to hold or give insulin?

RainMom · Nov 23, 2014

If the MD instructed to give it, then I think you were right. Check policy. We typically hold sliding scale insulin if NPO but not always.

icuRNmaggie, BSN, RN · Nov 23, 2014

The pt who is NPO for aspiration risk still needs a source of glucose. It is safer for him to be on D5 1/2NS to prevent hypoglycemia. I agree with the charge nurse on this one because she was willing to err on the side of caution and watch how his FSBS trends.

If the patient is on prednisone, methylprednisolone or solucortef I would absolutely cover a FSBS >200 with SSI.

If the pt is NPO for surgery or a procedure and has an elevated FSBS, hold the SSI and notify the provider. OR teams do not want the pt to be at risk of becoming hypoglycemic during the case.

The Society for Critical Care medicine recommends keeping the glucose in the 150 to 180 range in critical illness as this is associated with better long term outcomes.

Every patient is different. Every patient responds differently to an SSI and so it is difficult to answer the question whether to hold or give the insulin.

You were right to notify the MD and you should thank the charge nurse for helping you out with a complex situation because depriving the brain of glucose causes irreversible brain damage, coma and death.

Loo17 · Nov 23, 2014

j Had a patient npo who's bs was about 200s they were on sliding scale insulin which I covered with regular and also detemir. Accu checks were q6 hours. The previous shift was also covering the bs. My charge told me I was wrong in covering with the sliding scale and she got a order for half ns with d5. I don't agree with the fluids bc he was already so high. Was I wrong for giving the insulin? I was anyways taught to cover the insulin bc other factors besides food can elevate the bs. I even called the md who said to give it. So I guess I'm confused as to when to hold it and when to give it if their sugar is high. They were npo for a failed swallow exam.

If the patient was NPO giving SSI ordered "TID before meals" would not be correct ( at least where I work). Your accuchecks were order Q6H so my assumption would be that the sliding scale was ordered with the expectation that the patient would not be eating. At my hospital, there is a separate sliding scale order set for NPO patients as well as Q6H accuchecks vs before meals. It might reduce confusion if the MD order included "do not hold for NPO status". If your charge nurse interpreted the order to be held s/t NPO status someone else might as well.

I would agree with your charge nurse however that a diabetic patient that is NPO should be on maintenance fluids. Really most patients that are NPO should have an order for fluids.

Raviepoo · Nov 23, 2014

In a case like that, bother the MD. Ask what he or she wants you to do.

RainMom · Nov 23, 2014

In a case like that, bother the MD. Ask what he or she wants you to do.

I even called the md who said to give it.

Looks like MD ordered to give.

Karou · Nov 23, 2014

How long had the patient been NPO? I would look at what their BSG trends has been, what medications they were on (any that could raise the BSG), and what IVF they had. You did correct by calling to clarify though. What did the physician say about the NPO status when you called him the first time? Apparently your charge convinced him to order the IVF with dextrose and I wonder what changed his mind. I don't think either you or the charge nurse were wrong in this situation.

In this situation it usually just depends on the physicians preference, and of course monitoring the patient for hyper/hypoglycemia. Diabetes is never a one solution fits all disease, so it really just depends on the individual patient and the entire picture of their situation.

Totally aside... I wonder why they weren't already on a supplemental IVF? If a patient were made NPO for a failed swallow study then it's reasonable to assume they will be NPO for a while, in which case they need some supplemental IVF (like clinimix or TPN).

ViolinTreble · Nov 24, 2014

Thanks everyone! Yes sounds like she did the right thing. They are on NS got the order for half ns d5 from the PA on call not the doc. I was worried the sugar would go up since his bs stew in the 200s the lowest was 199. Thanks for clearing up my confusion but I am still do confused as to hold the insulin when a pt js npo or not just the sliding scale ones. Thanks I am lucky to have such a wonderful charge nurse who knows her stuff.

Karou · Nov 24, 2014

Thanks everyone! Yes sounds like she did the right thing. They are on NS got the order for half ns d5 from the PA on call not the doc. I was worried the sugar would go up since his bs stew in the 200s the lowest was 199. Thanks for clearing up my confusion but I am still do confused as to hold the insulin when a pt js npo or not just the sliding scale ones. Thanks I am lucky to have such a wonderful charge nurse who knows her stuff.

There isn't a blanket rule to role insulin if a patient is NPO. That decision is based off of many different factors and determined by the patients physician.

A NPO patient can be receiving other forms of nutrition like TPN intravenously or supplemental formula through a peg tube or NGT. These patients will still absolutely need their sliding scale and standard insulin as ordered.

If a patient is NPO for a short while then any insulin they may or may not receive depends on what the physician has ordered. It can be a good idea to call and clarify the order, reminding the physician that the patient is NPO and not receiving any dextrose containing IVF or other nutrition. You may get an order to hold the insulin or give it. Again, diabetes is not a one size/solution fits all disease. Always monitor your patient and follow BSG trends, use your nursing judgement, and practice common sense.

Your charge nurse is a great resource but ultimately the physician is responsible for clarifying what he/she wants done in these situations.

KelRN215, BSN, RN · Nov 24, 2014

The patient was NPO for a failed swallow study and wasn't on some other kind of nutritional support like TPN or NG feeds? Normal saline alone is insufficient, so I'd agree with your charge on getting the IVF changed.

Was this patient a type I or type II diabetic? If type I, he doesn't produce any endogenous insulin so definitely still needs his basal insulin and should be corrected as indicated to bring his blood sugar to his goal range. When I worked in the hospital, our NPO patients who were insulin dependent were on finger sticks more frequently- q 3 or q 4hr.

tokmom, BSN, RN · Nov 24, 2014

We hold SSI for NPO status but typically give the long acting. There are so many variables involved and as one person said, it's not a one size fits all.

AgentBeast, BSN, RN · Nov 25, 2014

You do NOT hold sliding scale insulin just because a patient is NPO. Sliding scale insulin is correctional insulin to get the patient back down into a normal range whatever that might be for this patient. It is appropriate to hold prandial insulin and also to get an order to give typically half of the basal insulin.