Insulin dosage question

Keepstanding, ASN, RN · Aug 29, 2008

i have never seen this in my school nursing career. i most often get clear, defined instructions on how much insulin to give, what the normal bs levels should be and what the correction factor is. i would not be comfortable with this kind of arrangement.

good luck on sorting this out. and at such a busy, crazy time of the school year.

praiser :heartbeat

siestababe · Sep 1, 2008

As a nurse, and the mother of a type 1 diabetic, I can say that the dosage does vary. If the student is on the N and R combo BID, he/she shouldn't need to bolus during the day; however, if he/she is on the pump or using a pen, then of course she will need to take a bolus. Most type 1 diabetics now base their doses on the carb/insulin ratio prescribed by their MD. You, as the nurse, should have a copy of that, as well as a correction factor in case of hyperglycemia. In the case of my daughter, I just had her put in her blood glucose level and the amount of carbs she was about to eat on her pump and had the teacher (we didn't have a FT nurse at our school) OK the dose she was to receive before she pushed the "enter" button. Most if not all pumps are preprogrammed and do all the math. Sounds complicated, but most families are ready and willing to give the nurse all the education you need. If not, contact her MD and get the scoop.:)

Hope this helps!

blondy2061h, MSN, RN · Sep 4, 2008

I'm on a pump, and my dose can range from a fraction of a unit to 10 units. It varies HUGELY. I let my pump do the math, but I sometimes over rule what the pump recommends, particularly if I'm sick, have been running low, or plan on exercising soon. I can see why the doctor would want the parent to figure out the dose. They know their child best.

joy09 · Sep 4, 2008

I have run into notes by the doctor to "let the parent change the dosage". I have specific instructions and expect to get changes immediately from the doctor's office. I found one parent who had a brittle diabetic really didn't understand the whole carb to unit ratio etc. Also, her math was wrong on the dose she calcuated for hyperglycemia scale. Why couldn't this be in writing? Our med order sheet stipulates that we may speak with the doctor and the health update does as well so we can contact the doctor if we aren't comfortable. See my post on insulin orders.

blondy2061h, MSN, RN · Sep 5, 2008

But doctors aren't involved in each dose change. If I'm high after breakfast consistently, I don't wait for my doc to tell me I need more insulin at breakfast. If I'm low at night consistently, I don't wait for my doctor to tell me to lower my night time basals. I change my dosing calculations someway probably every other week. It's a continual fine tuning process.

Jolie, BSN · Sep 5, 2008

The parent must be working from a formula to determine each individual dose.

I agree that the nurse should have that information available to double check with the parent.

Just blindly accepting a number without understanding how it is calculated doesn't seem reasonable or safe.

joy09 · Sep 5, 2008

I will change the dose (more likely, the student does it himself) as the parent directs however, most orders are written specifically with coverage on a sliding scale. If the student is consistently high or low, I inform the parent and it is evaluated by the doctor. If carb:insulin ratio needs to be changed, it's faxed from the doctor's office. This doesn't seem unreasonable. It isn't convenient but the bottom line is, I can't take changes in insulin from a parent, only from a physician. If the doctor writes for the parent to change the specific dose at any given time, I am going to abide by it. Does that make sense? Is it unreasonable to expect a change in the sliding scale or the carb:unit ratio? I don't want to be a stick in the mud, just safe and appropriate. What do you think?

blondy2061h, MSN, RN · Sep 6, 2008

I do kind of think it's unreasonable to expect a doctor to have input every time the formula is changed. Faxing logs every two weeks to a doctor's office over a disease you have for years, and years, is just ridiculous, particularly when the parent knows the child better than the doctor. After all, they're the one that deals with the disease everyday. The doctor has hundreds of patients, all different. Imagine if they were all faxing logs every two weeks? It's impossible to keep up with, especially as endocrinology is a low-paid, and therefore rarer, specialty.

If you understand the formula being used to calculate the dose, you understand the rational for making changes in it, and you have an order for parents to calculate the dose, you're not being unsafe or doing anything blindly.

My insulin script simply has a daily max of 61 units written on it (and I usually use about 40).

PvtSchlNurse · Sep 21, 2008

The initial orders I receive on the Health Plan that is filled out by the MD has an order that the Nurse can accept changes from the Parents. To make me feel better, I ask for something in writing from the Parents. I even added an extra page to our Diabetic HP that is just for Parents to fill out when there are changes say, in the insulin to carb ratio or the correction factor formula changes. That way I have "proof" of the changes I have received from the Parents.

Documentation is so very important.

I think we are so used to having a set "order" to follow like a sliding scale which you don't see much anymore. Like someone said previously most insulin doses are now based on BS before the meal + CHO intake at a meal.