Concern for Type I diabetic

kidzcare · Feb 5, 2015

Cookies and twinkies! Wow. Did the student carb cover for the pop tart breakfast at least?

She would tell me she did. She had a long history of lying to everyone in the school. It was my first few months (I started towards the end of the school year) and I just trusted the numbers she would tell me for the first month or so until one day I said "That doesn't seem right. Let me see the glucometer" and turns out she had been lying about having some low sugars later in the day to get out of class and have a sugary snack that she wanted to share with friends. She would then bolus herself.

I was such a straight laced kid that it NEVER occurred to me that she (or any student) would be untruthful. It still blows me away when the kids lie right to my face.

kidzcare · Feb 5, 2015

How sad for that poor student. Hopefully, the relatives were able to help her get into a healthy routine. I feel so bad for these kids, in these situations. They need help managing something of this nature and magnitude and when they don't feel like they have someone they can trust to help them out, they are constantly trying to claw their way out of a no-win battle. So sad

It was such a hard situation to watch. I came in to the school in March, just as she would be leaving my school, so I didn't work with her for too long. This girl was dealt a rough hand and I'm sure that will follow her the rest of her life. The mom was such a piece of work and dad was not involved. Many calls were made to DCFS and I don't really know what the situation is now. There was a younger brother who was not taken, so I assume the reason this girl was removed was medical neglect.

SHGR, MSN, RN, CNS · Feb 6, 2015

The student actually does all of this independently, and while I monitor the process here at school, I'm not sure there is much help while at home.

I think this may be the big clue here. How many middle school kids do ANYTHING independently (much less manage a complex condition like T1DM which is difficult for adults including health care professionals!!!). Is she puberty age? That can throw sugars out of whack too. Another poster mentioned she might be eating carbs secretly, like many kids do.

Doesn't mean she is a bad kid. Just probably a normal kid asked to do a lot more than other kids her age.

Also- call for greater than 500? Really? If it were my kid I'd want a call greater than much less than that. 250 maybe?

mariebailey, MSN, RN · Feb 6, 2015

I think it's a great idea to have a release signed so you may communicate with the endocrinologist freely.

KelRN215, BSN, RN · Feb 6, 2015

They use an insulin pen. The student actually does all of this independently, and while I monitor the process here at school, I'm not sure there is much help while at home.

An 11 year old doing everything independently? Mom probably isn't supervising her at home and she's skipping doses or not giving them correctly. She's a bit young to be underdosing herself on purpose to try to lose weight (google diabulimia if you haven't heard of it before) but at an age where she doesn't want to be different than her peers so may very well be eating extra carbs because they are.

Is the family limited? If she's on a set dose in the morning without regard to her sugar levels or carbs to be consumed, is the Endo trying to design the simplest insulin regimen possible for them so they can't screw it up? When I see orders for diabetics with set doses of NPH and Humalog with no sliding scale or carb counting, my assumption is usually that the Endos were trying to dumb down the plan for the family. Most kids we see have orders that are something like this: Administer 1 unit humalog for every 50 mg/dL that blood glucose is greater than 150 mg/dL during the day and 180 mg/dL during the night. Administer 1 unit humalog for every 15 g CHO to be consumed. So the family has to calculate how much to give based on the child's blood glucose level and carbs to be consumed. Some families we don't trust can do that math and those are the kids who end up on set doses.

We have 1 patient currently who sounds similar to your case. Teenager who's completely uninterested in his illness and parents who don't think they have to supervise him. Diabetes team tried to work with them for several months before involving child protective services. After a clinic appointment where his HgbA1C was > 14%, we (VNA) ended up involved. At the time we took the case, he was on set doses of insulin at home and had a lunch time sliding scale on school days only, because the only person the Endo could count on to actually check his blood sugar was the school nurse. Now that he has nursing support in the home, he's on a sliding scale and things are a little better but not much.

SassyTachyRN · Feb 6, 2015

Sadly, I have found that with most type 1's, the best care they get is at school from us...

Supernrse01, BSN · Feb 6, 2015

I think this may be the big clue here. How many middle school kids do ANYTHING independently (much less manage a complex condition like T1DM which is difficult for adults including health care professionals!!!). Is she puberty age? That can throw sugars out of whack too. Another poster mentioned she might be eating carbs secretly, like many kids do.
Doesn't mean she is a bad kid. Just probably a normal kid asked to do a lot more than other kids her age.
Also- call for greater than 500? Really? If it were my kid I'd want a call greater than much less than that. 250 maybe?

I completely agree with you and normally call way before a blood sugar reaches that level, unless of course the first check is that level!

Supernrse01, BSN · Feb 6, 2015

An 11 year old doing everything independently? Mom probably isn't supervising her at home and she's skipping doses or not giving them correctly. She's a bit young to be underdosing herself on purpose to try to lose weight (google diabulimia if you haven't heard of it before) but at an age where she doesn't want to be different than her peers so may very well be eating extra carbs because they are.
Is the family limited? If she's on a set dose in the morning without regard to her sugar levels or carbs to be consumed, is the Endo trying to design the simplest insulin regimen possible for them so they can't screw it up? When I see orders for diabetics with set doses of NPH and Humalog with no sliding scale or carb counting, my assumption is usually that the Endos were trying to dumb down the plan for the family. Most kids we see have orders that are something like this: Administer 1 unit humalog for every 50 mg/dL that blood glucose is greater than 150 mg/dL during the day and 180 mg/dL during the night. Administer 1 unit humalog for every 15 g CHO to be consumed. So the family has to calculate how much to give based on the child's blood glucose level and carbs to be consumed. Some families we don't trust can do that math and those are the kids who end up on set doses.
We have 1 patient currently who sounds similar to your case. Teenager who's completely uninterested in his illness and parents who don't think they have to supervise him. Diabetes team tried to work with them for several months before involving child protective services. After a clinic appointment where his HgbA1C was > 14%, we (VNA) ended up involved. At the time we took the case, he was on set doses of insulin at home and had a lunch time sliding scale on school days only, because the only person the Endo could count on to actually check his blood sugar was the school nurse. Now that he has nursing support in the home, he's on a sliding scale and things are a little better but not much.

My thought is Mom has given instruction at home and feels that is all that is needed. I have spoken with Mom several times concerning things I am noticing that need reinforcement at home. It's hard, as you pointed out, for an adult to wrap their thoughts around something like this, let alone an 11 year old child. Sadly, I feel like most of the time, I am wasting my breath. The student is observant and like a sponge and is trying to grasp everything I talk about.

Wave Watcher · Feb 6, 2015

Long story (made as short as possible) :)
I have a student who was diagnosed as Type I, earlier this school year. Sugars have been all over the place and of course, several adjustments have been made in dosing.
My concern is, the student is in my clinic almost every morning at the same time due to hyperglycemia. I'm talking between 190-500 every time. Student is taking morning dose of insulin at home, before school. I have spoken with mom (several times) to voice my concerns over the consistent pattern but I am not noticing any improvements. I'm not sure what else to do. Should I fax the blood sugar log to the student's physician or is that overstepping my boundaries?
What would you do?

I would also be concerned if mom/dad is giving the correct dose of insulin EVERY morning before school. Also, as a newly diabetic your student is not always going to be compliant. Do not put it past him/her to be eating (sneaking) food at home before school or at school before coming to see you. Also, hormones can play a large roll in fluctuating BS. As you know a new diabetic can be hard to manage....along with educating the parents. Sometimes, they are still in denial months later. Good luck and hang in there!

KelRN215, BSN, RN · Feb 7, 2015

My thought is Mom has given instruction at home and feels that is all that is needed. I have spoken with Mom several times concerning things I am noticing that need reinforcement at home. It's hard, as you pointed out, for an adult to wrap their thoughts around something like this, let alone an 11 year old child. Sadly, I feel like most of the time, I am wasting my breath. The student is observant and like a sponge and is trying to grasp everything I talk about.

Yes this sounds pretty identical to my patient. When confronted with the facts, the kid's parents basically say "it's his disease, it's his responsibility to manage it." The kid is 14.

Supernrse01, BSN · Feb 9, 2015

Yes this sounds pretty identical to my patient. When confronted with the facts, the kid's parents basically say "it's his disease, it's his responsibility to manage it." The kid is 14.

Wow! That is awful and I feel bad for the road your student is travelling. IT won't be an easy one and I hate that!

KSM-RN, BSN, MSN, RN · Mar 31, 2016

How long before a dfs call is made? Once a week absences with 3-4 a week large ketones? Canceled endo appts?