Very high BGL .... thoughts?

sapphire18 · Nov 13, 2012

Not wanting to sound rude, but just be sure the MD is aware. It isn't our job to medically manage patients.

Also, he probably needs some lifestyle modification and a sliding scale.

KBICU · Nov 13, 2012

Just because he's a symptomatic now doesn't mean he will stay that way. Sounds like he needs a DKA workup or an insulin regimen change. Regardless he is at a higher risk for infection, stroke, MI, Etc as well as all the micro complications r/t uncontrolled diabetes.

tokebi · Nov 13, 2012

The elderly are more prone to HHS -- hyperosmolar hyperglycemic state -- the slower, the less acute, type II equivalent of type I DKA. Although the first crisis seems to have been resolved with the trip to the hospital, current treatment regimen is obviously not adequate. The danger of HHS is severe dehydration and altered mental status, leading to coma. Like mentioned already, be sure the MD is aware. At LTC I worked in the past, we always had the protocol to notify MD for BGL>400. For LTC residents, physicians often wouldn't know what's going on with them unless the nurses called them. It might be helpful if you faxed to the MD the monthly or weekly BGL trend together with current MAR.

KitkatPRN · Nov 13, 2012

The MD is most definately aware and has been called almost daily with updates. In fact, I called yesterday twice d/t the high levels, outside of the sliding scale parameters. The Lantus has been changed from 20 units to 24 units, to now 28 units. He is having a CMP with diff & a BMP today, agian. I know how to manage someone with high/low blood sugars. I know I don't diagnose but I was just curious if someone else saw something like this & the patient had something underlying more serious than a UTI or easily explainable infection, as this patient has nothing obvious that the MD or nurses can detect. Hopefully, more tests can find the underlying cause or the MD will get the diabetes managed. (one last note: we have a NP who is avaliable Mon-Fri, she has seen him and reviewed his BGL's almost daily & she works with his MD, too).

morte, LPN, LVN · Nov 13, 2012

Is he perhaps, actively dying? It seems his pancreatic islets cells have "given up"? Is this not the time to consider CMO?

Anna Flaxis, BSN, RN · Nov 13, 2012

Has he been worked up for pancreatic cancer?

classicdame, MSN, EdD · Nov 13, 2012

He is not getting enough meds. Period. Talk to MD

sapphire18 · Nov 13, 2012

Why are you sure that he has an infection?

Also, agree with classicdame.

CDEWannaBe · Nov 13, 2012

classicdame is right on. One thing you can do is make sure the patient gets plenty of water. Will help him feel better and keep the kidneys flushed of all that extra glucose they're cleaning up.

Anna Flaxis, BSN, RN · Nov 13, 2012

I think it's quite possible that there is an underlying cause to his developing diabetes at this late stage in life, and that the doctors don't want to work him up for it because of his advanced age and dementia. Would knowing the cause change treatment decisions, if, for example, he was diagnosed with cancer? Probably not. The focus would still be on symptom management. In that way, classicdame is right, he needs more insulin.

Does he have an advance directive? Do you know his/the family's wishes for his medical treatment?

Sun0408, ASN, RN · Nov 13, 2012

I have only seen something like this once so far. The pt was in the ICU on an insulin gtt and no matter how many units we went up he was still in the 500 range and climbing. I think before he died he was on 75 units of insulin an hour with levels going higher and higher. We were all confused on this one, we called every MD on his case and soon they were all at the bedside trying to figure it out. The cause was never found.

Sorry, I don't know all the details, it was not my pt.