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?
Hypoglyclemia is one of the few areas in our hospital that is not micro managed by protocols.
We have protocols in place, feed first if asymptomatic. D50 if the pt is unable to swallow. But the MDs don't get bent out of shape if you use your own judgement about when to feed and when to push.
I've just pushed the D50 if I'm familiar with the pt, and experience has taught me the pt has to eat the fridge in order to correct their hypoglycemia.
I think what you did was OK *if* you notified the MD. If your facility has text-paging, a simple FYI text would do. If it does not, I would have pushed the D50
D50 is usually last resort in the protocol I'm used to. We would use some form of carbs, glucagon or glucose gel and then d50 if they were unresponsive or unable to take PO.
Thank goodness I work in Australia. If you did your actions are just great! There always will be 'what ifs'' and these can be argued just as well in a court of law as 'why did you follow the protocols and not use your brain as a health professional''
Having generic protocols to push glucose down veins instead of CHO orally for a patient under the care of an RN with a degree, with critical thinking skills and the patient not NPO, in a ward situation is not the way IMHO. Unless of course under endocrinologist orders.
Patients are people not numbers and they all react and differently and all come from various lifestyles and cultures and environments and all have different management of THEIR diabetes.
Just looking at numbers and grabbing for a quick fix?
After all the patient will still have diabetes when they go home, the medical side should not take their management with quick fixes, over completely and the patient along with their beta and alpha cells in their pancreas, will need to know how best to increase their BGL's with CHO, and get relo's to know the use of a glucagon pen.
Honestly, I would talk to whomever in your facility is in charge of EBP if that's what the protocol is. It's ridiculous. At my hospital, the only way you give someone D50 is if they're totally unconscious. A conscious or semiconscious person can drink or eat just fine. The juice and crackers are determined to be 5g of carbs, give the crackers with peanut butter so it's not just pure sugar hitting them, and check q15 until the CBG > 70. It's ridiculous to give someone who's awake and talking D50... it sounds like your place is just looking for an excuse to charge the patient more money. D50 is a drug and has to be charged while juice is free.
That being said, as long as your protocol is D50, you should use D50, even though it's one of the dumbest things I've heard in a while.
Unfortunately, glycemic control is about to become a pay for performance issue which I think is odd because "normal" is not always normal for everyone. And some diabetics are just plain brittle and difficult to control. I would only give D50 to someone unconscious because all it is going to do is raise their glucose level temporarily then they'll bottom back out until they are able to have some protein ingested somehow. I'm also not a big fan of juice, I would much rather get some protein and complex carbs into them as quickly as possible, like the turkey sandwich someone mentioned earlier. However, I work in a rural hospital with no dietary services available at night, so you do the best you can with the resources you have available. It sounds like a complicated situation but it seems to me that you are trying to prioritize the best way you can, and the fact that you are looking for feedback and always striving to be the best caregiver you can, which a great nurse does make! So good job! :)
I would definitely work on getting this protocol changed.. Why give something like D50 when there are simpler, cheaper, safer options. Don't beat yourself up over this. You used critical thinking, just make sure to inform the MD and document.
The patient is having hypoglycemia unawareness as stated earlier which is a form of autonomic neuropathy. The actions you took to increase his blood glucose seem appropriate to me, if he was my patient and able to talk and swallow safely, then I would have started with a PO carbohydrate source also. The bigger critical thinking point that I would address would be, to determine why this patient is having frequent hypoglycemia. Has his renal function decreased which is causing his insulin to last longer, is the patient not eating as much at mealtimes, etc. Considering his unawareness I would look more at adjusting the insulin regimen to prevent the hypoglycemia from occurring to begin with.
At my job we have to treat a bgl of 60 with d5w50. It doesn't matter if the patient is symptomatic or not . Op I understand your rationale however you should have followed the protocol....
I worked in a Diabetes and Endocrine clinic for awhile. I am also the mother of Type 1 IDDM. Not trying to criticize you at all, but anything under 60 should get D50. Especially , if they are asymptomatic. If they are asymptomatic at that reading, they are having frequent hypoglycemia, and have grown immune to recognizing the symptoms, and therfore have a higher chance of seizing/and or brain damage. I have actually seen brain damage from a hypoglycemic event. It is similar to residual injury from a CVA.
I worked in a Diabetes and Endocrine clinic for awhile. I am also the mother of Type 1 IDDM. Not trying to criticize you at all, but anything under 60 should get D50. Especially , if they are asymptomatic. If they are asymptomatic at that reading, they are having frequent hypoglycemia, and have grown immune to recognizing the symptoms, and therfore have a higher chance of seizing/and or brain damage. I have actually seen brain damage from a hypoglycemic event. It is similar to residual injury from a CVA.
I don't think anyone is saying that a BG under 60 shouldn't be treated, just not necessarily with D50 if it can be avoided.
The American Association of Clinical Endocrinologists recommend oral agents as a first choice in patient without neurological changes.
My hospital has had one patient, who as best we can guess, died due to D50. The patient was a severe vasculopath with near daily MI's, within 60 seconds of getting an amp D50 by central line the patient went into VT/VF and couldn't be revived. Injecting D50 is basically like giving stomach acid IV, except it's more syrupy, and should be avoided whenever possible.
imintrouble, BSN, RN
2,406 Posts
Hypoglyclemia is one of the few areas in our hospital that is not micro managed by protocols.
We have protocols in place, feed first if asymptomatic. D50 if the pt is unable to swallow. But the MDs don't get bent out of shape if you use your own judgement about when to feed and when to push.
I've just pushed the D50 if I'm familiar with the pt, and experience has taught me the pt has to eat the fridge in order to correct their hypoglycemia.