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.
I'm sure there's some exceptional cases where holding a pt's lantus is indicated. What about the already low blood sugar pt who's been nauseous and isn't likely to eat anything all day? What if someone's NPO for 24 hours? Never say "never".
Don't feel bad. I have seen very experienced nurses hold Lantus without a MDs order. That being said, you should never hold any insulin without a doctor's order. If one of my patients is running low, I will sometimes call the MD to see if they would like to adjust the dose of insulin. A lot of the time the MD will say "Change the dose of Lantus from 25 units to 20 units." We have changed to giving Lantus in the morning at the hospital I work at. Sometimes if I don't feel comfortable calling the MD, I will call the pharmacy and ask them questions about meds.
I'm sure there's some exceptional cases where holding a pt's lantus is indicated. What about the already low blood sugar pt who's been nauseous and isn't likely to eat anything all day? What if someone's NPO for 24 hours? Never say "never".
But you should call the doctor first and get an order to hold it. If one of my patients is going for surgery, I will call the doctor in the morning (if there aren't already orders) and ask how much Lantus they want given before surgery. Many times if a diabetic patient isn't eating the doctor will order IV fluids and still want you to give the Lantus and sliding scale (if appropriate).
I'll second prinsessa here. The liver is going to continue to throw out glucose whether the patient is eating or not (especially if they are not eating). That's one reason why insulin in general, and Lantus in particular, aren't just held "because they're NPO." Usually there are pre-op protocols for insulin before surgery.
I understand the rationale behind not holding Lantus, but we hold it all the time where I work and I've never heard of someone getting in trouble for it. Especially if it's a new introduction and the patient's bsbs hasn't been over 70 all day. I'm going to hold it if the patient needs d50. If it's borderline I'll possibly call. Or I'll gove lantus and hold regular if bs is 120s.
And where I work, the insulin order set says specifically "do not hold basal insulin." There are still some nurses who do not understand lanuts (and I am definitely not an expert) yet they feel qualified to manage it on there own despite orders to the contract from the endocrinologist. I had one nurse tell me "his blood sugar was only 85 at HS, so I just gave him half his lantus dose."
I've held Lantus ...and I would be hesitant to believe that I should "never" hold a specific medication.
How did the order read? I've had some circumstances where the pt was NPO for a procedure and that doctor wrote to hold it, but the have sometimes written to give a reduced dose. Generally, however, there is no real indication to hold it, particularly without a call to the doctor.
I would never adjust/hold a dose of lantus w/o a doctors order. I just meant that I'm sure there's some exceptional situations where it's being held is indicated.
Wow, didn't realize this post was still going. I literally have been exhausted every night coming home, and getting up that I haven't even looked on AN.
Sure missed this support! Yes, it was definitely a lesson learned. It wasn't reported as a "med error" but a "chalk it up to lesson learned" due to the fact that this patient has such all over the place BS. I have been working with the doctor to keep him informed of trends, and changes.
The hardest thing I keep dealing with is in LTC is..."oh, their BS always run like that".(I called on a resident who only gets Levimir HS who BS were running above 300-400 daily and the other nurse was like, "why, they are old they aren't gonna do anything"...well surprise surprise the doctor did do something and asked for a follow up in a week..or the famous." no big deal, they always scream out someone is hitting them"..and..."I wouldn't worry about a 5.5 potassium, their fine and the doctor would be more mad if you called at 10pm, just clal in am".
I feel like everything I learned in nursing school about being diligent is being tossed out. I want to do what is right, not was is common....this is very overwhelming. Everyone keeps telling me "you're doing an awesome job". But on my division I'm not always following what the aids tell me as normal and they really, really hate me being the "new nurse" changing things around and investigating and acting on things such as residents not being turned. Everytime I ask an aide to do something I get the "I've been here for 6 years, such and such always does this...it doesn't matter if we keep pulling them up in bed, they slide back down"...grr...JUST PULL THEM UP!!
There are some situations where it's okay not to wake the doctor up and just leave something on sick call. When I worked thirds and received a call from lab about an INR that's slightly high (not critical), I see no point in waking him up at one am. It's not like he's hone order vitamin k or something. And we're not going to give another dose of coumadin until the next evening. It can wait until morning. A K+ of 5.5 I'd call just to cover my butt, though really it wouldn't hurt the pt to wait till morning to get the kayexalate.
BrandonLPN, LPN
3,358 Posts
I'm sure there's some exceptional cases where holding a pt's lantus is indicated. What about the already low blood sugar pt who's been nauseous and isn't likely to eat anything all day? What if someone's NPO for 24 hours? Never say "never".