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.
I would have given the insulin, 3u can cause a drop in BG but the patient has a history of taking higher doses at home. A big factor to consider is if there is any IVF infusing & if there is Dextrose in it?? That alone is a source of nutrition. Though it is a good critical thinking measure to hold insulin for short-term NPO, with a BG level greater than 300 I would want to intervene and get that level down.
A doctor must be contacted if your going against his/her orders!!! Cover your butt at all times and document the outcome it's a pain, but that's what were paid to do.....
I have to agree with the post above. What if the pts is on IVF? Dextrose? In our hospital regardless of NPO status any sugar higher than 300 needs to be called to the PA/MD/NP even if it says to give for example 8units. Still call. Some pt can hadle a sugar that high without any sx but some can't and if they are NPO. That sugar can keep rising. Remember the body under stress will try to fix it self but side effect of the hormones that are being release to help a sick pt will increase the sugar.
I just came across that issue not too long ago.. my patient was having surgery in the morning and their HS blood sugar was in the 200's. I asked the charge nurse and she said to cover it. I would think 300 would be way too high to leave! Besides like someone else said most people don't eat after their HS dose anyway, and with the infection and stress I would think it could stay up and put more stress on their body while they are already having to have surgery. I talked to a nurse who said that they "new information that's out" is coverage is pretty much always needed and it's strongly recommended not to hold it but I don't remember what her source was.
I agree that you should have called the doctor. The insulin needed to be given . Was the patient on an IV? I would think so as he was NPO plus had an infection?
Specializes in Hospice, Ortho/Neuro Rehab, camp nurse.
Tough question, However, being a T1 diabetic myself, I would have called the MD. I was in the hospt for a partial hysterectomy and my PCP held all my insulin because I was NPO, well I finally had to go AMA because my blood sugar went up to 900, and she still wouldn't let me have insulin. I believe a diabetic knows their own body and own diabetes. If you r Pt takes more at home than prescribed in the hospt, then ask them as well. The high blood sugar probably added to his/her not feeling well.
For a BS of 309 I would call MD especially if they did not put a hold on novolog. You were thinking the right way, don't forget (your license) She does not have the power to think for you. Next time say s omething like " I don't feel comfortable, with that decision, and am going to notify the MD" you will not get in any trouble for protecting your Pt's, yourself, and your license.
what about the "brittle diabetics" in this scenario. is it possible that you cover the 304 HS with 4 units and it bottoms the person out as pt was just on NS IVF? tricky tricky!
or is it sucha low dose rapid acting insulin that it likely woundt bottom the pt out?
or basically just call the md!
what happens when the "resident" says "what doyou think?" which happens alot depending on where you work! haha need advice to experienced RN's out there and thanks !
what about the "brittle diabetics" in this scenario. is it possible that you cover the 304 HS with 4 units and it bottoms the person out as pt was just on NS IVF? tricky tricky!
or is it sucha low dose rapid acting insulin that it likely woundt bottom the pt out?
or basically just call the md!
what happens when the "resident" says "what doyou think?" which happens alot depending on where you work! haha need advice to experienced RN's out there and thanks !
I am not a CDNE but I have been on insulin, for ten years, treating my Type 2. It depends on how 'brittle' the person is, as to whatever or not you give the four units. Unless the patient is extremely brittle, I would give the insulin and monitor the patient. If the reesident said 'what do you think', I'd tell him to check with the attending.
i would hold the insulin...the patient is NPO>>>>you give insulin now....patient may bottom out cause more problems....i would either get order from doctor since the patient is npo for any new orders or just continue to monitor sugar...but definately wouldnt give insulin until i got clarification from my doctor.
i would hold the insulin...the patient is NPO>>>>you give insulin now....patient may bottom out cause more problems....i would either get order from doctor since the patient is npo for any new orders or just continue to monitor sugar...but definately wouldnt give insulin until i got clarification from my doctor.
As a nursing student and a mother of a child with Type One Diabetes, the hospital is the scarist place for ANY paient with diabetes. Personally, we have been told, by our endoncro, to take all supplies, insulin, and testing equipement if we ever go to the hospital, to follow her sick day orders. Just because we grace the doors of a hospital, her orders do not stop!
That said, as a nursing student, I have argued this with other nurses and doctors. Depending on the Type of diabetes the patient had, with type one, no I would not have held the dosage. I would have checked blood ketones, not urine because it is several hours old and blood is best, and called the doctor treating for diabetes and asked for orders. With Type Two, I would have called the doctor and followed that order. Most hospital doctors do not have a true understanding of diabetes and ingore it and treat the other reason why the patient is in the hospital. The reason for the hospital stay and diabetes must be treated hand in hand.
FYI>>>>If you treat a patient with Type One, ask them what they do for sick days, if their endocon. gave any directions for surgery, etc., and call that doctor. If it is a child, over the age of say seven, and they have had diabetes for a while, ask them first and then ask the parent. Our son is now ten and had it for four years. Children with Type One are trained to deal with their own illness, with support, yes, but they have to learn awarness and cues that their body gives them. Ask them and have the parent add more if needed. It's their name on the patient chart, not the parents. Good luck.
If you are unsure on how to work a doctors order based on the patients situation (such as NPO status), call the doctor. Explain the situation and your concern. In this situation it seems that giving the insulin would be a good idea since they were over 300. You can always go back and re-check their blood sugar. I think it would be better to give the insulin, re-check it a later and see an 80 rather than holding the insulin, waiting till breakfast check and seeing a 450. Not to sound crazy here, but I'm sure you have dextrose available in IV form just in case the bottom drops out. After all, if you are unsure on the docs. order, call the doc. They may have forgotten the patient was NPO.
criola2
7 Posts
I would have given the insulin, 3u can cause a drop in BG but the patient has a history of taking higher doses at home. A big factor to consider is if there is any IVF infusing & if there is Dextrose in it?? That alone is a source of nutrition. Though it is a good critical thinking measure to hold insulin for short-term NPO, with a BG level greater than 300 I would want to intervene and get that level down.
A doctor must be contacted if your going against his/her orders!!! Cover your butt at all times and document the outcome it's a pain, but that's what were paid to do.....
GOOD LUCK!!!