Reflecting last day shift

**CalicoKitty, BSN, MSN, RN** · Feb 21

You could contact the provider for sliding scale orders for people that are NPO. If it says give with meals (and is NPO) it should be held, but if their glucose levels are high, that would also warrant treatment. Just contact the provider They could/should get a one time or new sliding scale order (some orders say give half if NPO).

DavidFR, BSN, MSN, RN · Feb 21

You weren't in the wrong. I'd have held the insulin. Your order said with meals. Your patient was NPO. So she was not having a meaI. You'd porobably have sent her hypo if you'd given it.

I speak with the comfort of working in a country where it is a nurses' perogative to hold a medication with a simple justification written next to the prescription. A simple comment next to the prescription is enough to justify my action and no doctor or administrator has the right to get shirty with me. I sometimes have trouble understanding how your system works in the US. You're educated professionals with BSNs and MSNs yet a doctor throws his toys out of the crib and it seems your professional judgement is automatically relegated to nothing. Please correct me if I'm wrong - I personally couldn't work like that.

The "if it's prescribed you give it" mentality assumes that prescribing doctors never, ever make mistakes or write orders that can be vague or open to misinterpretation. Ha ha ha.

In this case however, I believe that you followed the prescription perfectly if your order said "with meals". That you had the decency to call the endocrinologist anyway just in case suggests to me you were being more conscientious than most. That the endocrinologist got mad suggests that he/she just needs to learn some manners.

mtmkjr, BSN · Feb 27

DavidFR said:

You weren't in the wrong. I'd have held the insulin. Your order said with meals. Your patient was NPO. So she was not having a meaI. You'd porobably have sent her hypo if you'd given it.

I speak with the comfort of working in a country where it is a nurses' perogative to hold a medication with a simple justification written next to the prescription. A simple comment next to the prescription is enough to justify my action and no doctor or administrator has the right to get shirty with me. I sometimes have trouble understanding how your system works in the US. You're educated professionals with BSNs and MSNs yet a doctor throws his toys out of the crib and it seems your professional judgement is automatically relegated to nothing. Please correct me if I'm wrong - I personally couldn't work like that.

The "if it's prescribed you give it" mentality assumes that prescribing doctors never, ever make mistakes or write orders that can be vague or open to misinterpretation. Ha ha ha.

Thankfully that is not the mentality at least not in most areas of nursing in this country. The nurse IS expected to hold medication that is not appropriate. The difference is, I guess, that we DO have to notify the provider and depending on the medication write a note or comment as to why it was not given.

Insulin should not necessarily be held just because the patient is NPO. If the order was written "with meals" certainly do need to get that changed to an NPO regimen. But if the blood sugar is elevated the SS insulin dose is to cover that level, regardless of whether additional carbs are being consumed.

Synaptic90 · Feb 27

Just because the patient is NPO does not give you the right to hold insulin to a patient, more so if they're receiving D5W. There are some medications that are mixed with d5 as well and others that can raise glucose levels like steroids. However, you can always clarify with pharmacy and the physicians to modify existing orders.

DavidFR, BSN, MSN, RN · Feb 27

mtmkjr said:

Thankfully that is not the mentality at least not in most areas of nursing in this country. The nurse IS expected to hold medication that is not appropriate. The difference is, I guess, that we DO have to notify the provider and depending on the medication write a note or comment as to why it was not given.

Insulin should not necessarily be held just because the patient is NPO. If the order was written "with meals" certainly do need to get that changed to an NPO regimen. But if the blood sugar is elevated the SS insulin dose is to cover that level, regardless of whether additional carbs are being consumed.

At 4-5 mmols I would not be administering insulin and I would be verifying the blood sugar appropriately in the light of the 5% Dextrose. Most of our diabetics get 2,5% Dextrose. Too many times in my early years I followed such insulin orders to be faced with a hypo down the line. I have learned to evaluate more sucessfully. Each to their own professional judgement.

My point is that here where I am it would just be accepted that I'd used my judgement to act in the interests of the patient. In the scenario described above, the nurse would not be "in the wrong". The endocrinologist however would be in the wrong for speaking inappropriately to a colleague. A doctor disagrees with a nurses' actions and of course they have the right to ask why and to argue otherwise, but not to "get mad"

DavidFR, BSN, MSN, RN · Feb 27

Synaptic90 said:

Just because the patient is NPO does not give you the right to hold insulin to a patient, more so if they're receiving D5W. There are some medications that are mixed with d5 as well and others that can raise glucose levels like steroids. However, you can always clarify with pharmacy and the physicians to modify existing orders.

This is where our systems differ. Here I DO have the right to hold insulin providing I justify my actions and monitor appropriately afterwards.

mtmkjr, BSN · Feb 27

DavidFR said:

This is where our systems differ. Here I DO have the right to hold insulin providing I justify my actions and monitor appropriately afterwards.

As we do. We have a right and responsibility to hold a medication that is not appropriate. And just like you we have to justify our actions and monitor appropriately.

We also notify the provider.

I think the poster you were quoting could have worded it differently. We do have a right to not administer but we have to have a proper rationale. In this case the insulin should have been held only long enough to update the order for NPO status through communication with the provider.

Toaster2k18 · Apr 7

Thank you all for the input. I'll definitely be more aware of these situation moving forward.