# Insulin Sliding Scales

1. Okay, here is the question and I really need help on this.
Doctor's order: AM dose: Humulin NPH 15 units and Humulin regular 5 units SC. The AM blood sugar is 230. How much total insulin should be given?

Blood Sugar Regular Insulin
0-180 0 units
180-200 2 units
200-220 4 units
220-240 6 units
>240 Call Physician

The reason I am asking is that we don't technically have a Pharm instructor. We had someone thrown in to teach the class that has never taught before and so everyone is pretty much trying to help each other. On top of everything else, she told us she is dyslexic so we have alot of fun trying to review our notes after her classes. Personally I think the patient would get the regular dosage of 15 U and 5 U, but do I have to take the sliding scale into account or not at this regularly scheduled time or recheck in a couple of hours and if the levels are still up then use the sliding scale?
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3. first of all, you'd need to double-check the orders....there may be some intricacy that you have not mentioned here.

but, typically sliding scale is ordered in addition to scheduled dose. i will have to make a couple assumptions here, because you have not stated all the necessary info... so i'll assume that it's about 0730, it is right before breakfast, and the accucheck was just completed. you want to know total dose to administer before the meal, right?

you would give the scheduled dose of - humulin nph 15 units and humulin regular 5 units sc, plus the sliding scale dose indicated as 220-240 = 6 units regular. therefore the toal dose would be humulin nph 15 units and humulin regular 11 units.

a sliding scale in instituted because: the physician determines how much the client has historically needed as a baseline throughout the day to keep him going.. this is the "scheduled dose".....but, because intake, state of health/illness, activity, etc can cause the bs levels to fluctuate, they also add a sliding scale to compensate for these variations. in this way, you don't od the client with a "too large" scheduled dose of insulin and have them bottom out regularly, but you also have a way of keeping the high bs's in check.

clear as mud???

(of course, if the assumptions that i made are wrong...forget everything i just said!
4. Quote from CyndiW35055
Personally I think the patient would get the regular dosage of 15 U and 5 U, but do I have to take the sliding scale into account or not at this regularly scheduled time or recheck in a couple of hours and if the levels are still up then use the sliding scale?
Just a quick note, that in your notes you should not use the word "regular" unless you are referring to the actual insulin, especially since the pt. is getting Regular insulin also. My endo taught me that early on, because it can cause a lot of confusion.

Christine is correct about the sliding scale. It should be given after a blood sugar check and before the am meal, and the normal dose should be given PLUS the amount indicated on the scale.

I'm not sure how often pt. checks B.S. or should be checked, but if NOT pregnant the usual is before meals (if taking any kind of short-acting insulin, like Novolog or Humalog), and then 2hrs post-prandial. I'm a little different since I'm on a pump (only pumps Novolog - no long acting), and I test 10x/day.

If the pt. is inactive (ie. bedridden), then will require higher doses, hence the sliding scale. Also, illness is a stress on the body, and stress makes the blood sugar rise. I know even a migraine can cause my B.S. to go WAY out of whack, and I programmed a special basal rate into my pump for such times. To make sure the sliding scale is appropriate, the doc should have left orders to test 1 or 2 hours post-prandial. That way after a normal ADA meal, you will know if the scale itself needs adjusting.
Last edit by RedSox33RN on Apr 25, '04
5. Thank you both so much. As for the info given on here, that is exactly how it was guven to me. I really appreciate your help.

Cyndi
6. I agree with the above, the sliding scale is in addition to the scheduled. Also maybe you just copied the scale wrong but what would you give for a sugar of 180, 200, 220? I have had doctors enter sliding scale that way and Murphy's law says that my patients blood sugar will also be one of those numbers that can fit in more than one category.
7. Sliding scales refer ONLY to regular insulin (rapid acting), not NPH.
8. I would call the doctor to get a clarification of the orders-- ask whether they want the sliding scale Regular Insulin in addition to the standing order dose of Regular Insulin.
9. As stated originally, this wasn't taught. This was actually a class assignment/homework that we had to figure out for ourselves. And I really appreciate all of your help on this. What she wanted was the NPH or 70/30 plus the regular amount AND the sliding scale amount also. Thank you all so very much. Cyndi
10. NPH 15 units. R 11 units. But only after a recheck before. And a follow-up would be nice.
11. Quote from batmik
I agree with the above, the sliding scale is in addition to the scheduled. Also maybe you just copied the scale wrong but what would you give for a sugar of 180, 200, 220? I have had doctors enter sliding scale that way and Murphy's law says that my patients blood sugar will also be one of those numbers that can fit in more than one category.
The sliding scale at the nursing home where I'm currently in clinicals starts at 201. So, you know definitely that a 200 does not get more. I had a patient last week with a sugar of 230 and standing order (notice I said "standing" and not "regular") for 5 units regular insulin + sliding scale of 2 units regular insulin (BS between 201 and 250), so I gave a total of 7 units regular insulin. My preceptor was a little confused, but I assured her it is what we were taught in Nursing Pharmacology.

Calling the doc is not required in this case when the sliding scale you are using specifies to not call the doc until the sugar is much higher. Such calls could put you in disfavor. Also, re-checking BS more often that indicated in the patient's chart could put you in disfavor, too, with the doc, your supervisor, and the patient. Of course, we are talking about an asymptomatic patient here. Definitely show concern if the patient shows signs of an acute episode. You would want to get aggressive with patient care in that instance.

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