What are your thoughts?
Pt has a history of DM. Pt has a GT feeding which is being held for surgery. Pt on 1/2NS IVF. I called the MD and received an order to change to D5 1/2NS (I was worried about his glucose level). PRIOR to IVF change, his BS was 131 at 2100. Changed IVF at 2200. Checked BS at 0600 and it was 153 (Accuchecks are AC/HS). Pt has insulin coverage: Novolog 3 units for BS >150, so I gave it.
Gave report to AM RN. RN stated I should've held the insulin coverage because it was labeled a "high dose" coverage (low dose would've been only 1 unit of insulin for BS >150). She attempted to explain the reasoning behind it but I didn't get it. From my understanding, pt is on a constant dose of D5, so the insulin coverage (which I consider is a little amount) would be OK to give. Plus, I've been told by other nurses that bc the pt is on D5 it's ok to give the insulin coverage. I've given insulin coverage before to pts on D5 and never had a problem with hypoglycemia afterwards.
But I've been told otherwise by another nurse--she had a similar situation but the pt became hypoglycemic, so now I think she doesn't give coverage anymore...
What do you think? What would you have done? And what's your reasoning behind it?
Btw, the AM RN said she thinks the BS will go down to 80 by noon. I think it'll be in the 110-120s. I'm tempted to call around then and find out. I told the nurse that and she said "Don't worry about it--if anything I'll give the pt D50 [amp]"." <---her implying that it will drop...a LOT. Hmm..ok....
Jul 27, '11
The way our department handles meds with surgery patients is to call the anesthesia department and ask them which meds to give. Including insulin. If a pt. is going to surgery, usually the anesthesiologist wants them to have cardiac meds and nothing else. Other times they don't want them to have them b/c they will give something IV for HTN if needed, etc. So, the way I would have handled the situation would be to call the doctor or anest on the case. You did just follow the order. :shrugs:
Jul 29, '11
Yep, we call the Md or surgery to see what they want. When we have pts NPO we do accuechecks q 6 hrs.
I would have given the insulin with an IV of D5.
Aug 3, '11
You did the right thing. If and when the BS drops later, it isn't because of your insulin coverage; rather the IVF tricking body into having more sugar available now *due to D5 IV* but at your time, the glucose was freely causing damage to the vessels and organs and thus you covered.
Aug 4, '11
Remember, rapid acting insulin leaves the body in as little as 20 minutes and up to 2 hours for some people. The safe thing to do is what you do with ALL prn meds, check later for outcomes (repeat BS check). With D5 I would have done the same and, as a diabetic, would want my nurse to as well.
Aug 5, '11
It's not necessarily good practice to treat a BG of 153, particularly in a hospitalized patient. Pushing BG below 150, or even 170 or 180 for that matter, does not help prevent conditions related to diabetes, but it does significantly increase all cause mortality risk.
Aug 7, '11
It depends, our hospital has a sliding scale, it includes a higher Insulin unit coverage for the day and a lower one for the night (because as we all know, blood sugars tend to drop between the night and the early morning, even if your not diabetic). In the case of 153, I wouldn't have covered because he has been NPO, is going into surgery, once out of surgery will begin liquids, and that's even if he isn't too nauseated to take them. If his blood sugar was in the 2-300's then I would have gave him some coverage, but even then not the whole dose.
Aug 23, '11
I would have given the coverage as well since the pt is being maintained on IVF D5. That would prevent the sugar from drastically falling down.
Sep 23, '11
I would have covered it....at my hospital for sliding scale insulin we have parameters that state do not hold insulin even if pt is npo. I say you did the right thing but you should also follow your facilities protocol.
Sep 25, '11
I'm surprised to hear so many mixed responses on it. We were always told it was not within our scope of practice to hold medications without A) a doctor's order or B) documented contraindications to give it (ie low respiratory rate/sedation with narcotics) It is part of our insulin orders to call when the patient becomes NPO and get new orders or clarify current orders/IV fluids. i would say you were absolutely correct to give the ordered dose of insulin. We do have some nurses that work at our facility that hold insulin while a pt is NPO regardless of what the blood glucose is. In fact this past week we had one held when the blood glucose was in the 350s and the night nurse had called specifically to get the insulin coverage changed from moderate to mild sliding scale while the pt was npo.
Sep 26, '11
Just re-read this thread. ADA recommends REGULAR insulin for tube feeders. See their site for standards of care. www.diabetes.org
Oct 3, '11
I would not have covered it. Yes there are some medications that you should have an MD permission to hold but your nursing judgment and critical thinking should come into play here. Several of you have stated that you will ask an MD before holding anything...does that mean that if your patient has a BP of 90/60 at 1am you're going to wake the MD up to tell him that you're going to hold the med? If so then I imagine you have a lot of upset docs on your hands.
In my facility we use a barcode scanning system which gives you an option to exception off medications with reasons like "clinical decision, Low/Normal BP, Low BG, etc."
My thought process on insulin is that I do not administer if it is like your patient at 153 if the patient is NPO ESPECIALLY if it's a high dose algorithm. You could be asking for a major drop. Of course as many have stated you can administer D50 if need be, however by doing this you are a.) compromising your IV site and b.) their blood sugar is going to rise dramatically and it will become a vicious cycle.
I also work on a diabetic floor so we deal with this day to day. Hope this helps.
Oct 3, '11
Unless the blood sugar is greater than 200, my personal philosophy is NPO=no insulin. I always like them a little on the high side than on the low side. And when I have to list a reason on the EMR as to why I didnt administer insulin with a BS of 185 or something, I put 'Pt. not eating/NPO' or something like that.
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