NR 560 Week 2 Capstone Topic Brief Example

Capstone Topic Brief: Mealtime Insulin Given Before the Meal Tray on One Medical-Surgical Unit, With the Population, Its Exclusions, a Structured Question and the Outcomes the Project Will Count

Student Name

College of Nursing, Chamberlain University

NR 560: Professional Nursing Capstone

Instructor Name

Month Day, Year

Capstone Topic Brief: Mealtime Insulin Given Before the Meal Tray on One Medical-Surgical Unit, With the Population, Its Exclusions, a Structured Question and the Outcomes the Project Will Count

The Problem in One Sentence

On our medical-surgical unit, mealtime insulin frequently reaches patients ahead of the meal tray, or before anyone knows whether they will eat, and a share of them become hypoglycemic within two hours.

Why This Problem

The problem was chosen because it is frequent, measurable, within nursing's control and linked to harm. A three-month review of our unit's glucose records, done with the nurse manager's approval, found 38 readings under 70 mg/dL among 212 patients receiving scheduled mealtime insulin. In 21 of the 38, the most recent mealtime dose had been given before the tray was documented at the bedside or to a patient who ate less than half the meal. Hypoglycemia in hospitalized patients with diabetes has been associated with longer stays and higher mortality (Turchin et al., 2009), and it was associated with higher mortality among hospitalized patients whether or not they received insulin, in a separate analysis (Garg et al., 2013). The timing of a dose is a nursing action, which makes this problem one a nursing capstone can address directly.

Population, With Its Exclusions

Included: adults aged 18 or older on our medical-surgical unit with an active order for scheduled rapid-acting mealtime insulin, whether with or without long-acting insulin, and eating an oral diet.

Excluded: patients receiving continuous enteral feeding or parenteral nutrition, since their carbohydrate intake is not tied to meal trays; patients on intravenous insulin infusions; patients who are nothing by mouth; patients on correction-scale insulin only, without a scheduled mealtime dose; and patients receiving insulin through their own pumps, whose management follows a separate policy. These exclusions keep the project focused on the moment it can change, the gap between the mealtime dose and the meal, and they will also keep the evidence search from returning studies of feeding regimens and critical care.

Setting

A 30-bed medical-surgical unit for adults, inside a community hospital of roughly 280 beds, staffed across day, evening and night shifts. The medication administration record times mealtime insulin for 07:30, 11:30 and 17:00, and a dose counts as on time within an hour of each. Meal trays arrive from a central kitchen at variable times within about 45 minutes of the scheduled meal times.

The Structured Question

In adult medical-surgical inpatients receiving scheduled rapid-acting mealtime insulin (P), does giving the dose only once the meal tray is at the bedside and the patient has begun to eat (I), compared with giving it at the scheduled medication time (C), reduce the frequency of blood glucose below 70 mg/dL within two hours of the dose (O), without increasing the frequency of glucose above 300 mg/dL before the next meal (O2)?

How the Question Will Be Searched

The structured question sets the search terms. The population terms are hospitalized adults, inpatients and medical-surgical or general ward settings. The intervention terms are insulin, short-acting or rapid-acting insulin, prandial or mealtime insulin, meal timing and meal delivery. The outcome terms are hypoglycemia and hyperglycemia. CINAHL and PubMed will be searched first, followed by the guideline pages published by the two main diabetes professional bodies. Limits will be English language, adults and publication from 2008 onward, with older landmark studies admitted if they are still cited in current guidance. Studies of critical care, insulin infusions, pediatric patients and enteral feeding will be set aside at the title stage, matching the exclusions above. A running log of each search string, date and result count will be kept so the week 4 summary can report how the sources were found.

Outcomes the Project Will Count

Primary outcome: point-of-care glucose readings under 70 mg/dL within two hours of a mealtime dose, per 100 mealtime doses, from point-of-care glucose records.

Balancing outcome: episodes of blood glucose above 300 mg/dL before the next scheduled meal, per 100 mealtime doses, to check that later dosing does not cause excessive high readings.

Process measure: the proportion of mealtime doses documented as given after the tray was at the bedside, using a new tray-time field in the medication administration record.

Each is chosen because it can be counted with data the unit already collects or can collect with one added field.

Feasibility at a Glance

The project is feasible within a capstone term for three reasons. First, the primary outcome uses point-of-care glucose values already recorded in the electronic record, so no new testing is needed. Second, the change involves the timing of a nursing action rather than a new drug, device or order set, which keeps the approval path short. Third, the unit's nurse manager and diabetes resource nurse have agreed to support a trial, and the pharmacy informatics team has confirmed that a tray-time field can be added to the medication record.

The main feasibility risk is tray timing itself. If trays arrive very late, nurses may be waiting with insulin in hand while other patients need them. The proposal section will need to address how nurses learn that a tray has arrived and how the medication pass is sequenced around meals.

Approval and Ethics

Because the project changes the timing of an existing ordered medication within professional guidance, it is being treated as a quality improvement project rather than research. The hospital's quality office has reviewed the brief and agreed that it does not require institutional review board approval, provided that data are reported only in aggregate and no patient is identified. The change will need approval from the nurse manager, the medical director of the unit and the pharmacy and therapeutics committee, since it alters the scheduled administration window. Individual consent to the timing change will not be sought, since it stays within the range of standard practice, but they will be told why their insulin now comes with their meal.

What the Brief Leaves Out

The brief leaves out basal insulin dose adjustment, correction-scale insulin and discharge education, which each deserve separate attention. It also leaves out the kitchen's tray delivery schedule; the project will work with tray arrival times as they are rather than try to change them. National and professional guidance on inpatient diabetes care addresses all of these topics (ElSayed et al., 2025; Umpierrez et al., 2012), but a single capstone cannot.

References

ElSayed, N. A., McCoy, R. G., Aleppo, G., Balapattabi, K., Beverly, E. A., Briggs Early, K., Bruemmer, D., Echouffo-Tcheugui, J. B., Ekhlaspour, L., Galindo, R. J., Garg, R., Khunti, K., Lal, R., Lingvay, I., Matfin, G., Pandya, N., Pekas, E. J., Pilla, S. J., Polsky, S., . . . Bannuru, R. R. (2025). 16. Diabetes care in the hospital: Standards of Care in Diabetes-2025. Diabetes Care, 48(Suppl. 1), S321-S334. https://doi.org/10.2337/dc25-S016

Garg, R., Hurwitz, S., Turchin, A., & Trivedi, A. (2013). Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care, 36(5), 1107-1110. https://doi.org/10.2337/dc12-1296

Turchin, A., Matheny, M. E., Shubina, M., Scanlon, J. V., Greenwood, B., & Pendergrass, M. L. (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32(7), 1153-1157. https://doi.org/10.2337/dc08-2127

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 97(1), 16-38. https://doi.org/10.1210/jc.2011-2098