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Insulin question

Posted

Specializes in Critical Care, Pediatrics, Geriatrics.

Pretty much every patient that I have taken care of has been on sliding scale insulin or an insulin gtt. So I completely understand checking the BS before injections or according to protocol, then administering appropriate units/adjust the gtt rate accordingly, and holding the insulin if BS is WNL or too low...etc.

I was charge the other day during our last clinical. One of my students had a pt that was getting scheduled insulin that morning, and he had SSI AC/HS. I can't remember which type of insulin was his scheduled insulin was...sorry but I am sure it was not regular, and it wasn't Lantus, maybe an intermediate acting insulin. I should have paid more attention. Anyway, his scheduled insulin was not on the floor yet. The student checked the BS and it was 85. Held the Reg SSI and the pt ate breakfast. At 9 or so the scheduled insulin came up and she administered that. Before lunch she rechecked his sugar and it was 45 but was not showing any clinical signs of hypoglycemia. We alerted the real nurse, got some crackers and juice, and then I went and got my instructor. He seemed to be fine, instructor said no need for D50, rechecked the BS p 30min and it was 150.

I didn't think to ask these questions then, but after I got home I started wondering. If a pt is getting scheduled insulin, you still check the BS right and hold only if the pt's BS is lower than 70? or would you hold if the BS was WNL as well? Did the pt's blood sugar drop because he had already eaten...i didn't think that intermediate insulin would peak that quickly? And my last thought, is perhaps she didn't wipe away enough of the alcohol...I didn't watch her take the BS. Could that have produced a false low, since the patient was not showing any s/sx if hypoglycemia. Would you have rechecked it to make sure it was accurate?

Sorry if these are dumb questions. :monkeydance:

cardiacRN2006, ADN, RN

Specializes in Cardiac.

I always recheck a low blood sugar-always.

It really depends on what the insulin was and how many units were scheduled. But for me, as a new nurse, I always want to know what the BS is prior to giving insulin.

What if they didn't really eat any breakfast?

lsyorke, RN

Specializes in Med-Surg, Wound Care.

It's hard to make the call on this without knowing what kind of insulin the patient is on. If it was humalog you wouldn't hold the insulin for a "normal" blood sugar, since that humalog would cover the calories from the meal.

zacarias, ASN, RN

Specializes in tele, stepdown/PCU, med/surg. Has 14 years experience.

Look at your hospital's policy. At my hospital, we check the blood sugar twice if it's low or above 400 to verify. Also, the scheduled long-lasting insulin (lispro or aspart) can be given without regard to meals generally. But since he did get low later, it is possible that his SS needs to be adjusted.

SharonH, RN

Specializes in Med/Surg, Geriatrics. Has 20 years experience.

I didn't think to ask these questions then, but after I got home I started wondering. If a pt is getting scheduled insulin, you still check the BS right and hold only if the pt's BS is lower than 70?

It depends on the ordered parameters. In case there are no parameters and if it is a fasting blood sugar and the patient has a pattern of blood sugars in the 60s in the morning and 200+ at lunch, then I would probably administer it. Unless of course, the patient was symptomatic.

or would you hold if the BS was WNL as well?

NO

Did the pt's blood sugar drop because he had already eaten...i didn't think that intermediate insulin would peak that quickly?

It's hard to say but I suspect that the patient either didn't eat as much breakfast as you thought, or I wouldn't be surprised if he was on a combination insulin i.e. 70/30 which has a faster onset and a quicker peak. Or it was some other combination of factors.

And my last thought, is perhaps she didn't wipe away enough of the alcohol...I didn't watch her take the BS. Could that have produced a false low,

NO

since the patient was not showing any s/sx if hypoglycemia. Would you have rechecked it to make sure it was accurate?

I would have rechecked it anyway and most places have a standing policy in place for hypoglycemia and for most of them, they would require a lab draw to confirm a blood sugar of 45.

We had no policy in place in my last facility except OJ and hold insulin for 450.

We got it clarified, finally, and it depended on the patient. ALWAYS give Lantus. DON'T give regular. Recheck in an hour after giving OJ or SSI.

I certainly would have done a finger stick for your patient and asked if he was WNL. Depending on how brittle someone is, and the nurses there know that, your would give or hold, depending.

CarVsTree

Specializes in Trauma ICU, MICU/SICU. Has 4 years experience.

What did the Sliding Scale say? In my hospital, sliding scales generally do not require a dose until over 140.

Why did the student give it based on a post meal sugar? Or did they just give it because the pt ate. Sounds like the SS is based on fasting BG.

It's hard to answer your questions without knowing the orig. order.

As for being asymptomatic, I had a pt. who was 39 and asymptomatic. I re-checked via glucometer, drew a stat glucose for the lab, administered D50, then checked the glucose lab result and the glucometer was correct.

Even with alcohol or a dilute sample, you USU won't drop more than a few points.

nurse4theplanet, RN

Specializes in Critical Care, Pediatrics, Geriatrics.

What did the Sliding Scale say? In my hospital, sliding scales generally do not require a dose until over 140.

Why did the student give it based on a post meal sugar? Or did they just give it because the pt ate. Sounds like the SS is based on fasting BG.

It's hard to answer your questions without knowing the orig. order.

As for being asymptomatic, I had a pt. who was 39 and asymptomatic. I re-checked via glucometer, drew a stat glucose for the lab, administered D50, then checked the glucose lab result and the glucometer was correct.

Even with alcohol or a dilute sample, you usu won't drop more than a few points.

The SSI insulin was held. The accucheck was before breakfast. The pt ate 100% of his tray. The scheduled insulin was given at 9 without checking the BS again. The next AC check was done before lunch...that was the low BS.

I should have paid more attention to what type of insulin the scheduled insulin was. I should have made sure the student checked the BS before giving the scheduled dose. If it was below normal limits, then I should have made sure it was held. I should have made her double check the sugar while I notified the nurse/CI/got juice and crackers. I guess I just took for granted that this NS has had a high performance and knew what she was doing. Lesson learned.

Thanks for all the replies.

Shoulda, woulda, coulda - you're a student, and learning. And you did.

:)

marilynmom, LPN, NP

Specializes in Adolescent Psych, PICU.

Definatly always recheck a very low or very high BS. I have checked mine before and it would show something like 60, an I could tell I wasn't at a 60, I rechecked it like 1 min later and it was actually at like 120 which is good.

Those glucose machines can sometimes blip like that.

Also some people are just asymptomatic with low BS, my dads BS can get down to around 30 and he is asymptomatic. I actually start having low symptoms around 90 sometimes.

You can still give Lantus during a low but no way would I give anything else if the patients BS is low because it's going to bring it down too much, I had a nurse actually do that to me one time and I ended up passing out with a BS of 20.

And don't be so hard on yourself or the other students--your just a students right?!

JoycMarr

Has 10 years experience.

As someone said above, you should always recheck a low blood sugar. False lows may come from not having enough blood on the strip also.

mel1977

Specializes in Brain Injury Rehabilitation.

we are getting rid of the SS where I work-but from the few we do have. Depends. If they get a scheduled, we give it no matter what unless the bg is too low-or we'll give it during the meal. Then if it is high and requires the SS we'll give the additional insulin. Many times we just make it a judgement call on how low it is. If you held it until they ate, you'd have to make sure they ate a good meal and most of it or you could bottom them out if one assumes they ate and then the didn't still getting the insulin.

CarVsTree

Specializes in Trauma ICU, MICU/SICU. Has 4 years experience.

The SSI insulin was held. The accucheck was before breakfast. The pt ate 100% of his tray. The scheduled insulin was given at 9 without checking the BS again. The next AC check was done before lunch...that was the low BS.

I should have paid more attention to what type of insulin the scheduled insulin was. I should have made sure the student checked the BS before giving the scheduled dose. If it was below normal limits, then I should have made sure it was held. I should have made her double check the sugar while I notified the nurse/CI/got juice and crackers. I guess I just took for granted that this NS has had a high performance and knew what she was doing. Lesson learned.

Thanks for all the replies.

I'm still confused... You were a STUDENT in charge of a STUDENT??? Where was the instructor in all of this?

What i am trying to find out, I know student held the SSI, but what was the order. At what sugar are you giving insulin? Do you know what i mean??? For example: BG=140 give 1 Unit ___________ insulin. I know you don't remember the type of isulin, but what was the actual number of units ordered?

Thanks!

And yes, I agree... You are a student and you are there to learn. Don't be hard on yourself. I'm just trying to better understand why the coverage was given. Since it is coverage, I don't see what the student was covering...

CarVsTree

Specializes in Trauma ICU, MICU/SICU. Has 4 years experience.

The SSI insulin was held. The accucheck was before breakfast. The pt ate 100% of his tray. The scheduled insulin was given at 9 without checking the BS again. The next AC check was done before lunch...that was the low BS.

This is where the error occurred. Giving insulin because someone ate makes no sense unless they were on carbohydrate coverage which is a whole other ball o' wax.

Did you guys talk to your instructor about all this? What did she have to say? I don't see the learning experience. You're at clinicals to learn and it sounds like your instructor is leaving a lot to be desired here.

nurse4theplanet, RN

Specializes in Critical Care, Pediatrics, Geriatrics.

I'm still confused... You were a STUDENT in charge of a STUDENT??? Where was the instructor in all of this?

This is our final semester. It's geared towards nursing leadership. In previous clinicals in past semesters we are responsible for our own pts under the leadership of the CI alone. In our last clinical rotation a student is assigned as charge nurse (everyone gets two chances to charge) and has three of their peers to supervise at one time. We make the assignments, get report, pass on report, check to make sure their charting/meds are given on time, assist the students with procedures, make sure they are checking pt charts and staying on task. The CI is responsible for everyone but it trains you for leadership responsibilities.

nurse4theplanet, RN

Specializes in Critical Care, Pediatrics, Geriatrics.

This is where the error occurred. Giving insulin because someone ate makes no sense unless they were on carbohydrate coverage which is a whole other ball o' wax.

Did you guys talk to your instructor about all this? What did she have to say? I don't see the learning experience. You're at clinicals to learn and it sounds like your instructor is leaving a lot to be desired here.

The insulin was not given 'because the pt ate breakfast'. It was given because it was a scheduled dose, and I cannot remember the exact order (which I take full responsibility for), but it was not regular or long acting insulin...I am sure it was an intermediate insulin. The scheduled dose was ordered to be given (if it had been on the floor) at the same time as the SSI, but the sliding scale was held because the BS was within normal limits. All medication is checked by the CI with the student administering the medicine, not with the student charge nurse. The scheduled dose (from my understanding of the information I am receiving here) would not have been held unless the BS was low. What complicates the problem is that the scheduled insulin was not in the pt's med drawer at the appropriate time it was supposed to be administered. It came up an hour and a half later after the student had gotten the go ahead to give it from the CI at the appropriate time. The student gave the medication without my knowledge or the rechecking with the CI...I guess she assumed it was okay. No BS was taken before giving the scheduled dose. When the next accucheck was due for the SSI...the low blood sugar reared its ugly head. Nothing was said to the student or to me that a mistake was made on our parts by the CI. It was only after I got home, that the incident started to bother me and I had all these questions about scheduled insulin. So I came here for insight.

Like I said, we should have taken the BS before giving the scheduled dose, because it was an hour and a half after it was initially supposed to be administered. If it had been in the med cart on time, it would have been administered anyway because the morning BS was not abnormally low. I have learned a very important lesson here.

vegnurse21

Has 10 years experience.

I cannot stress enough (even as a brand new nurse) how important it is to recheck blood sugars that are either 300...I had an aide come up to me once and said a pt's BS was 453. Well luckily I was in orientation still and my preceptor said to check it again. Well, we did and he was 124. Checked again on the opposite hand and it was 128. Can you imagine what would've happened if the guy had 12 units of insulin?! :uhoh3: Phew. Definitely a learning experience cuz my immediate thought was 'give insulin NOW!'.

CarVsTree

Specializes in Trauma ICU, MICU/SICU. Has 4 years experience.

The insulin was not given 'because the pt ate breakfast'. It was given because it was a scheduled dose, and I cannot remember the exact order (which I take full responsibility for), but it was not regular or long acting insulin...I am sure it was an intermediate insulin. The scheduled dose was ordered to be given (if it had been on the floor) at the same time as the SSI, but the sliding scale was held because the BS was within normal limits. All medication is checked by the CI with the student administering the medicine, not with the student charge nurse. The scheduled dose (from my understanding of the information I am receiving here) would not have been held unless the BS was low. What complicates the problem is that the scheduled insulin was not in the pt's med drawer at the appropriate time it was supposed to be administered. It came up an hour and a half later after the student had gotten the go ahead to give it from the CI at the appropriate time. The student gave the medication without my knowledge or the rechecking with the CI...I guess she assumed it was okay. No BS was taken before giving the scheduled dose. When the next accucheck was due for the SSI...the low blood sugar reared its ugly head. Nothing was said to the student or to me that a mistake was made on our parts by the CI. It was only after I got home, that the incident started to bother me and I had all these questions about scheduled insulin. So I came here for insight.

I see, now this is making sense to me. I thought the student gave the SSI insulin after the pt. ate. Didn't realize it wa scheduled insulin. Therefore, it was not in error. And I don't think I would have re-checked at that point. Looks like the pt's insulin schedule needs to be revised.

I still don't like the idea of a student being in charge of a student though. We "pretended" to be in charge when I was in my last semester, but we never oversought the administration of meds. In real life charge nurses don't make sure people are giving meds on time either. They help when needed.

Don't feel bad, pt. just bottomed out. Thanks for clarifying everything and don't sweat it.

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