Very concerned

MunoRN, RN · Aug 8, 2018

I'm also unclear why you gave insulin to a patient with an unexplained BG drop to 44. The D50 is often only a temporary fix, the BG will drop back down if the underlying cause is not addressed, and persistent hypoglycemia is not all that rare in patients with metabolic derangement, like you might see in a patient in dialysis dependent ARF.

These patients may often require a continuous dextrose infusion to maintain normal BG, so this is probably something to learn from. Even if BGs aren't technically ordered through the night, it would be prudent nursing judgement to reassess BG in a patient with hypoglycemia where the intervention could likely have only been temporary. Also, consider the potential need for ongoing dextrose administration and whether the insulin is truly indicated in this situation.

Sour Lemon · Aug 8, 2018

I'm going to make this as clear as possible . I work nights at a hospital on a tele floor. I'm currently on orientation and am towards the end of it. So, one night I had a pt who was in ARF, dialysis, and a Type 2 DM. So the pt BG drops to 44mg/dL and when asked states "I don't feel so well". I run in there to give OJ to which pt states "I don't want anymore ". Protocol is 50u of D50 if unable to give PO. So I gave 50u D50W. Pt shot up to above 200. I offered milk and pt refused (was also ineffectively coughing/ had fluid in lungs). Offered graham crackers (refused). After the elevated BG I administered the Levemir that was scheduled. 10 units of levemir which has no peak. Anywho out of my 4 pts I rounded on this pt the most because they had fluids and labs that I did. Pt had no BG checks during night (we don't do them). Every time I rounded I asked how pt was feeling (pt is aaox3). My last round was during lab draw around 0545. Pt actually told me "thank you for your help" and when asked if she was in pain (pain assessment) or if she felt weak/off (BG) pt stated "no I'm good, just want to get some sleep."
Gave report to day nurse who sees pt asleep and goes and continues getting report from other nurses. I was now giving report to other nurse and to finish charting.
1.5 hours after handing report to day nurse, preceptor runs to me stating "pt has a BG of 14! I run in and pt is non-responsive. Day charge nurse was pushing 2 amps D50 when I wheeled computer. When I mentioned pt only had LEVEMIR given preceptor yelled "WHY WOULD YOU GIVE THAT WITH A 200mg/dL BG!?" I'm a T1DM so it wasn't that I have a med I knew nothing about. So I told preceptor "but why wouldn't I?" She gave me a look of hatred as Rapid Response was called. Pt taken to ICU.
I sat at the nurse's station in tears. I'm being looked at as the one who did this even though my pt was aaox3 BEFORE report and pt wasn't checked after I gave report. I'm freaking out. They're investigating and pt is ok. What would normally happen? Would I lose my license or job? I'm really freaking out to where I have chest pain.

When someone has a critical low, I'll usually ask the MD if they want to continue/adjust x, z and z (since I have to call the MD anyway). I also ask for an order to check at midnight or 3AM just to be extra cautious. If I don't have an order, I typically check anyway although it's technically "not allowed".

I've found that opinions vary widely when it comes to issues like this one. Cover all the bases and you're less likely to have someone get hysterical on you. The yelling was uncalled for, IMO ...if it was actual yelling and didn't just feel that way. Our perception can get a little off when we are stressed.

Hugs.

ButterflyRN90, ASN, RN · Aug 8, 2018

I'm also unclear why you gave insulin to a patient with an unexplained BG drop to 44. The D50 is often only a temporary fix, the BG will drop back down if the underlying cause is not addressed, and persistent hypoglycemia is not all that rare in patients with metabolic derangement, like you might see in a patient in dialysis dependent ARF.
These patients may often require a continuous dextrose infusion to maintain normal BG, so this is probably something to learn from. Even if BGs aren't technically ordered through the night, it would be prudent nursing judgement to reassess BG in a patient with hypoglycemia where the intervention could likely have only been temporary. Also, consider the potential need for ongoing dextrose administration and whether the insulin is truly indicated in this situation.

So she would've needed to head to IMCU anyway? We don't do dextrose drips/insulin drips on our floor.

What am I supposed to do now though?

Guest219794 · Aug 8, 2018

I'm going to make this as clear as possible . I work nights at a hospital on a tele floor. I'm currently on orientation and am towards the end of it. So, one night I had a pt who was in ARF, dialysis, and a Type 2 DM. So the pt BG drops to 44mg/dL and when asked states "I don't feel so well". I run in there to give OJ to which pt states "I don't want anymore ". Protocol is 50u of D50 if unable to give PO. So I gave 50u D50W. Pt shot up to above 200. I offered milk and pt refused (was also ineffectively coughing/ had fluid in lungs). Offered graham crackers (refused). After the elevated BG I administered the Levemir that was scheduled. 10 units of levemir which has no peak. Anywho out of my 4 pts I rounded on this pt the most because they had fluids and labs that I did. Pt had no BG checks during night (we don't do them). Every time I rounded I asked how pt was feeling (pt is aaox3). My last round was during lab draw around 0545. Pt actually told me "thank you for your help" and when asked if she was in pain (pain assessment) or if she felt weak/off (BG) pt stated "no I'm good, just want to get some sleep."
Gave report to day nurse who sees pt asleep and goes and continues getting report from other nurses. I was now giving report to other nurse and to finish charting.
1.5 hours after handing report to day nurse, preceptor runs to me stating "pt has a BG of 14! I run in and pt is non-responsive. Day charge nurse was pushing 2 amps D50 when I wheeled computer. When I mentioned pt only had LEVEMIR given preceptor yelled "WHY WOULD YOU GIVE THAT WITH A 200mg/dL BG!?" I'm a T1DM so it wasn't that I have a med I knew nothing about. So I told preceptor "but why wouldn't I?" She gave me a look of hatred as Rapid Response was called. Pt taken to ICU.
I sat at the nurse's station in tears. I'm being looked at as the one who did this even though my pt was aaox3 BEFORE report and pt wasn't checked after I gave report. I'm freaking out. They're investigating and pt is ok. What would normally happen? Would I lose my license or job? I'm really freaking out to where I have chest pain.

For starters, take a deep breath and try to look at this with some objectivity.

Your preceptor yelled, and looked at you with hatred? Maybe, but maybe you are still reacting emotionally.

There are some parts that don't make sense to me:

Where was your preceptor in all this?

Why were you there 1.5 hours after giving report to days?

Why don't you do blood sugars?

As an ER nurse, it is beyond my comprehension that a floor nurse managing a hypoglycemic diabetic can't do a blood sugar. Even if Levemir is not in the picture, a hypoglycemic patient is likely to become hypoglycemic after a little D-50 spikes the sugar. I also have the luxury of an easily accessible doc. I would ask, then check sugars either way. So, I will let somebody more knowledgeable on levemir and floor practices weigh in on the appropriateness of giving the med. I can manage DKA or HHNK. I can run drips of regular, or use it to manage K. But I am no expert on levemir.

You are not going to lose your license.

It is unlikely you are going to lose your job.

Good luck. I hope it works out well for both you and the patient.

MunoRN, RN · Aug 8, 2018

So she would've needed to head to IMCU anyway? We don't do dextrose drips/insulin drips on our floor.
What am I supposed to do now though?

A continuous infusion of IV fluids that contain dextrose usually doesn't require the patient moving up to critical care any more than if they were getting a continuous NS infusion. If BG checks were required too frequently then that could potentially necessitate transfer to a higher level of care.

We learn the best from our mistakes, embrace the opportunity to learn.

macawake, MSN · Aug 8, 2018

Okay first of all, I'm glad your patient is now doing okay and I'm sorry that you are experiencing the level of stress and anxiety that you are.

1.5 hours after handing report to day nurse, preceptor runs to me stating "pt has a BG of 14! I run in and pt is non-responsive. Day charge nurse was pushing 2 amps D50 when I wheeled computer. When I mentioned pt only had LEVEMIR given preceptor yelled "WHY WOULD YOU GIVE THAT WITH A 200mg/dL BG!?" I'm a T1DM so it wasn't that I have a med I knew nothing about. So I told preceptor "but why wouldn't I?" She gave me a look of hatred as Rapid Response was called. Pt taken to ICU.

Of course I wasn't there, but I very much doubt that it was hatred that you saw in her eyes/on her face.

I'm not a U.S. nurse and we measure blood glucose in mmol/l in my part of the world, but after converting 14 mg/dl I realize that was a very low blood glucose. I would guess that your preceptor was probably frightened/worried for the patient and experiencing a lot of stress at that time. I have no clue how things work in the U.S., but as your preceptor, is she in any way responsible for checking on your "actions" during your shift?

Pt had no BG checks during night (we don't do them). Every time I rounded I asked how pt was feeling (pt is aaox3).

You can't change the past, but going forward it seems a good idea would be to not simply accept that you "don't do" blood glucose checks during night shifts. Again, I work in a different country so I can't offer you any advice. Here I wouldn't need a physician's order to do an extra BG check (or however many I deemed necessary), if I was concerned that something might be going on with the patient. On the contrary, it would be expected of me that I take the initiative and do the test and then take appropriate action and notify a physician about the result and propose a plan of action and get further orders if needed.

I work nights at a hospital on a tele floor. I'm currently on orientation and am towards the end of it. So, one night I had a pt who was in ARF, dialysis, and a Type 2 DM. So the pt BG drops to 44mg/dL and when asked states "I don't feel so well". I run in there to give OJ to which pt states "I don't want anymore ". Protocol is 50u of D50 if unable to give PO. So I gave 50u D50W. Pt shot up to above 200. I offered milk and pt refused (was also ineffectively coughing/ had fluid in lungs). Offered graham crackers (refused). After the elevated BG I administered the Levemir that was scheduled. 10 units of levemir which has no peak.

The blood glucose likely only temporarily spiked because you administered the D50. From what I understand from your post, after that the patient didn't drink or eat anything. Since the patient's BG had already dropped once, it wasn't unreasonable to assume that it could happen again.

I'm freaking out. They're investigating and pt is ok. What would normally happen? Would I lose my license or job? I'm really freaking out to where I have chest pain.

I'm sorry, but I don't know.

I realize it might be easier said than done, but please try to take a deep breath and calm down a bit. Learn from this. You can't change the past, but by learning from this experience you can reduce the risk of something similar happening again in the future.

Again, I am sorry that you are going through this and I realize that it's scary.

I do hope everything works out well, best wishes!

Guest219794 · Aug 8, 2018

What am I supposed to do now though?

You are supposed to take this situation and learn from it. Learn everything you can about insulins, long and short acting. Learn so much, you can teach veteran nurses about it.

There will be a process, ideally centered around education. Accept it gratefully and non-defensively. This is harder than it sounds because:

Your preceptor should have created an environment in which you would have approached her.
If you are correct that you are not allowed to do BGs on hypoglycemic PTs, well, that is just idiocy.
The day nurse accepted a PT who had been treated for hypoglycemia then given insulin, and did not check on the patient.

But, if this is what you focus on, you won't learn what you need to. And, if you focus on any of this during the corrective process, it will indicate that you don't accept responsibility.

You asked what you should do. Take every learning you can from this.

ButterflyRN90, ASN, RN · Aug 8, 2018

For starters, take a deep breath and try to look at this with some objectivity.
Your preceptor yelled, and looked at you with hatred? Maybe, but maybe you are still reacting emotionally.
There are some parts that don't make sense to me:
Where was your preceptor in all this?
Why were you there 1.5 hours after giving report to days?
Why don't you do blood sugars?
As an ER nurse, it is beyond my comprehension that a floor nurse managing a hypoglycemic diabetic can't do a blood sugar. Even if Levemir is not in the picture, a hypoglycemic patient is likely to become hypoglycemic after a little D-50 spikes the sugar. I also have the luxury of an easily accessible doc. I would ask, then check sugars either way. So, I will let somebody more knowledgeable on levemir and floor practices weigh in on the appropriateness of giving the med. I can manage DKA or HHNK. I can run drips of regular, or use it to manage K. But I am no expert on levemir.
You are not going to lose your license.
It is unlikely you are going to lose your job.
Good luck. I hope it works out well for both you and the patient.

I was there 1.5 hours later because even though I completed giving report, my preceptor wasn't done with whatever she was doing. Per my plan from my NM, my preceptor is supposed to write down any positive or negatives that occurred during the shift, discuss them with me and then sign the bottom with me. I couldn't leave until SHE was ready to. So I was standing by the wall just checking to see if I missed any notes for my previous shift while I waited for her.

My preceptor was in the pt room when I was scanning the Levemir and telling me "you should have taken the time to assess her sacrum since we just turned her, just saying". Any accucheks that are scheduled are done by PCAs. Unless we notice or the pt mentions feeling off/low/high or it's time for scheduled meds and it STILL wasn't done, the PCAs do them.

I thought I was reacting emotionally to her looks until I went to see her in the nurses lounge where she slammed her locker, looked at me and then slammed the door without saying a word to me. She had been working her 7th shift with me so I thought she left due to exhaustion, but her reaction to my presence wasn't exhaustion only.

City-Girl · Aug 8, 2018

If you're still on orientation, are you consulting with your preceptor before making your decisions for patient care such as giving the Levemir to a recently hypoglycemic patient? or maybe at least clarified the dose with the physician.

AnnieOaklyRN, BSN, RN, EMT-P · Aug 8, 2018

When will hospitals start using D10 like we do in EMS? We use a 250 mL bag of D10, which equates to 25 grams, BUT only run it until the patient wakes up or becomes more alert and verbal with a sugar >80. This allows us to not cause the patient's sugar to go from low to high in minutes. It is also MUCH gentler on their veins then D50 is, as it is much thinner and can just be run by gravity.

I cannot speak as to whether you should have given the insulin, as I know very little about that type. I will say that you should have bene a little more responsible and checked the patients BS in the AM and probably also during the night. You will know this next time!! Also educate the patient on the importance of eating with a BS drop! I find if the patient refuses and I tell them the consequences they will usually manage some food before we obtain a signed refusal, providing someone else is home to watch them.

In regards to your preceptor I would definitely attempt to talk to her about her behavior and how you feel and try and talk things out. If this does not work you need to go to your manager and let her know your learning style is just not matching up with your preceptor and you would like to see if someone else is willing step in. She clearly has some anger issues or something, as slamming a locker door isn't going to change anything and will only increase the tension between the two of you. Do this on your next shift!!!

Annie

cleback · Aug 8, 2018

Unfortunately, I think it would be an easy mistake to make as a newer nurse, particularly since the bs was 200s at recheck. Without knowing the whole picture, her bottoming out may be more related to her medical history than the detemir you gave. When you have a pt with hypoglycemia, it's important to ask why and see if it's a trend.... does her daytime regimen need to be changed? Was she npo earlier? When in doubt, call the doc.

Also my hospital just implemented a new policy to recheck bs q15 min with interventions and then 1-2 hrs after hypoglycemia is resolved. Perhaps that could be something implement at your facility.