Long Acting Insulins

[pink-e-g]

I am a new RN working in a long term care facility with the elderly. I made the decision to hold a long acting insulin (Lantus) at bedtime for one of my residents. I was warned by the nurse from the previous shift that this resident's CBG's are known to plummet. Her CBG at the time I held the insulin was 100, and she was to get 44 units of Lantus. The next day I received a note from management that it is never advised to hold a long acting insulin because they have no peak and that I should have given the insulin. The resident's morning CBG was 330, and management said that this was very dangerous. I know I don't have very much clinical experience at this point (3months), but I don't believe a CBG of 330 is necessarily dangerous, is it? I've already experienced others with CBG's in the 500's, etc. Looking in hindsight, I probably would have given the insulin with a snack. My question is: is there ever an instance that a long acting insulin should be held? Long acting insulins still have the side effect of hypoglycemia. I just want to know for future reference. Thank you in advance to anyone who replies:)

[anh06005, MSN, APRN, NP]

I think giving it with a snack would have been safest. If you were worried you could have checked their blood sugar 2-3 am to make sure it was ok.

Holding a long acting insulin affects their blood sugar the next 18-24 hours and for some it may take a few days to get back to normal. So, no, it probably won't be devastating to the patient but if it happens fairly often it can increase their risk of diabetic complications which is the entire point of the insulin.

Glad you thought it through and realize you could have made a better choice. We all have times where we don't quite do what's right. As long as there's no harm and you learn from it the move on along and chalk it up to experience!!

Also you could always check with another nurse. Or if there's a pharmacist available check with them. It's always a good learning experience to hear something explained by an expert when you don't quite have the experience.

[RN403, BSN, RN]

Pp pretty much nailed it. I would have given it with a snack and re-checked their sugar in the middle of the night.

With long acting insulin it is usually the fasting AM glucose that matters most. If that number is normal-high then it is okay to continue giving the prescribed dose of long acting insulin. If number has been consistently low, you might hold it and give the doctor a call. The pt might need a lesser amount of insulin in this case.

[Lev, MSN, RN, NP]

Next time you have a question, ask a nurse who is more senior than you, or better yet, the provider, if you should hold the insulin or give the insulin. Then, document the interaction if it was with the provider. I would have also questioned the Lantus with a blood sugar of 100 depending on the patient's trend. If I decided to give it, I would have given it with a snack and done a 3 am glucose check. The provider should be notified either way to see if dosing needs to be adjusted.

[messymissy]

I know from past personal experience, that with just 3 months working. I was the more experienced nurse!! That was scary!!

One thing you could have done was check the residents AM BS and see what the trend is. If the resident has good glucose control a BS in the 300's is dangerous. I have had to in the past do 0300 finger sticks because the resident was getting a short acting insulin and Lantus at 2100. It took several times of me calling the MD at 0300 before they stopped the short acting insulin. Never be afraid to check someone's blood sugar.... Insulin and Diabetes can be scary as a new nurse. But you will get it figured out. I think I do more reading and research as a working nurse than I ever did as a student.

Take care

[Loo17]

It would be good to look at the previous few days trends. If the patient is consistently around 100 at bedtime and receives the same dose of Lantus nightly, and is consistently within normal range in the morning, I would not be concerned with giving the dose of Lantus. Also, you should never hold long acting insulin without a doctors order.

One month into My very first nursing job I asked my supervisor if I should hold the Lantus at bedtime for a BS of 90, she said yes. The next day I was given a verbal warning by the unit manager. It didn't matter that the supervisor suggested I hold it, she was not the doctor and there was no order to hold. I was very discouraged that I could not trust my supervisor for guidance and that she didn't have my back. Live and learn.

Holding Colace for a night in the patient with increased stools is one thing, but Insulin, BP meds (without parameters) is another.

A sugar in the 300's could be bad for this patient if they have an active infection or are a brittle diabetic.

[ktwlpn, LPN]

It's important for you to get to know insulins,it's one of the most common meds in LTC.You need to know their onset and peak action,how (if) they can be mixed,etc.Make yourself a few index cards for reference.

[pink-e-g]

Ktwlpn, that is great advice. I did just that as soon as I received my note from the manager. I now carry a little booklet of fast acting and long acting insulins with their onset, peaks and durations. This experience definitely gave me a wake up call and made me realize I didn't know my insulins as well as I thought I did.

[pink-e-g]

Loo17, thanks for the advice! I often find myself asking the supervisors for advice, but I have to keep in mind that even with advice from others, I'm still solely responsible if I do something I shouldn't be doing. I'm still feeling people out to see who I should and shouldn't be taking advice from. You also mentioned something else that got my attention. Holding BP meds without parameters: I'm guilty of that as well...I consulted my supervisor beforehand, but now I'm wondering if I should have called the physician instead. So much to learn still. As a nursing student, I was taught that we had the power to decide when to hold medications (even BP meds). I think I better find out my facility policy regarding which meds require a physician's order before I hold anything else! Thanks again!

[Loo17]

You always have the power to hold a BP medication temporarily due to nursing judgement however you have to follow up with the doctor. Some docs will get angry at you for bothering them and then get angry at you when you don't lol. I try not to take it personal because Im just doing my job.

[imintrouble, BSN, RN]

It's all about the trend. I'd check previous HS and AM blood sugars.

I also ask the patient, if their response is reliable. Oops. LTC. This might not apply.

I almost never hold Lantus. If I do I get an order.

[mmc51264, BSN, MSN, RN]

We never hold Lantus. 100 is normal. Pt should have a night time snack anyway ( a carb and a protein). Like others have said, I would have notified provider and clarified.