Sliding scale insulin...give or hold?

ArmaniX, MSN, APRN · Apr 5, 2015

Patient is not eating? I personally would hold and contact the doctor. If this is a change in patient condition it should be addressed. Maybe the doctor will adjust the sliding scale. My concern is that eventually the patient will become hypo and I would not want to contribute to that.

Larry3373 · Apr 5, 2015

2units is not much and it is very unlikely that a patient would become hypo unless they were a very brittle diabetic with a hx of getting hypo often. So it depends on the patient. I had a patient recently who tolerates 30 units humalog (fast acting) bid and SS coverage on top of that. some people are just very insulin resistant. Technically, we are not supposed to be just holding medications without a doctors order, although it happens all the time. If a pt is NPO and going to surgery or something, I might hold it. Also, you need to consider why the patient is getting ss coverage. Keeping blood glucose wnl promotes healing and helps with preventing infections (hence the reason postoperative CABG patients are on an insulin gtt, diabetic or not). So again, depends how the patient normally responds to insulin in small doses which will be a good indicator if they are likely to bottom out, but I wouldn't be worried about only 2 units.

CT Pixie, BSN, RN · Apr 5, 2015

I worked LTC with many pt who had sliding scales.

Depending on the patient, I might have held the 2 units as well. Many of my patients BS would bottom out on me if they were 159 got 2 units and weren't eating. Of course, I'd have to call the doc and tell them I held the insulin and why and see if the doc wanted me to give it anyway. Rarely did the doc say give it anyway. What they would normally do is have us encourage the patient to eat (or take a supplemental drink like Ensure or whatever), retake it and see what the number was and go from there.

anh06005, MSN, APRN, NP · Apr 5, 2015

As PP's have said it depends. Some patients are sensitive to insulin and 2 units can drop their blood sugar pretty well. At 159 and without food the blood sugar may very well drop quite a bit (again, depending on the patient).

So I don't think there is exactly a right or wrong answer. If I gave the insulin I'd probably check their blood sugar in an hour or so to see how they reacted. 159 isn't horribly high. If I had to choose a patient be a little high or a little low I'd choose a little high any day of the week.

canigraduate · Apr 5, 2015

One of the fundamental rules with fast acting insulin is not to give it if the patient is NPO, whether per order or voluntarily. Particularly for a BG under 200. If this question had been about NPH or Lantus, that would be a different story.

You need to be especially careful of this in an LTACH, where you don't really have extra time to recheck FSBG's and monitor the patient to see if they are becoming hypoglycemic. You would probably find out the patient was crumping when unresponsive. It would be easier and better for the patient to avoid this situation in the first place. If the BG is still elevated at the next check, you can deal with it then (if the patient is eating by then).

Talk to the patient and see why they are not eating. If they aren't feeling well, this warrants a call to the doc. A diabetic who doesn't want to eat is abnormal. If it's because the family is bringing a special lunch, then don't call the doc, but still hold the insulin so they make it to lunch time without incident.

Another thing to consider is if this person is on a long-acting insulin. If they are, giving them sliding scale in addition to the other insulin with not enough intake to cover it will just send them spiraling down faster.

Lastly, it is important to know how much the patient actually ate and if they have snacks they plan to eat in their room. If poor intake = 50%, then you should be OK to give the insulin. If it is

Based on the very limited info in your post, I would stick with holding it until you found out more.

(PS - You never, ever, EVER, practice based only on numbers. You must base your practice off of the whole clinical picture.)

Mully · Apr 5, 2015

Just give it. Problem solved lol.

_firefly, BSN, RN, EMT-B · Apr 5, 2015

I typically don't run into this situation because I have newly admitted patients and I have no idea how much they will eat. I check before their meal arrives and cover before they start eating. Really the main point of fast acting insulin is typically to cover the expected rise in sugar that comes with eating. Given this situation I would prefer to not give insulin and would feel uncomfortable doing so.

A principle I learned from ICU training is make many small moves and don't do anything that is going to drive the organs or chemistry fast in a new direction. The body has a fairly sensitive equilibrium. It can adjust, but it takes time. Healthier people can handle faster changes in most cases. Sicker people cannot. If you fairly rapidly drop the blood sugar on an older acute patient you may push them beyond their ability compensate and then you, or someone, will have to do all the work of titrating sugar and insulin all day to get them back to stable equilibrium. And legally, yes you cannot retime, change dosage, or hold a med without an order (unless the patient refuses). So make that call, and ask why (ask lots of whys). In my opinion, the most dangerous part of nursing is doing anything blindly.

Anna Flaxis, BSN, RN · Apr 6, 2015

I am still orienting in LTACH (Long Term Acute Care Hospital.) I disagreed with both my preceptor AND my charge nurse today, but I did not argue with them. I did what they recommended because I am still orienting and they have the upper hand. A patient's fasting blood sugar was 159 and he should have had 2 units of Novolog based on his sliding scale. However, they recommended that I hold the insulin due to his lack of appetite/poor intake for breakfast.
Please correct me if I am wrong, but I thought that sliding scale insulin is to be administered based on blood sugar RESULTS, not based on food intake.
What would you guys do? What do you recommend I do in the future?
Thanks.
A.Wilkes, RN

Technically, they are correct. Novolog is a fast acting insulin and should be followed by food intake. If the patient is not eating, then the fast acting insulin should not be given.

Annie Wilkes RN · Apr 6, 2015

Thank you all for the responses! He is a frail 80 something year old. Very weak. We did his next fingerstick at 1200 and it was 228 mg/dl. We gave the ordered 4 units, as he had eaten the majority of a grilled cheese sandwich and a few sips of his supplement. At 1630, his fingerstick was 131 mg/dl. He also takes scheduled Glipizide BID po. No other insulin- just the sliding scale and the po Glipizide.

I was just concerned because I thought sliding scale insulin was a "correction bolus" of insulin...not based on food intake. Thank you for your responses.

nursingpower · Apr 6, 2015

159?? Fasting glucose? That is high for a fasting glucose.

1. What does the orders say? If the physician orders state to give 2 units for 159 you should give it. YOU ARE CORRECT! Sliding scales are designed to treat hypoglycemia despite diet. Sliding scales are not to treat for future food intake. It is to bring a person BG back to a normal range. ITs FOR CORRECTION. We will never know how much a person will eat!

Think of it like this. Say normal fasting BG range is from 70- 110. Anything above 150 is abnormal. THAT'S A MINIMUM 40 POINT BUFFER RANGE! (150-110=40) 2 units of insulin given at 110 or less may cause hypoglycemia. With that being said, your preceptor and charge nurse are implying that 2 units will make someone with 159 BG hypoglycemic? That means they will drop more than 89 pts to get below 70 (159-70=89). Also many ppl are not symptomatic until their BG level is about 50 (average). My fasting BG was 59 when my PCP checked me. (I was NPO for cholesterol studies) I was hungry and had hunger pains but I was driving, walking conversing just fine. So considering that, it's no way 2 units of regular insulin with drop a BG by 100 pts to cause symptoms where you would have to return and treat.

I've work in an CVICU for 6+yrs. We use sliding scales for diabetics and non diabetics who are having stress hyperglycemia. We give 2 units if they are 150-170. I've never seen anyone get hypoglycemic getting 2 units when starting out >150. NEVER.

2. Why do we treat hyperglycemia? It places them at higher risk for infection in addition to increasing the risk of damage to blood vessels end organs. Maybe you should provide some research to your preceptor and charge nurse about treating stress hyperglycemia and the use of sliding scales. Furthermore they are telling you to go against physician orders based off of ignorance and fears. So the patient suffers from hyperglycemia because of it.

Did the physician orders state, "Hold if pt has no appetite"? If they want you to hold it, you should have the preceptor/charge nurse call the physician to obtain and order to not give the medication to cover yourself. They have to have a better reason to go against a physician order than a low appetite. That's for holding ANY MEDICATION. Any nurse who feels the need to hold should call the physician and clarify the order or get orders to hold.

But I feel your situation. You didn't feel like arguing with them. I know you can't wait to get off of orientation.

nursingpower · Apr 6, 2015

Thank you all for the responses! He is a frail 80 something year old. Very weak. We did his next fingerstick at 1200 and it was 228 mg/dl. We gave the ordered 4 units, as he had eaten the majority of a grilled cheese sandwich and a few sips of his supplement. At 1630, his fingerstick was 131 mg/dl. He also takes scheduled Glipizide BID po. No other insulin- just the sliding scale and the po Glipizide.
I was just concerned because I thought sliding scale insulin was a "correction bolus" of insulin...not based on food intake. Thank you for your responses.

I just seen this after I typed my reply. So this could have been prevented had they treated the first hyperglycemic event. SMH. Poor patient was hyperglycemic all day. Wonder how many days of this is going on.