Kid with diabetes - need the hive mind

  1. Because I respect your collective opinions, and just to make sure I'm not missing something or there's nothing I should be considering:

    New to me diabetic 15-yo. Long-time diabetic. My first contact with mom was by phone: she stated student had a "critical low" and "almost ended up hospitalized" this summer. The student was well-known to the previous school nurse.

    My experience with him: never low. Always high. Like kidney function-breaking, A1C-in-the-sky high.

    This year he has been in the clinic 19 mornings and eight afternoons (not always the same days). We've been in school 9 weeks. Over 500 BSG in the AM on most of those days (he's not checking BSG at home). Protocol says 6 units of insulin, check ketones, call parent if BSG over 400. Very rarely does he have ketones.

    Trouble-shooting with parent: is he getting Lantus? How much? After about the fourth week, mom is telling me she is making sure he is getting the Lantus.

    I accept part of this may be hormonal. I accept that one week he was getting sick (no ketones until the very last day before he went to the doctor). When he is home, mom tells me that he has "very high" ketones. I have yet to see the cherry purple strip on this kid.

    The pattern I'm seeing indicates he is being careless with carb counting. He also doesn't bring his equipment every day, and it's a process to get him to tell me all that he's eaten for lunch....he will routinely forget to add that he's consumed chocolate milk or a juice.

    That's the easy explanation. I guess I'm looking for zebras. I contacted the children's hospital (provider of record) and they had nothing much to add (told me to follow the protocol even when mom wants to add more insulin). I asked mom point blank if she thought he was doing this to get out of classwork. She said "I don't know." She agreed to discuss it with him but here we are....9 weeks in....and he may absence fail some subjects because even if you're in the clinic, you can absence fail.

    Today I'm contacting the counselor to ask if there's anything that can be done on his 504. He is literally missing the first period class twice a week because his BSG is so high he cannot function.

    Thoughts? I mean, they pay me to be here whether he's managing well or not. But I fear for his young adulthood if he surfs at 500 the whole school year.
    •  
  2. 8 Comments

  3. by   ohiobobcat
    Ugh- this sounds like a rough one. It's obvious that something is being missed with this kiddo with his diabetes care.

    -Does he have extra supplies he can keep at school. Some of my T1D kids have extra meters, glucose test strips, urine test strips, pump supplies, etc that are all kept in my office. That might help with the forgetting of equipment. Is this kid on a pump or insulin pen?

    -The carb counting thing stinks. All of my T1D kids bring lunches from home, and carbs are pre-counted by a parent.

    -My T1D students have it written into their 504s that they shall not be penalized for missing class because of diabetes and will be allowed extra (reasonable) time to make up work missed because of diabetes issues. Is he a good student when he's not stuck in your clinic?

    -I have enlisted teachers to encourage my T1D to stick to their schedule of when they need to come see me. Teachers get busy too, and sometimes they forget, but it sometimes it helps kids get into the habit of coming to see me.

    -I would definitely involve his guidance counselor and maybe an admin because of how much this health issue is affecting his academics.

    -Are the parents/student compliant with his diabetes clinic appointments? I have a kid who hasn't been to an endocrinologist in 2 years and has been on the same insulin regimen since she was 13. Guess what her last A1C was? 12.4!!!! Mom and student both do not get (for whatever reason) how BAD this is and it's hard to make them see that. I got the standard "We are waiting for the referral to go through." line from mom at the recent 504 meeting. Because if the clinic is OK with these numbers and are not adjusting anything...well, that seems a little weird to me.

    I am interested what others here have to say about this, too.
  4. by   OldDude
    What does his diabetes management plan say to "do" or "not do" for hyperglycemia? If he feels too bad to be in class then he feels too bad to be in school. Otherwise he can return to class until you recheck in two hours or in accordance with the DMP. Being "absent" from class at school removes the parent from taking any ownership of the issue and rewards the student for any avoidance behavior - if that is the case here.
  5. by   ruby_jane
    We have a spare set of supplies here.

    Protocol is that parent dictates when he stays when he's over 400. Parent is now stating "he's missed so much school" that she wants him to stay - which he can. He just feels terrible as his elevator goes from 500 to 200. I have referred his teachers to contact the parent to describe what's happening in the classroom.
  6. by   lvoyles
    I had a student very similar to that for the last two years. She is being "home schooled" this year, but I am expecting her back anyday! We had the routine that she would get her tray and bring it to my office to count carbs before she ate anything. She would tell me what she was going to eat and what she wasn't. I always emphasized that she had to eat everythingl since I was giving her insulin before she ate. She would finish her lunch in my office if there was something she was still eating. She would come back in an hour to check BS. Her 504 allowed her to not get in trouble for absences, which her parents abused. They would want to check her out early so they could get in the front of the line for the ice cream truck at dismissal because they wouldn't want her to get too hot since she is diabetic. Oh my. As a new school nurse, I felt compelled to provide lots of education and "fix" this family. Looking back, I think that hurt my chance to make a long term difference. A little bit goes a long way. When her BS was way high, I told her that she would probably not feel well this afternoon when it comes down fast, and I was almost always right. Just communicate and document! I hope you can make a life long difference! I am sure you will!
  7. by   ruby_jane
    Quote from lvoyles
    They would want to check her out early so they could get in the front of the line for the ice cream truck at dismissal because they wouldn't want her to get too hot since she is diabetic.
    OY. Nope... I've been doing this six years and I think that the only thing I can do is be consistent. Whether that provides a life lesson or not, I cannot say.
  8. by   OldDude
    Quote from ruby_jane
    We have a spare set of supplies here.

    Protocol is that parent dictates when he stays when he's over 400. Parent is now stating "he's missed so much school" that she wants him to stay - which he can. He just feels terrible as his elevator goes from 500 to 200. I have referred his teachers to contact the parent to describe what's happening in the classroom.
    But...he is still missing school when he's in school and there is no incentive to change if everything continues status quo. I can't imagine his diabetes doctor is OK with this; missing class and lack of BG control.
  9. by   WineRN
    Maybe he is just riding the "I can eat whatever I want because I can just take more insulin to cover me" train of thought? Does he seem to want to be in school?

    I think having the teachers talk to the mother is a great idea.
  10. by   Flare
    I am blessed to have 2 diabetics this year that are really with it and diligent kids. This isn't to say that they don't have their highs and lows, but they are responsible and report to me and their parents are responsive when i call with concerns. I have not always had such a break.
    In fact, i have a student that I called a parent with concerns with acanthosis nigricans last year who told me he started metformin last week. I called mom who tells me he is not diabetic, but pre-diabetic and does not need to test sugars or count carbs in school. I told her i need documentation from the doctor. I have yet to get anything. Coming soon from me - a release form for me to call the doctor. Shall we start a pool on whether or not it get signed / how long it takes?

close