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?
The nurse shouldn't have given the Humalog under these circumstances and Lantus shouldn't be held. I think her initial judgment was very poor in not calling the doctor and questioning 35u for a brittle diabetic with a post-prandial BG of 108. I had a similar situation and the other nurses rode me for holding insulin so we clarified with the doctor and my judgment was deemed correct and I was allowed to hold EXCEPT for the Lantus which smooths things over and works - well, I'm not going to educate the educator.
I wouldn't trust her after that, either. And I understand why the doctor in question saw the need to institute that he be called - there are nurses who work like automotons and simply follow the orders without question, as did the nurse who created the problem with this poor woman.
Suesquash, unless that order for the humalog was specifically written to be given AFTER a meal the order was not followed. While some doctors use to write if patient has eaten only portion of meal give such and such dose of humalog at nurses descretion, yes they would write it just like that.However more commonly most humalog orders read to be given before a meal. I chose not to go into that part as I did not know how that original order might read in regards to the humalog coverage.
I do agree with you, that it sounds like policies got put in place for good reason .
Suesquash, unless that order for the humalog was specifically written to be given AFTER a meal the order was not followed. While some doctors use to write if patient has eaten only portion of meal give such and such dose of humalog at nurses descretion, yes they would write it just like that.However more commonly most humalog orders read to be given before a meal. I chose not to go into that part as I did not know how that original order might read in regards to the humalog coverage.
I do agree with you, that it sounds like policies got put in place for good reason .
Yup. Whatever happened, poor nursing judgment was used.
I would like to thank all of you for your input. I guess the doctor is going to have to get used to getting phone calls in the middle of the night. I just wish she would be more professional on the phone at 0300.
Working in research is sometimes not as cut and dry as working the hospital. We obtain a medication list from the coordinators for each subject, and that is what the subjects have to take. No changes and no deviations from that medication list. But then when they are admitted to our inpatient research unit, we find out that our subjects change their medication regimen in a way the see fit for certain situations (i.e. Taking humalog after eating when they have a low prepranial BS, or only taking 1/2 of a B/P medication at HS for a low B/P during the day. It is up to the subject to take their medications as they would normally take them at home. Now with this new rule, the subjects can't really do that. The subjects' autonomy is gone. There will need to be better med hx's taken by the coordinators to avoid late night calls to them too.
I have learned a valuable lesson from all this. Poor Doctor will be getting a lot more calls than she likes. I feel sorry for her and her family, esspecially considering she has 11 month old baby at home :stone, but she will be getting exactly what she wants.
Approach your doctors when the dust settles and bring up a dialog in regards to patients rights in regards to how they want to take their meds. Ask them how they feel about it. Any patient as we all know has the right to refuse a med often times even our patients in hosp only want to take half a dose of say senokot meaning only 1 pill as opposed to 2. In which case we discuss that with the doctor. Sometimes through open dialog a happy medium can be reached. Our diabetic instructors emphasize that a diabetic, as long as they are not newly diabetic, know their bodies best and adjust accordingly based on that and their own personal experience as to how they react to insulin dosing. Again try bringing up a discussion as to how the doctor would feel about this. Good luck
AH, so the patients are engaged in research about determining for themselves what they should take and when they should take it?
She'd better get used to being awakened, and I rescind my comment about poor nursing judgment being used. If the patients are there and supposed to be screwing around with what they take and when how are the nurses supposed to make decisions?
Now I'm completely confused. As I'll bet the OP is!
I think that we need to all calm down a little bit. It isn't nice when you have a doctor belittle your professional judgement with something such as insulin administration or b.p meds and in having said that it's the same for any kind of meds regardless of how wide a therapudic range they have. In my opinion bizzieRN is entitled to feel the way she does after the response from her docter and likewise it is not always fitting to just explain a doctor's displeasure as a "hissy fit" however in having said that you can't be sure of the severity of the "hissy fit" at either end of the scale. i think that none of us were there so if bizzieRN feels that way it's obviously justified.
SuesquatchRN, BSN, RN
10,263 Posts
The nurse shouldn't have given the Humalog under these circumstances and Lantus shouldn't be held. I think her initial judgment was very poor in not calling the doctor and questioning 35u for a brittle diabetic with a post-prandial BG of 108. I had a similar situation and the other nurses rode me for holding insulin so we clarified with the doctor and my judgment was deemed correct and I was allowed to hold EXCEPT for the Lantus which smooths things over and works - well, I'm not going to educate the educator.
I wouldn't trust her after that, either. And I understand why the doctor in question saw the need to institute that he be called - there are nurses who work like automotons and simply follow the orders without question, as did the nurse who created the problem with this poor woman.