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Was I wrong to hold Insulin?

Posted

I had a bood sugar check of 75 during the 5:30 check. I was supposed to give 6 units of Novolog and there was no hold order in the MAR. I consulted 2 other Nurses on the floor who agreed the blood sugar was too low and I held it. This is an elderly lady with an unreliable appetite. Later on in the evening I went and checked her blood sugar again and it was 133. (was I even wrong to recheck? mabye) The next time I went into work the care manager for the unit told me that I should have called the Dr if I was going to hold her insulin for under 100. She also said that I should have given her regular Novolog and given her a milk shake. What if she wont drink the milkshake? I dont have time to chase 7 Diabetics all over the place watching everything they eat and drink. I did the check when I was supposed to and it was low, so I held it. What do you think?

eatmysoxRN, ASN, RN

Specializes in Med/Surg,Cardiac. Has 1 years experience.

I would have held it as well. Always follow policy though.

hodgieRN

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience.

I am assuming that there was an order to give 6 units of insulin regardless of the blood sugar and not simply a sliding scale. Endocrinologists will write orders for insulin on top of the sliding scale insulin for patients for resistance. At my hospital, any insulin that is held needs doctor approval, but that's for Levemir or base coverage. If it was a sliding scale, I wouldn't have given insulin for a blood sugar level of 75, but there is a "did not meet criteria" option. I don't get the idea of giving milk for hypoglycemia and then give them insulin. Doesn't that defeat the whole purpose? If you need to give carbohydrate coverage to off-set impending hypoglycemia, why give the insulin? But I do know that any insulin orders that do not specify holding it for anything under a certain range, there needs to be an order from the doc.

I am assuming that there was an order to give 6 units of insulin regardless of the blood sugar and not simply a sliding scale. Endocrinologists will write orders for insulin on top of the sliding scale insulin for patients for resistance. At my hospital, any insulin that is held needs doctor approval, but that's for Levemir or base coverage. If it was a sliding scale, I wouldn't have given insulin for a blood sugar level of 75, but there is a "did not meet criteria" option. I don't get the idea of giving milk for hypoglycemia and then give them insulin. Doesn't that defeat the whole purpose? If you need to give carbohydrate coverage to off-set impending hypoglycemia, why give the insulin? But I do know that any insulin orders that do not specify holding it for anything under a certain range, there needs to be an order from the doc.

Agree!!!!

classicdame, MSN, EdD

Specializes in Hospital Education Coordinator.

this is called nursing judgment. If your clinical assessment does not match the intent of the order you are to notify the MD. I think you did the right thing.

There is now an order in the MAR to hold if the blood sugar is under 100. Im glad that has been cleared up:)

I would have held it as well. However, to cover yourself notify a MD and document.

I had a bood sugar check of 75 during the 5:30 check. I was supposed to give 6 units of Novolog and there was no hold order in the MAR. I consulted 2 other Nurses on the floor who agreed the blood sugar was too low and I held it. This is an elderly lady with an unreliable appetite. Later on in the evening I went and checked her blood sugar again and it was 133. (was I even wrong to recheck? mabye) The next time I went into work the care manager for the unit told me that I should have called the Dr if I was going to hold her insulin for under 100. She also said that I should have given her regular Novolog and given her a milk shake. What if she wont drink the milkshake? I dont have time to chase 7 Diabetics all over the place watching everything they eat and drink. I did the check when I was supposed to and it was low, so I held it. What do you think?
As a Diabetes Educator, you were right to hold the six units. Be proud of your self for using your nursing judgment. It is true that you must follow policy, but you have a brain too. The only thing I would correct, a patient is not a diabetic, a patient is a human who has diabetes. As medical professionals, we treat human beings not conditions. Please don't call them by their diagnoses or condition. Thank you for doing the right thing.

Appropriate to hold the insulin in an elderly patient with CBG of 75 but if your institutional policy says you must notify the prescriber when you judge that the insulin should be held, then you should follow that policy.

Giving the insulin and then offering the patient a milkshake would frustrate the CRAP out of me, as a prescriber! What is the point of that? Why would anyone give a milkshake to a diabetic patient? Sheesh.

turnforthenurse, MSN, NP

Specializes in ER, progressive care. Has 7 years experience.

I would have held it; however, make sure you follow your facility's policy. Where I work, we have a standing order to hold all pre-prandial insulin if the blood sugar is 70 but we still need to notify the doctor. We ALWAYS need a doctor's order to hold insulin and this needs to be documented. A patient's blood sugar may be 82 so they may not get coverage but they may have some Lantus scheduled...say, 20 units at bedtime. We still need to call the doctor to see if they want us to hold it or at least adjust the dose. You also weren't wrong to recheck the blood sugar; I would have done the same thing, especially if the patient has an unreliable appetite.

Edited by turnforthenurse
typo

Thanks Anne! great answer. As a nursing student with type 1 diabetes I am tired of being known as the "diabetic". Nice to know other people are aware :)

pussNbootsDolly

Has 2 years experience.

Quick question!!

I understand you DO NOT HOLD Lantus for a Blood Sugar of 59.

What about Humulin N ? It is scheduled at 44 units Q am in the wee hours (6:00 am).

Can I simply just Hold Humulin N, chart it as such and tell the oncoming nurse, or do I need to call the Doctor at 6 AM/

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience.

Quick question!!

I understand you DO NOT HOLD Lantus for a Blood Sugar of 59.

What about Humulin N ? It is scheduled at 44 units Q am in the wee hours (6:00 am).

Can I simply just Hold Humulin N, chart it as such and tell the oncoming nurse, or do I need to call the Doctor at 6 AM/

Do you not have a hypoglycemic protocol to follow?? I know with all our DM pts or any pt on SS insulin pharmacy adds the hypo protocol, this states what to do if the BS is that low. But to answer your question, yes I would hold and call the PCP if no other protocols to follow were added to the MAR. A BS of 59 is very low and the pt needs further interventions now. Did you treat the low BS??

Chica_bella813

Specializes in ICU/CCU/Oncology/CSU. Has 8 years experience.

I completely agree you did the right thing by using your judgment. I think its ludicrous for your superior to tell you to give a milkshake while giving her the insulin. this is an elderly woman, her body will metabolize things a little slower and eventually it would have caught up with her in a negative way. You were also very smart to recheck it. After the recheck I would have called the Md and said this am she was 75 I with held her insulin waited and now she is at 133 are you okay with her receiving the 6 units after she ate 1/3 of her breakfast. Especially with the elderly we have to be very cautious to how they respond to meds. Kudos to you!

Thank you Anne36 so much for reminding everyone ...just like a patient is not a room number! :-) They have names and should be used!

Edited by Pvida
forgot to put senders name

Mudwoman

Specializes in Certified Diabetes Educator. Has 20 years experience.

As nurses, we think that because we have a brain and we can think, that gives us the right to stretch that line in the sand when it comes to what we can LEGALLY do and what CRITICAL THINKING says we "should" do. The reality is that you do not have the scope of practice to ignore a doctor's order. If your critical thinking skills say that insulin probably should be held, then call the doctor. Only the doctor can give you the order to hold that insulin. I know it is a pain to do that; especially if you are chasing 7 diabetics, but nurses can not decide to hold a medication. There has to be a doctor's order to do so or standing orders from that doctor that if the patient is eating less than "x" % of their meals and their blood sugar is less than "x", hold the insulin. You could get such an order for this patient and save everyone (including the doctor) calls every time someone decides insulin is not such a good idea.

Basal insulins such as Lantus and Levemir are never held.

Treating a low blood sugar requires giving ONLY a food with carbs. Never give any food with fat in it as fat slows the absorption of carbohydrate (glucose). Once a blood sugar is stable, giving a protein with a carb will help keep that blood sugar stabilized.

solarusmoon

Specializes in Diabetes. Has 11 years experience.

Holding insulin without an MD order is practicing medicine and outside the scope of practice for an RN. You need to call the provider and either ask MD to hold or ask for a lower dose. What if the patient is Type 1? Also - why would you be giving Humalog at 5:30am? Is that when breakfast is given? Humalog is a rapid acting insulin that should be given when the meal tray is in front of the patient... in my hospital our orders say that if PO intake is uncertain that Humalog can be given at the end of the meal (once you see what patient has eaten)... obviously every hospital is different. Hope that helps... :)

solarusmoon

Specializes in Diabetes. Has 11 years experience.

@Mudwoman - This! Great answer!!!! :)