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?
Did I misunderstand- the patient arrived at 1700- shift change is 1900? The day nurse was finishing her end of shift rounds, doing I&O passing her with meals and meds, evaluating her ordered glucoses and giving any ordered "with meals" insulin. In the middle of all that she gets a new admission and manages to get him a supper tray, and at least begin the admission process- I think you are nit-picking. If the patient had been there 6 hrs, was showing ALOC, unstable VS, or anything that would indicate a "critical" status I imagine a glucometer would have been done stat. As it was, the problem was identified within a few hours of admission and addressed. That is why we have 24/7 nursing staff. By-the-way- She isn't a doctor. The decision to get a "stat" admission glucose isn't hers to make without supportive police and SS indicating the need. It wasn't a bad idea, but the admitting physician should have admitted the patient as "critical hyperglycemia" if ther was any indication of this patients glucose status. I would bet- based on the fact the patient wasn't showing profound outward changes in his physical status, that the patient has been living in this range for a while. Take a well controlled presons glucose over 400 and you are going to need an ICU. As much as it was a busy patient for you, getting a patient a supper tray who arrives at supper time and giving it to him without checking labs is not the end of the world. It wasn't a glass of juice that bumped his glucose almost to 4digits- it was his non-compliance. That isn't your co-workers fault.
Specializes in Medsurg/ICU, Mental Health, Home Health.
Thanks, everyone, for your input and taking the time out to read what I typed. I'm not going to do anything about it. I may mention it to her casually (not that she didn't get his accucheck but that his sugar was so darned high!) I know I should have asked what his AC sugar was, and that was completely my fault. I also believe I came across in a way that I did not intend to come across. I was angry that I had to try to correct this problem when I did. Had the accucheck been obtained, this problem could have been nipped in the bud. I know that there is plenty of blame to go around, trust me. I still believe I was not wrong in being angry. I don't make it a point to become angry over trivial things, but, as I said, my charge nurse who is never upset was mad. Sorry if you all got the wrong impression of me. I think I picked the wrong day to change my username as well, haha.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
No worries, CamaroNurse. You were upset-- probably a good choice to come on here and vent your feelings. It may have helped you not say something to your friend in the heat of the moment, which, if you're like me, tends to create more issues!
Yes, you've caught me. I really just want my friend to get fired. Instead of caring for patients, I go around and read her charts to see what has and has not been done. Then I add it to my list in her entry of my notebook of atrocities committed by day shift nurses. All of the night shift nurses have these notebooks. On Monday, Wednesday and Saturday nights, we share the entries with each other. It's such a blast! The best is biting the heads off of new day shift nurses during report, reprimanding them for not clearing their IV pumps. That's why I became a nurse!
I'm sorry you took that personally and it wasn't meant to be. As I said, I used to work nights, I worked all the shifts! And like it or not, the different shifts have different personalities. And yes, what you describe is very typical of night shift-not meant to be a slam. It's just kind of funny how things never change.
Did I misunderstand- the patient arrived at 1700- shift change is 1900? The day nurse was finishing her end of shift rounds, doing I&O passing her with meals and meds, evaluating her ordered glucoses and giving any ordered "with meals" insulin. In the middle of all that she gets a new admission and manages to get him a supper tray, and at least begin the admission process- I think you are nit-picking. If the patient had been there 6 hrs, was showing ALOC, unstable VS, or anything that would indicate a "critical" status I imagine a glucometer would have been done stat. As it was, the problem was identified within a few hours of admission and addressed. That is why we have 24/7 nursing staff. By-the-way- She isn't a doctor. The decision to get a "stat" admission glucose isn't hers to make without supportive police and SS indicating the need. It wasn't a bad idea, but the admitting physician should have admitted the patient as "critical hyperglycemia" if ther was any indication of this patients glucose status. I would bet- based on the fact the patient wasn't showing profound outward changes in his physical status, that the patient has been living in this range for a while. Take a well controlled presons glucose over 400 and you are going to need an ICU. As much as it was a busy patient for you, getting a patient a supper tray who arrives at supper time and giving it to him without checking labs is not the end of the world. It wasn't a glass of juice that bumped his glucose almost to 4digits- it was his non-compliance. That isn't your co-workers fault.
I have to say Camaro- the fact that are sensitive to the fact that confrontation is sometimes a risky road shows a level of maturity not seen in many younger nurses. Sometimes it can be hard pointing out an error or lapse in judgement to someone that we have to work with everyday. I firmly believe that seeking counsel of others with more experience and wisdom *insert chuckle here* can be very beneficial. Many nurses young and old fail to do that oftentimes. Best wishes to you in your future endeavors.
By the way... does anyone know when I became one of the "old" nurses??
It sounds like you have spent a lot of time checking up on all the things your co-worker does not get done. That is quite typical of night shift nurses IMO, they were usually the most judgmental during report and they were always the first ones to point out what didn't get done.
As a night shifter, this really, really annoyed me...all the more so because upon further reflection, I think you might be right. I'll have to watch myself a little more closely, make sure I'm not falling into that pattern.
suanna
1,549 Posts
Did I misunderstand- the patient arrived at 1700- shift change is 1900? The day nurse was finishing her end of shift rounds, doing I&O passing her with meals and meds, evaluating her ordered glucoses and giving any ordered "with meals" insulin. In the middle of all that she gets a new admission and manages to get him a supper tray, and at least begin the admission process- I think you are nit-picking. If the patient had been there 6 hrs, was showing ALOC, unstable VS, or anything that would indicate a "critical" status I imagine a glucometer would have been done stat. As it was, the problem was identified within a few hours of admission and addressed. That is why we have 24/7 nursing staff. By-the-way- She isn't a doctor. The decision to get a "stat" admission glucose isn't hers to make without supportive police and SS indicating the need. It wasn't a bad idea, but the admitting physician should have admitted the patient as "critical hyperglycemia" if ther was any indication of this patients glucose status. I would bet- based on the fact the patient wasn't showing profound outward changes in his physical status, that the patient has been living in this range for a while. Take a well controlled presons glucose over 400 and you are going to need an ICU. As much as it was a busy patient for you, getting a patient a supper tray who arrives at supper time and giving it to him without checking labs is not the end of the world. It wasn't a glass of juice that bumped his glucose almost to 4digits- it was his non-compliance. That isn't your co-workers fault.