I had a pt, who I had taken care of for a few days and was familiar with, that had a low blood sugar when I was coming onto my shift. His reading was 63 and he has a habit of getting low but being asymptomatic. Apparently, the day shift nurse had the same level of concern (not hugely worried) that I had. She was pretty much monitoring and supplementing with snacks.
This pt was on isolation precautions and had several issues that I was on the phone with the doctor and lab about. We needed blood cultures and to start a new abx. I had to wait for lab to come to get the culture before I could begin the new antibiotic. The order was to get one from his portacath and one peripheral and if unable to obtain form the portacath (which I knew would happen as his pc didn't return) then two peripherals.
So, I was trying to group his care d/t his being on isolation. After all was said and done, I ended up getting the new antibiotic going (late because lab was dragging their feet) and after it was running I discovered his blood sugar was 46. Now, by this time, I had been in his room for about 30 minutes and still had things to do (drsg changes,etc). I knew good and well that the protocol was to give d50 by IV but he was completely asymptomatic. I decided to give him juice and crackers, let him eat that while I was doing the other stuff and recheck the blood sugar and if it was still low go for the d50.
My rational for this was:
1. He was asymptomatic and the juice and crackers may do just fine. I'd be in the room with him monitoring him the whole time.
2. Why stop the abx, even if just for a brief time unless absolutely necessary PLUS unhooking the abx and opening up that central line= more opportunity for infection.
3. This one is sort of selfish: I could call out and have someone bring me the snacks which frees me from having to ungown and regown.
4. He has a history of getting pretty low but comes right back up.
Well, he did just fine with the juice and crackers. His blood sugar was near 80 within fifteen minutes. I felt like I made a decent choice based on good rationales. However, when giving report to the oncoming nurse, the nurse flipped out. They were incredibly concerned that I did not follow protocol. Now I'm second guessing my decision.
I'm a new nurse with just at a year under my belt. I'm open to any tips, criticisms, etc. I really just want to learn and do what is right and in the best interest of my pts.
What do you think? Was I totally out of line? Should I have just followed the protocol?
As has been said ... don't beat yourself up. However, the underlying assumption that "I will always make good decisions as a new nurse" is probably not realistic.
Be careful, too, about changing "priorities" because the patient is in isolation. Is the gowning/regowning a pain? Yep, it sure is. But it's not a reason or excuse to deviate from what would otherwise be the standard of care.
Our policy is to never give D50 unless the patient unable to take PO (is unresponsive/decreased LOC). D5, D10, and/or juice is always the first preference. D50 is basically caustic sludge, if something else will work it should be used instead. Also remember that all glucometers are allowed a 30 mg/dl +/- margin of error and many haven't shown to be more accurate than that, so it's possible your BG of 46 may not have been 46. Always use the number in combination with your assessment of the patient, which it sounds like you did, good job.
As has been said ... don't beat yourself up. However, the underlying assumption that "I will always make good decisions as a new nurse" is probably not realistic.
Be careful, too, about changing "priorities" because the patient is in isolation. Is the gowning/regowning a pain? Yep, it sure is. But it's not a reason or excuse to deviate from what would otherwise be the standard of care.
Giving D50 for a BG of 46 is policy at some places but it doesn't rise to the level of Standard of Care. Claiming you did something because it's the Standard of Care is pretty bulletproof, policies don't provide anywhere near the same level of protection.
Giving D50 for a BG of 46 is policy at some places but it doesn't rise to the level of Standard of Care. Claiming you did something because it's the Standard of Care is pretty bulletproof, policies don't provide anywhere near the same level of protection.
My point was the OP's repeated references to including the patient's isolation status as part of his decision making. And I'm cautioning against that.
I'm shocked that your policy doesn't state that of the pt can take po to give juice first. I've never seen a policy where you give D50 as a first resort. It's not cost effective or the best practice! Maybe you can suggest a policy change to your manager or something! You made the right choice! Great nursing instinct!
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I feel like I made a bad choice now. It bugs me that I felt confident in my decision until it was challenged.
NO......the patient was fine.....now you have learned some other things to take into consideration the next time you are called upon to critically think about this situation or one similar...it all a learning curve. ((HUGS))
I usually only do D50 if I assess that the patient is unable to eat safely. If IV access is even slightly questionable glucagon IM is always available to us.
I generally start with juice, then milk or ice cream or PB and crackers.
I think our policy states below 70 AND symptomatic...
PO is always first on our protocol if the pt is awake, alert and able to swallow. D50 only last so long, food should be offered if they can tolerate it.
As others have said, always follow your facility's protocol. Where I work, if they are asymptomatic and aren't NPO, we supplement with snacks, recheck within 15min and then again in 1hr. If they are NPO, we either give 1/2 amp of D50 or a full amp, depending on the blood sugar. D50 is extremely acidic and caustic to the veins, so I try to avoid unless I have to give it, per protocol of course. If the blood sugar is still low after 2 rescue interventions, we need to notify the physician.
You should have more than one "protocol" intervention for hypoglycemia. I believe D50 should only be given to patients who are non-responsive or cannot take PO. This "D50 first" protocol is probably one of those ad-hoc protocols that nurses are so famous for.
If that is truly the policy, needs to be changed. Almost always go lowest invasiveness first. I work LTC had a patient with a 29, called doc, he said as long as he could swallow, don't send him out...we have no IV capacity. He (the patient) wasn't really "with it" but his swallow reflex was intact, and we treated successfully. And I raised holy heck the next morning about him not getting his hs snack!
Altra, BSN, RN
6,255 Posts
As has been said ... don't beat yourself up. However, the underlying assumption that "I will always make good decisions as a new nurse" is probably not realistic.
Be careful, too, about changing "priorities" because the patient is in isolation. Is the gowning/regowning a pain? Yep, it sure is. But it's not a reason or excuse to deviate from what would otherwise be the standard of care.