Was I taught the wrong thing in school?

[qaqueen]

As a recent grad and new med/surg nurse, I realize that there is a difference in textbook and real world nursing.

However, one of the things that my instructors drilled into our heads was the "sick day protocol" for diabetics. "Take your insulin, monitor blood glucose more frequently."

The source of my confusion is I had a pt with blood glucose of 309 at hs check. On the sliding scale prescribed, the pt would have gotten 3 units of Novolog (at home the pt would have take a lot more). Because the pt was NPO, my preceptor instructed me to hold the insulin. This pt was in pain, very stressed and had an infection, was going for a procedure in the morning. Seems like a perfect combo to raise the blood glucose to me.

So here is the question, do you hold the insulin or give it when your pt is short term NPO? Any insight would be greatly appreciated.

Thank you

[JaneyW]

Did you call the MD to let him/her know about the result, pt's status and that the insulin was held?

[qaqueen]

Nope, I just did what the preceptor told me to do.

It isnt that I cant think for myself, but I guarantee you that thinking for yourself is NOT encouraged for new grads in this department.

[JaneyW]

That's a tough situation to be in. Especially because soon they will wonder why you can't think for yourself even after they have discouraged it. I just think that maybe that situation may have needed some collaboration with the physician and not stopped at nursing judgment alone. You can always frame it that you need the experience of calling the MD. I have to say, though, that I am not a diabetes expert. I would love to hear from others on this.

[morte, LPN, LVN]

I think your preceptor needs to brush up.....and the doc needed to be called.....no expert here...but i would have given the coverage, a standing dose of routine evening insulin==i might hold...depending when the NPO status was instituted.....no matter what, if the doc didnt address these concerns in adm. orders he/she needed to be called....

[qaqueen]

Thank you both! I see the point, doc knew the pt was NPO and didnt indicate to hold coverage so he should have made the call. Thank you again.

[dansingrn]

Standard sick day management is to treat the hyperglycemia, adding even more insulin if ketones are present (even if NPO, even if vomiting!). Definitely needs insulin in presence of infection, so clarification with the provider is indicated here.

[classicdame, MSN, EdD]

common problem at my facility where policy is NOT to give rapid acting HS. What people do not remember is that you then have to do SOMETHING ELSE. Like call the MD. If not on a basal insulin that needs to be added to regimen. But first things first. Get BS down.

[qaqueen]

Thank you all again. I appreciate the info and will follow with the doc in the future. You all rock!

[KendiKay]

Another point of view.......If blood sugar was over 300 at hs, wouldn't he/she not be eating anyway since is it hs? I would have gone ahead and given it (if I didn't have a preceptor breathing down my neck) and then checked bs in 3-4 hrs to see if it was therapeutic. Since you had a preceptor, it is expected that they know more d/t experience etc. Sorry that you had to do that. You will be a great nurse because you knew it wasn't right. Good luck in future!

[blondy2061h, MSN, RN]

If the patient has type 1 diabetes, holding insulin is just asking for DKA. The ideal situation is to have coverage for high glucose and meal coverage calculated separately, plus a set dose of basal coverage. The tough calls of giving SSI when hyperglycemic and not eating are very hard and shouldn't need to me made.

An ideal plan is set long acting dose (Lantus or Levemir) that's given regardless.

Then a set dose for meals (either set dose, or calculated based on how much is eaten).

Finally, a sliding scale of sorts that is given on top the meal dose for hyperglycemia. This could also be given if the patient isn't eating.

The reality of it is, the majority of hospitalized patients that get insulin aren't needing it long term and therefore this is overly labor intensive for little added benefit. That is why sliding scale remains popular. And will continue to be so.

A patient with a BG over 300 definitely needs insulin and I don't agree with holding the dose. I would have called the doctor and asked how much insulin they wanted for the 304 and if they wanted ketones tested.

A hospitalized patient who's body just needs help preventing hyperglycemia should probably just be getting corrections based on BG that are given regardless of eating for simplicity. Possibly a sliding scale with orders to give half dose if patient not eating.

Patients with long term insulin reliance should really be on a top of plan I described above, in my opinion.

[Valerie Salva, BSN, RN]

common problem at my facility where policy is NOT to give rapid acting HS. What people do not remember is that you then have to do SOMETHING ELSE. Like call the MD. If not on a basal insulin that needs to be added to regimen. But first things first. Get BS down.

I agree 100%.