NPH insuln

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I would like some feedback from other nurses regarding the following scenario.

Your patient is an 80-year-old man with a diabetic foot ulcer. This is hospital day #2, his first morning after admit. He became mildly confused overnight. When you check his CBG it is 127. He is on a low insulin sliding scale and is also scheduled to receive 18 units of NPH insulin. The order says, give at 7am with food. When you assess him in the morning, he states he is not going to eat. You talk to him for several minutes and try to ascertain why he doesn't want to eat but he cannot give a reason. Further you explain that he will be getting insulin and needs to have breakfast. He is adamant that he will not eat it is now 7am and you will be giving report in a few minutes.

Would you:

a) ask the on-coming nurse to call the doctor to see if they will adjust the NPH dose

b) give it because the hospital policy is that NPH is given by the off-going shift and NPH is an intermediate insulin

C) ask the on-coming nurse to wait to see if the patient does eat breakfast and then give the full dose

D) Other opinions?

I would appreciate some feedback.

Thanks

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For your choices I would do B. Tell oncoming RN about the eating.

He needs his insulin, and by lunch his BG might rise on it's own anyhow, regardless.

(hope that's right)

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Specializes in Geriatrics, Transplant, Education.

Since NPH is intermediate acting...wouldn't you also be more concerned about making sure the patient is going to eat their noon meal? In my limited experience, I have had far greater issues with patients that were given their 8am NPH dose and then later in the day missed lunch. I work 3-11pm, and more than once I have had hyperglycemia happen at 4pm when pts state they missed lunch and their NPH is peaking. Will be interested to see what others have to add to this discussion.

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Specializes in Hospice, Rehab.

I've had this experience with patients. NPH insulin is variable in its effect from person to person, as well as variable in its effect on a person based on their activity levels. I'd normally give straight NPH insulin based on the patient's history and eating patterns.

Believe it or not, you can usually trust a seasoned diabetic to tell you how they react to an insulin.

I've had patients that would crash on me (BG of 50 or so) at 3 am the morning after a 430 pm dose of NPH. Best part: patient was like 340 at 2100. I held the bedtime coverage based on the patient waking up that AM at 48-55 past two mornings.

Patients that are relatively slow absorbers of the NPH insulin will sometimes surprise you like that. Also, some sites are less effective at absorbing the NPH. I know a patient that injected NPH into his thigh one day and got no effect from it; although when injected into the abdomen it had fairly consistent effect.

So the right answer is to give long and intermediate acting insulin as ordered, but report patterns such as borderline lows occurring the same time each day.

Short acting insulin should be given very closely to a meal and I would consider a patient that did not eat breakfast to be at risk if given either a short acting or a combination like 70/30. Those merit immediate physician calls.

Come to think of it, if in doubt, call the physician anyway. They don't want the patient crashing either and refusing to eat meals is something that in itself should be noted, especially if its a repeated pattern.

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You stated that the order said give at 7am with food. So if he isn't going to eat, I would not give it and inform the day staff. They can see if he actually does eat, take another BG either way and call the MD. Once dose of NPH missed for a BG of 127 IMHO is better than tanking out. I would worry about liabilty issues if you give the NPH and are not around to make sure he eats.

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You stated that the order said give at 7am with food. So if he isn't going to eat, I would not give it and inform the day staff. They can see if he actually does eat, take another BG either way and call the MD. Once dose of NPH missed for a BG of 127 IMHO is better than tanking out. I would worry about liabilty issues if you give the NPH and are not around to make sure he eats.

I agree with this one. The risk of the pt tanking is greater than his BG going high enough for short-term adverse effects if he doesn't eat.

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Here is a good link. Not quite the OP question, but it's good.

https://allnurses.com/diabetes-endocrine-nursing/insulin-question-215130.html

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Here is a good link. Not quite the OP question, but it's good.

https://allnurses.com/diabetes-endocrine-nursing/insulin-question-215130.html

The nurse posting in this link seems to know what he/she is talking about; however, I have seen patients end up in my ED for taking their insulin when they were only fasting overnight for blood tests in the AM. As with most things, there is no one rule that will cover everyone. The best you can do is evaluate each situation separately and use your best judgement. You will become more comfortable doing that with experience. And don't give a hoot about the doctor being mad. I know I'm not telling you anything when I say your first concern is the patient's welfare. The doctor is not with the patient the way you are and doesn't know the situation as intimately as you do, so develop a thick skin and plant your two feet firmly when he tries to give you crap. :yeah:

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So, the reason I asked this question is that the on-coming nurse bullied me into giving the insulin when I strongly felt I did not want to. I asked her to call the doctor to see if we could get a range to give IF the patient decided to eat. She refused and insisted I was in the wrong for not automatically giving it. As it turns out, when I went to work last night the patient ate poorly all day and was hypoglycemic most of mid-day with a CBG down to 54, 60, 70 etc. I don't know if he was symptomatic or not because when she gave report, she did not mention how his CBGs were. I saw them in his medical record. I learned a lesson from this, and it is to not let another nurse take away my critical thinking and decision making just because she wants to "stick to the policy" when in fact, there may not even be a policy.

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I once held Humalog for BS of 48, pt alert and able to eat, gave lots of good snacks. BS came up nicely, charted it all. State came in and read my detailed note. I got in trouble for using my nursing judgement. I should have called the DR and let he/she make that decision. If you think you should hold the insulin call the DR.

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So, the reason I asked this question is that the on-coming nurse bullied me into giving the insulin when I strongly felt I did not want to. I asked her to call the doctor to see if we could get a range to give IF the patient decided to eat. She refused and insisted I was in the wrong for not automatically giving it. As it turns out, when I went to work last night the patient ate poorly all day and was hypoglycemic most of mid-day with a CBG down to 54, 60, 70 etc. I don't know if he was symptomatic or not because when she gave report, she did not mention how his CBGs were. I saw them in his medical record. I learned a lesson from this, and it is to not let another nurse take away my critical thinking and decision making just because she wants to "stick to the policy" when in fact, there may not even be a policy.

When someone tries to bully me, I always ask them if I missed their name on my license. ;) I also love people that spout off policy when there usually isn't any. Check the policy yourself so you are armed for the next round. Or get some advice from your nurse manager (without using names) in case it happens again. I think the previous poster has the right course of action. Hold the dose, call the md, chart and advise the next nurse what you did.

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I once held Humalog for BS of 48, pt alert and able to eat, gave lots of good snacks. BS came up nicely, charted it all. State came in and read my detailed note. I got in trouble for using my nursing judgement. I should have called the DR and let he/she make that decision. If you think you should hold the insulin call the DR.

Got in trouble how?

By that logic we should never hold medications unless we first call the Dr.??? That's a crock! Problem is, it's YOUR license on the line if you do give the med, even if the doctor tells you to, and the patient dies. Wonder what the state would say about that!

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