Sliding scale insulin...give or hold?

[Annie Wilkes RN]

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

[canigraduate]

In addition to the 2 examples you provided: DKA, TPN. Diabetic patient that is post-op but still NPO. Those are the easy ones, I'm sure there's something I'm not thinking of in my current sleepy state.

Thanks. Those situations had slipped my mind, although I'd be leery of the post-op NPO diabetic if I didn't know them. I worked post-surgical for a while and had a couple drop to the 40-60's before they were caught.

[SassyRN_972]

I would have given it. Sliding scales are outdated and an old practice anyway. We are constantly chasing the blood sugar. First of all, a person who has been getting novolog sliding scale for a while will not show you a great drop from 2 units. It's important to maintain blood glucose control because you don't want huge spikes here and there since that would be detrimental to wound healing. I know a lot of nurses are worried about bottoming patients out, but it is very very unlikely that that would happen with two units. Our hospital doesn't treat blood sugars unless they're above 150 anyway so that is a pretty sturdy number to begin with. I've seen many a time RNs hold the patients sliding scale insulin for the most random reasons that weren't clinically justifiable. I'd say your instinct was right and evidence based but you should do as they tell you since you're still in orientation.

[CapeCodMermaid, RN]

A low blood sugar is more worrisme than a high blood sugar in someone who is in his eighties. Hypoglycemia contibutes to falls and increased confusion. 70-110 might be an acceptable range for a younger person but might be too low for an octogenerian. Older people shouldn't be kept in such tight control.

[myrachandler]

I would have held the Insulin. Often the sliding scale Insulin is given at mealtimes to cover what the client is going to eat. To give Insulin, if not long-acting, when a client is NPO/not eating can cause hypoglycemia. Hypoglycemia, to me, is more of a risk for this client.

[Anna Flaxis, BSN, RN]

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.

And here is one of the problems with your traditional "sliding scale" insulin. You are reacting to an already elevated CBG and not taking nutritional intake into account. This strategy often results in drastic swings in CBG levels, can result in poorly controlled hyperglycemia, and can result in hypoglycemia when doses stack up in the person who is not taking PO well.

While it's not very likely that 2 units of Novolog will drop the pt's CBG from >150 to

One of the problems with SSI protocols is that often, the only time the physician is contacted is when the CBG falls outside the parameters of the scale (a hypoglycemic event or a CBG >300, for example), and so the patient's glucose can be poorly managed with lots of swings up and down or persistently high levels.

This is why we have to think and don't just give meds simply because they are ordered.

[Anna Flaxis, BSN, RN]

A correctional dose is to treat what their BG is right now and has nothing to do with eating. When used as a nutritional dose the patient does then need to eat, because the amount given isn't based on what the BG is now but what it's expected to be due to eating.

If they aren't eating the patient still needs the correctional dose, only the nutritional dose should be held.

The purpose of administering insulin is to allow for proper glucose metabolism. Without sufficient insulin to go along with circulating glucose, regardless of whether or not that glucose comes from food they're about to eat or from their body's stores of glucose, the patient won't produce and metabolize that glucose properly.

That's a assuming that the patient is on a physiologic insulin protocol, not your traditional SSI protocol.

In the physiologic protocol, the patient would be receiving a basal dose of long acting insulin (50% of their 24 hour total insulin needs calculated by weight and a few other factors), then the rest of their 24 hour insulin need divided into 3 pre-prandial doses, which would be held if the patient is not eating. It's true that the correctional dose would still be given without regard to PO intake, but the parameters for a correctional dose would be different from the parameters for your typical SSI dosing protocol (example, "standard dose" would be one unit less than in traditional SSI- so risk of hypoglycemia is reduced) because the patient is also receiving basal dosing.

I was under the impression the OP was using a traditional SSI Protocol. Maybe I'm wrong about that.

[nursingpower]

Wrong. Rapid acting insulin needs to be followed by food intake. If you use it to "correct" for a pre-prandial CBG, and then the patient doesn't eat, you risk hypoglycemia.

Again, wrong. Have you ever heard of relative hypoglycemia? For some folks whose bodies have acclimated to running at higher CBG levels, a CBG WNL can make them symptomatic.

Managing stress hyperglycemia and managing diabetes long term are two different things. Plus, I'll bet that your patients who aren't taking PO are getting dextrose intravenously.

No, her preceptor works in a different setting than you do. Aggressive blood glucose management in the post surgical setting is best practice well backed up by evidence. You might want to consider that management of blood glucose in other settings is not from the same cookie cutter.

A thinking nurse who knows her meds and her pathophysiology is capable of using nursing judgment to determine whether it is safe to administer a medication or not. It's called "critical thinking", and it is what we are taught to do in nursing school.

I do agree that if the nurses are routinely holding the dose because of poor PO intake, then the physician needs to be notified. This could indicate a change in patient condition that needs to be medically evaluated.

But, knowing that if the patient is not eating, then rapid acting insulin should not be given (unless the patient is receiving some form of glucose, such as dextrose containing fluids) is basic nursing critical thinking.

Yep, your rationales explain why the patient's next BG level was 228. Go figure.

I hardly think getting D5 1/4NS constitutes as as diet. Again...the patient's BG nearly doubled because the patient wasn't treated the first time.

[nursingpower]

From Novolog's website:

• NovoLog® is fast-acting. Eat a meal within 5 to 10 minutes after taking it.
  

From Humalog's website:

Hypoglycemia is the most common adverse effect of Humalog therapy. The risk of hypoglycemia increases with tighter glycemic control. Severe hypoglycemia may be life threatening and can cause seizures or death.

I think it's more important to hold it and let patients be a little high than give it and make them go too low.

I think it's more important to treat hyperglycemia as the physician orders state to prevent worsening hyperglycemia. The patient's blood sugar went from and untreated 159 to 228. Don't seem that beneficial to the patient.

[nursingpower]

a sliding scale is to return a patient to normal, it is different than the routine carb counting premeal fast acting insulin, totally different use. yes, he should have gotten the 2 units, as proved by his later BS of over 200. good call.

Exactly. In this case, some continue to support disregarding physician orders despite knowing that the next BG level was worse. It seems very clear that the patient should have gotten the 2 units.

[nursingpower]

A correctional dose is to treat what their BG is right now and has nothing to do with eating. When used as a nutritional dose the patient does then need to eat, because the amount given isn't based on what the BG is now but what it's expected to be due to eating.

If they aren't eating the patient still needs the correctional dose, only the nutritional dose should be held.

The purpose of administering insulin is to allow for proper glucose metabolism. Without sufficient insulin to go along with circulating glucose, regardless of whether or not that glucose comes from food they're about to eat or from their body's stores of glucose, the patient won't produce and metabolize that glucose properly.

a lot of people forget the whole glucose metabolism piece. Great point!

[nursingpower]

That was thought to be true up until the last few years, all current recommendations are for less aggressive BG control, typically 110-180. The 'old' 80-110 recommendations for some post-op and critically ill patients no longer exist from any professional practice group, all advise a goal of

This is a fine example of using evidence based practices. Many people used to going by "What we've been doing" In this case the patient's BG worsened because of assumption and fear. A patient with a sliding scale should have BG within normal ranges if followed correctly.

[SassyRN_972]

Agreed. I've seen many physicians be baffled at a patient's poor glycemic control. Turns out the RNs weren't communicating with the physicians why they were holding the sliding scale insulin so he wasn't even aware. He ended up adjusting his PO meds as well as upping the levemir in order to regain control. It was a mess.

Also, a glucose spot check is always an available option for the RN.