SARASOTA MEMORIAL HOSPITAL
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1 SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE CARE OF THE INTRAPARTUM PATIENT RECEIVING CONTINUOUS INTRAVENOUS INSULIN ADMINISTRATION (obs25) DATE: REVIEWED: PAGES: 9/93 8/15 1 of 7 PS1094 ISSUED FOR: Nursing RESPONSIBILITY: RN - Obstetrics PURPOSE: KNOWLEDGE BASE: To outline nursing guidelines for safe administration of intravenous insulin by continuous infusion and assessing and evaluating nursing care for the intrapartum patient with insulin dependant diabetes. During the intrapartum period, a continuous intravenous insulin infusion may be utilized to control maternal blood glucose levels and thus decrease the incidence and/or severity of neonatal hypoglycemia. The usual dosage for intravenous insulin is u/hour to maintain a maternal blood glucose level in the range of mg/dl. Because it is so easy to adjust insulin doses with an insulin drip, it is rarely necessary to administer a bolus dose of insulin. In the rare event that an insulin bolus dose was ordered, the insulin would be drawn from a bottle of Regular insulin obtained from the Pyxis. An insulin syringe, with a detachable needle, would be used. Due to differing concentrations of insulin in a solution bag, NEVER draw insulin from an insulin solution bag for a bolus dose. EQUIPMENT: PROCEDURE: 1. Two sites are needed should other IV medications be required (such as Pitocin or magnesium sulfate). 2. IV solution as ordered by physician (Lactated Ringers and D5LR). 3. IV blood tubing, regular IV tubing, pump tubing. 4. #18 gauge IV catheter Units Regular Insulin mixed in 50 ml Normal Saline per physician order. 6. Infusion pump and tubing. 7. Fetal monitor 8. Stethoscope 9. AccuChek machine 1. Verify provider order for OB Glycemic Control of Patients in Labor. 2. Ensure proper patient identification 3. Explain procedure to patient and assess patient s level of understanding. Document medication education. Encourage patient to verbalize to nursing staff if any of these symptoms are experienced: a. Signs and Symptoms of hypoglycemia: 1. Cold, clammy skin
2 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 2 of 7 2. Shakiness 3. Sweating 4. Mental confusion 5. Lightheadedness 6. Irritability 7. Tachycardia b. Signs and Symptoms of Hyperglycemia: 1. Polydipsia (extreme thirst) 2. Polyuria (frequent urination) 3. Polyphagia (hunger) 4. Blurred vision 5. Headache 6. Drowsiness 7. Hyperpnea (deep respirations) 8. Nausea c. Signs and Symptoms of Diabetic Ketoacidosis 9. Blood glucose level >300mg/dl 10. Ketouria 11. Polyuria 12. Nausea/Vomiting 13. Altered level of consciousness 14. Labored breathing 15. Acetone fruity breath odor 4. Obtain serum glucose- split specimen with AccuChek for meter check. 5. Start Primary IV site with blood tubing and #18 gauge IV catheter: a. Lactated Ringers per Intrapartum order set. Utilize this site for bolus of fluids, antibiotics, magnesium sulfate and oxytocin administration. 6. Start Secondary IV site with regular IV tubing, and Dial-a-Flo: a. 125ml/hr until delivery or as per physician order. Use dial-a- flo to control rate of mainline. b. Regular Insulin 50 units added to 50 ml Normal Saline (will produce a concentration of 1ml NS=1 Unit Regular insulin). Insulin will be premixed in the pharmacy. The Insulin bag will be infused via infusion pump and will be piggybacked to the most proximal port to the D5LR IV tubing line. c. Insulin is NOT compatible with any other medications; other medications must be administered in the primary site listed above. This site is dedicated to insulin administration only. d. Two licensed nurses will perform independent verification. They should verify the order, insulin solution rate, concentration of the solution (units/ml), patient ID, and pump settings (ml/hour) at the bedside. This information will be recorded in the EMR. e. If the patient is symptomatic, eg., sweating, shaking, dizzy, faint, headache, hunger, pounding heart, confusion, irritability, stammering, combative, or convulsing, or if the patient states I am having an insulin reaction, or low blood sugar, do a fingerstick with an AccuChek Inform Monitor. If the blood sugar is less than 70mg/dl, turn off the
3 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 3 of 7 insulin drip and treat according to protocol for NPO patient listed in Procedure (dia14) Insulin Reaction/Hypoglycemia Protocol for the Adult Patient (listed below). f. Insulin to be infused on pump per provider order based on AccuChek assessment: AccuChek Units/hour < > 190 Call MD 7. Assess blood glucose via AccuChek every 30 minutes x 2 after initiation of insulin drip, then hourly during duration of therapy. Titrate insulin dose per blood glucose per above. Maintain glucose between mg/dl. Refer to the insulin reaction/hypoglycemia protocol for the adult patient attached to this procedure. 8. Assessment of patient s status: a. Vital signs per unit guidelines for Vital Signs in labor for high risk patients. b. Respiratory status: 1. Auscultate lung sounds every 4 hours 2. Note any fruity breath odor 3. Note skin color and peripheral circulation 4. Document signs and symptoms of respiratory infection c. Level of consciousness: 1. Document patient s mental state, any inappropriate behavior or verbal responses. d. Skin integrity: 1. Note condition of skin at injection sites 2. Assess feet bilaterally and document any lesions, ulcers, ingrown nails, etc. e. Renal status: 1. Note any signs and symptoms of urinary tract infections 2. Monitor and document intake and output f. Fetal monitoring per unit guideline for assessment of high risk patient. 9. Patient remains NPO during infusion of insulin, unless otherwise ordered by provider. 10.Discontinue all oral and SQ hypoglycemics while IV insulin Infusion. 11.Report maternal history and delivery information to the newborn nurse to initiate the glucose monitoring protocol for the newborn. NOTE: Normal insulin dosages should be withheld during labor or before a scheduled cesarean section.
4 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 4 of 7 DOCUMENTATION: 1. EMAR: a. Primary IV: time, rate, insertion site, solution. b. Secondary IV: time, rate, insertion site, solution, additive. 2. Labor and Delivery Flow sheet in CPN/QS: a. Primary and secondary IV infusions: solution and rate. b. Time of initiation of insulin administration, dose and titrations. c. Patient symptoms, result of blood glucose test, any treatments, patient response, and physician notification as needed. d. Patient education regarding understanding of treatment and procedures and signs and symptoms of hypo/hyperglycemia. e. Maternal and fetal assessments per high risk Intrapartum patient guidelines. 3. Glucose/insulin flowsheet in CareVision: a. Blood glucose test. REFERENCE: Stepp-Gilbert, E. (2010). Manual of High Risk Pregnancy & Delivery. (5 th Ed.). St. Louis MO: Mosby. Creasy, R., Resnick, R., Iams, J., Lockwood, C., & Moore, T. (2009). Maternal Fetal Medicine: Principles and Practices. Philadelphia, PA: Saunders. SMHCS Nursing Procedure. Insulin Reaction/Hypoglycemia Protocol for the Adult Patient (dia14). REVIEWING AUTHOR (S): Debbie Dietz, MSN, RNC-OB, C-EFM, APN, Labor and Delivery Dr. Felice Baron, Director, Maternal Fetal Medicine Algorithm for Intrapartum Glycemic Control
5 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 5 of 7 of Patients with Diabetes in Labor 1. LR per provider order (site#1) for any boluses of fluid, Pitocin, or antibiotics. 2. D5LR at 125ml/hour (site #2). 3. Insulin infusion premixed by pharmacy (50 units Regular insulin in 50 ml NS), delivered via plum pump piggy backed to D5LR (site #2) tubing to port closest to insertion site. 4. Insulin is not compatible with the infusion of another medication. 5. Check split specimen blood glucose for meter check. 6. Check capillary glucose every 30 minutes x 2, then every one (1) hour while patient in labor. 7. Maintain glucose between mg/dl, titrate insulin to glucose level per below. 8. Algorithm for insulin infusion: 9. NPO Blood Glucose Insulin Rate in Units/Hour < >190 Call and inform MD 10. Notify Newborn Nurse of patient s admission and when delivery is imminent as infant may be hypoglycemic at birth. 11. Utilize the 1.7 Glycemic Control Flowsheet in SCM to document Maternal Fetal Medicine Sarasota Memorial health Care System Revised June 2009 Blood Glucose (bg Result) Patient Condition Action
6 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 6 of 7 1. Less than 70 Able to swallow OR feeding tube (without IV line) 1. Give the following by mouth (15 grams fast acting carbohydrate): one glucose gel tube. If feeding tube (and no IV), dilute gel with 50 ml warm water; instill. Resume tube feeding. 2. Wait 15 minutes and repeat bg. 3. If patient is still symptomatic and/or bg less than 70, treat again with 15gms carbohydrate. 4. Repeat bg and treatment every 15 minutes until bg greater than or equal to 70 mg/dl. 5. Give patient a protein and carbohydrate snack (i.e., peanut butter or cheese and crackers, or meal, if available or be sure tube feeding infusing). 6. Document events. 2. Less than 50 Able to swallow OR feeding tube (without IV line) 1. Give the following by mouth (30 grams fast acting carbohydrate): two glucose gel tubes. If feeding tube (and no IV), dilute gel with 50 ml warm water; instill. Resume tube feeding. 2. Wait 10 minutes and repeat bg. 3. If patient is still symptomatic and/or bg less than 50, treat again with fast acting carbohydrate. 4. Repeat bg and treatment every 10 minutes until bg greater than or equal to 70 mg/dl. 5. Notify Physician. 6. AFTER low blood glucose is resolved and above 70 mg/dl, give patient a protein and carbohydrate snack (i.e., peanut butter or cheese and crackers, or meal, if available, or be sure tube feeding infusing). 7. If blood glucose not responding to oral carbohydrates go to #3 (less than 70). 3. Less than 70 Unresponsive, unable to swallow, or NPO OR feeding tube (with IV line) 1. Give intravenously 25 ml of 50% Dextrose (lifeshield) 2. Repeat blood glucose within 5 minutes. 3. If blood glucose less than 70, give remainder of Dextrose 50% (25ml). 4. Repeat blood glucose in 5 minutes. 5. Notify physician, document events. 6. After low blood glucose is resolved and above 70 mg/dl, give patient a protein and carbohydrate snack (i.e. peanut butter or cheese and crackers, or meal, if available, or be sure tube feeding infusing) Unresponsive, unable to swallow, or NPO (Without IV line) 1. Give intramuscularly 1 mg Glucagon IM 2. Turn patient on side. 3. Initiate IV line. 4. If IV can not be started and blood glucose not improving, activate Rapid
7 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 7 of 7 Response Team and notify physician. 5. Repeat bg within 5 minutes 6. If bg not increasing, give 50 ml of 50% Dextrose. 7. Notify physician. Document events. 8. When patient is conscious and able to swallow, give glucose gel if blood glucose still <70. When blood glucose is > 70, give patient a protein and carbohydrate snack (i.e., peanut butter or cheese and crackers, or meal, if available, or be sure tube feeding infusing).monitor patient closely. 4. Greater than 70 but less than 120 and symptomatic 1. Give patient a protein and carbohydrate snack (i.e., peanut butter or cheese and crackers, or meal, if available, or be sure tube feeding infusing).monitor patient closely. 2. Repeat bg in minutes. 3. If symptoms persist or worsen and blood sugars are decreasing, treat with 15 grams fast acting carbohydrate. 4. Recheck blood sugar in 15 minutes 5. Document events.
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