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

[Anna Flaxis, BSN, RN]

Here's the thing, though. If he were on a physiologic insulin regimen, he would be receiving basal doses (perhaps his oral agent is taking the place of that) plus nutritional boluses based on PO intake (and held if not eating), and a correctional dose at the same time as the nutritional bolus. The correctional dose would be adjusted for the whole picture, and would be lower than that of most Sliding Scale regimens. That is not what I'm hearing being described.

Giving a rapid acting insulin to someone with poor PO intake is risky- maybe in this particular case, it would have worked out just fine given that the dose was 2 units and he'd have to be very insulin sensitive to become low as a result. But you can't safely assume that is the case for everyone, so I think the preceptors were correct in exercising caution- particularly if poor PO intake is a new development for this person..

[Mully]

Wait a second... he's a frail 80 something year old in LTACH?! Why are we treating him at all? I say give the man a sandwich and let him R.I.P.! bahahaha

No for real though, a good motto someone taught me in anesthesia is thinking to yourself, "If I give this drug and it causes a problem, can I fix that problem?" For instance, if I give too much phenylephrine, could I fix the problem of a B/P that's now too high?

Or in this case...

If I give the insulin and all the fears and nightmares of this thread come true and the patient becomes symptomatically hypoglycemic, can I fix it? Well, if he's NPO because he just didn't feel like eating dinner... then the worst that could happen is you make him drink a glass of OJ. Or if he's got a PEG tube, a little OJ bolus. Or Coca-cola! Yum. Not so bad, eh?

Obviously everyone has opinions on both sides of this raging 2 units of insulin debate, and both sides make valid points. It's best to make a decision and move on. I've found the above thought process can help you make that decision with confidence.

[SassyRN_972]

I totally agree

[nursingpower]

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.

What is crazy is that a patient is in the hospital or facility with physician orders and nursing staff but yet the patient has uncontrolled diabetes. In regards to the diabetes, the patient might as well go home. I know physicians who are frustrated with nursing holding medication put in place to help the patient. To hold any medication the physician should be notified unless the order has holding parameters.

In this case his next BG at noon was 228 mg/dl. Two things: 1. went against a physician order to treat hyperglycemia. 2. did not call physician to made aware of holding dose. These two actions combined is technically not within the scope of nursing practice. I guess the main theme is that the patient was not harmed per se.