Very concerned

Guest219794 · Aug 8, 2018

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.

My preceptor was in the pt room when I was scanning the Levemir

1- Your preceptor was in the room when you were giving levemir.

Did you tell her about the low BG?

If so, she is responsible for the outcome.

If not, you made a mistake.

2-Any accucheks that are scheduled are done by PCAs. Unless we notice or the pt mentions feeling off/low/high

This makes no sense. You can do BGs if they feel low, or if they feel high. Surely you can do one if it is clearly medically indicated, as it was in this case.

RNKPCE · Aug 8, 2018

Look for your hospital policy for hypoglycemia protocol. One normal or even elevated blood sugar after a hypoglycemic reaction is not enough. We check 15 minutes after treatment if normal or up we have to check again in 30 minutes. If after 15 minutes still low we do further treatment and check in 15 minutes. if ok then we have to check in 30 minutes to see if it is sustained. We also must notify the provider for low blood sugars. Given this low blood sugar I would have done a 2-3am blood sugar at a minimum. I would have checked with the provider before administering insulin. We can do blood sugars PRN. We haven't let techs do blood sugars in more than a decade. This is a learning experience you may end up becoming a diabetic resource down the road. Not sure about your preceptors response or her supervision/guidance. On a side note I hope you are on the clock while waiting for preceptor to finish so you can do your paperwork.

ButterflyRN90, ASN, RN · 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.

At this stage they're expecting me to not run to her for every little thing. I wasn't confused about Levemir and I was on top of everything so it wasn't as if I slacked throughout the night. I consulted with my preceptor when in doubt but the last few times all I'm told is "use your brain". I've been a nurse for years but not in a hospital so for certain drugs I definitely consult, however, now I'm being told that I have to wait to see if I go back to night shift with my DAY preceptor. So I'm a bit frustrated with how they're turning this not into a learning experience but as a punitive experience. (I get sick during day shift and wasn't progressing. When switched to nights I had only positive comments written including that I was doing everything in a safe and timely manner) this is turning into an incredibly terrifying and negative experience currently. I'm just nauseated thinking about this and it's eating me alive.

Guest219794 · Aug 8, 2018

At this stage they're expecting me to not run to her for every little thing. I wasn't confused about Levemir and I was on top of everything so it wasn't as if I slacked throughout the night. I consulted with my preceptor when in doubt but the last few times all I'm told is "use your brain". I've been a nurse for years but not in a hospital so for certain drugs I definitely consult, however, now I'm being told that I have to wait to see if I go back to night shift with my DAY preceptor. So I'm a bit frustrated with how they're turning this not into a learning experience but as a punitive experience. (I get sick during day shift and wasn't progressing. When switched to nights I had only positive comments written including that I was doing everything in a safe and timely manner) this is turning into an incredibly terrifying and negative experience currently. I'm just nauseated thinking about this and it's eating me alive.

While you may understand Levemir, there is a lot of room for growth in your understanding of managing hypoglycemia. Maybe I misunderstood your prior post, but not re-checking a BG after a hypoglycemic incident shows a need for more training before you are independent. Really, it is a big deal, and any properly trained nurse knows this.

Do you really think that you were on top of everything? Is there nothing you could have done differently?

It sounds like you have an antagonistic relationship with your night preceptor. She now hates you, you wait for 1.5 hours standing against a wall waiting for her to finish her shift, and she uses sarcasm, like "You should have checked XYZ, just saying.", and "use your brain". From your description, this is not an optimal learning environment.

It is unfortunate (and unusual) that working days makes you sick. Do you really believe that they are considering moving you to days to punish you? If so, that is really weird.

What would you like to see happen? How do you best see this resolved? What would you do differently next time? Given an identical situation in the future, what might you do differently?

So far, you have expressed concern over how this patients severe decline has affected you, but not much about your role in the incident. It may be a bit early for that, but you might consider heading that way soon.

Good luck in the process.

ButterflyRN90, ASN, RN · Aug 8, 2018

My preceptor was in the pt room when I was scanning the Levemir
1- Your preceptor was in the room when you were giving levemir.
Did you tell her about the low BG?
If so, she is responsible for the outcome.
If not, you made a mistake.
2-Any accucheks that are scheduled are done by PCAs. Unless we notice or the pt mentions feeling off/low/high
This makes no sense. You can do BGs if they feel low, or if they feel high. Surely you can do one if it is clearly medically indicated, as it was in this case.

1) She was in the room while I pushed D50. She was aware.

2) I asked the pt if she felt ok (high/low/weak/off) and she stated she was fine but wanted to sleep since we kept her up (vitals/labs/is and os). PCAs do the routine checks is what I meant. Just like they do 2 sets of vitals and nurses do 1 per shift for a total of 3 scheduled vitals q4 (or if needed).

ButterflyRN90, ASN, RN · Aug 8, 2018

While you may understand Levemir, there is a lot of room for growth in your understanding of managing hypoglycemia. Maybe I misunderstood your prior post, but not re-checking a BG after a hypoglycemic incident shows a need for more training before you are independent. Really, it is a big deal, and any properly trained nurse knows this.
Do you really think that you were on top of everything? Is there nothing you could have done differently?
It sounds like you have an antagonistic relationship with your night preceptor. She now hates you, you wait for 1.5 hours standing against a wall waiting for her to finish her shift, and she uses sarcasm, like "You should have checked XYZ, just saying.", and "use your brain". From your description, this is not an optimal learning environment.
It is unfortunate (and unusual) that working days makes you sick. Do you really believe that they are considering moving you to days to punish you? If so, that is really weird.
What would you like to see happen? How do you best see this resolved? What would you do differently next time? Given an identical situation in the future, what might you do differently?
So far, you have expressed concern over how this patients severe decline has affected you, but not much about your role in the incident. It may be a bit early for that, but you might consider heading that way soon.
Good luck in the process.

I've mulled this over for 2 days now. I researched Levemir far more detailed than I probably should have. I have thought about what I could have done differently ad nauseum. I know about hypoglycemia but I cannot use myself as the example and her recheck was 200mg/dL. I didn't just push D50 and walk away. The only 2 things I could think of were to find peanut butter (barring allergies which she had none in regards to PB) and stick 2-3 spoonfuls in her mouth (we don't even have PB which is another issue entirely), check more often which would've probably caused her to be sent to IMCU anyway OR I was told to "hold". The last time I "held" a medication I was reprimanded.

The nausea is not that uncommon (search allnurses) in day shift or night shift (my clock isn't built for days) and before starting this job I did nights for 5 years.

I had been thinking of my role SINCE they called rapid response that day. I have not even slept well because all I can think about is "did I do this!? Is this my fault!?" So it's not too early and it has already hit me and is eating me alive.

LovingLife123 · Aug 8, 2018

Your preceptor may have been in the room while you were scanning the Levemir, but did she know you gave it?? I'm not sure what stage you are in with precepting. The Levemir should have been held after a blood sugar of 44. Your patient should have been closely monitored after that. Additional blood sugars should have been completed.

Why did your patient's sugar drop to begin with? Did you ask this question? Did you think about why?

It's a teaching moment, and you need additional teaching. Learn from it and move on.

Night__Owl, BSN, RN · Aug 9, 2018

I see two main issues that caused this:

1) you could have rechecked the pt BG, as others have said. However, it stands to be mentioned that you DID reassess the pt for symptoms of hypoglycemia.

2) The patient was somewhat noncompliant, refusing to eat a snack with protein or fat calories. Knowing that D50 is only a temporary fix, I possibly would have made a quick phone to the hospitalist before giving the Levemir, just to update them. That's one of the "flags" that I have trained to go up in my mind. For example, I had a pt with a new cardiac stent who decided to be a stubborn old man and refuse his Brilinta "until he could talk to the doctor in the morning." I phoned the cardiologist and let him know, just to ensure that there was nothing further I could do for the patient to avoid a bad outcome for him.

That said, having one mild hypoglycemic episode is NOT an automatic reason to hold Levemir. Had the patient hypothetically missed it and then eaten a couple snacks, you could have been in a totally different situation, with the patient having a super high BG in the a.m.

It's not the end of the world. You did make multiple attempts to get the pt to eat a snack, which would likely have averted the whole thing. I would be sure that this is documented well on your end. And just remember in the future, if you are following a protocol (in this case the hypoglycemia protocol), and the patient does something that puts you "off the script," phone the doctor.

ms boogie, BSN, MSN · Aug 9, 2018

It would be important to remember the diet restrictions of your patients as well. Patient's in ARF and on dialysis should not be given orange juice secondary to the potassium content. Apple juice would be an appropriate choice for that population. This case should teach you that you have much to learn. In orientation it is important to remember that you have 2 ears and 1 mouth. Be humble, listen and learn. This advice will serve you and those you serve well.

JKL33 · Aug 9, 2018

Butterfly -

Take it as a learning experience and let other people be responsible for their own reactions.

You learned a few valuable things:

- D50 causes a profound spike, and (IME) it will drop again rather rapidly...pretty much without fail unless, as Muno noted, the underlying issue is corrected.

- You must do what a prudent nurse would do, even if it's not on a protocol. You know the means to make things happen if you feel that a particular protocol might not meet your patient's needs.

- Neither a patient, a protocol, nor a preceptor are where the buck stops in this type of situation. You always, always have the option of contacting the admitting service responsible for the patient. Even if the protocol or policy says notify provider for W, X, and Y - but your patient's problem is Z.

- Think twice and/or speak with admitting service in any situation where you're administering any kind of insulin to any patient who recently had an acute hypoglycemic episode

Take a deep breath. You can't let yourself be eaten up by this. First of all, how you comport yourself in the aftermath will matter. Secondly, you just don't deserve it - even if there are things you could've done differently. This isn't a perfect world.

My guess is your best chance of navigating the aftermath successfully will be by staying calm, maintaining a concerned but pleasant professional demeanor, and by coming up with a few suggestions of what you might do differently if you were faced with this again. Others' culpability and/or reports of their reactions should be left out.

Find your calm and stay there! Take care ~

ButterflyRN90, ASN, RN · Aug 9, 2018

It would be important to remember the diet restrictions of your patients as well. Patient's in ARF and on dialysis should not be given orange juice secondary to the potassium content. Apple juice would be an appropriate choice for that population. This case should teach you that you have much to learn. In orientation it is important to remember that you have 2 ears and 1 mouth. Be humble, listen and learn. This advice will serve you and those you serve well.

Yea, I learned that way after my preceptor mentioned "why didn't you put sugar in the OJ"? So I'm sure she would've given OJ too, but I digress. I already wrote down what I could've done differently.

Triddin · Aug 9, 2018

At this stage they're expecting me to not run to her for every little thing. I wasn't confused about Levemir and I was on top of everything so it wasn't as if I slacked throughout the night. I consulted with my preceptor when in doubt but the last few times all I'm told is "use your brain". I've been a nurse for years but not in a hospital so for certain drugs I definitely consult, however, now I'm being told that I have to wait to see if I go back to night shift with my DAY preceptor. So I'm a bit frustrated with how they're turning this not into a learning experience but as a punitive experience. (I get sick during day shift and wasn't progressing. When switched to nights I had only positive comments written including that I was doing everything in a safe and timely manner) this is turning into an incredibly terrifying and negative experience currently. I'm just nauseated thinking about this and it's eating me alive.

If it makes you feel, after several years in, I still use my peers as sounding boards when I am uncertain. When to give insulin is a common one, especially in situations such as this. It also depends how you present your concerns to your preceptor. "I'm uncertain if I should give to x his levemir because of his hypoglycaemia episode and am thinking of calling the doctor to clarify what he wants to do as the patient is refusing complex carbs" is a lot more reassuring to preceptor than "I don't know if I should give levemir or not" It sounds like you've already been having some struggles, but just know that we don't nurse alone- we are a tea, for a reason

As for the nausea, I think almost all of us feel that way after a mistake. What I find works it writing down what happened, factors which lead to it - inexperience, policies, floor dynamics, business. Don't assign blame but recognize your part. Figure out how you could prevent this from happening again- calling the doc, more frequent sugars etc. Once you've done that, let it go. Don't fixated on it, and focus on practice in the future. All of us make mistakes, and many have the potential of being lethal