Very concerned

AceOfHearts<3 · Aug 9, 2018

When I was a floor nurse we always had to report extreme high or low blood glucose levels- anything greater than 400 or less than 50 (could be 70). That meant paging the provider and seeing if there was any change in the orders. If the sugar is 70 or less we treat.

The techs did our routine blood glucose checks, but I could do them too. Our techs also would alert us and immediately grab the glucometer if a patient wasn't feeling well or looking right.

When I push D50 I recheck the patients blood glucose after 15 minutes and either repeat the D50 push or if the level is stable I'll check again in an hour. I like to check again in another 1-2 hours to be totally sure.

I've had a patient with ARF and they couldn't maintain a stable blood glucose level until we had their D10 drip adjusted to a high enough rate. As a floor nurse it wasn't uncommon to have a patient on a D5 or D10 continuous infusion to keep their blood glucose steady (typically when NPO).

Working in the ICU I come across situations on a fairly regular basis where I'm not entirely sure. I'll ask a more experienced ICU nurse if I can pick their brain- I'll layout the situation and what my thoughts are, then ask what they think. I've never encountered somebody who has refused or belittled me for doing this. A lot of times I'm on the right track and I feel better about the situation, but sometimes they'll toss out something I didn't think about or know and that's ok- everybody has something to learn every shift. I find explaining what my thoughts are to be a good strategy- it shows I'm critically thinking and not just running to somebody else for the answer.

Ddestiny, BSN, RN · Aug 9, 2018

The problem was not in giving the Levemir (assuming it is a normal med for her, at a reasonable dose, etc. Levemir is appropriate with even lower-ish sugar because some people spike high in the night, which is typically why long-acting insulin is given to begin with). The problem was in not having blood sugar checks to follow-up this low sugar. Her sugar was shot up high with no protein or fat to "catch" the rebound effect. If she didn't want to eat some protein, then the other option is to tell her that you will be doing frequent accuchecks to watch for the inevitable crash. The option then would be on the patient -- do you want a couple spoons of peanut butter, or do you want me to be in here every hour getting your sugar? It is within your power to give this kind of option. Your job is to keep her safe. And as always -- educate, educate, educate.

Asking for symptoms is better than nothing....but consider that the patient kept saying that she wanted to sleep (normal for night, of course). Unfortunately sleeping and diabetic coma look quite similar. I have heard of situations where patients' overnight critically low sugars were not found until the 4am labs resulted -- which takes at least 45 minutes depending upon how quickly the floor's blood is taken down to be processed. So the sugar will be even lower when you finally get that critical result call. The patient is, of course, "asleep".

Our policy is that critically low blood sugars must A) be communicated to the physician, who may order increased accuchecks, adding dextrose to fluids, change insulin orders, etc and B) must have followup Q15 minutes until normal, then frequent (hourly) accuchecks x___ hours (can't remember how many). But even if you don't have an order or a protocol, you have the ability to get those accuchecks without an order.

There are other variables to consider as well.... why was pt's sugar low to begin with? Is it part of her disease process, is she not eating, have her anti-diabetic med doses been too high? What has been her response to the levemir in the past? If she's taken it before you should be able to track the before and after sugar. Is she receiving something different in the hospital than what she takes at home? My hospital rarely gives oral anti-diabetics, they usually manage hyperglycemia with insulin even if the pt doesn't use it out of the hospital. Some of this information may give insight into how to avoid this in the future. Whenever I'm unsure about the dosing of insulin, I always check what the previous response was and check sugar more frequently as a "safety net".

Take this as a learning experience. We all have them, no one is immune. Be glad the patient is okay. Work to repair your colleague relationships. It's hard transitioning from non-hospital to hospital care, I've been there...you have a knowledge base, but it's not always helpful. You're not a new grad but you might feel like one in a lot of ways. It's an awkward spot. Good luck with navigating the transition.

mrsboots87 · 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.

On this note, peanut butter is not the best choice for a renal patient either because if the phosphorus content. This is more important in some renal patients then others. Just food for thought.

TriciaJ, RN · Aug 9, 2018

OP, I think your preceptor looked at you with hatred because your error is technically HER error. Her sarcastic blow-off responses to your questions and making you wait 1.5 hours for her to finish after a shift are not signs of a good preceptor. But that's really a separate issue at this point.

Is there someone with whom you can ask to debrief the situation? Either your manager or a nurse educator? It might be helpful to sit down a discuss this particular situation. Take the excellent points made by the other posters and be prepared to state what you would do differently next time and ask for feedback. This will show that you are prepared to take responsibility for your practice and learn from your errors. It would also give you the reassurance you need about your future in that job.

I wouldn't throw your preceptor under the bus; that can only backfire. But maybe it will come out that she really isn't the best person for the job.

Good luck.

peachtreednurse, RN · 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.

One thing you need to learn and learn quickly is that there are safeguards in place to keep both you and the patient safe. The statement "we don't do them." accepted as irrevocable was a terrible oversight. There is NO WAY without BS assessment at the least and/or a call to the physician at best, ( AFTER contacting preceptor) should any type of insulin been given...additionally research of the medical record should have indicated if the drop was a new or sudden change or if a pattern was evolving to help back your decision making process. This is just pitiful; for all involved. What was the physician's position upon receiving report. Your performance seems to hinge on duties one, two, three, performed by rote, and may not be connecting to the reasons for action or inaction.You say you have been a nurse for years, these are basic protocols...hoe many years and in what capacity?? You need not reply but I also feel you are highly affected about losing your position,especially when you state---

"I wasn't confused about Levemir and I was on top of everything so it wasn't as if I slacked throughout the night", and

" At this stage they're expecting me to not run to her for every little thing."

A BS of 14 on a critically ill patient should be given the distinction of being far more than a learning experience...more like..."extremely lucky"

How was the change of condition accounted...with what interventions?

It might be of some benefit to review some texts of 'NURSING DIAGNOSES'

ButterflyRN90, ASN, RN · Aug 9, 2018

OP, I think your preceptor looked at you with hatred because your error is technically HER error. Her sarcastic blow-off responses to your questions and making you wait 1.5 hours for her to finish after a shift are not signs of a good preceptor. But that's really a separate issue at this point.
Is there someone with whom you can ask to debrief the situation? Either your manager or a nurse educator? It might be helpful to sit down a discuss this particular situation. Take the excellent points made by the other posters and be prepared to state what you would do differently next time and ask for feedback. This will show that you are prepared to take responsibility for your practice and learn from your errors. It would also give you the reassurance you need about your future in that job.
I wouldn't throw your preceptor under the bus; that can only backfire. But maybe it will come out that she really isn't the best person for the job.
Good luck.

I spoke to my clinical manager the day of and she just told me I didn't directly cause it and to go home and rest and not let it eat me up. Too late. I did write extensively on what happened and then picked apart where I could have done things differently. As for the person mentioning to not use PB my train of thought is to get pt BG stabilized rather than focus on the phosphorus portion. I did read through everyone's comments and took bits and pieces to see different ways in how this could have been handled. Thank you!

SeasonedOne, RN · Aug 9, 2018

OK....welcome to the wonderful world of nursing.

QUESTION: So what is the REAL reason the patient's BS got so low?

ANSWER: The patient had no protein or fat to maintain his BS level.

Next time, and there will be a next time....

Think about it!

SeasonedOne's BS Metabolic Time Table:

2hrs - Sugars (Juice, Candy, Honey, Fruit, etc.)

4hrs - Carbs (Pasta, Bread, Spuds, Cookies, Cake, Chips, etc.)

6hrs - Fats (Oils, Cheese, Ice Cream, Milk, Coconut, Margarine, etc.)

8hrs - Proteins (Meat, Fish, Eggs, Nuts, Peanut Butter, etc.)

1. If the patient didn't want juice for a BS 44, how about 2 packs of sugar, 1/2 a soda, etc. They are still breathing and talking, you have time. The IV D50 bumped the BS up quickly but depending on the other metabolic issues, would it take about 2 hours to drop again?

2. You offered the patient carbs, but he declined. Remember the phrase: "OJ and IC (Orange Juice and Ice Cream). A sugar and a fat - bump the sugar and then maintain the sugar for up to 6hrs. Sometimes a gentle threat. "I need you to eat the ice cream(peanut butter by spoon, eggs, Ensure, etc.) or you are going to wined up in ICU." It usually gets their attention and they will eat. You tried but persistence is the name of the game with low BS and challenging patients.

3. Protocol be darned, if you have a low BS episode, check BS every 2 hours for at least 6 hours after the episode. If you had done that, you would have seen the downward trend and been able to intervene saving the D50 episode. By the time someone is going to know his BS is a problem, you are going to be 44 again or lower. Case in point-trust the numbers(recheck), observe, think, then act.

4. I would have given the Levemir too, but I would have been watching to see if the trend was gentle or dropping more and encouraged more fats, carbs and protein intake.

5. People freak out for high BS. Most people can tolerate 3-500 without a lot of issues after the D50. You just flooded the circulatory system with the sugar. In the next 2 hours all those starving cells are going to gobble it up and the tank will need filled up again. It's not rocket science, just supply and demand. Yeah, ok not good long term, but you need time to manage the situation and keep the patient stable. Remember you can always bring highs down over time but a low can kill 'em.

6. You aren't the first one to have something happen...and for the most part, you did pretty good if this was your first time with a low BS. Here's something to think about....

Actual Stuff: Walked into ICU for an AM shift and the nurse tells me they had to give the patient D50 every 2 hours because his BS bottomed out. LIGHTBULB MOMENT, Right? My first question was: Did you feed him! Their answer was we didn't have anything. I called the kitchen who brought us enough to feed patients snacks for the next 24 hours. Ensure, they had....I grabbed a can and had him drink it. BS went to 550. Then he had bkft., BS and sliding scale insulin q2h throughout the day. Doc rounded, we talked. Told him would have his BS down by the afternoon. His BS was between 100-180 by supper. No more D50 after that as well.

Diabetes doesn't have to be scary, difficult to manage or drive you nuts! Most people over-react and have you ever looked at how the patient reacts, lol ....most of them are calm as a cucumber. They may tell you what they need (best case), but it is patients like you had that give us all premature grey hairs if we trust them.

Best of luck and lesson learned.

Been there,done that, ASN, RN · Aug 9, 2018

"I sat at the nurse's station in tears." NEVER let them see you sweat or cry. You will not lose your job.

It was a blood sugar issue that could have gone in any direction. Now you know....if you are following hypoglycemia standing orders, you still need to notify the physician for further orders.

It's all a moot point.. you are on orientation. Your preceptor is responsible. Where was s/he?

Trauma Columnist · Aug 9, 2018

Okay, please don't continue to beat yourself up over this. Take this as a lesson learned and move on:

1. ARF pts often have hyperkalemia so OJ is a big no-no. Your hospital policy should have something else, perhaps grape juice. However, the pt needs protein in order to bring his/her glucose up.

2. Insulin (and many meds) do not metabolize the same way for a pt with ARF versus someone who has normal renal function. So, giving the Levemir (long-acting insulin) without protein is going to drop their glucose.

3. Was this an acute renal failure pt or a pt who is ESRD (end stage renal disease) - most meds need to be adjusted to account for renal function.

Again, don't beat yourself up over this. Do you have a mentor on the floor? Someone who is experienced, and is willing to help you learn the nuances of pt care?

Best wishes

Have Nurse, ADN, RN · Aug 9, 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?

Have a sit down with your Director and your Preceptor. From what I read it appears you were not under Supervision, only nearing the end of your Orientation.

Own your mistake. You won't do it again. And ask for more Orientation with a Preceptor who is actually there for you for situations such as this.

And I absolutely agree with my colleague that protein also should have been given. The glucose needs a protein molecule to ride on to help stabilize the blood sugar.

Have Nurse, ADN, RN · Aug 9, 2018

OP, I think your preceptor looked at you with hatred because your error is technically HER error. Her sarcastic blow-off responses to your questions and making you wait 1.5 hours for her to finish after a shift are not signs of a good preceptor. But that's really a separate issue at this point.
Is there someone with whom you can ask to debrief the situation? Either your manager or a nurse educator? It might be helpful to sit down a discuss this particular situation. Take the excellent points made by the other posters and be prepared to state what you would do differently next time and ask for feedback. This will show that you are prepared to take responsibility for your practice and learn from your errors. It would also give you the reassurance you need about your future in that job.
I wouldn't throw your preceptor under the bus; that can only backfire. But maybe it will come out that she really isn't the best person for the job.
Good luck.

I agree. It's certainly a "wake up" call for the Preceptor.

Jedrnurse, BSN, RN · Aug 9, 2018

It might be of some benefit to review some texts of 'NURSING DIAGNOSES'

Reviewing the conditions/patho involved? Sure. There are especially good online resources available to review T1DM.

But conflating that with nursing diagnosis rigamarole? Yuck.