TO HOLD OR NOT TO HOLD: UNDERSTANDING INSULIN

You’re about to walk into your patient’s room with a syringe full of insulin. The unit secretary shouts, “Hey. The physician just made your patient NPO.” Ugh...now what? Do you give the insulin? Do you hold it?

Are you confident that you would know what to do every time?

If you don’t, you’re not alone. However, by understanding the different CATEGORIES of insulin, I guarantee you will!

There are 3 categories of insulin: Basal, Prandial (bolus), and Correction (sliding scale).

Basal (Lantus, NPH, Levemir)

This is the insulin your body needs just to meet its basal metabolic functions. Let’s say you decide not to eat for a day. If you’re NOT a diabetic, your cells still need glucose for energy, so your liver continuously kicks out a small amount of glucose (gluconeogenesis) – prompting your pancreas to secrete a small amount of insulin – to feed your body’s cells (energy). Remember?  Insulin acts as the key to unlock the door of the cell to let the glucose in.

If you ARE a diabetic and decide not to eat, your liver will still kick out glucose but since your pancreas doesn’t secrete insulin (Type I), all of your insulin needs, need to come exogenously (shot) – we need to give you a shot of basal insulin…even when you’re not eating – remember, the liver will still kick out glucose! 24 hours a day – 365 days a year – you have glucose in your bloodstream whether you’re eating it or your liver is kicking it out!

Therefore, basal insulin should NEVER be held.  Patients with Type I diabetes need basal insulin 24 hours a day.  If they are NPO, the general rule of thumb is that they need ½ of their usual dose.  For example, if they are on 50 units of Lantus a day, when they are NPO, they need approximately 25 units.

If NPO – Give ½ dose

Prandial (Novolog, Humalog)

Its only job is to cover the meal. Let’s say you go a long time without eating. Remember, your liver takes over and kicks out glucose while your pancreas kicks out insulin. Now let’s say you decide to eat. Your pancreas says, “Incoming!!! She’s eating!!” and BOLUSES your body with the insulin it needs to cover that meal.

If you’re a diabetic, we have to mimic this by giving you a shot of PRANDIAL insulin WITH your meals. You know it’s a Prandial insulin when you see the insulin ordered WITH meals, ex. Novolog 5 units WITH breakfast, 8units WITH lunch, 10units WITH dinner, etc.

Prandial insulins should be given immediately with meals. If patient is NPO, this insulin should be held. No meal…no insulin!!!

If NPO – Hold

Correction (Novolog, Humalog, Regular)

Its only job is to correct an elevated glucose level.  Most institutions have protocols (sliding scale).  These protocols are designed to be given independent of nutritional intake. So, even if the patient’s not eating, if you check a blood glucose level and it’s elevated, give correction insulin!!

If NPO – Give

Caring for patients with diabetes can be complicated. However, by understanding how the different categories of insulin act in the body, you can feel confident you will know what to do every time your patient needs insulin.

I wrote an article about this several years ago, click here to read!

Disclaimer – please follow your institution’s policy and procedures regarding insulin therapy.

Thanks so much for reading. Let me know if this post helps you to understand what to do!!

Thanks for choosing to become a nurse. I'm cheering for your success!

Renee

If you like this post, say thanks by sharing with others!