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?

[icuRNmaggie, BSN, RN]

Hypoglycemic encephalopathy is a horrible way to die with coma, seizures, cerebral edema and brain stem herniation.

I would rather have a high blood glucose, I can fix that.

I think your supervisor acted outside of her scope and you should have investigated why her glucose was 53, did she give herself too much insulin, any med changes, and why is her appetite poor? I would have given her skim milk and peanut butter and crackers or cheese and crackers. The Doctor should have been notified. Your supervisor is either incompetent or just plain lazy. This incident should be reported to your director.

[litbitblack, ASN, RN]

I to think your supervisor acted out of her scope. Obviously you questioned your pts diet which indeed had been different than usual. I would have offered her a snack of low fat milk, peanut butter and crackers and rechecked it 30 minutes afterwards if there were no further symptoms. Depending on what her result was I would either have her give herself the insulin or hold it and have her notify her doctor. All pts that are on insulin should have diabetic education. Sometimes they are not sure if they should hold it or not and the doctors need to make sure they are educating their patients. As for the supervisor, you are not overstepping your bounds because you disagree with her advice. It is our jobs as nurses to advocate for our pts and you are in the right if you decide to question someone else's advice.