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.
Specializes in Diabetes ED, (CDE), CCU, Pulmonary/HIV.
Sliding scale insulin is correction insulin given to correct a blood sugar that is already high and should be given even if pt is NPO. Even though many/most physicians will order it as the only insulin coverage, use of sliding scale only often leads to widely fluctuating BG values. Our DM management order set specifies that sliding scale is correction insulin and should not be held. The insulin that would be held is the mealtime bolus of fast acting insulin. Bedtime basal insulin such as Levemir, Lantus, or NPH generally would not be held. Sometimes a doctor might order a reduced dose of NPH if pt is NPO because of its pronounced peak. A BG of 309 needs to be treated.
i would have omitted short term but given long acting/ mixed, and monitored glucose levels...
This is the stuff us new nurses need to know. Nowhere in my nursing books did i read that NPO(nothing by MOUTH) included injections. Was I absent that week!! I gave insulin for a BG of 389 5 hrs before the residents surgery. The resident has always had trouble with high BG because she eats everything. I saw the paperwork for the pre-surgery instructions which did say NPO. They also said that her BG was an issue to watch. The doctor cancelled the surgery because I gave the insulin. How was I supposed to know!!!! All these secret/assumed rules of nursing should be published somewhere because some older nurses where I'm at don't want to share the knowledge. I also found out that it is IMPOSSIBLE to pass medication to 32 residents within the 2 hour window that law allows. Plus there are multiple med passes in one shift and treatments and 20 charts with new orders and residents falling and residents to feed, etc,etc. How the HECK is one person supposed to finish all that in 8 hours? No one prepared me for that one! Think I'll specialize in something other that nursing homes..lol
I'm a diabetic- on insulin for the last 3 years . There is very little about taking care of diabetics that is the same as living as one- LOL I've learned a LOT !!
At 309, I'd definitely take the insulin (and at home, probably about 30 of NovoLog, with my 70 of Lantus- even at hs) . But that's how my diabetes works -- one of the things I've learned is that we're all so different. I feel ok until I hit the 50s... my grandma (not on insulin) feels lousy when she hits 100. She has spikes when she eats corn- I don't. I start to pee a lot when I'm in the upper 200s. Others don't until well over 300. (I'm on chemo now, so all numbers are messed up- my pre-chemo A1C was in the 5.0s...)
Add additional medical problems like infections and medications- and that throws things out of whack..
Agree- let the doc know, especially if the patient is NPO (and some may holler- but that's fine. You didn't beat him into going to med school- you're just doing your job :)).
I'm also a T1 and I would agree with the above parent that EVERYTHING I need comes with me to the hospital and as long as I am able I am managing most of the decisions. If the patient is suddenly low, then you have access to dextrose for the IV. I would think you would want to monitor closely. The only time I would think to hold the insulin is if you had recently given a dose (like in the last 1.5 hours) stacking bolus insulin is a bad idea and must be done with care. Sometimes after a bolus you really do have to ride it out a little and see what happens because it takes time to work. For example, if you test 300 at 2 hours post meal and meal bolus ( I understand this patient is NPO now but may not have been a hour ago). You may still have the insulin on board to cover the high it just hasn't worked out yet. It is possible at that point you didn't get enough but that is in the "it depends" world.
I am new to nursing so my knowledge on this is personal and learn through trial and mostly error. However, I have a question about a situation like this one. As the nurse, if you find a situation like this one and think the patient needs closer monitoring, say for instance your order is to test 5 times a day but right now you need another in an hour to make sure your decision was right, do you have to get a new order from the doc or can you do the retest on your own??
I am new to nursing so my knowledge on this is personal and learn through trial and mostly error. However, I have a question about a situation like this one. As the nurse, if you find a situation like this one and think the patient needs closer monitoring, say for instance your order is to test 5 times a day but right now you need another in an hour to make sure your decision was right, do you have to get a new order from the doc or can you do the retest on your own??
Something that comes from this- if at all possible (with all diabetics- regardless of meds/insulin), get an order for the scheduled accucheks with a PRN attached to it- then you don't have to worry about it when things are getting hairy. :)
You're right to be concerned. Complications of diabetes with an infection can lead to ketoacidosis in Ti an T2 (though not common in T2). That can be lethal.
I took care of patients on a coma stim unit who were there for either poor self management, or medical negligence with blood sugars in the 20s to 1000s.....they were toast.
a big problem in many facilities is that people do not really understand the need or use of insulin. Now that we have various forms of insulin available there is more to remember and some people are stuck in the past. Your body needs insulin 24/7, eating or not. If the patient's BP was elevated would you hold the BP med??? This is a time to talk to MD. No point in letting patient stroke out just to meet some stupid (and arbitrary!) schedule.
a big problem in many facilities is that people do not really understand the need or use of insulin. Now that we have various forms of insulin available there is more to remember and some people are stuck in the past. Your body needs insulin 24/7, eating or not. If the patient's BP was elevated would you hold the BP med??? This is a time to talk to MD. No point in letting patient stroke out just to meet some stupid (and arbitrary!) schedule.
Very true...when my BG was say, 110mg/dl at hs, I'd be asked if I still wanted my Lantus.... YES !! That's why it's not 210 !! In the morning at breakfast (during my admission for leukemia), and later for other meals, I'd do the sliding scale after I ate (NovoLog) since I didn't know how much I'd be able to get down. The nurses were great about letting me call the shots (no pun intended) which helped a lot...one nurse did ask me if I got really out of it from chemo and prns for side effects if it was OK to use their standard orders, and I said ok, if I was that out of it, go ahead.... but my goals have always been to keep 'normal' non-diabetic blood sugars (and until the chemo/leukemia, I did once I got things under control when I was diagnosed with a random BG at 389mg/dl during a routine pre-employment lab- UA showed >2000 glucose....). I always bring my monitor and strips, glucose tablets, and check anytime I feel funky, before calling the nurse to let her know if it's off...they do the routine ac/hs blood sugars with thier equipment.
On our sliding scale protocol, if the person gets any coverage at HS, (2100), we have to check the blood sugar again between 0200-0300. Also on that, is if the patient is NPO, then we switch to Q6 blood sugar checks and sliding scale coverage instead of ACHS. (Our orders also say to "notify the MD for blood sugars of 360 or higher x 2"....tho no one has been able to tell me if that is 2 scheduled blood sugar checks, or rechecking it twice in case of machine error..)
In the above case, I would have given the insulin, and then rechecked it a bit later to see what happened. If it happened to be a bit too low for comfort, I'd call the MD and mention that he happens to have NS infusing and ask if he wants to change that... (our protocol also says to give the D50 amp if its less than 60, but so far I've caught it before then and told the MD)
And as for all the type 1 DM's.. yeah, totally! Listen to the patient! Ideally the nurses can get the docs to write an order regarding insulin per the pts regular routine or some crap, which ive seen a couple times.
We have a few docs who write this little math equation to figure out how much insulin to give... BG-130/30 - similar to that, depending on the pt, instead of the usual low/med/high algorithm.
If he is only NPO for a few hrs, and has been having decent PO intake, I would give it. If he is going to be NPO for a few days, I would not give it, but I would also call the MD and possibly get an order for Procalamine IV or IVF with Dextrose (depending on the situation). There was once a pt at our hospital that was NPO for 7 days, lost x amount of lbs and had not had any nutritional replacement. That is bad nursing. Anyways OP, in your scenario, seems like he was only gonna be NPO for a couple of hrs, so he would have gotten it, plus 3 units Insulin is not that much.
Myxel67
463 Posts
Sliding scale insulin is correction insulin given to correct a blood sugar that is already high and should be given even if pt is NPO. Even though many/most physicians will order it as the only insulin coverage, use of sliding scale only often leads to widely fluctuating BG values. Our DM management order set specifies that sliding scale is correction insulin and should not be held. The insulin that would be held is the mealtime bolus of fast acting insulin. Bedtime basal insulin such as Levemir, Lantus, or NPH generally would not be held. Sometimes a doctor might order a reduced dose of NPH if pt is NPO because of its pronounced peak. A BG of 309 needs to be treated.