Opinion re: managing low blood sugar?

  1. With all the knowledge and experience out here, I'd like you folks' opinion regarding the following scenario:

    I was day charge over this past weekend on my floor (Med/Surg-Tele). In taking report from night charge, I learned Saturday that one pt had an 0600 blood sugar of 48 and was given OJ w/sugar. I became a bit upset (this happens all the time) because 1.) our hospital has a standing protocol for all blood sugars below 70: give an amp of D50 and call the doc.; 2.) breakfast doesn't hit the floor until 0800 unless called for earlier, and it rarely is even in these cases; 3.) I've seen pts drop from 60's to 20's in 1/2 hour even with OJ and food, and you can't tell if this pt is one of those. Anyway, night charge basically brushed it off with "pt states she's always this low in the am," and "the OJ worked." (Pt was 68 one hour later.)

    On Sunday, same pt was 42, and the same scenario occurred. Night charge and I got into a debate regarding blood sugar management, my opinion being I'd rather push the D50 and spend the rest of the day bringing her down, hers being that D50 was "overkill." (For the record, insulin was being adjusted incrementally.)

    I was off Monday, but upon returning to work Wednesday I learned that Monday 0600 pt blood sugar was 36 & OJ was given (AGAIN) because she "was alert and talking." Within 1/2 hour, pt was unresponsive and CODED with a blood sugar of 22!!! Luckily, pt was brought around and as of Friday was still in ICU. Same night charge was on.

    I'm angry because I believe we could have avoided putting this poor woman through this life-threatening situation, and I feel vindicated in my opinion because of what happened, but I suppose this could have been an isolated case....what do you think?
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  2. 42 Comments

  3. by   New CCU RN
    Well, it seems to me that there is just more than one issue going on here with this patient.

    First of all, I do agree with you about the D50. It is pretty much standard procedure were I work. It works much faster and is pretty much a solid fix. You can check 20 min later and know they are up.

    I will not comment on that nurse's decisions. And I don't think she is to blame for the patient coding. Perhaps there was some underlying issue going on with the patient. Did the patient stop breathing spontaneously? Just wondering the details of the code.

    One thing I am wondering is why that patient's insulin seems to have not been changed by the docs. Where they on any NPH or some combo in addition to SS? Sounds like the nightly dose was too high and it needed to be adjusted.

    Anyhow, I hope the patient makes it through this...very sad news.
  4. by   renerian
    NO offense but I have hypoglycemia and I would want the OJ and not the D50.

    Don't shoot the messenger.

    renerian
  5. by   Rapheal
    I was taught in nursing school that adding sugar to OJ can cause rebound hypoglycemia. Do not have enough experience to know(just starting work as an RN next week). But we were told not to add the sugar to OJ and to follow the OJ with a protein snack. Hope your patient does well. Sounds like a harrowing day.
  6. by   litepath
    I'm angry because I believe we could have avoided putting this poor woman through this life-threatening situation, and I feel vindicated in my opinion because of what happened, but I suppose this could have been an isolated case....what do you think

    ~~I can't wait to hear/read the replys to this thread. The not-so-obvious pathos are interesting, but what i wonder about is the protocol and what about it not being followed? Can that protocol be resonably not followed in light of the situation? Seems lke you would have to follow the protocol unless MD wrote specific orders not to??
    ~~thanks

    ps: this is one of the main resons I visit this board; to help differentiate the abstract from the concrete, Before i begin practicing.
  7. by   CraftyLPN
    In our LTCF if we had res go below 50 ..we would give the glucotose (sp) and follow up w/ high protien/ carb snack
  8. by   LilgirlRN
    I blame the doc here for not changing the dose of whatever she is taking for her diabetes. If you have a standing protocol, it should be followed.
  9. by   baseline
    This is an issue our diabetes case managers battle on a daily basis. I keep urging them to join this board as I think their input would be wonderful! From my perspective, if there is a protocol in place, if this chart goes to court, I hope the nurse has a good answer to the lawyer for why she did not follow it. The answer "I think oj and sugar works better" is NOT in her favor. Adding sugar in the first place went out a long time ago. We use apple juice, and please don't forget the protein and complex carbs.

    If nurses have a poor understanding of diabetes, physicians are much worse in my experience. Old protocols and habits die hard, and in todays nursing world it is so hard to stay on top of everything.

    Do you have diabetes specialists at your hospital? Sounds like they should have been involved in this from the beginning. Educating the physician AND the nurse in question.

    I just don't have enough information to ramble on any further. I will suggest the ADA site is quite helpful.
  10. by   Nurse Pepper
    If protocol wasn't followed the night nurse should have gotten a specific order from the physician. Nursing judgement is one thing but the fact that the protocol was ignored is what would concern me especially since you follow that nurse. What else may have been disregarded during that shift that you were not made aware of?
  11. by   Tweety
    I think the point is that they aren't following hospital policy.

    That said, our hospital protocol is to start with juice for a rapid rise in glucose out of the danger level, followed by a more slower released snack like skim milk and peanut butter and crackers. But we don't intervene until they fall below 60. Not having the protocols near me, I can't say exactly what we do, but I'm sure this is it.

    If the patient is still alert and not overly symptomatic I go with the juice.

    We can't push D50 without an MD order anyway, so if they can swallow, I don't waste time. I still call the MD of course.
  12. by   baseline
    I am so happy to hear that so many of you are following the juice with the complex carb and protein snack!!! Yippee Ki Yay!!!!
  13. by   Nurse2BinNC
    One thing I am wondering is why that patient's insulin seems to have not been changed by the docs. Where they on any NPH or some combo in addition to SS? Sounds like the nightly dose was too high and it needed to be adjusted.
    This is my first concern, is why the insulin was not adjusted for a pt who has reoccuring hypoglycemia. I am a nursing student in my final semester so I don't have alot of nursing experience on this subject, but as the mother of a 12 yo with type 1 diabetes since age 9, If her blood sugar is continually running low in the mornings, I lower her night time insulin and for the next couple of days get up in the middle of the night to check her blood to make sure that I am having the appropriate effect without allowing it to get too high.


    Our first action when her blood becomes too low is to give her juice and a high protien/complex carb snack like peanut butter and graham crackers.... But if Hospital protocol is to administer D50 then protocol should be followed at all cost.
  14. by   baseline
    Originally posted by AHarri66
    [B (For the record, insulin was being adjusted incrementally.)
    [/B]
    Sounds to me like they were working on the insulin dose, but we don't have enough info. Bottom line. Protocol was not followed.

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