Insulin and the student nurse

Things to understand about insulin: Insulin is usually prescribed for a client who makes no insulin on his/her own, or makes insulin but is insulin resistant meaning it takes much more insulin to maintain a normal blood sugar. Insulin is prescribed in two ways:

Routine insulin dose is prescribed by the doctor based on body weight of the client and is usually divided into two doses (half in am half in pm) or (a 2/3 in am 1/3 in pm) regimen. Typically this is a intermediate or long acting type of insulin by itself or with a small amount of rapid or short acting insulin added. This should maintain their blood sugar in a normal range. If a patient is currently NPO or will definitely not be eating soon (actively vomiting) hold and get further direction.

Routine doses of Lantus insulin are given at bedtime. This type of insulin has a steady effect for 24 hours. It is likely to be held when the patient is NPO after midnight

Sliding scale Insulin is given on a particular schedule based on the patient's fingerstick blood sugar in addition to routine insulin. The blood sugar is checked on a particular schedule most commonly AC & HS. Depending on the blood sugar you will give a certain amount of insulin. It is always a rapid or short term acting insulin (Regular or Lispro insulin) and is prescribed usually for three reasons: to enhance the already prescribed long acting insulin, to provide temporary short term coverage for a diabetic client (helps the MD to establish trends), or to provide a non-diabetic with coverage for elevated blood sugars related to other conditions (i.e. steroids, TPN). With TPN the sliding scale may be Q 6 hours because they are receiving it around the clock at a steady rate and are usually not having meals.

Insulin administration should always be discussed with the primary nurse before giving. In fact most facilities require that two licensed people verify insulin dosages, which could be your instructor and the nurse. The instructor and primary nurse should be in agreement before you proceed.

Questions your instructor will ask about insulin:

What is the morning blood sugar? It makes a difference if the blood sugar is 34 or 334 as to how you will proceed.

Is the patient nauseated, vomiting or NPO? If so, the patient will not be eating and if you give them insulin they will become hypoglycemic. If it is sliding scale usually it will be given. If they are NPO for surgery sometimes they receive half their routine dose. However, always report any insulin given to the OR nurse so they are aware.

What is the onset, peak, and duration of this insulin?Students really dread this question but its important information to know. The onset is important because you need to give it in an appropriate time frame in relation to when the patient eats. The peak lets you know when the greatest chance of hypoglycemia is, and the duration is when is the coverage going to run out. Remember is you are giving premixed insulin or you are mixing insulins the effect will be the patient will have the onset, peak, and duration of both types of insulin in the mixture. Make a chart on an index card to keep in your pocket.

The client's blood sugar is 100 should you give the insulin? If it is the patient's routine dose, most likely yes. Wait until the patient has their meal tray if it has rapid or short acting insulin mixed in. The whole idea of scheduled insulin is to maintain the blood sugar in a normal range.

The client is on 30 units of NPH in the am and the blood sugar is 240, should you give the sliding scale as well? Yes, the idea is that the routine insulin dosages will maintain the blood sugar within normal limits, while the sliding scale is regular insulin designed to cover the elevated blood sugar now.

The patient is not diabetic but he is getting regular insulin as a sliding scale. What do you tell the patient? If you have already ascertained this is not an error and you understand why they are receiving it you can tell the patient the rationale. Common reasons for non-diabetics to have elevated blood sugar is TPN (Mr. Jones while you are unable to eat you are receiving a high concentration of sugar in your IV and you need extra insulin.) and high dose steroids (Mr. Jones you are receiving solumedrol, a steroid medication, to reduce inflammation in your lungs caused by the pneumonia. That medication increases blood sugar requiring extra insulin) Also inform patients this is a short term situation and likely will not continue once they are off those medications.

What does 70/30 mean? 75/25?

Always read the label. A ratio on the label indicates premixed insulin. 70/30 means that 70% of the insulin is NPH and 30% is Regular. Therefore if you have 10 units to give your patient, 7 units would be NPH and 3 units would be Regular. There is 75/25 insulin which is 75% NPH with 25 % Lispro.

The patient is NPO -should you give the insulin?

First, ask why are they NPO? If they are NPO, but receive tube feedings or TPN, they will still get the insulin. If they are NPO for surgery, you may have to hold or give a smaller dose if ordered. Be sure to communicate with the OR if any insulin was given. In any case, be sure to check with the nurse before giving any insulin in these situations.

The patient is going for dialysis. Are you going to give the insulin?

Check with the dialysis nurse. While patients can eat while on dialysis it depends on the institution because some dialysis units do not allow food. If you do give the insulin but be sure to take or send their meal tray to the dialysis unit.

In what order do you mix insulins?
Having to mix insulins in front of your nursing instructor at 7:30 in the morning can be intimidating. Here's an easy way to remember the order depending on if you are in a RN or LPN program: Remember your goal: I want to be an RN (Regular then NPH) or I want to be an LPN (Last Put NPH)

In regards to mixing insulins you are limited to Regular and NPH. Do not mix others even if it means the patient is going to have 2 injections.