orienting: have different "opinions" on holding insulin. who do I listen to?

Specialties Geriatric

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I am on a 2 week orientation at a 26 bed LTC facility. I have been assigned 4 different nurses to follow during this time. Each seems to have a different opinion about holding or adjusting insulin dosages per sliding scale as well as long acting insulin administration.

The concensis seems to be a preference to keep the patients at high levels to keep them "from bottoming out". These nurses know the residents well and a couple are diabetics themselves so I feel they know more and I am underconfidient in my judgement.

When a patient has a sliding scale to follow, shouldn't we follow it? If a patient has an order for long acting insulin at HS, shouldn't we give that dosage?

Is it a judgement call or do I follow the orders as written?

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Specializes in Going to Peds!.

Give long acting. Period. If the patient is low, FEED THEM! You don't hold the long acting.

For meal coverage, give it if the patient eats, usually >50-75% of their meal. Sliding scale, if they're bottoming out after a sliding scale dose, then it probably needs adjustments to the scale dosing.

Sent from my HTC One X using allnurses.com

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Specializes in ER.

part of being a seasoned nurse is developing good instincts or judgement call as you say it, though

that won't necessary put you off the hook legally.

my advise - follow your agency's protocol/policy in sliding scale.

they are place there to put on good use :cat:

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Thanks for the comments. I guess what I am trying to distinguish is, what level is "bottoming out". And how accurate the term even is. Is bottoming out considered anything below the low norm of like 70? It appears that since these patients regularly run high, the nurses think a level of around 140 is low. On the sliding scale, that warrants insulin, but the nurses are holding or adjusting that. I am confused. I know that because I am inexperienced, I am looking at this in a literal view. If the order reads " x,y,z" then that is what I should give but these seasoned nurses have the experience of knowing how the patient responds based on their experience with that particular patient and use their instinct to determine altering the dose. I ask, ask ask and usually the response I get is something like"I know how fast they bottom out" or "I can drop in a heartbeat" or some other personal or patient experience story.

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As Amy says, DO NOT hold long acting insulin. It is meant to keep a resident at a normal glucose level and will not cause them to "bottom out". Read your facility's policy on sliding scale coverage. You should follow the sliding scale as written for that particular resident, but usually facilities have their own hypoglycemic protocol regarding when to hold and notify the physician. If a resident has a glucose of 70 and has a set scheduled dose of quick acting insulin, I would personally hold the medication. Nursing judgement can always be used, but you need to chart why the insulin (or any medication) is held, and you MUST notify the physician and family when this occurs (and chart the notifications.) If residents are having problems maintaining glucose levels on their ordered insulin doses, physicians need to be aware so that doses can be adjusted.

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Dosing or not dosing of insulin one of the many things regarding care of type 2 diabetics that drives me crazy withholding long term insulin is crazy. These people rarely get enough insulin on their sliding scales to accommodate their carb intake. I wish insulin for Type 2's would be dosed more like type 1's if they are on insulin they probably would end up healthier with lower blood sugars

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Specializes in adult psych, LTC/SNF, child psych.

Ugh I work with nurses who say the same thing. Like this one resident is supposed to get Lantus 60 units in the morning and sliding scale coverage if needed for the corresponding fingerstick, but there's one nurse who always gives me some strange story about what she did INSTEAD of following the order. "Umm, yeah I gave her Lantus 40 units and didn't give sliding scale but you can give her some if you're okay with it..."

ARG! Either do it or don't do it, but don't tell me that my only option is to not give her anything or give her what you decided not to give her!!!

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Okay, 140 is not bottoming out. Bottoming out is having a resident with a finger stick of 27mg/dL. It has happened to me twice working LTC and it's not pretty. Different people are symptomatic at different glucose levels, but anything above 60-70mg/dL is not bottoming out. Just because they're diabetic doesn't mean that their BS can't be within "normal range" with proper insulin administration. On the other hand, I've had residents that start acting funny at 70mg/dL. Needless to say that my patient with a blood glucose of 27 was about to seize...

Holding insulin and/or adjusting it as per your judgement is definitely not the "right" thing to do, unless of course you have hypoglycemia or some other circumstance that *legally* warrants you holding it. This does not apply to a basal or long-acting insulin.

My LTC resident that had a BS of 27 did have her insulin "titrated" by nursing for about 3 nights though, because the MD did not return our call and I refused to find her unresponsive in the am. But the examples you gave are... not right LOL

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Specializes in ER, Addictions, Geriatrics.
Ugh I work with nurses who say the same thing. Like this one resident is supposed to get Lantus 60 units in the morning and sliding scale coverage if needed for the corresponding fingerstick, but there's one nurse who always gives me some strange story about what she did INSTEAD of following the order. "Umm, yeah I gave her Lantus 40 units and didn't give sliding scale but you can give her some if you're okay with it..."

ARG! Either do it or don't do it, but don't tell me that my only option is to not give her anything or give her what you decided not to give her!!!

Why does your coworker think that she is able to just make up whatever dose she thinks the patient needs? That's terrifying! If the current dose isn't working for the patient, then the doctor should review and adjust. That's soooo not in her scope.

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Specializes in Assisted Living nursing, LTC/SNF nursing.

Unless the Resident has specific orders to hold insulin if BG levels are below a certain level, then that is okay. Otherwise, you'd better be calling the Dr. and get his opinion/order on what to do. You can suggest things and let him/her know if this happens often or has it been a problem lately and maybe an adjustment needs to be made. But, only if the Dr. says so, not the nurse. Period (at least in my state).

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I always give long-acting for the most part. I had one patient on long-acting at night and he was getting TID with meals at night shortly before the long-acting. I noticed he was always low in the AM (In the 60's but asymptomatic) so I asked the doc if I could titrate insulin just a little bit. Doc said do what you think is best and wrote an order- nurse to titrate insulin based on glucose levels with 5 units of ordered novolog) so I started giving him 5 less units of fast acting with his night time meal then gave him his regular long acting. His sugars before bed were a little higher, about 20 points, from 150 to 170 area but he was in the 80's in the mornings and his sugar was more level through the day. His sugars had always been really high or really low when I had him in a different unit because no one else was paying attention to his levels really and just giving what was ordered and not asking for more when it was high or less when it was low, and he was a very brittle diabetic so it was better for him to run a little high than bottom out and to have long-acting added which he wasn't on previously to bring it down lower all the time. It's better to be a little high than low (and I'm now a DM nurse so I hate when sugars are high but it's just immediately dangerous to be too low) but you have to use best judgment. If the patient is injured because you did just was was ordered you'll be in trouble. You can feed them to raise sugars or give them emergency insulin to lower sugars but don't let the patient be hurt by this problem, you gotta use your head.

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The dose ordered should not be changed just because the nurse felt like it. Routine long acting insulin should be given as ordered. If you find that bs are dropping throughout the day or are lower at a specific time of day, notify the doctor so it can be adjusted. Sliding scale is just that. It depends on what the bs is. If it tends to drop the bs to low call and get it adjusted. For shorter acting insulins I always wait to make sure the resident is eating prior to giving. If they don't eat i hold the insulin. If this is something that is routine the doctor needs to be notified so changes can be made.

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