Lantus part II, oh how I want to scream!

  1. 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 it. Honestly, who holds lantus for a normal gluc reading?? that is absurd. At 0600 the pt was like 78...what is this charge nurse's deal?? I am a new nurse and it just ticked me off bc she was like "well we will call you at 5am when her sugar is 40 something". The mentality of the nurse...she did a FS one hour after I gave the lantus...I tried to tell her that onset isn't until like 2-3 hours and she still did a FS (110 at that). How can I get it through her head lantus is a basal insulin...NOT a BOLUS! The patient had not even had novolog insulin since like 7 or 8 hours before all of this. Is this something to communicate with my supervisor? I mean if we have nurses holding lantus bc they think it is going to "bottom them out" that is a real problem
    Last edit by evans_c1 on Aug 14, '06
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  2. 37 Comments

  3. by   Ms.RN
    isnt part of nursing job educating other people? if patient doesnt know about insulins, would you go talk to the supervisor? maybe part of her problem is lack of knowlege. frankly i learned that i shouldnt mix lantus with other insulins and that it shouldnt be held even if patien'ts bs is low after i graduated from nursing school and started working as a nurse. in fact, i learned about this from this website from reading threads. all my pharmacology instructor told us in the class was "there's a table in the textbook that has lists of insulins and their onset and duration. read it and memorize it". thats it!!!
    maybe you can teach her why she shouldnt be holding lantus insulin, and give her a reasoning behind it. if she doesnt listen to you after that then you can talk to the nurse educator and hopefully she will get through her thick head :lol_hitti
    Last edit by Ms.RN on Aug 14, '06
  4. by   purplemania
    Go to the Sonofi-Aventis website (they make Lantus) or get pharmacy to give you a drug insert. It is not necessary to hold Lantus or Levimir because they are basal insulins.

    You would hold Byetta and Symlin, two other new injectables, because they are tied into what we eat. They are not insulin however.

    Updates on diabetes meds would be a good topic for an inservice or even a CE. I did one recently and creating the curriculum really taught me a thing or two. There is a LOT of new stuff out there - like the vaccine Exubera that was just released.
  5. by   Tweety
    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.
    Last edit by Tweety on Aug 15, '06
  6. by   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.
  7. by   veronica butterfly
    Quote from evans_c1
    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 thought that was retarded so I gave it. Honestly, who holds lantus for a normal gluc reading?? that is absurd. At 0600 the pt was like 78...what is this charge nurse's deal?? I am a new nurse and it just ticked me off bc she was like "well we will call you at 5am when her sugar is 40 something". The mentality of the nurse...she did a FS one hour after I gave the lantus...I tried to tell her that onset isn't until like 2-3 hours and she still did a FS (110 at that). How can I get it through her head lantus is a basal insulin...NOT a BOLUS! The patient had not even had novolog insulin since like 7 or 8 hours before all of this. Is this something to communicate with my supervisor? I mean if we have morons holding lantus bc they think it is going to "bottom them out" that is a real problem
    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.
  8. by   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. He recently had multiple surgeries and his Lantus was held and he went on regular insulin coverage until completely recovered from anesthesia. His anesthesiologist preferred to not have a long acting insulin on board. Better to have a higher blood sugar during anesthesia, than a low one.

    But it's up to your doctor or endocrinologist to make this decision. Do NOT assume that Lantus is always given regardless of blood sugar. Consistently low blood sugars mean that the Lantus dose should be adjusted.
  9. by   evans_c1
    Quote from veronica butterfly
    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.
    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.
  10. by   cannoli
    What was the blood sugar at 2200, before the lantus was given?
  11. by   evans_c1
    it was 111...however, is it necessary to always check a BS before you give lantus...if that is the only insulin you are giving. I mean, it is a basilar insulin and will not effect it then anyways, right?
  12. by   snowfreeze
    A note to your nurse educator is needed in this situation. When I started nursing we had 70/30, regular and I am not sure what else cuz that was all we used back then.
    I learned the new insulins as they came out, education should be a part of each unit. Have the reps visit each shift and they usually bring pens or food, two things we all appreciate.
  13. by   Tweety
    Quote from evans_c1
    it was 111...however, is it necessary to always check a BS before you give lantus...if that is the only insulin you are giving. I mean, it is a basilar insulin and will not effect it then anyways, right?

    Right, it will not have a big effect on the CBG of 111 at that particular time. However for the next 24 hours it will have some effect on CBG's.

    During this time you stated the patient was NPO. Critical thinking mandates that this be a consideration. Ask yourself "if this patient needs 50 units to maintain stable CBG's when eating, what effect is it going to have on him/her while he/she is NPO".

    While I think your CN was wrong in recommending it be held, I certainly don't think she's mentally unstable.

    You too are going to have those "duh" moments in your life and I'm sure you're going to appreciate not having your mentally challenged.
  14. by   CarVsTree
    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.
    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
    Be careful that nutritional intake matches insulin coverage. If nutrition ceases (new NPO status, interruption of feedings, etc), the insulin dose must be adjusted downward. You cannot adjust a 24-hour insulin on a stat-basis.
    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.
    Last edit by CarVsTree on Aug 15, '06

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