Insanity over Insulin!

[KimmieKoo72]

I'm a new LPN, I work in LTC. The floor I usually work on I have 33 residents.. 9 of which are diabetic and require accuchecks and coverage. About a week ago I had my first resident bottom out on me. The resident could not hold their head up and was basically limp in the wheelchair. They were able to speak and answer questions.. but it was really really scary. Considering this was my first experience with someone bottoming out. The resident turned out just fine after 2 instant glucose tubes, glucerna and another dinner tray... the main problem was that they had not eaten well durring the day, which made their sugar low. This resident has a routine order for novolog 3 times a day before meals. I know alot of nurses would say "hold it, per nursing judgement." But I am under the understanding that you can not hold a long acting insulin. Since this has happened I have major anxiety about giving insulin. I'm very cautious with it, I double check everything 3 times before I give it.. and with the brittle diabetics I make sure they eat the majority, if not all of their meals and I give them glucerna like it's going out of style. But I am just wondering if anyone else shares some of this anxiety.. or how the more experienced nurses look at this. I think I'm going to look around my area and see if any area hospitals are doing any type of inservices or CE's about diabetes. I think expanding my knowledge on this disease as much as a can will help my anxiety and boost my confidence. Any other tips, ideas, tricks???

[KrisRNwannabe]

what was the patients blood sugar when you checked it? if it was on the lower side I wouldn't have given it. You have to make judgements like this sometimes regardless of whether it is long acting insulin or a BP med you just have to make a judgement call. what kind of long acting was it like 70/30? if she hadn't eaten well all day it should have been held.

Kris

[Kymmi]

I think you need to remember that long acting insulin that you give isnt going to affect the blood sugar quickly however the insulin that was given the previous shift will. We always check blood glucose levels prior to insulin adminstration however I work in ICU. I am trying to remember when I worked in LTC whether we did a routine glucose check each AM on our residents.

My thought when I read this post was occasionally a drop in blood sugar happen for various reasons however if blood glucoses run routinely low (or high) then a adjustment in the insulin dosage needs to be made by the MD. The MD needs notified so he knows what is going on. I've seen people hold insulin because the sugar was low and didnt bother to get the dosage changed instead they would just hold it and then the next dose would be given but the one after that would be held etc etc without the MD being made aware which was really not the right way to handle the low glucose levels. Instead of holding the insulin every so many doses the routine dose needs adjusted to meet the patient needs.

I sure hope that I made sense with what I wrote...I know what Im trying to say but sometimes I have a hard time typing it out. :)

[deeDawntee, RN]

First of all, I would relax. You are asking all the right questions and you WILL run into this again; people will become hypoglycemic. You handled it fine. There isn't a lot you can do, because like you said, if the long acting insulin was given before the patient was not feeling well and not eating, there really is not much you could do about it, especially since you have 33 other patients to keep an eye on as well. Also, even if the patient is eating, stress or a brewing infection can lower blood glucose. You will know those few residents after awhile who have the tendency to drop their sugars and you will develop a 6th sense about it and will start checking sugars just to be certain they are OK.

Certainly a class on diabetes would be educational, but I think you are doing fine. Do you have a standing order for IM glucagon if the patient can't take anything by mouth? I work in an ICU and we had a patient who was very hypoglycemic, we couldn't give anything IM because of coagulapathy and as an emergent direct admission, we had no IV access. (I don't want to gross you out...but, his nurse squirted some of the glucose gel up his rectum, and it worked! Sometimes you do what you have got to do to save a person's life...)

:lol2:

[KimmieKoo72]

Thank you all so much for your input. I really appreciate any advice I can get! Nursing is forever a learning field and I have so much more to learn!!!

[kiszi, RN]

Novolog is not a long acting insulin. It's short acting, shorter than regular. The only insulin I'll never hold is Lantus, which is sounds like this pt. might be better off with. Routine novolog for someone that doesn't always eat sounds like an accident waiting to happen. You should check with the Dr. about ordering something else.

[TheCommuter, BSN, RN]

This resident has a routine order for novolog 3 times a day before meals. I know alot of nurses would say "hold it, per nursing judgement." But I am under the understanding that you can not hold a long acting insulin.

Novolog is not a long-acting insulin. It is just the opposite: it's a very rapid-acting insulin, which is why it is given during meals (to keep the postprandial blood glucose levels from skyrocketing too high). Please review the different insulins, as it might bestow some confidence upon you to give insulin again. In addition, review the insulins for the safety of your patients.