Early prandial administration to hyperglycemic patient?

Hello all,

I have a scenario I'd like to run by all the great nursing/medical minds here.

A patient with DM I, post MI and major open heart VAD installation has a blood glucose of 332 at 1700 (patient had been on an insulin drip earlier in the week due to sugars in the 450's).

The patient is ordered 12 units of prandial aspart at 1700 and the sliding scale calls for 4 units of aspart at 1700 for a glucose of 332.

While the prandial and sliding scale are both ordered at 1700, policy is prandial must be given 15 minutes before dinner or during dinner. Trays do not get to the floor until 1830 most days, yet finger sticks are done at 1700. (not a perfect system by far, I know).

So my question:

Given the bg of 332 and the fact that the patient has multiple large incisions (including partial dehiscence on a groin flap, chest tube sites, 2 JP drains, driveline site, and multiple femoral cath/ peripheral IV/PICC sites) do you veer off the normal course and give the 12 units now at 1700? Or do you wait til 1830 and give the prandial with dinner and only give the 4 units sliding scale now?

I know hospital policy trumps all, but I'm looking more for what your nursing/medical instinct tells you to do (and your nursing instinct may tell you just to follow policy, that's fine). Also, what would the evidence say to do?

Once I get a consensus I will tell you what the MD told me to do and how everything turned out!

Thanks!
If the patient's blood sugars continue to be elevated, its time to collaborate with the physician/provider and maybe increase the dose of preprandial insulin or increase the sliding scale (maybe from a medium dose to a high dose sliding scale). Maybe the patient would benefit from a dose of Lantus or Levemir QAM or QHS. Are the trays always delivered by 1830? Why not wait to check the blood sugar until it is closer to the same time the trays are delivered?

Our blood sugars are checked half an hour before meal trays and the insulin given promptly thereafter. I would give the prandial and sliding scale together.

Quote from turnforthenurseRNIf the patient's blood sugars continue to be elevated, its time to collaborate with the physician/provider and maybe increase the dose of preprandial insulin or increase the sliding scale (maybe from a medium dose to a high dose sliding scale). Maybe the patient would benefit from a dose of Lantus or Levemir QAM or QHS. Are the trays always delivered by 1830? Why not wait to check the blood sugar until it is closer to the same time the trays are delivered?

Quote from SaoirseRNOur blood sugars are checked half an hour before meal trays and the insulin given promptly thereafter. I would give the prandial and sliding scale together.

This seems like a lot of trouble for no reason. Because its convenient for the CNA to get the blood sugar approx 90 minutes before the insulin is theoretically supposed to be given? It takes 30 sec to get a finger stick, I don't think this is a valid reason to alter someone's care. In this instance I would call the MD and have him put a "now" order in or just have him say go ahead and give the sliding scale early because its bad news bears for this dude to be hanging out that high. I would then think its time to reevaluate the treatment plan because his sugars are being pretty poorly controlled.

Quote from sarakjpThis seems like a lot of trouble for no reason. Because its convenient for the CNA to get the blood sugar approx 90 minutes before the insulin is theoretically supposed to be given? It takes 30 sec to get a finger stick, I don't think this is a valid reason to alter someone's care. In this instance I would call the MD and have him put a "now" order in or just have him say go ahead and give the sliding scale early because its bad news bears for this dude to be hanging out that high. I would then think its time to reevaluate the treatment plan because his sugars are being pretty poorly controlled.

Quote from NurseCollins799Hi Sara,So it's not about convenience for the CNA's. They are required by nurse management to do fingersticks at 0800, 1200 and 1700 during my shift. The problem lies with Food Services, whose department is being overhauled by new management due to late trays (and other issues). But change is slow. They should be getting us trays by no later than 1730. Once they accomplish this, the CNA schedule will work nicely.So given the situation, do you follow policy and hold the 12 units til trays are on the floor and just give the 4-unit correction dose now?Also, do you know if Endocrine bases the correction dose on the assumption that the prandial is being given at the same time (since they are both ordered for 1700?). Or do their calculations say that 4 units will correct 332 to 100 whether or not they are eating and getting the prandial dose?

By our policy you'd be fine giving the correctional since it is independent of the nutritional dose, you'd still be giving it even if they were NPO. We use pens now, so they're going to get 2 pokes anyway.Was this BG of 332 an outlier? From your description it sounds as though they've been running consistently high, which is isn't unusual for a type I after major surgery/illness, they're going to need a lot more insulin than normal, more long acting would help. I'm a little skeptical about how much good 4 units for a BG of 332 in a type I is going to do.

How about getting the prandial order changed to 1800? That way you can give coverage and prandial at same time. Sure BG are due to be checked at 1700, but you still have that hour window afterward that you are legally allowed to give it. Otherwise, if it were me, I'd still give it all at once at 1700 with some crackers and juice. That way its given at the correct time, AND it follows policy to give with food (since you're giving a snack.) I would maybe have pt skip his snack part of dinner if he were compliant with that because I don't want to add to his overall daily carb count just Cruz I'm worried about him bottoming out before his tray gets there. I've seen BG go from over 500 to the 60's like that in one patient I had.

Quote from MunoRNBy . We use pens now, so they're going to get 2 pokes anyway.

You ohave two DIFFERENT orders. One is how often you check glucose levels. The other is what medication do you give. WHEN you give the medicine really does not have much to do with WHEN you check the glucose level. In this case the dynamics of the medication overrides the clock - in other words, you know that the safest time to give THIS PARTICULAR medication is withfood. So either have the patient call you when the food is delivered, deliver the tray yourself and give medication then, or give her a snack. This medication peaks in 5-15 minutes. If the food is consumed AFTER the administration then you have lost the effect you desired.