Labor pt with IDDM.

  1. Hello there!


    I had my first IDDM pt in labor on Pitocin. The orginal order from the OB was LR and clear liquids only. I am still a fairly new RN to labor and I asked another "Seasoned Labor Nurse" about my pt's IV fluids and her management. The "Seasoned" RN told me that all our diabetic pt's are all clear liquids and LR, and told me not to worry about it. I did not listen to her and ended up calling our Diabetic Educator and the family doctor to get different IV fluid orders for my pt, as I was worried that she was going to bottom out. My patient became symptomatic; and had BS in the 50's, good thing I was on top of things already. I was very upset about this incident, and now I am very concerned about with Whom I am working with. This particular RN has been a Labor Nurse for 25+ years. I wanted to know your thoughts?

    Respectfully
    Deniseldrn


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  2. 15 Comments

  3. by   2banurse
    I would thank god that you were my nurse and not the other one.

    Kris
  4. by   mother/babyRN
    Me too. When in doubt always ask....We sometimes don't hang ivs with dextrose in them, which goes against what I am used to. Will always query the docs and if they don't agree, they do think about it and come back to Earth and change or explain things..
  5. by   ShandyLynnRN
    I have seen it done a few ways.... mostly just FSBS q4 hrs, and LR and clear liquids. I have also seen insulin added to D5 for IV fluids when the patient was followed by a perinatologist. I honestly don't see patients with IDDM much.
  6. by   louloubell1
    I guess I'm not understanding, but what was it that caused you concern re: LR & clear liquids. I see that you said her BS did begin to bottom out, but this isn't what I would expect from a pt with IDDM. I wouldn't be expecting to see a pt with IDDM bottoming out even if NPO with no IVF, that is unless they had still been receiving insulin.
  7. by   TeresaRN2b
    Ok, maybe I am confused, probably am since I am only a student. My son is IDDM though and I know he has never been off insulin. Even when ill and very sick and vomitting and bottoming out blood sugars. Without insulin his BS would go off the chart within a few hours. Having dealt with IDDM with him for 5 years I would have totally questioned those orders as well. Unfortunately I have seen a lot of people in the medical field including doctors not understand insulin and diabetes the way they should. I had an ER doc that told my husband not to give my son his insulin because he had low blood sugars (He also had ketones). Which I called his endo shortlly there after and he told me the complete opposite to increase his insulin. I have seen my mother in law and sister in law who are both RNs not give insulin to my son when his BS was below 80 and he was in their care. By the time I picked him up within hours his BS was above 300. I do not know enough about hospital care of IDDM or about OB nursing, but what I do know about IDDM I would have questioned that order as well and been very glad to have you as a nurse if I were the patient.
  8. by   mark_LD_RN
    it all depends ,was the patient still getting insulin or di they recieve a long acting insulin like lantis prior to labor. I would not be overly concerned over the order of lr and clears unless pt had insulin on board,but I would have done frequent cbg. just to see. you know things change with the stress of labor. I personally believe in letting patients eat to toleration
  9. by   bagladyrn
    Just wondering, was this patient on an insulin drip during labor? How often were her sugars being checked? I'm also not sure of the protocol of calling the "family doctor" to overrule the OB managing the patient - could get you in the middle of something there - careful! Did you ask the other nurse what policy they have in place for handling low sugars on these patients? You may have wanted to have the lr hanging in case you needed to fluid bolus the patient at some point in labor - wouldn't want to bolus an IDDM pt. w/a dextrose solution! It can be quite a juggling act with these patients during labor.
  10. by   mark_LD_RN
    i was wondering the same things baglady rn.
    I also don't think it was appropriate to call the family doc instead of the ob. and they must have some kinda protocol for handling IDDm patients and low blood sugars.
  11. by   DeniseLDRN
    Just wanted to clear some things up:

    1.) I called the OB FIRST and she asked me to call the Endocrinologist for IV fluid orders for the patient, called the doctor and he had never seen patient. Then I called the family practice doctor only to find out patient had not been seen for a very long time! The family practice dr. refused to care for patient, so OB ended up calling for a consult with another dr. to write IV fluid and insulin orders for the patient.

    2.) Yes, my patient had taken a long acting Insulin in the morning prior to coming in, That was why I called the OB in the first place. The other nurse told me not to worry about it, she said my patient would be fine. I called the OB and told her about my patient, and she was very concerned esp after she learned that pateint had been not seen anyone for management of her IDDM for her entire pregnancy!

    3.) There is no policy on how to manage a IDDM patient on our unit, as I looked for one. I did speak with my unit director about the incident as it was unfolding, and I asked if we had a policy for IDDM patients...I was never directed to one!

    The OB wanted a consult because they did not feel comfortable writing fluid and insulin orders for the patient. There were NO orders for checking blood sugars on this patient and LR was the only fluid ordered. I asked the patient to to check her blood sugars for me, so I would know what they were (she brought her own glucometer). Patient did end up with BS in the 50's. Pt ended up getting D5LR @125cc/hr and sliding scale Insulin orders.

    I hope that all this helps clear things up a bit!

    Respectfully
    Deniseldrn
  12. by   OBNurseShelley
    How strange a pt with IDDM was not managed during her pregnancy??? Was the OB NOT AT all concerned about the pre-natal effects?? When I had taken care of a diabetic in labor we do fingersticks every hour and have ivf's ordered according to the bs, either d5 or insulin drip or just lr, they're usually on a triple lumen so the fluids can be adjusted accordingly as well as pitocin. It amazes me that an OB doc can't even manage a pt's fluids. I guess it's a whole different world when you're used to working with perinatalogists, in a high-risk setting.
  13. by   DeniseLDRN
    OBNurseshelly:


    The OB was under the impression that the patient was seeing an Endocrinologist during her pregnancy. The patient lied to the OB about seeing the Endo and her family practice doctor, for her IDDM. The OB was shocked when they found out that the patient had not ever even seen the Endo, and had not seen her family practice dr for over a year. Our unit is considered "low" risk, but we have our fair share of high risk patients from time to time. This patient was able to do her own BS, with her own glucometer (she had brought with her) during and after delivery. There were never any orders written to check pt's bs, during labor or after delivery. That was why I was asking pt to check her bs for me, so I would know what they were.
    I was very concerned with the care of this patient, that was why I posted this thread in the first place. Thank you for posting how you handle these clients at your facility, I really apprecitate your reply. thanks!


    Respectfully
    Deniseldrn
  14. by   mark_LD_RN
    sounds like the doc needs to be more on top of his patients. the ones here would know if she was seeing an endocrinologist they would have a consultation report in chart.

    and your unit needs to have some kind of policy for dealing with IDDM patients. we do not need doctors order to check their blood sugar via finger sticcks here it is part of out protocol, we also have protocol for dealing with low sugars.

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