What are the key nursing assessments for an adult patient with diabetes, cardiovascular disease, and potential renal issues, who is receiving heparin, insulin Lispro (Humalog), insulin glargine, furosemide (Lasix), pantoprazole (Protonix), lactated Ringer's infusion, and potassium chloride?

Nursing Assessment Guide for Multi-Drug Regimen in Diabetes and Cardiovascular Patient

THERAPEUTIC EFFECTS TO MONITOR

Insulin Lispro (Humalog) - Rapid-Acting

• Blood glucose reduction within 15 minutes of administration, peak effect at 30-90 minutes, duration 3-5 hours 1
• Monitor capillary blood glucose 2 hours post-meal; target <180 mg/dL in hospitalized patients 2
• Assess for improved mental status and resolution of hyperglycemic symptoms 2

Insulin Glargine - Basal Insulin

• Provides 24-hour basal coverage with no pronounced peak when given once daily 3, 4
• Monitor fasting blood glucose; target <140 mg/dL premeal for noncritically ill patients 2
• Assess for stable glucose control between meals and overnight 4

Heparin Injection

• Monitor aPTT every 6 hours until therapeutic (1.5-2.5 times control), then daily 2
• Assess for bleeding: gums, urine, stool, injection sites, petechiae 2
• Check platelet count at baseline and every 2-3 days for heparin-induced thrombocytopenia 2

Furosemide (Lasix)

• Assess urine output hourly initially; expect diuresis within 1 hour of IV administration 5
• Monitor daily weights (expect 0.5-1 kg loss daily in fluid overload) 5
• Auscultate lung sounds for decreased crackles/rales 5
• Assess for reduced peripheral edema and jugular venous distension 5

Pantoprazole (Protonix)

• Assess for resolution of epigastric pain, heartburn, or GI bleeding 2
• Monitor for absence of coffee-ground emesis or melena 2

Potassium Chloride 10 mEq in 100 mL

• Monitor serum potassium levels; target 4.0-5.0 mEq/L 2
• Assess cardiac rhythm on telemetry for peaked T-waves (hyperkalemia) or U-waves (hypokalemia) 2

BLACK BOX WARNINGS

Insulin Products (Lispro & Glargine)

• Never administer IV insulin glargine - subcutaneous route only 4
• Hypoglycemia is the most common adverse effect; can be life-threatening 2, 4

Heparin

• Can cause fatal hemorrhage; monitor closely for bleeding 2
• Heparin-induced thrombocytopenia (HIT) can occur; monitor platelet counts 2

PERTINENT LABORATORY MONITORING

Immediate Priority Labs

• Capillary blood glucose every 2-4 hours while NPO or on insulin drip; every 4-6 hours when stable on subcutaneous insulin 2, 6
• Serum potassium daily (or more frequently if on diuretics or insulin) - insulin drives potassium intracellularly 2, 6
• Serum creatinine/eGFR at baseline and with any clinical change 2
• aPTT every 6 hours until therapeutic on heparin, then daily 2
• Complete blood count with platelets every 2-3 days on heparin 2

Ongoing Monitoring

• HbA1c every 3 months until glycemic goals achieved, then every 6 months 7
• Serum magnesium weekly (furosemide causes losses) 2
• BUN/creatinine every 2-3 days on furosemide 2

DRUG COMPATIBILITIES & ADMINISTRATION

IV Compatibility with Lactated Ringer's

• Heparin: COMPATIBLE with lactated Ringer's 2
• Insulin (regular only): COMPATIBLE with lactated Ringer's - never mix glargine or lispro in IV solutions 4
• Furosemide: COMPATIBLE with lactated Ringer's but administer separately via Y-site 5
• Pantoprazole: COMPATIBLE with lactated Ringer's 2
• Potassium chloride: COMPATIBLE with lactated Ringer's; maximum concentration 40 mEq/L peripheral line, 80 mEq/L central line 2

Critical Incompatibilities

• Never mix insulin glargine with any other insulin or solution 4
• Never mix insulin lispro with NPH or other insulins in same syringe 1

MECHANISM OF ACTION (SIMPLIFIED)

Insulin Lispro (Humalog)

Rapid-acting insulin that lowers blood glucose by facilitating cellular uptake of glucose into muscle and fat cells; works within 15 minutes 1, 8

Insulin Glargine

Long-acting basal insulin that precipitates in subcutaneous tissue and slowly releases over 24 hours with no peak, mimicking natural basal insulin secretion 3, 4

Heparin

Anticoagulant that activates antithrombin III, preventing clot formation by inhibiting thrombin and Factor Xa 2

Furosemide (Lasix)

Loop diuretic that blocks sodium and chloride reabsorption in the ascending loop of Henle, causing rapid diuresis and reducing fluid overload 5

Pantoprazole (Protonix)

Proton pump inhibitor that irreversibly blocks gastric acid secretion by inhibiting H+/K+-ATPase enzyme in parietal cells 2

Potassium Chloride

Electrolyte replacement that maintains normal cellular function, cardiac rhythm, and neuromuscular transmission 2

Lactated Ringer's

Isotonic crystalloid solution providing hydration and electrolyte replacement; lactate is metabolized to bicarbonate 6

CRITICAL NURSING PITFALLS TO AVOID

Insulin Administration

• Never stop IV insulin without giving subcutaneous basal insulin 2-4 hours prior - most common cause of DKA recurrence 6
• Do not give insulin if potassium <3.3 mEq/L - can cause fatal cardiac arrhythmias 6
• Verify injection site rotation and check for lipohypertrophy - causes erratic absorption and unexplained hypoglycemia 2
• Hold insulin if patient is NPO without dextrose-containing IV fluids 2

Hypoglycemia Management

• Modify insulin regimen when blood glucose <70 mg/dL 2
• Diabetic patients on furosemide require 26% higher insulin doses 5

Electrolyte Monitoring

• Monitor potassium closely when combining insulin, furosemide, and potassium replacement - insulin and furosemide have opposing effects 2, 6
• For patients on ACE inhibitors/ARBs with diuretics, monitor potassium and creatinine at least annually 2

Renal Function

• Adjust heparin, furosemide, and potassium doses based on creatinine clearance 2
• Ensure adequate hydration before and during furosemide administration to prevent acute kidney injury 2