No Sugar Tonight (Da-un-do-dow dow da-un-do-dow)

[Penelope_Pitstop, BSN, RN]

I work 7P-7A on a fairly busy adult medicine floor. Thursday morning, I reported off to a nurse with whom I've worked for more than three years (and who is more experienced than I am). I knew one of the patients would be discharged. I was correct, and when I returned Thursday evening, there was a new patient in his place. He'd arrived at 1700 or so as a direct admit, diagnoses dehydration and diabetic foot ulcers. She said he was a miserable old man and was only happy after she gave him a supper tray. Also, the hospitalist on call hadn't been up to assess him yet, but did provide a few orders concerning insulin, antibiotics, and diagnostic studies.

I went in to assess the man, and he was cool with me, but not rude or anything. I learned that he took pain medicine at home and hadn't had any all day. I paged the hospitalist and received an order for pain medicine, as well as assurance that he would be up to see the man in person. After the patient's pain medicine kicked in, he was very pleasant and cooperative, deciding to nap until the doctor arrived.

By this time, it was HS accucheck hour. The PCT came out to tell me that the machine was reading "critical high." I told him to repeat the test as per policy and looked on the computer to see what he was before supper. That's when I discovered my problem. No one had yet performed any sort of glucose test on him. But, as I told you, he ate a meal. Also, the RN before me gave him orange juice with his food. The tech came out and told me the reading was still "critical high" (that means greater than 500) and that the patient had said to him, "it doesn't surprise me because I'm really thirsty and peeing a lot. I knew it would be high. And I haven't had insulin in a few days because of insurance issues." The thing is, the admitting nurse, whom I'd relieved, KNEW all of this. Yet did not think it pertinent to do a fingerstick!

Thankfully, the hospitalist then arrived, I told him what the deal was, and he ordered a stat Basic Metabolic Panel. He assessed the patient, wrote a few new orders, then told me to page when the result came back and we'd figure out a plan then for getting his sugar down.

The man's sugar was...*drumroll* 967! His vitals were stable, sodium was low and potassium was high, but he didn't have a gap, so thankfully no DKA. The on-call hospitalist was by this time someone else, and she gave me orders for a NOW dose of 20 units of Novolog, plus 45 units of Lantus, and normal saline at 250 mL/hr, as well as Q2 accuchecks. By 6 AM, his sugar was 170 and his I's & O's began to regulate. So all turned out well, and I was glad that it happened by the time 7AM rolled around (although I was reporting off to a different nurse this time).

What grinds my gears is that NO ONE DID AN ACCUCHECK! I'm sorry, but if a patient is admitted for diabetic reasons, or is a diabetic admitted for any other reason, wouldn't a glucose reading be obtained relatively quickly? (Especially if the patient was a direct admit and therefore didn't receive the usual ER lab studies). I feel terrible that I hadn't asked what his sugar was before supper, but I assumed that this nurse, who is actually one of the most experienced day shift nurses, and whom I've worked beside and known for so long, wouldn't have fed him without checking the sugar. If she had done this, his sugar wouldn't have climbed so very high!

ARGH!

So...what do I do now? Talk to my coworker? Go to management? Write an incident report? All of these things?

Thanks!

[Virgo_RN, BSN, RN]

Does your facility not have some sort of insulin protocol for diabetic patients?

[caliotter3]

Wow! I'm not experienced enough in such things as to advise you. I would imagine the least would be to talk to her. I think she had a massive brain out to lunch episode.

[Penelope_Pitstop, BSN, RN]

Does your facility not have some sort of insulin protocol for diabetic patients?

I don't understand what you're asking. We have set sliding correction scales, yes, but physicians are not required to choose one of those. We also have a hypoglycemia algorithm, but not one for critical blood sugars (anything greater than 400 is considered critical).

[Hoozdo, ADN]

Always talk to your coworker, if possible, before you write an incident report. Some hospitals treat incident reports in a punitive manner.

[Penelope_Pitstop, BSN, RN]

Always talk to your coworker, if possible, before you write an incident report. Some hospitals treat incident reports in a punitive manner.

*Sigh* I knew that's what people would say. But I hate confrontation. If left to my own devices, I would more than likely do...absolutely nothing. No incident report, no mentioning it to anyone (although everyone who worked that midnight shift with me knew what happened), and certainly no confronting my friend. The weird thing is, I'm plenty assertive for the most part. I guess I don't hate confrontation, just hate confronting friends. Maybe in posting this, I was hoping one of you would offer to talk to her for me?

[canoehead, BSN, RN]

Don't confront, just mention it, because if it was you who forgot, you'd want to know, right? So don't feel guilty, or angry. If you've worked with a good nurse for years eventually s/he'll forget something, it's no biggie in the grand scheme.

[Penelope_Pitstop, BSN, RN]

Don't confront, just mention it, because if it was you who forgot, you'd want to know, right? So don't feel guilty, or angry. If you've worked with a good nurse for years eventually s/he'll forget something, it's no biggie in the grand scheme.

I know I keep making this difficult, but I have noticed a variety of "forgetting" lately from this person. And I do feel angry. But...I promise...in my anger, I will not sin!

[mamamerlee, LPN]

You ABSOLUTELY must talk to your 'friend'. "Oh, byethe way, remember Mr Diabetic leg ulcers? His blood sugar afer dinner was over 900!! And I couldn't find where the results were from earlier fingersticks." She should figure it out from there....

[madwife2002, BSN, RN]

Didn't this pt have labs drawn in the ER what did they show? one meal and OJ doesnt normally send somebody's blood sugar up to over 900 in my experience.

Why was the pt not sent to the ICU?

Do you think it was a true reading because normally it would take a lot longer than a few hours to bring down such a high reading?

What time was the pt admitted and what else was going on?

If you have noticed a lot of errors recently there must be a problem going on with that RN-

I know you dont like confrontations but if you write her up which is what you may have to do without discussing this with her, I seriously think the confrontation will be worse.

You def have a difficult decision to make

[oramar]

Is this an acute medical floor in a hospital? If it is I can't imagine why the doctor didn't order routine labs including a blood glucose. I have worked many places and they all had insulin and diabetic protocols. However, the doctor had to order the protocol and we would carry it out. We certainly could not implement any particular protocol with out OK from doc. You see some of the docs had their own protocol that was different from the hospitals and you didn't want to do something that would conflict with that. So the docs are guilty here also. In the rare case where the diabetic patient got admitted and nothing was ordered we would remind the doc that their were no orders. Yes, once in a while if we saw something amiss we would do a finger stick on our own. But then we would call the doc if something was wrong. But to answer your question about bringing it up to the nurse. All I can say is if I had a brain fart no one ever hesitated to bring it up to me.

[Penelope_Pitstop, BSN, RN]

Didn't this pt have labs drawn in the ER what did they show? one meal and OJ doesnt normally send somebody's blood sugar up to over 900 in my experience.

Why was the pt not sent to the ICU?

Do you think it was a true reading because normally it would take a lot longer than a few hours to bring down such a high reading?

What time was the pt admitted and what else was going on?

If you have noticed a lot of errors recently there must be a problem going on with that RN-

I know you dont like confrontations but if you write her up which is what you may have to do without discussing this with her, I seriously think the confrontation will be worse.

You def have a difficult decision to make

The patient did NOT have labs drawn in the ED, as he was a direct admit.

The patient was not sent to ICU because we were able to get his sugar down, and he was otherwise stable.

Yes, I think it was a true reading, because the lab took so long to report the critical value to me. The rest of the chemistries came back almost an hour before the glucose because they had to verify it or recount it or do whatever it is they do to quadruple check critical findings. The patient himself admitted that he hadn't taken his insulin at home for a few days, so this hyperglycemia was a-brewin' for some time! In brittle diabetics, I have seen blood sugars swing up and down and all over the place pretty darn quickly. And for HHNK patients (I'm guessing that's what was going on here), decreasing osmolality is one of the most important things to do. That was done with the saline. After the hyperosmolality begins to be resolved, the glucose is going to drop. Add that in with the Novolog and...there you have it.

I go back to work tomorrow night, so I still have some time to decide what to do. Thanks, everyone!