Here's a clinical scenario that comes up pretty frequently where I work: a patient with diabetes is ordered for sliding scale Novolog to be given immediately before meals. The dose is based on the blood sugar, which is checked at the same time. There are many many variations of this scenario--maybe the patient has a standing order in addition to the sliding scale (that's not to be given if NPO), maybe the patient is taking metformin or other PO hypoglycemics also and has never used insulin at home, maybe the patient is getting other insulin for basal coverage, maybe the patient is a brittle type 1 diabetic, maybe the patient has an A1c of 13 and uses an entire insulin pen in 2 days but is rarely able to get a sugar level less than 200. There are thousands of scenarios, and each patient has a unique need. In addition to the patient's history and current treatments, there is also the day to day patient situation. What's the patient eating? How's his or her mental status? Appetite? Etc etc etc.
The orders for pre-meal insulin tend to be pretty broad and, if followed strictly without a lot of critical thinking and knowledge about the patient, not extremely effective. Here's a hypothetical example of a fairly common and uncomplicated situation that many of you may face pretty regularly:
Your pt is a 52 year old type 2 diabetic female POD 2 femur ORIF. Her diabetes is managed (not very well) on POs at home, her A1c is 8.6, and her post-op sugars have been running pretty high (200-300, let's say). The MD hasn't restarted her metformin yet, and an endocrine consult recommended the patient be on lantus and both standing and sliding scale novolog AC during her hospital admission. You're the nurse today, and the patient's AC blood sugar is 230. She ate breakfast 4 hours ago, is not really in the mood for lunch so doesn't order. So, now her "AC" isn't technically "AC"--but you checked the blood sugar anyway because she's "due" for both standing and sliding scale novolog (though the standing is not to be given if "NPO"--which she isn't, she's just not eating right now). For this test result, she would get 3 units novolog per scale, and the standing order is for 5 units.
If you don't call the doctor for advice (which I'm sure s/he REALLY would appreciate) you have to do something--give insulin/not give insulin. Give insulin with juice to cover your a$$ if you're worried the pt will drop too low (which is REALLY not likely, and probably not the best for the patient who should avoid the simple carbs--no carbs may be better than simple ones). Hold insulin because the patient's not eating. (But she had breakfast, and there's no reason to expect that she won't have dinner)
I recently witnessed a kind of tense conversation between a nurse and a diabetes NP--the nurse hadn't given insulin because the patient was confused and refusing to eat, but the blood sugar was high. The NP was saying the blood sugar was high--not only that, but it was consistently high, and the patient needed the insulin and the nurse should have given at least the sliding scale. While she's probably right, the NP wasn't taking the verbage of the order into account, nor the limits of what a nurse can do in that situation where to GIVE the insulin may be interpreted as going against the order (especially if, god forbid, the patient gets hypo after getting the insulin without sufficient po intake). Ultimately I think the pt probably needs more consultation and higher lantus dose-but the nurse had 4 busy patients, and this was not the only patient with sliding scale insulin ordered and a questionable appetite. She did NOT have the time to address the issue with the doc, who also did not have time to address the issue. At least the NP was there to make a new rec to the doc--but not without getting frustrated with the nurse who was basically just trying to not make a call that was outside her scope of practice. I feel that this kind of thing happens ALL THE TIME, and the nurse may find his or herself doing a substantial amount ,of coordinating/paging docs, nutrition, asking for consults, etc--just because a patient is not eating a meal, her blood sugar is high, and she has insulin ordered for "before meals"
Do any of you have thoughts on this? Similar problems, or maybe you've found a solution to this issue? Love to hear what you have to say.
I like to also consider what other drugs the pt is taking. For example, if your pt is on corticosteroids, the blood glucose will be high whether they eat or not.
I use a LOT of insulin drips in my practice, (accuchecks Q1hr) and titration of insulin. New evidence based practice says use the insulin drip if glucose is over 180. The old limit was 150. A large study was done proving that clinical outcomes do not change in the ICU/CVICU with the lower 150 limit.
I don't have a link now, because I am tired..........rough night shift. I am sure I can find it later if someone will find it interesting.
Actually if we are treating a patient new to insulin under the care of the endocrinologist we will do post-prandial glucoses to check the patient's reaction to their insulin dose. This is also used to calculate their insulin to carb dose if they will be carb counting on discharge.
But... very few of our patients are that tightly controlled. Our low dose scale (which most are on) only gives 1 unit of Regular or Novolog for a glucose of 180 with no nutritional dose. Hardly seems worth the expense of the syringe and tracking down another RN to double check the dose with you.
@doozsa, I would like to see that study you quoted. My understanding with the danger of too tight control was that wide swings in glucose levels was thought to be the problem. And for the study that tried to keep Hb A1C below 6 (the ACCORD trial), it has been postulated that participants may have been having hypoglycemia while asleep and not realizing it.
But... very few of our patients are that tightly controlled. Our low dose scale (which most are on) only gives 1 unit of Regular or Novolog for a glucose of 180 with no nutritional dose. Hardly seems worth the expense of the syringe and tracking down another RN to double check the dose with you.
@doozsa, I would like to see that study you quoted. My understanding with the danger of too tight control was that wide swings in glucose levels was thought to be the problem. And for the study that tried to keep Hb A1C below 6 (the ACCORD trial), it has been postulated that participants may have been having hypoglycemia while asleep and not realizing it.
Here is a link to the New England Journal of Medicine describing the NICE-SUGAR study.
"In conclusion, our trial showed that a blood glucose target of less than 180 mg per deciliter resulted in lower mortality than a target of 81 to 108 mg per deciliter. On the basis of our results, we do not recommend use of the lower target in critically ill adults."
Hoozdo, ADN
1,555 Posts
I like to also consider what other drugs the pt is taking. For example, if your pt is on corticosteroids, the blood glucose will be high whether they eat or not.
I use a LOT of insulin drips in my practice, (accuchecks Q1hr) and titration of insulin. New evidence based practice says use the insulin drip if glucose is over 180. The old limit was 150. A large study was done proving that clinical outcomes do not change in the ICU/CVICU with the lower 150 limit.
I don't have a link now, because I am tired..........rough night shift. I am sure I can find it later if someone will find it interesting.