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Myxel67

Myxel67

Diabetes ED, (CDE), CCU, Pulmonary/HIV
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Myxel67 has 15 years experience and specializes in Diabetes ED, (CDE), CCU, Pulmonary/HIV.

Myxel67's Latest Activity

  1. Myxel67

    does DKA or HHNKS always accompany high blood sugar

    BG values associated with HHS range from 600 to 2000 mg/dl. So pt with BG in 700's might not yet have the level of dehydration associated with HHS. Most pt's I have seen with HHS have had BG values from around 900 to 1300 or 1400. DKA occurs at much lower BG levels, but is dependent on how much insulin is present. A type 1 diabetic who had not had any insulin for 2 or 3 days might develop DKA with a relatively low BG (250 - 400, for example). Check pH from ABG's and anion gap from chemistry. A nondiabetic may have urine ketones (but no acetone in blood) because of lack of carbohydrate intake. It is also possible for a type 2 diabetic to have a moderate level of acetone in the blood, but not be acidotic. An ER doc diagnosed me with DKA a couple of years ago. I told her it was unlikely and that the blood acetone was probably because I had not eaten in 5 days (severe influenza), ABG showed pH slightly elevated (7.48 - 7.52 which was probably result of breathing difficulty and hyperventilation r/t pneumonia and anxiety (not Kussmaul respirations.) Anion gap was WNL. BG was 245--high for me, but not likely to produce DKA in a person with type 2 DM. She called an endo to see me anyway. He came in to tell me that I did not have DKA, which was no surprise to me...
  2. Myxel67

    Was I taught the wrong thing in school?

    Sliding scale insulin is correction insulin given to correct a blood sugar that is already high and should be given even if pt is NPO. Even though many/most physicians will order it as the only insulin coverage, use of sliding scale only often leads to widely fluctuating BG values. Our DM management order set specifies that sliding scale is correction insulin and should not be held. The insulin that would be held is the mealtime bolus of fast acting insulin. Bedtime basal insulin such as Levemir, Lantus, or NPH generally would not be held. Sometimes a doctor might order a reduced dose of NPH if pt is NPO because of its pronounced peak. A BG of 309 needs to be treated.
  3. Myxel67

    Lantus insulin question

    Many people with diabetes (including type 1) still use NPH for basal coverage. This is especially true for patients of pediatric endocrinologists. Although the NPH nsulin dose might need to be decreased, it should not be held. After treating the low BG, the most important thing is to identify the cause of the hypoglycemia and correct that, if possible.
  4. Myxel67

    insulin pump concern

    Try tucking the pump into your bra. That's a fairly common place for women who don't want to wear it at the waist.
  5. Myxel67

    I need some help for my CDE test on Sat.

    How did you both do? Hope all went well.
  6. Myxel67

    CDE Salary

    cde salaries in south florida are similar to those of nurse clinicians, endocrinologists here are more likely to hire arnps. are the nurses working as independent contractors? we bought a vacation/retirement home in ormond beach last year and will be relocating. i'd love to talk to your instructor. please pm me if she is willing to give any more specific information.
  7. Myxel67

    Support the Diabetes Educator's Bill

    Medicare still provides coverage as you stated, but unfortunately Medicaid stopped covering DM education over 2 years ago--and that's a shame.
  8. Myxel67

    SSC w/ pt skipping meal

    The Med-Surg textbook I used in nursing school back in 1993 stated that SS insulin is given for an already high BG,, and is not in anticipation of any additional meal/food. To me this means that the SS insulin would be given even if the pt was NPO, or just did not want to eat. Usually the BG is checked ac & hs and coverage is given based on the BG at the time. Nurses often hesitate to give the ac insulin (even if the BG is 300+) if the pt is not eating, or if the meal tray has not yet arrived. Most sliding scales are the same at bedtime--even though no meal is being served--so the concept of the scale being just to correct the high BG is easier to see. At the hospital where I work, we developed an insulin order sheet with instructions on how to order basal/bolus insulin. There is even a weight-based dosing chart with doses calculated using 0.5 units/kg and 1 unit/kg. The correction scales are at the back. So what do 90% of the doctors do? You guessed it--they go straight to the last page and order the correction scale as the only insulin coverage!
  9. Myxel67

    New nurse's daughter just diagnosed with Type 1

    A friend's grandmother picked up her toddler's type 1 DM in an unusual, but very logical way. She noticed that ant's were attracted to the child's wet diapers!
  10. Myxel67

    Any ideas?

    The 90 degree angle tip comes from Dr. Pita--an endo in Miami who spoke at a meeting I attended a few years ago. My theory of why it works is that the Lantus microcrystals form a more regularly shaped depot that maximizes the sub q surface area from which the Lantus crystals are absorbed. Also, I meant Abilify--not Ability in the list of psych meds. I wondered if the resident's psych meds had been changed or increased about a year ago when her control worsened. Wow--2224 for a type 1 The max I've seen for a type 1 is 994. The 1300 and 1700 were definitely type 2's--not an iota of acetone in the blood! My favorite quote frrom an an endo, "The only place for Regular insulin in a hospital is in an insulin drip." (Dr. Ariel Ziskin). I didn't see your profile before I started this reply--are you a CDE? ARNP? Where do you practice? I haven't been on this site in over a year. Once I start coming back, I addicted again!
  11. Myxel67

    Any ideas?

    First, it's important that there be a scheduled set dose of Novolog before each meal--not just a sliding scale if BG exceeds a certain level. Usually the Lantus (basal) dose should be about 50 - 60% of total daily insulin. If she really needs 40 units of Lantus, then minimum dose of Novolog should be between 10 - 13 units before each meal, even if her BG is only 70. The SS would be additional Novolog as a pre-meal correction if BG is above target (usually 120). If the Novolog is SS only (example: BG The Lantus dose is evaluated based on the FBG. There is a titration scale with the Rx info. FBG 121 - 140 add 2 units Lantus, FBG 141 -160 add 4 units of Lantus, FBG 161 - 180 add 6 units Lantus, FBG > 180 add 8 units Lantus. After each change wait 3 days to adjust again. Novolog dose is evaluated based on BG at following meal. High BG before lunch means not enough Novolog to cover carb content of meal and/or correct for a high FBG. If you find that Lantus dose is climbing to higher and higher levels, pt my do better on NPH at bedtime and before breakfast. Other suggestions since absorption may be a problem. Make sure needle is long enough. For doses > 30 units standard 12 mm needle is better than the short 8 mm needle. Also, make sure Lantus is given at a 90 degree angle. Check to make sure insulin isn't being injected into a site where the sub q tissue is lumpy or hard. The arms often don't provide sufficient area for adequate site rotation. BG values of 600 and above are in the range for HHS (hyperglycemic hyperosmolar syndrome--BG can go as high as 2000). HHS, if it develops, actually has a higher mortality rate than DKA. HHS is much more common among residents of LTC facilities. Things to look for: Is there an underlying infection? Is she able to get up and get water for herself? Make sure she drinks water--not juice. Hyperglycemia causes dehydration via osmotic diuresis. I've had pts with BG between 1300 -1700 on admission. Also, check her psych meds. The atypicaal antipsychotics (Zyprexa, Risperdal, Seroquel. Ability, etc.) may lead to high BG, even in those who don't already have DM, and would increase insulin needs in those who do. Hope some of this helps. Often the answer is the right insulin Rx from the doctor and BG checks before each meal. OFP, RN, CDE Addendum: This post is intended to be an explanation of how to use basal/bolus insulin therapy--not how to manage any particular case. Many physicians still think a sliding scale is pre-meal insulin, as opposed to being a correction scale for BG that is already high.
  12. Myxel67

    testosterone and curly hair?

    perhaps cutting 4 inches off reduced the weight pulling the hair down and allowed the curls/waves to form. i've always had very curly hair, but it curls more when it's not too long. one of my brother's had beautiful blond straight hair. he hit puberty and it got darker and curly. my hair actually got straighter when i was pregnant. my mother told me she used to have very curly hair too, but after bearing 14 children, it was straight as a board. :balloons:
  13. I'd like to see a fact check to make sure this story wasn't just a plant by the religious right. A sort of so what if the test says she's brain dead. A miracle could happen and she could wake up tomorrow. Terry Schiavo with a twist. I see references all the time to an article about presidential IQ's. Estimated Jimmy Carter's IQ as 176 and Ronald Reagan as 105. The story was totally fake. We tend to believe what we read in the paper. I've become very skeptical in my old age--might possibly have something to do with the outcome of the 2000 presidential election.
  14. Myxel67

    Lantus insulin question

    When there are frequent problems with low BG values--especially in older adults, there may be kidney or liver problems which interfere with treatment. If kidneys are not functioning well, insulin stays in the body longer and may lead to hypoglycemia. When there is a problem with liver function, the liver may not be able to make, store, or release glucose effectively.
  15. Myxel67

    Do you ever massage your patients?

    I used to use massage often when I worked as a floor nurse. I think human touch goes a long way to help a pt. relax and feel calm. It's too bad the nurse doesn't often have time to give a short massage -- something that used to be a regular part of hs care. :balloons:
  16. Myxel67

    Cortisone

    It doesn't matter where they put the steroids--BG values will soar. I've had pts whose BG rose because of cortisone injections into a joint or the foot. Ask your doctor about using Novolog or Humalog instead of Regular. You'll get much better control. The NPH is a good idea--especially if your FBG is high. Don't rely on an a.m. dose of NPH to cover lunch. Most people need rapid acting insulin with every meal. Ask your PCP about starting with bedtime NPH first. I'm so sorry you were injured and hope your recovery goes well. Glad to hear the Januvia was working for you.
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