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?
Specializes in Medsurg/ICU, Mental Health, Home Health.
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.
Yes, it's an adult medicine floor in an acute care setting.
The doctor did order a BMP (basic metabolic panel) and CBC, as well as blood and wound cultures (AND Accuchecks AC and HS with standing insulin coverages). The patient was admitted around 4 or 5 PM, and the nurse before me obtained orders around 6 PM. At that time, she fed him. The unit clerk was putting in the orders when I was in report and wasn't finished until around eight PM. The labs were put in for "routine" because they weren't ordered "NOW" or "STAT." I changed them to STAT after talking to the doctor because we couldn't get a reading with our glucometer.
So...this is what we have...
Patient arrives on floor from home. Hospitalists are notified of arrival. Admission paper/computer work carried out. Nurse speaks to hospitalist on telephone. Hospitalist gives basic telephone orders, including diet, insulin coverage, lab work and consults. Hospitalist states he will be up to see patient soon but is swamped in ED. The same nurse who receives these orders gives the patient a tray (I don't know if it was a diabetic meal) and orange juice for supper, without performing the ordered accucheck and subsequently administering the ordered prandial insulin.
So, with the basic labs ordered, I don't think I'd be rushing to perform an accucheck. That was done with the labs.
But, until the hospitalist writes orders, all my patients are npo until further notice. Dinner was a mistake.
Also, charting "patient states he is non-compliant with home medications, including insulin therapy ordered at ____, has not taken since (date). labs reveal blood glucose 900 following admission."
The other nurse did botch the job, but the HOSPITALIST and the PATIENT hold the ultimate responsibility for the patient's yucky condition. I realize that patient's non-compliance should have been detected on admission to the floor, regardless of direct admit status. Who did the admit interview?
Specializes in Medsurg/ICU, Mental Health, Home Health.
So, with the basic labs ordered, I don't think I'd be rushing to perform an accucheck. That was done with the labs.
But, until the hospitalist writes orders, all my patients are npo until further notice. Dinner was a mistake.
Also, charting "patient states he is non-compliant with home medications, including insulin therapy ordered at ____, has not taken since (date). labs reveal blood glucose 900 following admission."
The other nurse did botch the job, but the HOSPITALIST and the PATIENT hold the ultimate responsibility for the patient's yucky condition. I realize that patient's non-compliance should have been detected on admission to the floor, regardless of direct admit status. Who did the admit interview?
Nice save, btw.
First of all, thanks for the compliment.
Anyway, the nurse did keep the patient NPO until orders were obtained. She received the order for a Carb-controlled diet along with accuchecks and 10 standing units of Novolog with each meal. THEN she fed the patient. And the lab results were, at the absolute earliest, going to be back to the floor about 10 PM because of routine status, whereas a fingerstick doesn't take nearly as long to obtain results.
The nurse who did this was the one who did the admission interview.
I agree with all the people who say to keep it calm. Getting emotional/angry will only cause problems between the two of you. I like Mamamerlee's suggested approach. Or you could simply say the next time you see her: "Hey, don't forget to check the blood sugar of pts who . . ."
I also agree with canoehead: When we make a mistake, we want to know. But we don't want the person to blow a gasket over it. We want a gentle reminder.
Specializes in Medsurg/ICU, Mental Health, Home Health.
I agree with all the people who say to keep it calm. Getting emotional/angry will only cause problems between the two of you. I like Mamamerlee's suggested approach. Or you could simply say the next time you see her: "Hey, don't forget to check the blood sugar of pts who . . ."
I also agree with canoehead: When we make a mistake, we want to know. But we don't want the person to blow a gasket over it. We want a gentle reminder.
Thanks, but, as I stated, I hate confrontation and am terrified to even mention this calmly to someone. I am angry, because I was left to deal with this issue. I don't think I am wrong in my anger. I'm pretty sure other people here would admit to being ****** about the situation at hand. However, in my anger I have no plans to sin (which wound be tantamount to "blowing a gasket.") So, even if I do end up needing to go to management (and I would choose the assistant manager who has known both of us for a long time and used to be a staff nurse alongside of us) or to write an incident report (dear heavens NO, I think that's even worse) I wouldn't be accusatory or emotional. I was just wondering what, to improve patient outcomes and prevent errors of this nature, I should do. Thank you all for your suggestions.
When I have a diabetic patient that is one of the FIRST questions I ask after the admitting diagnosis-what was his blood sugar?-there is more than enough blame to go around here.
... So, even if I do end up needing to go to management (and I would choose the assistant manager who has known both of us for a long time and used to be a staff nurse alongside of us) or to write an incident report (dear heavens NO, I think that's even worse) I wouldn't be accusatory or emotional. I was just wondering what, to improve patient outcomes and prevent errors of this nature, I should do.
If you have a peer buddy, and someone higher up (supervisor or clinical director) who you might bounce ideas off of that would be helpful. Do you know someone in quality control or education who is a friend you trust? They might be able to neutralize this situation where the other nurse gets the info and you get to relate your side in a safe zone.
Best wishes. Man, I really hope I never get dm, but I hope someone likes you scoops me up off the floor if I ever do.
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!
Is there something personally going on in this person's life that could be causing her 'forgetfulness'-home issues can impact work life.
Specializes in Medsurg/ICU, Mental Health, Home Health.
When I have a diabetic patient that is one of the FIRST questions I ask after the admitting diagnosis-what was his blood sugar?-there is more than enough blame to go around here.
otessa
I know that I should have asked. Usually, I don't ask what a patient's sugars are. And if she told me no accucheck was done, I would have asked the PCT to perform one at that moment. Then, when it came back "critical high," I would have changed the labs to STAT (because technically they were already ordered, just not STAT) then called the doctor to let him know what was going on and to expect another call with the glucose reading, and inform the charge nurse. Until I received the reading, I would have went along with report, then told the day shift RN to go home.
If you have a peer buddy, and someone higher up (supervisor or clinical director) who you might bounce ideas off of that would be helpful. Do you know someone in quality control or education who is a friend you trust? They might be able to neutralize this situation where the other nurse gets the info and you get to relate your side in a safe zone.
Best wishes. Man, I really hope I never get dm, but I hope someone likes you scoops me up off the floor if I ever do.
Again, thanks for the compliment, but all I did was follow hospital policy and carry out physicians' orders!
Is there something personally going on in this person's life that could be causing her 'forgetfulness'-home issues can impact work life.
otessa
Good question, but not that I know of. She started on the floor about nine months before I did and was dealing with the aftershocks of a messy divorce at that time, and it didn't effect her work (if anything work was a sweet release). She just seems really laid back lately (as in - over the last ten months or so). I just worry about this for other reasons, too, because she's often charge or a preceptor.
Is this normal practice for this nurse or just a goof-up? If having a conversation with her will not change future behavior there is no reason to mention it. Do you believe this nurse knows to get a fingerstick BS but for some reason it slipped her mind? I know I may get blasted here- but what purpose would it serve to mention it? There was no bad outcome, it would only make her feel bad for creating a bad situation for the patient and for you having to clean up the mess.
NOw, if she was lazy or neglectful or apathetic....then it would be worth mentioning. But otherwise, I would not say anything. seriously. good luck.
Specializes in Medsurg/ICU, Mental Health, Home Health.
OK- here is my two cents...
Is this normal practice for this nurse or just a goof-up? If having a conversation with her will not change future behavior there is no reason to mention it. Do you believe this nurse knows to get a fingerstick BS but for some reason it slipped her mind? I know I may get blasted here- but what purpose would it serve to mention it? There was no bad outcome, it would only make her feel bad for creating a bad situation for the patient and for you having to clean up the mess.
NOw, if she was lazy or neglectful or apathetic....then it would be worth mentioning. But otherwise, I would not say anything. seriously. good luck.
This isn't what I would call "normal" for her, but her performance has declined. Every time I follow her, I catch errors when doing chart checks (it's always something different, too...sometimes consults aren't called in but the order for it has been signed off, or lab orders are entered incorrectly or not at all but she has signed them off) and if she's back the next day, I'll tell her about it. Her reply is always something like "whoops...sorry!" But it's never a major error or a huge deal because I fix those problems. Also, she doesn't fill out her flow sheets completely or write progression of care notes even if one hasn't been written in days. So, yeah, I think she's getting a bit on the lazy side. Normally I would say nothing (because she wasn't back yesterday morning), but my charge nurse who caught wind of it wasn't very happy, especially since the patient stated that his sugar was high, he hadn't taken his insulin in days, he was polydipsiac, polyuric, and was admitted for complications related to diabetes. She trusts my judgement and didn't want to tell me what to do, but she usually shrugs things off herself. I take stuff in stride as well if it can be fixed, but something about this feels different in the pit of my stomach...
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
I agree...the pt did mention not having any inulin in the last few days due to insurance issues. Even in the LTC home where I used to work, first thing we did with a new admit is take a BG. So I think a few people dropped the ball in this case. You did a good job catching it. I would mention it to your coworker, because they do need to know they missed it, but it can be done in a nice way. Do you guys have a program where you can can emotional support at your work that maybe you can suggest to her. Most places I work have that available. I used it once at one of my jobs and it was so good just to talk to someone neutral.
Penelope_Pitstop, BSN, RN
2,369 Posts
Yes, it's an adult medicine floor in an acute care setting.
The doctor did order a BMP (basic metabolic panel) and CBC, as well as blood and wound cultures (AND Accuchecks AC and HS with standing insulin coverages). The patient was admitted around 4 or 5 PM, and the nurse before me obtained orders around 6 PM. At that time, she fed him. The unit clerk was putting in the orders when I was in report and wasn't finished until around eight PM. The labs were put in for "routine" because they weren't ordered "NOW" or "STAT." I changed them to STAT after talking to the doctor because we couldn't get a reading with our glucometer.
So...this is what we have...
Patient arrives on floor from home. Hospitalists are notified of arrival. Admission paper/computer work carried out. Nurse speaks to hospitalist on telephone. Hospitalist gives basic telephone orders, including diet, insulin coverage, lab work and consults. Hospitalist states he will be up to see patient soon but is swamped in ED. The same nurse who receives these orders gives the patient a tray (I don't know if it was a diabetic meal) and orange juice for supper, without performing the ordered accucheck and subsequently administering the ordered prandial insulin.
Then I arrive at 7PM.