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Discussion

resident's order

I need to vent about my shift last night. I hope this makes sense. Here goes. A patient had been having low blood sugars all day (even after D50 given IVP). They were fingersticking him every hour, he had D10 infusing at 100cc/hr, blood sugars in the 40's. The resident wanted two amps of D50 injected into the liter of D10 and run at 100ccs per hour. I thought this order seemed odd. Our pharmacy closes at 1900, so I had no help there. I talked to the nurses in ICU (that have been nurses forever) and they said they had never done that before. So I called the dr. and told her that was out of my scope of practice. She still wanted the order carried out. I called her supervisor who said "give one mg glucagon im in addition to what the resident ordered" (glad i called him). so I finally had to call the nursing supervisor at home who stated we don't mix solutions like that. Now I understand why the resident wanted him to have more sugar in the solution, but she couldn't get it through her head that I couldn't mix the solutions. (the patient's sugars stabilized as we gave him juice and milk, so he was ok!). My question is where do we document that we weren't going to carry out the dr.'s order, right in the nurses notes?

Now what made me the most upset is the dr.'s supervisor came in the morning and he was talking to another dr. and said " the reason his sugars were so low is because the nurses were giving the pt glipizide when he was npo" and then kind of snickered. :angryfire The deal was that the pt got his 0600 dose of glipizide and then was made npo later that day for a procedure the next morning. The glipizide was held that evening and the next morning. I guess nurses are supposed to have ESP and should have guessed the dr's would make him npo that day!!

If you can't guess, I haven't been a nurse very long, and neither has the other RN I worked with. Any input on what I could have done differently would be appreciated. I just feel sick about the whole situation. Thanks for letting me vent.

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You absolutely did the right thing questioning and refusing to carry out an order that was unfamiliar to you and mixing solutions that are out of your scope of practice.

I'd have to get out my calculator, and I don't have enough caffeine in my system yet to do the math, but do you know what the dextrose concentration of the ordered solution would have been? I'm guessing that it may well have been too concentrated to infuse safely thru a peripheral IV.

Document fully in the nurses care notes and put down all conversations and what you did to try to get the order done, and how it couldn't be done...that will show that you tried to carry it out and were very leary of it in the first place..but still tried. Write down all conversations as accurately as you can! Especially the nursing supervisors!

You did exactly the right thing. The doc who ordered the patient be made Npo should have investigated and realized the patient had been given glipizide. If that doctor had ordered fluids with dextose this could have been prevented. You were looking out for the patient too bad those doctors refuse to look at their part in this.

Exactly Jolie! I was also thinking that in a hypoglycemic state, I am less likely to put 100% into what a patient may be saying because I know that lack of sugars does indeed effect their thinking (well after getting hit by some, I saw it effects much! LOL!). I listen, but I listen more to the physician at this point...and when I read that the MD okayed that..I was flabergasted really!

Its like okay...if you want a higher concentration of IV order it that way...not have me mixing the two! Also, what is wrong with one or two glucose tabs in this situation (or sublingual gel)??? If the patient was able to swallow, then I feel the hypoglycemic state was an acute and treatable probelm that can outweigh an NPO state depending (like if it were for surgery...okay fine, if the anest. wants absolute NPO in lue of 2 glucose tablets for hypoglycemia then wait a few more hours??? Plus I don't know too many surgeons or anest that like working on a hypoglycemic patient in the 40's risky! But then again I don't know why the patient was NPO).

  • Author

Thanks for all the responses. I actually called another hospital last night that has a pharmacy 24/7 (how nice!), and she figured it to be about D15%. But the patient was able to drink the oj and milk with no problems. The pt was npo for an upper gi. Too bad for the pt, but I learned that anytime a diabetic pt is made npo, ask the dr. if they want pt to supplement with iv fluids. that seems so obvious now:) The response that you couldn't believe the MD supported the resident: the 1st yr residents supervisor was a 3rd yr resident! The resident that placed the initial order is one that we continuously have problems with. Our residents rotate thru at the beginning of each month. hmm...its gonna be a loong month...

  • Experts

Actually, anything stronger than Dextrose 10% should be given thru a central line, other than glucose pushes. That is the protocol with any type of TPN, which contains glucose......You definitely did the right thing. :)

  • Experts

Got the flu, brain not percolating.So how did you calculate the new concentration?

Oh and also you did exactly the right thing. I also can't imagine no pharmacy for 2 shifts out of 3? And you have residents..teaching program? So where was the attending over those 2 ** residents?

  • Author

The pharmacist calculated the concentration:) Pharmacists are a wonderful resource (when they are here!). They are out the door at 1900. My sister works at a small hospital and she said she's lucky if they have a pharmacist from 8-12! The attending was probably home sleeping. Yes, this is a teaching hospital....lucky me!

Got the flu, brain not percolating.So how did you calculate the new concentration?

Oh and also you did exactly the right thing. I also can't imagine no pharmacy for 2 shifts out of 3? And you have residents..teaching program? So where was the attending over those 2 ** residents?

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