Insulin protocol Flashcards
1
Q
What is stress hyperglycemia?
A
When blood sugar occurs during acute illness in pt w/ previously normal glucose tolerance.
2
Q
What adverse effects of hyperglycemia occur in hospitalized pt, irrespective of its cause?
A
- Infection, poor wound healing, decreased WBC fxn
- Delayed gastric emptying
- Volume and electrolyte disturbances
- Delayed hospital d/c, increased morbidity and mortality in pt w/ acute MI, CVA, CABG
3
Q
What are continuous insulin infusion (insulin drip) recommendations based on?
A
- immediate blood glucose results
- rate of change in the blood glucose since the last measurement
4
Q
Risks of using IV insulin
A
- Hypoglycemia (BG < 70)
- counter-regulatory hormones can be harmful
- Severe hypoglycemia (BG <50)
- transient cognitive deficits, stroke, MI, death
- DKA
- if drip turned off with no alternative basal insulin source in a type 1 diabetic
5
Q
If a pt with type 1 DM is NPO, what are the insulin needs?
A
- Pt needs basal insulin at all times or is at risk of DKA.
- Should have insulin drip or start pt on glargine
6
Q
UCSD units that use the “insulin computer protocol”
A
- ICU
- PCU
- ED
- OR
- Reproductive medicine
7
Q
Physician responsibility
A
- Order insulin computer protocol in EPIC
- consult regarding tx orders and clinical decisions:
- if computer’s calculated rate doesn’t make clinical sense (very high or low)
- what to do if pt is off the insulin drip for an extended time period
- carbohydrate mismatch or change in the pt’s oral, enteral, or IV intake or nutrition (i.e. pt becomes NPO or nutrition stopped for any reason)
8
Q
Pharmacist Responsibility
A
- Approves and verifies the protocl per MD medication orders
- resource for nurses and physicians
- May “reset” the computer protocol when clinically indicated:
- when pt is off insulin drip for 8hrs or more (e.g. NPO for procedure)
- when pt source of nutrition is interupted
- pt fails to transition off insulin drip and needs to be restarted
- when the pt’s clinical status dramatically changes
- when questions arise based on the pt’s clinical condition
9
Q
Nursing responsibility
A
- Log-in to web based calculator
- select pt unit and patient
- enter BG levels as directed and add indicated comments
- enter all POC BG values in calculator (even when drip is on hold)
- computer protocol will give recommendations for adjustment of the insulin rate and recommendations to give a supplemental bolus of insulin (on initiation only)
10
Q
Q1h vs Q2h blood glucose check
for continuous insulin drips
A
- EVERY HOUR
- Blood glucose POC is checked and insulin calculator used
- Anytime BG is out of range when checking q2h, must resume hourly testing until stable for another 3 consecutive draws
- EVERY 2 HOURS (never more)
- If the hourly checks are within target range for 3 consecutive draws, the RN may modify the POC BG to q2h
11
Q
What do you do if the pt POC blood glucose is <70 mg/dL?
A
-
Stop the insulin infusion
-
Tx the low glucose according to hypoglycemia protocol
- located where?: Medication resources and in the eMAR
-
Tx the low glucose according to hypoglycemia protocol
- If the insulin computer protocol ever recommends holding the insulin drip, call the pharmacist to discuss further.
- usually there has been an interuption in source of glucose (TPN, TF, IVFs, IV drip, etc) or the pt’s insulin sensitivity is improving and the ISC needs to be reset
- Recheck BG q15min until BG is >80 twice before restarting the insulin drip
- then infuse per computer protocol
- If the first repeat is BG >90 the calculator will recommend restarting the drip, but UCSD policy states >80 twice, so select “I DO NOT AGREE” and then Yes (to are you sure?).
- When >80 twice, it will give adjusting insulin rate
- then infuse per computer protocol
12
Q
UCSD hypoglycemia protocol
treatment for Consicous pt able to swallow and take PO?
A
- Treatment
- (consicious): give fast acting carbohydrate
- 4 glucose tablets (16g) or
- 4oz juice or
- 8oz skim milk or
- 1 tube glucose gel
- (unconscious): give 25ml (12.5g) of D50 IV over 5 minutes
-
or if no IV access, give 1mg glucagon IM (DO NOT REPEAT)
- turn pt on side, may induce vomiting
- start IV in case need another dose
-
or if no IV access, give 1mg glucagon IM (DO NOT REPEAT)
- (consicious): give fast acting carbohydrate
- Retest: within 15-30 min from initial glucose test
- repeat tx if BG < 80, and retest within 30min
- continue until BG > 80 twice
- Assess: possible causes and need for consult
- most commonly: interruption in food, tube feeding or IV dextrose and decreased steroids no matched with decreased insulin
- Need medicine or endocrine consult for recurring hypoglycemia?
- Need to stop oral agent or reduce insulin?
- Notify: MD of the event
- SBAR (include vitals, symptoms, time of last nutritional intake, time/dose of glucose lowering agents, response to therapy)
- Ask for change in regiment
- Document:
- event
- time of glucose checks
- s/s
- treatment
- resolution assessment
- correspondence with MD
- changes in therapy
13
Q
Example of hypoglycemia event documentation
A
- 11:00am- Pt shaky and diaphoretic. BG=46
- 11:03am- Pt given 4 glucose tablets
- 11:25am- BG=74. Pt given 8 oz milk. Lunch served.
- 11:55am- BG=128
- 12.20pm- BG=169. Pt denies complaints. Pt states he feels “Fine”.
- 12:40pm- Dr. Smith notified of pt’s hypoglycemia, tx, and current status. Insulin dose changed per MD.
14
Q
Nursing documentation
A
- enter POC blood glucose results into Insulin Computer Calculator
- Chart insulin infusion rates and any bolus doses in the EPIC eMAR
- Enter comment directly in glucose meter for critical values
- Document detail of hypoglycemia even in EPIC doc flow sheet
15
Q
“Nutrition On Hold Unexpectedly Guideline”
- Needed when?
- Found where?
A
- Interruption in nutrition:
- NPO status for procedure
- tube feeding is stopped
- feeding tube is inadvertently pulled out
- TPN is held or stopped for any reason
- algorithm guideline found in Medication resources
