Rapid/regular insulin sliding scale?

[Yahabebe]

I apologize ahead of time for the length and confusing elements of this post. Several times during a clinical rotation this past semester, I recall diabetic pts being exclusively on sliding scales of either rapid acting or regular insulin.

My first question is, why was I not giving pts basal as well as prandial insulin? I never remember giving pts 2 different kinds of insulin. That means that I was only covering the meals they ate/their pre-meal hyperglycemia, not covering them for the rest of the day. That seems strange...

Second, I remember being told NOT to give rapid acting insulin if my patient was NOT planning to eat. However, many of my pts were exclusively on sliding scale rapid acting/regular insulin, which means if the accucheck came out hyperglycemic, then they were getting rapid acting/regular insulin regardless of whether or not they were planning to eat. That means I'm possibly bolusing an "I'm not hungry" pt. into hypoglycemia..? And should I apply the "don't give if their not eating" rule to regular insulin as well as rapid acting?

Finally, what if my pts BS was WNL and thus not high enough to meet sliding scale requirements, but they WERE planning to eat? That means they did not get insulin even though they would be eating, say, breakfast at 0800 and possibly end up hyperglycemic right after that, but not have another accucheck scheduled until 1100 or so. What is the reasoning behind that? I'm just a little confused on all things insulin...

thank you

p.s. no one has explicitly laid out for me which insulins mix and which do not. I know lantus goes with nothing, and regular and NPH can be mixed. But what about rapid acting and long acting together? Or any other combination for that matter...

[mpccrn, BSN, RN]

1st, pharmacy can tell you which insulins mix, we have a chart on insulin capatability at our nsg. station.

2nd, you're thinking waaaay too much on the whole insulin issue. unless you have a crystal ball it's almost impossible to tell ahead of time who's going to eat and who's not. doc's and you for that matter should be looking at the insulin requirements the day before to get a good feel on the insulin requirements needed for the individual patient.

3rd, if a patient becomes symptomatic, an additional accu check takes only seconds to do and to treat either way.

4th, in an ICU setting, it's not uncommon to have patients strictly on sliding scales. studies have shown that a tighter glucose control can only improve the overall condition.

5th, bottom line, glucose levels are just too easy to fix quickly one way or the other.

[hickvilleRN]

I agree with all of that, plus another thing. Sometimes the patients are hyperglycemic because of something we are doing, not because they are diabetic. Maybe they are on IV steroids. Then we just want to correct the hyperglycemia at the time, because if we put them on a long acting insulin and change the dose of the steroid, they can become hypoglycemic.