New Nurse, when to send a patient out.


I am a new Nurse, first job in a Nursing home. We just had a meeting about INTERACT and trying to avoid sending patients to ER when not necessary...

last night had a patient who is a diabetic, blood sugar before dinner was 77, gave her 30 grams of Carbs, blood sugar up to 130...she was a little sleepy but not not lethargic. The med nurse held off on her insulin (22 units of NPH) she ate a little of her dinner, started to become more lethargic, I took her vitals, temp did a quick assessment. she was responding to verbal commands but very sleepy and lethargic. I called the MD ( who is always very impatient with me cause I'm new) and reported her condition. He ordered only half of her insuline dose to be given. I mentioned to him that she was becoming lethargic and not herself. He snapped at me that her sugar wasn't low enough to cause these symptoms. Then I mentioned to him that she usually runs around 200-250 so that is low for her. Then he snaps "well then send her out if you want"

later I learned that my DON isn't too happy that I sent her out and that I should have made suggestions to the MD first. Like What? I'm not too confindent yet on making these decisions, I thought best to be safe than sorry.

What other assessments could I have made? or could I have requested what type of lab tests? Any suggestions or comments on this situation would be appreciated.



netglow, ASN, RN

4,412 Posts

Ridiculous response from the MD. Hate it when they just say "do what you want, then" --just like a little kid. PMO.

Your supervisor sounds like a doormat. Just by her response she doesn't sound like she has the experience needed for her job.

All I can think of is a review of her hx, comorbidities, etc. You say you did do an assessment. I assume you didn't find anything of note. Your MD should know that lethargy is a sign you should consider if it is a marked change in the elderly... usual suspects are UTI, stroke...

MN-Nurse, ASN, RN

1,398 Posts

Specializes in Med Surg - Renal.
I mentioned to him that she was becoming lethargic and not herself. He snapped at me that her sugar wasn't low enough to cause these symptoms.

Which would infer that something ELSE could be wrong with her.


12 Posts

Has 1 years experience.

Yeah, because the only cause of lethargy is a low blood sugar, right?I would go with neuro assessment and cardiac assessment. Also would consider what medications the patient is on. By showing the MD that you are thinking critically it may flip a switch in them to think critically as well and consider that something deeper may be going on. Good work advocating for your patient; better to over react than to under react. Experience will help you to discern, but really I am always paranoid of the worst case scenario.


1,131 Posts

Specializes in ICU.

You did not mention her vital signs? HR, RR, BP, Temp???? Very basic things to do when you suspect something wrong with your patient. Were these done and were they stable?


437 Posts

So her blood sugar was lower than her usual. Have had diabetics tell me they feel bad for quite a while after low blood sugars. You treated it appropriately and lowering dose of insulin seems appropriate. Maybe lethargy was just because blood sugar was low.

Did they keep her at hospital or was she sent right back? When she gets back read the discharge summary to see if they found another reason she could have been lethargic. Then you will have an idea if you overreacted or made the right decision. Either way just use it as a learning experience. Each situation will be different and sometime 20-20 hindsight is the only way to know rather we are right or not.


511 Posts

Could it be that she was just suffering from a lack of sleep?


932 Posts

The dr. was being a snot, no question about it. But when you call a dr. you need to have more data than just that her bs was low -- and depending on the time of day, 77 is really not low enough to be a concern if you can get some food into her. Did she have parameters for her insulins? That would have been a good thing to get from that conversation for future concerns.

Things to have in front of you before you call: What were her vitals? What was her pulse ox? Was she hypotensive? (is she on anti-HTN meds and does she have parameters)? Was she hypoxic? Is she on O2? What did her skin and mucus membranes look like? What about her lung sounds? What was her neuro status, output, what did her urine look like? Smell like? What about her bowel sounds, was she constipated? Did she have diarrhea? How long had the symptoms been going on? Was she lethargic and confused? Or was she lethargic but appropriately responsive?

Many, many things to consider. You'll get it with practice. But don't let the drs. get you down. The best defense is a good offense, which consists of a page full of assessment info and info about her meds and other dx. And also, a clear idea of what you want, but that comes with practice.

Out of curiosity, what did the hospital diagnose her with?


173 Posts

Mazy, thanks for the great response and all the advice. Went to work tonight and found out my patient was admitted with Hypoglycemia, and acute renal failure. So I am glad I went with my gut and sent her out. I did learn from this to do a very thorough assessment before calling the MD and have all the information available when I call him.

Every day is a learning experience, I just cant wait for the day that I don't doubt myself! :confused:

thanks for all the repsonses


CapeCodMermaid, RN

6,089 Posts

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

The worst place for an old person to be is in the hospital. The ambulance ride there is traumatic, the staff doesn't know them as well as you do. If they are a bit confused they become moreso. That's why we should all try to treat them in the facility.That being said, there are times when it is prudent to send someone out. It's important to trust your instintcts. You will learn as you get more experience what you can and can't treat in your facility.A good idea is to read the hospital summary. Did they do anything there that you couldn't have done?


33 Posts

Specializes in Med-Surg. Has 2 years experience.

Acute renal failure? Do you treat that at your facility? You did right! Trust your instincts.


664 Posts

Specializes in LTC.

Good girl! ALWAYS trust your instincts even when more experienced people don' I'm sure the Doctor and your boss feels like eating crow...heck I do after reading your update..I seriously was just gonna say she probbly was lethargic based on the fact that she'd been low..but n o...something else was wrong. You did good. Always always go with your gut. 8 out of 10 times it'll be's the 2 times it's wrong that make you feel stupid....but you know the residents better then any one.

As for suggestions for the could have said "You want us to just monitor it then?" And if he said yes, then you chart that, then when **** hits the's his fault because he ordered you to just monitor it.... Always chart everything you talk about with the doc..."Notified MD of xyz, MD orders to monitor for further changes this evening"

Sounds like you've got good common sense and a good gut...