A nurse administers NPH insulin to a post-op patient (2 days post-appendectomy) at 8:00 am. At 2:00 pm, the patient is found guarding his right lower abdomen, extremely lethargic but conscious, diaphoretic, and slightly combative.
The patient’s vital signs are: T=99.1, HR=80, BP=109/62, RR=18, SPO2=97%. What should the nurse do first?
A.
Assess the patient’s blood sugar using a bedside finger stick blood glucose test.
B.
Administer the next dose of insulin STAT.
C.
Administer Narcan (Naloxone) STAT.
D.
Administer 2L O2 via nasal cannula.
The Correct answer and Explanation is:
The correct answer is A. Assess the patient’s blood sugar using a bedside finger stick blood glucose test.
Explanation
In this scenario, the patient is experiencing several concerning symptoms, including guarding of the right lower abdomen, lethargy, diaphoresis, and slight combativeness. These symptoms can indicate a potential complication related to the patient’s recent surgery or metabolic issues, particularly with the administration of NPH insulin.
NPH insulin is an intermediate-acting insulin that typically peaks 4-12 hours after administration. Given that the patient received this insulin at 8:00 am, it is possible that the patient is experiencing hypoglycemia, particularly if their blood glucose levels have dropped significantly due to the insulin dose, inadequate intake, or other metabolic demands following surgery. The lethargy and diaphoresis are classic signs of hypoglycemia, making it imperative to confirm the blood glucose level as a priority.
Assessing the blood sugar level is crucial because if the patient’s glucose is low, immediate treatment (such as administering glucose) can be initiated to prevent further complications, including potential loss of consciousness or seizures. On the other hand, if the blood sugar level is within normal limits, it would prompt the nurse to investigate other potential causes for the symptoms, such as pain from the surgical site, infection, or other metabolic imbalances.
Option B (administering the next dose of insulin) is inappropriate as the patient may already be hypoglycemic, which could worsen their condition. Option C (administering Narcan) would only be relevant if there were clear signs of opioid overdose, which are not present here. Option D (administering O2) may be beneficial for any patient showing signs of respiratory distress but does not address the most pressing issue of potential hypoglycemia.
In summary, assessing the patient’s blood sugar is the immediate priority to determine the appropriate course of action based on the patient’s metabolic status.