Pls help, dumb ? abt insulin & ss

  1. I'd really appreciate it if anyone could answer a quick question about sliding scale coverage. I'm an RN and just started working LTC night shift. Last night at 2:00 am one of our diabetic residents awoke with pain in her right foot and requested her prn vicodin. After giving the pain med I assessed the foot for circulation motion and sensitivity and found nothing unusual.

    So I decided to check her sugar since we were taught in school that this is an independent nursing action. Her BS was 325 and she has orders for sliding scale coverage. My question is can a nurse administer the sliding scale insulin after doing a random accucheck? It seems most ss orders read "acccucheck at 6am and 9pm with sliding scale for BS > 200." Or something to that effect.

    She ended up asking to go to the ER because the pain became more severe. The ER doc gave her Demerol and insulin coverage then sent her back. I probably should know this but...if she hadn't gone to the ER could I have administered the sliding scale without waking the nursing home medical director?

    I'll ask the DON when I go back to work Wednesday but would appreciate any feedback. Many thanks!!
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    About lyceeboo

    Joined: Feb '01; Posts: 110; Likes: 149
    from US
    Specialty: med/surg, ortho, rehab, ltc

    16 Comments

  3. by   SouthernLPN2RN
    I have had this problem myself and I called the MD with the level and went per his order. It wasn't the middle of the night though. This is something I would check with the DON about.
  4. by   txspadequeenRN
    This is what I have always done. I check the BS anytime I feel it is needed. However, because the SS orders I have are time specific (and not PRN) following ordered BS anything I give extra I obtain as a one time order. But this is a good question ...
  5. by   floatRN
    If it is within an hour or two of the next scheduled accu check, I have given the sliding scale insulin early to cover a random high blood sugar. Otherwise, I would call the MD for a one time order.
  6. by   rn/writer
    You might want to speak with the DON and approach the doc for an order that is situational rather than time specific to cover just such emergencies--especially, if this is a frequent problem for this resident.

    You would also want to take into account timing of previous and next meals, insulins, and any other factors that might be causing problems. Other factors include illness, stress, change in diet or activity level, dehydration, and just about anything that can influence blood sugar.

    Also look into how long it has been since her last insulin adjustment. If she has frequent bouts of elevated blood glucose, she may need a change. Do you know her hA1c level? That will tell you something about her overall control.
  7. by   augigi
    I agree, you need a PRN or one time order, not a time-specific sliding scale. Another question is why is her BSL so high at that time of night?? Perhaps her overall insulin regime needs reviewed.
  8. by   lauralassie
    Quote from lyceeboo
    I'd really appreciate it if anyone could answer a quick question about sliding scale coverage. I'm an RN and just started working LTC night shift. Last night at 2:00 am one of our diabetic residents awoke with pain in her right foot and requested her prn vicodin. After giving the pain med I assessed the foot for circulation motion and sensitivity and found nothing unusual.

    So I decided to check her sugar since we were taught in school that this is an independent nursing action. Her BS was 325 and she has orders for sliding scale coverage. My question is can a nurse administer the sliding scale insulin after doing a random accucheck? It seems most ss orders read "acccucheck at 6am and 9pm with sliding scale for BS > 200." Or something to that effect.


    She ended up asking to go to the ER because the pain became more severe. The ER doc gave her Demerol and insulin coverage then sent her back. I probably should know this but...if she hadn't gone to the ER could I have administered the sliding scale without waking the nursing home medical director?

    I'll ask the DON when I go back to work Wednesday but would appreciate any feedback. Many thanks!!

    :spin:
    I wouldn't give the insulin without calling the Dr. Otherwise, your admin a med without an order. We know what makes sense, but are the Dr's plans for that pt. different than what we think.
  9. by   brendamyheart
    You will always need an order to give SS insulin when it out of the normal time for a BSFS. With the information you would give the doctor he may need to adjust any regular insulin given, such as NPH etc. On the other hand elevated BS could mean a sign of infection.
  10. by   miko014
    You would also want to take into account timing of previous and next meals, insulins, and any other factors that might be causing problems.
    Absolutely...especially if she had anything besides regular insulin after her HS check. I'm always a bit more nervous about covering people during the night anyway because if they drop too far and you think they are just sleeping, it could be awhile before anybody notices anything is wrong. Bottom line, ALWAYS cover your butt - get the one time order! I'd mentionit to the doc, but you need more than one number to show that her BS is out of control. I'd either recheck her during the next few nights or see about an order for an hA1c. Just my two cents!
  11. by   ArmyMSN
    2 a.m is about the time dawn phenomenon occurs - body's response to low blood sugar - kicks in the body's hormones (cortisol) and makes insulin (injected type) less effective.

    I'd not give the SSI, but would report it to the MD that morning and ask what to do in future if I ever had to get a FSBG again.
  12. by   lyceeboo
    I completely forgot about dawn's phenomenon. Thanks for all the supportive & informative replys! I'll ask my DON but I think you've given me the correct answer. Guess I wasn't sure if standard ss insulin orders are time specific.

    But I won't hesitate to call the doc next time since the unresolved pain was probably a good reason to wake him & update him on the BS at the same time. That would have been the most conservative, safe thing to do. Only problem was one of the night shift C.N.A.'s is kind of bossy. She kept telling the resident, "You need to go to the ER."

    I explained than the ER might make her wait & that they might not be able to do much more for her than I could do with new orders and close monitoring. But after the aide got her all worked up about it the resident felt she needed an ambulance ride to the ER. Guess there's another lesson for me...about not losing control of the staff.

    When I called to ask the DON about it she wasn't in. The ADON said that the LTC will have to "eat" the ambulance ride because the resident wasn't admitted. ADON said she would have called the resident's husband and asked him to drive her to the ER since it wasn't an emergency. (The ER is 5 minutes away from the NH and the husband lives 30 minutes away & has terminal cancer!) Anyway the ADON did say I did the right thing.


    Thanks again!
  13. by   ktwlpn
    Quote from lyceeboo
    I'd really appreciate it if anyone could answer a quick question about sliding scale coverage. I'm an RN and just started working LTC night shift. Last night at 2:00 am one of our diabetic residents awoke with pain in her right foot and requested her prn vicodin. After giving the pain med I assessed the foot for circulation motion and sensitivity and found nothing unusual.

    So I decided to check her sugar since we were taught in school that this is an independent nursing action. Her BS was 325 and she has orders for sliding scale coverage. My question is can a nurse administer the sliding scale insulin after doing a random accucheck? It seems most ss orders read "acccucheck at 6am and 9pm with sliding scale for BS > 200." Or something to that effect.

    She ended up asking to go to the ER because the pain became more severe. The ER doc gave her Demerol and insulin coverage then sent her back. I probably should know this but...if she hadn't gone to the ER could I have administered the sliding scale without waking the nursing home medical director?

    I'll ask the DON when I go back to work Wednesday but would appreciate any feedback. Many thanks!!
    Why did you check her sugar? I would have done so only if I saw s/s of hypo/hyerglycemia. We look at the hgbA1C -I don't think anyone would have thought twice about 325 (we have alot of non-compliant IDDM's on bid or qid fs with sliding scales with parameters to call the md for below 60 and above 400-most of our folks get coverage from the 150's up to the 400-450's routinely) I wonder if she has a history of an osteo in that foot? I have never heard of anyone at our ltc giving the sliding scale coverage in a situation like yours.I would be afraid to bottom her out before the next fs and meal is due..I fear my brain has turned to mush
  14. by   lyceeboo
    S/S hypo or hyper? Well she looked kind of drowsy/tired but I'm new to the NH so I don't know what this residents baseline energy level is. Then again we all look tired at 2am! Guess I checked BS because I was thinking diabetic neuropathy. (I did VS too just to have the info available if I needed to call the doc.)

    This may sound manipulative but I felt that by demonstrating my genuine concern and giving her a lot of attention I could get a better idea of what was causing her pain. ie -- She may have been in moderate pain but also suffering from lonliness. I couldn't tell because I don't know her well enough.

    She did seem much happier and showed fewer s/s pain when the CNA started making such a fuss about how I needed to sent her to the ER right away. But like they taught us in shool...The pain level is anything the pt says it is!

    BTW do you know why it says warn at the bottom of my last reply? Guess I'll have to check what those symbols mean. Thanks for your feedback ktw! Have a good one.

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