Very concerned

RNinHere · Aug 11, 2018

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).

Since you gave her a long acting insulin you should have checked her BG during the night and in the a.m. Didn't you wonder what that insulin would do to a type 2 diabetic with hypoglycemia?

TriciaJ, RN · Aug 11, 2018

I would have done as you did, OP, including giving the Levimir. I would have added a 3am blood sugar check, but since she didn't drop til after 6am, its possible the same thing could have happened to me. Between you and me, the reaction of your preceptor is more concerning than your judgement. If she's supposed to be supervising you, she should have known about the situation, and advised you to do things differently if that's what she wanted.

Even if the blood sugar didn't drop before 6am, a documented 3am blood sugar check would have provided some CYA.

ViviRN · Aug 11, 2018

I think the patients bs would have dropped regardless of the Levimir. I do not believe you did harm by administering it. I think the pt just bottomed out which was bound to happen... and I think the nurses were frustrated and pushing their frustration onto you, using you as the scape goat.

Next time re check their blood sugar 30 mins to 1 hour before end of shift just so you can say in report "recheck at 0630 was x,y,z" and if it's critically low again you could just follow procedure at that time and pass it along.

Although based on your report, you had no reason to believe the pt was hypoglycemic at that time.

Although not as severe, I am precepting to a new facility and experiencing some harshness and unkind attitude as well. So I feel your pain in that regard. I am nauseous every day when I go into work and dread it.

It's making me want to quit. Hazing is def real and it sucks.

NormaSaline · Aug 11, 2018

The pt is fine but has ongoing BG issues which the ICU nurses can't even resolve. Shoots up from 500s to the 40s.

I've read a lot of comments urging OP to consider what caused the hypoglycemia, but aside from not giving food with fat or protein, I haven't seen answers. What is causing this lability?

Guest219794 · Aug 12, 2018

I think the patients bs would have dropped regardless of the Levimir. I do not believe you did harm by administering it. I think the pt just bottomed out which was bound to happen... and I think the nurses were frustrated and pushing their frustration onto you, using you as the scape goat.
Next time re check their blood sugar 30 mins to 1 hour before end of shift just so you can say in report "recheck at 0630 was x,y,z" and if it's critically low again you could just follow procedure at that time and pass it along.
Although based on your report, you had no reason to believe the pt was hypoglycemic at that time.
Although not as severe, I am precepting to a new facility and experiencing some harshness and unkind attitude as well. So I feel your pain in that regard. I am nauseous every day when I go into work and dread it.
It's making me want to quit. Hazing is def real and it sucks.

Well, there was one reason-

The patient is diabetic and had a hypoglycemic episode treated only with medication that is known to cause a relatively brief spike in blood sugar, then refused to eat, and takes medicine for the express purpose of lowering her blood sugar.

That might make me a bit suspicious.

kalycat, BSN, RN · Aug 12, 2018

Adding sugar to OJ is an ANCIENT treatment... and contraindicated. I worry what else your preceptor is teaching you incorrectly on.

I read through this whole thing and was hoping someone would mention this. I've only been a nurse for 4 years and was told numerous times in nursing school to never do this.

OP: I'm a CICU nurse in a high acuity facility. Everyone here has given you excellent information. We too have a standardized hypoglycemia protocol. It doesn't matter if you're treating labile BGs or BPs or anything in between, if you do an intervention to address an issue, CHECK YOUR WORK. Re-assess, and document that you re-assesssd. We do primary nursing care, but I've worked with techs/PCAs in the past... my rule of thumb is that the minute the pt has a concerning abnormal, I take over that task until I am reassured that the pt is stable.

I don't think much of your preceptor or the culture at your facility. I'm not sure why she was bringing up a skin assessment when you clearly had other issues going on. Also, I have a hard time imagining a tele floor that can't do dextrose or insulin drips. Our open heart patients are sometimes on insulin gtts for 2-3 days post op and on a tele unit for most of that time.

I wish you the best and I agree with the others - your facility's actions do not reflect "just culture".

Know your protocols and know where your resources are. I like to pick the brain of my colleagues as well, but until you know who to trust for advice, look it up on whatever standardized resource your facility uses. In my State, one of the few things RNs can do without an order is a blood sugar check. Use your tools, and check your work. You will bounce back from this.

lmichelle25, BSN, RN · Aug 12, 2018

1) She was in the room while I pushed D50. She was aware.
2) I asked the pt if she felt ok (high/low/weak/off) and she stated she was fine but wanted to sleep since we kept her up (vitals/labs/is and os). PCAs do the routine checks is what I meant. Just like they do 2 sets of vitals and nurses do 1 per shift for a total of 3 scheduled vitals q4 (or if needed).

Maybe your preceptor seems angry towards you because she doesn't want any blame placed on her for not being more aware of what you were doing and telling you things like "use your brain" as a response to your questions? Don't take it personally, it seems like it might be self preservation on her part instead of using this to become a better preceptor. I'm sorry you had to go through this, but I'm sure you'll be better equipped to handle a situation like this in the future. So, hopefully, that will help you sleep and feel better about how things went. I hope you end up with a preceptor who is better suited to educate new nurses on the floor! Good luck!

ComeTogether, LPN · Aug 12, 2018

I think because the pt wasn't accepting anything PO it may have been a good idea to hold the levimir, but each patient is different and each doc has different expectations when it comes to this type of med and potentially brittle diabetics. Considering that this drug is long acting over the course of 12 hours and you gave report to day shift I would have expected them to monitor him closely if he continued to take nothing in PO. Either way its certainly a learning experience and I don't think you did anything horrific or anything that many other new nurses would't have also done.

Here.I.Stand, BSN, RN · Aug 12, 2018

Adding sugar to OJ is an ANCIENT treatment... and contraindicated. I worry what else your preceptor is teaching you incorrectly on.[/Quote]
I graduated in 2003 and never heard of this. I thought wth, OJ IS sugar!

BlinkyPinky · Aug 13, 2018

Someone actually wrote " Welcome to the WONDERFUL world of nursing !!"

Seriously ????

This is only one example of 100's as to why I dislike most of it - ESPECIALLY hospital. And yes I did it for 2 years at the hospital

OP: please re- read all of these good- advice posts . You should have re- checked the BG, regardless of what is usually ( not) done. That's just appropriate nursing care

Someone mentioned you might have been task- oriented Vs being more flexible. I agree. And I battle against that trait as well - of being task- oriented. We as nurses have so much to do in a shift , esp you hospital nurses. But in this case , I think you have seen that flexibility needs to be utilized. ( check the BG after getting such a low reading on a PT , never mind what the techs are going to do or not do ).

Lastly - chart , document , chart , document. Ad infinitum. Because if you don't know this yet , it is the NURSE who will bear the brunt of blame for sentinel events ( even less severe events )-- NOT the physicians , not the managers ,the bean counters , the techs , the CNAs. keep adding to this list. No that's not cynical - it's TRUTH.

Nurses have tons of responsibility and , in my opinion , little autonomy or respect OR backup.

And to the poster who said OP seems more concerned about how this has affected her rather than the patient ? See previous paragraph.

She or he is coming here because she is UPSET and of course she's worried about her job and livelihood and license - Get Real

Kooky Korky, BSN, RN · Aug 16, 2018

OK....welcome to the wonderful world of nursing.
QUESTION: So what is the REAL reason the patient's BS got so low?
ANSWER: The patient had no protein or fat to maintain his BS level.
Next time, and there will be a next time....
Think about it!
SeasonedOne's BS Metabolic Time Table:
2hrs - Sugars (Juice, Candy, Honey, Fruit, etc.)
4hrs - Carbs (Pasta, Bread, Spuds, Cookies, Cake, Chips, etc.)
6hrs - Fats (Oils, Cheese, Ice Cream, Milk, Coconut, Margarine, etc.)
8hrs - Proteins (Meat, Fish, Eggs, Nuts, Peanut Butter, etc.)
1. If the patient didn't want juice for a BS 44, how about 2 packs of sugar, 1/2 a soda, etc. They are still breathing and talking, you have time. The IV D50 bumped the BS up quickly but depending on the other metabolic issues, would it take about 2 hours to drop again?
2. You offered the patient carbs, but he declined. Remember the phrase: "OJ and IC (Orange Juice and Ice Cream). A sugar and a fat - bump the sugar and then maintain the sugar for up to 6hrs. Sometimes a gentle threat. "I need you to eat the ice cream(peanut butter by spoon, eggs, Ensure, etc.) or you are going to wined up in ICU." It usually gets their attention and they will eat. You tried but persistence is the name of the game with low BS and challenging patients.
3. Protocol be darned, if you have a low BS episode, check BS every 2 hours for at least 6 hours after the episode. If you had done that, you would have seen the downward trend and been able to intervene saving the D50 episode. By the time someone is going to know his BS is a problem, you are going to be 44 again or lower. Case in point-trust the numbers(recheck), observe, think, then act.
4. I would have given the Levemir too, but I would have been watching to see if the trend was gentle or dropping more and encouraged more fats, carbs and protein intake.
5. People freak out for high BS. Most people can tolerate 3-500 without a lot of issues after the D50. You just flooded the circulatory system with the sugar. In the next 2 hours all those starving cells are going to gobble it up and the tank will need filled up again. It's not rocket science, just supply and demand. Yeah, ok not good long term, but you need time to manage the situation and keep the patient stable. Remember you can always bring highs down over time but a low can kill 'em.
6. You aren't the first one to have something happen...and for the most part, you did pretty good if this was your first time with a low BS. Here's something to think about....
Actual Stuff: Walked into ICU for an AM shift and the nurse tells me they had to give the patient D50 every 2 hours because his BS bottomed out. LIGHTBULB MOMENT, Right? My first question was: Did you feed him! Their answer was we didn't have anything. I called the kitchen who brought us enough to feed patients snacks for the next 24 hours. Ensure, they had....I grabbed a can and had him drink it. BS went to 550. Then he had bkft., BS and sliding scale insulin q2h throughout the day. Doc rounded, we talked. Told him would have his BS down by the afternoon. His BS was between 100-180 by supper. No more D50 after that as well.
Diabetes doesn't have to be scary, difficult to manage or drive you nuts! Most people over-react and have you ever looked at how the patient reacts, lol ....most of them are calm as a cucumber. They may tell you what they need (best case), but it is patients like you had that give us all premature grey hairs if we trust them.
Best of luck and lesson learned.

I have noticed that a lot of people who have DM2 feel low at some pretty high levels - like 140, 170. I guess they are used to running high, so when they get as "low" as the numbers I mentioned, they actually feel low.

I once had a pt with a 29. He was refusing food, too, like OP's pt. Fortunately, I had some milk with me (this was in a jail cell area) and got him to take a few sips. Other inmates held him up, as he was stumbling about and sliding off of the bench. Others ran to their cells and got a couple of cookies and other sugary stuff. He was better in a few minutes, but I made sure he ate breakfast. He lived to see a few more decades of life. Yes, I was freaked out by that low 29 and by his food refusal and even got reprimanded for giving milk because it was not in vogue at that time. I had no time to run for juice - kitchen too far away, infirmary also - so used what was at hand and the other inmates gave some of their sugary bounty. Yes, I did a couple of rechecks at 2 hours and 4 hours later.

op - you will be OK. Do what your boss said. I hope you and the other nurse can smooth things out.

MissMRN · Aug 17, 2018

I'm confused why someone continued to feed a patient who wasn't protecting their own airway and didn't call RRT instead. Where was your preceptor during all this?