Did I just get thrown under the bus? Or I'm a bad nurse?

[proudauntie415, LPN, RN]

New nurse and going on my first month in LTC (first nursing job) and boy, is it difficult. I don't get a break, barely pee and just overwhelmed. They say I'm doing a very good job and happy to have me, but I feel just like a bumbling idiot most of the time. I constantly question my interventions, and having a hard time building that confidence.

Here is my question, a very crazy evening and did not get a chance to check a blood sugar until about 10:15 ish, it was due at 9. It showed 62. For this resident that's pretty low, but I knew it wasn't critical. So I held the Lantus, gave a shake. About this time it was shift change, gave report and explained the situation to the night nurse, wasted my Lantus right in front of her because she said she would draw up her own. I informed her that my thought was it would be better for her to finish the shake, but wasn't going to give the Lantus until after she finished and waited a bit or so (30 mins -ish).

Well, now I realize, I really didn't need to hold the Lantus (its that slow) at all. residents blood sugar was very high the next morning around 450 something (that isn't rare for her anyhow) And resident was pleasant, calm, no s/s hyperglycemia, to her it was just another morning. But still, when I came on the next evening..... I saw that the Lantus was never given later that night after I left.

When I asked the night nurse about why she didn't give it she informed me that she can't give a medication that was ordered within my time to give. There is the "hour before and hour after" rule. But technically the Lantus is written for HS, only the BS check is for 9pm. Either way, why didn't she just tell me--hey, I'm not gonna give the Lantus? Or explain to me, "ya know, you don't need to hold the Lantus?"

So all in all, I made the error cause I made the choice to hold it, thinking I was doing the right intervention ( I did make a note on holding). Doctor of course gave me a stearn NEVER hold Lantus lecture. I respectively chalk it up to lesson learned....but I feel kinda like I got thrown under the bus here...and now I have a med error I guess? So frustrated. Just need some encouragement.

[VANurse2010]

(1) Don't ever hold Lantus. If you're more comfortable, give a snack or OJ or whatever and raise the blood sugar, but don't hold it.

(2) The night nurse is full of it and doesn't know what she's doing. If she was that concerned about the timing, she should have called the doctor and got an order to give it (at which point the doctor would probably have been none too pleased to be called over such silliness)

(3) The "hour before, hour after" rule may be policy, but in reality it's more nursing school theory/silliness than something you are strictly bound by in the real world. Good clinical judgment and pt. advocacy need to play a bigger role than that rule.

[gonzo1, ASN, RN]

I've been a nurse for 9 years and I didn't know "never hold the lantus". On the scale of med errors this is so small. I doubt any place would fire you over this unless they have a long waiting list of nurses that want to work for them. LOL.

What you might do next time if you are wondering about giving or not giving a med look the med up in a med book or on the internet and you very well might have seen good parameters for when to give or not give. The night nurse would be in more trouble than you, for not following up. I work ICU and stuff like this is often late due to codes and other things going on.

Sounds like you are doing a great job of learning to be a nurse. Keep up the good news.

[proudauntie415, LPN, RN]

Okay, thanks guys.

I was just beating myself up over this. Yes, VAN I have learned for sure, NEVER hold that Lantus. I was just shocked cause I was giving the report on what was happening at the nurses station, holding the Lantus in my hand and asked her specifically does she want me to waste this and she said she would draw up her own.

I just really want to do right by my patients and be a diligent, knowledgeable nurse that can provide the best care. I really had hoped that a seasoned RN with years of experience would of said, "don't waste it, just go give it". :/ Instead she did her 2AM accu check, gave her SSI and went on about her night shift.

Feel bad, but thanks guys. You are right on the nose about keeping my drug book handy. I was "familiar" in the sense I knew it was a long acting insulin and general night time insulin, but really didn't know the full scale. So I will be sure look closely at nursing implications in my med books on meds when I make a nursing judgement!

[VANurse2010]

Just a quick point, Lantus is often given at night but it doesn't have to be. It can be given in the morning or split into divided doses bid. I've also seen it given once a day at 1700.

[proudauntie415, LPN, RN]

You are right VANurse, sorry, I meant when I said "general night time insulin" as just saying it was this specific residents routine nightly long acting dose! But I too have seen it in the days and so forth, honestly, if she is getting so high starting mid day, why doesn't she get a morning dose I wonder, since around 2am accu checks she always ends up low, give it to her earlier and let it works it course throughout the day with her SSI? IDK. Gonna have do my research and break the old pharm book !

Thanks again!

proudauntie

[VANurse2010]

If it's given at the same time everyday, then I don't think it should make much difference. Her low BG at 0200 may have more to do with bedtime snack or lack thereof. 0200 is a bit unusual in LTC. Order carried-over from a recent hospital stay?

[turnforthenurse, MSN, NP]

Never hold Lantus without a doctor's order. If you are giving a larger dose of Lantus, speak with the doctor because the dose may need to be adjusted and most of the time they will adjust it instead of ordering to hold it. I think I have only had an order to hold Lantus once. And make sure you document!

[fishhawk]

first i would have checked the bld sugar again. i have found time and again if i stick twice i get 2 readings. machines are not 100% accurate. if not enough bld on strip it will read low. then i would call doctor if it was still less than 100. dr would probably adjust dose of lantus or order snack and you would be covered. cya.

[fishhawk]

ive been a nurs over 30 years. in a facility i worked 20 yrs the doctors ordered mild and or peanut butter to maintain bld sugar longer when it was low. also in ltc cnas dont always pass out hs snack like suppose to so nurses have to check on that.

[LiLev]

Wow, as a nursing student I kind of thought we could count on the veteran nurses to help us through our freshman year because we do lack experience. Hope this is the exception and not the norm.

[proudauntie415, LPN, RN]

Yeah the 0200 accu check is routine for her because this resident has such out of control all over the place blood sugars and she gets SSI at that time too.

I agree whole heartily about re-checking the BS again, and I would have. But I was ending my shift and that was the point of me trying make sure she knew what was going on.(but you're right a double check right at that moment wouldv'e been wise) I didn't plan for it to be held and not given at all, I just thought hold until she has her snack...then give. Which was what this nurse gave me the impression she would.

Usually I will give her the Lantus and milk with graham crackers.

Basically it felt like she had my back and would go give that Lantus in about 30 mins and no problem. But no, it turned into something more.

However, there are some great seasoned nurses who have been so helpful!