Conflict with preceptor over re-checking blood glucose

[sweetmama81]

I have started at a new facility. I am not a new nurse, just new to the facility. A patient had a very high blood sugar. I had never seen the BS this high for the patient. I rechecked it to make sure it was not a false high, but it went higher (not by much though) so I went with the higher number. This also required me to call the MD/notify charge nurse. When I told my preceptor what happened, she told me that I shouldn't have checked it again and should have went with the first number. I explained my rationale (that it could have been a false high and I would have been covering with an inaccurate number) and she told me that she had never done this before. She didn't think it made sense. I asked for the policy and she said "just forget the policy for now, what is your nursing rationale?" She said go with the MD order. I have always thought that a facility would have a policy on what to do with abnormal blood glucose, not just hypoglycemia. I was even given a funny look for giving apple juice instead of orange juice (due to severe CRI) when a BS was low. What do you think? What is the policy at your facility? what is best evidence based practice? Appreciate any response.

[loriangel14, RN]

I would go with the facility policy.I would have done what you did and rechecked it.

[ClearBlueOctoberSky]

I don't think we a have a written policy, but I have rechecked my high's, especially when it means I need to notify the MD. I think it just makes sense.

As for the OJ vs Apple Juice, we do have a standard hypoglycemia policy that starts with us giving just 15 grams of sugar. How it's delivered (juice, soda, oral glucose, milk or medpass) depends on us. So if you have that severe CRI, or someone that won't drink one of the choices, you have other options.

[amoLucia]

I have a motto - "when in doubt, err on the safe side'. Sounds to me you were in doubt; you rechecked your reading to be careful/safe.

Sounds like you did fine to me!

[mammac5]

I work inpatient diabetes exclusively. If an RN called me with a very high (especially if unexpected) CBG on one of my patients, the first thing I would do is asked whether he/she rechecked it. Same with unexpected lows. That is using good critical thinking and (in my opinion) separates task-oriented nurses from those nurses who are actually thinking.

When I'm on call, I want SBAR from any RN who calls me with blood sugar issues:

SITUATION: Your pt's pre-lunch blood sugar reading was 325 when we checked it just now. I rechecked it and it was 320.

BACKGROUND: His pre-breakfast CBG today was 180 and he was given the #units of Novolog that was ordered for meal as well as 3 units of correction that was ordered to cover the 180. He ate 100% of his breakfast.

ASSESSMENT: Other vital signs are WNL and he's feeling fine.

RECOMMENDATION: Please review the insulin orders since it seems he needs higher doses.

OR

SITUATION: Patient so-and-so has a pre-supper blood sugar of 49. I rechecked it and it was 47. I've treated this accoding to the hypoglycemia order set with 4 oz of apple juice and will recheck the CBG in about 15 mins.

BACKGROUND: You probably remember he was admitted with very high glucose into the 400s. He rec'd his basal insulin as ordered last night and has gotten meal + correction insulins today with breakfast and lunch. He's had some nausea but no vomiting, slept most of the day and ate

ASSESSMENT: He was diaphoretic at the time his CBG was checked but was able to answer questions clearly. All other vital signs WNL. Seems his hyperglycemia has responded well to insulin but now his appetite is down and he doesn't require as much insulin as he did at first.

RECOMMENDATION: Would like to hold the supper dose of insulin and ask you to review orders for future doses.

That's what I want, as a NP. What I don't want is someone calling and saying, "Mrs. XXX's blood sugar was 60 just now. What do you want me to do about it?"

[classicdame, MSN, EdD]

We have a policy and it clearly states to do what you did. If you suspect the reading is not accurate (low or high), recheck. If it is 450 we do a venous draw. We treat per protocol and call MD if out of range.

If you are giving someone BP meds once a day and checking BP every 4 hours, what will you do if the BP is out of range/ Tell the patient you cannot have meds till tomorrow? NO. These are both the same types of issues. This is why a licensed person is taking care of the patient. I think your preceptor was lazy and did not consider the fact that the patient may need attention. But you did!!!

[Sun0408, ASN, RN]

I would have done the same as you, depending on how high the BS was; I may have to send a sample to the lab per policy.. As for the apple juice vs OJ, several nurses I have come across are not aware pts with Renal issues should not have OJ.. We I was a new nurse, I worked on a renal floor, we didn't even stock it for that pt population.

[JenTheSchoolRN, BSN, RN]

I always recheck a high or low BS. I don't work acute care, I'm a school nurse with diabetic students, but if one of them suddenly pops up with a number that isn't within their norm at that time of day, I recheck.

As for apple vs. orange...I actually have apple and orange juice on hand; 4 oz of either has the recommended 15 grams of carbs. But I tend to go for the apple first, mainly because I have so many students with citrus allergies and well, they just plain LIKE apple juice better than orange juice.

[CDEWannaBe]

Best policy if blood sugar seems abnormal is to clean the skin where blood sample is being taken from and retest.

[Rose2013]

I always retest with an unusually abnormal value

[liketheairport]

I'm not a nurse, yet, but I figure what could it hurt to test again? I've been diabetic for quite a long time and I think I even learned this in diabetes education: if my blood sugar is abnormally high or low, I always re-check it.

[delphine22]

I recheck, and on the other hand.

All hospital juices are formulated to each have 15g carbs in 120 mls/4 oz. In real life, grape juice is the sugariest of fruit juices (more than orange) but as long as you've got your 15g in, it doesn't matter what you use, of course except for the renals. Last place I worked, where I would write "FS AC/HS" on the diet part of the pt whiteboard, I would make sure to write "No orange juice!" if they were renal, because the techs will just run and grab juice if someone is low (calling me at the same time) and I want them to know.