Sliding Scale Insulin

suanna · Oct 5, 2007

It depends, is you sliding scale in addition to a programed insulin like lantus or an oral agent or is it the only hypoglycemic agent being used. If all you are holding is the bolus dose of insulin but mantaining the blood sugar on other agents 200 seems a bit high but not completely nuts for a med surg floor. If this is the only agent being used it is too high and needs to be adjusted but we are just RNs and don't get to make that call. A lot of the non-endocrine docs go with "glucose 80-200" range... very old school. Unless the patient is fragile most protocals I have used aim for glucose 80-140. Good luck!

RN BSN 2009 · Oct 5, 2007

Hi.

I'm not sure which insulin this particular unit uses because I haven't had a diabetic patient as of yet.

Well, that is until today.

She was not on oral hypoglycemics, even before her hip replacement.

woody62, RN · Oct 5, 2007

Hi.
I'm not sure which insulin this particular unit uses because I haven't had a diabetic patient as of yet.
Well, that is until today.
She was not on oral hypoglycemics, even before her hip replacement.

I am on NPH and metformin, twice a day. When I am in the hospital, I am on a sliding scale of regular insulin. My sliding scale begins at 182 with one unit of regular insulin to be given. My sliding scale goes up as my blood sugar rises. When I first started on a sliding scale, in 2000, it didn't start until my blood sugar is 200 plus, then I received two units of regular insulin. The sliding scale is left to the individual physician. It has been established that diabetic patients heal faster and better when their blood sugar is kept as close to normal as possible.

Woody:balloons:

al7139, ASN, RN · Oct 5, 2007

Hi,

I work on a cardiac/medicine floor. We use sliding scale, but the docs do tweak them based on the pt. Lots of times we see orders that start coverage at 150 or 200. This is not very unusual, especially if its a pt who is taking scheduled lantus or oral meds like glucophage. The usual insulins we use are regular or lispro to give extra coverage. They are rapid acting insulins that can cause hypoglycemia fast. 200 is not

unusually high for a diabetic who is in the hospital. I look at why my pt is in the hospital and how they have been trending on their sugar levels. I also take into consideration how much they are eating, and what other meds they are on. If they do not have a history of diabetes, they are usually on stroke protocol, on TPN, on tube feeds, or on steroids. You have to look at the whole picture to see why the md may have not wanted to start coverage until 200. Did they have a previous history of DM? Did they have a stroke? Do they eat or are they not getting adequate nutrition? Are they on scheduled lantus insulin or oral diabetes meds? Are they on steroids such as solu-medrol (these can cause a syndrome called steroid induced diabetes). Have they had hypoglycemic episodes if they are covered below 150-200?

Lots of times we have orders to cover starting at greater than 100. I often withhold coverage until 120 especially at night when the pt will go for a long period of time without food, or if they are not eating very much.

The patient is in the hospital because they are sick, and often the stress of illness can cause blood sugars to get higher even if they are the most compliant pt at home with their diabetes or not diabetic at all, so blood sugars in the 150-200 range or greater are not unheard of. Wait till you see a pt with a blood glucose of 800! Thats high!

Hope this helps!

Amy

cmo421 · Oct 5, 2007

Sliding scales are often in practice. Many hospitals now have a protocol to go by,very specific in nature.I used to find them very scary,always thinking I would make them crash. It is shown that sugars 80-110( fasting) are the common goals. Now depending on ur facility,the normals might be somewhat different. In the trauma area we had to keep there sugars in this parameter. Many not even diabetic,just on steriods and such making there sugars abnormal. Most on drips and checked every1-2 hrs. For those on prn insulin or schelduled injections, we checked them q3-4 hrs. Evidence based practice is the goal standard now and backs tight glucose control. As a newly diagnose diabetic myself,it is hard. I have been told by my primary doc that 80-110 is where she wants me. Good sugars promote healing and fend off neuropathies.

kanzi monkey · Oct 5, 2007

Check out http://www.guideline.gov to get some current evidence-based practice recommendations. The one I have posted below is pretty thorough RE: managing hyperglycemia in a hospital setting:

http://www.guideline.gov/summary/summary.aspx?doc_id=5852&nbr=003868&string=insulin+AND+protocol

Also, if you have access to medline, cinahl, or some other internet database, try doing a search there--suggested keywords: "insulin protocol" "sliding-scale" "sliding-scale and monotherapy" "inpatient hyperglycemia"

There is an excellent article from an issue of Diabetes Spectrum in 2005 (vol.18 no.1 p. 20-26) called "Hyperglycemia in the Hospital" by Thompson et al. It covers recommendations delineating treatment for known T1, T2, and other episodes of high BG in a med-surg setting.

-Kan

RN1989 · Oct 5, 2007

Being that you are on Ortho, chances are it is the ortho surgeon writing those orders. Unfortunately many doctors have a tendency to think that they can manage ALL of the meds and conditions and do not ask for consults with nephrology, endocrinology, cardiology, etc. Because of this, you may often see SS insulin that is technically wrong according to good diabetes control but there isn't a lot you can do about it. Just one of those little things to irk good nurses.

lsyorke, RN · Oct 5, 2007

Being that you are on Ortho, chances are it is the ortho surgeon writing those orders. Unfortunately many doctors have a tendency to think that they can manage ALL of the meds and conditions and do not ask for consults with nephrology, endocrinology, cardiology, etc. Because of this, you may often see SS insulin that is technically wrong according to good diabetes control but there isn't a lot you can do about it. Just one of those little things to irk good nurses.

So true. Ask your diabetic patient!!! Most know exactly what they need, insulin wise, and will tell you. Carb counting used by most diabetics makes sliding scale obsolete. The insulin dose, with carb counting, is based on what they are going to eat, not strictly on what their current glucose level is.

RN BSN 2009 · Oct 5, 2007

Thanks so much for your help!

grace90, LPN, LVN · Oct 6, 2007

My patient's chart said to withold insulin if chemstick reveals a glucose less than 200.
Is it just me or doesn't that seem a little too high to NOT give insulin? Am I missing something here?
Are sliding scale protocols different for each patient? Thanks in advance

At the hospital I work at, there is a standard scale with a low, medium and high level. Most patients use that scale. But occasionally we'll see a different scale. It's possible that the reason scale insulin is held for

ZippyGBR, BSN, RN · Oct 6, 2007

do you not have a facility wise 'standard' sliding scale prescription ?

again this may just be a ringhtpondian thing but we have a standard sliding sclae with a specific prescription and monitoring chart which does include theability to set up none standard sliding scles - such as for some ofthe less well controlled DMIIs who have become used to running high and hypo at 'normoglycaemic' levles