Would you have given the meds??

wow. Does your particular nurse practice act protect you then?

Wow. BS of 65 seems kind of high. My last FBS was 66 (at my yearly physical). Granted, since I'm not a diabetic, this is a glucose level that I can tolerate, and am probably used to. But technically BS > 70 is normal, and for alert persons a little under that, a quick carb will do the trick.

Is D50 as fun as a cookie?

(yes, being silly. not mocking a protocol--I understand that many people can't tolerate BS this low.)

I have been struck while reading this thread by the confusion about diabetes classification. To clarify:

A person with type 1 or insulin-dependent diabetes does not make insulin. Their BGL is more prone to fluctuation when they are sick or have changes in routine (like fasting, changes in diet and exercise), and they are at risk or DKA if insulin is insufficient; you should almost never withhold insulin from someone with T1/IDDM - if they are fasting or have a hypo they need a reduced dose of insulin and closer than usual monitoring +/- an IV dexrose infusion.

A person with type 2 or non-insulin-dependent diabetesmay be managed by diet alone, with oral ypoglycemic meds, or with a combination of OHGAs and insulin (treatment with insulin alone is rare). Though they may be brittle, people with T2/NIDDM tend to have more stable BGLs. They are not at risk of DKA but may develop a non-ketotic version of hyperglycemia (HHS) if they have untreated hyperglycemia for a prolonged period of time.

On my unit we only give 50% dextrose to hypoglycemic patients who are unable to safely swallow, both because 50% is harsh on peripheral veins and because the quick upswing in BGL is more likely to need further intervention than the gentler increase of oral intervention.

As an endo CNS I would have given the prescribed medications. I would also have spoken with the patient about why she skipped dinner and explained why this was dangerous; asked her to let nursing staff know if she did this again, so we could monitor her more closely; documented this in her notes; and asked whoever I was working with to check her BGL more often than usual if I was unable to do so myself.

I would have mentioned it to the doctor if I saw him, but as the hypo occurred overnight and has now resolved, following intervention as dictated in the policy, I would not page him about it - he can look at the chart. Had he rung me I would have told him that if he wants me to do something other than the protocol when caring for his patients he can indicate a treatment plan in the notes or talk to the unit about changing the policy.

Thanks Talaxandra! Your post is great!


I think the confusion lies with the classification of diabetes. Type 1 diabetes usually has an autoimmune etiology where beta cells are destroyed leading to total insulin deficiency. Type 1 diabetes ALWAYS equals IDDM. Type 2 diabetes is a disease of progressive insulin resistance related to genetics and lifestyle. Type 2 MAY lead to a dependent insulin requirement, but the course of the disease is very different, and the consequences of missing a dose aren't usually as severe. Type 2 diabetics may also present with DKA in some situations. Type 2 DM USUALLY equals NIDDM, but MAY progress to insulin dependency. This dependency also manifests with less labile blood sugars than Type 1 diabetics. And it takes much longer to get to that point. (Type 1 develops over a very short, symptomatic course) Basically, once the PO meds stop benefitting the type 2 diabetic (or the pt can't tolerate them for other reasons), they may switch over to all-insulin.

I've posted a few links. The first talks about different classifications of diabetes. It was written in 1998, and I'm sure many things are different now, though I believe the major classification remains the same--that is, Type 1 is preferable to IDDM. The other article presents case studies of type 2 patients who presented to the hospital in DKA.

http://www.aafp.org/afp/981015ap/mayfield.html

http://clinical.diabetesjournals.org.../22/4/198.full

If the OP is still around--you say in your initial post that the patient had "IDDM". Do you know if the patient had type 1 or type 2 diabetes? If it was type 1, then the insulin should have been given, and the doctor seriously needs to read a book (especially because his pt is on oral hypoglycemics).

"Originally Posted by tewdles

Not every nurse has the luxury of a 10-15 min call back time for docs.

wow. Does your particular nurse practice act protect you then? "

Not saying that you practice medicine if the doc does not call you back in 10-15 minutes...just saying that routinely receiving return calls from MDs within 10-15 minutes is a luxury that many nurses do not have. Nurse Practice act sure does protect you then...even if you wait an hour...call someone else, wait 30 minutes...all covered...but that was not what you were assuming...right?

Question: What if the patient hadn't eaten? Would the PO meds and the insulin be held?

The BS was 127... not 27.

I can understand MD being miffed at not being notified for a BS of 39 (and no, I wouldn't have given anything PO for that - stat IV D50!) ... but I see no reason for you to hold the AM meds, particularly if pt. was eating!

cheers,

If patient is alert, I'm going the PO route. If they're not alert, I'm going the IV/subQ route. (As long as I'm not violating hospital policy doing so.)

Would have made sure the MD had been notified about the 39 BS-most MDs would want to be notified.

I would've given all the meds if her blood sugar was normal, meaning 80+. If I knew she wasn't eating, I might hold something, but you say she is aaox3 and able to follow simple commands, I'd have given her all her meds including any scheduled insulin and left her with plenty of access to snacks and instruction to eat.
I fail to see how another nurse not calling (IF that was protocol) is cause for this MD to act like that towards you. Perhaps she should've called, personally I probably wouldn't have unless I was calling regarding another issue. You just can't win with some MDs. Either they get mad at you calling for every little thing or they get mad when you don't call about every little thing.