Questions about Insulin

[Summers3]

Hello everyone! Sorry if my questions have really obvious answers but I want to ask about more about Insulin.

The other day I helped take care of a patient that was ordered to only have meal coverage. Usually I see meal coverage and sliding scale.... But this time it was only meal coverage.... So in general, why only meal coverage?! His blood sugar was 200 and the meal insulin will only take care of the carb he eats later, not the current 200 blood sugar?! So his blood sugar will still continue to be high even after the meal insulin.

So.... why just meal coverage for some patients?!

Also.... another question regarding lantus for night or morning etc. I see some take lantus only at night. I see some take in at morning and nights etc.... But once I saw someone taking as much as 120 units of lantus in the morning!!!!! This was my first time dealing with anything units this high so I was very surprised! I understand that this lantus AM dose is for controlling him for the entire day.... but 120 units?!

I now the units of insulin is adjusted for everyone's different needs.... but is there a max to it? And how do I really know 120 units won't make the patient severely hypoglycemic?!

Thanks!

[oceanblue52]

A lot of nurses can probably give more detailed answers to this...the only thing I can comment on is that patients have a HUGE variation in insulin sensitivity and hopefully the doctor has some idea of that when prescribing. For example I have taken care of one home home health patient who is VERY sensitive...we do not intervene until he gets to 250 b.s. And then it's very conservative: 1unit 250-300, 2unit 300-350 etc. another nurse established that after much work with his PCP because he bottoms out otherwise. so in his case we wouldn't do meal coverage because he is alone throughout the day and no one to monitor him for a hypoglycemic episode. Just a real world clinical example I thought of.

[Lev, MSN, RN, NP]

Sometimes providers do not adequately cover their patient's hyperglycemia. This is where you as a nurse can speak up. Sometimes this happens because the patient is on a different insulin at home that is not formulary at the hospital or they are on orals at home but can't get that in the hopistal because they are NPO or had a CT with dye and they are on metformin. When starting a patient on a new medication, you need to "start low and go slow" to minimize side effects. Hypoglycemia is the primary side effect we are worried about. Acute illness can cause unstable blood glucose levels.

Providers tend to follow the patient's home lantus schedule. Lantus is long acting. Some take once a day, some take twice a day. Some patients on very insulin resistant and require very high doses on insulin. First verify a patient's home insulin regimen before questioning a large dose. Then look at their trend of blood sugars. Did they get the same big dose last night and blood sugar was 120 this morning? - then you shouldn't have a problem. Usually patients get their usual long acting dose even if NPO. However, if the blood sugar before administration is fasting

[Kuriin, BSN, RN]

Agree with Lev that this is an opportunity to stand up and be an advocate. I've had numerous patients who's blood sugar is not well maintained and the patient's been in the hospital for several days still -- at that point, you talk to the doctor and recommend an increase in their longer acting insulin. They'll most likely do that compared to changing the sliding scale (at first).