There was a nurse telling me what I am doing is all wrong, but I 100% think I am right in this situation.
Patient is a diabetic. Has a sliding scale for insulin.
It will read: Humalog sliding scale
BS <100 0 units
100-200 Give 4 units
200-300 Give 6 Units
300-400 Give 8 units
Over 400 Call MD
What the nurse was trying to tell me is that if the patient has a blood sugar of 401 or above, she gives 8 units, and then if it is still over 400 after she checks again, she calls the MD. I told her why not just call the first time like the order says? She did not respond.
Am I overreacting? Is this common to do things this way in LTC? Seems everyone is reluctant to call the MD for small stuff, which then turns into larger problems.
Yes, that is what I meant. Thank you for assisting with the clarification. Here in Oregon (Portland Metro) the standard is to d/c sliding scales in the SNF setting, still a standard in hospitals.
First, that's a pretty terribly written sliding scale order. What are you supposed to give when the BGL falls on an overlap number? If it's exactly 100, 200 or 300 do you give the lower amount of insulin coverage or the higher? If this is your actual standard sliding scale order it needs to be updated.
I can't say I totally disagree with the agency nurse's thinking though. Blood sugars can vary so widely in a short amount of time that if I got an unusually high number and the resident was totally asymptomatic I would wait 5-10 minutes and check it again. If it was still high on the second check then I would call the MD for orders.
Blood sugars can vary so widely in a short amount of time that if I got an unusually high number and the resident was totally asymptomatic I would wait 5-10 minutes and check it again.
Is the patient's BGL the source of variance or is the meter? If the BGL is high what are you looking for in terms of symptom confirmation?
For someone asking, What is it replaced with?— in school nursing, most of the kids have a correction factor. It adds a tiny bit of math to the whole thing. What it means is, How much above target is their current blood sugar? Then you divide by the CF. If their target is 100, and their sugar is currently 200, and their CF is 50, you would do 200-100=100 (so there’s 100 “too much” sugar in their blood). If their correction factor is 50, you’d give 2 units. One for each 50 “too much.”
Oh no no no. A sliding scale like this (usually written 0-100; 101-200; 201-300, etc.) is not safe because the MD specifically ordered a call-out if the blood glucose level is above 400 and a nurse following the order AS WRITTEN could be endangering the patient. At my LTC the supervisor would ask the prescriber (when an order like this is first seen) if they could adjust it to "over 400: give 8 units and call MD". Otherwise the RN is defying an order if she gives the 8 units for >400. You are correct
For someone asking, What is it replaced with?— in school nursing, most of the kids have a correction factor. It adds a tiny bit of math to the whole thing. What it means is, How much above target is their current blood sugar? Then you divide by the CF. If their target is 100, and their sugar is currently 200, and their CF is 50, you would do 200-100=100 (so there’s 100 “too much” sugar in their blood). If their correction factor is 50, you’d give 2 units. One for each 50 “too much.”
We had some orders like this, with the correction factors, a few years ago...evidently many of my fellow nurses can't do math...it was more dangerous than the sliding scale orders. ?
We had some orders like this, with the correction factors, a few years ago...evidently many of my fellow nurses can't do math...it was more dangerous than the sliding scale orders. ?
Oy. Yes, I did run into one nurse who would panic at the thought of math and become unable to figure out how much to give. Sigh.
Specializes in Kidney Transplant, Case Management, Oncology.
In these situations, I think about how this case would be presented in court. If the nurse is not calling the doctor when the blood sugar is over 400, then they are not following orders, period.
I personally would not want to risk my license just to avoid placing a call to the doctor.
I imagine this is not the first time that you have witnessed nurses doing things their "own way" and it will not be the last. However, this situation seems especially dangerous since this involves critically high blood sugars. 400 is the maximum end of the scale. 401 is already exceeding the maximum treatable value.
You are right to question the actions of your colleague. You are looking out for both the patient and for your license.
On 11/16/2022 at 4:40 PM, nightwingcreations said:
We had some orders like this, with the correction factors, a few years ago...evidently many of my fellow nurses can't do math...it was more dangerous than the sliding scale orders. ?
I think it’s written like that in schools because most of the kids are type 1 diabetics.
When I was a school nurse, I had to count the carbs on their lunch trays, take the blood sugar, and based on carbs eaten and blood sugar, administer the insulin .
Nurse3389
9 Posts
Yes, that is what I meant. Thank you for assisting with the clarification. Here in Oregon (Portland Metro) the standard is to d/c sliding scales in the SNF setting, still a standard in hospitals.