Attention ALL Diabetic Nurse Educators

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Specializes in Nursing Education.

The other day a physician came up to me and told me that he would be changing the way in which he writes his orders for insulin coverage. Appreantly he returned from a conference where physicians were being told that the new way to cover blood sugar was by addressing the amount of carbs the patients takes in with each meal.

So, rather than writing simple regular insulin sliding scale coverage, his orders addressed the amount of carbs the patient took and then provided corresponding insulin coverage. For example: If the patient took in 10 carbs = 6 units of regular insulin.

Here are my feelings on this and I would like some opinions ... first, I am all for new practice standards that are based in research and are going to benefit the patient. However, asking nurses to count carbs for insulin coverage seems a little off the target and leaves room for significant errors. Am I wrong in this opinion? And, is this new approach the wave of the future - Please advise.

From my pespective, I would think that the Dietitan should be a lot more involved ..... asking nurses to count carbs seems a little off the mark to me.

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Specializes in Gerontological, cardiac, med-surg, peds.

There has been a revolutionary change in the standard of care on insulin therapy in the adult or teenage diabetic patient. The typical sliding scale is being replaced by basal dosing, carb counting dosing, and "correction" body-weight insulin dosing. This is based on years and years of research. Apparently, the sliding scale has been doing much more harm than good because it treats the problem "after the fact" (kind of like closing the barn door after the horse and cows have run away). This is a major treatment shift in that blood sugar is being treated on a proactive and anticipatory approach, rather than after the fact. The goal is tight glycemic control which will aid in diabetic patient healing in the hospital. With the new protocol, upper limits for glycemic targets in the hospitalized patient are usually along this line:

ICU: 110 or less

Non-critical care units--

Prepandial: 110 or less

Maximum glucose: 180 or less

In the case of the typical diabetic on sliding scale, blood sugar may go as high as 300 or 400 or as low as 40 or 60 with the next blood sugar check! It is much harder for the patient to recuperate with such widely fluctuating or out of control blood sugars. The new protocol maintains much tighter glycemic control which is so much more conducive for patient healing. The patient is also trained for carb counting to continue at home which (hopefully) will keep his/her blood sugar within the tight glycemic range and the patient will avoid all of the horrible effects of chronically high blood sugars (micro and macro circulation degenerative changes, heart disease, stroke, kidney failure, blindness, ulcers and amputations).

Under the new protocol, insulin is administered on a scheduled basis to meet both BASAL and NUTRITIONAL (aka bolus or prandial) needs. The basal insulin is usually Lantus, Ultralente, Lente, or NPH, or basal rate on an insulin pump. The nutritional insulin (bolus) is calculated and given at meals based on carb counting and rapid-acting insulin (Humalog, NovoLog, or regular) is used.

The CORRECTION DOSE is administered in addition to scheduled doses to treat hyperglycemia in the orally fed or NPO patient. There are scheduled blood sugar checks with the new regimen (TID, post prandial, etc), just like in the old "sliding scale" days. This is not to be confused with "sliding scale" insulin regimens that treat hyperglycemia with a "scheduled" insulin regimen. The typical sliding scale does not take into consideration that patients respond differently to insulin (sensitivity) and the correction dose formula is based on body weight. If frequent dosages of "correction" insulin are administered, the "scheduled" insulin regimen should be adjusted for the subsequent day.

Correction Dose Insulin Calculation

(NOTE: It is the physician's or advanced practice nurse's responsibilityto provide the TARGET FSBS and SENSITIVITY FACTOR for the formula.)

Three pieces of data are needed to calculate the correction dose:

1. Current blood glucose (FSBS) value

2. Target blood glucose (FSBS) value

3. Insulin sensitivity of the patient - an estimation of how many points the blood glucose will drop by administering 1 unit of rapid or short-acting insulin. Sensitivity can be estimated by using the 1500 Rule or body weight

Correction Dose Formula: Current blood glucose minus goal blood glucose divided by sensitivity factor

(Current FSBS - Target FSBS)

Sensitivity factor

Example:

Current blood glucose 188

Minus goal blood glucose-120

Diffence between the two 68

Points to correct 68 divided by 30 (insulin sensitivity factor) = 2.26

Rounded down to nearest whole number = 2 units

1500 Rule:

1. Add all current doses to determine the total daily dose of insulin*

2. Divide 1500 by the total daily dose of insulin (TDD)

1500 divided by TDD = sensitivity factor

Some clinicians recommend using 1800 if rapid-acting insulin is used.

*If patient is new to insulin or previously on any oral agents, multiply weight in kilograms by 0.5

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Specializes in Gerontological, cardiac, med-surg, peds.

The Eli Lilly web site has some excellent resources on carb counting and the new protocols. http://www.LillyDiabetes.com

You will have to register as a health care professional to receive the carb counting materials. This service is free.

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Specializes in Nursing Education.

Wow .... Joy - thank you so much! I will certainly use this information as a teaching tool for my staff. We are trying to move forward on new research, but sometimes the information takes a while to get through the practice committee into general practice. The information you have provided is wonderful. Thanks!

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Specializes in Med/Surg, Geriatrics.

Wow, this is all very fascinating. I've been away from the bedside for only a year and look at what significant changes are being made in care!

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There has been a revolutionary change in the standard of care on insulin therapy in the adult or teenage diabetic patient. The typical sliding scale is being replaced by basal dosing, carb counting dosing, and "correction" body-weight insulin dosing. This is based on years and years of research. Apparently, the sliding scale has been doing much more harm than good because it treats the problem "after the fact" (kind of like closing the barn door after the horse and cows have run away). This is a major treatment shift in that blood sugar is being treated on a proactive and anticipatory approach, rather than after the fact. The goal is tight glycemic control which will aid in diabetic patient healing in the hospital. With the new protocol, upper limits for glycemic targets in the hospitalized patient are usually along this line:

ICU: 110 or less

Non-critical care units--

Prepandial: 110 or less

Maximum glucose: 180 or less

In the case of the typical diabetic on sliding scale, blood sugar may go as high as 300 or 400 or as low as 40 or 60 with the next blood sugar check! It is much harder for the patient to recuperate with such widely fluctuating or out of control blood sugars. The new protocol maintains much tighter glycemic control which is so much more conducive for patient healing. The patient is also trained for carb counting to continue at home which (hopefully) will keep his/her blood sugar within the tight glycemic range and the patient will avoid all of the horrible effects of chronically high blood sugars (micro and macro circulation degenerative changes, heart disease, stroke, kidney failure, blindness, ulcers and amputations).

Under the new protocol, insulin is administered on a scheduled basis to meet both BASAL and NUTRITIONAL (aka bolus or prandial) needs. The basal insulin is usually Lantus, Ultralente, Lente, or NPH, or basal rate on an insulin pump. The nutritional insulin (bolus) is calculated and given at meals based on carb counting and rapid-acting insulin (Humalog, NovoLog, or regular) is used.

The CORRECTION DOSE is administered in addition to scheduled doses to treat hyperglycemia in the orally fed or NPO patient. There are scheduled blood sugar checks with the new regimen (TID, post prandial, etc), just like in the old "sliding scale" days. This is not to be confused with "sliding scale" insulin regimens that treat hyperglycemia with a "scheduled" insulin regimen. The typical sliding scale does not take into consideration that patients respond differently to insulin (sensitivity) and the correction dose formula is based on body weight. If frequent dosages of "correction" insulin are administered, the "scheduled" insulin regimen should be adjusted for the subsequent day.

Correction Dose Insulin Calculation

(NOTE: It is the physician's or advanced practice nurse's responsibilityto provide the TARGET FSBS and SENSITIVITY FACTOR for the formula.)

Three pieces of data are needed to calculate the correction dose:

1. Current blood glucose (FSBS) value

2. Target blood glucose (FSBS) value

3. Insulin sensitivity of the patient - an estimation of how many points the blood glucose will drop by administering 1 unit of rapid or short-acting insulin. Sensitivity can be estimated by using the 1500 Rule or body weight

Correction Dose Formula: Current blood glucose minus goal blood glucose divided by sensitivity factor

(Current FSBS - Target FSBS)

Sensitivity factor

Example:

Current blood glucose 188

Minus goal blood glucose -120

Diffence between the two 68

Points to correct 68 divided by 30 (insulin sensitivity factor) = 2.26

Rounded down to nearest whole number = 2 units

1500 Rule:

1. Add all current doses to determine the total daily dose of insulin*

2. Divide 1500 by the total daily dose of insulin (TDD)

1500 divided by TDD = sensitivity factor

Some clinicians recommend using 1800 if rapid-acting insulin is used.

*If patient is new to insulin or previously on any oral agents, multiply weight in kilograms by 0.5

How would this regime be affected by glyburide5mg/metformin hcl 500mg tab

Dosage is 2 tablets twice a day.

Also I have noticed that my blood glucose is higher this time of the year. I realize some is due to inactivity, but do you know of any studies related to sunlight.

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Specializes in MS Home Health.

Great discussion and thanks for posting it.

renerian :)

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