I work on a med-surg unit with plenty of diabetic patients. Most are noncompliant with high A1Cs and are always demanding cookies.
I try to find a balance. Last week I had a 400 pound patient demanding multiple snacks outside of his diet. He had a wound that wasn't healing and I explained to him that high blood sugar levels could interfere with the healing process. He still demanded that I give him whatever he wanted. I managed to convince him to meet me in the middle and have one of what he wanted instead of two of everything and covered his carbs and blood sugar.
So question: when a diabetic patient demands sweets, has high blood sugars and isn't NPO or clear liquids for a procedure, do you just continue to give them all the snacks they want? Or do you insist that if they want to be noncompliant with the hospital diet that they must get their own treats?
Dealing with any disease on a daily basis can become overwhelming. As nurses, we want to jump in, find the problem, and right the wrong that is causing the issue. Although many times this will work, for many chronically ill patients, there is much more involved in "fixing" them. The nurse that cares for this patient while hospitalized, sadly, will likely have little impact on his overall glucose control. You are correct that education is not the answer, but likely motivating the patient to better care for themselves, and make better choices. How would this be possible in a twelve hour shift? It wouldn't. That is why they need follow up care, accountability, and further encouragement on an ongoing basis. Many outpatient diabetes management centers are providing this for patients, and seeing success in some patients. Unfortunately, not all patients are at a point in their lives that they are able to be motivated to care for themselves. Sometimes, their other illnesses, including depression, make the situation unbearable, and they can only do the best they can, even if that means their choices are not the best choices. Do you have an inpatient diabetes educator? These things should be addressed and perhaps, they could be addressed by someone that does not have a horse in the race, so to speak. This educator could make appropriate referrals and have this patient follow up for chronic disease management and weight loss programs that will have a much bigger impact on overall health than simply withholding a cookie.
Our meal service ends at 6:30pm. We have patients all the time that are kept NPO all day, finally taken for their scope or whatnot at 3:30pm, and come back to the unit at 7pm. We'll also have patients fall asleep or feel nauseated and not order dinner and be starving come 11pm. We have patients who get an upset stomach if they take their pills without food, so those crackers are a lifesaver for a 2am antibiotic. And we'll have patients that need applesauce or pudding to get down some horse pills. Finally, having juice and crackers available on the unit is a literal lifesaver with a hypoglycemic patient.
Okay, of course there should be something available for medication that can't be taken on an empty stomach or when someone is hypoglycemic. When I have a patient who is NPO all day I still get them to order food and then I just hold it until after the procedure. I really meant snacks for the purpose of snacking, or trying to beat the record for the most graham crackers eaten in one day.
Okay, of course there should be something available for medication that can't be taken on an empty stomach or when someone is hypoglycemic. When I have a patient who is NPO all day I still get them to order food and then I just hold it until after the procedure. I really meant snacks for the purpose of snacking, or trying to beat the record for the most graham crackers eaten in one day.
Yeah, can't say I disagree with you there in the graham cracker record issue. We're not able to order trays for our patients with an active NPO order, even if they're planning to rescind it after the procedure with our system. Crummy set up.
Maybe it's because I work oncology where my patients have a poor appetite and we're constantly trying to force calories into them wherever we can get them (yes, even diabetics from carbs), but this isn't much of an issue on my unit.
I personally don't find graham crackers too appetizing. Maybe too many nights of having graham crackers and peanut butter and milk shoved into me at 2200 at camp to prevent hypoglycemia.
Yeah, can't say I disagree with you there in the graham cracker record issue. We're not able to order trays for our patients with an active NPO order, even if they're planning to rescind it after the procedure with our system. Crummy set up.
Maybe it's because I work oncology where my patients have a poor appetite and we're constantly trying to force calories into them wherever we can get them (yes, even diabetics from carbs), but this isn't much of an issue on my unit.
I personally don't find graham crackers too appetizing. Maybe too many nights of having graham crackers and peanut butter and milk shoved into me at 2200 at camp to prevent hypoglycemia.
To be fair, I wouldn't be as opposed to snacks if there was anything available with any sort of nutritional value.
I explain to my patients in detail about their fingerstick blood glucose numbers and what they mean when I do my first rounds/before meds; document this education. If I check it and it's within a normal range, yes, you can have a small snack as described in our protocols after your meds, especially if you are getting long acting insulin as well. However, I make sure I'm clear that "this is your diet order while you are here, these are the parameters, and I will not be giving you XYZ after this time, and you will not receive it from me if your blood glucose is above XYZ number." However, I do not stop these patients if family members or they go down to the cafeteria and get food/bring food. I simply document that I educated and pt continues to eat foods outside of diet parameters, sometimes, I even document exactly which family member brought what into the room. I do the same with CHF pts when they ask for extra drinks - I educate them, check their numbers, determine if they can have an extra drink at night.
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I look at extra snacks,drinks, meds, any requests for special things - from a court of law perspective. I don't care about the HCAHPS and neither will an attorney when someone sues me. If I'm not following the parameters/orders that are laid out, the patient is going to say "well my nurse gave it to me and she should have known/explained it better." Then it's going to be my burden of proof to determine what a competent nurse would have done with the situation. I won't be able to start my statement with "Well, my manager/hospital/ownership group wanted better HCAHPS scores..." because we all know what would come after that - (Insert my mom's voice here) "If they told you to jump off the bridge, would you do that too?"
@llg- What else can you do as a floor nurse besides education? You have a valid point. I've found many times the pt knows more than I do regarding how to control their blood sugars. So to lecture them on things they already know seems kind of pointless. But I also understand that we need to control their BS for the brief period they're on the unit so they can heal better. I suppose we can also educate them/refer them to resources that can help them manage things like stress, etc. although I for one wouldnt be very good at educating them how to manage stress better...
A good many of these patients have a stash of junk food the family brings them or the family enables them in some other way.
One Xmas Eve, I had a new admission-a pt. w/a BKA. She was also legally blind, on hemodialysis, serious neuropathy and had C-dif to boot.
She had refused her supper tray so her husband went out & brought back this box of fried chicken from Popeye's with at least 10 pieces in it.
That was gone in less than an hour. Then, he went to the 24-hr Walgreens & came back with a quart of eggnog & she drank the entire quart in 30 minutes. Then, she starts complaining about how bad she felt, demanding blood sugars be taken & I guess I don't need to mention what all this did to her C-dif situation. Never mind the fact I had several other pts. to take care of, including two other admissions to complete. She took up all of my time & attention & I had to fight like h*ll to get to any of the other pts. I had to call the MD to get insulin orders because her blood sugar was over 400. When I explained what had been going on, he said "Just take the food away from her." Yeah, right, then the husband would bring her some more. I had tried to talk with him & explain healthier options, e.g. grilled chicken instead of fried, & in a reasonable amount, & his response was "Well, I got her what she asked for."
Next shift, Xmas night, was even worse. The pt. had visitors all day, bringing plates of food, including a whole sweet potato pie, a plate of sliced ham at least 4 inches high, regular soda, cranberry sauce, all sorts of desserts-you name it, she had it. The nurse before me told me in report she had been eating all day & the nurse had to get orders to cover her blood sugars. The MD still didn't see why we couldn't just take the food away or tell the visitors she couldn't have it. It was more of the same that night, complaints of discomfort, massive diarrhea, blood sugars & so forth.
The final outcome was that year, 12/26 fell on a Sunday. She started going into fluid overload mid-morning so a dialysis nurse had to come in to do an emergency treatment. Her last scheduled treatment had been on 12/24 just before she came to us. This pt. was a frequent flyer, ended up with an aka & a bka on the opposite leg.
Specializes in M/S, Pulmonary, Travel, Homecare, Psych..
I work on a med-surg unit with plenty of diabetic patients. Most are noncompliant with high A1Cs and are always demanding cookies.
I try to find a balance. Last week I had a 400 pound patient demanding multiple snacks outside of his diet. He had a wound that wasn't healing and I explained to him that high blood sugar levels could interfere with the healing process. He still demanded that I give him whatever he wanted. I managed to convince him to meet me in the middle and have one of what he wanted instead of two of everything and covered his carbs and blood sugar.
So question: when a diabetic patient demands sweets, has high blood sugars and isn't NPO or clear liquids for a procedure, do you just continue to give them all the snacks they want? Or do you insist that if they want to be noncompliant with the hospital diet that they must get their own treats?
This is a dangerous situation. It's one of those situations where the admin. of your facility will push for higher review scores (from the patient) and insist you comply with their demands.
BUT: Do not be naive about it. If their advice to you leads to a poor outcome for the patient........(snickers)....well, you'll get a nice close look at the belly of a bus while you go under it.
I deal with this by first, report the behavior to a superior, and document the fact. Usually they are no help, they'll be too busy to listen or will give you an over opinionated response "Then don't give it to him, let him complain all night." Again, don't be naive, if the patient complains, they won't admit that this was the advice you got from them. Tell them about the problem, document you did go to your superiors and then move on to the intervention that will truly save you, regardless of what happens.
That intervention is: Get the Doctor's input. And make them give a verbal for whatever their decision is. Ask them what they want done: Give the snacks and treat the blood sugar with the insulin orders as the stand? Give the snacks but perform more blood sugar monitoring checks? Refuse the snacks?
Once you have those orders done, you can proceed with grace. While talking to the Doctor, suggest a dietary educator consult. Perhaps even more will be necessary, such as a psych consult. Most certainly make sure the wound care team is aware of the non compliance, as they will have opportunities to educate as well.
In short, don't perform medicine without a license (doing things not explicitly ordered insulin wise....I only say it cause I know so many people who have done it). But make your care holistic by bringing in the Doctor and other members to adjust the plan of care. All the interventions will lead to a better educated patient who will then be allowed to practice autonomy.
Then, two years later, when that very same patient is having their leg amputated, there is proof they are not the victims of not being educated.
(folds arms in front of herself) "Well, I'd not have eaten all those snacks had my RN told me it was going to lead to this. She was practically shoving them down my throat. Get me a lawyer."
Cheap refined carbs,that I would not feed to my dog.
That's a bit judgmental and taking it a bit far. Yes, it is simple but it's not meant to be a replacement or to be eaten all the time. It would be much more of a problem/more expense to keep fruit and veggies continually available. That's why those are on meal trays and snacks aren't offered regularly.
How is that judgmental?
They are cheap and refined. And apparently BTDT has high standards for his/her dog.
I know several people who have dogs who get better food than the average American.
I personally don't see a huge difference in providing high fructose corn syrup to a diabetic and giving a knife to a superficial cutter.
Of course I know there is a difference- I would get in big trouble for providing a knife to a cutter.
As far as the soda- I work ER, so a little different. A non-compliant diabetic comes in with a sprained ankle? Sure, have a soda. In the big picture of you poisoning yourself, this is trivial.
OTOH, come in with complaints related to elevated bs, and I am not getting you a soda.
Thanks for the replies, everyone. I appreciate all the insight.
I have come to the conclusion that a patient can't be forced into compliance and all one can really do is document and educate. It is tough watching patients self-destruct.
outsidethebox
17 Posts
Dealing with any disease on a daily basis can become overwhelming. As nurses, we want to jump in, find the problem, and right the wrong that is causing the issue. Although many times this will work, for many chronically ill patients, there is much more involved in "fixing" them. The nurse that cares for this patient while hospitalized, sadly, will likely have little impact on his overall glucose control. You are correct that education is not the answer, but likely motivating the patient to better care for themselves, and make better choices. How would this be possible in a twelve hour shift? It wouldn't. That is why they need follow up care, accountability, and further encouragement on an ongoing basis. Many outpatient diabetes management centers are providing this for patients, and seeing success in some patients. Unfortunately, not all patients are at a point in their lives that they are able to be motivated to care for themselves. Sometimes, their other illnesses, including depression, make the situation unbearable, and they can only do the best they can, even if that means their choices are not the best choices. Do you have an inpatient diabetes educator? These things should be addressed and perhaps, they could be addressed by someone that does not have a horse in the race, so to speak. This educator could make appropriate referrals and have this patient follow up for chronic disease management and weight loss programs that will have a much bigger impact on overall health than simply withholding a cookie.