NPH insuln

Published

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

We had lectures on different types of insulins; their peaks and durations, I thought I made the right choice. But I guess when I held that insulin and did not get OK from Dr, I was changing the Dr order. The state came in for their annual review, read my note and called me at home. When I was on vacation. I was supposed to put this in the Dr.'s hands, not make my own decision. Live and Learn.

Up Vote Up Vote ×

So, looks like the WORD is (?):

Hold insulin only if MD is consulted. Request adj and document to CYA max. this means also need to be sure you are on top of a potential upswing... the self-rising stress factor. You need to have orders to be sure you can handle should that happen later in the day eg pt is able to eat at lunch, just nauseated in the early a.m. (?)

The only nursing judgement is really not, and that is sliding scale, which if it is the only script (post-op/infection) you are more likely to get the self-rise by lunch, so you need to be ready for it. (?)

There was this cardiologist who would not set parameters for a betablocker. He just sat there smug and said something to the effect of "why don't you just ask the intensivist" (obviously, some hissy fit thing going on between the two) Here he was up for consult... pt up from cath soon to cabg. I automatically glanced down at his lab jacket that said, " Dr. Smug... CARDIOLOGIST" and thought, (to self) if you don't want any part of it, why are you up here, and then, get out of that chair, because I'd like to use that computer! Took me and my RN 3 firm and tense requests before he would do it. :confused:

Up Vote Up Vote ×
We had lectures on different types of insulins; their peaks and durations, I thought I made the right choice. But I guess when I held that insulin and did not get OK from Dr, I was changing the Dr order. The state came in for their annual review, read my note and called me at home. When I was on vacation. I was supposed to put this in the Dr.'s hands, not make my own decision. Live and Learn.

What state did this occur in?

Up Vote Up Vote ×
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!

I totally agree. Personally I would rather be written up for holding the insulin first than calling the MD. Sure as heck if that patient tanks, the MD is going to give the excuse that the nurse should have used his/her judgement to save their butt. There are times when being written up or "getting in trouble" is worth it if the patient is ok. There is a reason why we were taught to look up meds we didn't know about. If they don't want nursing judgment, then they can use automatic machines to dispense the meds. ;)

Up Vote Up Vote ×
If they don't want nursing judgment, then they can use automatic machines to dispense the meds. ;)

LOL good one! :yeah:

Up Vote Up Vote ×
Specializes in Medicine, Surgery, Critical Care.
I totally agree. Personally I would rather be written up for holding the insulin first than calling the MD. Sure as heck if that patient tanks, the MD is going to give the excuse that the nurse should have used his/her judgement to save their butt. There are times when being written up or "getting in trouble" is worth it if the patient is ok. There is a reason why we were taught to look up meds we didn't know about. If they don't want nursing judgment, then they can use automatic machines to dispense the meds. ;)

Two things... new diabetes treatment guidelines day always give the patients usuals intermediate/long acting dose. If they are not going to each it is best to give them dextrose containing IV fluid. We are having a hard time with our docs on this but it keeps the patient on their usual regiment.

Second... It is always ok to use nursing judgment to hold in the hour you are calling a doctor. If you are holding without paramenter for long than the time it takes to get an answer from and MD that is considered prescribing :eek: Our hospital is looking closely as this because of 3 hour delays in holding medications with out physicians being aware. Avoid that if possible that can be a board of nursing thing ... :uhoh3:

Up Vote Up Vote ×
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

Option C. First 127 as a BG isn't that high. Second, You don't know that the patient will eat later and why risk a hypoglycemic episode? Third, policy won't protect you with the BON if a really bad outcome happens. (Think about it you are giving a medication contrary to the providers order if it is sans food.)

If he decides to eat later the insulin can be given at that time by the accountable nurse who can discuss the situation with the provider during rounds or make the phone call to the provider.

Your first responsibility is patient safety. Looking at this scenario I don't think that as a nurse I could safely manage this situation as it is happening right at report and I am transferring care to another nurse who has the time to plan care, implement and evaluate the plan.

Up Vote Up Vote ×
Specializes in med-surg.

I've been in this situation once before. My pt had scheduled NPH 15 units q pm in addition to a Novolog sliding dose scale. I checked her blood sugar at 9pm and it was 130. I felt uncomfortable with the idea of giving the NPH. I asked my charge nurse and she said it should be okay, so I reluctantly gave both insulin injections to her(I also gave her some milk).The next day I heard that her blood sugar crashed into the 40's. So, in your situation I would have held the NPH, especially if the pt isn't eating. I've also learned to trust my gut instinct.

Up Vote Up Vote ×
+ Join the Discussion