I don't think I am caught up for nursing. med error

feb127 · Mar 16, 2016

In ltc the md makes the decision on Coumadin & when to hold,resume, increase/decrease...... Are u a RN or lpn? As far as insulin why are there not set parameters and instructions as when to hold?

Fireflynurse · Mar 16, 2016

I am a LPN. a new grade actually. at school, instructor told us that residents need a nurse whom will think instead of blindly follow orders and to my best judgement and training at skilled nursing facility, it was best for the resident to hold the insulin but it is apparently wrong to do it at this assist facility. There is no parameters and instructions set in this facility. Not like in the skilled nursing care facility that they have. The coumadin, I was not sure but DON was there, she encouraged me to withhold it and did not tell me to call the doctor so I held and did not call. She the one that told my supervisor that I withheld it and she didn't know what I was thinking which make me every more upset. I am so lost. as a new grade, I don't think that I should work alone at all but that's how this facility works

In ltc the md makes the decision on Coumadin & when to hold,resume, increase/decrease...... Are u a RN or lpn? As far as insulin why are there not set parameters and instructions as when to hold?

quiltynurse56, LPN, LVN · Mar 16, 2016

Definitely as for a set of parameters and protocols for these medications. Make sure it is written too. That way, everyone knows what to do including future new nurses at this facility.

LeChien, BSN, RN · Mar 22, 2016

Always call the MD when you are holding a medicine with no parameters. You need an order to hold them.

Your DON should be someone to look up to but she doesn't sound like it.

Fireflynurse · Mar 23, 2016

Thank you LeChien. My supervisor said the same thing during our phone call. It has been a few days since my original post. It turned out my DON already two weeks in from giving a month notice ( DON requires a month of notice? ) and she was asked to leave by our regional director two days after my Coumadin incident. I am not sure if it was related to her early departure or not.

Even since my original post, I regain some confidence because I spotted first sign of CVA on a resident and I spot a medicine that was not suppose to give it to HTN patient on the patient's MAR. the doctor said I have the neck for it. well.. I think he was just trying to make me feel better. :)

But I will continue on this journey and it will get better, I am sure of it :)

Always call the MD when you are holding a medicine with no parameters. You need an order to hold them.
Your DON should be someone to look up to but she doesn't sound like it.

TheCommuter, BSN, RN · Mar 23, 2016

it was best for the resident to hold the insulin but it is apparently wrong to do it at this assist facility.

It was not wrong to hold the insulin for a finger stick blood glucometer reading of 70. However, you needed to telephone the physician to obtain the order to hold the insulin. It is the same story with the Coumadin.

Call the physician anytime you get the urge to hold a medication that lacks parameters on when to give/hold. Get it in writing that you obtained the physician's permission to hold the medication via an order.

It is not within our scope of practice to simply hold medication without an order, even when our clinical judgment dictates that giving the drug might be unsafe. If you think giving the drug will be unsafe, place the call to cover your behind.

Good luck to you!

Fireflynurse · Mar 23, 2016

Thank you TheCommuter. After my mistake mentioned from my original post , I called the MD when I saw something that I suspected was the cause of consistent HTN in a resident. He told me that I did a good job finding this cause so I feel more confident to talk to the doctor when I feel it is not unsafe . :)

nortonplusRN · Mar 23, 2016

Thank you TheCommuter. After my mistake mentioned from my original post , I called the MD when I saw something that I suspected was the cause of consistent HTN in a resident. He told me that I did a good job finding this cause so I feel more confident to talk to the doctor when I feel it is not unsafe . :)

Awesome! What med did you spot that cause HTN?

Fireflynurse · Mar 23, 2016

midodrine. the MD has reduced the dosage. It is still required to reduce the side effect of dementia meds .

Awesome! What med did you spot that cause HTN?

TeaPlease · Mar 25, 2016

Congrats on using your nursing judgement! Please don't be concerned about "bothering" your supervisor, DON, OR the doctor when you feel that something should be held OR if you question an order. 99% of nursing education is learning on the job. Most supervisors and some doctors enjoy giving a little education in response to a question.

As to giving routine insulin dosage to a client with a blood glucose reading on the low side----if I don't have parameters written with the insulin order, I'll recheck glucose mid-meal or after the meal and will give the insulin if the numbers improve. THEN I will ask for parameters during business hours...or will leave a message with the powers that be voicing my concern over the client, and will include a weeks worth of glucose readings so the MD can decide if an altered dose is appropriate. But if you have an immediate concern PLEASE don't hesitate to text your boss or call the MD.

MedChica · Mar 25, 2016

You have to call in labs, anyway. You cant hold coumadin any more than you can increase/decrease the dosage.

Would I have held that pts insulin? Not likely. Depends, though. Ive never seen s/s start that low, Ill say that. 4u, really? Id probably call to clarify orders, number one. Looks suspect.

Anyway, I'd go with whatever works for the individual. If the pts a/oÃ—4 and tells me to administer, I will. Id watch with glucagon at the ready but, hey - they know their own body. If the pt cannot express needs, however? I will hold and monitor. Ive been given enough lectures on 'prudent nursing' from the senior nurses that I always err on the side of caution.

Anyway, sometimes, pts will have ac 5 - 35u novolog/humalog in addition to their s/s. If their accucheck is 110, yes, theyre too low for s/s -- but, unless I knew the pt ran very high (and I do have one who runs high. We give him his 20u, regardless), I wouldn't give the insulin just because there's an order to do so, either. I will hold, write a note and monitor for s/s hypoglycemia.

What about the pt who wont eat? Are you still going to give the insulin - see what I mean?

I don't just administer just because the MAR says so. If that's a med error then I guess Ive made many.