Diabetic care for a 5 year old kinder

Jolie, BSN · Sep 22, 2010

Our district does not have a nurse in any building full time. Each building designates 1 or more para-professional(s) to receive training as a health assistant, focusing on first aid, CPR, seizure, asthma and diabetic management and other special procedures such as tube feedings. Any student with a special health need is identified at the beginning of the year (or time of diagnosis) and the nurse meets with the parents, student and para to create a plan of care, backed up by physicians' orders.

In the case of your young diabetic student, there would be set times for glucose checks (am, pre-lunch, during PE, afternoon) as well as instructions to check glucose when symptommatic, along with a flow chart for interventions based upon blood sugar levels. Most of this is carried out by the para, with phone consultation with the nurse and/or parents as necessary. If insulin is given, it is checked and signed by 2 staff members.

This works well for us because we have a generous amount of time and budget for education, a motivated para-professional staff that works consistently with the same students, and parents who are willing to provide information and support by phone. A nurse is always available in the district and can be at any buildng within 5-10 minutes in a true emergency, but daily management of blood sugars is not a true emergency :)

schooldistrictnurse · Sep 22, 2010

This is a description of how things are done in my district as well.

Supernrse01, BSN · Sep 22, 2010

I ditto that response! :lol2:

LACA, BSN, LPN, RN · Sep 22, 2010

Our district must be the exception...Almost ALL of our schools have a nurse full time (I cover a high school and elementary that are side by side...if the schools are like that, one nurse usually covers both). EVERY elementary in our district has a full time nurse.

If we have a diabetic child, there MUST be a nurse on premises at all times during the school day. The only diabetic I had last year is now at the middle school. Since the elem, middle, and high are within walking distance, I cover him if the middle school nurse has to leave. But because she's not a regular ed nurse (I am), she can't cover my two schools. I HAVE to have a sub for any days that I miss.

mustlovepoodles, RN · Sep 26, 2010

I have a small elementary school with 2 students who have diabetes. The younger one is only 6, diagnosed last year. I do NOT walk around after these kids all day long! The older one(4th grade) has a pump and is almost independent now, just needs some help calculating her carbs. I see her once a day, at lunch. The 6yo needs a lot more support, of course. She comes to see me after breakfast (all our students get free breakfast andlunch). I check her meter, calc her carbs(she brings me her tray so I can see exactly what she ate), and I give her insulin. I don't see her again until she comes in before lunch to check her BG. If she's high 200-400, I check ketones and send her to lunch. 25 min later, she's back with her tray, I calc her carbs and give her insulin. I see her one more time 2 hrs after lunch to check BG--this is about 30min before the buses load. I *always* want to know her BG before we send her home on the bus!

This particular child is extremely sensitive to insulin; i NEVER give her a shot before her meals. Even *one* unit of insulin can mean the difference in stable and hypoglycemia. I have seen this child come in at 450 in the morning and be 52 in the afternoon. :eek: Thankfully, her teacher is very comfortable with having a child with diabetes in the classroom. On the occasions that the girl feels low(and she always knows when she's low!) the teacher has her check her BG at her desk; if she's

Frankly, I have a lot of respect for the parents of these children. How much trust must they have to turn their little children over to people they barely know and just *hope* that everything goes okay? I don't know if I could do it.

Neveranurseagain, RN · Sep 26, 2010

The MD orders I have for the diabetic in my school is to administer insulin (regular) to cover the lunch time carb count, plus extra units to cover a BS of over 250, twice in a row. She has MD orders to get her BS checked at 9:45 am, 11:45 am and at 2:15pm. Occasionally I do need to give her the extra units, but not very often as it has to be >250, twice in a row and I give it at lunch time with the carb count. The only time I recheck her BS is if it is under 100 or I'll check it outside these times if she is symptomatic.

What do the MD orders say? I never take orders from the parents, only the MD. A few times the parents have told me to give insulin to cover a high (>400) BS but I don't have MD orders to cover it--only if the BS is over 250, twice in a row, at lunch time. So if the parents request extra insulin, then they need to give it. I even called the MD's office, and they confirmed not to take orders from the parents. And this child is brittle-60 to over 400 in the same 6 1/2 hr time span, even with careful carb counting.

Clear as mud??? And should you be taking orders from parents???

Jolie, BSN · Sep 26, 2010

And should you be taking orders from parents???

Interesting question, and a source of much debate in our district.

There is 1 peds endocrinology group in our city that treats every diabetic child, so our orders are consistent and always read to accept insulin orders from parents. (That means the nurse, though NOT the paraprofessional.) This physician group has a very clear ideology that parents must become independent in managing their child's diabetes on a daily basis, and push it from the time of diagnosis. Of course, this results in some parental orders that are questionable, making it imperative that the nurse, and not the para is communicating with the parents, contacting the physician when necessary, and drawing the line at what orders we will accept or not. Usually, an out-of-line order from a parent indicates a need for education, not a new trend in diabetes management :)

Neveranurseagain, RN · Sep 26, 2010

In our district, every medication, including insulin, must be accompanied by a physician order. You might want to check with your state BON on whether or not you can take orders from parents. If an incident happens involving the child, where is your RX? Where would you stand legally? Can parents legally give you orders? It seems to me that clear cut orders should be generated from an MD. I do however, understand the need for parents to be able to manage their children's DM, but can they legally give orders to an RN? What is the school district's attorney opinion on this? It seems to me that without clear cut standing orders from an MD, the parent is prescribing insulin, with the RN carrying out the orders. Might be a slippery slope with the BON.

The MD may write an order to accept orders from the parents, but is it legal? But then again, an MD would never write an order that is questionable. :lol2: The orders he writes may not be legal with the BON.

Jolie, BSN · Sep 26, 2010

Yes, we've checked.

Just as in the hospital setting, a physician may designate a dosage range based upon severity of pain, or order a titration based upon assessment findings, the insulin orders we receive are basically a very broad range. Most of the time, the appropriate course of action is clear from the student's flow chart. Occasionally, there will be a gray area. That is when the local endocrine group expects the parents to give instructions, and the physicians' orders are written to cover that.

But that's also why it is imperative for the paraprofessionals to notify the nurse when the child's blood sugars are out of range. It needs to be the nurse who communicates with the parents because 1.) paraprofessionals are not qualified to take phone orders from anyone and 2.) Sometimes the parent's ideas on treating out-of-whack blood sugars are simply not consistent with safe and effective nursing care, either because they're not yet experienced with managing diabetes, or because they have unconventional ideas, which they are free to try at home, but not at school on my watch.

The endo group here has a "hot line" for emergency school calls. I've only had to use it once, but thanked my lucky stars that it was promptly answered when I had a middle school student in my office and mother on the phone insisting that the child carry out a treatment that was blatantly unsafe. (The student had a pump and could have done this completely without my knowledge. I think it was divine inervention that it happened in my office.) The physician's orders were broad and could have been construed to either support or contradict the mother's request. My phone call prompted discussion with the office nurse that revealed serious problems with this child's management at home.

Gampopa · Oct 5, 2010

I need a doctor's order to change the care of my kids with DM (or any other chronic illness). I have one 6th grder who's mother, after a recent doctor check up, poped her head in the office and said so-and-so is to have his BG tested only before lunch. Sorry. we live in a rural area and it took 2 wks to have the doctor sign off on the new DMMP. He's chronically hyperglycemic 300s-500s so to be testing him before lunch was against my better judgement but the MDs opinion and orders prevailed. (Still think it's a stupid order.) I will consult with the parent but not take orders from them. Also, an RN is the only school staff that can give or confirm insulin. If the parents want they can appoint a nonschool person to come in and give insulin. Regular scool staff are prohibited from doing so.

geocachingRN · Oct 15, 2010

Thank you all for your input. I will write the head of the local endocrinologist group about accessing a hot line, that's a great idea! We are also throwing "out of the box" thinking out there like this:

What about starting a list of retired nurse volunteers who would be willing to help monitor or fill in? Has anyone done this?

(REVIEW OF THE ISSUE: In CA an RN/LVN must give insulin. There are court cases and laws that are under review, and while they are under review, the local districts are playing it safe and having an RN/LVN administer insulin).