Blood glucose protocol in LTC facilities

[rnto?]

So, the other day just as I was coming on shift one of the night turn nurses who is both an RN (as am I) and who has been a nurse longer than I've been alive was dealing with a low blood sugar on a patient. I went to the room to help her as the patient was to be mine when she left. She gave him OJ with sugar packets added but before she could get it into him he became unresponsive with a blood glucose of 24. Another RN who is in mgmt. at the facility was also involved. I was the runner person, first getting them the OJ, then glucose gel, then the mgmt. RN decided to start an IV to give an amp of D50, so I ran to get all of that stuff. His glucose came up, he was fine, but the DON was upset because no one called the MD until after the fact. (I had just walked into the situation and deferred to the two much more experienced RNs who were telling me what to get them). She said that if a person becomes hypoglycemic and unresponsive, we are not to do anything without calling the MD. If the MD doesn't answer we are to call the paramedics, but we shouldn't give glucagon or D50 without an MD order. The facility protocol says to give OJ or call the MD if the patient is unresponsive. The night turn RN says that her license would be in jeopardy if she didn't do anything and the patient died before the MD called back or the paramedics got there. I don't know what the laws are on this topic. Any ideas?

[noc4senuf]

Be Moore this is a LTC forum and we are talking of RN/LPN's that work there. I have never even asked if any of my nurses are ACLS certified as it is not called for. We do administer IV's, and fluids but, we do not monitor or treat cardiac rhythms.... at least not where I have ever known.

[Havin' A Party!, ASN, RN]

... facilities typically accept ACLS protocol that allows a certified RN to obtain IV access, administer fluids, diagnose and treat cardiac rhythms with appropriate medications WITHOUT the supervision of an MD...

Not sure this is totally correct from my experience (as an ACLS RN in an ICU). A little too general a statement for my liking.

But it's certainly not applicable in LTCs.

[Be_Moore]

Not sure this is totally correct from my experience (as an ACLS RN in an ICU). A little too general a statement for my liking.

But it's certainly not applicable in LTCs.

AHHH, LTC's. I was thinking about an LTAC..which I am now assuming that these are not. Sorry for the confusion. I will say, however, that it is pretty correct for the acute care setting. I'll use 2 examples to support my case. 1) Paramedics can do it in the back of an ambulance and they have less overall education than RN's, just more "hands-on" ACLS training. 2) At my facility (Level I Trauma / Teaching), codes are run by RN's almost entirely. The medical staff is typically a 1st year intern and 3rd year resident team, and while they are there "supervising" they aren't changing the decision making processes in terms of medications that get administered...that runs strictly per protocols and guidelines established by AHA.

But once again, I was thinking LTAC not LTC's. The whole thing makes a lot more sense now.

[Dalla]

Thank goodness for this forumn! As a new grad starting her first nursing job in a rehab unit at LTC, I am sad to say I would not know what to do in this situation. I have only done admit orders on two patients, neither which were diabetic, so I am not sure I would have known to ask for orders for an unresponsive diabetic. You can bet I will remember this thread next time I do an admit!

[CoffeeRTC, BSN, RN]

I think what needs to come out of this post is that you need to check your facility P and P for diabetic emergencies. I will be honest and tell you I forget ours.

In cases where I've been involved..If I have a full code person who is bottomed with the blood sugar and non responsive , I will be having the other nurse (only 2 of us) calling the doc (if they don't already have an order for it) while I'm getting the glucagon ready. It takes forever for the docs to get back to us (unless we have a direct # or pager since I work after hrs) so for the most part...I'm giving the first injection. I do know all of the docs I work with and for the most part, I'm very sure that they are going to give me the order. I will also be getting the DON a call too just to let her know what is happening.

[achot chavi]

"The DON is correct"

sad...but true!!!

So lets all learn from this to get standing orders for such an emergency to cover us.

As CCM stated, we all know the doctors who have our backs,... but I'd hate to rely on that to protect my license!!!

[morte, LPN, LVN]

i am going to have to go with the paramedic come back on this one "it is easier to defend a live one than a dead one"

[Havin' A Party!, ASN, RN]

... At my facility (Level I Trauma / Teaching), codes are run by RN's almost entirely. The medical staff is typically a 1st year intern and 3rd year resident team...

Agree with you on this one, BM.

Oftentimes, because MD residents are required to do training rotations in all of the facility's units, they end up spending only a few months in ICU / ED or even Telemetry. As such, seasoned unit RNs will out-trump them in experience many times over.

[evilolive, BSN, RN]

Great discussion! The lowest BS I ever saw was 37... on a G-tube resident. I couldn't give him OJ because of his dysphagia, and we didn't have anything along the lines of glucose gel. Thankfully he did have an order for Glucagon SC, but he didn't even have that in the med cart! I had to borrow from another resident just to get his sugar back up. About 30 minutes later he was up to around 140... (I think, this was months ago).

I would definitely like to see this implemented for all of our diabetics in house. Heck, our admission orders are so screwy sometimes. We admitted two more diabetics last week and just this morning I noted the order for accuchecks for them. *slaps forehead*

I work 11-7 so most of the time I rely on days/evenings to help get orders that are non-emergent.

I'm going to talk to day shift tomorrow about this and see if we can get more thorough diabetic orders. It's funny how we get sliding scales for almost everyone, but not glucagon..

[morte, LPN, LVN]

Great discussion! The lowest BS I ever saw was 37... on a G-tube resident. I couldn't give him OJ because of his dysphagia, and we didn't have anything along the lines of glucose gel. Thankfully he did have an order for Glucagon SC, but he didn't even have that in the med cart! I had to borrow from another resident just to get his sugar back up. About 30 minutes later he was up to around 140... (I think, this was months ago).

I would definitely like to see this implemented for all of our diabetics in house. Heck, our admission orders are so screwy sometimes. We admitted two more diabetics last week and just this morning I noted the order for accuchecks for them. *slaps forehead*

I work 11-7 so most of the time I rely on days/evenings to help get orders that are non-emergent.

I'm going to talk to day shift tomorrow about this and see if we can get more thorough diabetic orders. It's funny how we get sliding scales for almost everyone, but not glucagon..

i must be missing something, why couldnt you give OJ?

[CapeCodMermaid, RN]

Couldn't you just pour the OJ in the Gtube?

[mondkmondk]

I remember back when I was an LPN and a night shift nurse, one of my patients bottomed out on me with a sugar in the 30's and I gave him OJ with sugar. Checked him a few min. later and his sugar went up to the 60's. Called the MD to report it and was royally chewed up one side and down the other for giving OJ with sugar. The MD yelled at me and told me he should've been called prior to me giving anything including straight OJ without sugar. Boy, I never did that again. I mean, for that particular doc's patients. Our facility medical director had issued standing orders for his patients in our facility which was about 90% of the facility back then, bless him.

Blessings, M.