First SNF Job and seeing awful DM care

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I need some advice nurse family :(

I started my first LVN job this past week at a SNF. I was orienting with a nurse who has worked at the facility for over 6 years. She seemed like a great nurse! Knows her patients, has a great routine, fast and efficient. But... I ran into a dilemma while working with her.

I was helping with med pass at around 8 pm. The patient we were working on had DM II. I checked her blood sugar with a result of 164. According to the M.D.'s order, pt. is to receive Humalog 2 units per sliding scale. Due to it being at bedtime pt. is also due to receive Lantus 22 units. I verified my insulin with her. The nurse told me that she is familiar with this patient and "secretly" will give her less Lantus because the pt's blood sugar can drop pretty low and she was worried that was going to happen if I gave the full dose of Lantus 22 units. She wanted me to change the Lantus to 10 or 15 units instead of giving the ordered 22 units but then document that I gave the 22 units!

In my mind I was trippin! What the heck! If she knows this about the pt. why hasn't she contacted the doctor to change the dose of the Lantus if she knows this patients blood glucose drops low.

My real question is this:

Since pt's blood sugar was 164 before bed, is it correct to give the Humalog 2 units per sliding scale and her regular dose of Lantus 22 units before bed as ordered? I don't know these residents well yet since its my first week. Is the patient at risk for dropping low giving her long acting insulin and her short acting insulin before bed? I'm confused. I'm freaking out because I will have the cart by myself this week and am completely freaked out by what the nurse told me and what she does for this patient. Please help me nurse community!

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Specializes in LTC, Hospice, Case Management.

You are correct! 1) You should be following physician orders. Lantus is long acting and should not cause a problem during the night. If really nervous about this maybe give a bedtime snack. 2) Yes, this nurse should have called the Dr. a long time ago and gotten this order changed if she really is falling low at night - maybe she doesn't need that Humalog.

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Thank You Nascar Nurse! I just needed some sort of comfort and confirmation on this issue. These SNF units are just a nightmare and watching other nurses makes me feel like I'm losing my sense of security of knowing what to do. Could be just my nerves because I'm new to SNF and just overwhelmed. Hoping I will learn fast and do some good at this facility.

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In the Florida nursing homes, this is done all of the time. The full time permanent unit staff won't call the doctors to make changes on insulin orders. Instead, the have their own "secret insulin doses" that they give instead. I worked as a "float nurse" and they would always get mad at me for giving the actual dose of insulin that the doctors ordered.

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Specializes in Gerontology, Med surg, Home Health.

Secret medication doses? I thought I'd heard it all.

If you read the American Medical Directors latest paper....sliding scale insulin is not a good way to manage diabetic patients in a long term care setting. I've been saying this for years but most of the docs are too lazy or ill informed to figure out the correct basal rate and forego the sliding scale. It's not a good way to manage these patients...too much nursing time and the patients hate all the finger sticks.

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Thank you for your feedback Blackcat99. Good to know. As for myself, I will never be that nurse that gives "secret insulin doses". There's just no justification for this type of patient care. It doesn't help the patient, if anything it compromises their care and safety. It's shocking that some nurses just do what they want. For one, it's illegal due to the fact that they are not giving the prescribed dose and falsifying the medical record that they are. And second, they are technically prescribing and impersonating a physician. I value my nursing license and most of all the patients health and safety. It's insanity that some nurses are so lazy to make an effort to actually nurse and take two seconds to document and put in a request to the physician. I did in fact quit. I only made it 4 days through orientation and left lol. The things I saw at this facility are just sickening. It put my nursing license at risk for losing it working there. I'm happy to say I start my new job this coming Monday. I really appreciate your knowledge in informing me that this is a frequent issue.

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Specializes in Mental Health, Gerontology, Palliative.

I had this scenario a wee while back. Patient wasnt eating, blood sugars poorly controlled due to multiple other medical morbidities and I was concerned that to give her insulin could drop it too low.

I withheld the insulin and contacted the doctor ASAP, Dr gave a stat order to give a reduced dose for that day

Its incredibly bad practice to give a reduced dose without a Drs order.

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I am Psych NP in LTC and I know our PCP's almost never use a sliding scale in this setting. Too much nursing time, too much opportunity for errors, etc.

But secret doses? Wow. That would terrify me

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Specializes in Short Term/Skilled.

I've had residents in the past who saw outside endo's who refused to change their insulin orders. One brittle man would get coverage at 101. I would always hold it per nursing judgement and later on when the patient was under 100 again they started to see the pattern. I understand what she is trying to do, because it's scary to have a brittle diabetic who may bottom out on you later in the shift but the thing to do is give him/her a snack and check the sugar PRN if needed. Unless a trend is established the orders will never be changed. They need to see that the AM blood sugars are chronically low.

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Specializes in Care Coordination, Care Management.

I haaaaaate sliding scale. I worked as a Care Coordinator in a family practice. Often, our patients who went to the hospital ended up on sliding scale. I wish hospital providers would get some updated education on pharmacological management of diabetes.

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what we often ask of our docs is no sliding scale at bedtime but we still check their blood sugar

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