Opinion re: managing low blood sugar? - page 3

1. 
   Mar 3, '03

   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.
2. 
   Mar 3, '03

   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;
   
   BG <50 OJ and protein snack if not symptomatic OR amp D50 if symptoms such as XXX are present.
3. 
   Mar 3, '03

   Aharri66
   
   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.

   Last edit by Sharon on Mar 3, '03
4. 
   Mar 3, '03

   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?
5. 
   Mar 3, '03

   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......
6. 
   Mar 3, '03

   BrandieRNq,
   
   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.
7. 
   Mar 17, '03

   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.
8. 
   Apr 5, '03

   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.
   Any thoughts or opinions?
9. 
   Apr 5, '03

   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??!?!?
10. 
    Apr 6, '03

    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.
11. 
    Jan 14, '06

    The policy at my institution is to treat with fluids or food if patient is able to take po. For instance orange juice without sugar (though for us old nurses who treated pts with oj and sugar for years it is a hard practice to break) and to recheck blood sugars until wnl. If pt can't take po then give D50w. The problem I see with immediately giving d50w is the blood sugar may go up to much. An aide where I work who is diabetic with an insulin pump was taken to the er because of low blood sugar and treated with d50w more than once over her objection. She said she felt terrible until she could get her blood sugar down again and recover from the out of whack sugars. Seems to me the docs should have adjusted the patients insulin dose long before she had 3 mornings of hypoglycemia. Practice changes over time. What we do today may change tomorrow. Don't be too critical of the nurse who gave oj with sugar. She did get the patients blood sugar to wnl which is the goal. With tight control d50w may be too much.
12. 
    Jan 14, '06

    I am an insulin dependent Type II. On those rare occassions whem my AM blood sugar is below 55, I drink 4 oz of regular soda. If it is below 44, I drink 8 oz of OJ with an teaspoon of sugar. Below thirty, 911 is called. They generally either give me 50D IVP or orally. And this is after I've drank 40z of regular soda. My NPH is held for a few hours and I monitor my blood sugar for the four hours. I have never had to chase the rebound because I have never experienced it. Of course I talk with my PCP and see him when indicated.
    
    Grannynurse
13. 
    Jan 14, '06

    [QUOTE=AHarri66]I feel vindicated in my opinion because of what happened,QUOTE]
    
    There's no room for this in nursing, IMHO.
    
    The DW is a diabetic, and she agrees with another poster - she'd prefer the OJ over the D50. Appropriate assessment and monitoring would have been of great value here.

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