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Would you have given the meds??



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Oct 07, 2009 04:19 PM

Would you have given the meds??


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???

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51 Comments
No. 1
from canoehead
Old Oct 07, 2009, 04:28 PM

Default Re: Would you have given the meds??
I would have made sure she ate her breakfast, and then given all of the meds.
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No. 2
from hypocaffeinemia
Old Oct 07, 2009, 04:30 PM

Default Re: Would you have given the meds??
Originally Posted by LaurelethRN Sulfate View Post

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???
I think that the MD in question is being a bit irrational by wanting to hold all hyperglycemics and insulin. Hypoglycemia is easily fixed, but severe hyperglycemia is a catch-up game and with the added stress of hospitalization he'd be setting the patient up for the inevitable ICU transfer for an insulin drip all the while increasing her risk of infection.

A more reasonable and stable-minded MD would have merely put the patient on a sliding scale regular insulin protocol and then tweaked from there. Especially with the knowledge the patient is eating now.

Either that or ordered more frequent FSBGs. Which nursing should consider doing anyways regardless of how it was ordered.

Regardless of how to best medically manage it, the physician clearly has anger management issues based on how you describe his reaction.
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No. 3
from cherick22
Old Oct 07, 2009, 04:30 PM

Default Re: Would you have given the meds??
It all depends on your facilities protocols. We have list of steps to follow which includes giving snacks twice then notify the MD if the bs was still less than 70. If protocol was followed and this MD still has an issue with this then he needs to indicate that when he's writing his orders.
If the patients bs was 127 when you left what was he so mad about? Did it go lower? Did she eat breakfast?
Sounds like MD on a power trip
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No. 4
from cardiacmadeline
Old Oct 07, 2009, 04:47 PM

Default Re: Would you have given the meds??
I would have given the meds. If I was unsure of the insulin dose, I would call the MD. I never hold scheduled insulin without an MD order. The physician sounds like he was out of line. Guess he doesn't understand the consequences of holding hyperglycemics and insulin.
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No. 5
from classicdame
Old Oct 07, 2009, 04:51 PM

Default Re: Would you have given the meds??
REGULAR insulin sliding scale is NOT the best choice for hospitalized patients. There is a lot of literature out there stating otherwise. In fact, the RABBIT Trial study states there is no supporting documentation to state that Regular SSI has EVER been effective in an acute care situation. Sounds like lots of education needed all around.

ALSO, I think MD acted a little foolishly. So what if you never tend to his patients - one less AH to worry about
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No. 6
from nursejoy1
Old Oct 07, 2009, 05:03 PM

Default Re: Would you have given the meds??
Our Medical director has stated that we may NOT hold insulin if blood glucose is 80 or greater. A few times that nurses have held it (correctly in my opinion) he really had a fit.
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No. 7
from hypocaffeinemia
Old Oct 07, 2009, 05:06 PM

Default Re: Would you have given the meds??
Originally Posted by classicdame View Post
REGULAR insulin sliding scale is NOT the best choice for hospitalized patients. There is a lot of literature out there stating otherwise. In fact, the RABBIT Trial study states there is no supporting documentation to state that Regular SSI has EVER been effective in an acute care situation. Sounds like lots of education needed all around.

ALSO, I think MD acted a little foolishly. So what if you never tend to his patients - one less AH to worry about
There's a ton of literature available about tight glycemic management in the ICU (my area). Short of placing everybody on an insulin drip protocol with Q1h checks, there are so many variables constantly changing that basal insulin requires constant readjustment and the patients still require sliding scale novolog or regular on top of it. Maybe in teaching hospitals where there are constant residents to tweak the exact combination as needed 24 hours a day they can avoid sliding scales. Not at most hospitals, though. Patients here are so labile and with so many variables I'm sure each and every one would benefit from an endocrinology consult.
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No. 8
from silas2642
Old Oct 07, 2009, 05:07 PM

Default Re: Would you have given the meds??
Originally Posted by LaurelethRN Sulfate View Post
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???
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.
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No. 9
from mamamerlee
Old Oct 07, 2009, 05:14 PM

Default Re: Would you have given the meds??
The nurse discovering the low sugar was responsible for notifying the MD. If the pt's sugar was 127 at breakfast, she should have rec'd all of her meds unless you had an order otherwise.
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