Would you have given the meds??

flightnurse2b, LPN · Oct 7, 2009

i personally would have called the doctor for the blood glucose of 39 and followed up from there, because really the lab is critical... i would have called when i came on shift.. to clarify if he wanted to hold/adjust med times and the 70/30, just to be on the safe side.

we have a hypoglycemia policy which we can active for blood glucose of less than 60 and it has protocol of what to do if the pt is alert/not alert, has IV/no IV, etc... but we still have to call the MD to report the levels.

sorry the MD was such a jerk to you. he didn't have to act that way!!!

**LaurelRN, MSN · Oct 7, 2009

i think that you should have paged an md if her glucose was down to 39 and asked what he wanted to do with the meds-- hypoglycemia can be dangerous; remember that glucose is the brain's only source of energy. however, he should have also written an order "page md if blood glucose is less than x or hold meds if glucose less than;" you're a nurse, not a doctor. personally, i think that he just freaked because something bad could have definitely happened if her glucose dropped too low and he would have been responsible for the incident.

let me clarify....

the glucose was 39@ 0600- i didn't come in until 0700. i was unaware that the offgoing rn had not paged the md. we do have a hypoglycemia protocol- that does say to page md- however the offgoing rn didnt state that she had not paged him. i guess my mistake was --assuming she had-- ....i would have if it were me. i did hold the 70/30 until after breakfast when her fsbs was retaken and it was 189 or something similar. i am very careful with meds, orders, and protocols and try to use sound critical thinking.

i am not a doctor...but this particular one has had a number of cases where things went really wrong with his patients ___(one of the reasons i was very careful about rechecking her fsbs before i gave her oral meds, even though it had been rechecked after the 2nd oj and was 105). i understand his train of thought on this....but i really felt i had done the right thing by rechecking the fsbs, having her eat, and then giving the meds.

i'm really frustrated because i sincerely feel that the offgoing rn had the responsibility to call the md- clarify the orders and if she couldn't, let me know. i really just kind of feel like i;ve been thrown under the bus for something i didnt even have a responsibility for

SuesquatchRN, BSN, RN · Oct 7, 2009

I would have given it. Had it been regular insulin I would have called for clarification. Had the off-going nurse's note not stated that the physician had been notified I would have notified.

Of course, in the best of all possible worlds with no fires to put out.

He's a jerk.

linzz · Oct 7, 2009

Must agree that the Doc. was pretty harsh. I think the previous nurse should have notified the Doctor about the low BG right away. My spouse is diabetic and we keep careful track of BG's, treat any hypo episodes and notify the Doc. right away about any hypoglycemic events and change the doses of the meds.

Anyways, you did well and the patient was cared for.

mamamerlee, LPN · Oct 7, 2009

I reiterate what I stated earlier - it was definitely the responsibility of the previous nurse to call the MD. That should have been clarified in report.

kanzi monkey · Oct 7, 2009

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i'm really frustrated because i sincerely feel that the offgoing rn had the responsibility to call the md- clarify the orders and if she couldn't, let me know. i really just kind of feel like i;ve been thrown under the bus for something i didnt even have a responsibility for[/size]

this is frustrating. the off going rn should have reported this. one thing that may help you in the future--when you are getting report, highlight any issue that may be (or lead to something) critical. ask the off going rn how it was addressed and what the plan is. if it wasn't addressed, it is what it is. no blame needs to be laid on anyone, the previous nurse may have been caught up with something else, it doesn't matter why. you have the information you need, and you know that you need to contact the md.

i'd also let the other nurse know what happened. in report you are both responsible for clarifying important information--hopefully she will learn from this scenario also.

and you know, some docs would have yelled at you for not giving the insulin in this case. it depends on the patient, the circumstances, and the clinician. but the yelling thing--the fact that the doctor was a huge orifice about it is not your problem, it's his.

these kinds of things happen all the time. this is where developing a little thick skin is most important. consider this--what if the pt did have critical hypoglycemia after you gave her meds, or, say she went into dka because you held the insulin? regardless of what you had done, you would find a way to blame yourself for the outcome of the pt, and someone else would try to pin it on you (because they're so scared that they are to blame). it's impossible to not let this get to you. my advice is--surrender to your powers of assessment and critical thinking, and separate them from your emotional self. always know the rationale for what you're doing. if questioned about it later, you state your assessment and your rationale and stick to it. it's ok to acknowledge when things could have been done differently, but usually your assessment/rationale/actions will not be far off from what any other reasonable clinician in your position would have done.

floatRN · Oct 8, 2009

The blood sugar was a critical result and the previous nurse should have notified the MD. If she couldn't reach the MD, she should have told you to follow up on it. If you thought the MD had been notified and the patient's blood sugar was ok when you gave the meds, you did nothing wrong.

I recently had a patient with very low blood sugar before breakfast. Blood sugar was up to normal after juice and snack. Patient had lantus ordered as well as humalog to be given with meal. I called the MD to clarify whether I should still give these meds and if he wanted the dose adjusted. The MD was irritated with me and said of course I should give all meds because if the patient eats and has no insulin, the blood sugar will be critically high. So, sometimes you can't win either way, but if you check with the MD then at least you have covered yourself.

SteffersRN87, BSN, RN · Oct 8, 2009

Those endocrinologists! If you give the meds and the patient becomes hypoglycemic, they yell. If you don't give the meds and the patient becomes hyperglycemic, they yell. I usually follow the RN that did not notify the physician (or never rechecked the sugar of 30). I would hold all meds until the endocrinologist rounded and ask if he or she wants to consider a dose or medication adjustment. If you are every unsure - call! Getting yelled at over the phone is nothing compared to in person.

litbitblack, ASN, RN · Oct 8, 2009

Lol....Cant win for losing here. I see his point as to why hes mad he wasn't notified for the critical sugar. He should have been the one to make the decision to hold the meds or not before the next morning. But.....The previous nurse should be getting crap for that not you.

PostOpPrincess, BSN, RN · Oct 8, 2009

That blood sugar of 39 should've been addressed STAT and with D50. I'd be afraid she would be passing out as I give her the OJ/crackers to drink.

At the same time I'm giving D50--my resource is calling that doctor stat.

Edit to Add: You should look into your hospital policy for hypoglycemia (emergency one). You need to have that at all times on you.

PostOpPrincess, BSN, RN · Oct 8, 2009

I would have talked to the MD about the previous FS of 39 in case s/he wanted to adjust the meds or investigate why the pt got so low.
This is what I would do next. I would hold everything because you can always fix the increasing blood sugar with the "giving" of meds (IV insulin works quick) rather than taking back something P.O. that stays in the system for the whole day.
I would've start working backwards as to why the patient's blood sugar dropped and go from there. As for the other nurse, I would've asked all of these already because the doctor is going to ask the same thing. And when I get the call from the doctor, I would want to make sure he does his rounds with this patient first. (or send his NP).
Next, I'd be writing an incident report to investigate the process as to what occurred and why. NOT as punitive for the nurses, but to check the processes that led to this incident.

PostOpPrincess, BSN, RN · Oct 8, 2009

One more thing, if you know something is a critical lab value and you ASSUME that it needs to be called (prudent nurse) you should follow up with a phone call to the M.D.--regardless of whether or not the previous nurse has contacted him already. If this were to ever go to trial, a lawyer could ask you specifically, "what would a prudent nurse have done?" CALL THE DOCTOR.

Never, never, never, never, never, never ASSUME something can be given until the ENTIRE situation has been assessed and re-assessed. DO NOT give any drugs until another perspective (especially the physician who probably knows this patient well) has been notified and you both banter over the next avenue.

Those are actions of a prudent nurse.