What would you have done?

I would have explained to the patient the rationale for giving insulin to cover her, and that just because she receives insulin perioperatively does in no way mean she will be on insulin when she goes home. Then, I would have allowed her to make her choice (because the patient has the right to refuse treatment, and if she insists on no insulin, you can't force her to take it), and documented what I did and why.

The biggest concern to me is that she's eating solid food so soon after surgery. But, if she's tolerating food without vomiting, then she certainly can take her PO meds, meaning she can take her Metformin, so there's no reason she shouldn't have it if she wants it and it's ordered.

Ok I'm a newer nurse just off orientation, and last night was my 2nd night flying solo.

So here is my situation, what would you have done and did I do anything wrong? (I got conflicting responses from senior nurses on the floor).

My patient is NIDDM. She went down for surgery late afternoon and came back. Because she was NPO all day she didn't recieve her metformin. She came back from surgery and immediately called for food and forgot to let any of us know she was about to eat. Her blood sugar 2 hours later was 255 (10pm). Talked with patient she REALLY didn't want insulin to cover her. Talked with 2 senior nurses one said do insulin one said go ahead give her metformin.

For me giving her the metformin still made sense. She eventually came down to her normal ranges, but nurse who said to give insulin said technically it was a med error for me to give metformin that late because her normal time was in the AM. (BTW she ate more when i gave her the metformin).

I briefly talked with doc about it when I was calling him reguarding something else, he had no problem with me giving the glucophage. But still other nurses acted like what I did was wrong and I"m confused about why,(because I gave a med that was skipped didn't give it twice when I wasn't supposed to) in the end patients sugar went down, and she was happy about not having insulin....

What orders did you have for insulin coverage or giving the Metformin? I would have followed the orders or called the doc explaining the patients concern and obtaining his orders for what should follow. This outcome was good, but the next time it may not be, always consider the patients safety first. Call the doc that's what they get paid for!!

Just my worth.

Have a good one,

mydnightnurse

You should have called the doc with the elevated glucose.

I would have explained to the patient the rationale for giving insulin to cover her, and that just because she receives insulin perioperatively does in no way mean she will be on insulin when she goes home. Then, I would have allowed her to make her choice (because the patient has the right to refuse treatment, and if she insists on no insulin, you can't force her to take it), and documented what I did and why.

The biggest concern to me is that she's eating solid food so soon after surgery. But, if she's tolerating food without vomiting, then she certainly can take her PO meds, meaning she can take her Metformin, so there's no reason she shouldn't have it if she wants it and it's ordered.

Yup I did explain to her that recieving insulin is just to cover her since she hasn't had her metformin for the day. That its not a permanent thing. She still didn't want the insulin and asked why she couldn't have her metformin since she didn't have it in the morning. (I thought good question and asked 2 senior nurses). As far as eating and drinking so soon after surgery doc gave her orders for it, she wanted to eat (we're talking very very minor surgery and nothing to do with the abdomen). So she ate right away and had no issues. I did chart what I did and that patient refused insulin.

What orders did you have for insulin coverage or giving the Metformin? I would have followed the orders or called the doc explaining the patients concern and obtaining his orders for what should follow. This outcome was good, but the next time it may not be, always consider the patients safety first. Call the doc that's what they get paid for!!

I had sliding scale orders, and orders for Metformin 1000mg PO QD. She skipped her dose of metformin since she was NPO... so technically it was a missed dose and I could have given it. I did call the doc later and discussed it with him, he had no issue with it and we rechecked her BS twice and it came back down within 3 hours. I agree I probably should have called but at the time didn't see the issue with it.

You should have called the doc with the elevated glucose.

I didn't call since it was only 255 and she was diabetic with orders for insulin coverage and metformin, I thought a diabetic without meds who has eaten its expected to be high.

I see your points I should have called doc first just to be safe... Ugh being a new nurse is hard get such conflicting answers from everyone, at the time I didn't see it as anything to call about. And I'm fairly doc call happy.

Oh I wanted to add, thank you for your replies!

Another concern is when was her next daily dose of metformin going to be given. If it was 8a might that be too close to the dose you gave her. If she wouldn't take the sliding scale I would have called the doctor and let him/her know the situation. He might say okay document that she refuses the insulin and start her metformin in the morning before breakfast like she normally takes it.

Crunchy, I understand what you did and why you did it, but here is how *I* would handle it should such a situation arise again.

You have standing orders for ss insulin. The merformin can be given within a 1 hours range on either side.

Giving the metformin was, indeed, a med error even though it was probably the right thing to do.

When the patient refuses a medication, which is her right, but she is clearly wrong about refusing it and needs intervention, call the MD and get instructions. Do not take it upon yourself to give a med x hours late instead of following the standing orders. It is, technically, operating beyond your scope and could really bite you in the butt.

I have always been amazed at how many different responses one can get from different nurses when asking a question about practice. My rule of thumb is this. When in doubt always speak to the physician and document that you did so.

Thank you all for imput. I feel bad I didn't call sooner and I"m normally quick to call. I will keep this as a learning experience and remember it for next time.

I wanted to add the time of her metformin was change changed to 8pm instead of the next morning, orders were written as every day with no specifics to time and in our facility they are given when patient prefers and at same time every day. So her metformin will now be taken with dinner vs breakfast. Doc did agree with me on what I did but stated, but I see your point about how it could have gone the other way.

Thank you all... lol the first year gets easier right?

Thank you all for imput. I feel bad I didn't call sooner and I"m normally quick to call. I will keep this as a learning experience and remember it for next time.

I wanted to add the time of her metformin was change changed to 8pm instead of the next morning, orders were written as every day with no specifics to time and in our facility they are given when patient prefers and at same time every day. So her metformin will now be taken with dinner vs breakfast. Doc did agree with me on what I did but stated, but I see your point about how it could have gone the other way.

Thank you all... lol the first year gets easier right?

Then I rescind what I said. You did the right thing.

I wouldn'c all for a BG of 255 unless the patient was extremely brittle or the order were to call for >+255, either.

At 10 pm I would have given the ss dose or nothing if the pt refused and restarted the metformin in the am, I would have been concerned the am dose would have been too close from the pm dose

Very true you will get different answers from different people. My rule of thumb that has served me well these past (yikes) 20 years I have been nursing is ALWAYS, ALWAYS, err on the side of caution. That is what always runs through my mind when I have a decision to make.

I learned that after I had a LOL fall and I was a brand new nurse. I had never seen a broken hip before so I assessed her and thought her hip was broken. So I went and got another nurse who had been a nurse for over 30 years. She looked at it and told me "No her hip isn't broken." So I didn't go with my own assessment but instead listened to the more experienced RN. I am an LPN so I assumed with her RN and more experience she would know. Well come to find out the next day they did an x-ray and yep indeed her hip was broken. I felt terrible that she laid there all night with a broken hip! So long story short err on the side of caution, listen to yourself and make sure you do thorough documentation! Good luck in your career :)