Please help with diabetes scenario/case study!

Nrs_angie, BSN, RN · Nov 18, 2007

Wouldn't the fact that the NURSE changed the order to heparin be a problem? "The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor" Unless the nurse is an APN or NP, they would not likely have prescriptive powers. And why would you infuse insulin with dextrose (D5W)? I believe that dextrose is only added if the patient's blood glucose drops too quickly in response to the insulin. I know that only regular insulin should be infused via IV but I do not see any information about mixing it for IV administration. 10ML/H doesn't sound right because (if I'm doing my math correctly) that would be 1000 u/h which would be unsafe if the safe range is .5-1u/kg/day (3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.
Seems like that are many errors in this scenario! But as a new student myself, I am probably missing something!

Hi there.... Im not trying to be rude at all.... but I have already said this several times

WE HAVE ALREADY ESTABLISHED THAT THE NURSE IS WRONG FOR CHANGING THE ORDER TO HEPARIN....

WE GOT THAT.... NO HEPARIN.... NO HEPARIN...NO HEPARIN.... ITS BEEN ESTABLISHED!!!!!!! WHO CARES WHAT ITS MIXED IN.... WE BETTER NOT EVER GIVE HEPARIN TO A PATIENT IN DKA WHO'S COAGS ARE NORMAL.... BAD IDEA.

just because you know the heparin is wrong, doesnt get you off the hook. as the nurse you also need to know that you need an order for a continuous infusion of IV insulin... which means you need to call the Doc and all the orders corrected... and any additional orders you need... but when you call you also need to have an idea of what is an appropriate dose for the situation and the patient... so that when you get the order you know if it correct or dangerous... do some math beforehand and you will be ready to page the MD.

now if you read my post about DKA....

the golden standard of treatment is an initial dose of continuous IV insulin of 0.1 units/kg/hr.... lets assume that the man weighs 220 lbs, which converts to 100 kg which converts to 10 u per hour, which adds to 240 units in a 24 hour period..... THE CORRECT INSULIN DOSE SHOULD BE 10 U PER HOUR INITIALLY. (depends on the patient's weight, but since we don't know, we assume 100 kgs, to get a general idea, the concept still applies even if he doesn't weigh 100 kg)

I have no idea where you get the .5-1u/kg/day... assume the man weighs 100 kg.. at most that would be no more than 4 units per hour. that won't be enough insulin for someone whos SBG is 700.... that would only be enough after initial treatment... when the BG starts to come down and the insulin needs to be tapered down as per protocol.

furthermore.... as I already said if the patient is dehydrated... initial therapy should include an isotonic solution.... but once the BG reaches 250 then fluids should be changed to D5 and 1/2 NSS to prevent hypoglycemia and cerebral edema.

Again, Im sorry if I was rude.... Just trying to get you students to develop your critical thinking skills... Everyone keeps getting hung up on the Heparin.... we already know its wrong... talk about beating a dead horse... You still need to correct the orders which means you need continuous IV insulin. Please either look up DKA in a med-surg book or read my previous posts carefully.

Good Luck and Happy Holidays!

lenciekaye · Feb 10, 2012

Regular Insulin is 1:1 concentration, regular insulin is given subcutaneous.

Here is the case study:
A 45 y.o male brought to the ED with C/O dizziness, weakness, polyuria and polyphagia. He has a history of DM on 70/30 insulin 25 units in am & 15 units pm.
V/S: T95, P88, BP160/92, Pain 3/10, BGM critical high!!!!!!!!!
Lab Values:
Chem 7: Glu 700, BUN 43, Creat 1.2, Cl 108, CO2 20, NA 132, K 4.8
CBC: WBC 12.6, Hgb 10.7, Hct 32, Plt 200
Coag: PT 13.6, INR 1.2, PTT 30
Acetone Trace present
ABG: pH 7.33, pCO 38, pO 96, HCO 21

The doctor's orders are"
(1) NaHCO3 1amp in NS 1000 ml to infuse @ 42 ml/hr.
(2) Regular insulin 10 units IVP X 1 dose
(3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor.

Can anyone help me identify the medication errors in this case study? I am a brand new nursing student and was given this assignment to do ... we haven't covered the diabetes chapters yet and I am going nuts with reading about insulin, the different strengths, etc. I do see that changing the heparin drip was a problem! But i am stuck on the NaHCO3 ... wouldn't that bring down the patient's K levels? His K levels are resting at a normal value right now. Can anyone explain the combo insulin therapy to me? I am going to hit the books and see what i can find. I'll be checking back frequently.
~ Desperate for help