Blood Sugar Coverage...Did I do the right thing?

[Little_Mouse]

...or the wrong thing?

Pt has Accucheck and coverage AC and HS. HS BS level was 50. Rechecked and it was 68. Gave OJ and Applejuice. Notified Charge RN. Rechecked 30min later and it was 150. Charge RN said to give the insulin coverage and give juice after wards and to hold the Lantus.

My gut feeling was that I should have held the short acting insulin and given the Lantus. The pt was sleepy, but drank sips of the juice when I gave it to her (which had some added sugar too).

Anyway, I told another coworker (staff RN) about the situation and the RN had the same idea I did: hold the short acting, give the Lantus. But instead I followed the charge RN's suggestion since...she had more experience and was the charge nurse. So I held the Lantus and wrote in it "held since pt did not eat dinner"...the pt only had 20% of her meal.

I'm up late and just worried about the pt. I guess 68 isn't horribly low, but it's still low. What should I have done?

[CoffeeRTC, BSN, RN]

1) Check your P+P for default parameters.

2) Giving sugared juice is not current thought.

3) 68 really isnt that low, but remember to nurse the patient, not the number.

4) Don't cover a "contrived/created" elevated BS.

5) Don't hold Lantus, or other basal insulins.

6) Assess the why of this patient having this reading at this time, ?didn't eat last meal or snack, etc.

Best answer yet.

If this happens more than a few times...the doc needs called and something needs to change.

[Esme12, ASN, BSN, RN]

I think the lessons here are:

1) Don't hold Lantus as a general rule.

2) Charge nurses are not infallible. If something seems off or you disagree...double check with someone else.

When in doubt..............call the MD but i would have held the short acting too.

[ChristineN, BSN, RN]

I agree with the consensus that I probably would have held the fast acting Novolog and given the Lantus. Since Lantus stays in your system for 24hrs, the pt may have been unnecessarily high the next day/required more Novolog than usual.

And the pt's blood sugar at 150 wasn't "high." The pt was on a short acting high from OJ and sugar. You don't generally check a pt's blood sugar after they eat and they dose, yet, essentially, that is what you did. In a few hours, the pt's blood sugar will come crashing down as the OJ leaves the system and the insulin kicks in.

When giving a diabetic a bedtime snack, I try to always give a carb (ie crackers) and a protien (ie milk or peanut butter). The protein will help the blood sugar stay up longer, and come down gradually, helping to prevent the pt going hypoglycemic overnight.

[wooh, BSN, RN]

I agree with give the Lantus (to keep it down) and hold the short acting (you had to work to get it there, don't undo you're work, might as well just left them at 68.) That said, 68 doesn't really bother me unless the patient is feeling it.

All that said...

Before I knew better, there patients that I held Lantus on and gave the short acting. Never killed anyone. I'm sure you're patient is fine, as someone else said, get some sleep so you can get back to work for more insulin administration!

[cb_rn]

Please call the doc next time. If you don't have parameters or protocols, you're stepping out of your scope of practice by prescribing/witholding meds without any physician orders to stand on if something untoward should happen

[imintrouble, BSN, RN]

I would have called the MD concerning the Lantus, then asked about the short acting insuling when I had him on the phone.

I don't hold Lantus ever unless I've contacted the MD.

[88blessedhands]

I have observed that it's a common practice to treat blood sugar on the first reading. Meaning if it is low on the first reading we address the problem and note in the MAR that the blood sugar is low and the sliding scale was held; and in the next readings( for rechcecking puopses) as long as the sugar is not sky high we no longer give the Sliding scale and wait for the next scheduled accuchecks. With regards to Lantus either we hold it with reference to the initial reading which is below 70 or clarify with the Doctor.

At times when the initial reading is between 80 to 90 during initial reading we give Lantus provided pt is able to have HS snacks.

what I used to do when I am new in the facilty I would ask their usual practice but if I am not comfortable with the answer I always ask house Doctor to ensure patient safety and relieve myself from wories.

But sometimes we get so stubborn against our gut feeling and would kept on thinking about it. It's just being human:)

[RedhairedNurse, BSN, RN]

I gave the 2 units of Novolin R coverage for the 150.

And surprisingly, the pt did not have any parameters regarding a blood sugar

As a nurse, you can not hold a medicine without a doctors order. By doing so, you are indeed practicing medicine.

If I need to hold insulin, I notify the doctor to make my recommendation then write the order.

[qt_rn]

Maybe its the difference between Canada and the US, but in Canada it is standard practice to use your nursing judgment when it comes to holding certain medications, although it is always appreciated when we have parameters! Are nurses in the USA not allowed to use your nursing judgment? That's part of our education isn't it? Or is it more related to being fearful of lawsuits that nurses are prohibited from using your own judgment? Just curious! As a new grad I would actually be relieved to be required to call the dr in these situations as my nursing judgment develops because then they couldn't get mad at us for calling them but it seems that dr's biggest pet peeve is to call them when we don't have to...

If I called the dr to ask which insulin to hold they would be very upset with us "bothering" them! It is common for us to hold digoxin in hr is

Does your workplace have protocols for low bs? Protocols are very helpful and help ensure that we are all following the same steps when dealing with common issues. We have very set out protocols on what to do when our pts have low bs. If you are able to correct the bs with some fast acting glucose then we write a note in the drs book for when they come in the next morning (sometimes the long acting dose needs to be decreased, or other meds adjusted), but we would never call them unless there was more going on...

Anyways in this situation I would have a hard time deciding who to listen to, especially since the charge nurse is the supervisor however I would have held the short acting and given the long acting insulin for the reasons everyone else has already stated. Maybe next time when you disagree with the CN you can explain your reasoning?