Question for experinced icu rn's

[ashleyf19]

Well i have a question for you all, i have been really upset about this but my pt was on an insulin drip she was admitted initially for intracrainal bleed with increased icp and was on an EVD. Well for the past 4 hours her BS had becoming coming down and at 0100 was 83.My pt was NPO and her only fluids were NS with no dextrose. So i chose to verbal order a transition protocol. Well for some reason she ended up shooting up to 300 later on that day and the MD came in and apparently was really upset that i did this as was the diabetic nurse, and the charge nurse discussed why i did this with me. Was i really out of line for doing this? I really assumed her sugars would continue to decrese or stay the same for being NPO? i just cant let it get out of my head, and i normally never make these kinds of mistakes in judgment.But i know its not good to keep I guess from now on ill make sure i call the md instead of VORV'ing orders

[Reno1978, BSN, RN]

So i chose to verbal order a transition protocol.

I'm not exactly sure what this statement means as far as what changes you ended up making to this patient's insulin gtt. However, I wouldn't write a VO if a VO was not given to me by an MD. If I had a patient under similar circumstances, on an insulin

gtt, and their glucose was trending downward, I would call the doc and let them judge what I should do with the insulin gtt, not decide myself that a change is needed and to make that change.

Where I've worked, there has been pretty specific instructions as to what changes ought to be made to insulin gtts based on the patient's blood glucose. A result of 83 wouldn't make me want to make immediate changes. I would definitely keep a close eye on it, and perhaps check it Q1H. Was there no protocol in place for a patient on an insulin gtt to make an appropriate intervention if the blood glucose gets too low?

[getoverit, BSN, RN, EMT-P]

Was the patient receiving IV steriods? I"m also assuming your unit does not have a written protocol in place for insulin gtts. How do you know what to titrate it to?

Like reno1978 said, I don't understand what you mean by "verbal order a transition protocol".

For an insulin gtt with a cbg-83, I'd stop the gtt and recheck the sugar q30min. Very unlikely that the sugar level will continue to decrease without the gtt, esp if they are receiving steriods. When the level reaches 120 mg/dL, I'd restart the drip at 50% of the previous rate. Of course, that's just our protocol. Maybe this is an opportunity for your medical director and nurse manager to adopt an insulin protocol.

Sorry that happened but don't beat yourself up over it.

[Kymmi]

Agree with the above 2 posters. I would not write a verbal order without actually speaking to the MD and updating him on the patient status and obtaining a verbal order from him directly.

We run insulin drips frequently in our unit and we have a set standard for titrating the drip based on the blood glucoses. Fingerstick or A-Line glucoses are done q 1 hour unless the readings have been between 90-130 for at least 4 hours then we can go to q 2 hour glucose checks. If the glucose is between 80-89 the drip is off and we recheck glucoses q 15 minutes and restart at 1/2 the rate it was previously run at when glucose reaches 115. Below 80 and d50 1/2 amp is given and drip restarted when glucose reaches above 115. Anything above 130 we have titrating orders also.

Alot of people do assume that if the patient is NPO with no dextrose running thru the IV then the glucoses will drop however due to the stress of the illness and various medications it causes havoc on the system and glucoses do crazy things therefore the best way to control glucoses in order to acheive better healing is thru IV insulin drips and strict monitoring.