Question regarding Humalog insulin

  1. 0
    Hi All,

    I have a quick insulin scenario that I need help understanding. I am a student nurse currently working my gero rotation. I had a patient who is Type 1 diabetic with severe depression. Lunch is served at 12pm and i tested her BS at 11:15am. BS was 555 (normal for her). The sliding scale for BS > 450 = 6 units. The staff nurse advised me (and my instructor) to administer only 3 units of insulin AFTER lunch because the patient has a poor appetite (due to depression).

    This doesn't make sense me. I understand the rationale of administering only half the dose (wouldn't want BS to drop too low if giving 6 units since pt eats little); however, I don't understand why you wait to give insulin after lunch if the BS is already high. Wouldn't it make more sense to give before the meal?

    Can someone who is proficient with insulin please explain? I'm so confused.
    Thanks.
  2. 16 Comments so far...

  3. 4
    I am no insulin expert, but with a BS of 555, I would not hesitate to give all 6 units. I wouldn't worry if they didn't eat a bite. As for giving it after the meal, I don't get that rationale either. A BS of 555 is never normal for anyone.

    What I hate about Diabetes is, one pt may crash on 6 units of Novolog insulin, where another pt wouldn't go down a point. The only thing I can think of in this situation, is the staff nurse was very familiar with the pt, and knew what her reaction to insulin would be.

    Where I work a BS of 400 will get you at least 10 units of short acting insulin. Greater than 400 we call the doc, and he would order 12- 16 units. None of this is carved in stone, and it boils down to the pt and their history.
    DolceVita, slaughtergryl, tvccrn, and 1 other like this.
  4. 4
    My first comment is 555 is NOT normal for anyone. I understand that you are saying that 555 is what this patient usually runs but its apparent that her current insulin coverage isnt working. I would give the entire 6 units that is ordered before lunch as ordered. If it isnt given the way it is ordered then the MD needs to be aware and give a order to only adminster half and give it after lunch which I doubt he would do. If you have no orders to change the dose or the time then it must be given as ordered otherwise that is considered practicing medicine without a license which is a major violation and very risky to your nursing license.
    Now that I explained that part I would highly recommend someone contact the MD to let him know that the sugars are running very very dangerously high so that he can make adjustments to the insulin dosage. If the MD is not aware of the current trend of sugars and the insulin dosage isnt addressed I could see big time trouble heading for this patient...its only a matter of time until the patient goes into DKA. Also glucoses that high will effect the kidneys, cardiovascular system so even though your supervisior/instructor or whoever says that they are "normal" for that patient just remember they are NOT normal for anyone so they need to be addressed.
    DolceVita, tvccrn, lkwashington, and 1 other like this.
  5. 5
    Gosh, it sounds like the staff nurse is explaining to you why the patient typically has blood glucose in the 500s instead of giving you a valid explanation for halving the patient's insulin dose! Wow.

    The MD really needs to reevaluate this patient's sliding scale because it's obviously ineffective. Where I work, patients with blood glucose that high typically have a long-acting basal insulin given at night, like lantus. Their sliding scale typically includes both a correctional scale (insuling given, no matter what, to correct hyperglycemia) and an additional dose of faster acting insulin for meals, to cover the CHO consumed. So, a patient with a morning blood glucose of 250 may get 4 units on their correctional scale, because their glucose is elevated, and 5 units for every meal, for a total dose of 9 units BEFORE breakfast.

    Perhaps an endocrinologist should be involved to get this woman's blood glucose under control.
    DolceVita, slaughtergryl, tvccrn, and 2 others like this.
  6. 1
    First of all, no one should be running 555!!! Ever!

    I take humalog ac & hs - - I am very resistant. I am not giving you advice, just telling you what my own dosing is -- 10 units ac PLUS coverage for my sliding scale. After some juggling, over a year or so, I find 1 unit for each 30mg/dl over 150 is fairly good for me. So if my BS is say, 240 before a meal, I would take 10 plus 3. (240 - 150 = 90; 90/30 = 3) If I know I am likely to eat a bit more than usual, I might adjust it up a bit. The lowest I've been in a very long time is 86.

    A doc needs to review this lady's dosing.
    tvccrn likes this.
  7. 0
    Will move to the student nursing assistance forum.
  8. 1
    I have cared for a brittle diabetic, such as you are describing. We had to check her blood sugar every four hours, around the clock. If she hit 200, it was time to eat--no exceptions, as she would go from 200 to unconcious in less then 30 minutes if she didn't. If she was in the 300's during the night, we'd recheck her an hour later--usually because she was beginning to trend downwards, but not always. A blood sugar in the 400's was a "safe" range for her.

    No, it's not normal, no it's generally not healthy, and every other diabetic (including my spouse) would feel like total crap in the 400's. Most are lethargic and have a headache, digestive upsets, etc at this poing. Not this little tiny lady.

    It also took very, very small amounts of novalog to maintain her. 70/30 and Lantus had been tried with her, without success as even small amounts made her very difficult to maintain.

    Just wanted to point this out, that despite all of the information about diabetes that we have, and the "rules" of how it's supposed to work, there are exceptions. And on the diabetic support message boards, there is a saying "your own mileage may vary". Which I have found to be very, very true.

    I wouldn't bat an eye if my DH gave himself 35 units of novalog before a big meal (he doesn't anymore--thank God for the insulin pump!) but I recently had a pt. whose sliding scale dictated I give him 25 units, and yeah, I was hesitant to give him that much, but his blood sugar at lunch was 304.

    Again, trust the nurses that know this pt, they have worked with her for a while, and it sounds like she is the exception to all the diabetes rules.
    slaughtergryl likes this.
  9. 1
    In most diabetics, I would agree that it should be given before lunch, and the entire dose. Most diabetics that I've seen have orders to "call the doctor" if the BS is greater than 400. This woman is clearly running outside the average/norm...and from what the staff is telling you, she typically runs extreme.

    Since her appetite is quite poor, the rational is to avoid letting her BS get too low, as it will likely be difficult to get her to eat, and glucogon injections hurt. Seriously hurt!

    I would be interested to know a little more about her history. How long has she been diabetic? What was her last A1C? What are her co-morbidities? Has the MD recently reviewed her blood sugars? How often is her blood sugar tested? What is her range? Does she drop low if given the entire 6units? What was the staff nurse's rationale for administering after lunch?



    Quote from Blondie24
    Hi All,

    I have a quick insulin scenario that I need help understanding. I am a student nurse currently working my gero rotation. I had a patient who is Type 1 diabetic with severe depression. Lunch is served at 12pm and i tested her BS at 11:15am. BS was 555 (normal for her). The sliding scale for BS > 450 = 6 units. The staff nurse advised me (and my instructor) to administer only 3 units of insulin AFTER lunch because the patient has a poor appetite (due to depression).

    This doesn't make sense me. I understand the rationale of administering only half the dose (wouldn't want BS to drop too low if giving 6 units since pt eats little); however, I don't understand why you wait to give insulin after lunch if the BS is already high. Wouldn't it make more sense to give before the meal?

    Can someone who is proficient with insulin please explain? I'm so confused.
    Thanks.
    DolceVita likes this.
  10. 0
    Thank you all for your insight. I feel, as nursing student, I am still trying to understand the ways of insulin.
    I appreciate all your comments.
  11. 0
    Quote from SunnyAndrsn
    In most diabetics, I would agree that it should be given before lunch, and the entire dose. Most diabetics that I've seen have orders to "call the doctor" if the BS is greater than 400. This woman is clearly running outside the average/norm...and from what the staff is telling you, she typically runs extreme.

    Since her appetite is quite poor, the rational is to avoid letting her BS get too low, as it will likely be difficult to get her to eat, and glucogon injections hurt. Seriously hurt!

    I would be interested to know a little more about her history. How long has she been diabetic? What was her last A1C? What are her co-morbidities? Has the MD recently reviewed her blood sugars? How often is her blood sugar tested? What is her range? Does she drop low if given the entire 6units? What was the staff nurse's rationale for administering after lunch?
    Hi Sunny,

    Here is some history on the patient....what I know, that is. She is a Type I diabetic starting in early childhood. Last A1c is unknown. Co-morbidities include: CHF, CAD, DM, RA (started as JRA), hypothyroidism, depression (r/t medical issues). The MD last reviewed orders on 5/25/10. Her BS is tested ac & hs. Although I do not work with this patient on a regular basis, I have seen her drop as low as 128 and highest was 555. The staff nurse on this particular day ended up given her the entire 6 units AFTER lunch and she seemed to tolerate it well. The staff nurse did not give a clear rationale as to why she would administer the insulin after lunch. Upon questioning this (for my own understanding, not to be defiant), the only answer I got was "that's just what we do here."

    Hope this gives you more insight...thanks.


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