Administer insulin when glucose is 53?

[Trixyp]

I work in an adult day care center, and I am one of the newer nurses on staff, and I'm also pretty new to the nursing world. All the nurses there share all of the patients, and we each do part of the paperwork.

Many of the patients there are able to self medicate, and a few give their own insulin. So one patient came in to check her blood glucose level so she could administer her insulin. She said she felt a little tired, and her level read 51. This was unusually low for her, so I rechecked it, and it read about the same, this time 56. Her sugar is usually around 130-140 before she gives herself insulin.

She asked if she should still give herself the insulin.

I began to question her as to what she had eaten that day and how unusual it was for her sugar to be that low. She said today was different, as she only had a little bit of oatmeal for breakfast (4 hours prior) . I asked if her insulin had a sliding scale, and she said no, she just gives herself regular insulin 3 times a day, and her doctor never told her to do anything different if it gets very low or very high. (She did not keep with her the packaging for the insulin that states the dosage, only the insulin vial, and in our records, all it states is she is on insulin because it is expected that she administer herself.)

At this time, my nurse supervisor came in and overheard the conversation, and began to question her.

I recommended she go get something with sugar to drink so she could get her blood glucose closer to its usual level, and let us test again in 20 minutes so she could give her insulin as usual and have her lunch in a little bit as she usually does since her doctor has not told her to hold her insulin. (Our protocol for sugars under 60 is to give something to eat or drink anyway)

My supervisor said "no, because then it would be wrong".

So then i recommended we call her physician and ask what he would like us to do as he prescribed the medication. My supervisor denied that recommendation as well. She then instructed the patient to give herself

'less" insulin than usual, and find out from her doctor later what she should do if it gets to low in the future.

Then the patient asked if having low blood glucose could hurt her, and my supervisor replied "Oh its nothing you'll just feel tired and have no energy."

This nurse is above me, so I could not say otherwise unfortunately. Then my shift was over, so I left.

So last i heard (Via a staff member who stayed later than me), the woman was being given juice and cookies because she started to feel very shaky and started acting lethargic. Then she had lunch as usual...(im assuming her sugar shot way up as well.)

I have not been back to get the full story with all the numbers yet.

So now I'm completely confused as to what should have been done in this situation instead? What would have been the proper way to handle this?

[SHGR, MSN, RN, CNS]

This is kind of a tough situation as the client is acting autonomously, you are not privy to all her information (is this really regular insulin? Or a rapid-acting analog? Does she have a basal insulin? ) and yet as the nurse you are accountable. So yes, a low can be bad... can lead to an arrhythmia...MI, stroke, etc, and lows are associated with dementia later on. Treat with 15-20 grams fast acting carbs and recheck in 15 min. So some education is needed. But I'd also want to see a few day's worth of sugars and an a1c level. Also in the elderly lows are more concerning than highs, within reason. She may actually have too tight of control. A1c goal of 8.0 is desirable in 75+.

[misstrinad]

Oh my. Low bs can cause a multitude of issues, as someone listed above. Was this supposed to be her first insulin dose of the day and another dose was expected to be given in a few hours? If so I would have held the insulin and given her a snack and rechecked right before lunch. I never advise taking less medication than ordered. Either take the dosage or don't take it bc there is a reason to not take it. I would call the Dr and get clarification on what to do for bg under 60 to avoid the possibility of a questionable issue like this in the future.

[lifelearningrn, BSN, RN]

I'm a new nurse so I'd have been a little confused of how to handle this too... however, I think had it been one of my patients, I would have held the insulin, given her some juice, recheck in 15 and either go ahead with the dose or skip it entirely if the BG was still lower than usual.

Since she is not on a sliding scale, I think your manager having her take a different dose was a bad call.

[akulahawkRN, ADN, RN, EMT-P]

I'm a new nurse so I'd have been a little confused of how to handle this too... however, I think had it been one of my patients, I would have held the insulin, given her some juice, recheck in 15 and either go ahead with the dose or skip it entirely if the BG was still lower than usual.

Since she is not on a sliding scale, I think your manager having her take a different dose was a bad call.

Not just a bad call, but for that day, possibly a dangerous supervisor. From what is relayed in the story, there's no treatment of the low blood sugar until much later (only because the patient became very symptomatic presumably after giving herself "less" insulin), a recommendation to change a dose (no sliding scale) without an order allowing it, denial of a call to the physician for clarification, and giving inaccurate teaching.

[misstrinad]

Our orders for rechecking bg for either a high or low readings (after treating) are to wait 1 hour for recheck. Can anyone weigh in if 1 hour is appropriate or should it really be checked at 15 min? When it's a particularly concerning number I myself check at 30 min, 1 hr, and 2 hr marks after treating so that I am sure I am keeping a close eye on it, especially if I don't know the patient's normal trends well.

[workinmomRN2012, BSN]

Long or short acting insulin? Give protein (PBJ) or glass of milk or OJ with 2 pkts of sugar, then recheck. Get a sliding scale order

[workinmomRN2012, BSN]

Last night one of my diabetic patients was on a clear liquid diet, upgraded from NPO following a procedure, her bs was 94. The order was for 18u of levemir @HS. I called the doctor and asked for the order to be changed to 10u and gave liquids- ginger ale/juices. The juices take the place of snacks so she doesn't bottom out in AM. If this were short acting insulin I would not feel comfortable giving it. I learned from LTC, any bs below 100 treat with protein, milk, oj and sugar. Always recheck :)

[ChristineMP]

It's interesting to see all the different ways of handling this. The written policy for insulin in the facility I worked at was for any reading under 100, hold the insulin. For readings under 60, treat with glucose (or juice or soda) and recheck in 15 minutes. We would also notify the resident's doctor.

[jrost80RNBSN]

You were right, the insulin should have been held, and she should have gotten something to spike it along with a meal and then recheck it. Your supervisor needs some counciling, a BS of 51 and insulin could send the patient into hypoglycemic shock. I have seen bs as low as 38 and the patient was trembling uncontrolablly and sweating. You made a good sound nursing descion. You are both nurses and above all you need to be an advocate for your patient. Next time i'd challenge her.

[pebbles049]

In our facility we do 15 to 20 grams of fast acting carbs and recheck in 15 min. for blood sugar under sixty or depends on patient 70. Also notify md. I would have wanted to do that and not play with an even lower blood sugar in the afternoon. It is not fun when someone is so low that you have to give them the glucagon injection. Without a doctors order I would not have administered a lower dose of insulin.

[dream'n, BSN, RN]

From the OP, this was Regular insulin three times a day; I'm assuming prior to meals. When in doubt, think it out...which would be worse; patient BS bottoming out or patient BS rising to 200 or so? Obviously low BS is more acutely dangerous. Therefore, hold the insulin, give drink/food, and call the Dr.