Did i handle this situation correctly???

Nurses General Nursing

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Im a fairly new lvn with about 6 months expierience working in ltc. Well i worked prn at a ltc facility.so wat happened is a pt had just come in yesterday evening so the am nurse asked me if i could get an order for the pts cpap machine so i called the md on call and got the order.then later on when i checked the pts bs it was at 168 and pt was scheduled 45 units of intermediate insulin and had a sliding scale apart from that which he was supp to get 3 units from his bs reading.pt asked me if he could only take 25 units of the intermediate since he was worried his bs would become low due to him have to take the 45 units and sliding scale.i told him i didnt have the power to give him the 25 units i had to follow mds orders.pt was concerned because he said he started feeling lightheaded at about 100ish bs so i told him id call the md and ask his opinion and see if hed give permisssion for the 25.well to make story short the md on call pretty much reamed me a new one.he said that he was not changing any orders that pt had to take order as is or nothing at all.he was pretty much a jerk.i understand he was upset cause i had called him about the order earlier but i feel he overreacted.did i handle the situation right or wat could i have done differently???

Specializes in LTC, Memory loss, PDN.

The fact that the doc on call had a hissy doesn't mean you did wrong. You acted in pursuit of doing what's best for the pt. and I don't see how you can go wrong with that. If this (doc going ballistic) is the worst thing that happens to you this week, you're having a great week. I promise this won't be the last time this happens. Vice versa, if this is the worst that the doc encounters, he's doing allright also.

Now, more experienced nurses would not have called the doc because there's really nothing he can do. Insulin is not something you take lightly and docs on call will usually not mess with it unless the pt is critical. Even if the pt. was a retired endocrinologist not suffering from impaired memory or judgement, the on call doesn't know this. Here's what you can do instead. Carefully look over the pt.'s glucose levels, insulin records and A1c (should all be part of hx), chances are this is not an isolated case.

Be prepared to recheck glucose level and have snack (complex carbs) available. It's better to manage this with diet than with insulin anyway. Work that pen (document) and, this may be difficult for a prn nurse, arrange for pt. education.

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the fact that the doc on call had a hissy doesn't mean you did wrong. You acted in pursuit of doing what's best for the pt. And i don't see how you can go wrong with that. If this (doc going ballistic) is the worst thing that happens to you this week, you're having a great week. I promise this won't be the last time this happens. Vice versa, if this is the worst that the doc encounters, he's doing allright also.

Now, more experienced nurses would not have called the doc because there's really nothing he can do. Insulin is not something you take lightly and docs on call will usually not mess with it unless the pt is critical. Even if the pt. Was a retired endocrinologist not suffering from impaired memory or judgement, the on call doesn't know this. Here's what you can do instead. Carefully look over the pt.'s glucose levels and insulin records, chances are this is not an isolated case.

Be prepared to recheck glucose level and have snack (complex carbs) available. It's better to manage this with diet than with insulin anyway. Work that pen (document) and, this may be difficult for a prn nurse, arrange for pt. Education.

he was a new admit...this was only his second night there.he said he adjusted his insulin at home depending on his bs's but i told him i couldnt do that i had to follow the scheduled orders.

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Specializes in LTC, Memory loss, PDN.

Yeah, a lot of admits in LTC come with sketchy or missing histories. I think you did great. The pt. is going through a very stressful change and along the way he has to give up more control. I guess being compassionate and allowing as much control as possible is what I'd go for, such as having the pt. choose the site etc. He does sound like he needs some serious education.

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I'd talk to the patient about his diabetes a bit to get a sense of his history. Then spend a moment perusing his record. If he seemed to have a good understanding of his disease and treatment (factoring in any recent issues he may have had--ie, infection, surgeries, etc), I would give him what he asked and document it. I'd let the doc know in a way that wouldn't require a call (so pass on to inform him/her the next day and facilitate a conversation between pt and provider).

If the patient asked for MORE insulin, wouldn't give it w/o an order.

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my clinical instructor always told me that it is illegal to give part of the ordered medication. You either give it all or none at all. Though, no one on the floor really practices this- ha. And, it seems kind of foolish. But, I guess where it gets tricky is when the patient wants more later- you really shouldn't give him the left overs of the last batch, but you didn't do that.

Sounds like you handled it the way I would- with precaution.

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Specializes in Med surg,.
In my experience a patient has the right to refuse any medication. The patient was refusing almost half of the ordered dose. My hospital policy states that it is allowed.

We can not hold half an insulin order from a patient at patients request. In order to do so we must first call the MD get an order, then hold it. This is just our hospital policy. There are really strick on insulin orders. The patient sounds like he needs teaching on long acting insulins. I would have educated and explained the long acting insulin reaction. I would have looked at his previous BGM's and seen if he dropped at the peak time of the insulin and then if there was a significant drop at peak time, I would have then called the dr. LIke someone else stated, have all my ducks in a row.

It just sounds like the patient needs some education.

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I would have given the patient the 25 units he requested then rechecked his blood sugar later according to the insulin you gave him. If it was still high I would explain to the patient the need for the remaining insulin. If it was low I would document the 25 units I gave the patient. A patient has every right to take only the meds they see fit. If it is still high and the pt accepts taking the remaining insulin then no harm no foul. But in the end if the patient needs the remaining insulin and still refuses the dr does need to be notified. I would be less concerned about a dr yelling at me and more concerned about being a lpn in a ltc facility. LTC facilities have very little leeway in their scope/protocol. In the hospital I would have given the 25 units, rechecked, and then wrote a dear doctor note or told him when he came in about the pt concerns. However, in the ltc's I feel you are not always given autonomy and further more I don't feel like supervisors and managers are as supportive. I worked in a LTC in Florida as an LPN and I have never seen such back biting among staff. Now I am an RN in the hospital for the past 3.5 years and the difference is night and day. Furthermore, I haven't been reamed out in a long long time, haha. And please note, while it is embarassing and hurts your feelings that you got yelled at, that dr will never remember that he even spoke to you the next time he sees you.

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Specializes in LTC, Wound Care.
he was a new admit...this was only his second night there.he said he adjusted his insulin at home depending on his bs's but i told him i couldnt do that i had to follow the scheduled orders.

You see, this is where I don't do well...becuase I have NO problem telling these patients "well, obviously the way you were doing it at home wasn't working too well, becuase you ended up here. Now let's try OUR way, and see how it goes"

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Specializes in Pediatric/Adolescent, Med-Surg.

So did the patient's blood sugar crash that night? I'm curious to hear how this played out.

I have given half doses of ordered medications, but only per pt request, and only of meds I knew the pt had orders to adjust at home. For example, I had a hospice pt that was on Neurotin for pain, but sometimes it would make him lethargic so his mother would request only half a dose (which did seem to still affect his pan). Since the mother had orders to adjust his dose at home, I had no problems doing so in the hospital. For something like Insulin though, I would be much more learly about giving a half dose without an order.

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Specializes in Home Health CM.
the doc even told if the pt wanted to handle his diabetes since he wanted to adjust his dosages.sheeshh im just afraid of doing something wrong and losing my license somehow.thats one of the parts i hate about nursing.=(

That's what makes me mad :devil: about docs sometimes.....there are a few that act like they are the only ones with critical thinking skills and that the patient (or the nurse) doesn't know didily.....most people know their own bodies better than the doc or a nurse does, in this case, the patient. He didn't feel right when his blood sugar is around 100. Although that may be on the high end of normal, that may be his baseline where he feels he can function best. It all has to be balanced and factored in.

I agree with the other PP, he does need education about intermediate acting insulins, though because they should not cause his BS to plummet. If he took all 45 units, and then had dinner, his BS should not go too low, I would think.

BTW, was he admitted for his blood sugars being out of control or for another reason?

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I'd talk to the patient about his diabetes a bit to get a sense of his history. Then spend a moment perusing his record. If he seemed to have a good understanding of his disease and treatment (factoring in any recent issues he may have had--ie, infection, surgeries, etc), I would give him what he asked and document it. I'd let the doc know in a way that wouldn't require a call (so pass on to inform him/her the next day and facilitate a conversation between pt and provider).

If the patient asked for MORE insulin, wouldn't give it w/o an order.

i'm with you, kanzi.

i tend to listen to my pts.

they know themselves and their history.

and, 45u of intermediate, sounds like a lot for bs of 168...

recognizing the insulin peaks at 8-12 hrs and lasts up to 24 hrs.

i have no idea how this pt trends, but myself, i listen to my diabetics.

no need to automatically believe drs know best.

most often, diabetics do.

i'd be very hesitant in giving the full 45, and would share my concern with the forthcoming nurses.

(i wouldn't have called dr however...would want to observe pt trending before i randomly asked for reduction)

leslie

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Specializes in Home Health CM.
i'm with you, kanzi.

i tend to listen to my pts.

they know themselves and their history.

and, 45u of intermediate, sounds like a lot for bs of 168...

recognizing the insulin peaks at 8-12 hrs and lasts up to 24 hrs.

i have no idea how this pt trends, but myself, i listen to my diabetics.

no need to automatically believe drs know best.

most often, diabetics do.

i'd be very hesitant in giving the full 45, and would share my concern with the forthcoming nurses.

(i wouldn't have called dr however...would want to observe pt trending before i randomly asked for reduction)

leslie

What do you know.....was just reading in my Med Surg Text (Lewis) and it states that "ideally, regimens should be mutually selected by the patient and the health care provider." Now can we just get the health care providers who won't listen to their patients to read and hinder that? :lol2:

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