BS 94, Lantus 20 units, give HS snack?

knotizer12 · Jul 16, 2018

See I really should have asked that. I was just wondering if any of my more experienced nurses would have just given a snack. Her chart/MAR mentioned nothing about giving her a snack at HS.

KelRN215, BSN, RN · Jul 16, 2018

Lantus doesn't peak and 94 mg/dL isn't low. I wouldn't give a snack unless the patient specifically asked for one as I wouldn't be worried about their blood sugar bottoming out from the long acting insulin I'm administering.

MunoRN, RN · Jul 16, 2018

The purpose of an HS snack for diabetics isn't to prevent hypoglycemia, it's to prevent hyperglycemia, as well as to reduce excessive ketone production at night. In theory at least, an hs snack helps prevent nighttime and AM hyperglycemia, sometimes called 'dawn phenomenon which is though to occur at least in part due to a fasting state which triggers the release of glycogen, which is poorly modulated particularly in type 1 diabetics resulting in hyperglycemia.

A BG of 94 is a normal BG, although as others have mentioned it's not one size fits all and it would be helpful to look at their trends. Are they normally 250 at hs and then drop to 70 by 5 AM, if so starting the night at 94 might be problematic, otherwise their routine appears to be working and there's no apparent reason to mess with it by holding the lantus.

Kallie3006, ADN · Jul 17, 2018

Was this a new order or a change in units for this patient? If not, I would not have given a HS snack for the purpose of preventing a hypoglycemic episode. I'm sure if the patient's FBS in the morning had been problamatic then that would have been known to the OP and a more cautious approach may have been warrented, and that of course would have also included the Dr.'s orders and or parameters if this was an established concern for the patient.

JudyB88 · Jul 17, 2018

OJ is not considered a "snack" for a diabetic. Please be cautious of what constitutes a snack. It should always be a carb and a protein. Like a PB&J sandwich or cheese crackers or gram crackers and milk. Giving just a sugar actually spikes your BS and then it drops lower than previous.

JudyB88 · Jul 17, 2018

Very concerned about some of the comments on here about insulin and snacks. Good rule of thumb is that all diabetics should be offered an evening nutritional snack since EVERY time they experience a hypoglycemic event, they lose brain cells. Hyper (within reason of course) is much less dangerous than hypo. As for giving the lantus, yes a bedtime snack should have been offered. Lantus "peaks" generally within 6-8 hours. But realize it's peak is not like a short acting, much more subtle. However, if the resident's last meal was at 5pm and Lantus given at 8pm, likely would see significant effect at 2-4am and if resident is sleeping, likely not to notice the early signs of hypoglycemia. If they awaken and put call light on, we all know response time is slower at night with less staff to respond, and then if night nurse does not immediately recognize and respond, then a full blown hypoglycemic response will occur. The fact that the night nurse responded the way she did, she probably offered a snack and monitored this resident. A better way for her to have handled this would have been to educate you so you knew how to handle the same situation the next time. I don't understand why nurses feel they can be critical of others instead of just offering education. Obviously you wanted to do what was best for your patient or you would not have taken the time to post on here to get experienced nurse opinions. In the future, ask...ask...ask questions. If one nurse won't explain, ask another, ask a supervisor, look it up. No one but you will protect your license. Diabetes is something I'm passionate about (after losing a2 patients to brain death due to hypoglycemia). I would not even allow my MD's to put resident's on sliding scales except during the 1 st week of admission or for up to 2 weeks when having a critical event like a serious infection causing difficult control. I got my medical director to support a protocol that prevented SSI without his or my approval beyond 1 week. It was difficult to enforce at first but when they saw the outcomes, of f0 re-hospitalizations for 4 YEARS they all stayed on board. (there were other components to protocol such as adding oral agents and monitoring labs and reduction of fingersticks). My point is, good for you for finding out what you could have done better, always offer a nutritional snack (a carb and protein, not just juice).

knotizer12 · Jul 17, 2018

JudyB88 said:
OJ is not considered a "snack" for a diabetic. Please be cautious of what constitutes a snack. It should always be a carb and a protein. Like a PB&J sandwich or cheese crackers or gram crackers and milk. Giving just a sugar actually spikes your BS and then it drops lower than previous.

I am very aware of this; my point was that our hypoglycemia protocol ONLY says we can give a simple sugar and/or snack if the resident is hypoglycemic.

JudyB88 · Jul 17, 2018

You should definitely question this policy because it is unsafe and you personally could be held to a higher standard as a nurse. The policy is outdated. Please take time to educate your DON or staff ed person, they probably just don't realize the policy is outdated. Scary

knotizer12 · Jul 17, 2018

It mentioned nowhere in this resident's MAR that she was to be offered a snack at HS; the reason I bring this up is because I have seen on other resident's MARS that they are to be offered a snack. Therefore I am unsure if I need a doctor's order or not. It seems silly but I do worry about this kind of thing. Call it new nurse syndrome. Anyway, thanks for all the knowledge, y'all!

JudyB88 · Jul 17, 2018

You do not need a doctors order to offer a snack, just good, prudent nursing judgement. It's great that you are asking the questions, it will make you a great nurse.

allnurses Guide · Jul 17, 2018

JudyB88 said:
EVERY time they experience a hypoglycemic event, they lose brain cells.

Do you have a citation on this? It has been my understanding that irreversible CNS damage/hypoglycemic neuronal death is only associated with severe and prolonged hypoglycemia and in those cases is related to glucose reperfusion. I know they have been examining that there are CNS locations more susceptible to neuronal death but I haven't seen any papers that implicate mild hypoglycemia as a cause of neuronal death.

guest907278 · Jul 18, 2018

True. Not every patient has the same tolerance to insulin. I have had patients who react sharply to humulin or lantus, and those who does not. I even had a patient with BS of around 120 hs, then called the noc nurse at around 4 am with a bs of around 60, though it only happens sometimes. If the other nurse reacted that way towards you, there might have been something with that patient with regards to his/her insulin sensitivity. Ask ask ask your superiors/incoming and co-nurses who are involved in patient care, check history. I applaud op for being aware of the issue and taking steps.