Lantus part II, oh how I want to scream! - page 3
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
Aug 17, '06Quote from evans_c1my 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
This I agree with. The nurse should not hold a medication without notifying the doc. Suppose the nurse held the insulin, the doc comes in and see the CBGs not knowing it was held, and then changes medication.
We use nursing discretion to hold the medication, but we notify the MD for clarification and further insturctions. Siri can correct me if I'm wrong, but the nursing judgement to hold the medication will hold up in court, but the court will ask "what would a prudent nurse then do?". I'm sure the answer isn't going to be "hold the medication and then go about your business and hope for the best".
Hospitals should have clear policies on what to do with a diabetic patient when they are made NPO. Our policy is to notify the MD if he/she hasn't addressed the issue.
I think we are all in agreement here, that under normal circumstance, i.e. the patient is on a diet and taking his normal p.o. we don't hold the Lantus.
Where nursing judgement and critical thinking comes in is that: the patient is NPO.........yes he needs insulin.....but does he still need his home dose that he takes every day? Perhaps he does because his illness and stress are raising blood glucose levels. Possibly not because he's NPO he needs an adjustment for the next 24 hours.
Aug 17, '06Quote from RarelyIt has never caused his bg to drop even lower unless he has some sort of other problem going on.
I really appreciate your post and the reinforcement to give Lantus and how it works for your child.
I highlighted the above, because we are talking about a hospitalized patient, who presumably has other problems going on, i.e. he's sick enough to be hospitalized, and he's being made NPO, nothing by mouth. We as nurses need to take this into consideration, which is why we're discussing it. The same critical thinking when you administer insulin to you child "what is going on here?" is how we approach it too, rather than blinding giving medications, including Lantus.
Aug 17, '06Great thread. No black and white answer to this question, it seems, but I sure am learning alot from all the different experiences with Lantus!
Aug 17, '06Quote from TweetyAbsolutely right Tweety! I agree that after or when contemplating hold on insulin a call to the MD is required. About a week or so ago, I got the Lantus dose cut in half for my pt. Hewent from TPN and Lantus to a poor appetite and Lantus. I actually was surprised that they had the pt. on Lantus while on TPN, usually they do an insulin drip. Anyway his Lantus dose was cut in half and as the pt's appetite increased they were able to adjust his Lantus/coverage as they see fit. However, without the nurse communicating the pt's reaction to the Lantus, not just for night shift but over the whole 24h period, the team probably wouldn't have adjusted it. If I had just held it and no one realized, that pt.'s BG would have surely been whacked out.We use nursing discretion to hold the medication, but we notify the MD for clarification and further insturctions. Siri can correct me if I'm wrong, but the nursing judgement to hold the medication will hold up in court, but the court will ask "what would a prudent nurse then do?". I'm sure the answer isn't going to be "hold the medication and then go about your business and hope for the best".
Aug 17, '06Quote from evans_c1Thanks!thanks that could be the best post i have read on here by far! that is awesome!
Aug 17, '06Sue, you bring up a good point. Lantus doses aren't etched in stone. They are changed as patient conditions and needs change over time.
Aug 17, '06Our diabetic educators keep telling us over and over not to hold the lantus when the patietn is NPO. In fact, i think it is even on our diabetic standing orders not to. However, while Lantus is a basil insulin, it is still insulin, and there are times when it should be held or at least decreased. At these times the physician should be called. As a prior poster mentioned, sometimes the dosage is not right anyway despite weather they are eating or not, and needs to be adjusted. If the patient is NPO to boot, this is dangerous. While it is a basil insulin with relatively no peak (supposedly), if the patent's BS while NPO is 72 after the lantus is worn off or just at 24 hours post lantus, and they will continue NPO, there might be a problem giving it. The nurse who DOESN'T question this, i have a problem with. I have had patient's BS drop to 25 @ 2 am after PM lantus doses, and they were just lucky i thought to test them. Many M/S units don't test untill breakfast, and won't be seeing insulin reaction on their patients they think are just sleeping. While nursing judgement CAN save you, the lack of nursing judgement can send you to your grave.
Aug 17, '06Quote from TweetyThank you Tweety. That is exactly what I would do in that situation. Call the MD and get an order. He/She is charging enough money to "pop in" for 7 minutes q 24 hours. Let him/her make the call. Oh, yeah, and get admin to inservice everyone. You new grads out there, keep up the good work. But please understand us oldsters don't have all the latest info (although in a perfect world, we would). Let admin know of inservice needs. We need your input. Patient care first, folks.:spin:I understand the body makes glucose while a patient is NPO, particularly a sick body under stress. However, our policy is to clarify orders. If this is a patients normal dose when they are eating they may not need the same dose when NPO. It is clearly written in our policy to call the MD for insulin doses of the NPO patient...lantus included. We don't just hold it and we just don't give it, we let the MD decide and if it's safe, we proceed from there.
I do understand what you're saying. It's frustrating that you want to get them to understand it's not a bolus and won't "bottom them out". But I also understand the concern of 50 units being given to an NPO patient. Don't be so harsh. This charge nurse has experience under her belt regardless if she needs an update on Lantus.
I agree with purple. Sounds like an inservice is needed.
Aug 17, '06Quote from veronica butterflyThank you, excellent post.I would have called the doc to double check whether the complete lantus dose should be given. Yes, I know lantus isn't a bolus, but a diabetic who takes 50 units at bedtime probably has very unpredictable blood sugars, especially when sick, especially when fasting.
With all due respect, "retarded" is a rotten term to describe a situation ("retarded" people are now referred to as developmentally delayed). And please, oh please, never call another nurse a "moron", even if she is one. This job is hard enough without nurses turning on each other, judging, and criticizing. Especially as a new nurse, there's lots to learn from other nurses with lots of experience, they may not always be right, but no one is.
Aug 18, '06I look at what the patient is NPO for. At my facility, lantus is given at night unless the patient has been getting it at some other time of day.
Rarely will a patient be NPO prior to midnight on my shift. So, if they are to be NPO it will be:
1- after midnight for CABG next day- long procedure. Anesthesia usually writes for 1/2 dose or no dose of lantus the night before.
2- after midnight for cath lab in AM- probably short procedure, unless they said specifically some plan to do a large number of stents and that is very rare. So the cardiologists don't want me calling them about insulin unless it's an emergency. I give lantus, make sure they eat their bedtime snack, ask again at midnight and maybe give some juice if they want. Hold AM insulin which was gonna be their oral meds, or sliding scale, or humalog.
3- they could be on TPN and lipids in which case pharmacy controls the insulin and they are on a special sliding scale regular insulin only, and that's just for the duration of TPN.
4- special case of multiple NPO procedures scheduled next day that looks to me like they'll wind up NPO all day, but not under anesthesia, maybe some conscious sedation. THEN I may call a doc to explain the schedule and clarify the lantus order. One doc may not have ordered all the tests and so may not have thought to fiddle with the insulin dose.
Those are the type NPO cases I've seen.
Now, if a non NPO patient has lantus, and for some reason ran low BG's all day long, I'm gonna have a talk with the patient. Are they eating a sensible diet in hospital, when at home they normally eat a lot more? Re-confirm their home doses of what insulins, and what oral diabetics. Ask if any of these meds are relatively new to them or if they have changed doses recently before hospitalization.
Then it depends on the doc. I'm gonna want to get ahold of the doc who has the most to do with the patient's diabetes management if I feel, at that point, that I want a different dose of lantus, and that may not be the cardiologist on call. If I can't get ahold of the person I want, I MAY hold lantus. I will not change the dose on my own, but I have the option to hold it. If I do, I'll check BG at midnight as well as bedtime. I'll monitor closely and then talk with the doc in the AM and ask for clarification.
And as far as holding meds goes... I'm not used to calling a doc if I held a med, unless it's emergent. I hold cardiac and blood pressure meds when appropriate. But I do make sure the doc knows the next time he rounds, if something wasn't given, so he can make appropriate decisions. Now if I have chest pain I can't treat due to unstable low blood pressure, I just hope I have time to call the doc.
In cases where the doc clarifies to me that certain patients need their meds, regardless of blood pressure, I'll pass that on so the next shift doesn't make the same mistake. I will probably also write it on the MAR and order sheet as a verbal order. Yano, if my judgement was wrong I sure don't want my coworkers getting chewed out for having similar judgement.
Aug 18, '06Quote from IndyExactly! It's not a simple as "never hold lantus". Talk to your patients!!! There are no hard and fast rules for any insulin. Hubby takes lantus twice a day.. that's not a normal scenario, but it's working well for him.Now, if a non NPO patient has lantus, and for some reason ran low BG's all day long, I'm gonna have a talk with the patient. Are they eating a sensible diet in hospital, when at home they normally eat a lot more? Re-confirm their home doses of what insulins, and what oral diabetics. Ask if any of these meds are relatively new to them or if they have changed doses recently before hospitalization.