brittle diabetic pt

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pt. had FSBS of 525 and i gave the sliding scale coverage of aspart. 2 hours later i checked the FS and it was 563. the pt. is a brittle diabetic. lot of times his sugar is so high that the glucometer doesn't even administer any reading. so there is a parameter of giving 20 units of Aspart if there is no reading. i was really concerned abt the pt. so i gave him 20 units of aspart and then afterwards called the doctor to update abt the situation. the doctor told me that it was ok to give 20 units and asked me to recheck after 2 hours and continue the same. after like 2 hours, he was due for his lantus 16 units. when i checked the FS at 9pm, the fs was 134 and since the doctor had ordered not to hold the lantus, i gave him his regular lantus. pt was sleeping comfortably when i left. but the next day, i heard that the pt had to be sent out because his FS had drooped to 20 during the night. noone has told me that it was my fault. but still i can't help feeling guilty . did i do anything wrong? since i am a new grad nurse, your remark on this one would be really helpful. thankyou

I figured this was LTC. We don't have the lab to check a venous sample or for ketones in LTC.

The IDT ( RNAC, DON, dietary, etc) needs to get involved and good care planning needs to happen. Good charting explaining the risks and benefits of following a good diet needs to happen too. I second the endo consult to get some form of control medically.

Check to see what your machine goes up to before it reads error or HI. I'm sure he is getting the labs done at dialysis, maybe your facility can get that info from them? Also they should know about his blood sugars too. They probably have a dietician that has spoken/ educated him on food/ diet control.

Chart, chart, chart all of your care with him.

At the very least, if he is getting all that insulin and then going to bed..he needs a snack at hs. Ohh....what about belly and thighs for the injections?

Every so often we get someone tough like this.

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i am glad that i started this thread. this has now prompted me to look more deeply into this pt's situation now. i work 3-11 shift and my whole time is spent doing meds, few treatments and tons of paperwork. sometimes i am so tied up with things that i get out around midnight. and i confess that i have never looked into his chart and as other nurses at my job,i had been just working with reports from other nurses. so now i'm gonna find out what's really going on with this pt.

thanks

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Specializes in geriatrics, psychiatry.

Thank you so much for posting this!! SO helpful!

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Specializes in Hospice.
It sounds like there's social and medical factors preventing this patient from having good health. The fact that this patient has poor blood glucose control is in no way your fault. It sounds like this patient probably needs a good endocrinologist, nutritionist, and probably a psychologist or social worker.

Or a hospice consult.

OP, your resident is being kept alive artificially by means of hemodialysis. I suspect your resident is well aware of this. The dietary restrictions involved in that, on top of the restrictions required to control insulin-dependant diabetes are notoriously difficult to live with. It's unlikely that staff will be able to do much more than play metabolic catch-up until the resident is able to relinquish life-prologing treatment altogether.

Until then, all the suggestions by previous posters are ecxellent ones. My point is, the best you can do is all you can do. This resident's instability and poor condition are not your fault.

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Specializes in orthopedic/trauma, Informatics, diabetes.

the problem with hard to manage DM (we actually HATE the term brit-tle) involves many factors.

1-when people come to the hosp, they are put on a diet that is NOT like the one they are eating at home.

2-Snacks. We have a problem that nurses forget to make sure that pts are eating something betweem 2100-2200. At our hosp, they get supper between 1800-1830 and sometimes a snack that is gross. Then they go all night with nothing.

3-Providers don't know what the heck they are doing. We have had up to a 36 hour delay in getting insulin ordered and I fight tooth and nail to get an endo consult.

4-Someone mentioned societal issues. Most people cannot afford the regimen that is used in the hosp: Lantus and Hunalog/Novalog. The cheapest route is NPH but certainly not as efficient.

As a parent of 2 type 1 children, I am fortunate that we can afford insulin pumps and continuous glucose monitors. T1s are in more danger in a hosp setting if they don't have an advocate or well educated about how to treat. Many T1s that are diagnosed as adults do not get anywhere near the education they need They are also misidentified as T2 because they are not a kid. What everyone needs to remember is that kids that have T1 GROW UP.

Obviously the pt that was described in this scenario is due to many of the contributing factors to failing as a diabetic. It is hard work to manage. And expensive.

The lantus did not cause the crash, the 20 units of Humalog did. that pt should have been put on an insulin gtt and then titrated back to Lantus/Humalog. This is a medicine physician NOT knowing how to treat a diabetic pt. I don't know that I would have called this a "brittle" diabetic. Just a mis-treated one. Without knowing hx and A1c, there is no way of knowing. if the pt is on dialysis, they obviously have not been managing well.

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Specializes in Hospice.

OP stated in her second post that the resident is on dialysis and later referred to an av fistula.

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Specializes in Public Health, TB.
the problem with hard to manage DM (we actually HATE the term brit-tle) involves many factors.

1-when people come to the hosp, they are put on a diet that is NOT like the one they are eating at home.

2-Snacks. We have a problem that nurses forget to make sure that pts are eating something betweem 2100-2200. At our hosp, they get supper between 1800-1830 and sometimes a snack that is gross. Then they go all night with nothing.

3-Providers don't know what the heck they are doing. We have had up to a 36 hour delay in getting insulin ordered and I fight tooth and nail to get an endo consult.

4-Someone mentioned societal issues. Most people cannot afford the regimen that is used in the hosp: Lantus and Hunalog/Novalog. The cheapest route is NPH but certainly not as efficient.

As a parent of 2 type 1 children, I am fortunate that we can afford insulin pumps and continuous glucose monitors. T1s are in more danger in a hosp setting if they don't have an advocate or well educated about how to treat. Many T1s that are diagnosed as adults do not get anywhere near the education they need They are also misidentified as T2 because they are not a kid. What everyone needs to remember is that kids that have T1 GROW UP.

Obviously the pt that was described in this scenario is due to many of the contributing factors to failing as a diabetic. It is hard work to manage. And expensive.

The lantus did not cause the crash, the 20 units of Humalog did. that pt should have been put on an insulin gtt and then titrated back to Lantus/Humalog. This is a medicine physician NOT knowing how to treat a diabetic pt. I don't know that I would have called this a "brittle" diabetic. Just a mis-treated one. Without knowing hx and A1c, there is no way of knowing. if the pt is on dialysis, they obviously have not been managing well.

Thank you. I have always detested "brittle" and I learned long ago not to refer to a person as a "diabetic". They are more than their disease, they are a person with diabetes.

I volunteered at camp for kids with T1D. Even though most had pumps, they were eating, or not eating foods they weren't used to and we had many highs and lows. I was with a cabin of 11 year old girls who were picky eaters and only wanted to eat the snack bars and Ensure we had for hypoglycemia, bless their little hearts.

I second a hospice or palliative care consult.

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