A Diabetic rant

LynnLRN · Jul 4, 2012

At my facility the lantus shows up on the MAR with a message that says do not hold for NPO or low blood sugar. Most docs will just decrease the lantus if the pt tends to drop at the same time a few days in a row. So maybe its just where you work that people don't understand lantus.

KelRN215, BSN, RN · Jul 4, 2012

Hey guys.
I've been a type 1 diabetic for fifteen years now and I'm set to graduate the program in May 2013 -- I clarify that because I don't want anyone to think I'm already working or think that I'm trying to be a know-it-all, but this drives me nuts.
At a few facilities I've been to I've noticed an alarming trend regarding Lantus. Now, I'm sensitive to this because I actually take Lantus and know how it works, but a lot of med-surge nurses don't seem to know -- and equally alarming is SOME DOCTOR'S DON'T, EITHER!
A patient had a blood glucose of 56 (low, not that terrible, to be honest... an OJ will fix it just fine) at bedtime check and because of that the nurse called the doctor and with held the lantus!
Now, lantus is a baseline insulin. It lasts ~24 hours and keeps the blood sugar at normal operating level (65-110 or thereabout) for that time period. If you with hold lantus there is no insulin left in the body (for practical purposes) to keep glucose normal!
Needless to say, patient woke up with a glucose of 500+ because they had no lantus on board. Morning shift nurse (more experienced) corrected the error by calling doctor again and administering the lantus.
Please, please, please be a patient advocate. If I were in the hospital you couldn't pry my insulin from my cold dead fingers because I don't trust that the knowledge is out there on exactly how diabetes and the meds work. If you're not diabetic and your glucose has never hit 500, I can't explain to you how crappy you feel for a long time even after it returns to normal.
/rant

So she held a standing dose of insulin and didn't recheck the sugars at all overnight?

This is precisely why I would ONLY speak with the Endocrine team about Diabetic patients when I worked in the hospital. Fortunately, at the hospital I worked at, Endocrine was automatically consulted upon admission of a patient with known diabetes (I only ever saw them if they had something neurological or neurosurgical going on)... I didn't take care of a lot of Diabetic patients in my time there, but I had a few who Neurology or Neurosurgery Docs would have screwed up royally if it had been up to them.

SHGR, MSN, RN, CNS · Jul 4, 2012

I made cards regarding types of insulin and their actions. They fit in a plastic sleeve to wear with your name tag. I refer to mine a lot! I gave them to all of the nurses in the ED. It has been most useful! If this attachment works, you are more than welcome to use them.

What a great idea!! I love the idea of having the onset, peak, duration chart so available!

hecallsmeDuchess · Jul 4, 2012

@DixieLee, thanks, I printed out your chart.

@OP, I also think it depends on how many units of Lantus the pt is supposed to be getting. Usually, if a pt is 56 I'll give some carbs, recheck the sugar then call the doc if it is still low (again depending on how many units ordered) so they can decrease it. But 56-500, someone dropped the ball big time for that to happen. When people run low, even once on my shift, I keep a close eye on their levels to make sure I don't have any surprises, and when I leave I pass on the surveillance to the next shift.

Justabitoff · Jul 4, 2012

I'm a type 1 diabetic and was once hospitalized. During an overnight, my blood sugar was high and the nurse just randomly decided to give myself 4 units of insulin, despite the fact that wasn't my correction factor and it had actually been an hour since they tested me! I woke up high, but still the nurses were not going to give me any insulin because no one had told them to. It was like being 300 mg/dl was A-OK (note: it isn't!). I was so ******. The doctor who finally came by in the morning apologized, but OMG. I just don't understand how people can become nurses without at least learning the basics of how these medications work!

84RN · Jul 4, 2012

I've seen the same things happen and it's really appalling.

Two of our kids have type 1 diabetes, and younger one dx at 18 mos, so I've been managing her diabetes for 8 years now. You wouldn't believe some of the things we've had medical professionals tell us. When my eldest was dx at age 22, his BG was 500 on admission with ketones, and the positive hx of family type 1, no risk factors for type 2, and still several physicians told him that "this may be able to be controlled with diet and exercise."

The discharging dr reluctantly gave us a prescription for novolog because I wouldn't leave the hospital without it, but wrote up a sliding scale, and NO basal insulin, and told us to get an appointment with an endo in a few days. Thank God I knew better, and was up all night checking him every two hours, giving injections of novolog (trying to be his insulin pump, lol) and able to keep him out of DKA, and took him to another ER the next day, because--surprise-none of the area endos could manage to fit him in. The experience at the next ER wasn't much better, but we did manage to finally see an endo and get appropriate medical care. The ER physician at the second hospital admonished me for insisting on an endo consult, and not allowing him to just prescribe the insulin because, and I'm quoting here because I'll never forget it...."diabetes isn't rocket science."

Last year I was doing an RN refresher course (stayed home for over a decade), and saw the same thing you described. One of the floor RNs held the basal insulin and then was surprised at how much the patient's bg increased over the course of the day.

MN-Nurse, ASN, RN · Jul 4, 2012

Needless to say, patient woke up with a glucose of 500+ because they had no lantus on board. Morning shift nurse (more experienced) corrected the error by calling doctor again and administering the lantus.

No checks during the night?

Blufea · Jul 4, 2012

That's terrible.

cjcsoon2bnp, MSN, RN, NP · Jul 4, 2012

I think that what I would have done personally is ...

(1) Check the B/S level prior to administering any insulin.

(2) Once I saw the B/S level was 56 I would give OJ and rechecked the B/S.

(3) Once the B/S was in the acceptable range I would then contact the MD and let them know of my plan to give the Lantus as ordered and continue to monitor the B/S periodically throughout the night.

My younger brother has IDDM since he was 11 and we have learned over the years (and many hospitalizations) that missing your dose of Lantus only ends up causing more problems then it ever solves.

!Chris :specs:

ShantheRN, BSN, RN · Jul 4, 2012

And this is why I did my own diabetic management the one time I was admitted for surgery. Even with a morphine PCA I had more confidence in myself than my nurses. Sad, but true. It was suggested I could leave my pump at home and manage with shots. I just blinked and said "if it was that easy, I wouldn't be on the pump to begin with...." It's just as well because neither of my nurses knew anything about insulin pumps.

Diabetes management education is sadly lacking. I work in oncology and we don't even treat hyper in the steroid induced diabetics until they hit 200. I wish the docs could walk around with their BS that high for a day. I bet they would lower the threshold. It boggled my mind during my med surg rotation that none of the pts got post prandial BS done. How can you know if the insulin was sufficient if you don't check that? It drove me nuts.

So yeah....I feel your pain, OP!

morte, LPN, LVN · Jul 4, 2012

too tight a control has had some less than stellar consequences, from what i have read. Inre: post prandial BS, YES. It has been years that it has been known that many type II go undx, d/t compensation in FBS but obvious in post prandial, and the neuropathy that can come with diabetes can occur in this time period, can be, in fact the presenting complaint for type IIs. Need a GTT of at least 3 hours, or longer, with insulin draws, to get the "picture"''. What we really need is some one to invent a way to check blood sugars without "sticking" someone, over and over again. I have seen persons whose fingers were black and blue, ALL of them.

And this is why I did my own diabetic management the one time I was admitted for surgery. Even with a morphine PCA I had more confidence in myself than my nurses. Sad, but true. It was suggested I could leave my pump at home and manage with shots. I just blinked and said "if it was that easy, I wouldn't be on the pump to begin with...." It's just as well because neither of my nurses knew anything about insulin pumps.
Diabetes management education is sadly lacking. I work in oncology and we don't even treat hyper in the steroid induced diabetics until they hit 200. I wish the docs could walk around with their BS that high for a day. I bet they would lower the threshold. It boggled my mind during my med surg rotation that none of the pts got post prandial BS done. How can you know if the insulin was sufficient if you don't check that? It drove me nuts.
So yeah....I feel your pain, OP!

JZ_RN · Jul 4, 2012

I am not diabetic, but this is just a case of not really knowing your drugs. If a person has a low BS, you can bring it up in 15 minutes with a snack/juice/whatever. You can still give lantus, because it has no peak, and the sugar will be up before it has much effect anyways. I agree with you, that is frustrating. Especially with some of the brittle diabetics and such.