At least once a month a student who has diabetes will have a pre-lunch blood sugar of less than 60 mg/dl [3.3 mmol/L] (sometimes without symptoms). Orders state that he is have an additional juice along with his regular lunch within five minutes, and after eating lunch he is to self-administer 4.5 units of Humalog insulin. As a nurse, I would like to recheck his blood sugar prior to the insulin administration to verify that his pre-lunch blood sugar has risen, but his doctor’s orders do not specifically allow us to recheck his blood sugar unless he is symptomatic, the student’s mother does not want it done, and also does not allow me to contact the physician regarding this matter. For my own peace of mind, is it prudent to want to recheck? The student does have a history of low blood sugars staying low even after ingesting multiple servings of fast acting carbs.

I appreciate your conscientious concern. If I am understanding your letter about this student, he periodically has asymptomatic glucose readings near 60 mg/dl [3.3 mmol/L] before lunch, with instructions to drink some juice, then to consume his usual lunch, and then to take his prescribed dose of insulin after he eats. You would like to check his glucose reading after the meal but before the insulin.

I understand your concern and desire to be complete. While I see it as a health givers prerogative to assess glucose readings if you feel the child may be in danger (especially concerns of hypoglycemia), I think the parents’ and doctors’ request to relax is very, very reasonable. After all, after the juice and after a meal, one certainly should anticipate the glucose reading to increase. I am not too concerned with a glucose reading in the 60s mg/dl [3.3 mmol/L], especially right before a meal. (What better time to have a low-normal glucose reading and no symptoms to boot?)

Ask yourself what you might do differently if you found the glucose reading still in the 60s mg/dl [3.3 mmol/L] or even lower after the meal, which I think we’d all agree is not a likely scenario. Well, you might encourage more to eat (but he just ate and may not want more). You might delay his insulin administration, but he just ate so you know he needs insulin to help manage the postprandial readings. I think I’d be more inclined to have the postprandial testing you’ve outlined if he had hypoglycemic symptoms. There are other times when a two-hour postprandial glucose reading is appropriate, mostly to ascertain that the dose of short-acting insulin for the meal is appropriate. Maybe the family and you could work out to check that a couple of times per week.

DS