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

[KLKRN, RN]

A directive appeared in one of the hospitals I work at, a teaching hospital attached to a university. The directive was reminding all nurses that you never withhold insulin without calling the doctor and explaining the situation. then let him /her decide.

In another hospital I work at, a small rural hospital, the endocrinologist was EXTREMELY upset that someone held the insulin the night before without calling her.

So, always call the doc.

THEN! You document your butsky off! And remember to add: "Will continue to monitor closely."

[RNandlovingit]

Um since when does a nurse ever need an order to hold insulin? That is a nursing judgment. I worked on a cardiac unit with lots of diabetics and we would always hold the insulin if we felt it was warrented given that particular paiteints circumstance, and make sure we documented why we held. If the patient was nauseated, its rapid acting insulin. I definetly would have held, and rechecked the blood sugar in couple of hours. If still high, patient still nausesated I would have then called the doctor to see what he would like to do!

[KLKRN, RN]

I agree with you in principle. However, not all nurses know how to use critical thinking. I've seen nurses hold Lantus because they felt the sugar was too low, and the blood sugar be all over the chart the next day.

In addition, I've seen ifast-acting nsulin held, blood sugar shoot up to over 400 because the nurse who held it never checked it again and just passed it on.

Not all diabetics are alike, and not all nurses are alike.

I wouldn't personally have a problem with a pt in ICU who is being carefully monitored by a conscientious, experienced ICU nurse.

But then I'm not a doctor. There are doctors who want called before any insulin is held under any circumstances.

[leslie :-D]

Um since when does a nurse ever need an order to hold insulin? That is a nursing judgment. I worked on a cardiac unit with lots of diabetics and we would always hold the insulin if we felt it was warrented given that particular paiteints circumstance, and make sure we documented why we held. If the patient was nauseated, its rapid acting insulin. I definetly would have held, and rechecked the blood sugar in couple of hours. If still high, patient still nausesated I would have then called the doctor to see what he would like to do!

i look at holding an order, as not giving it until the next scheduled time.

what you describe is delaying an order.

you reassessed the bs in 2 hrs and inevitably still called the md.

all i'm saying is a nurse does need an order to 'hold' it- not delay it.

leslie

[KLKRN, RN]

Thanks for that clarification.

[woody62, RN]

I am an insulin dependent Type 2. And when I am in the hospital, I am also on a sliding scale. And my sliding scale is as low as this patient's. All things being considered, if my blood sugar was 156 and I was nausea and refusing dinner, I would expect the nurse to call my physician and inform him. And likely my physician would instruct her to give me the regular insulin and monitor me closely. And in all likelyhood, he would have a stat blood sugar drawn. Of course, this would be if I were in the hospital.

Woody

[Becca608]

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

Nursing student sighs and wonders "Will I ever have the wisdom of this awesome nurse?"

[meownsmile, BSN, RN]

I have to agree that if the insulin was being held it warrents a call to the doctor for the order. If you just held for a while to see how much he ate and he ate his meal then of course give it. But if for any reason you hold it with the intention of not giving it at all it has to be called, regardless of the time. That doctor is a doctor and the calls at odd hours are part of the bargain they signed on for.

Dont ever be afraid to call a doctor.

[purple_rose_3]

I would have called the doctor and explained the situation before holding the insulin. I would have also asked the patient what they normally do at home in regards to their insulin. I'm sure this isn't the first time they have ever felt nauseated.

[Chaya, ASN, RN]

This has happened to me more than once. I hava always called the MD; generally they order me to give half the indicated dose of insulin and usually this works out very well. The glucose level will be moderately controlled without bottoming out. I also ask for a follow-up plan so I am not re-calling every couple of hours. For instance, when to recheck glucose, when to cover (if not the routine time) and when MD needs to be called.

[nservice]

This is a great learning experience! It's also a great opportunity for patient teaching. Many diabetics do not understand sick day management for their diabetes. If they are sick and not eating, they hold their diabetic meds. The stress/illness causes their BG rise regardless of oral intake. Many, if not all of the DKA admits to the hospital are caused by some sort of infection to begin with.

As for holding insulin (or any medication). Check your hospital policy and procedures. Most will state that the MD must be notified if no previous parameters were given.

[whydoidoit]

I work nights, and the day nurse had given 40 units of 70/30 for a BS of around 250 before dinner. Needless to say about 2 hours into my shift I was called to the room to find an unresponsive patient who would only read LOW for her BS! I really felt like the day nurse should have questioned #1 if the resident was going to eat dinner (which she didn't or very little of) and #2 if that much insulin was really needed. Gave me a good adrenaline rush anyway!