Would you have given the meds??

Nurses General Nursing

Published

okay- here's the situation

69 yo female in because of weakness, fell at home after being at rehab for 3 weeks. normal aging issues- cad, htn, but completely aao x3-also iddm. offgoing nurse gives me report, says pt's fsbs @ 0600 was 39- she gave oj and graham crackers- rechecked the fsbs- it was 50- gave another oj. rechecked 105. pt states she was a little shaky and a bit diaphortic- but otherwise ok- that she knows it was because she took her hs insulin and didn't eat.

so she has metformin and actos ordered for 0800. i recheck her fsbs-it was 127- she's eating- so i give it but not her 70/30.

pt was fine all morning. in the mean time, i am floated to icu and get a call about 3 hrs later stating the md wants to talk to me.

i get there, he says did i plan on trying to kill his pt..because that is what would have happened. i explained what had happened- then reiterated that fact the the pt stated she had not eaten dinner. he freaked!! said he was going to my nm and i would not be taking care of any of his pts again.

so, it is not so much i think i was wrong...the problem came down to the fact that the offgoing rn did not notify him that the pts fsbs was 39 @ 0600- he said if he had know he would have given the order to hold all hypoglycemics and insulin...

what do you all think???

Specializes in Cardiac Telemetry, ED.

I think it's fair to assume that the previous nurse acted as a prudent nurse and notified the MD of the low CBG. ***HOWEVER***What I learned in my days as a floor nurse was to NEVER assume that the previous nurse notified the MD of anything. If I did not see any mention of MD notification of a critical lab value in the previous nurse's charting, then I would notify them myself. I have come onto shift at 1500 one too many times to find a K+ of 3 from 0600 that was never followed up on by the previous nurse to just assume anything. Next time, specifically ask the nurse if the MD was notified. If not, then do it, and write an incident report.

Specializes in Cardiac Telemetry, ED.

Oh, and yes, I would have given the meds. You are being thrown under the bus.

I'd have given the PO meds. The 70/30, not sure on. I so rarely give 70/30 (our population mostly gets lantus and humalog), that I'm really not sure what I would have done. Humalog works so quick and lantus is so "long" that it's a much easier decision than 70/30. Either way, you keep an eye on them so whichever way that blood sugar decides to go, you can fix it. Sounds like that was done, and monitoring is the most important part.

Blood sugars are always a rock and a hard place, and of course, whatever it does is the nurse's fault, because it couldn't possibly be that the patient's sugars are out of control for whatever reason they're in the hospital!

The MD was irritated with me and said of course I should give all meds because if the patient eats and has no insulin, the blood sugar will be critically high.

If the patient is a Type 1 diabetic, then insulin should never be held. If they're Type 2, they may have some ability to make their own insulin. Actually, in the OPs pt, if they are at a stage that they are requiring insulin, it's not likely that the PO meds are having much effect anymore.

Specializes in PICU, NICU, L&D, Public Health, Hospice.

So...you probably learned something from this experience....I know I did...specifically this - that doc is a jerk and you don't have to deal with him anymore....YAY!

You got the crappy end of this stick, were likely embarrassed in front of peers, and you deserve better. I would write this incident up and make sure that my superiors are aware of the inappropriate behavior of the MD. You, after all, are not his hand maiden, not his anger management therapist, and not his employee. Seems to me as if the entire situation would have been avoided had that doc actually addressed the anticipated glucose instability of an acutely ill, hospitalized diabetic in his orders....oh my gosh...did I actually just suggest that maybe the doc was to blame for the entire scenario???? There are arrogant and inappropriate docs in all specialties (nurses too), stay in nursing long enough and you will meet quite a number of them.

I have yet to see a diabetic labeled as Type I or Type II. I was wondering that recently about one of my patients and was unable to find the answer, even the patient didnt know and couldn't tell me when they were diagnosed. Histories only report NIDDM or IDDM which still doesnt identify the types. Still think the OP did the right thing.

I have yet to see a diabetic labeled as Type I or Type II. I was wondering that recently about one of my patients and was unable to find the answer, even the patient didnt know and couldn't tell me when they were diagnosed. Histories only report NIDDM or IDDM which still doesnt identify the types. Still think the OP did the right thing.

I usually find that my adult Type I patients know their way around the disease more than the Type II ones. They have been dealing with it for a long time, they know their A1c, and they are more concerned (in general) about keeping their blood sugar under control (especially in the hospital setting). I have found some of them to have more labile sugars--more likely to get below 60 or go over 300. I don't think I've ever had a Type I diabetic NOT know the distinction between Type I and Type II. Many people with Type II, however, don't know which type they have, are less comfortable around insulin, and typically have less understanding of the disease. This is totally my own anecdotal experience.

Type I diabetics will never get oral hypoglycemic treatment because all PO meds require that the patient have some capacity to make their own endogenous insulin, and Type I diabetes is defined as absolute insulin deficiency. I stay away from NIDDM/IDDM because I don't feel that this distinction adequately describes the difference between Type I and II. Many people with Type II diabetes will ultimately require exogenous insulin treatment, but this is a later stage of the disease and the patient typically has a very different course than a patient with Type I diabetes.

Specializes in acute rehab, med surg, LTC, peds, home c.
I think that you should have paged an MD if her glucose was down to 39 and asked what he wanted to do with the meds-- hypoglycemia can be dangerous; remember that glucose is the brain's only source of energy. However, he should have also written an order "page MD if blood glucose is less than x or hold meds if glucose less than;" you're a nurse, not a doctor. Personally, I think that he just freaked because something bad could have definitely happened if her glucose dropped too low and he would have been responsible for the incident.

The night nurse did page the MD, this nurse gave the meds at 0800. If the MD wanted to hold the meds and insulin, he should have given that order when the nurse called him at 0600. I dont see anything wrong with what she did, in fact I would have given the 70/30 as well. The pt was eating and had a BS of 127, what's the problem? That MD has issues, she did nothing wrong.

Specializes in acute rehab, med surg, LTC, peds, home c.
The night nurse did page the MD, this nurse gave the meds at 0800. If the MD wanted to hold the meds and insulin, he should have given that order when the nurse called him at 0600. I dont see anything wrong with what she did, in fact I would have given the 70/30 as well. The pt was eating and had a BS of 127, what's the problem? That MD has issues, she did nothing wrong.

Correction: After reading more of the thread, I realize that the night nurse did not page the MD, so I would have let him know about the bs of 39, but still, I would not have expected him to hold the insulin or meds with a bs of 127 and pt is eating.

Specializes in Certified Diabetes Educator.

For a FSBS of 39, I would have pushed D50. Then given her meds. You never, ever, hold meds without calling the DR and getting an order to do so.

Specializes in acute rehab, med surg, LTC, peds, home c.
You never, ever, hold meds without calling the DR and getting an order to do so./quote]

I disagree, you can use your judgement and hold meds if you deem it neccessary, then just let the MD know. We are not order following drones and as long as you have sound reasoning to back it up, you will be fine.

Specializes in Certified Diabetes Educator.
You never, ever, hold meds without calling the DR and getting an order to do so./quote]

I disagree, you can use your judgement and hold meds if you deem it neccessary, then just let the MD know. We are not order following drones and as long as you have sound reasoning to back it up, you will be fine.

At the hospital I work at with the DR's I work with, that philosophy is a good way to loose your license. Waiting 10-15 min for a call back from the physician is not being a drone.

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