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 12/17 1 of 5 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 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. IV Supplies 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 5 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. Ketonuria 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 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 PRN Adapter, start fluid as follows per blood sugar: a. Blood Glucose < 130mg/dl, initiate D5LR b. 125ml/hr until delivery or as per physician order. Use dial-a- flo to control rate of mainline. c. 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. d. 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. e. 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. f. 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

3 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 3 of 5 blood sugar, do a fingerstick with an AccuChek Inform Monitor. If the blood sugar is less than 70mg/dl, turn off the insulin drip and treat according to protocol for NPO patient listed in Procedure (dia14) Insulin Reaction/Hypoglycemia Protocol for the Adult Patient (listed below). g. Insulin to be infused on pump per provider order based on AccuChek assessment and algorithm for Intrapartum Glycemic Control of Diabetic Patients in Labor (attached). 7. Assess blood glucose via AccuChek on admission and 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 can have clear non-caloric liquids per Provider order and/or anesthesia 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. For Hypoglycemia: See SMHCS Nursing Procedure. Insulin Reaction/Hypoglycemia Protocol for the Adult Patient (dia14).

4 TITLE: CARE OF THE INRAPARTUM PATIENT PAGE: 4 of 5 DOCUMENTATION: 1. EMR: 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. Glycemic Control Flowsheet in CareVision: REFERENCE: California Diabetes and Pregnancy Program (2013). Pocket Guide for Professionals. Palmer, D. & Inturrisi, MB (2004). Insulin infusion therapy in the Intrapartum period. Journal of Perinatal and Neonatal Nurses. 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

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