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AS YOU ENTER your patient’s room, ready to administerhis insulin, the unit secretary informs you that your patienthas just been made N.P.O. Do you give the insulin? Hold it?Give a reduced dose? Ask three nurses, experienced ornovice, and you’ll probably get three different answers.

In this article, I’ll help you make the right decision byreviewing insulin categories and discussing how to sort outthe information to provide the best patient care based onthe evidence. But first, consider these eye-opening factsabout diabetes.

Diabetes on the riseMore than 23 million Americans have been diagnosed withtype 1 or type 2 diabetes, and another 6 million have thiscomplex disease but are undiagnosed. Even if a patient ishospitalized for another condition, his diabetes will affecthis outcome while in your care.1 For a refresher on the roleof insulin, see The glucose and insulin dance.

Diabetes typesThe types of diabetes are defined by what’s happening at thecellular level:• Type 1 diabetes is caused by pancreatic beta cell destruc-tion and an absolute deficiency of insulin. Lacking endoge-nous insulin, a patient with type 1 diabetes needs exoge-nous insulin to survive. Without it, he has no “keys” formoving the glucose in his bloodstream into his cells.• Type 2 diabetes results from the impaired ability of cells touse insulin, accompanied by a relative lack of insulin orimpaired insulin release in relation to blood glucose levels.The patient has some “keys,” but many of them are rustyand can’t open the door. Type 2 diabetes is a much morecomplex disease than type 1 and can be even more chal-lenging to understand and manage. Even if a patient withtype 2 diabetes doesn’t normally rely on insulin, he mayneed it while hospitalized.

Sorting out insulin productsWith dozens of insulin products on the market and moreon the way, administering insulin can be challenging, with ahigh risk of mix-ups and other errors. In fact, insulin is onthe Institute for Safe Medication Practices’ list of high-alertmedications; this list is endorsed by the Institute forHealthcare Improvement as part of its 5 Million Lives

Hold the insulin!Hold the insulin!By Renee Thompson, RN, MSN

Your hospitalized patient has diabetes and is N.P.O. Read on to find out how to manage this and other not-so-sweet situations.

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Campaign. Understanding the categories of insulin andhow they work in the body is the first step to preventingerrors and administering safe and effective therapy.• Basal insulin is given to cover the body’s basal metabolicneeds in the absence of food. The basal insulins used mostoften in the hospital setting are NPH, Lantus (insulinglargine), and Levemir (insulin detemir).

NPH, the oldest formulation, is given twice a day, oncein the morning and once in the evening. Lantus andLevemir, the newest generation of basal insulins, start towork within 30 minutes and maintain a consistent supplyof insulin for 20 to 24 hours. Because of this “peakless-ness,” they’re given once a day. They can’t be mixed withother insulins, so the safest time of day to administer

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Or maybe notOr maybe not

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Lantus and Levemir isbefore bedtime.

No matter what typeof basal insulin yourpatient is using, find outwhat schedule he uses athome and make allattempts to mimic thatwhile he’s hospitalized.In general, hospitalizedpatients who are N.P.O.and on basal insulin needhalf of their usual dose.2

• Prandial and preprandi-al insulin is given to pre-vent postprandial hyper-glycemia. Because rapid-acting prandial or bolusinsulin mimics the nor-mal pancreatic responseto eating, it’s given witheach meal. Regularinsulin is considered apreprandial insulinbecause it takes about 30minutes to start working.Prandial insulins such asHumalog (insulin lispro),NovoLog (insulinaspart), and Apidra(insulin glulisine) start working in 5 to 10 minutes.Administering these insulins at the right time is critical tominimize the patient’s risk of hypoglycemia.

For example, a patient might take 5 units of NovoLogwith breakfast, 8 units with lunch, and 10 units with din-ner. If the breakfast dose is scheduled for and administeredat 0800 but breakfast doesn’t arrive until 0900, the patientis at risk for hypoglycemia.

To prevent this complication, ask your patient to informyou or the nursing assistant when he receives his meal andtell him not to start eating until you’ve administered hisrapid-acting prandial insulin. If he needs assistance to eat,ask the nursing assistant to let you know when she’ll beavailable to help him so you can give the insulin at theappropriate time. • Correction insulin, also called sliding scale insulin, is givento reduce an elevated blood glucose level to a normal range.Giving correction insulin is the worst way to manage dia-

betes. Rather than main-taining normal blood glu-cose levels, we’re actuallywaiting until hyper-glycemia occurs, then try-ing to bring it down to nor-mal.

What makes mattersworse is that many of usdon’t administer this typeof insulin correctly. In myexperience, holding correc-tion insulin for a patientwho’s N.P.O. is the mostcommon mistake thathealthcare providers makein relation to insulin man-agement.

For example, using cor-rection insulin, if yourpatient’s blood glucose is200 mg/dL you’d generallyadminister 4 units of regu-lar insulin. But suppose theunit secretary informs youthat the healthcare providerjust made your patientN.P.O. Do you administerthe correction insulin asordered, or should you

hold it because the patient is N.P.O.?The correct answer is to administer the insulin as

ordered. Correction insulin is designed to be given indepen-dent of nutritional intake. You may hesitate to give insulinto a patient who’s not eating for fear of causing hypo-glycemia. But more patients die of hyperglycemia (becauseof its negative effects on the healing process) than hypo-glycemia. The challenge is to be vigilant for signs of hypo-glycemia while also keeping the patient’s blood glucosewithin the target range.

Getting tight with glycemic controlHyperglycemia in hospitalized patients is predictive ofpoor outcomes. Other evidence indicates that ICUpatients with blood glucose levels above 130 mg/dL aremore likely to die.3 Research supports a target blood glu-cose under 110 mg/dL in a CCU; in a medical-surgicalunit, research supports a fasting blood glucose level of

The glucose and insulin danceAs you know, diabetes is about the relationship between glucoseand insulin. All body cells, including brain cells, require glucose forenergy, which explains why early signs of hypoglycemia includealtered neurologic function.

When a person without diabetes eats, the pancreas boluses thebody with the insulin it needs to take care of the glucose con-tained in the meal. The insulin lets the glucose enter the cells.(When teaching patients about diabetes, you may use the analogyof how insulin acts as the key to unlock the door of the cell andlet in the glucose.) When insulin levels are high, such as after ameal, the liver stores extra glucose.

Between meals, when insulin levels are low, the liver releasesstored glucose to maintain normal blood glucose level and bodyfunctions. Twenty-four hours a day, 365 days a year, a healthyadult has glucose in his bloodstream whether he’s eating or it’sbeing produced by his liver. This concept is critical for you tounderstand and properly ensure that your patient is receiving theinsulin needed to maintain homeostasis.

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126 mg/dL or less and a nonfasting level of 130 to 180mg/dL.4

However, fearing hypoglycemia, many nurses are stillmost comfortable when a patient’s blood glucose level isjust under 200 mg/dL and don’t aggressively treathyperglycemia.5 In the past, standard treatment for apatient with hypoglycemia was a big glass of orange juicewith three packets of sugar, for a carbohydrate load of 45grams. The nurse would encourage him to drink it rapidlyand keep checking his blood glucose until it reached 200mg/dL or more. Not understanding the importance oftight glycemic control, she overtreated the hypoglycemiaand put the patient at risk for more serious complications.

The current recommendation for treating hypoglycemiain a conscious patient is to provide 15 to 20 grams of glu-cose.4 Follow your facility’s hypoglycemia protocol andencourage all team members to follow this method formanaging a patient’s low blood glucose level.

Spotlight on common errorsNow let’s look at a few common scenarios in whichinsulin may be incorrectly administered. • Where’s the starting point? You might think that because apatient’s blood glucose is elevated before a morning doseof NPH, you don’t need to administer correction insulinalong with scheduled doses of insulin. In reality, thescheduled doses of insulin, whether basal or prandial, arebased on starting out at a normal blood glucose level. Forexample, if your patient’s blood glucose is 200 mg/dLbefore he receives his basal insulin (40 units of NPH), youshould give 4 units of correction insulin as ordered inaddition to the basal insulin. The correction insulinreverses the current hyperglycemia, and the basal insulincan then keep the patient’s glucose levels normal.• When not to mix it up. A common prescribing mistake isto order a short-acting formulation (such as regularinsulin) as correction insulin for a patient whose prandialinsulin is a rapid-acting formulation such as NovoLog. Apatient who takes a rapid-acting insulin should use thesame insulin as his correction insulin. If necessary, contactthe prescriber to change the order so that the patientreceives the same rapid-acting insulin for his prandial andcorrection doses.

You can safely mix the two doses of rapid-acting insulintogether in one syringe (for example, the prandial and thecorrection dose of NovoLog). Here’s an example: Yourpatient is scheduled for NovoLog, 5 units with breakfast.His morning blood glucose is 200 mg/dL. The correction

dose is 4 units of NovoLog, which you add to the 5 unitsalready ordered. By giving one injection of 9 units, you’vetaken care of hyperglycemia before and after the meal.

Putting it all togetherDiabetes management is all about timing—the one thingthat isn’t always in your control. Use a team approach tokeep your patient safe from complications.

In most hospitals, a patient’s capillary blood glucose levelis tested before each meal and at bedtime. Many hospitalsstill follow the classic 0700, 1100, 1600, and 2100 schedule.This is appropriate if meals arrive at 0730, 1130, and 1630,with a bedtime snack at 2130. Because the ideal time tocheck a capillary blood glucose level is 30 minutes before ameal, find out when meals are delivered in your unit. You’llneed to know when a patient’s capillary blood glucose levelis tested because you have only 1 hour to give correctioninsulin based on that test result. If your facility uses elec-tronic medical records, you should be able to get the precisetime of the last blood glucose test. If you can’t administeryour patient’s correction insulin dose on time, check hisblood glucose level again to ensure that you’re administeringthe appropriate dose.

By understanding the basics of diabetes and the types ofinsulin, and having the commitment to pull it all together,you can help ensure the best outcome for a hospitalizedpatient with diabetes. G

REFERENCES1. American Diabetes Association. Total prevalence of diabetes & pre-diabetes. http://www.diabetes.org/diabetes-statistics/prevalence.jsp. AccessedJuly 25, 2008.

2. Clement S. Better glycemic control in the hospital: Beneficial and feasible.Cleve Clin J Med. 2007;74(2):111-120.

3. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapyin critically ill patients. New Engl J Med. 2001;345(19):1359-1367.

4. American Diabetes Association Clinical Practice Recommendations 2008.Diabetes Care. 2008;31(suppl 1):S1-S108.

5. Campbell KB, Braithwaite SS. Hospital management of hyperglycemia.Clin Diabetes. 2004;22(2):81-88.

RESOURCESACE/ADA Task Force on Inpatient Diabetes. American College of En-docrinology and American Diabetes Association consensus statement on in-patient diabetes and glycemic control. Diabetes Care. 2006;29(8):1955-1962.

Derr RL, Sivanandy MS, Bronich-Hall L, Rodriguez A. Insulin-related knowl-edge among health care professionals in internal medicine. Diabetes Spectr.2007;20:177-185.

Institute for Healthcare Improvement. 5 Million Lives Campaign.http://www.ihi.org. Accessed September 25, 2008.

Lubitz CC, Seley JJ, Rivera C, Sinha N, Brillon DJ. The perils of inpatienthyperglycemia management: How we turned apathy into action. DiabetesSpectr. 2007;20:18-21.

Renee Thompson is director of academic service partnerships at the University ofPittsburgh (Pa.) Medical Center’s Center for Nursing Excellence.

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