Nurse's Discretion Dilemma

[BizzieRN]

I am a night charge nurse that works in diabetic research. Two nights ago I was given shift report about a subject with a low blood sugar. Well come to find out the evening nurse had allowed the subject to administered 35 units of Humalog with a BS of 108, post dinner. At the time for HS snack the subject was down to 56 and symptomatic. Administered the snack right away, and continued to monitor his BS Q15mins until symptoms subsided. The subject continued to be on a roller coaster with his BS's and finally at HS he was 52 and I suggested to the nurse assigned that he should obtained fingersticks at his discretion and administer OJ and crackers before bed. Then came the big question....should I administer the 30 units of Lantus? I advised no. The subject was obviously unstable and I wanted to avoid any more dips in his BS. We should wait until morning and see what the doctors would like to do with his regimen of insulin. So the nurse held the Lantus, and agreed to report to the day nurses to notify the doctors in the morning. 0200 the subject was back up to 78,asymptomatic. The next morning the day nurse failed to notify the doctor, and the doctor found out the hard way about the Lantus being held the night before. The doctor had a hissy fit! And these are the new rules that came from the Doctor's hissy fit...

Now if a nurse is going to hold any medication....we have to obtain a doctor's order. Now if the subject wants to administer any more or less insulin than what is written in their medication history....we must obtain an order.

Nurse's discretion is somewhat of a gray area, but it falls under the oath of patient safety. I know in a hospital setting I held insulin all the time for low BS, also B/P meds, without an order. I'm just wondering if I used my nursing discretion correctly? I know Lantus peaks in 6 hours (and good thing the subject didn't get lantus, b/c he was down in the 40's in the AM), but I am monitoring subject safety. And I thought that was the safest thing to do within my scope of practice for that particular study.

The doctors do not want to be notified in the middle of the night unless the subject is symptomatic, or if it's an emergency. But its such a catch 22 sometimes! The doctors get mad b/c my night nurses don't call them, but whenever we call we get rude answers and attitudes. Plus the questioning of why it couldn't wait until morning. Sometimes I feel like I never make the right decision, and my nursing discretion sucks....

These new rules about obtaining an order for holding medications are irrational. Do nurses need to have the hands held so much or am I feeling belittled?

Anyways, thx for letting me vent.

[Straydandelion]

Nurses are no longer absolved of poor practice as a result of following doctor's orders. Thus, nurses are held to standards of care that are more rigorous than in days past and are held accountable for increasing professional judgment.

http://www.nursingworld.org/mods/archive/mod310/cerm101.htm

I would say definitely call, but a nurse has to use good judgement also. I will be interested to hear what others have to say.

[CoffeeRTC, BSN, RN]

I would have held it, but called the doc about it that night.

I work LTC and a lot of times you need to go with your gut. In that type of setting it is easier to treat hi BS rather than low.

[greenterra]

Hi BizzieRN!

It sounds to me like you are a great patient advocate. Your Doc sounds like his priorities are not screwed on quite right-- a minor setback in whatever research is being done is definitely a reasonable cost to pay to avoid serious harm to the "subject", and playing around with blood sugars less than 60 for prolonged periods sounds like an accident waiting to happen.

And what kind of protocol tells the subjects that they don't have the autonomy to decide to hold their insulin dose if it is less than 60 on their own?

Is there any kind of chain of command in this non-hospital facility that might help give you a reasonable scope of practice? Another suggestion-- contact your state board of nursing ASAP and try to get an immediate opinion. I bet they will say that if a nurse fails to hold insulin when needed, even under a doctor's order, and the client/patient/subject is injured, that nurse can be held negligent.

[lpnflorida]

In our hospital we have to notify the doctor and then based on his orders we will either give or hold. We don't get to make the decision as it is considered prescribing. Yes, we can hold until we speak to the doctor that is prudent. Policy is we contact them right away.

If a medication such as a blood pressure medication has a written order with parameters, if spb

[lovingtheunloved, ASN, RN]

Wake the docs up enough times, and they'll change their minds.

[Dolce, RN]

Wake the docs up enough times, and they'll change their minds.

Yes, and state, "It is our new policy initiated by Dr. So-and-so to notify you of any medication being held for a patient. I held Mr. Johnson's colace tonight because his stool was just a littttle too runny today. Can I please get an order for that?" Be sure to make this phone call at 2:30 am.

[lpnflorida]

One can hardly equate colace to insulin .

I can see the point.I can make a case for calling a doctor in some cases and why we do not for others. That is using our nursing judgement, with the understanding a doctor gets in a snit about why you did not give something to his patient when his orders read to give we accept the position we put ourselves in.

As nurses most of us know which doctors are reasonable in regards to low bp say 102/68, no parameters but we know as the doctor has told in the past if patient is not having symptoms give the med . We know of other doctors who want to be notified, that does not mean at 3 am we call him because we held a med at 9 pm, we use the good judgement of calling him within a reasonable time, say by 10 pm. Those are nursing descretion types of scenarios.

The one in regard to Lantus unless I had an order to hold the med I would call the doctor with my concerns and let him make the decision.

We also had that happen on our a unit. A nurse held Lantus, again she had a strong rational as to why, however the doctor felt differently.Was not pleasant when he asked her when she got her medical degree to prescribed or change orders. He made his point.

It is why our diabetic policies and order sets have been changed in our facility with standardized order sets in regards to treating diabetics it goes step by step by step in the new orders now.

This way our patients get good care /treatment of their diabetics. We are happier as we are guided better and protected as we follow policy and orders. Lastly the doctors are happy.

[thegreenmile]

Responding to a page at ANY hour is the responsibility of the physician on call. If being on call is an irritant, that turns them into a monster, then these physicians have the same professional choices that you and I have, seek other employment that doesn't require this duty. We must adhere to our legal scope of practice. In doing so it does not give the Dr. ANY right to demean, belittle or harass us. I simply, with poise and ettiquette, confront them with their behavior and remind them of my job responsibilities as well as their own. I then make certain that the unit manager is aware of the Lateral Violence that took place and remind her that I was undeserving of the treatment I received and refuse to tolerate it. It never ceases to amaze me how unprofessional professionals can be. I believe that we are treated exactly how we allow ourselves to be treated. :argue:

[lpnflorida]

Responding to a page at ANY hour is the responsibility of the physician on call. If being on call is an irritant, that turns them into a monster, then these physicians have the same professional choices that you and I have, seek other employment that doesn't require this duty. We must adhere to our legal scope of practice. In doing so it does not give the Dr. ANY right to demean, belittle or harass us. I simply, with poise and ettiquette, confront them with their behavior and remind them of my job responsibilities as well as their own. I then make certain that the unit manager is aware of the Lateral Violence that took place and remind her that I was undeserving of the treatment I received and refuse to tolerate it. It never ceases to amaze me how unprofessional professionals can be. I believe that we are treated exactly how we allow ourselves to be treated. :argue:

First off this doctor the original poster was speaking of was mad he was not called. Now her statement he had a hissy fit,, to me does not indicate positively anything about lateral violence. If a doctor gets justifiably angry at us when we don't follow his orders, our response should be I am sorry . It won't happen again. Now if she had given a better description as to what the hissy fit entailed, then one could look at lateral violence. One doctor's hissy fit, might only be a look , a statement of his displeasure which had not ever been seen before. Or in the case of a very meek , mild doctor I once observed. Walking down the hallway, throwing his hands up in the air saying MERRY CHRISTMAS,, We knew when we saw it and heard it, just how upset he was, even though it was only spoken to the air as he was walking away. that was his so called hissy fit.

[thegreenmile]

I was refering to the paragraph in the post thats copied and pasted below:

"The doctors do not want to be notified in the middle of the night unless the subject is symptomatic, or if it's an emergency. But its such a catch 22 sometimes! The doctors get mad b/c my night nurses don't call them, but whenever we call we get rude answers and attitudes. Plus the questioning of why it couldn't wait until morning. Sometimes I feel like I never make the right decision, and my nursing discretion sucks...."

Sorry you've misinterpreted my comments........

[lpnflorida]

Thegreenmile,

I am sorry I misunderstood.