Insulin...When/ When not to give

[yurnurse]

I had an issue at work the other night that I just can't get over so I decided to ask you very knowledgable nurses. I had a diabetic resident who at dinner time started to have an upset stomach and was complaining of nausea. He refused to eat because of that. His predinner B.S. was 155 in which I did not cover him with any insulin because his is rapid acting and all of his doses are high (for 155 coverage is 15 units.) Well since he did not eat I held his insulin and his pills. I informed the supervisor of my actions in which she said that was ok just make sure that I documented what was going on. Well now its 1110pm and I am about to go home when the the NOC supervisor calls the unit and questions my actions. She states that I am not a physician and that I can not make the choice to hold a residents insulin. I explained the situation to her stressing the fact that he has not eaten anything and that he would be receiving alot of insulin. She said that it was ok, we would just monitor him closely and if he bottomed out they would give him something to eat. Ummmm, I'm sorry but does the work nauseous not mean anything to you. In the end I gave the 15 units and documented my butt off as to why. Was that the right thing to do and was what the supervisor said right? TIA

[EmmaG, RN]

A sliding scale dose that high tells me the person is pretty resistant to insulin and needs it. I wouldn't have held the insulin without contacting the physician for orders to either give as ordered or for a reduced dosage.

In the end I gave the 15 units and documented my butt off as to why.

Did you recheck the blood sugar before giving this dose?

[nightmare, RN]

You did right documenting.I hope the supervisor was there when he hypoed!

[leslie :-D]

yes, it requires an md order to hold.

in times like this, i often give the pt 30-60cc of a supplement/juice, w/half-1 packet of sugar, depending on their bs.

sometimes it's a tough call.

even when they're not eating, or even actively vomiting, any stress on the body will raise their blood glucose levels.

these nsg judgments are not usually black and white.

it depends on the pt, their presentation, other relevant diagnostics/comorbidities, etc.

but you were right in documenting thoroughly and comprehensively.

leslie

[TheCommuter, BSN, RN]

I would have called the physician, explained to the MD that the patient stated he would not be eating dinner that evening, and perhaps attempted to obtain a telephone order to withhold the sliding scale insulin dose. When you pass the buck onto the doctor, you are essentially covering your butt in the most prudent manner possible. As always, document concisely.

[EmmaG, RN]

even when they're not eating, or even actively vomiting, any stress on the body will raise their blood glucose levels.

Some of the most consistently highest sugars I've seen are in these instances.

[yurnurse]

I did, it went up to 201 which called for 21 units of insulin and I offered to call the doctor but the supervisor insisted that it was getting to late so to just give it. I am in my 3rd semester of nursing school and I know the real world is different than class but I was taught that if they don't eat to hold insulin which is why I did. Plus he received 29 units of Lantus insulin as well.

[yurnurse]

I honestly appreciate everyone's replies. I have been sick all day wondering if I did the right thing. I am not always sure as to when I can do something and call it a nursing measure which is why I asked the supervisor. Thank you again this was very helpful and the next time I will be sure to call the MD first.

[TheCommuter, BSN, RN]

Plus he received 29 units of Lantus insulin as well.

Lantus is an extremely slow-acting insulin that works to keep blood glucose levels regulated over a 24 hour period. Many poorly-controlled diabetics can receive high doses of HS Lantus along with sliding scale insulin, and never bottom out.

You probably already know to never mix Lantus with other insulins.

[leslie :-D]

but I was taught that if they don't eat to hold insulin which is why I did.

i'm sorry, but that is ill-advised.

unless there are accompanying parameters, you need to notify the md whenever you hold a med.

and again, when someone is sick, our bg levels increase.

w/an ill diabetic, it is all about balance.

furthermore, we'd have our butts in a sling if all we did was 'follow orders'.

there is a lot of nsg judgment that goes w/our interventions.

and this is where critical thinking comes in.

nursing is the farthest from anything absolute.

please keep that in mind.

leslie

[EmmaG, RN]

I honestly appreciate everyone's replies. I have been sick all day wondering if I did the right thing. I am not always sure as to when I can do something and call it a nursing measure which is why I asked the supervisor. Thank you again this was very helpful and the next time I will be sure to call the MD first.

We're always learning :)

The fact that he went up to 201 without eating tells me he could have received the scheduled dose of insulin at dinner time without problems. However, it's always a good idea to notify the MD, as he may have wanted to adjust the scale until the patient was back on his diet again.

[CITCAT]

Yes it is a problem, I understandable first i would hae called to dr. got a order to address the nausea,blood glucose and diet It hard to say because of the patients condition other dxs and previous glucose values and primary type of insulin When in doubt call the Doctor remember its your ------ not the supervisiors when it comes down to the brass tax