brittle diabetic pt

pt. had FSBS of 525 and i gave the sliding scale coverage of aspart. 2 hours later i checked the FS and it was 563. the pt. is a brittle diabetic. lot of times his sugar is so high that the glucometer doesn't even administer any reading. so there is a parameter of giving 20 units of Aspart if there is no reading. i was really concerned abt the pt. so i gave him 20 units of aspart and then afterwards called the doctor to update abt the situation. the doctor told me that it was ok to give 20 units and asked me to recheck after 2 hours and continue the same. after like 2 hours, he was due for his lantus 16 units. when i checked the FS at 9pm, the fs was 134 and since the doctor had ordered not to hold the lantus, i gave him his regular lantus. pt was sleeping comfortably when i left. but the next day, i heard that the pt had to be sent out because his FS had drooped to 20 during the night. noone has told me that it was my fault. but still i can't help feeling guilty . did i do anything wrong? since i am a new grad nurse, your remark on this one would be really helpful. thankyou
I see nothing wrong. This is the textbook definition of brittle, difficult-to-control diabetes.

Nope. You followed the orders. The Lantus didn't drop him, because it's basal insulin.

The right regimen can be tricky to find for certain diabetics. You followed the MD's orders and I don't see a thing wrong with what you did. Maybe a review of his diet by the RD as well as a review of all his meds by the MD would be a good idea. Good luck to you

I don't think that this patient's insulin management regimen is safe. And that's not your fault at all. Rapid drops in blood sugar (i.e. 100 mg/dL/h) can result in seizures even if the blood sugar is "normal" or even higher than normal. At my hospital, it is policy to recheck a blood sugar at 0200 for a patient that has received insulin at dinner time and/or bedtime. The peak effect of NovoLog takes place within 1-3 hours and the duration is up to 5 hours. If I'm understanding you correctly, after receiving 20 units at about 1900, the patient dropped from 563 to 134 at 2100 which is a drop of greater than 200 mg/dL/h! And the Novolog is expected to lower the blood sugar further! For a patient that is "brittle", closer monitoring is especially important.Sorry you had this experience. Maybe it'll prompt some safer practices, though. Best of luck to you!

thanks for all the replies. i kinda feel relieved now. the pt. hasn't returned to the facility yet and i heard he's fine at the hospital. the pt also has end renal disease along with all the pych issues.. very non-compliant with diet regimen (if he doesn't get his Ensure drink, start punching the walls/banging his head). i did some research and found that with pt. on dialysis ,it is hard to manage glucose level. but i am glad in way, that this gave me more opportunity to learn.. always look at the bright side, right?

Quote from SaltyNurseI don't think that this patient's insulin management regimen is safe. And that's not your fault at all. Rapid drops in blood sugar (i.e. 100 mg/dL/h) can result in seizures even if the blood sugar is "normal" or even higher than normal. At my hospital, it is policy to recheck a blood sugar at 0200 for a patient that has received insulin at dinner time and/or bedtime. The peak effect of NovoLog takes place within 1-3 hours and the duration is up to 5 hours. If I'm understanding you correctly, after receiving 20 units at about 1900, the patient dropped from 563 to 134 at 2100 which is a drop of greater than 200 mg/dL/h! And the Novolog is expected to lower the blood sugar further! For a patient that is "brittle", closer monitoring is especially important.Sorry you had this experience. Maybe it'll prompt some safer practices, though. Best of luck to you!

This is a brittle diabetic. Did he get a snack at bed time?

jeez.. i think i am not quite sure abt that night. usually he is eating his snack when i go to give his lantus, but that night he was sleeping and i had to wake him up to give him his shot.. now i really sound like newbie , don't i?

You gave two aspart doses within 2 hours? That's called "stacking insulin" in the diabetes management world. Aspart effects the blood sugar for about 4 hours, so essentially, the patient had half of the dose they were given 2 hours prior affecting their glucose level, plus 20 units more, which, as you stated, was more than they would normally get for that level. I'm not sure what type of facility you work in, but having a parameter for a glucose that is too high for the meter to read seems odd to me. If a glucose is over 400 at my facility we have to check a venous glucose. You would get an actual reading from a lab.Were ketones checked at any point? Most people become significantly more insulin resistant if ketones are present, then IV insulin is the most appropriate route. I'm also curious about whether this patient's hydration was assessed. High glucoses, especially routinely, can cause dehydration, which then causes subq insulin to be harder absorbed. Where were the shots given? Some long-term diabetics build up scar tissue, making insulin absorption irregular. Site rotation is important.I'm not sure why sliding scale insulin + lantus is being used for a "brittle" diabetic. Ideally, she would be on an insulin pump. If that's not possible, she should be on long acting insulin, like lantus, once or twice a day, plus a dose of fast acting insulin every time she eats that's based on how many grams carbs are eaten. From here, correction insulin can also be given based on blood sugar. It can be dosed using an "insulin sensitivity factory." Basically, that's a number that is determined to the best ability, of how much one unit will lower blood sugar. You take the current glucose, subtract the goal glucose, and divide that by the sensitivity number. Basically it would be (560-130)/30 = 14 units. I just plugged the 30 in there for calculation demonstration. It would have to be determined. This is generally how insulin pump users determine their doses, and how an endocrinologist would have someone correct high glucose. Sliding scale is too unspecific. It works well for someone who has their own endogenous insulin that just needs "backup" but for someone with no insulin production, like a type 1 diabetic, or a long time type 2 diabetic, it's a nightmare. It basically says that, say, a 150 and a 199 will need the same amount of insulin (at least the sliding scales I've seen used do), when, in reality, they're very different numbers for some diabetics.It doesn't sound like activity level or what she's eating is being accounted for in her insulin use at all. I know, sadly, a lot of "diabetic diets" are either calorie based or just "don't eat sugar," when in reality, it's carbs that raise blood sugar, not calories or just sugar. If she's not eating the same amount of carbs at each meal, insulin should not be being dosed the same, just based on blood sugar, at each meal. How often is the blood sugar being checked? For someone with type 1 who isn't in control, it's often recommended 8+ times per day.I know you really don't have control of what insulin she's on, or how it's dosed, or even her diet, but I'm just trying to provide some insight into why her blood sugar really isn't controlled. There's a variety of things that effect blood sugar, and too often just the blood sugar itself is considered while people throw essentially random insulin doses at it. No type 1 would be well controlled on that regimen. If the lantus dose is correct and the blood sugar is normal before bed, a bedtime snack should not be needed in most people, as the Lantus should not be dropping the blood sugar, just keeping it even. Has endocrinology been consulted?

i really appreciate the fact that u took your time to explain this to me. as i have mentioned earlier, this is my first job as a RN and i have been working there for abt 6 weeks but i have already seen that pt being sent out to hospital for 4 times because of his hypo/hyperglycemic condition. when i was orienting with a nurse, she couldn't get the FS reading on that pt X6 attempt. that device would work on other pts but on him . after few attempts, she would notify the doctor before sending him out. and this seems to be the everyday kinda scene overthere. The MD must have been fed up with this or what (god knows), his order now says: "Give 20 units of ASpart if no reading. recheck after 2 hrs and repeat". After reading your response, i am kinda scared now. when his FS is too high for the glucometer to administer, it just shows " hi" and underneath "ketones" blinks. as far as i know, i don't think that pt gets like regular labs done. i don't know the reason why he's not on insulin pump. and there's no restriction on his diet but they try to restrict his fluid, but nobody follow up on anything. noone's tracking his I/O .he demands like 2 sandwiches 2 soups for his dinner. Also, i have seen on the MAR sheet, the only site documented for injection would be RA since he has AV fistula on LA. i get a feeling that something bad might happen to that pt very soon and i don't want to be blamed for anything.and now i am kinda at a loss abt what can i do to help that poor guy.

It sounds like there's social and medical factors preventing this patient from having good health. The fact that this patient has poor blood glucose control is in no way your fault. It sounds like this patient probably needs a good endocrinologist, nutritionist, and probably a psychologist or social worker.

I figured this was LTC. We don't have the lab to check a venous sample or for ketones in LTC. The IDT ( RNAC, DON, dietary, etc) needs to get involved and good care planning needs to happen. Good charting explaining the risks and benefits of following a good diet needs to happen too. I second the endo consult to get some form of control medically. Check to see what your machine goes up to before it reads error or HI. I'm sure he is getting the labs done at dialysis, maybe your facility can get that info from them? Also they should know about his blood sugars too. They probably have a dietician that has spoken/ educated him on food/ diet control. Chart, chart, chart all of your care with him. At the very least, if he is getting all that insulin and then going to bed..he needs a snack at hs. Ohh....what about belly and thighs for the injections?Every so often we get someone tough like this.