bolus insulin for meals

[sweetieann]

I have a question regarding boluses to cover meals. Say a pt is getting glucometer checks before meals. At what point would you hold off on giving meal coverage? example: Say pt's blood sugar is 70 before a meal. Would you still give insulin to cover their meals? I'd say yes. Now...what if there blood sugar before meal was less than 70? ("hypoglycemia")??

Of course for any questions, I call the Dr. but just wondering opinions. One one hand, if they start out low and they eat, the food could bring them back WNL...on the other, holding all meal coveage could cause them to spike too high.

[robinbird]

I would go by the sliding scale insulin order for the patient. Usually you cover a CBG (capillary blood glucose) above 150. The scale was designed to take into account that the patient would be eating after the CBG check. You also want to make sure that a patient will be eating soon before you give the insulin. Some fast acting insulins require that you to wait until the tray is delivered before giving the insulin.

[robinbird]

Oh, I didn't really answer your question. I definately would NOT cover a CBG of less than 70 (or less than 149, for that matter), even when the patient will be eating.

[VivaLasViejas, ASN, RN]

I'd rather deal with a spike than a crash.

I routinely wait to check blood sugars until the kitchen staff announces that dinner carts for the neighboring unit are ready. My unit's meals are the last to come out---our residents don't usually get to eat until at least 1745---so it doesn't make sense to check sugars and give insulin at 1630. I do my insulin run right AFTER dinner too; I've seen too many people crash when they're given SSI and then don't eat their food for some reason. And no, I don't give coverage for anything lower than the parameters set by the MD, nor do I give even a scheduled dose when the FSBS is 70 or less, even if the pt. does eat.

Just my two cents' worth.

[sweetieann]

right, but what about covering the carbs, etc they will eb eating for a meal? If they are 149 AC and I don't give them meal coverage to cover what they will be eating, they are going to spike very very high.

[sweetieann]

(I should add: we have a regular sliding scale, and also carb coverage insulin--1 unit for every 60 grams of carbs--2 seperate things). So if they were, say 80 on the glucometer before meal, they wouldn't be high enough to get sliding scale, but since they might be having 60 grams of carbs, I'd still want to give the unit of insulin to cover that. But what's the cut off point? At whiat point do you say "they're low enough before their meal that they need the uncovered carbs to bring them up". If they are hypoglycemic before meals, I obviously wouldn' cover their carbs at meals, because they need those carbs to bring them back to normal range. But if they're above hypglycemic at meals, if I don't cover their carbs per their carb counting orders, they could spike pretty high I'd think...

[VivaLasViejas, ASN, RN]

That may be different..........doctors often use carb counts in the hospital, but in the LTC setting it's rarely done (too complicated for the cooks, I guess). In the presence of a FSBS in the low range of normal, however, I still wouldn't give any insulin until I knew for sure that the patient had actually eaten at least 50% of his/her meal.

[pink85]

I understand what you are asking. There should be an order to hold the insulin if the patient's blood sugar is a certain number or lower. That is how it reads on diabetics orders that I have received. That number is usually what they would consider to be a treatable hypoglycemic number which is different for children, teens and adults.

[sweetieann]

thanks so much! i thought there should be a parameter, too. hopefully the Docs rewrite the orders, or they can except a few pages from me with questions!

[frann]

You're patients on a pump aren't they?

my dd is on pump. if she low-70 isn't that low for us, just a little. she'll treat the low with 15 carbs of gummies. eats meal if she's having one and bolus for the meal after she's eaten.

It would be better for her a1c if she would bolus before the meals if she were normal. but I pick my battles.

What kind of pump does you're patient have? I guess they are in LTC? Pumping insulin is a art. sometimes the answers aren't allways cut and dry. And I think its even harder to pump insulin if you aren't in the drivers seat.

[classicdame, MSN, EdD]

you are using the term "insulin" in a generic sense and there is no generic answer. Regular insulin is generally not given at meals UNLESS the blood sugar is elevated. Rapid Acting insulin is given with carb consumption, whether it is a meal or a snack (some orders require specific levels of carbs before covering). The key is knowing what is best for YOUR patient as no two diabetics are the same. I recommend you contact your Educator about resources on insulin administration. Perhaps an inservice is in order - I doubt you are the only one feeling less than confident about insulin administration. It is a lot more complex than can be addressed in this forum. So glad you are seeking assistance!

[jmgrn65, RN]

Covering with the meal is important, I would look at their trends. see if there is a pattern. Evidence based practice is having tighter controls of blood sugars and treatment of sugars as low as 120 is the standard now. the normal range at least at my facility is 70-99.