With all the knowledge and experience out here, I'd like you folks' opinion regarding the following scenario:
I was day charge over this past weekend on my floor (Med/Surg-Tele). In taking report from night charge, I learned Saturday that one pt had an 0600 blood sugar of 48 and was given OJ w/sugar. I became a bit upset (this happens all the time) because 1.) our hospital has a standing protocol for all blood sugars below 70: give an amp of D50 and call the doc.; 2.) breakfast doesn't hit the floor until 0800 unless called for earlier, and it rarely is even in these cases; 3.) I've seen pts drop from 60's to 20's in 1/2 hour even with OJ and food, and you can't tell if this pt is one of those. Anyway, night charge basically brushed it off with "pt states she's always this low in the am," and "the OJ worked." (Pt was 68 one hour later.)
On Sunday, same pt was 42, and the same scenario occurred. Night charge and I got into a debate regarding blood sugar management, my opinion being I'd rather push the D50 and spend the rest of the day bringing her down, hers being that D50 was "overkill." (For the record, insulin was being adjusted incrementally.)
I was off Monday, but upon returning to work Wednesday I learned that Monday 0600 pt blood sugar was 36 & OJ was given (AGAIN) because she "was alert and talking." Within 1/2 hour, pt was unresponsive and CODED with a blood sugar of 22!!! Luckily, pt was brought around and as of Friday was still in ICU. Same night charge was on.
I'm angry because I believe we could have avoided putting this poor woman through this life-threatening situation, and I feel vindicated in my opinion because of what happened, but I suppose this could have been an isolated case....what do you think?
The policy at my institution is to treat with fluids or food if patient is able to take po. For instance orange juice without sugar (though for us old nurses who treated pts with oj and sugar for years it is a hard practice to break) and to recheck blood sugars until wnl. If pt can't take po then give D50w. The problem I see with immediately giving d50w is the blood sugar may go up to much. An aide where I work who is diabetic with an insulin pump was taken to the er because of low blood sugar and treated with d50w more than once over her objection. She said she felt terrible until she could get her blood sugar down again and recover from the out of whack sugars. Seems to me the docs should have adjusted the patients insulin dose long before she had 3 mornings of hypoglycemia. Practice changes over time. What we do today may change tomorrow. Don't be too critical of the nurse who gave oj with sugar. She did get the patients blood sugar to wnl which is the goal. With tight control d50w may be too much.
I am an insulin dependent Type II. On those rare occassions whem my AM blood sugar is below 55, I drink 4 oz of regular soda. If it is below 44, I drink 8 oz of OJ with an teaspoon of sugar. Below thirty, 911 is called. They generally either give me 50D IVP or orally. And this is after I've drank 40z of regular soda. My NPH is held for a few hours and I monitor my blood sugar for the four hours. I have never had to chase the rebound because I have never experienced it. Of course I talk with my PCP and see him when indicated.
I feel vindicated in my opinion because of what happened,QUOTE]
There's no room for this in nursing, IMHO.
The DW is a diabetic, and she agrees with another poster - she'd prefer the OJ over the D50. Appropriate assessment and monitoring would have been of great value here.
If the nurse felt the need not to follow protocol, she should have called the physician.
I think that's sort of the issue here. If the night nurse didn't want to follow the protocol, she should have notified the doc to get an "alternate" order, to cover herself.
Always CYA.
May have needed an incident report done from day nurse the second time.
Interesting discussion, this must happen everywhere.
We have glucose gel or glucose tabs for conscious patient but they hate taking them so we usually end up giving OJ, followed by graham crackers with peanut butter and/ or milk. We then retest in 15-20 min. After the second incident I would have wanted to ask what the patient had to eat the evening before and if any insulin was given. If I see a pattern of low AM scans I make sure the pt gets a protein snack at bedtime, especially if insulin is given at noc. 4-8 oz of skim or 2% milk and a couple of graham crax with maybe a thin spreading of peanut butter can stablize the glucose level overnight.
i've seen orders that state to call md w/bs 400, w/no ss orders.
one time, i had a diabetic pt whose 6a bs was 33; she was diaphoretic, unarousable-called the md stat-no call back. i took choc syrup and administered it intrabuccally as well as sl. when she started coming to, i gave her a few spoons of ice cream and then finally a cup of milk. 1/2 hr later her bs was up to 74. i called the md x3; it took him over an hr to call back.:stone
from that experience alone, whenever i deal with an iddm pt, i make sure that i have orders from ea md for tighter parameters for low bs's and ss orders for hyperglycemia.
I've always seen food given before D50...as long as the patient has a gag reflex and can eat and drink without difficulty. I've always seen something fast acting like juice to bring up the blood glucose quickly, followed by a carb and protein combo like peanut butter and crackers, cheese and crackers, or a hard boiled egg and toast.
D50 seems pretty drastic...it is pretty hard on the vein and nasty if it infiltrates...it also has the same rebound effect that adding sugar to juice has if not followed with a complex carb and protein soon after administration.
Years and years ago, our diabetic educator talked about the rule of 15s or something like that...it was something about giving 15 grams of carbohydrate, followed by 15 grams of protein and blood glucose should go up 15 points in 15 minutes or something like that...
rita359
437 Posts
The policy at my institution is to treat with fluids or food if patient is able to take po. For instance orange juice without sugar (though for us old nurses who treated pts with oj and sugar for years it is a hard practice to break) and to recheck blood sugars until wnl. If pt can't take po then give D50w. The problem I see with immediately giving d50w is the blood sugar may go up to much. An aide where I work who is diabetic with an insulin pump was taken to the er because of low blood sugar and treated with d50w more than once over her objection. She said she felt terrible until she could get her blood sugar down again and recover from the out of whack sugars. Seems to me the docs should have adjusted the patients insulin dose long before she had 3 mornings of hypoglycemia. Practice changes over time. What we do today may change tomorrow. Don't be too critical of the nurse who gave oj with sugar. She did get the patients blood sugar to wnl which is the goal. With tight control d50w may be too much.