Very high BGL .... thoughts?

  1. I'm a new LPN (Jan. 2012) and I work LTC. I take care of a patient and his main dx is dementia. He had routine labs drawn and had a BGL over 800 (was never diagnosed with diabetes & is over 75 y/0). He was treated @ the hospital & returned to our LTC facility a week later. He now gets Lantus daily (24 units) & his blood sugars continue to spike up in the 500's with no s/sx of other infection: v/s stable, afebrile, UA negative for infection, LCTA, losing weight (probably d/t elevated BGL). Any thoughts/advice?
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    About KitkatPRN

    Joined: Feb '11; Posts: 136; Likes: 103
    RN; from US
    Specialty: 5 year(s) of experience in LTC, Rehab


  3. by   sapphire18
    Not wanting to sound rude, but just be sure the MD is aware. It isn't our job to medically manage patients.

    Also, he probably needs some lifestyle modification and a sliding scale.
  4. by   KBICU
    Just because he's a symptomatic now doesn't mean he will stay that way. Sounds like he needs a DKA workup or an insulin regimen change. Regardless he is at a higher risk for infection, stroke, MI, Etc as well as all the micro complications r/t uncontrolled diabetes.
  5. by   tokebi
    The elderly are more prone to HHS -- hyperosmolar hyperglycemic state -- the slower, the less acute, type II equivalent of type I DKA. Although the first crisis seems to have been resolved with the trip to the hospital, current treatment regimen is obviously not adequate. The danger of HHS is severe dehydration and altered mental status, leading to coma. Like mentioned already, be sure the MD is aware. At LTC I worked in the past, we always had the protocol to notify MD for BGL>400. For LTC residents, physicians often wouldn't know what's going on with them unless the nurses called them. It might be helpful if you faxed to the MD the monthly or weekly BGL trend together with current MAR.
  6. by   KitkatPRN
    The MD is most definately aware and has been called almost daily with updates. In fact, I called yesterday twice d/t the high levels, outside of the sliding scale parameters. The Lantus has been changed from 20 units to 24 units, to now 28 units. He is having a CMP with diff & a BMP today, agian. I know how to manage someone with high/low blood sugars. I know I don't diagnose but I was just curious if someone else saw something like this & the patient had something underlying more serious than a UTI or easily explainable infection, as this patient has nothing obvious that the MD or nurses can detect. Hopefully, more tests can find the underlying cause or the MD will get the diabetes managed. (one last note: we have a NP who is avaliable Mon-Fri, she has seen him and reviewed his BGL's almost daily & she works with his MD, too).
  7. by   morte
    Is he perhaps, actively dying? It seems his pancreatic islets cells have "given up"? Is this not the time to consider CMO?
  8. by   Anna Flaxis
    Has he been worked up for pancreatic cancer?
  9. by   classicdame
    He is not getting enough meds. Period. Talk to MD
  10. by   sapphire18
    Why are you sure that he has an infection?

    Also, agree with classicdame.
  11. by   CDEWannaBe
    classicdame is right on. One thing you can do is make sure the patient gets plenty of water. Will help him feel better and keep the kidneys flushed of all that extra glucose they're cleaning up.
  12. by   Anna Flaxis
    I think it's quite possible that there is an underlying cause to his developing diabetes at this late stage in life, and that the doctors don't want to work him up for it because of his advanced age and dementia. Would knowing the cause change treatment decisions, if, for example, he was diagnosed with cancer? Probably not. The focus would still be on symptom management. In that way, classicdame is right, he needs more insulin.

    Does he have an advance directive? Do you know his/the family's wishes for his medical treatment?
  13. by   Sun0408
    I have only seen something like this once so far. The pt was in the ICU on an insulin gtt and no matter how many units we went up he was still in the 500 range and climbing. I think before he died he was on 75 units of insulin an hour with levels going higher and higher. We were all confused on this one, we called every MD on his case and soon they were all at the bedside trying to figure it out. The cause was never found.

    Sorry, I don't know all the details, it was not my pt.
  14. by   KitkatPRN
    I'm thinking cancer, too. The family (wife, mainly) is wish-washy in regards to starting comfort measures, which has been brought up to her many times by the NP, MD & nurse manager. When I worked last night, he was in the 550's, given 10 units regular insulin, 3 hours later was still in the mid 500's, had not eaten anything & was taking in fluids. It's just so frustrating not to at least get the blood sugars where they need to be for him. I'm hoping the tests show something today but I'm not holding my breath. Thanks for the input !!