scenario:

KelRN215, BSN, RN · Mar 26, 2013

Was the patient symptomatic? What were his/her goal blood sugar ranges? Was the patient on oral hypoglycemics or insulin? Were the medications held when the patient was made NPO? When I worked in the hospital, we typically didn't treat until the blood sugar was lower than 70 unless the patient was having symptoms of hypoglycemia.

How would you have handled this?

MendedHeart · Mar 26, 2013

My hospitals parameters are less than 80..the only symptom he had was he was a tad bit lethargic...

I dont know the answer to the other questions..I was the nursing assistant. .I was not in the student clinicak setting. .

With that being said---

I would have called the MD to switch his IV fluid to a dextrose source instead of try to fix his glucose for 8+ hours

Esme12, ASN, BSN, RN · Mar 26, 2013

Did the patient have any insulin to cover glucose any time while NPO?

I would do it differently as well......First if I gave glucose IV, the glucose dropped even lower, and the IV is infiltrated...the patient would not leave the floor without the MD being notified that the glucose wasn't really correct due to the IV and the repeat was lower. This patient needed a patent IV AND/or an order from the MD that the patient could be transported without a nurse (if the patient was symptomatic) and/or a patent IV.

I am not sure I would go straight for a IVF change mostly because many meds given during procedures are not given with Dextrose so the dextrose would be taken down as soon as they arrived at their destination.....and over all in that short period of time wouldn't provide a large source of glucose. Since they were leaving the floor so quickly my focus would have been on having a patent IV. But this depends on what meds they have been on (I know they are NPO) even on at home of recently admitted to the hospital. What was causing the glucose to drop?

Post op/procedure.... I would think the MD would address this issue with an IV change to an IVF containing glucose until stabilized.

nurseprnRN, BSN, RN · Mar 26, 2013

My hospitals parameters are less than 80..the only symptom he had was he was a tad bit lethargic...
I dont know the answer to the other questions..I was the nursing assistant. .I was not in the student clinicak setting. .
With that being said---
I would have called the MD to switch his IV fluid to a dextrose source instead of try to fix his glucose for 8+ hours

Maybe not. There's a lot less sugar in a liter of D5/anything than you think, less than 200 calories. There's only 50gm of dextrose in that whole liter, and giving that much water (or even saline, if it's D5.9NS) fast enough to make any kind of significant difference in his blood sugar could well be disastrous in terms of his fluid balance and serum sodium (if it's D5W or D5.45NS).(Look that up or ask again if you don't know what I mean).

I'd check his blood glucose more often, even hourly or q2h, and let the physician know it's trending down, and solicit adding glucose sublingual, po, or IV as part of the medical plan of care if it reaches a certain level (depending on what was normal for the patient and what else could be influencing his serum glucose-- fever?).

MendedHeart · Mar 27, 2013

Thank you..Do you think since this seems to be reoccurring on my unit with NPO diabetic pts going for procedures that it would be a good quality improvement iniative?..it happened again today at work but not as low and pt could eat immediately after procedure.

Esme12, ASN, BSN, RN · Mar 27, 2013

Yes, but.....I would bring it up with the manager first. Not all nursing facilities really want things "pointed out"....if you get my point. They may have a culture of not liking change and might view those who do as not being a "team player" , and as much as this pains me to say, especially from a new nurse.....and especially from your co-workers and thinking the new nurse is a "know it all".

It really bugs me to say that but some facility cultures are not conducive to change or they may want you to follow the proper channels....or they may not want you to "bother" at all. I think you are smart and that you want to hit the ground running and I want to be sure you don't get stonewalled because you are the "new kid".....it isn't right or fair, it just is. Tread softly and wisely.

Personally, I think you are on the money....there is a problem and I would look into it for your own practice. Find out what the common denominator is....what meds are they on...what meds did they get the night before.

nurseprnRN, BSN, RN · Mar 28, 2013

A better way to go about this might be to plant a bug in the nurse manager's ear. "Hi, Ms. NM, I'm a student on your floor this semester and I really appreciate the chance to work with your staff. I've learned a lot here, especially from Nurse A-- she was very helpful to me when I had a patient with XYZ and she helped me understand it. One thing I have a question about is about diabetics who are NPO for procedures. I only saw two patients like this, but they both had really low blood glucoses before their procedures. I don't know a lot about DM yet, and I've heard that some places have protocols for monitoring and stabilizing them with IV glucose while they are NPO, or modifying the NPO. Do we do anything like that here?" Then thank her for whatever she tells you, and back off. I'm betting that something will stir in there, and sooner rather than later, something will come up. If she asks you for a copy of such a protocol, go find one. :)

MendedHeart · Mar 28, 2013

Thats a good suggestion but its on the floor I currently work as a NA and will be working as a RN as soon as I pass my boards. Maybe something to mention during Unit Based Council meeting? We have shared governess where I work

Esme12, ASN, BSN, RN · Mar 28, 2013

Feel out the culture.....but that is what the shared governance is supposed to be. I would ask a trusted staff RN, educator or your manager about this and see what they think first.

Do you think the staff will be receptive to the "NA" suggesting this? As much as I dislike that it exists there is lateral bullying that occurs.

I think it needs to be addressed...I am just giving you food for thought about how to best approach this.