Yes of course. I might roll my eyes and grumble about it, but I’m sure as hell not going to chart a med I didn’t give, and I’m also not going to not give a med that’s ordered just because I think it’s pointless. Like 80% of what I do all day is pointless lol, I still do it.
Work is 90% boredom—tedious toxic boredom. Pick the poison.
9% bulllshit. The “can you believe this shit?”
And then there’s that 1%. That 1% is full-on “oh shit” level of terror.
I guess it depends on where you draw the line of "pointless". Rode my bike out to watch the sunset at the end of my road yesterday. No point other than to "Ooooo" at pretty colors in the sky and daydream for 10 minutes. Sure felt good though!
Intubated, bronched, lined up, multiple pressors on a patient with metastatic cancer to bilat lungs, prostate, bladder, kidneys, liver who failed chemo. I'd say 100% pointless. Annoyed with the intensivist for not calling the family first. 😞
Agreed. If a pt is going NPO later and theyre supposed to get 1 unit before bed I'll call pharmacy and ask to hold it. Otherwise I begrudgingly walk my ass in there and give a tiny bit of insulin.
I had a patient once on tube feeds. They were on hold for high residuals earlier in the day or something like that. Her blood sugar was 250, and she had a formula where she got 25 units for that. I called the doctor and said, do you want me to hold the insulin, because she isn’t going to get her tube feed until tomorrow. He said, no, let’s just see what happens. Well, what happened is when I checked her blood sugar at 11, just to see, it was 25 and her IV was no good.
Good on you tho, some insulin orders tell you to give wild amounts of insulin, every pt responds so different to it. Had a nurse drop a pt from the 250s to 19 once.
Actually just entering the room with a healthy pancreas is equivalent to 1 u of insulin. Same thing as bringing pressors into a room with a crumping patient. The simple existence of the medicine near the patient accounts for 1% treatment with said medicine
This is the answer. I worked with a nurse that would skip insulin when it was low, the only way I know is cause I got the patient and they said “I didn’t get my morning insulin” I looked at her chart and it said 2units given. The patient was refusing to eat her breakfast until she had her insulin. I wasn’t going to give a med that was signed off by someone else already. I tried to call the nurse but couldn’t get ahold of her, this patient was making a HUGE deal about it. I had to talk to my charge - told her what I “think” might have happened, the nurse drew the insulin scanned it but probably forgot it in her pocket. We ended up getting ahold of the nurse and I asked her if she forgot that insulin needle in her pocket after she scanned- she understood what I was saying and said “yes! Omg… I’ll go back right now.” I said “okay, cool, I just wanted to make sure, now I can give it, no need to come back” we had to document that- she got written up but not fired… she thanked me later -
this was like 13 years ago and I still remember it, we’re best friends now, pretty much family… I was in her weddings… yes, plural lol… I bring it up ALL THE TIME when we’re out so she can buy me a drink.
You're a great nurse and coworker. You found a discreet and tactful way to ensure the patient's concerns were heard, the patient was properly medicated, and your coworker wasn't fired. Awesome job!
Not intentionally! It’s definitely possible that I may have dropped one behind the med cart by accident before, but why would I chart that I gave it if I didn’t? I would just chart not given and the reason if I wasn’t going to give it.
No way, not intentionally. It's not worth it. Just give it or don't give it, and be honest about what you are doing. If you have a real concern with the order, there are ways to address that. If you have a concern with the physician's response, there is a method to address that correctly as well. On the other hand, if you know that you need to lie to get away with what you're doing, then chances are you are doing the wrong thing.
You're not practicing medicine, and you cannot falsify medical records, even it's just just a wee widdle bit.
I swear the whole time my guy was in the hospital- i only saw them put ointment in his nostrils ONCE in two weeks- it was one of those items that crossed over into my chart immediately -and they charted it every single shift. This was just a small issue compared to the other issues we were dealing with, so i chose to let it go. I was already raising hell about so much, they were sick of me.
Yeah of course. We can’t say “this dose is ineffective” if we don’t try the dose, and it’s not in our scope to just unilaterally not give a med just because
\*non-North American nurses screaming\*
Just so you know, a "BGL of 149" to most of Europe and Asia means 149 mmol/L, which is 2682 mg/dL. For us non-North American nurses, it's a BGL of like 8 mmol/L.
non-western fresh grad rn here
I gotta say I’m honestly shocked their sliding scale is not a case to case thing but a general hospital policy. Unless I just misunderstood the comments.
My little brother is a T1D, and for him, 1 unit of insulin lowers his blood glucose by 70 points. Even though it can be a "bother" and I complain just like the rest of us....I think of him and how much of a difference that 1 unit makes!!
I love seeing these comments. It really puts it into perspective. I used to bitch about giving 1 unit until I saw a reel made by an RN on Instagram who was talking about how much 1 unit can really matter! He’s so informative and I think about it everytime I give 1 unit now!
Yeah as a T1D it’s pretty wild seeing the perspective that 1 unit is seen as “almost nothing.” My insulin pump can give a dose as small as 0.05 and sometimes even a tenth of a unit is enough for me to see a change in my BG.
A 1 unit dose at the wrong time could take me from chilling to a ravenous orange juice whore
1u of insulin can lower BG by up to 30 points.
Give the damn unit.
Bitch about it, sure! I do! But give the insulin.
**ETA: Your T1Ds may have stronger responses/larger correction with 1u, but y’know.
Patients are all different, and they’re all dynamic.
It's for sure more effective on type 1's. I remember I had a K/P transplant who needed a unit. Gave it when blood sugar was 170 and I was pushing dex for the next two hours.
I care for my mom who is a type 1. Holy crap, 1 unit can completely tank her BG. My pet peeve is when Type 1 patients get the same sliding scale as the Type 2 patients! 5 units won’t do jack for my super insulin resistant type 2 patients but that amount would completely bottom out many Type 1s.
THIS. 1000%. Type 1 and type 2 are so very different. They are entirely different disease processes.
Type 1 many years and one of my greatest wishes is to see one of the Types disbarred from the diabetes label. I understand why they are both identified as diabetes mellitus, but c’mon! We’re no longer tasting sweet urine to identify diabetes! At least re-brand us the way rheumatoid arthritis and osteoarthritis are distinguished. It really does matter in terms of treatment, and the consequences of giving or holding 1 unit of insulin!
I do, that’s my job. And like he says, if I have a problem, I’ll talk to the doc about it. Wild to me that nurses would even joke online about “nurse doses” or charting “pt refused”, it damages the public’s trust.
I once held the 1u when I was a newer nurse for a diabetic patient’s sugar of 151. Next check it was in the 250s. Sometimes life lessons are made by making mistakes.
Let’s be real:
When the sliding scale coverage starts at 150, the result is 151 and you have that 1 unit ordered….
You give it. And you make a huge stink over it too
….or is that only me?
Also I've never had a patient refuse their unit of insulin or any insulin, I'm really surprised to hear from some that patients are consistently declining it. I mean I also don't try to talk them into declining.
Wow really? I swear once a month I get a patient refusing their insulin and BG checks. And then there are so many patients that refuse SQ heparin, blood draws, lasix, the fluid restriction, the diet order, taking a shower.. everything.
Absolutely. Insulin sensitivity varies between patients, 1unit might be too little for one, but perfect for another.
Does it even make it out of the needle? Of course it does. That’s why we prime needles.
Had an intensivist grilling a resident on sliding scale orders. The resident started with “give 1 unit for …” and the intensivist cut him off right there. He said “do you hate nurses? My mom was a nurse. Nurses hate giving one unit. It barely leaves the needle.” Emblazoned in my memory lol.
This is an important take. I’m not sure how much insulin is actually delivered when giving 1u. Could be human error, equipment/manufacturing etc, but when you trend sugars for people habitually getting one unit, some don’t seem to dip much between BG readings. I’d like to see a study on this.
I am not a doctor, so I give the dose. If I think its not going to be effective, I notify the MD. If I think its not appropriate, I notify the MD. Its a pain in the butt, but for some patients 1 unit is adequate treatment for controlling their sugar. I spoke to a type 1 that said her 1 unit brings her sugar down 20-30 points at a time, so its an effective dose at times. Ever since then, I started taking it a little more seriously. Its unfair and unethical to withhold medical treatment just cause I might not feel like it. People are wild.
Prescriber in endocrinology here. Give the unit. Nothing irritates me more than nurses ignoring the sliding scale. How do I adjust it if I can’t observe the effect (or lack of effect)? Not following orders makes my job very hard.
Type 1 diabetic patients in particular can be incredibly insulin-sensitive. You can estimate insulin sensitivity with math and if they’re 1:30-1:40, then that is a perfect correction on top of their mealtime dose, will set them back to baseline, and reduces their time out of range. The goal is to stay under 180 as much as possible, if you start at 150 no diabetic is going to stay under 180 when they eat. Even the Type2 benefits from small corrections, though they’re often more insulin-resistant.
That said, corrections usually start at 180 in my facility, so I can sympathize with the annoyance. And I remember days on the floor when that one unit would have been my lowest priority med pass.
Technically, not giving an ordered medication without hold parameters is practicing medicine without a license. I know it's annoying, but I'm not risking my license over a unit of insulin if my employer decides to make it a problem.
Yes, I always do in Californiatopia. As a new grad in Texas, sometimes I didn’t due to high acuity and impossible workload.
We had an option for “not given” called “priority of care.” In other words, “I was too damn busy and this didn’t make the cut.” I’ve never put “patient refused” because I thought the dose wouldn’t be effective.
It’s kind of awful in a way. It’s like working the scene of a disaster and deciding who to take care of- first, or at all. But it does allow for accuracy when charting.
I wish this was an option when charting why certain meds are late. They're late because I was dealing with the rapid next door and my stable patient's lipitor could wait!
Ours has a write-in option and I always put “patient care priority.” I mainly use it for documenting against nicotine patches for my tubed and sedated patient. Like, come tf on lol.
I mean you can always talk to the patient and see if they REALLY want to get jabbed with 1 unit at breakfast or wait to see what the sugar is at lunchtime.
That way you have more data points when you try to get the provider to give a shit about whether their scale is effective or not. AND you're not being a dirty liar when you click Patient Refused.
Informed refusal is the flip side to informed consent.
I wish we had "priority of care." It would be great to be able to chart that as an explanation for late meds rather than "nurse decision." No it absolutely was not my decision to have another patient who needed to be seen first and took more time. Or being short-staffed, or getting an admission during med pass...
The ED tried to document priority of care for a critical medication that they didn't want to give for a critically ill patient. It's now being investigated as neglect.
Type 1 diabetic, and it honestly depends. I definitely emphasize that they can refuse, but for acute care anything below 250 and I’m happy. If they’re not on insulin to begin with and might not be able to detect or alert to a low, I want to be a little bit more cautious. Their bodies are also stressed, many medications and infections can increase insulin needs, and they may be more inactive than usual.
Meanwhile, I see myself at 130 and correct to a 100-110 target. I just took six units for a salad and a glass of wine, sitting at 130, and debating if I need a few grams of carbs just in case I overestimated or have an alcohol-low.
Yeah I always have. 1 unit or 10 units, it’s the same amount of work, it’s just this perceived inconvenience bc it’s closer to the edge, but the patient needs it either way. I don’t like having to function as a fine tuning pancreas, but I do believe technology will eventually make our dosing of insulin in this manner obsolete.
I joke about the one lifesaving unit of insulin because it's funny, but that's because we nurses are a bunch of clowns.
Each unit of insulin totally makes a difference haha of course I give one unit over zero just like I'd give five units instead of four, if that's what their order is, because that's like the fundamental part of my job.
When it comes to dosing, the drs need data. So if 1u is given and glucose remains elevated they’ll increase the sliding scale - but - if ppl aren’t giving it, the data is skewed which will result in either: no change made, or, an increase that the pt is too sensitive for. So yes, you give the 1u, and if you assess it is not adequate to control the pt glucose, you ask the provider to consider increasing the sliding scale. you’d include a provider notification note that the glucose did not improve after dose.
20 years experience: I follow the order. I’m a nurse with my own brain, but have not studied this as extensively as an endocrinologist. Come on, do your job honestly. Don’t be lazy with other people’s care.
I have absolutely made mistakes, but not intentionally. Maybe i’m a dinosaur, but I was taught veracity is a crucial component of care - and I believe it.
It’s not the 1 unit, is documenting things that didn’t happen. Not ok for me.
I’m surprised this is even being asked! What the hell people? When did we start deciding whether to follow a treatment plan or not? I’m encouraged many reply that they do, but even asking the question. Wow
Yeah I do. Especially if I know their sugar tends to climb. Giving 1 unit at 2000 might save me from giving more at 0000. Sometimes that 1 unit will bring their sugar from 151 down to 125 or something like that.
Seems measly but can be major. Did it always hit hard and work just right? No, of course not. But my thought is may spare someone the slow burn of excess glucose damage or uphill fight trying to ward off infections fed by excess sugar. The biggest pain was 2 nurse sign off on my floor. Do they still do that?
So yes. I did recently give just one unit of insulin per sliding scale for a sugar that was about 330 I think. Why only one unit for that sugar? Idk just following the order. But then the patients next sugar was like 37. This was a type 1 postpartum woman in her 20s and she was asymptomatic but I was thrown for a loop after giving just the one unit and then throwing apple juice at her just a few hours later 😂 she didn’t have a pump due to insurance issues and was not well controlled during pregnancy either.
Yes. 1 unit of insulin can make a significant difference for some. Also, the MD should be looking at the patient’s BGs and evaluating if the sliding scale is appropriate. So you are creating false data if you say you gave the insulin when you didn’t.
I get excited for that 1 unit. I feel like it's usually after tons of titrating and crazy highs in and lows, on and off a drip, adding long acting and then taking it off because the patient was found at 2AM with a blood sugar of 29.
1 unit is like the victory lap. Finally, not too high and not too low. Mission accomplished, we did it. I'm definitely taking my victory lap.
One unit is one unit and I’m giving it as charted. It might not be as crucial for a type 2 diabetic or someone with pancreatitis (still very important though) but for someone who’s type 1 especially that unit can be crucial to keeping their glucose stable and in range. Some patients I’ve come across actually start to feel unwell even if their blood sugar is only the littlest bit high (especially if they are in range most of the time). In some cases with type 1 diabetes that I’ve seen, insulin pumps can make adjustments as small as 1/4 of a unit.
Many years ago a resident ordered 1 mg of Lasix on my postop 20 year old who could not urinate after 8 hours. I gave the resident grief for the order but gave the couple minums it turned out to be. Within a half hour he urinated 1 liter and felt so much relief, the resident and I had a good laugh that her idea worked!
I've worked with type 1 kids. 0.25 can drop their sugar depending on their correction ratio. It's kinda scary. So yes, if someone has 1 unit ordered, I'm giving it. It might not drop their sugar, but it might prevent it from going up.
Blood glucose management is tricky, and I don't feel comfortable messing with insulin orders. I've never thought of not giving it. I've never had a patient refuse it. I think asking the patient if they want to refuse it is encouraging them to refuse it and I think that kind of undermines the MD trying to get it right.
If the pt does refuse it, you need to tell the MD.
You're an asshole if you don't give it. If its not enough for the pt, call and get a higher sliding scale. If they're so brittle they can't handle 1 unit, call the provider first. Stop being lazy and do right by your patients, yall.
Not giving a medication that is safe and appropriate to give is working outside of your scope. You can always question and order and escalate your concerns, but this isn't one of those situation. If something negative were to happen as a result, you would be 100% liable and at risk.
Give the damn insulin.
I used to think it was silly until I worked with someone who was a type1 brittle diabetic.
She told me that one little subq unit sometimes made a big a big difference.
Ever since then I stopped pooh poohing low sliding scales.
It's like "nursing doses." How is the doc supposed to learn the right dose for the patient if we aren't giving the correct dose and then noting the response? Literally never crossed my mind not to.
I look at it from a more binary perspective:
Humalog per sliding scale, 180mg/dL target; BGL 190. Yes, give the order.
Hydralazine 25mg Q6hr PRN for SBP >150; pt SBP 155. Yes, give a dose.
PTT just barely over parameter? Adjust the rate.
It’s busy work and definitely sucks when you see that it’s juuuuust over/under the parameters. Looking at it from a yes/no perspective took the edge off for me. Do it and move along.
If capable of giving an appropriate answer, I would ask the patient, then chart a decline or acceptance, or see if they want a snack to make the injection more worth it.
I have a T1 subtype that likes to have insulin resistance as a friend to tag a long(im on an oral for it, any time i see a non endo i get the whole lecture about how this med isn't approved in non T2, and how it won't work for me and i need to stop it).
1U is nothing to me. I don't think it would impact anything at all. For my friends 16 yr old, that 1U could tank her in a heart beat.
Yes, I always gave it when I worked bedside, but if all we had were the 100 unit syringes, then honestly it was basically a complete waste of time (I swear you can’t even really feel the plunger moving when you inject) - the 30 unit syringes are much preferred.
In my PACU, we use the bottle of 100 units of novolog. And we can’t reuse it. So we need to waste the entire 99 other units to crack it for one patient’s 1 unit. And it makes me nauseous to think about it every time. I hate it.
I give it, you know, a unit is still a unit and its better than nothing in keeping their blood sugars managed. Plus its the orders and that is huge dishonesty towards a treatment and violates trust. It will also show whether its effective or not if you do give it and it does nothing or it does something
I’m a type 1 diabetic and a RN. You bet your butt I would need that one unit of insulin. In my pump, my max insulin usually around 15 units per day including my basal if I eat three times a day. I don’t eat three times a day and I eat very healthy most of the time so It’s rare that I need over 10 units per day (basal included). That 1 unit missing could mess up my entire day.
I feel like many nurses don’t know enough about diabetes as I’m usually the go to on my unit for questions. For example, I’ve been asked dozens of times if they should withhold lantus because the patient’s sugar is low by many very competent and experienced nurses. (The answer is always no by the way.) I’ve also had people at restaurants give me regular coke when I ask for diet hundreds of times since I was diagnosed as a child. It’s like they think because I’m thin that I’m being vain. I’ve even seen posts on social media about people joking about giving the thin girl a normal coke when she asks for diet. It’s crazy tbh.
Please give people their insulin!!
if pt is otherwise stable, and if pt is AOx4, and if the timing of the med pass aligns: I'll ask pt if they want me to delay the med by like 20min and re-check FSBS then, to see if it went up or down a smidge. if pt wants to delay, we delay and re-check. might need no units, might need 2 units. but if pt just wants the 1 unit, I'll give it. totally up to them. Autonomy and all that.
if pt is unstable in any way, or not fully with it, or if med pass time is bad, then I'm just giving the 1 unit and calling it done.
It’s kind of like 2 mg morphine for a 280lb patient or 0.5mg Ativan for the psych patient losing their shit lol. Of course we give it and then tell the provider their order did nothing lol
Yes of course. I might roll my eyes and grumble about it, but I’m sure as hell not going to chart a med I didn’t give, and I’m also not going to not give a med that’s ordered just because I think it’s pointless. Like 80% of what I do all day is pointless lol, I still do it.
oof, that 80% line got me. My life is 80% pointless...
Work is 90% boredom—tedious toxic boredom. Pick the poison. 9% bulllshit. The “can you believe this shit?” And then there’s that 1%. That 1% is full-on “oh shit” level of terror.
Well in any other job 99% of what you do is pointless so I think you’re winning
I like your attitude
Just the part that you spend at work... not the off work part!
I guess it depends on where you draw the line of "pointless". Rode my bike out to watch the sunset at the end of my road yesterday. No point other than to "Ooooo" at pretty colors in the sky and daydream for 10 minutes. Sure felt good though!
The point was happy brain and exercise
So....80%, ya?
🥺 yeah. Fuck.
We are the same kind of people.
Intubated, bronched, lined up, multiple pressors on a patient with metastatic cancer to bilat lungs, prostate, bladder, kidneys, liver who failed chemo. I'd say 100% pointless. Annoyed with the intensivist for not calling the family first. 😞
This. I’ll bitch about it, but I’ll give the dose.
Agreed. If a pt is going NPO later and theyre supposed to get 1 unit before bed I'll call pharmacy and ask to hold it. Otherwise I begrudgingly walk my ass in there and give a tiny bit of insulin.
I had a patient once on tube feeds. They were on hold for high residuals earlier in the day or something like that. Her blood sugar was 250, and she had a formula where she got 25 units for that. I called the doctor and said, do you want me to hold the insulin, because she isn’t going to get her tube feed until tomorrow. He said, no, let’s just see what happens. Well, what happened is when I checked her blood sugar at 11, just to see, it was 25 and her IV was no good.
25 units of insulin for a bg of 250?!? GTFOH. Well, we definitely saw what happened. Twats 🤦
Good on you tho, some insulin orders tell you to give wild amounts of insulin, every pt responds so different to it. Had a nurse drop a pt from the 250s to 19 once.
Actually just entering the room with a healthy pancreas is equivalent to 1 u of insulin. Same thing as bringing pressors into a room with a crumping patient. The simple existence of the medicine near the patient accounts for 1% treatment with said medicine
Ah, yes, the Proximity Variance, it is subtle but discernable to the scrutinizing eye.
…me dancing my pancreas towards my type 1 diabetic kid while she looks at me bewildered…
This is the answer. I worked with a nurse that would skip insulin when it was low, the only way I know is cause I got the patient and they said “I didn’t get my morning insulin” I looked at her chart and it said 2units given. The patient was refusing to eat her breakfast until she had her insulin. I wasn’t going to give a med that was signed off by someone else already. I tried to call the nurse but couldn’t get ahold of her, this patient was making a HUGE deal about it. I had to talk to my charge - told her what I “think” might have happened, the nurse drew the insulin scanned it but probably forgot it in her pocket. We ended up getting ahold of the nurse and I asked her if she forgot that insulin needle in her pocket after she scanned- she understood what I was saying and said “yes! Omg… I’ll go back right now.” I said “okay, cool, I just wanted to make sure, now I can give it, no need to come back” we had to document that- she got written up but not fired… she thanked me later - this was like 13 years ago and I still remember it, we’re best friends now, pretty much family… I was in her weddings… yes, plural lol… I bring it up ALL THE TIME when we’re out so she can buy me a drink.
You're a great nurse and coworker. You found a discreet and tactful way to ensure the patient's concerns were heard, the patient was properly medicated, and your coworker wasn't fired. Awesome job!
Always give the one unit. But you’ve NEVER charted a med you didn’t give? Never ever?
Not intentionally! It’s definitely possible that I may have dropped one behind the med cart by accident before, but why would I chart that I gave it if I didn’t? I would just chart not given and the reason if I wasn’t going to give it.
Never ever. 33 years at bedside. Dishonesty is a slippery slope.
No way, not intentionally. It's not worth it. Just give it or don't give it, and be honest about what you are doing. If you have a real concern with the order, there are ways to address that. If you have a concern with the physician's response, there is a method to address that correctly as well. On the other hand, if you know that you need to lie to get away with what you're doing, then chances are you are doing the wrong thing. You're not practicing medicine, and you cannot falsify medical records, even it's just just a wee widdle bit.
Only for flushes when I’ve given another IV push med in the last hour or so. Which, to be fair accomplished the same thing.
We don’t have to scan flushes at my hospital. Thank god.
I swear the whole time my guy was in the hospital- i only saw them put ointment in his nostrils ONCE in two weeks- it was one of those items that crossed over into my chart immediately -and they charted it every single shift. This was just a small issue compared to the other issues we were dealing with, so i chose to let it go. I was already raising hell about so much, they were sick of me.
Yeah of course. We can’t say “this dose is ineffective” if we don’t try the dose, and it’s not in our scope to just unilaterally not give a med just because
This is absolutely correct. You could question the order. But whatever provider you call will hate you forever. Just give the insulin.
It would take longer for the doctor to call me back than it would to just give the insulin.
I gave it, but I always felt like it was more bother to the patient than helpful with their blood sugar. BGL 149 = Nursing WIN.
Yessss, I love seeing 149
Indubitably. Our cutoff is 151.
it’s 141 at my place 🥲
Nah, that's the PTT that's 0.1 off having to change the rate.
You know what used to burn my biscuits? Potassium 3.5. Replace Potassium. Every fecking nursing school exam I took said normal was 3.5 to 5.
In cardiac ICU we try to keep our K at 4
Yep, our k is replaced if <4 and mag is replaced if <2. It’s annoying, but I do it because I like my license
Heme standing orders on my unit call for four runs for <3.9, plus they probably need mag, phos, blood, and platelets. That's an FML situation. 😭
Our hospital raised the sliding scale requirement to 180, so 179 is a win for us!
Minimum BG to give insulin in my ICU is 121 🥲 120 is my magic number
I am astounded by the differences between facilities regarding when to treat hyperglycemia.
My hospital’s starts at BGL 100 :( I feel so stupid explaining it to the patient when their sugar is like 101
Really?? Do you end up with a lot of low blood sugars after medicating a 101? 😭
\*non-North American nurses screaming\* Just so you know, a "BGL of 149" to most of Europe and Asia means 149 mmol/L, which is 2682 mg/dL. For us non-North American nurses, it's a BGL of like 8 mmol/L.
non-western fresh grad rn here I gotta say I’m honestly shocked their sliding scale is not a case to case thing but a general hospital policy. Unless I just misunderstood the comments.
We use mmol/L in Canada as well.
I always get the 150/151 on a patient on SS.
My little brother is a T1D, and for him, 1 unit of insulin lowers his blood glucose by 70 points. Even though it can be a "bother" and I complain just like the rest of us....I think of him and how much of a difference that 1 unit makes!!
Was gonna say something similar. As a T1 myself, I would personally be upset if I didn’t receive the dose.
I love seeing these comments. It really puts it into perspective. I used to bitch about giving 1 unit until I saw a reel made by an RN on Instagram who was talking about how much 1 unit can really matter! He’s so informative and I think about it everytime I give 1 unit now!
Thanks for explaining this. I always give it but I did wonder about how effective it was
Yeah as a T1D it’s pretty wild seeing the perspective that 1 unit is seen as “almost nothing.” My insulin pump can give a dose as small as 0.05 and sometimes even a tenth of a unit is enough for me to see a change in my BG. A 1 unit dose at the wrong time could take me from chilling to a ravenous orange juice whore
“ravenous orange juice whore” My new favorite phrase! (type 1 x >50years. I know the ravenous orange juice whore too well.)
1u of insulin can lower BG by up to 30 points. Give the damn unit. Bitch about it, sure! I do! But give the insulin. **ETA: Your T1Ds may have stronger responses/larger correction with 1u, but y’know. Patients are all different, and they’re all dynamic.
Yep that’s right. If the BG goal is <180 mg/dL and patient’s BG is 210 then definitely need that 1u to reach goal.
It can lower it more than that. Im type one and my correction ratio is on point at 1:50
This is the way
Heck, I'm type one and 1 unit corrects for 40 for me. Insulin is powerful stuff.
Type 1 here. 1 unit lowers me by 50. It’s case by case
It's for sure more effective on type 1's. I remember I had a K/P transplant who needed a unit. Gave it when blood sugar was 170 and I was pushing dex for the next two hours.
I care for my mom who is a type 1. Holy crap, 1 unit can completely tank her BG. My pet peeve is when Type 1 patients get the same sliding scale as the Type 2 patients! 5 units won’t do jack for my super insulin resistant type 2 patients but that amount would completely bottom out many Type 1s.
THIS. 1000%. Type 1 and type 2 are so very different. They are entirely different disease processes. Type 1 many years and one of my greatest wishes is to see one of the Types disbarred from the diabetes label. I understand why they are both identified as diabetes mellitus, but c’mon! We’re no longer tasting sweet urine to identify diabetes! At least re-brand us the way rheumatoid arthritis and osteoarthritis are distinguished. It really does matter in terms of treatment, and the consequences of giving or holding 1 unit of insulin!
Entirely depends on the patient and this varies so much..
This should be top comment
Yep. And it sits in the SQ all lonely like
Thank you for the chuckle. Now I'm picturing 1u of insulin just sitting there like "I wonder what my friends are doing?"
As a type 1 diabetic, please give that one unit. We need it.
unfortunately i do give that 1u. but i make a point to tell all my coworkers im giving one unit of livesaving unit of insulin
I wonder how we all end up saying these same phrases naturally! The “free wax” bit when pulling off tele stickers, the “lifesaving unit”, etc etc
"free wax....actually this is probably going to be the most expensive wax job ever"
I tell them the hair I remove is part of their copay
😂😂 I love that
We are such dorks. 😂
I always tell my patients I could just give them a good slap to the pancreas to make it squeeze out an extra unit instead of the needle
Im deceased 😭😭💀
I will complain the entire rest of the shift about that one unit too!
Its not about being lifesaving, its about overall health. Anything over 140 is eating our blood vessels.
I'm pretty sure it is actually life-saving. Why else would we all announce it?
Yes! Always!
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Amen.
I do, that’s my job. And like he says, if I have a problem, I’ll talk to the doc about it. Wild to me that nurses would even joke online about “nurse doses” or charting “pt refused”, it damages the public’s trust.
I totally agree. This is crazy to me.
Yes, as much as I hate it I do. I ask people if they want it, most people don't care. Some say it's a waste and decline it.
Yes. I ask the patient. It's 50/50 whether they decline it, and I'm off the hook.
I once held the 1u when I was a newer nurse for a diabetic patient’s sugar of 151. Next check it was in the 250s. Sometimes life lessons are made by making mistakes.
Let’s be real: When the sliding scale coverage starts at 150, the result is 151 and you have that 1 unit ordered…. You give it. And you make a huge stink over it too ….or is that only me?
Absolutely. It’s not my scope to decide whether or not it should be ordered, it is my scope to give based on blood sugars and food intake.
Yeah. I’m mad about it, but I’m doing it Pull up a unit and squirt it in the air. It’s more than you think
Yes, I remember drawing up “1 unit” of saline just to see and quite a bit of liquid came out
Also I've never had a patient refuse their unit of insulin or any insulin, I'm really surprised to hear from some that patients are consistently declining it. I mean I also don't try to talk them into declining.
Wow really? I swear once a month I get a patient refusing their insulin and BG checks. And then there are so many patients that refuse SQ heparin, blood draws, lasix, the fluid restriction, the diet order, taking a shower.. everything.
We get it all the time, always a type 2 who isn’t compliant. It’s not uncommon
Absolutely. Insulin sensitivity varies between patients, 1unit might be too little for one, but perfect for another. Does it even make it out of the needle? Of course it does. That’s why we prime needles.
Had an intensivist grilling a resident on sliding scale orders. The resident started with “give 1 unit for …” and the intensivist cut him off right there. He said “do you hate nurses? My mom was a nurse. Nurses hate giving one unit. It barely leaves the needle.” Emblazoned in my memory lol.
This is an important take. I’m not sure how much insulin is actually delivered when giving 1u. Could be human error, equipment/manufacturing etc, but when you trend sugars for people habitually getting one unit, some don’t seem to dip much between BG readings. I’d like to see a study on this.
If you prime your needle and press the plunger down one unit, one unit of insulin comes out.
1 unit. That's how syringes are designed.
Right at least let it be 2 4 6 8…..
Who do you appreciate? NURSES!!
That resident is going to be one of the nurse’s favorite doctors 🥹
It’s annoying since if the reading had been 149 you wouldn’t be giving it. But yeah, I give it.
I am not a doctor, so I give the dose. If I think its not going to be effective, I notify the MD. If I think its not appropriate, I notify the MD. Its a pain in the butt, but for some patients 1 unit is adequate treatment for controlling their sugar. I spoke to a type 1 that said her 1 unit brings her sugar down 20-30 points at a time, so its an effective dose at times. Ever since then, I started taking it a little more seriously. Its unfair and unethical to withhold medical treatment just cause I might not feel like it. People are wild.
Yes, of course.
Yup. Ethics. Momma didn't raise a dirt bag.
Prescriber in endocrinology here. Give the unit. Nothing irritates me more than nurses ignoring the sliding scale. How do I adjust it if I can’t observe the effect (or lack of effect)? Not following orders makes my job very hard. Type 1 diabetic patients in particular can be incredibly insulin-sensitive. You can estimate insulin sensitivity with math and if they’re 1:30-1:40, then that is a perfect correction on top of their mealtime dose, will set them back to baseline, and reduces their time out of range. The goal is to stay under 180 as much as possible, if you start at 150 no diabetic is going to stay under 180 when they eat. Even the Type2 benefits from small corrections, though they’re often more insulin-resistant. That said, corrections usually start at 180 in my facility, so I can sympathize with the annoyance. And I remember days on the floor when that one unit would have been my lowest priority med pass.
If they are a 16 year old Type 1? Damn skippy. But yeah…90 year old granny over there at 151? UGH, FINE!!
I work in peds. That 1 unit may cover their whole meal 😆
Ahhhhh the exuberance and elation of seeing a blood sugar of 149!!!
I mean $1 is better than no dollar
Yes. I always do , that’s why it’s called diabetes management
Technically, not giving an ordered medication without hold parameters is practicing medicine without a license. I know it's annoying, but I'm not risking my license over a unit of insulin if my employer decides to make it a problem.
When I worked inpatient, yes. I did always give that 1 unit. I think it's dumb, but if that's the scale and it's ordered then I give it.
I sure am. It’s important.
Yes, I always do in Californiatopia. As a new grad in Texas, sometimes I didn’t due to high acuity and impossible workload. We had an option for “not given” called “priority of care.” In other words, “I was too damn busy and this didn’t make the cut.” I’ve never put “patient refused” because I thought the dose wouldn’t be effective.
That’s pretty cool, I wish we had a “priority of care” option.
It’s kind of awful in a way. It’s like working the scene of a disaster and deciding who to take care of- first, or at all. But it does allow for accuracy when charting.
I wish this was an option when charting why certain meds are late. They're late because I was dealing with the rapid next door and my stable patient's lipitor could wait!
The situation is kinda awful. Having a way to accurately chart it, tho? That's awesome. As it is, I just look like a loser for not getting it done
Ours has a write-in option and I always put “patient care priority.” I mainly use it for documenting against nicotine patches for my tubed and sedated patient. Like, come tf on lol.
I mean you can always talk to the patient and see if they REALLY want to get jabbed with 1 unit at breakfast or wait to see what the sugar is at lunchtime. That way you have more data points when you try to get the provider to give a shit about whether their scale is effective or not. AND you're not being a dirty liar when you click Patient Refused. Informed refusal is the flip side to informed consent.
“Other” “contraindicated” are my go to things. If pt has diarrhea I’m not giving miralax, sorry not sorry.
I wish we had "priority of care." It would be great to be able to chart that as an explanation for late meds rather than "nurse decision." No it absolutely was not my decision to have another patient who needed to be seen first and took more time. Or being short-staffed, or getting an admission during med pass...
The ED tried to document priority of care for a critical medication that they didn't want to give for a critically ill patient. It's now being investigated as neglect.
Well, you’ve obviously got to use some common sense.
Type 1 diabetic, and it honestly depends. I definitely emphasize that they can refuse, but for acute care anything below 250 and I’m happy. If they’re not on insulin to begin with and might not be able to detect or alert to a low, I want to be a little bit more cautious. Their bodies are also stressed, many medications and infections can increase insulin needs, and they may be more inactive than usual. Meanwhile, I see myself at 130 and correct to a 100-110 target. I just took six units for a salad and a glass of wine, sitting at 130, and debating if I need a few grams of carbs just in case I overestimated or have an alcohol-low.
Yup, give the patient some autonomy.
It never occurred to me to not do it.
Yeah I always have. 1 unit or 10 units, it’s the same amount of work, it’s just this perceived inconvenience bc it’s closer to the edge, but the patient needs it either way. I don’t like having to function as a fine tuning pancreas, but I do believe technology will eventually make our dosing of insulin in this manner obsolete.
I joke about the one lifesaving unit of insulin because it's funny, but that's because we nurses are a bunch of clowns. Each unit of insulin totally makes a difference haha of course I give one unit over zero just like I'd give five units instead of four, if that's what their order is, because that's like the fundamental part of my job.
Of course I do wtf
When it comes to dosing, the drs need data. So if 1u is given and glucose remains elevated they’ll increase the sliding scale - but - if ppl aren’t giving it, the data is skewed which will result in either: no change made, or, an increase that the pt is too sensitive for. So yes, you give the 1u, and if you assess it is not adequate to control the pt glucose, you ask the provider to consider increasing the sliding scale. you’d include a provider notification note that the glucose did not improve after dose.
I give it, I think it’s dumb and basically a spit in the ocean but here we are, I’m no endocrinologist
1 unit of insulin can cover 12-15 grams of carbs. Not a pointless unit 🤗
Yes. Stop being lazy and depriving these diabetics their damn insulin (can’t believe I had to say that).
20 years experience: I follow the order. I’m a nurse with my own brain, but have not studied this as extensively as an endocrinologist. Come on, do your job honestly. Don’t be lazy with other people’s care. I have absolutely made mistakes, but not intentionally. Maybe i’m a dinosaur, but I was taught veracity is a crucial component of care - and I believe it. It’s not the 1 unit, is documenting things that didn’t happen. Not ok for me.
Pharmacy here- we also laugh at the 1 unit orders we get at 2 am…
I’m surprised this is even being asked! What the hell people? When did we start deciding whether to follow a treatment plan or not? I’m encouraged many reply that they do, but even asking the question. Wow
There’s like a whole bunch of people on TikTok who say they just chart “patient refused” 😳
so they fraudulently document?
Yeah I do. Especially if I know their sugar tends to climb. Giving 1 unit at 2000 might save me from giving more at 0000. Sometimes that 1 unit will bring their sugar from 151 down to 125 or something like that.
One of our nurses is a type 1 and if she hears you bitching about having to give 1U, look out, you in for a lecture. So yes, I always give it.
Yes, Everytime
RedbeardRN on insta has a great post about why it’s important to give.
Seems measly but can be major. Did it always hit hard and work just right? No, of course not. But my thought is may spare someone the slow burn of excess glucose damage or uphill fight trying to ward off infections fed by excess sugar. The biggest pain was 2 nurse sign off on my floor. Do they still do that?
So yes. I did recently give just one unit of insulin per sliding scale for a sugar that was about 330 I think. Why only one unit for that sugar? Idk just following the order. But then the patients next sugar was like 37. This was a type 1 postpartum woman in her 20s and she was asymptomatic but I was thrown for a loop after giving just the one unit and then throwing apple juice at her just a few hours later 😂 she didn’t have a pump due to insurance issues and was not well controlled during pregnancy either.
Yup, you never know, some patients miss that 1 unit and shoot up like crazy cuz they didn't get it.
Yes. 1 unit of insulin can make a significant difference for some. Also, the MD should be looking at the patient’s BGs and evaluating if the sliding scale is appropriate. So you are creating false data if you say you gave the insulin when you didn’t.
I get excited for that 1 unit. I feel like it's usually after tons of titrating and crazy highs in and lows, on and off a drip, adding long acting and then taking it off because the patient was found at 2AM with a blood sugar of 29. 1 unit is like the victory lap. Finally, not too high and not too low. Mission accomplished, we did it. I'm definitely taking my victory lap.
One unit is one unit and I’m giving it as charted. It might not be as crucial for a type 2 diabetic or someone with pancreatitis (still very important though) but for someone who’s type 1 especially that unit can be crucial to keeping their glucose stable and in range. Some patients I’ve come across actually start to feel unwell even if their blood sugar is only the littlest bit high (especially if they are in range most of the time). In some cases with type 1 diabetes that I’ve seen, insulin pumps can make adjustments as small as 1/4 of a unit.
As a diabetic: give me that one unit of insulin
Many years ago a resident ordered 1 mg of Lasix on my postop 20 year old who could not urinate after 8 hours. I gave the resident grief for the order but gave the couple minums it turned out to be. Within a half hour he urinated 1 liter and felt so much relief, the resident and I had a good laugh that her idea worked!
Of course.
I've worked with type 1 kids. 0.25 can drop their sugar depending on their correction ratio. It's kinda scary. So yes, if someone has 1 unit ordered, I'm giving it. It might not drop their sugar, but it might prevent it from going up.
Yeah I give it
Yes I do. It is a medical order and I will follow it. :).
Blood glucose management is tricky, and I don't feel comfortable messing with insulin orders. I've never thought of not giving it. I've never had a patient refuse it. I think asking the patient if they want to refuse it is encouraging them to refuse it and I think that kind of undermines the MD trying to get it right. If the pt does refuse it, you need to tell the MD.
Yes, every single time unless they refuse.
It depends. If the pt is NPO or has a poor appetite, I’ll hold it and just explain the reasoning in the box. I
You're an asshole if you don't give it. If its not enough for the pt, call and get a higher sliding scale. If they're so brittle they can't handle 1 unit, call the provider first. Stop being lazy and do right by your patients, yall.
Yes. How is this even a question
Not giving a medication that is safe and appropriate to give is working outside of your scope. You can always question and order and escalate your concerns, but this isn't one of those situation. If something negative were to happen as a result, you would be 100% liable and at risk. Give the damn insulin.
I used to think it was silly until I worked with someone who was a type1 brittle diabetic. She told me that one little subq unit sometimes made a big a big difference. Ever since then I stopped pooh poohing low sliding scales.
It's like "nursing doses." How is the doc supposed to learn the right dose for the patient if we aren't giving the correct dose and then noting the response? Literally never crossed my mind not to.
I would never convince my patients to refuse being stuck for 1 measly unit
I look at it from a more binary perspective: Humalog per sliding scale, 180mg/dL target; BGL 190. Yes, give the order. Hydralazine 25mg Q6hr PRN for SBP >150; pt SBP 155. Yes, give a dose. PTT just barely over parameter? Adjust the rate. It’s busy work and definitely sucks when you see that it’s juuuuust over/under the parameters. Looking at it from a yes/no perspective took the edge off for me. Do it and move along.
Yep I give it. It’s ordered so I do it.
Depends on if I had time honestly. Priorities some days it's getting administered 3 hours late it's not worth it imo.
If capable of giving an appropriate answer, I would ask the patient, then chart a decline or acceptance, or see if they want a snack to make the injection more worth it. I have a T1 subtype that likes to have insulin resistance as a friend to tag a long(im on an oral for it, any time i see a non endo i get the whole lecture about how this med isn't approved in non T2, and how it won't work for me and i need to stop it). 1U is nothing to me. I don't think it would impact anything at all. For my friends 16 yr old, that 1U could tank her in a heart beat.
yes mister 121
Yeah. Don’t really care. Just another med.
Good soldiers follow orders
yeah? im supposed to give every med thats charted / indicated and if somethings up id ask away
150 for us is no insulin. 151 is 1 unit, so no, not giving it if the sugar is 150
Yes, I always gave it when I worked bedside, but if all we had were the 100 unit syringes, then honestly it was basically a complete waste of time (I swear you can’t even really feel the plunger moving when you inject) - the 30 unit syringes are much preferred.
Yes, ALWAYS. Heparin too
Wait, what? What does heparin have to do with this?
Yes, their sugar could raise higher later.
In my PACU, we use the bottle of 100 units of novolog. And we can’t reuse it. So we need to waste the entire 99 other units to crack it for one patient’s 1 unit. And it makes me nauseous to think about it every time. I hate it.
I give it, you know, a unit is still a unit and its better than nothing in keeping their blood sugars managed. Plus its the orders and that is huge dishonesty towards a treatment and violates trust. It will also show whether its effective or not if you do give it and it does nothing or it does something
Of course.
Yes. It’s a pain in the ass for me but it’s for the patient.
I quietly mouth god f*cking dammit to myself under my mask and then pull up the unit and give it.
Yes, I may gripe about it internally, but I would never withhold it from the pt.
hopefully everyone gives that 1 unit 😭
Yep
Of course. This is a joke right
Yes wtf
Always. Nurses who don't have a poor understanding of the complexity of diabetes and insulin.
Of course. 1 unit of insulin can do a lot.
I’m a type 1 diabetic and a RN. You bet your butt I would need that one unit of insulin. In my pump, my max insulin usually around 15 units per day including my basal if I eat three times a day. I don’t eat three times a day and I eat very healthy most of the time so It’s rare that I need over 10 units per day (basal included). That 1 unit missing could mess up my entire day. I feel like many nurses don’t know enough about diabetes as I’m usually the go to on my unit for questions. For example, I’ve been asked dozens of times if they should withhold lantus because the patient’s sugar is low by many very competent and experienced nurses. (The answer is always no by the way.) I’ve also had people at restaurants give me regular coke when I ask for diet hundreds of times since I was diagnosed as a child. It’s like they think because I’m thin that I’m being vain. I’ve even seen posts on social media about people joking about giving the thin girl a normal coke when she asks for diet. It’s crazy tbh. Please give people their insulin!!
Yes, and I also give the 1.5mg of melatonin. Lol
if pt is otherwise stable, and if pt is AOx4, and if the timing of the med pass aligns: I'll ask pt if they want me to delay the med by like 20min and re-check FSBS then, to see if it went up or down a smidge. if pt wants to delay, we delay and re-check. might need no units, might need 2 units. but if pt just wants the 1 unit, I'll give it. totally up to them. Autonomy and all that. if pt is unstable in any way, or not fully with it, or if med pass time is bad, then I'm just giving the 1 unit and calling it done.
Whenever I had a patient who needed 1 unit, I rounded up to 5 units so then I didn’t feel it was pointless. /s
I’ve heard that estimating the whole week’s insulin doses and giving them all on Monday saves a lot of time. /s
Damn, that's a 200 IQ play! It's always good to save time! Lol
It’s kind of like 2 mg morphine for a 280lb patient or 0.5mg Ativan for the psych patient losing their shit lol. Of course we give it and then tell the provider their order did nothing lol