2kay
    Yes, Lantus is a basal insulin, but it is also a 24h insulin. If the pt's BG was 87-105 NPO than why would he need the Lantus? You were very fortunate that the Lantus didn't lower your pt's BG to 40's and you'd be pushing Dextrose all night. I used to work for Aventis and specifically was on the Lantus team. It is a very effective insulin, but all insulins need to be either held or the dose possibly adjusted for an NPO patient.

    Does the pt. have IDDM or non IDDM? Is he achieving target BG with Lantus alone, or is he using Lantus and coverage with another insulin such as NPH, 70/30, or oral anti-diabetics. Does the pt. have IVF infusing with or without dextrose? These are all things that the physician must consider when adjusting the dose. As nurses, we need to know when to contact the physician for dose adjustment. As we all know, the ball is often dropped when the pt's nutritional status changes. Nursing is rarely black and white.

    Don't be so sure your charge nurse doesn't understand Lantus. She's probably spent a night pushing dextrose. I have and its not fun esp. for the pt. Low BG feels like sh**.

    http://www.medscape.com/viewarticle/506436

    You must consider what your patient's insulin and nutrition status. Remember that with Lantus if you give too much, your giving too much for 24 hours. Your charge nurse was right to question the dose. The right thing to do would have been to question the ordering physician or his resident. Giving it blindly will not always work out well for your patient.
    thanks for the input! I agree that sometimes it should be adjusted according to NPO status or whatever..but I was just critically thinking here. Not only did the patient have an operation, but also had a localized infection ..all of which as we all know will raise glucs. If I had to have went back I would have given it again given the exact same circumstance. If the CN wants to hold it..that is her baby and she can birth it! I just think that the night crew sees a lot of ppl bottom out (bc that is usually when it happens, like at 5 am) and freak out when they see Lantus for a npo pt. My other problem was she wasn't going to call the doc and just merely hold it...what good is that?
  6. by   nicolel1182
    I don't work in the hospital so I don't really know the RIGHT answer, but this is what I would of done:

    checked for a policy, if none then call the dr

    I didn't think nurses could just hold a medication because they thought it was the correct nursing judgement, thought they had to get a Dr's order. I dont think Nursing judgement would hold up in court would it??

    I also don't think a bunch of nurses should of been standing around argueing about this, nurses are supposed to stick together and educate eachother, not all try to be super nurse...in the real world right?
  7. by   sirI
    I dont think Nursing judgement would hold up in court would it??
    Yes, it does - most definitely!
  8. by   nicolel1182
    Quote from siri
    Yes, it does - most definitely!
    Ok, Wow, I didn't know that..So much to learn!!
  9. by   lsyorke
    Quote from SportyNurse
    You never hold Lantus.
    Never say never!!! There ARE situations when Lantus should be held. I can tell you if someone gave my husband his full dose of Lantus when he was NPO, they WOULD be bolusing him with d50 all day long. Talk to you patient, find out how his/her blood sugars are.. most diabetics know their levels and how dosages will effect them. And call the doc to clarify!
  10. by   CarVsTree
    Quote from nicolel1182
    I don't work in the hospital so I don't really know the RIGHT answer, but this is what I would of done:

    checked for a policy, if none then call the dr

    I didn't think nurses could just hold a medication because they thought it was the correct nursing judgement, thought they had to get a Dr's order. I dont think Nursing judgement would hold up in court would it??

    I also don't think a bunch of nurses should of been standing around argueing about this, nurses are supposed to stick together and educate eachother, not all try to be super nurse...in the real world right?
    Actually as Siri said, nursing judgement does hold up in court. We are allowed to hold medications that we see fit in our nursing judgement. Just this morning I held a muscle relaxer on a patient with hypotension (low blood pressure) and bradycardia (a slow heart rate). I did not want to give hime any medicine that would add to his problem. In addition, I put him on a heart monitor without a Dr's order (another nursing judgement). I also got the pump for the IVF ready before doctor even called me back because I knew he would be ordering fluids to help bring his pressure backup.

    We are not standing around arguing. We are discussing professionally the pros and cons of holding a basal insulin. As you can see by the many varied answers no two situations are the same. A lot can depend on your patient population. For instance the renal (kidney disease) nurse never holds Lantus. I, a Trauma nurse have instances where I most definitely hold it.

    Nurses are professionals who make many educated judgement calls without the need for an order from an MD. We are well trained and educated to this end. In addition, the nurse manages the care for the patient and picks up the many dropped issues that would be missed by physicians who have many more patients to see in a day than we care for in a day. We spend many more hours with our patients than the docs do. The doc sees the patient for a couple of minutes we care for them hours/days at a time. We get to know them very well.

    By standing around discussing we are not trying to be super nurse, we are trying to learn from each other and better our practice in the real world. I have learned so much valuable information from my URL friends at allnurses.com.
    Last edit by CarVsTree on Aug 16, '06
  11. by   Rarely
    Not a nurse (hopefully soon!) but thought I would weigh in on this with my limited understanding. My 9 year old is diabetic so I eat, sleep, and breathe insulin injections. I rarely hold his Lantus, even if his bg is very low. Lantus is a 24-hour insulin and is to be given at the same exact time every day. It has never caused his bg to drop even lower unless he has some sort of other problem going on. Take your pick - honeymoon phase, illness, etc. Novolog is an entirely different story. I make far more judgement calls where that is concerned. Illness, exercise, lack of activity, etc. can have a profound effect. It takes 3 hours to peak and 6 hours to wear off. All those things are taken into consideration when I give him insulin. Whenever his bg drops dangerously low it's because of Novolog combined with some other factor. In my personal experience, the only thing holding Lantus does is potentially cause bg to skyrocket later. It tends to make bg become very unstable when not given at the same time every day.
  12. by   evans_c1
    Quote from nicolel1182
    I don't work in the hospital so I don't really know the RIGHT answer, but this is what I would of done:

    checked for a policy, if none then call the dr

    I didn't think nurses could just hold a medication because they thought it was the correct nursing judgement, thought they had to get a Dr's order. I dont think Nursing judgement would hold up in court would it??

    I also don't think a bunch of nurses should of been standing around argueing about this, nurses are supposed to stick together and educate eachother, not all try to be super nurse...in the real world right?
    my bigger problem is that the charge nurse wanted to hold it and not call the doc...constituting a "med error" at our facility. that def. would not hold up in court and is def. not nursing discretion to hold it an just not call the MD
  13. by   evans_c1
    Quote from suemom2kay
    Actually as Siri said, nursing judgement does hold up in court. We are allowed to hold medications that we see fit in our nursing judgement. Just this morning I held a muscle relaxer on a patient with hypotension (low blood pressure) and bradycardia (a slow heart rate). I did not want to give hime any medicine that would add to his problem. In addition, I put him on a heart monitor without a Dr's order (another nursing judgement). I also got the pump for the IVF ready before doctor even called me back because I knew he would be ordering fluids to help bring his pressure backup.

    We are not standing around arguing. We are discussing professionally the pros and cons of holding a basal insulin. As you can see by the many varied answers no two situations are the same. A lot can depend on your patient population. For instance the renal (kidney disease) nurse never holds Lantus. I, a Trauma nurse have instances where I most definitely hold it.

    Nurses are professionals who make many educated judgement calls without the need for an order from an MD. We are well trained and educated to this end. In addition, the nurse manages the care for the patient and picks up the many dropped issues that would be missed by physicians who have many more patients to see in a day than we care for in a day. We spend many more hours with our patients than the docs do. The doc sees the patient for a couple of minutes we care for them hours/days at a time. We get to know them very well.

    By standing around discussing we are not trying to be super nurse, we are trying to learn from each other and better our practice in the real world. I have learned so much valuable information from my URL friends at allnurses.com.
    thanks that could be the best post i have read on here by far! that is awesome!

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