what would you do in this situation?

[wish_me_luck, BSN, RN]

Hello.

I was doing my practicum and a nurse had a medication order to give so many units of lispro and then add x number of units to it per sliding scale. It ended up being like 20 units and the bs was like 200. It sounded like a lot of insulin to give and the nurse even questioned the order with charge. Charge said to give it. I know stuff like that will come up when I am working.

So, my question is, could you not give the insulin that is a dose that does not depend on the bs and then give the sliding scale amount after about 15-30 minutes depending on the bs. AKA check bs, give the ordered amount of insulin, wait 15-30 mins, check bs again, then if it's still elevated give the sliding scale amount that was indicated? I mean, I would be afraid to bottom the person out. I definitely would have something like orange juice, peanut butter, etc. on hand. But, what would you guys do or what have you done if you have been in that situation?

[tokmom, BSN, RN]

That sort of is an odd way to giving insulin. Is this person not getting a basal or a longer acting insulin as well? My concern would be to give that much insulin that can last up to 6 hrs and then have a longer acting one in there that peaks somewhere in the middle. Does that make sense?

I would double check with the dr and I certainly woulnd't be giving that much insulin without making sure the pt ate really well and had a snack during upcoming hours.

[TheCommuter, BSN, RN]

A patient with an order for a large amount of routine lispro (Humalog) and sliding scale lispro is, in all likelihood, very insulin resistant. These types of diabetics will usually have very elevated blood glucose levels unless they receive the insulin.

I would give the patient the entire amount of insulin (routine and sliding scale) while they are eating. The patient is on that much insulin for a reason. The physician didn't wake up one day and simply decide to order 15 units of Humalog with meals routinely in addition to sliding scale Humalog. The patient most likely has had long-standing issues with control of his/her blood glucose levels. Giving the entire amount of insulin to an insulin-resistant diabetic typically will not cause the blood glucose to bottom out if balanced with ample food intake.

[wish_me_luck, BSN, RN]

basal, sorry, I was trying to think of the word. Thanks for comment. But, yeah, it was a basal amount plus sliding scale. Added together it was 20 units with a blood sugar of 200. I would imagine that would bottom the pt out. All of it was lispro. I would be terrified to give that much. That's why I asked. I was just wondering what you guys would do and if it's acceptable to give the basal amount, then re-check the bs, and if needed give the amount of sliding scale that was previously indicated?

[wish_me_luck, BSN, RN]

okay, I guess you could check previous insulin administrations in the computer to see how the pt tolerated it. The patient was not eating at the time administered, that's why I said you better have that OJ, peanut butter, etc. on hand just in case.

[TheCommuter, BSN, RN]

I would imagine that would bottom the pt out.

You will come across certain types of diabetics who will not bottom out even if they are receiving 95 units of Lantus BID, 25 units of Humalog with meals, Humulin per sliding scale, and Metformin 850mg TID. They tend to be overweight and/or obese, very insulin-resistant, with blood glucose levels that constantly remain elevated.

[psu_213, BSN, RN]

Ask the person about their usual home routine with insulin (i.e. do they take a routine dose with a SS dose before meals). If so, give it. There might also be extra insulin if their blood sugars are running high if their body is stressed by disease process/hospitalization. Also, have they been in the hospital getting this dose or is this a new pt to your facility? If you still don't feel comfortable with it, call the doctor. While the doctor may not like it if you call about all his/her insulin orders, I think calling him/her is better than 'free style' glucose management (such as the give some insulin, check blood sugar, give more, etc...).

[OR-RN2011]

I would agree with previous posters ask the patient, review the patient history and then call the Doctor. Some patients don't have any idea what is going on but many do and all you have to do is ask. It is important to include your patients in their care. It is also great you asked the nurse. It is important to patient safety to be humble enough to ask questions. Best of luck

[PediLove2147, BSN, RN]

I was just wondering what you guys would do and if it's acceptable to give the basal amount, then re-check the bs, and if needed give the amount of sliding scale that was previously indicated?

What I see happening with this practice: You give the basal, recheck and they are "normal" so you don't give the SS insulin, a couple hours later they are 300. If you just gave the full amount in the first place you wouldn't be chasing the high. Like someone else mentioned, the doctor didn't just come up with the dosing out of the blue, this is probably something they do at home and that their body is used to. Definetely double check if you don't feel comfortable but seeing what they've gotten previously (and tolerated) can tell you a lot.

[wooh, BSN, RN]

Try a CF induced diabetic's meal with carb counting. The 50 unit syringes won't be big enough.

The big secret to nursing is that it isn't about textbook patient on a textbook day with textbook values. For blood sugars, insulin doses, vital signs, don't look at one number by itself. Look at the pattern, the trends.

BP is normal, should you give the BP med? Most likely yes, as it's normal because of getting the BP med. Same with insulin. If a dose seems high, have they been getting about the same amount? What have the results of their previous doses been?

And in the back of your mind, know the "antidotes." Know where oxygen supplies are, where to get narcan from, where to get an amp of D50 or glucose tablets, etc...

You'll feel better giving doses that are uncomfortable for you if you feel confident about what to do if things do go wrong...

[clfrn]

I agree that if you feel uncomfortable with the dosage of ANY medication, you need to check with the patient, check the computer and see if this is the patients norm, and you can always double the order with the doctor. Always follow the your gut.

[rita359]

I agree, you have to look at the individual pt. Has he/she been getting the same dose of lispro prior to meals and still running a blood sugar of 200. Remember the goal blood sugar while pts are in the hospital is 100 or less. Patients blood sugar will go higher when he/she eats so you are really covering a blood sugar higher than 200 you got by blood sugar readings. This is where knowing when each insulin act and how long it acts and how much each dose is likely to reduce blood sugars comes into play. Also look at what kind of doctor ordered the dose. Is it the patients endocrinologist who ordered it or someone who doesn't know the patient well? Is the patient on solumedrol or another steroid that will send diabetic patients blood sugars out of whack and even some patients who are not diabetic will run high blood sugars. Treat the patient not the book.