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?

[CapeCodMermaid, RN]

Technically, unless you have a standing order to start an IV and give meds, you have committed assault.

We all know docs who don't call back. We all know docs who have our backs and would give an order after the fact. But the DON is correct. You can't give meds without an order even in an emergency. That nurse, I think, has it backwards. She couldn't be faulted for doing something she had no order for, but she certainly could be taken to task for starting an IV and giving meds without an order.

[Be_Moore]

Welcome to the morally gray areas of nursing! You have the knowledge of what to do. You have the expertise. You have the skills required. But you can't do it because you don't have an order, and the patients life is on the line. TECHNICALLY: The DON is right. The nurse wasn't nursing, she was practicing medicine by prescribing D50W.

MORALLY: The DON is wrong. There are 3 possibilities. 1) The patient gets fixed right now with D50W that hasn't been ordered. 2) The patient gets D50W late and they live, but have brain damage from being hypoglycemic while waiting on an MD to give the order. 3) The patient dies. Only one of the above choices is acceptable..you know it, I know it, and if the DON had been the primary care nurse you bet your A** she woulda pushed an amp of D50W and then told the doctor after the fact.

There is one simple solution: Any patient receiving insulin should have standing orders for Orange Juice, Glucose gel, and D50W. Period.

[Midwest4me]

In my experience in LTC the diabetics usually had standing orders covering sliding scale, glucagon, etc, How odd that the patient had no such standing orders. I agree with CapeCodMermaid. That RN comitted assault AND worked outside her scope of practice.

[rnto?]

What's frustrating is that the protocol says, "call MD" and the DON is perfectly fine keeping it that way. NONE of our patients have standing orders for glucagon, etc. So I am sure this situation is going to happen again. At least I've learned that from now on when I take admission orders or new insulin orders, I'll get the doc to order something for hypoglycemia.

[noc4senuf]

We have standing orders for the glucagon. I can't believe a nurse started an IV w/o orders.

[CapeCodMermaid, RN]

I was involved in a code blue at one facility. The nurse I was with started an IV without an order. She was used to working in the ER. Our DON freaked out. The doctor looked at her later and said, "What did you want her to do ?? Wait till I called back? The guy might have been dead!" He wrote an order to cover everything we did and the guy was fine. BUT, if the doc hadn't been so understanding, that nurse could have lost her license even if the outcome was positive.

When I call for orders, I try to cover everything I can think of...especially on diabetics.

[oramar]

The problem here is that there is no standing orders, no protocol. I have never worked at a place that didn't have them. It is awful to put the nurse in that situation and is the fault of the facility for not having them.

[nursekara78]

I agree with oramar. it is ashame that you facility does not have a better P&P. You could ask your medical director. Maybe he can discuss this with the DON or the MD's to routinely include specifics in their admit. orders. we have in our P&P to give glucagon if unresponsive and we give glucose gel if responsive. If your DON and medical director are not receptive to updating you P&P to include Tx if unresponsive, get your own orders for all of your DM res. Like Cape Cod Mermaid said, try to think ahead. It'll always make it easier when you don't have the time to call.

[Havin' A Party!, ASN, RN]

... can't believe a nurse started an IV w/o orders.

Agree... that seems out there.

[Havin' A Party!, ASN, RN]

The problem here is that there is no standing orders, no protocol...

That needs to be fixed pronto.

[Be_Moore]

I was involved in a code blue at one facility. The nurse I was with started an IV without an order. She was used to working in the ER. Our DON freaked out.

Seriously? Really? My argument to that is that if said nurse worked in the ER, she was probably ACLS certified...and if you have your ACLS, you don't NEED a doctor to even be present at the code. Most facilities will have stipulations that RN's can't intubate (even though it is within our scope of practice) because there are MD's who can do it. But these same 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. So I'm going to say that said nurse likely had her ACLS and if your facility doesn't recognize ACLS algorithms and protocols...