NR 560 Week 5 Proposal Draft Section Example

Proposal Draft Section: The Nurse Holds Mealtime Insulin Until the Tray Reaches the Patient and Eating Starts, With the Sequence, What Stops Being Done and How Poor Intake Is Handled

Student Name

College of Nursing, Chamberlain University

NR 560: Professional Nursing Capstone

Instructor Name

Month Day, Year

Proposal Draft Section: The Nurse Holds Mealtime Insulin Until the Tray Reaches the Patient and Eating Starts, With the Sequence, What Stops Being Done and How Poor Intake Is Handled

The Change, in One Action

The registered nurse gives each scheduled dose of rapid-acting mealtime insulin at the patient's side after the tray has been delivered and the first bites taken, and never before the scheduled window opens.

Why This Action

The appraised evidence shows that hypoglycemia on general wards is common and harmful, that guidance advises fitting the mealtime dose to what the patient eats, and that a systems approach targeting common causes of insulin-related hypoglycemia has reduced it without increasing severe high glucose (Maynard et al., 2015; Umpierrez et al., 2012). On our unit, 21 of 38 hypoglycemia episodes over three months followed a mealtime dose given before the tray arrived or to a patient who ate little. Linking the dose to the tray addresses that specific cause with a change in nursing timing, which the unit controls.

The Sequence

1. Before the meal. The nurse checks point-of-care glucose within the hour before the meal, as now, and reviews the mealtime insulin order and the patient's recent intake.

2. Tray arrival. When the cart arrives, the technician delivering trays calls out on the unit's phone system, "Breakfast trays on the unit," and places each tray at the bedside. For patients on mealtime insulin, the technician tells the assigned nurse directly that the tray is in the room.

3. First bites. The nurse goes to the room with the insulin dose, confirms the patient is willing to eat, sees that eating has begun and then gives the dose. Rapid-acting insulin given at the start of a meal still acts in time to cover the meal.

4. Documentation. The nurse records the time the tray reached the bedside in a new field in the medication administration record, then documents the dose.

5. After the meal. The technician records the percentage of the meal eaten, as now.

What Stops Being Done

Two current practices stop. First, the nurse no longer gives mealtime insulin as part of the general medication pass at 07:30, 11:30 or 17:00 before the tray arrives. Mealtime insulin is removed from the timed pass and becomes a separate, tray-linked task. Second, the medication record's late-dose warning for mealtime insulin is moved from 30 minutes after the scheduled time to 30 minutes after the end of the tray delivery window, so that waiting for the tray does not generate a warning that pushes nurses to give the dose early. A change that only adds a task, without removing another, is a change nobody has room for.

When the Patient Eats Poorly or Not at All

The change also needs a rule for poor intake, since that caused several of the unit's episodes. If the patient declines the meal or is too nauseated to eat, the nurse holds the mealtime dose and notifies the provider if glucose is above the ordered threshold. If the patient is unsure how much they will eat, the nurse waits until partway through the meal and then gives the dose; guidance allows mealtime insulin to be given shortly after a meal when intake is uncertain (Umpierrez et al., 2012). If the patient leaves the unit for a test before the tray arrives, the dose is held until the patient returns and eats. Any provider order for dose adjustment by intake, such as giving half the dose when less than half the meal is eaten, will be followed where written; the proposal will ask the hospitalist group to adopt such an order as standard.

Who Else Changes

The technician who delivers trays takes on one added step: telling the nurse when a tray reaches a patient on mealtime insulin. The nurse manager has agreed to add this to the technician task list. The dietary department is asked only to continue delivering trays as now, but to notify the unit if a cart will be more than 30 minutes late, so that nurses can plan. No change is asked of physicians beyond reviewing the intake-based dose order.

Education Plan

Nurses and technicians will learn the change in two weeks of short huddles at the start of day and evening shifts, led by the diabetes resource nurse. Each huddle covers the reason for the change using the unit's own count of lows, the new sequence, the rule for poor intake and the new tray-time field, and closes with a short practice at a workstation in the test environment. A laminated card at each medication cart will show the sequence in five lines. Night-shift nurses, who give few mealtime doses, will receive the card and a brief message from the manager. Education will not begin until the record changes are live, so that staff learn the process they will actually use.

How Patients Will Be Told

Patients used to receiving insulin before breakfast may notice the change and worry that a dose is late. Nurses will explain at the first affected meal that the insulin now comes with the food so that it works on the meal it is meant to cover, and that this lowers the chance of a low reading afterward. The explanation will be added to the unit's diabetes teaching sheet, which already covers recognizing low glucose, so patients hear one consistent message.

What the Section Does Not Propose

The section does not propose changing basal insulin, correction scales or the kitchen's schedule. It does not propose new equipment. It does not require nurses to stay in the room for the whole meal. It proposes one change in timing, supported by a communication step and a documentation field, and a rule for poor intake. National standards expect hospitals to have protocols that prevent hypoglycemia (ElSayed et al., 2025); this section describes one element of such a protocol that a single unit can adopt.

Risks the Next Section Must Address

The main risk is that waiting for trays will delay nurses during a busy morning, particularly if several patients' trays arrive at once. A second risk is that some doses will be forgotten once they are removed from the timed pass. A third is that high glucose before the next meal may rise if doses are delayed too long. The feasibility and stakeholder analysis will examine how these risks can be managed and who must agree.

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

Maynard, G., Kulasa, K., Ramos, P., Childers, D., Clay, B., Sebasky, M., Fink, E., Field, A., Renvall, M., Juang, P. S., Choe, C., Pearson, D., Serences, B., & Lohnes, S. (2015). Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocrine Practice, 21(4), 355-367. https://doi.org/10.4158/EP14367.OR

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