Sliding Scale Novolog Question

Joey_Boy, LPN · Sep 9, 2011

So he didn't get any coverage for his meal then? That's why these sliding scales aren't any good, because you cant do anything until after the fact. They're discouraged by the ADA http://spectrum.diabetesjournals.org/content/16/2/68.full

xtxrn, ASN, RN · Sep 9, 2011

I am confused a bit about insulin control/sliding scale. In clinical I had a pt. tonight who is Type 2 Diabetes, he is on a sliding scale of Novolog, BS check Q4. I got on the floor at 330, checked his BS at 4, it was 141. According to the sliding scale it said to give none. Now, he had dinner at around 530, then I checked it protocol Q4 at 800, so this would have been about 2.5 hours postprandial. It was 392! I told the nurse, she didn't seem concerned about it. Now his Novolog was only due 800, 1200 and 400 (according to the sliding scale) but shouldn't he have gotten insulin according to the sliding scale? Plus he was having snacks! I am confused.
Thanks!
:)

My reply is based on patients I've taken care of, and being a diabetic.

My first question is why is he not on ac/hs accucheks if he's not on TPN or continuous tube feeding? He won't get good coverage if the insulin isn't in sync with meals. The 4pm check is too far away from dinner to use that for the insulin dose- if dinner is at 5:30, you can have a VERY different bg, and the insulin will be wrong. The 8 a.m. accuchek may or may not be before breakfast. With the short acting insulins, you only have 5-15 minutes before the onset of action.

Second, some docs don't do a hs sliding scale (I DO take NovoLog at hs if my sugar warrants it). If someone is on a long acting (Lantus or Levemir) they will have some underlying coverage for pretty close to 24 hours (some people only get 20 hours).

A blood sugar of 392 needs to be reported to the doc if there aren't orders to cover it- which isn't going to happen if the nurse blows it off. If the doc decides to not treat that, it's his problem for the moment...but it really isn't too swift to not aim for the best blood sugars possible :)

With NovoLog, the optimum dose is correlated to the number of carbs consumed. The insulin:carb ratio is very different for each patient, and takes some time of doing ac, pc, AND hs accucheks for a while, to see what doses work. Other medications, stress, the illness he's in the hospital for, etc all effect the I:C ratio. It's a hassle- but not difficult, and much better for tighter control. But if the patient doesn't know his/her I:C ratio, the doc just has to punt, but it should be tweaked if needed.

There have been studies that show better overall outcomes in hospitalized diabetics if their blood sugars are a bit high (not 392!). And no doc really wants to tell nurses that the dose is dependent on what the patient eats. That's why patients who can do their own calculations and can tell what dose they need can have near normal blood sugars. (of course, steroids screw everything up- and if he was on steroids, it still should be addressed, but could be a reason the nurse didn't get too excited- I still would have reported it- what the doc does is his deal).

When I'm in the hospital (various diagnoses) my first thing is to ask for orders to let me decide the dose. I've been doing this for years, and when someone else gets involved, it can take weeks to get things back in order. If I'm in for something that effects how much I can eat (chemo) I take the insulin immediately after the meal to avoid taking a dose for what I THINK I'm going to eat, only to get grossed out after the first 3 bites :eek:

Another issue....visitors bringing candy/junk. When everything else sounds horrible, sometimes a piece of candy helps- and the patient doesn't say anything- that can also be an issue for mystery spikes

I hope this helps :) I don't mosey around all forums, but if I can be of help, please PM me - and ask the docs about the doses. It's ok for students to talk to the docs :)

silverhalide · Sep 10, 2011

Thanks, I will PM you for sure, thanks for all the info, I appreciate it. The Diabetes stuff is starting to click. It's really interesting. Makes me realize how you cannot be afraid to ask questions! :)

xtxrn, ASN, RN · Sep 10, 2011

Thanks, I will PM you for sure, thanks for all the info, I appreciate it. The Diabetes stuff is starting to click. It's really interesting. Makes me realize how you cannot be afraid to ask questions! :)

As soon as it makes sense with one patient, someone else will come along who reacts to things very differently :) Don't feel like you're not getting it, if that happens- you just got someone with different insulin sensitivity or reactions to illness.

Chet Joseph · Nov 30, 2011

I was on a sliding scale and it didnt work well now iam on carb counting and my blood sugar is doing great!!!

Chet Joseph · Nov 30, 2011

So he didn't get any coverage for his meal then? That's why these sliding scales aren't any good, because you cant do anything until after the fact. They're discouraged by the ADA http://spectrum.diabetesjournals.org/content/16/2/68.full

I was on a sliding scale and it didnt work well now iam doing carb counting with carb to insulin ratio and my blood sugar is great!!

CDEWannaBe · Nov 30, 2011

xtxrn is right on.

A sliding scale corrects a high blood sugar. A carb ratio gives extra insulin to cover the carbohydrates consumed. Insulin dependent diabetics should use both to adjust insulin.

The other option is to have a set insulin dose and try to eat the same # of carbs every day at the same times. Doesn't work well since most people's lives aren't regimented enough to make it work and there are so many other factors that affect blood sugar (exercise, glucose dump from liver, stress, illness or infection, etc.).

classicdame, MSN, EdD · Dec 1, 2011

The ADA guidelines for patients in acute care is different than when they are at home. However, I often see orders that mimic at home, and the patient's BS is not well controlled while in the hospital.

The ADA recommends D/C po meds for diabetes when in acute care, especially if surgery is involved. The preference is a basal insulin (Lantus or Levimir) plus a FIXED dose of rapid acting plus more rapid acting per a sliding scale. Doses for all insulin is weight dependent, which can vary daily as you know. See guidelines on www.diabetes.org.

mammac5 · Jan 2, 2012

The timing of the CBG (capillary blood glucose) check, insulin dosing, and eating is critical for good blood sugar management. If we just use SSI (sliding scale insulin) to chase blood sugars that are already high, we're playing a losing game. I read somewhere (wish I could recall the source) that the biggest cause of HYPOGLYCLEMIA in the hospital is the use of SSI.

SHGR, MSN, RN, CNS · Jan 10, 2012

The q4 checks should be used for someone who is NPO; qac and HS checks for someone who is eating (either of these can be checked more frequently or PRN of course). This was the standard we used when I worked med/surg and nursing was able to change the order if the person became NPO or was able to eat after having been NPO.

Also Type 2 is very different from Type 1, and since Type 2 has a component of insulin resistance (different for each individual) each person is going to have very different insulin requirements.

CDEWannaBe · Jan 12, 2012

I appreciated the information from this thread. Thanks mammac5 and hey_suz.

https://allnurses.com/diabetes-endocrine-nursing/need-evidence-based-659233.html

Even type 1s have different insulin sensitivities. There are so many variables that affect blood sugar for type 1 and 2. It's different for each diabetic and is perfected only through trial and error. Glucose control is an art, as much as a science.

I'm thankful hospitals are finally starting to modernize their guidelines for patient blood sugar control. It will make a huge difference in healing time and the patients' overall health and attitude.