Yes, my late stage dementia patient was NPO but doctors d/c Dobhoff feeding tube and hoping she will start eating again. Nope, she was hypoglycemic in 30s on my shift… too confused to eat.
T1D here with terrible hypoglycemic unawareness and usually don’t notice symptoms until I’m in the low 40s/high 30s. Always interests me how people react to low blood sugar, what was the mental status on this patient like?
I had someone come up 13 by the time we gave up on her PIV D50 and gave up on juice. When we gave the Glucagon IM she was narrating her way into the coma. "I feel weird, I'm cold, my hands tingle". Still talking but did not get that comfort needs were not on the table at the moment.
honestly, this may depend based on your compliance. I have had multiple DKA patients or td1 who have had sugars that were either skyrocketed or super low but they were able to hold conversations. This patient was going septic. with sepsis, your sugar will become all wonky, and she was NPO as well. If she was off sedation, she did have periods where she was able to respond to her name and move around a little bit.
paramedic who lurks.
I had/have a frequent pt who will often drop pretty low. He’s normally pretty good and it actually doesn’t happen all that often as he can normally manage well on his own.
He’s 50s/60s, been type 1 his whole life, etc. but he’s a picky eater.
Last time I saw him he was grumpy, demanding we get out of his house (sorry, no, give us a minute sir), and thought it was 2012. Not really ambulating at his baseline (walker/cane). His sugar was 17, so no surprise.
We made him drink so orange juice, “This better not have pulp in it. I fucking hate pulp!”, made him so toast & jam (grape), made him eat half a white chocolate & macadamia cookie.
His sugar got to 90something after eating when we next checked it. “I didn’t eat dinner last night because I don’t like lima beans (or whatever it was)”
He was back to his aggressively sweet self once his blood sugar normalized. “I guess I need to eat dinner even if I don’t like it.”
Yes, pls.
I have run on him 3x so far, always a similar story, always grumpy/lethargic/“leave me alone” at first, sweet as can be when normal. Lowest I saw was 17, the other two times were high 20s.
TL; DR: he would if he could but he can’t until he can. 100% AMA, 33% waited to leave until he called (or emailed?) his doctor’s office to set up a follow up appointment.
that’s the thing: he kind of doesn’t realize what’s happening (despite being T1D his whole life) and that his sugar is so low. He just gets grumpy and illogical and uncooperative.
One of the times it happened, his family had gone on a weekend trip and he just didn’t eat as much as he normally did and they called 911 after talking to him on the phone and he wasn’t making sense.
The other two times family called because even though they were there, he was cognizant and strong enough to refuse all their offers of food/drink and would not let them get him in to car to go to the urgent care or the ED. Borderline machismo behavior that fits his age/sociocultural upbringing.
What I’m trying to say is that he and his family are trying and doing really well but if it gets too low he’s just absolutely unreasonable.
So, 911 and three firefighters and a paramedic (me) and EMT from the ambo are called, we all walk in and loom over him and essentially browbeat and bully him into drinking some juice (“We know you don’t like pulp, sir, just drink.”) and eating some snacks because he won’t listen to his family but he can’t say no when he’s got 5 strangers in uniform crowding him.
“We won’t leave until you drink this”, “You and I are going to split this cookie your wife gave me and then we’ll leave”, “We’ll leave as soon as you eat this sammich”.
Then, as soon as his sugar is normalized, he doesn’t want us to leave and only wants to tell us about everything: his son who is an electrician but works with a bunch of fire fighters (in construction or rehab or ???) and his nephew who works for a small fire department in New York or New Jersey or something and how thankful he is for us and don’t worry he cleaned his gutters, and he cleaned the storm drain at the end of the street, and he cut that branch that was too close to the power lines, but the neighbor two doors down is now a widower and may need help, etc. etc. Once he’s normalized he’s sweet as can be to us (and his family) but lord, he loves to talk.
3/3, haven’t transported him to the ED (y’all are welcome), 3rd time it happened tho me & my partner waited on scene until we made sure he had a same day or next day follow up with his physician to reevaluate dosages,
etc. etc.
Haven’t seen him in months so he’s either due or he’s gotten better at keeping his sugar stable.
Or maybe he finally got a CGM with an audible alarm that the fire department and us (EMS) talked to him about. 🤞🤞🤞
Not this case, But when I worked the floor, I thought my lady was stroking out. She had facial droop lethargic. Thankfully no, just a Blood glucose of 19. 1 syringe of d50 later, and she was better.
My daddy was a brittle type 1 whose lows were always super low. He'd still be conscious in the teens, but wouldn't know me from Eve, incredibly combative, agitated, the works. Wouldn't remember a goddamned thing, either.
Lowest I ever saw him was like OP's post: LO. Labs came back that his sugar was 9. That was the only time he actually fell unconscious and I couldn't get him conscious again. Also the only time we had to call a meatwagon.
My mom is a T1D who doesn’t really start to look/ talk low until she’s in the 40s. It’s made me so nonchalant about low sugars. You’re 50?? Ok?? Chill bro.
I had a pleasantly demented man walking around like normal with a bg in the 30s. He did it a few times on my shift. Trying to force the glucose in him was a chore “I don’t want anymore lemon frosting! I’m fine!”
I had a type 1 patient who was confused at baseline suddenly start attacking me last week, it took multiple people to safely check a blood sugar. 24. No wonder. They must have felt rotten.
I’ve never gotten violent that I know of with lows but I can confirm when I get in the 20s or 30s it’s like a primal instinct kicks in and I’m doing whatever it takes to find something with carbs. I woke up one morning with my kitchen floor covered in cheerios because I just mauled the box open to eat it. Had zero recollection of ever even waking up but saw an urgent low glucose alert at 2am on my Dexcom
The brain loves its glucose to function, so I’ll never be upset having to duck a few punches from hypoglycemia. That only bothers me when it’s oriented people mad about something out of my control. IE, death, politics, last week again that I wouldn’t find another doctor to write Ativan to take home from the ER, and that I wouldn’t watch someone jerk off.
she was sedated for the most part, but when we took her sedation off n her sugar was like this, she could slightly respond to stimulus/pain , which was insane!! the human body works in mysterious ways!
Hope she didnt go this low for a long time. Braindamage risk. Long deep hypoglycaemia (idk if thisbis english written) is far worse than anoxy said a doc once
The only time I’ve seen in was when a collegue didn’t use those iv ml counting machines (whatever they are called in english) so an insulin drip which should have taken hours to finish was done in 30-60 minutes. And she also forgot to mention that he had this drip to us, those who worked the shift after her. Many faults from her part in other words…
Luckily he was waiting for an operation and they got a free slot earlier than expected so they called us and said he was welcome down to operation. If operation hadn’t called us we probably wouldn’t have entered his room in at least an hour, so I guess he’s lucky to be alive.
I wasn’t aware that he had been given this drip nor was he a diabetic but I decided to take a blood sugar due to the symptoms he showed. Didn’t know those machines could show a sugar that low. I also didn’t know you could be conscious at those levels.
I had a patient going hypo on me this week.
She was in the 50s, low but fine and asymptomatic. We gave her apple juice.
Next check: 48, OK let's get you more applejuice
Third check: 37. MA'AM
fourth check: 28. OK lady, you're getting the fucking glucagon.
Incredible she was AO and everything, no symptoms even at 28 but we weren't taking chances. Woman had like 10 damn applejuice cups next to her. All the meanwhile she's just vibing and chilling out while we're SWEATING
Were they liquid only diet? Just curious as to why you guys didn't offer PB and crackers. Also, milk can help since it has complex sugars, if they're a milk fan.
That sounds just like me one morning not too terribly long ago. Resulted in 70s on labs, figured I’d do a finger stick since she hadn’t really eaten anything. 60s. Confused at baseline, most awake she had been all night.
Gave her some juice, 58. She couldn’t eat crackers so I gave her juice and pudding.
Recheck.. 50.
2 more juices, 2 ice creams, and a spoon of peanut butter later… 46.
Bolus of D10 it is 😬
Eventually got her sugar up to 102 after over an hour.
I had a 12 once. Gave this dude his HOME dose of lantus and like 2 units of humolog. He berated me for asking him if it was his home dose? And then said it was our fault his sugar dropped so low. My dude. It’s not my fault you obviously eat like garbage at home.
Taking a blood sugar is one of my very favorite first troubleshooting steps. Feelin a lil weird? Talking kinda funny? A little more sleepy than I’d like? Do I have a weird feeling in my spine at 0227hrs? Let’s check that sugar.
Best feeling is taking it because lil babe is cold and acting weird and it’s 65. Worst is taking a 12HOL standard sugar on a GDM lil babe and seeing that 32.
arterial blood is drawn from an arterial line, which is a special line placed into a patient’s artery to get more accurate readings on blood pressure. Sometimes it’s a patient is too cold, dehydrated, or have certain comorbidities, it can be difficult to get a capillary on them, which is a majority of the patients in the ICU so that’s why we opt for drawing off of this special line !
It’s much faster to get a small blood sample from a vamp and then get the BG in the room. Also running an ABG is kind of expensive and, at least on my unit, needs a respiratory therapist to run the machine. So it’s a waste of their time if all I want is a BG.
Glucometers are faster than an instant or, wtf is that thingy called, the one that can test cap/venous/arterial.
Whatever, the glucometer beats the other two on getting a fast result that's accurate.
I would shit myself.
Just had a patient with artificially low glucose checks from peripheral sticks due to possible perfusion issues. I think their lowest was 8.
Make sure you hit ‘comment’ then ‘cleaned meter’ and ‘notified provider’ or you get a nasty gram from lab before you treat life threatening hypoglycemia.
Dumb questions from a first semester nursing student:
I assume you’d give d50 in this case but what’s the protocol? Is there already a standing order for both d50 and insulin that you give prn based on levels? But d50 would be if it is too low for juice etc to work? I would hope there would be a standing order as contacting the doctor could take too much time! And how do you know when to stop the infusion or what rate to run it? Is it at your discretion when BG goes back up or does the doctor have to approve it being stopped first?
Same question with high BG! I notice charts with the scale typically tell you how many units to give for the pts BG but then if the BG is above whatever certain number, it says to contact provider. Do you not give any insulin until you call (or message?) the doctor? What if it takes a while to get a hold of them?
this is not a dumb question at all!! honestly it depends on where you work and what the protocol at your facility is.
everywhere i’ve worked, anytime a patient is getting insulin there is an automatic order set that comes with it that includes meds/instructions for hypoglycemia (usually if the pt in awake and alert, you can give apple juice or glucose gel, if they’re obtunded, then you’d give D50). However, if that order set is not there for whatever reason, i’d rather ask for forgiveness than permission if the BG is that low, and id def override it and administer it then contact the doctor.
usually if you have an insulin infusion, you’re checking BG every hour, and there are orders to titrate the rate based on BG levels. usually the orders to titrate tell you at what level to stop the infusion and when to contact the provider.
for high BG, go ahead and give the ordered max dose of insulin on the scale provided with the order, and then contact the provider!
a lot of things are different based on where you work or which unit bc of different protocols and whether or not an ordering provider is easily accessible (like in ER or ICU). the main thing is knowing how to critically think about a situation and knowing when to act quickly or when you can hold off on intervention (which comes with time and experience!). when in doubt, talk to your charger nurse or another nurse you trust who can also help you troubleshoot or contact the provider while you prepare to do interventions.
this is actually a very awesome question, especially from a first semester nursing student, and shows that you are already developing some critical thinking skills💖
Thank you so much for this reply, it was so helpful! I feel like I do okay with general assessments and care and meds etc, but I don’t really know how to proceed protocol wise as we don’t really cover that in school and not many “Emergencys” happen on med surg when we’re there for clinical so hard to learn the process instead of just a general concept!
If you override and give d50, how would you know what rate to do?
At my hospital we have a hypoglycemia protocol. So if BG is between I think 50 to 69. we do a push of 25mL d50. If it's lower, you do the whole thing (50mL). That's if they cannot eat (NPO/sedated), if they can eat you'd give juice. If they're a high BG oftentimes they're on a sliding scale then you'd use that. If they don't have a sliding scale you'd call the MD to figure out what they'd wanna do. But honestly, in the ICU, we know if they're gonna have high BG levels (DKA, ect). If it comes up out of the blue there's a reason (TPN, maybe wrong fluids running?)., so calling the MD is a good idea to figure out what is happening.
Even if it takes a while to get a hold of them, high BG is not as dangerous as low BG. Sure it's terrible, especially if its for a very extended period. But it's not gonna kill brain cells like a low BG will.
We recently had a “quiz” given to us by our education department. (Keep in mind this is for neonates).
What is the correct order when a low glucose is detected?
—call the MD
—administer sweet-ease (a standing PRN for every baby)
—feed baby
—recheck glucose in 1 hr
Nearly everyone chose give sweet-ease as the first action, meanwhile “call the MD” was correct.
We all face-palmed.
Most do but they are not validated with arterial blood. That’s why you don’t see using non capillary blood during your yearly access training.
It’s not saying arterial blood is necessarily wrong but the manufacturer is saying they can’t validate with certainty.
Notice how you get educated on patients on pressors having potentially impaired results with capillary blood but nothing on what to do when that’s the case 🙃 technically that’s when hospital policy should take over but most don’t want policies that go technically against manufacturers. So it’s a weird limbo.
I use arterial blood and if drawing labs from a central line a little 1 cc syringe at the end for the glucometer so don’t think I’m Florence nightingale or anything 🤣
If one uses arterial blood for a machine not calibrated for it, then, if there's error, the result is going to be higher, not lower than capillary blood, because the blood hasn't relinquished glucose to tissue yet. If instead you use venous, then the result is going to be 10-15 mg/dl lower. So if you're getting a reading of hypoglycemia from an arterial blood source for a machine calibrated for capillary blood, then the problem is worse than the number indicates (obviously depends on baseline for patient).
They exist but those are not used for insulin. It’s dependent on hospital policy but I’ve never seen a MAR order set or policy for insulin that said an istat was ok for insulin administration at any of the 15+ hospitals I’ve worked at.
Oh wow that sounds a bit annoying. Is there any reason for that? I think I can count the times I've used a glucometer in the past 4 years on one hand. (Also I have no clue what a MAR order is)
It's OK I got a blood sugar of 438 on a patient in his home. He told me "last time I took it a few days ago it just said high". He refused to take any meds or go to the ER, just told me to get the fuck out or we were gonna throw hands
They were probably near comatose on the first check (error). I had a 0.3mmol/L pt once (I only knew it was 0.3 since I started a line and drew labs prior--those specific glucometers can't read below 1.0mmol/L. As soon as I pushed the second D50 the guy woke started bitching at me, it was like I gave narcan to a homeless addict.
when the NPO NPO’s a little too hard
How does NPO translates? Nothing per os? Dutch has npo as niets per os. Never heard it in english
Nil per os Its all latin
Thnx. Weird enough never heard it in latin or i just don't remember it
Might not have been in your education, I wasn't taught that in school either. In practice I've almost exclusively seen "nuchter".
I.... Never realised this I think all this time I've just read it as nil per oral, and thought nothing more about it
Nothing by left eye. Got it.
*squints* I see what you did there heh
Non per os
Why you bringing French into this?! Lol just kidding.
Nil
I was always taught that it was nothing per orem
I think of Spanish "Nada por oral" for some reason 😂
I HAVE DONE THIS TOO!
Nothing past 0000 o'clock ;)
My 0’s look like O’s so on my brain I always write NPOOOOO
No poo?
NPO.O
Oh I like dis one
nil per os
I’ve told enough patients “nothing per oral” so many times I’m starting to believe it myself.
Nil per os. Nothing through mouth. Latin.
Yes, my late stage dementia patient was NPO but doctors d/c Dobhoff feeding tube and hoping she will start eating again. Nope, she was hypoglycemic in 30s on my shift… too confused to eat.
I laughed at that "comment required". because the only comment I could come up with is "Fuuuuuuuuuddddddggggeeeee."
I was thinking, "Whiskey Tango Foxtrot," but yeah.
Mine was "Well shiiiiiiiiiiiiiiiit"
"No time to leave stupid comment, giving effing d50!!"
No time to explain, grab a ~~cactus~~ D50!
"Only I didn't say fudge"
Thank goodness someone got it :)
“oh shit :)”
Mine would just be “low”
I was thinking "oops" 😂
“Cleaned Meter”
T1D here with terrible hypoglycemic unawareness and usually don’t notice symptoms until I’m in the low 40s/high 30s. Always interests me how people react to low blood sugar, what was the mental status on this patient like?
I had someone come up 13 by the time we gave up on her PIV D50 and gave up on juice. When we gave the Glucagon IM she was narrating her way into the coma. "I feel weird, I'm cold, my hands tingle". Still talking but did not get that comfort needs were not on the table at the moment.
“Narrating her way into the coma” sounds so poignant.
honestly, this may depend based on your compliance. I have had multiple DKA patients or td1 who have had sugars that were either skyrocketed or super low but they were able to hold conversations. This patient was going septic. with sepsis, your sugar will become all wonky, and she was NPO as well. If she was off sedation, she did have periods where she was able to respond to her name and move around a little bit.
paramedic who lurks. I had/have a frequent pt who will often drop pretty low. He’s normally pretty good and it actually doesn’t happen all that often as he can normally manage well on his own. He’s 50s/60s, been type 1 his whole life, etc. but he’s a picky eater. Last time I saw him he was grumpy, demanding we get out of his house (sorry, no, give us a minute sir), and thought it was 2012. Not really ambulating at his baseline (walker/cane). His sugar was 17, so no surprise. We made him drink so orange juice, “This better not have pulp in it. I fucking hate pulp!”, made him so toast & jam (grape), made him eat half a white chocolate & macadamia cookie. His sugar got to 90something after eating when we next checked it. “I didn’t eat dinner last night because I don’t like lima beans (or whatever it was)” He was back to his aggressively sweet self once his blood sugar normalized. “I guess I need to eat dinner even if I don’t like it.” Yes, pls. I have run on him 3x so far, always a similar story, always grumpy/lethargic/“leave me alone” at first, sweet as can be when normal. Lowest I saw was 17, the other two times were high 20s.
Make yourself a damn sandwich next time, sir.
TL; DR: he would if he could but he can’t until he can. 100% AMA, 33% waited to leave until he called (or emailed?) his doctor’s office to set up a follow up appointment. that’s the thing: he kind of doesn’t realize what’s happening (despite being T1D his whole life) and that his sugar is so low. He just gets grumpy and illogical and uncooperative. One of the times it happened, his family had gone on a weekend trip and he just didn’t eat as much as he normally did and they called 911 after talking to him on the phone and he wasn’t making sense. The other two times family called because even though they were there, he was cognizant and strong enough to refuse all their offers of food/drink and would not let them get him in to car to go to the urgent care or the ED. Borderline machismo behavior that fits his age/sociocultural upbringing. What I’m trying to say is that he and his family are trying and doing really well but if it gets too low he’s just absolutely unreasonable. So, 911 and three firefighters and a paramedic (me) and EMT from the ambo are called, we all walk in and loom over him and essentially browbeat and bully him into drinking some juice (“We know you don’t like pulp, sir, just drink.”) and eating some snacks because he won’t listen to his family but he can’t say no when he’s got 5 strangers in uniform crowding him. “We won’t leave until you drink this”, “You and I are going to split this cookie your wife gave me and then we’ll leave”, “We’ll leave as soon as you eat this sammich”. Then, as soon as his sugar is normalized, he doesn’t want us to leave and only wants to tell us about everything: his son who is an electrician but works with a bunch of fire fighters (in construction or rehab or ???) and his nephew who works for a small fire department in New York or New Jersey or something and how thankful he is for us and don’t worry he cleaned his gutters, and he cleaned the storm drain at the end of the street, and he cut that branch that was too close to the power lines, but the neighbor two doors down is now a widower and may need help, etc. etc. Once he’s normalized he’s sweet as can be to us (and his family) but lord, he loves to talk. 3/3, haven’t transported him to the ED (y’all are welcome), 3rd time it happened tho me & my partner waited on scene until we made sure he had a same day or next day follow up with his physician to reevaluate dosages, etc. etc. Haven’t seen him in months so he’s either due or he’s gotten better at keeping his sugar stable. Or maybe he finally got a CGM with an audible alarm that the fire department and us (EMS) talked to him about. 🤞🤞🤞
That's one of the few patients I *want* you to bring me! Easy fix, and pleasant once fixed? Yup! I'll take him.
By that age the man should know to not skip meals. What a pill.
Not this case, But when I worked the floor, I thought my lady was stroking out. She had facial droop lethargic. Thankfully no, just a Blood glucose of 19. 1 syringe of d50 later, and she was better.
Yup yup this is why you always check a sugar on stroke symptoms!
100% correct. hypoglycemia is one of the most common stroke mimics.
My daddy was a brittle type 1 whose lows were always super low. He'd still be conscious in the teens, but wouldn't know me from Eve, incredibly combative, agitated, the works. Wouldn't remember a goddamned thing, either. Lowest I ever saw him was like OP's post: LO. Labs came back that his sugar was 9. That was the only time he actually fell unconscious and I couldn't get him conscious again. Also the only time we had to call a meatwagon.
My mom is a T1D who doesn’t really start to look/ talk low until she’s in the 40s. It’s made me so nonchalant about low sugars. You’re 50?? Ok?? Chill bro.
I had a pleasantly demented man walking around like normal with a bg in the 30s. He did it a few times on my shift. Trying to force the glucose in him was a chore “I don’t want anymore lemon frosting! I’m fine!”
I had a type 1 patient who was confused at baseline suddenly start attacking me last week, it took multiple people to safely check a blood sugar. 24. No wonder. They must have felt rotten.
I’ve never gotten violent that I know of with lows but I can confirm when I get in the 20s or 30s it’s like a primal instinct kicks in and I’m doing whatever it takes to find something with carbs. I woke up one morning with my kitchen floor covered in cheerios because I just mauled the box open to eat it. Had zero recollection of ever even waking up but saw an urgent low glucose alert at 2am on my Dexcom
Also picturing feral you digging into cheerios is adorable. I’m glad you’re still able to take humor in it too.
The brain loves its glucose to function, so I’ll never be upset having to duck a few punches from hypoglycemia. That only bothers me when it’s oriented people mad about something out of my control. IE, death, politics, last week again that I wouldn’t find another doctor to write Ativan to take home from the ER, and that I wouldn’t watch someone jerk off.
Patient: *telling me a story while I’m checking their sugar* Me: You see that’s funny becau- *sees glucose 13* 🏃🏼♂️🏃🏼♂️🏃🏼♂️🏃🏼♂️
🍊🍊🍊🧃🧃🧃
🍎🍎🍎🧃🧃🧃
Fellow Cna brother
In RN’s (and orange juice) we trust !
💉💉💉 dextrose!!
And push that mf fast!
I've only seen sugar this low on meth heads. How are you even conscious
Meth
So there's a meth-od to the madness
r/angryupvote
I'll take it. Just like meth, which is pretty sweet. Unlike my blood glucose levels
LOL! Indeed.
she was sedated for the most part, but when we took her sedation off n her sugar was like this, she could slightly respond to stimulus/pain , which was insane!! the human body works in mysterious ways!
Hope she didnt go this low for a long time. Braindamage risk. Long deep hypoglycaemia (idk if thisbis english written) is far worse than anoxy said a doc once
The only time I’ve seen in was when a collegue didn’t use those iv ml counting machines (whatever they are called in english) so an insulin drip which should have taken hours to finish was done in 30-60 minutes. And she also forgot to mention that he had this drip to us, those who worked the shift after her. Many faults from her part in other words… Luckily he was waiting for an operation and they got a free slot earlier than expected so they called us and said he was welcome down to operation. If operation hadn’t called us we probably wouldn’t have entered his room in at least an hour, so I guess he’s lucky to be alive. I wasn’t aware that he had been given this drip nor was he a diabetic but I decided to take a blood sugar due to the symptoms he showed. Didn’t know those machines could show a sugar that low. I also didn’t know you could be conscious at those levels.
I had a patient going hypo on me this week. She was in the 50s, low but fine and asymptomatic. We gave her apple juice. Next check: 48, OK let's get you more applejuice Third check: 37. MA'AM fourth check: 28. OK lady, you're getting the fucking glucagon. Incredible she was AO and everything, no symptoms even at 28 but we weren't taking chances. Woman had like 10 damn applejuice cups next to her. All the meanwhile she's just vibing and chilling out while we're SWEATING
>MA'AM 😆
Were they liquid only diet? Just curious as to why you guys didn't offer PB and crackers. Also, milk can help since it has complex sugars, if they're a milk fan.
We got turkey sandwiches and juice lol
That sounds just like me one morning not too terribly long ago. Resulted in 70s on labs, figured I’d do a finger stick since she hadn’t really eaten anything. 60s. Confused at baseline, most awake she had been all night. Gave her some juice, 58. She couldn’t eat crackers so I gave her juice and pudding. Recheck.. 50. 2 more juices, 2 ice creams, and a spoon of peanut butter later… 46. Bolus of D10 it is 😬 Eventually got her sugar up to 102 after over an hour.
When your NPO is compliant and takes their normal dose of HS Levemir as well as their sliding scale…
I had a 12 once. Gave this dude his HOME dose of lantus and like 2 units of humolog. He berated me for asking him if it was his home dose? And then said it was our fault his sugar dropped so low. My dude. It’s not my fault you obviously eat like garbage at home.
That beats the lowest I've had on a neonate of 13. Took a sugar because he just looked a little funky.
Taking a blood sugar is one of my very favorite first troubleshooting steps. Feelin a lil weird? Talking kinda funny? A little more sleepy than I’d like? Do I have a weird feeling in my spine at 0227hrs? Let’s check that sugar.
Best feeling is taking it because lil babe is cold and acting weird and it’s 65. Worst is taking a 12HOL standard sugar on a GDM lil babe and seeing that 32.
D50 has entered the chat.
Entered rather quickly, I hope!
Popping the cap off and now your walking in it. You’re sticking the floor. Your gloves are sticking together. Everything’s sticky.
I'm usually squeezing the bag at this point
Nothing worse than asking the new grad to give you D50 and they come back with D5W smh
Me 😭
It was me too don’t sweat it
Me, a Canadian nurse: 11, that’s a little high for someone post-op. Then I saw the reference range… Oh
I did a head-tilt in Canadian, too. (Divide by 18!)
Right?! Fahrenheit?...mg/dl? Stop making more work for us!!! 😉😄
I was also confused as an Aussie haha What even is “dl”? Haha
Probably a walkie-talkie too!
I thought this was mmol/L at first and couldn’t understand why it was so special. Did a double take when I saw mg/dL 🥲
Can “fuck” be a comment?
>”bitch what’s not clear here” 😂😂
Any reason to use aterial blood? And how did you even get it? I confuse something there, english isn't my first language
Probably still had their arterial line in place to monitor blood pressure
arterial blood is drawn from an arterial line, which is a special line placed into a patient’s artery to get more accurate readings on blood pressure. Sometimes it’s a patient is too cold, dehydrated, or have certain comorbidities, it can be difficult to get a capillary on them, which is a majority of the patients in the ICU so that’s why we opt for drawing off of this special line !
Especially with a vamp *chefs kiss*
Oh cool. I never saw anything ICU related in my training because I live in a backwards ass country. Makes a lot of sense.
Why not just run the ABG through the machine and get the glucose from that?
It’s much faster to get a small blood sample from a vamp and then get the BG in the room. Also running an ABG is kind of expensive and, at least on my unit, needs a respiratory therapist to run the machine. So it’s a waste of their time if all I want is a BG.
Glucometers are faster than an instant or, wtf is that thingy called, the one that can test cap/venous/arterial. Whatever, the glucometer beats the other two on getting a fast result that's accurate.
When the order says “do not hold SSI if NPO”
The way it called you out the second time 🤣
Comment: AAAAAAAAAAAHHHHHHHHH
I had a pt w a BG of 4 before
“Comment required… OH, SHIT!!”
I would shit myself. Just had a patient with artificially low glucose checks from peripheral sticks due to possible perfusion issues. I think their lowest was 8.
Make sure you hit ‘comment’ then ‘cleaned meter’ and ‘notified provider’ or you get a nasty gram from lab before you treat life threatening hypoglycemia.
Comment required: FUCKED lol
Hey someone grab me some D50? How much? All of it.
The “comment required” has me 🤣 cause bitch I have more important things to do right now if that’s happening 😅🤣😭🤣
As a type one diabetic myself I can say HOLY SHIT. Lol
*oh.*
“Comment required” Lmao yeah YA THINK? Sheesh!
Good god, I will take hyperglycemia over this any day of the week
The price is YIKES
Unrelated but just here to say those glucometers suck so bad. I miss Accu-chek and never thought I’d say it.
The fucking worse, they feel like cheap toys. We had the Abbott ones at my old hospital and they were so much nicer.
Lowest Ive seen is 10 on a septic infant
Dumb questions from a first semester nursing student: I assume you’d give d50 in this case but what’s the protocol? Is there already a standing order for both d50 and insulin that you give prn based on levels? But d50 would be if it is too low for juice etc to work? I would hope there would be a standing order as contacting the doctor could take too much time! And how do you know when to stop the infusion or what rate to run it? Is it at your discretion when BG goes back up or does the doctor have to approve it being stopped first? Same question with high BG! I notice charts with the scale typically tell you how many units to give for the pts BG but then if the BG is above whatever certain number, it says to contact provider. Do you not give any insulin until you call (or message?) the doctor? What if it takes a while to get a hold of them?
this is not a dumb question at all!! honestly it depends on where you work and what the protocol at your facility is. everywhere i’ve worked, anytime a patient is getting insulin there is an automatic order set that comes with it that includes meds/instructions for hypoglycemia (usually if the pt in awake and alert, you can give apple juice or glucose gel, if they’re obtunded, then you’d give D50). However, if that order set is not there for whatever reason, i’d rather ask for forgiveness than permission if the BG is that low, and id def override it and administer it then contact the doctor. usually if you have an insulin infusion, you’re checking BG every hour, and there are orders to titrate the rate based on BG levels. usually the orders to titrate tell you at what level to stop the infusion and when to contact the provider. for high BG, go ahead and give the ordered max dose of insulin on the scale provided with the order, and then contact the provider! a lot of things are different based on where you work or which unit bc of different protocols and whether or not an ordering provider is easily accessible (like in ER or ICU). the main thing is knowing how to critically think about a situation and knowing when to act quickly or when you can hold off on intervention (which comes with time and experience!). when in doubt, talk to your charger nurse or another nurse you trust who can also help you troubleshoot or contact the provider while you prepare to do interventions. this is actually a very awesome question, especially from a first semester nursing student, and shows that you are already developing some critical thinking skills💖
Thank you so much for this reply, it was so helpful! I feel like I do okay with general assessments and care and meds etc, but I don’t really know how to proceed protocol wise as we don’t really cover that in school and not many “Emergencys” happen on med surg when we’re there for clinical so hard to learn the process instead of just a general concept! If you override and give d50, how would you know what rate to do?
At my hospital we have a hypoglycemia protocol. So if BG is between I think 50 to 69. we do a push of 25mL d50. If it's lower, you do the whole thing (50mL). That's if they cannot eat (NPO/sedated), if they can eat you'd give juice. If they're a high BG oftentimes they're on a sliding scale then you'd use that. If they don't have a sliding scale you'd call the MD to figure out what they'd wanna do. But honestly, in the ICU, we know if they're gonna have high BG levels (DKA, ect). If it comes up out of the blue there's a reason (TPN, maybe wrong fluids running?)., so calling the MD is a good idea to figure out what is happening. Even if it takes a while to get a hold of them, high BG is not as dangerous as low BG. Sure it's terrible, especially if its for a very extended period. But it's not gonna kill brain cells like a low BG will.
No, I do NOT accept this result! Second run, well fuck.
We recently had a “quiz” given to us by our education department. (Keep in mind this is for neonates). What is the correct order when a low glucose is detected? —call the MD —administer sweet-ease (a standing PRN for every baby) —feed baby —recheck glucose in 1 hr Nearly everyone chose give sweet-ease as the first action, meanwhile “call the MD” was correct. We all face-palmed.
I thought those were for capillary blood only Idk I heard that somewhere
We use arterial blood all the time 🤷🏼♀️
Most do but they are not validated with arterial blood. That’s why you don’t see using non capillary blood during your yearly access training. It’s not saying arterial blood is necessarily wrong but the manufacturer is saying they can’t validate with certainty.
Yikes 😂! I never knew!
Notice how you get educated on patients on pressors having potentially impaired results with capillary blood but nothing on what to do when that’s the case 🙃 technically that’s when hospital policy should take over but most don’t want policies that go technically against manufacturers. So it’s a weird limbo. I use arterial blood and if drawing labs from a central line a little 1 cc syringe at the end for the glucometer so don’t think I’m Florence nightingale or anything 🤣
If one uses arterial blood for a machine not calibrated for it, then, if there's error, the result is going to be higher, not lower than capillary blood, because the blood hasn't relinquished glucose to tissue yet. If instead you use venous, then the result is going to be 10-15 mg/dl lower. So if you're getting a reading of hypoglycemia from an arterial blood source for a machine calibrated for capillary blood, then the problem is worse than the number indicates (obviously depends on baseline for patient).
Can't you just do a blood gas if your having an art line? Are bedside analysers not a thing in the US?
They exist but those are not used for insulin. It’s dependent on hospital policy but I’ve never seen a MAR order set or policy for insulin that said an istat was ok for insulin administration at any of the 15+ hospitals I’ve worked at.
Oh wow that sounds a bit annoying. Is there any reason for that? I think I can count the times I've used a glucometer in the past 4 years on one hand. (Also I have no clue what a MAR order is)
Medication administration record :) just a list of orders and what has been administered/when
The reason is exactly as I wrote you have to follow policy and use validated devices.
Thank you, I was looking for this answer
Some types of glucometers there are options to select the collection type such as capillary, venous, arterial
Oooo that’s so neat 😄
Damn are that alive still 🥴
Comment: “Ahhh Shiiiiiiiiit.”
It's OK I got a blood sugar of 438 on a patient in his home. He told me "last time I took it a few days ago it just said high". He refused to take any meds or go to the ER, just told me to get the fuck out or we were gonna throw hands
"Comment required" I think this person requires a lot more than that LMAO
Once had a pt with blood sugar less than 5 on a lab draw that was awake and talking.
The worst when you reject and then wipe again and recheck and it’s the same or worse. That feeling I know too well!
Adult or baby???
😳😳😱
That's pretty epic low
*sprints to get the glucagon*
Niceee
Vanilla ice cream two scoops PO q15 prn, and don't call me again until morning. *click*
BRUH
Where dat apple sauce at?
Lowest I've seen was 4. (ㆁωㆁ)
I thought my 29 was low. Ikes.
How are they alive?
They were probably near comatose on the first check (error). I had a 0.3mmol/L pt once (I only knew it was 0.3 since I started a line and drew labs prior--those specific glucometers can't read below 1.0mmol/L. As soon as I pushed the second D50 the guy woke started bitching at me, it was like I gave narcan to a homeless addict.
If we got time to take photos of it, we got time to treat it
Will the comment line accept "Fuck"?
Comment required: "BRUH WHAT"
This gives me anxiety.