Very concerned

[ButterflyRN90]

I'm going to make this as clear as possible . I work nights at a hospital on a tele floor. I'm currently on orientation and am towards the end of it. So, one night I had a pt who was in ARF, dialysis, and a Type 2 DM. So the pt BG drops to 44mg/dL and when asked states "I don't feel so well". I run in there to give OJ to which pt states "I don't want anymore ". Protocol is 50u of D50 if unable to give PO. So I gave 50u D50W. Pt shot up to above 200. I offered milk and pt refused (was also ineffectively coughing/ had fluid in lungs). Offered graham crackers (refused). After the elevated BG I administered the Levemir that was scheduled. 10 units of levemir which has no peak. Anywho out of my 4 pts I rounded on this pt the most because they had fluids and labs that I did. Pt had no BG checks during night (we don't do them). Every time I rounded I asked how pt was feeling (pt is aaox3). My last round was during lab draw around 0545. Pt actually told me "thank you for your help" and when asked if she was in pain (pain assessment) or if she felt weak/off (BG) pt stated "no I'm good, just want to get some sleep."

Gave report to day nurse who sees pt asleep and goes and continues getting report from other nurses. I was now giving report to other nurse and to finish charting.

1.5 hours after handing report to day nurse, preceptor runs to me stating "pt has a BG of 14! I run in and pt is non-responsive. Day charge nurse was pushing 2 amps D50 when I wheeled computer. When I mentioned pt only had LEVEMIR given preceptor yelled "WHY WOULD YOU GIVE THAT WITH A 200mg/dL BG!?" I'm a T1DM so it wasn't that I have a med I knew nothing about. So I told preceptor "but why wouldn't I?" She gave me a look of hatred as Rapid Response was called. Pt taken to ICU.

I sat at the nurse's station in tears. I'm being looked at as the one who did this even though my pt was aaox3 BEFORE report and pt wasn't checked after I gave report. I'm freaking out. They're investigating and pt is ok. What would normally happen? Would I lose my license or job? I'm really freaking out to where I have chest pain.

[chacha82, ADN, BSN]

One tidbit. If I've had to correct blood sugar, I always ask the MD about the next dose of insulin (ANY kind). The rationale is that if you have to give something, they're not "really" at 80, 100, whatever. So I don't usually give any type of insulin if I have just corrected a sugar. Your preceptor should have been close to you for all of this.

[EDNURSE20, BSN]

Firstly I don't get you wouldn't be monitoring there BGL during the night if your administering insulin, regardless if the person BGL had been low.

But you should alway monitor BGLs if the pt had been low, doesn't matter if it's during the night or if they don't normally check there levels that often. simply asking the pt how they are feeling is not enough.

Also this is something I would of discussed with other staff. Even when your off orientation. If something is happening to your pt that isn't normal, i always say something. Because if something happens, you've got back up instead of a sudden emergency that no one knew about.

[amzyRN]

Didn't you tell the MD about the drop in blood sugar to 44? I would have let them know and asked about the Lemimir. In my experience, subsequent insulin and anti-diabetic meds may need to be adjusted after hypoglycemia or as someone mentioned addressing the underlying cause. A change in condition warrants a call to the MD, even if it's not indicated in the MAR. Also, after a drop in blood sugar, more frequent checks are indicated.

[hawaiicarl, BSN, RN]

Interesting post

I agree with several things that previous posters mentioned.

1. Your preceptor is on the hook, and may have been so upset because of how this reflects on her.

2. Your manager is right, don't sweat it, sleep it off.

3. As the RN you should have told your PCA, I just had to medicate patient X for a low sugar, could you check her again in 2 hours?

4. Hanging a D5 NS at 50 ml/h (with an order) would have avoided the whole mess.

If it makes you feel better our intensivist specifically put in our policy, do not hold long acting insulins for low blood sugars. We would have RNs randomly deciding to hold long acting insulins just to see them spike to the 500s the following day, and it irritated the hell out of him.

Cheers

[Horseshoe, BSN, RN]

Pt had no BG checks during night (we don't do them).

You've had a lot of good information about why that makes zero sense given the patient's condition. I'll add one more thing to this. I used to work for a personal injury/medical malpractice lawyer, so I tend to see things from the perspective of "if I were sued for this, could I defend my actions as that of a reasonable, prudent nurse following standards of practice?" If that patient had died (a BG of 14 made that a distinct possibility), you would have had not one leg to stand on. "We don't do BG checks at night" might be prudent and SOP for a patient not having hypoglycemic issues, but it sure as heck wasn't defensible in this situation. This is where critical thinking pops in. Deviations from normal require departures from standard behavior, and that didn't happen here to the degree it should have. It might seem cynical to act in a legally defensive posture, but that's what our litigious society has brought us to (not to mention that checking this patient's BG through the night was the RIGHT thing to do regardless of liability).

I'm sure you are learning a lot as a result of this incident. That's a good thing even if the precipitating event was not.

[ButterflyRN90, ASN, RN]

Interesting post

I agree with several things that previous posters mentioned.

1. Your preceptor is on the hook, and may have been so upset because of how this reflects on her.

2. Your manager is right, don't sweat it, sleep it off.

3. As the RN you should have told your PCA, I just had to medicate patient X for a low sugar, could you check her again in 2 hours?

4. Hanging a D5 NS at 50 ml/h (with an order) would have avoided the whole mess.

If it makes you feel better our intensivist specifically put in our policy, do not hold long acting insulins for low blood sugars. We would have RNs randomly deciding to hold long acting insulins just to see them spike to the 500s the following day, and it irritated the hell out of him.

Cheers

I'm sweating it. They took my badge pending investigation results. I left work early and can't move, am having chest pain and am angry.

[Sour Lemon]

I'm sweating it. They took my badge pending investigation results.

Wow. That seems very harsh, to me.

[Workitinurfava, BSN, RN]

Have some humble pie. If you lose your job it will be due to your response to the situation. You need to ask for help more and develop better judgement before someone gets killed. Show more concern for the patient. Your responses on the forum don't show you are willing to learn from this. You were an LPN first so you had experience as a nurse right? I hope things work out for you but you need to d some serious self reflection.

[lrobinson5]

Total failure of the safety net that was supposed to be your preceptor. There is no way in hell I wouldn't step in and teach what to do in the event of a hypoglycemic patient. We have a very standard protocol when a patient's blood sugar falls below 70, and I wouldn't expect even a seasoned nurse to know exactly what is expected. There are specific ways and places you have to chart and you also HAVE to call the on call MD to discuss upcoming insulin doses as well as a review of the IV fluids. I would imagine that most people would hold the long acting insulin just because hypoglycemia presents a much more immediate threat than the possibility of hyperglycemia later. In my opinion, that is something the doctor should decide. If it were me I would hold the medication until the doctor gave me the go ahead to administer.

If you are in trouble for this I can't imagine that the other nurse is going to walk away either, not that it makes your situation better, but they are making you feel solely responsible even though they have to realize they messed up too. I am sorry that this happened, it wasn't a good experience for anyone involved, and I hope that they do try and make this a learning opportunity for nurses and PCAs on the floor.

The only other thing I can say is many people have different presentations for low/high blood sugar. Some people only start to feel off when they are dangerously low, while others are completely out of it the moment they drop below 70. It isn't good enough to just ask how they're feeling, you really need to check their blood sugar to make sure they're out of the woods after an episode like this.

Good luck to you.

[Triddin]

I'm sweating it. They took my badge pending investigation results. I left work early and can't move, am having chest pain and am angry.

That is a very harsh response imo unless you were already having performance issues?

[Alex_RN, BSN]

You poor dear. It will be all right. We all have our new grad mistakes. They are harrowing but you get through them.

Your hospital needs better procedures. At my facility, there is a whole roster of standard orders when someone is getting insulin. You would have known what to do (and what not to do).

Typically if someone is that hypoglycemic, you hold insulin and regularly check BG for awhile, like Q15 minutes until they are out of the woods, and then hourly for awhile. I cannot imagine management complaining about extra Accucheks. That long acting insulin will Mess. You. Up. Always better for BG to a little high than too low.

Congratulations, you are about to become the insulin expert.

[NurseCard, ADN]

You poor dear. It will be all right. We all have our new grad mistakes. They are harrowing but you get through them.

Except that the OP isn't a new grad.

OP: I am so sorry you are going through all of this. Some very useful advice given.