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.
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.
This is identical to our hypoglycemia protocol. We also have a prn accu-check order that is entered with the admission order set on all of our diabetic patients. This lets the nurse obtain an accu-check whenever and however often she/he feels is necessary.
This makes me feel sick FOR you. Nobody should be feeling so much devastation and fear after a critical event like this. As nurses, we have a lot of responsibility, but the kicker is that we are also human! Humans make mistakes. Any gap in understanding should be taken as an opportunity to educate and improve. There has been a whole movement in critical care nursing alone that emphasizes the importance of being able to admit mistakes without being punished, and by punished we also mean being made to feel as you currently do. You are the "second victim." Look it up.
I can see your reasons for doing everything that you did. You treated the hypoglycemia appropriately. I would have checked another BG, but I can see everyone has been through that already. Levimir and other long-acting insulins do not immediately affect any one critical value, and since you thought the previous low reading was resolved, you gave it as ordered.
The opportunity that I see for improvement is better communication with your preceptor. You said she "saw" you giving Dextrose IVP, and that she was later "in the room" when you scanned the Levimir. It would be best to inform her aloud of your actions in any situations that require a response to a critical event. Even after the hypoglycemia was resolved, the entire concept of insulin and blood sugar levels should be discussed in light of an order for Levimir. And on that note, I strongly feel that the root of this entire situation was not you- a nurse who at the end of her orientation was striving to be independent and followed the orders at a level I can see many doing.... but the preceptor who in my mind, failed to follow up on many levels. Whether or not you told her of the low BG level, she should have at some point looked back to see what it was. She should have facilitated a conversation involving higher-level thinking and asked questions such as, "What kinds of things can cause new hypoglycemia in a patient that has been doing well with his treatment for diabetes? Do you think there could be an underlying problem at the root of this? After the low blood sugar is corrected, what steps should be taken to monitor the patient closer?" There are reasons we orient nurses, and it is to have these conversations as you approach independence in a new area.
I would go about this in the following way: Set up a meeting with your manager. Admit what you have learned from this as well as ways you plan to improve. Continue to hold your head high and focus on staying positive. I don't think it would be inappropriate it to discuss your preceptor slamming doors instead of providing constructive feedback. But you could also just choose to focus on yourself. You should not be fired for this or put on probation.
Have some humble pie. If you lose your job it will be due to your response to the situation. You need to ask for help more and develop better judgement before someone gets killed. Show more concern for the patient. Your responses on the forum don't show you are willing to learn from this. You were an LPN first so you had experience as a nurse right? I hope things work out for you but you need to d some serious self reflection.
This response shows the kind of behavior that people are referring to when they say that nurses eat their young. I would be embarrassed to act this way. Why don't you show some support for your fellow nurses and try to remember where you came from.
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.
Learning is a continual process and I have some colleagues who lean toward giving long acting insulin after BG drop but I lean toward not giving any insulin since I can't 'unring the bell' once Insulin is given. With DMs who fluctuate I would rather see it go up as a BG of 200 is not a medical emergency. I'm in corrections; had a type1 who was all over the map so we go out to treat his BG drop and my colleague (LVN) was documenting. My colleague was fretting over us not giving ordered Levemir after BG rose and I stuck by giving no insulin at all. Don't beat yourself up, take it as a learning experience and recheck BG every time you encounter a situation such as this. You will not lose your license...it seems as if schools are putting the fear of God over loss of license, if we lost our licenses over every mistake we made as newer nurses there would be an incredible nursing shortage.
The failure to monitor is what you need to learn from. "We don't do overnight checks" will never be a valid excuse. Are we technicians, or licensed professionals who are expected to exercise critical thinking and nursing judgment?
And as a T1D, you should know that even severe hypoglycemia can be asymptomatic. I have seen a BG of 26 with the pt talking, alert, oriented, no sweats, etc -- as asymptotic as I am with a BG in the 120s. It's not enough to ask about sx and consider it an assessment.
THAT SAID.
Your preceptor is on the hook. Yes you are moving toward independence, but you ARE still orienting. What is your preceptor being paid/staffed for if she's not going to monitor you -- AND HER PATIENT.
Giving a long-acting insulin isn't necessarily wrong; in my experience more often than not we give it.
I have seen a pt with a BG of 10 and an ensuing acquired brain injury -- for failure to shut off an insulin gtt when her tubefeeds were stopped. I'm assuming she went 2 hrs between BG checks at most. The nurse is still working.
Does anyone remember the heartbreaking story of Kim Hiatt? If not, she was a longtime PICU RN who administered too much calcium to an infant who died. She was punished by the hospital and was so distraught she committed suicide. The "second victim" issue came into discussion following her death, and how we tend to punish ourselves.
Besides, who in their right mind would report errors if they fear for their livelihood?
It is a balance... obviously if someone is truly incompetent they shouldn't practice. They can't educate indefinitely. But as evidenced by Kim Hiatt -- and virtually every single other nurse -- one mistake does NOT mean a nurse is incompetent.
I COMPLETELY disagree with their choice to take your badge at this point. (((((Hugs))))) Yes you made a mistake that you need to learn from... but please try to be kind to yourself.
This response shows the kind of behavior that people are referring to when they say that nurses eat their young. I would be embarrassed to act this way. Why don't you show some support for your fellow nurses and try to remember where you came from.
I ignored that poster's response. I spoke with my clinical educator who explained most likely they'll just put me on days for a bit and with another preceptor. I still feel nauseated. The pt is fine but has ongoing BG issues which the ICU nurses can't even resolve. Shoots up from 500s to the 40s. I just got thrown with that 14. I did reflect but I cannot let it eat me up for 4 days straight now. I was close to the "Derek Shepherd drinking and not returning after botching a brain surgery" moment. Don't eat me alive. I've had enough of that. Thanks for the positive responses. Hopefully the call I receive is to get back on my feet. I love my jobs and my patients.
I COMPLETELY disagree with their choice to take your badge at this point.
Me too.
We have a bit of control over how we allow ourselves to be treated (ultimately we can't control others' actions but we can offer some "direction") and I have to say that I would think long and hard about how I would handle being given my badge back, all things considered. I'm about 90% sure I'd start planning my exit unless they turned things around by demonstrating a more genuine interaction from that moment forward.
If you've been having a decent orientation up to this point and weren't already headed for failure then the badge-yanking thing would sour me on this employer completely. It's just not how you treat people who are learning and are trying. Personally I can take a lot of things but not that kind of disregard and disrespect.
That is an over-the-top action that served absolutely no purpose at the time it happened other than to scare the sh*t out of you for these intervening days and make you feel like dirt.
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.
Adding sugar to OJ is an ANCIENT treatment... and contraindicated. I worry what else your preceptor is teaching you incorrectly on.
Always recheck bg levels till they are stable. After the initial rise due to the d50 a small snack or meal should have been given. And please never, ever give any kind of insulin until after speaking with the provider when a patient has had an episode of hypoglycemia. They could fire you and the preceptor for not following up on your situation. I would be curious to see how this looked in the chart (how you documented it). We are not doctors as much as some nurses like to think they are!
I would have done as you did, OP, including giving the Levimir. I would have added a 3am blood sugar check, but since she didn't drop til after 6am, its possible the same thing could have happened to me. Between you and me, the reaction of your preceptor is more concerning than your judgement. If she's supposed to be supervising you, she should have known about the situation, and advised you to do things differently if that's what she wanted.
Kallie3006, ADN
389 Posts
Is it possible the patient had sulfonylurea poisoning? OP stated pt was DM2 and on dialysis, just wondering.