Night shift giving breakfast insulins w/o tray

[findingmywayRN]

I know this is nursing 101 here, but I just started a new job at which I've been told twice (by two different charge nurses) that night shift nurses give the breakfast insulins - even though the trays don't arrive until around 8 am. At my 7 am sign off report (nights leaves at 7:30) the oncoming nurse was a little huffy that I hadn't given a patient 2 units of Reguar insulin due AC breakfast. This patient also had 8 am meds due.

Ever since nursing school I have ALWAYS brought the tray directly into the patient with the insulin, and would never dream of doing otherwise! Are other units having night shift do this, or is this just plain crazy???

[Spatialized]

I wish that I could print this discussion off and show to our managers, so they would see that what we are doing is both dangerous and not part of the norm.

We do our fingersticks between 6 & 7. Then we (the night shift) are required to give coverage for those that require it. If it is regular insulin, I don't have a big problem doing that, most of the time those on regular do not have an aggressive sliding scale. When it comes to those getting Novolog, I do it right before I clock out, usually when I see the trays coming down the hall. I give my AM Lantus between 7 & 7:30. There are days where I will not give the Novolog and pass that to the day shift. Rarely have I encountered any resistance to that, although there have been some occasions.

We're in the process of trying to get the policy changed, but as with nay policy change it takes time. Good to see that other folks are dealing with this.

Cheers,

Tom

[leslie :-D]

I agree with this 100%. I cannot understand why juice should be given with insulin if the patient is hyperglycemic. Out of all of the BGs that I check throughout the day the vast majority are high, not low. For hypoglycemia juice is definitely in order. But it doesn't make any sense to give a sugary drink to a diabetic as you are giving them insulin. It would be a better idea if they need something to drink to give them milk or water.

it depends on what the fasting sugar is...

i don't automatically give out juices to ea and every one.

but the brittle diabetics, i do.

i know how they crash and i try and anticipate this.

if i get a fasting of 500, i don't give juice.

but with 250, i do...again, w/the brittle ones.

most don't have appetites so i can't count on them eating breakfast.

it's unique to ea pt, to their hx and current status.

leslie

[indigo girl]

it depends on what the fasting sugar is...

i don't automatically give out juices to ea and every one.

but the brittle diabetics, i do.

i know how they crash and i try and anticipate this.

if i get a fasting of 500, i don't give juice.

but with 250, i do...again, w/the brittle ones.

most don't have appetites so i can't count on them eating breakfast.

it's unique to ea pt, to their hx and current status.

leslie

Ditto for me. Many people do not need any juice. Only those with

kind of low sugars or the brittle folks, and those that I know can not

be counted upon to eat. We do our best to judge their situations.

Trays do not come up until around 8 am.

[kanzi monkey]

I agree with this 100%. I cannot understand why juice should be given with insulin if the patient is hyperglycemic. Out of all of the BGs that I check throughout the day the vast majority are high, not low. For hypoglycemia juice is definitely in order. But it doesn't make any sense to give a sugary drink to a diabetic as you are giving them insulin. It would be a better idea if they need something to drink to give them milk or water.

I recently learned that milk is actually a preferred carb to give if a pt is hypoglycemic

From this website: http://www.lifeclinic.com/focus/diabetes/hypoglycemia.asp

"The American Diabetes Association (ADA) states that milk is better than juice or glucose because it has lactose, fat and protein that will help keep your blood sugar remain steady over time."

As far as what earle58 is saying about giving insulin with a simple carb, well, I don't know. I would say this is a good idea if you have just given a pt lispro, and suddenly their plan to eat changes. If you are giving regular insulin, the simple carb won't be as helpful by the time the insulin starts to work. And with a BS of >200, I would imagine the risk for becoming hypo with a sliding scale insulin (which is usually just a few units) would be slim, unless there was a pt condition that would make things otherwise (ie, pancreatic ca, or something else that may alter the rate of insulin in a way that is not typical for diabetics).

Those standing doses of lispro can be pretty high (20+ units), and I would definitely get nervous if I gave that to a pt who decided to be finicky with their breakfast though!

I have only once seen a pt dangerously hypoglycemic (BS 18!) who needed d50 IVP--he had hyperinsulinemia d/t mets to the pancreas I believe (I was a student at the time, so some info may have been lost in translation)

It was terrifying.

-kan

[leslie :-D]

kan, i agree about giving the milk, in terms of better stabilized sugars.

that's why i was changing from "juice" to "drinks".

it depends...some of my pts hate milk, so i give the house supplement/ensure.

interestingly, all my diabetics have ca w/mets (hospice).

even when it states mets in the pelvic region, i have to remember the liver and pancreas, and how this could affect blood sugars.

eventually, they all stop the accuchecks anyway.

at that point, we just don't know what we're dealing with, and do the best we can.

leslie

[woody62, RN]

I am unaware of NPH ever being given for insulin on a sliding scale. A sliding scale is given to lower one's blood sugar, in a fairly short period of time, so there would be no point of giving NPH. It goes against the recommendations of The American Diabetes Association, Joslin, all the physicians I know, to name a few. NPH does not begin working for an hour to an hour and half. Regular insulin begins working in five to fifteen minutes of being given. A patient is put on a sliding scale in an attempt to control excessive blood suagrs. While physicjans have lowered the starting point of blood sugars, some to the 160s, they still give regular insulin.

This discussion began on giving insulin too early for breakfast and having trays passed late. If a patient is on a regular dose of insulin, he knows what he has to do to prevent an episode of hypoglycemia. Premixed insulins generally have an onset of anywhere from five to thirty minutes. And peak from one to two hours to four to six hours. All others have onsets of one or more hours And peak from six to ten hours.

When I am hospitalized, unless my blood sugar is high and requireds a few units of regular insulin, I am more concerned about getting my NPH an hour before I eat. If I am being covered by a sliding scale, I need it right after my blood sugar is tested, I'm not worried about it dropping too much.

Woody:balloons:

[leslymill]

I agree with this 100%. I cannot understand why juice should be given with insulin if the patient is hyperglycemic. Out of all of the BGs that I check throughout the day the vast majority are high, not low. For hypoglycemia juice is definitely in order. But it doesn't make any sense to give a sugary drink to a diabetic as you are giving them insulin. It would be a better idea if they need something to drink to give them milk or water.

I worked nights for 22 years and it actually does make alot of sense to give juice with any end of shift insulin. The day shift refuses to do the AM FSBS and you feel forced to do it without any food forthcoming. I also tell them if they feel signs of hypoglycemia to report it. I could also teach them why I am giving them juice as a precaution they may not need at home. since breakfast wont be forthcoming in the hospital for sometimes up to an hour. I do tell diabetic pts and their day shift nurses they need their breakfast trays ASAP. That is the policy in most places. Some places have gone beyond this and diabetic trays are color coded to be passed out FIRST. One place I worked had the trays come up with pre-op op trays an hour before the regular breakfast trays came up. That was a good idea.

From a diabetic's control stand point your concerns are valid. From a pt safety stand point, juice with any insulin and no food in sight is common practice and is considered prudent.

I agree with the original poster and am curious, what does your facility do?

[penyegue]

I'm a night shift nurse. At my facility we do fsbs @ 7:00 a.m. It is the first shift that give insulins. Normally their bs is low to average early in the morning.

[findingmywayRN]

I'm really glad to hear this thread opened up a discussion about this practice! The patient this concerned did not take insulin prior to being admitted to the hospital.

I will speak with the nurse manager about this practice to hear her thoughts. I agree that BG's should be checked closer to the end of shift, especially since the trays don't arrive until long after night shift leaves.

[nitenurse02]

Our night shift gives the morning insulin. If their BS is below 115 or so, and they have a large dose of am insulin, I won't give their shot but will tell them to call when breakfast gets here and i tell the oncoming nurse that has that pt about the situation.

we try to do sugars after 615 or so. and cover as close to 700 as possible.

[classicdame, MSN, EdD]

NOT a good practice to give insulin without food to cover. Fast-acting acts in 5-15 minutes. Food should be in front of their face. Regular acts in 30 minutes - and if the order was a "generic" dose that the patient gets regardless of consumption, then you are looking at a possible hypoglycemic event. I would refuse to give it during the night shift.

In Europe, and some US hospitals, the patients have insulin delivered by pens and are able to dose themselves or at least it is nearby when the trays are delivered. Another option - nurse delivers tray to the diabetic patient with insulin in hand. Don't laugh - I did that for years and my patients thought it was a good idea. They did not get awakened twice and were being taught the importance of food + insulin. Remember, this is a self-monitored disease. We need to teach by what we do.