With all the knowledge and experience out here, I'd like you folks' opinion regarding the following scenario:
I was day charge over this past weekend on my floor (Med/Surg-Tele). In taking report from night charge, I learned Saturday that one pt had an 0600 blood sugar of 48 and was given OJ w/sugar. I became a bit upset (this happens all the time) because 1.) our hospital has a standing protocol for all blood sugars below 70: give an amp of D50 and call the doc.; 2.) breakfast doesn't hit the floor until 0800 unless called for earlier, and it rarely is even in these cases; 3.) I've seen pts drop from 60's to 20's in 1/2 hour even with OJ and food, and you can't tell if this pt is one of those. Anyway, night charge basically brushed it off with "pt states she's always this low in the am," and "the OJ worked." (Pt was 68 one hour later.)
On Sunday, same pt was 42, and the same scenario occurred. Night charge and I got into a debate regarding blood sugar management, my opinion being I'd rather push the D50 and spend the rest of the day bringing her down, hers being that D50 was "overkill." (For the record, insulin was being adjusted incrementally.)
I was off Monday, but upon returning to work Wednesday I learned that Monday 0600 pt blood sugar was 36 & OJ was given (AGAIN) because she "was alert and talking." Within 1/2 hour, pt was unresponsive and CODED with a blood sugar of 22!!! Luckily, pt was brought around and as of Friday was still in ICU. Same night charge was on.
I'm angry because I believe we could have avoided putting this poor woman through this life-threatening situation, and I feel vindicated in my opinion because of what happened, but I suppose this could have been an isolated case....what do you think?
At our facility, we are told that under 70 to give juice or milk and a protein snack such as peanut butter & crackers or a meat sandwich. If it doesn't come up in 15 minutes then we give another snack and if it still doesn't come up we call the doc. If we are called for a "man down" and they are nonresponsive, we check the blood sugar and then give glucogon. If the blood sugar doesn't start to rise in 10 minutes then you start an IV and give 1/2 amp at least of D50. If you aren't getting a response from that, I would be getting a hold of an ambulance and give the other 1/2 amp of d50.
But I am wondering why that nurse wasn't following the protocol. I know what would happen at my place if we didn't do what the protocol says, even though sometimes I dont quite agree with the protocols myself.
Brandi, As nurses we may certainly question physician orders, but I promise you, if you go off protocol and something goes wrong, someone will be asking you why. If the nurse felt the need not to follow protocol, she should have called the physician.
As stated above "CRITICAL THINKING" needs to be involved.
I am more inclined to lean on the amp of D50 if I have a pt who is symtomatic with a low sugar....whatever their low is.
I think we have not even approached that yet. Everyone who has dm has a different set point. Some folks feel great at say 70, while others would be symptomatic and need intervention with a sugar below 150.
So to give a blanket set of orders that says Give an amp below 70 is pretty lame indeed. The ADAs new recommendations would like DMs to live at 70.
At my hospital the standing orders were written with clauses...It said somthing like;
I think it is time to protect yourself because as the incoming nurse, the plaintiff's team will want to know what you did to prevent the episode from reoccurring. For instance: If you knew a nurse was violating standing medical orders, why didn't you do an incident report and follow protocol yourself? Every hospital I have worked or taught in requires the discovering nurse to report all medication errors including those involving standing orders and protocols.
Every time I have been in your position I not only did an incident report immediately I called the supervisor to the floor. I never had a co-worker repeat the experience. After all it does not take a code to kill brain or other organ cells just a blood sugar below 60. During the past twenty years I have seen patients and family members left with brain damage and other organ failure without coding because a nurse tried the OJ and not the D50.
I think the SS insulin was too high. We also use OJ and high protein snack, and do the FSBS q30 min for 3 hours. Our protocol is D-50 under 50. What kind of insulin was she on, Reg, 70-30, NPH?
does your facility use QAR's, or some way to report when protocol is not being followed. our protocol is 60, lab draw, juice, protein, milk, recheck in 20. of course if unresponsive d50. the first time this nurse errored i would have asked her if she was aware of the protocol. then the second time i would have written her up. some people get sloppy when they are never held accountable for their lack of action. i pick and choose my battles very carefully, i.e., i would not write someone up for charting a dressing change that they didn't do, or leaving me with an obviously clotted S.L., but hypoglycemia is no joke. one of the hospitals where i work encourage us to send an e mail to the charge nurse, and cc to the don, and they keep it anonymous. had a nurse i work with poo poo me when i reminded her that the baby she was discharging needed a hearing screen (our protocol for caput) she discharged without doing it, but i was able to add it onto a weight check the next day. i discussed it with the charge nurse and she told me to send her an e mail. no one is perfect and we all make mistakes, but there are sloppy nurses out there......take care and have a great week......
While I agree with you that critical thinking is essential to RN practice, tell me how you will defend yourself in court when you are asked why a protocol wasn't followed.
Even if you don't agree with it, it is the policy of the hospital. You are kidding yourself if you think that critical thinking is going to be enough backing!!!!! More than likely the hosp won;t be backing you either if a protocol was broken.
If the protocol seems to be overkill, well, work with evidenced based practice to get it changed!!!! Til that happens, you gotta follow it.
Just weighing in on the OJ versus OJ + sugar question. Most recent Certified Diabetes Educator information (received last week in Nutrition/Pharmacology class) is teaching BSN students that 4 oz of soda, OJ, or AJ is suffiecient to bring blood sugar up 30-50 mg/dl and no sugar should be added.
I also had a debate with another RN regarding initial intervention for low blood sugars in our LTC facility. While I have always been taught to give a glass of OJ with a packet of sugar, and follow with complex carbohydrate. This nurse insisted that the initial treatment should be a glass of milk and NOT orange juice.
Also, some nurses have been giving diabetic resource for low sugars.
Specializes in jack of all trades, master of none.
Oooh, what timing. I just had a similar thing happen to one of my residents, a very brittle diabetic. Ugh. I was just starting my med pass when my CNA told me that Ms. XYZ didn't look right.
I grab the accucheck & E-box, sure as S***, unconcious, accucheck is 22.!!!!!!! The thing that ticked me off was the nurse who I relieved initialed that she did the check, gave insulin per sliding scale, but didn't mark the results OR the amount of insulin given. I just love calling a doc to say, """ Duh, errrr, sorry, I don't know what her 6a glucose was, nobody bothered to write it down. But at 7:55a, it was 22 & she's unconcious, & yes I gave the Glucagon. Ummm, no she didn't eat, she is unconcious Doctor!And sorry, uh, I don't know what her 8p check was, nobody bothered to jot that one down, either.""
God, I HATE when I have to answer the infamous question. . . "What kind of f***in idiots do you have working there??" Ummm, BIG ONES??!?!?
When I have a patient with BS this low I am on the phone with the physician protochol or no protochol. I am willing to bet if the nurse in question had done this we would not be having this discussion.
We are told the MD was adjusting the insulin. Yet apparently there was little if any discussion about this between physician and nurse.
If in the nurses good judgement the protochol was inappropriate for this patient it needed to be discussed with the MD. Brandi, part of using critical thinking is to realize your limitations. Under no circumstance does a nurse have the right to ignore protochol or formal orders without discussing it with the doctor. ONLY if you deem an order dangerous are you allowed to not follow it. Even then you MUST discuss your concerns with the MD. A written protochol is legally the same as a formal order.
It may be this protochol was not appropriate for this patient but there is NO evicence presented that said the doctor had knowledge of this nurse's decision not to follow it.
The fact is simple if presented to a BON this nurse failed to follow the standard of practice.
Pleazzze don't tell me the MDs gets mad if you call or some other garbage excuse.
psychonurse
291 Posts
At our facility, we are told that under 70 to give juice or milk and a protein snack such as peanut butter & crackers or a meat sandwich. If it doesn't come up in 15 minutes then we give another snack and if it still doesn't come up we call the doc. If we are called for a "man down" and they are nonresponsive, we check the blood sugar and then give glucogon. If the blood sugar doesn't start to rise in 10 minutes then you start an IV and give 1/2 amp at least of D50. If you aren't getting a response from that, I would be getting a hold of an ambulance and give the other 1/2 amp of d50.
But I am wondering why that nurse wasn't following the protocol. I know what would happen at my place if we didn't do what the protocol says, even though sometimes I dont quite agree with the protocols myself.