Elevated blood sugar

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Specializes in ED, School Nurse.

I have a student (freshman in high school) whose blood sugars tend to run high. It's not unusual to see her in the 300s at the beginning of the day. I can usually get her down to low to mid 200s by the time she goes home. It's rare for me to see her go below 200.

She came in stating that her blood sugar was 600+ this morning and she feels kind of rotten right now. Blood sugar check shows 523 with mega-elevated urine ketones.

Have her cover with insulin. Start socking the water to her. Call mom. Mom says "We need to check her every 2 hours. Have her drink lots of water, maybe she can walk in the gym for a bit. What do you think?" I said "I think you need to come get your kid. She needs to not be here with elevated ketones and a 500 + blood sugar for at least 4 hours now." Meanwhile, the student is in absolute tears, feeling like she gets blamed every time this happens and that she's been trying so hard to manage her diabetes. She has anxiety to begin with, and I know yesterday was not a good day for her (we had an uneventful lockdown drill that sent her over the edge and she had to go home).

Have you ever let a child with a 500+ blood sugar stay in school? I feel kind of dumb even asking that, but maybe I'm overreacting? At what point does this become an ER visit? I don't have permission to speak with the Diabetes Center about this student, which I just realized. I'll talk to mom and get that rectified.

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Specializes in School nursing.

Nope.

Same thing happened to me last year. BG above 600 (meter reading "HI"), blood ketones of 4.7. Student felt rotten and looked it. I called Mom, reached her right away, and recommended student go straight to the ED. She picked student up within 15 minutes (but not before student vomited x2) and indeed took her straight to the ED. Student was borderline DKA. If I hadn't been able to reach Mom, I was going to call 911. I don't mess with numbers like that. (But I also know I have parent support for this plan.)

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No way. You did the right thing.

Poor kid.

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Specializes in school nursing, ortho, trauma.

well, i have - but it was more of a temporary pump malfunction (tubing was leaking), asymptomatic, no-ketone situation than the mess you're describing. If the student wasn't feeling well, was testing large ketones and the blood sugar wasn't coming down then that student needs to go home - if not to the ER.

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I had a student several years ago who had levels in that range about once a week or so, her other extreme was down to 18. It was a stressful year. Her orders from her physician clearly spelled out what should be done and when I had questions I called mom and also called her physician. As long as ketones weren't showing up we could keep her in school, have her drink water and see how her numbers reacted but ketones meant she needed to be seen by her physician or in the ER right away! I would not mess around with those numbers and insist mom come get the child or call for transport to the ER.

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Specializes in ED, School Nurse.

OK- thanks for the reassurance. I was 99.9% sure I was doing the right thing by sending the student home, but mom was so sure I could take all of these steps at school to fix it.

I've never seen a red ketone stick before. I should have taken a picture....

Then I thought, geesh, maybe I am being a harda**- I wonder what other nurses do? She didn't argue with me at all when I told her she had to come get her kid though, so I think she knew she was pushing it. This mom also thinks blood sugars in the 250-350 range equals "good control". Sigh. I gotta get that permission to contact the Diabetes Center about this kid.

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Specializes in Pediatrics Retired.

The kid can't be at school under those circumstances. If the link works, look at number 6 on page 6; wherein it clarifies a healthcare provider can discuss treatment with you without the parent's consent.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hipaaferpajointguide.pdf

In case the link doesn't work I copied and pasted:

6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to discloseprotected health information (PHI) about a student to a school nurse or physician?Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about studentsto school nurses, physicians, or other health care providers for treatment purposes, without theauthorization of the student or student's parent. For example, a student's primary care physicianmay discuss the student's medication and other health care needs with a school nurse who willadminister the student's medication and provide care to the student while the student is at school.

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Specializes in ED, School Nurse.

In case the link doesn't work I copied and pasted:

6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to discloseprotected health information (PHI) about a student to a school nurse or physician?Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about studentsto school nurses, physicians, or other health care providers for treatment purposes, without theauthorization of the student or student's parent. For example, a student's primary care physicianmay discuss the student's medication and other health care needs with a school nurse who willadminister the student's medication and provide care to the student while the student is at school.

Man, I learn something new every day at this site!

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Specializes in Community Health/School Nursing.

Good job. I have a diabetic I have taken care of for 4 yrs. I am close to the mother and student. I will keep her here if she is non-symptomatic and manage her BS closely. Otherwise, I would send home a student with a persistent +500 BS that won't come down.

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Yes, you did the right thing!!! The high numbers are one thing but the spilling of large jetones is a RED FLAG. Now tell me, how is this kid going to learn anything feeling miserable and visiting the nurse every 2 hours?

I have had parents that wanted kids to ice a painful joint every hour on the hour, get a nebulizer treatment every hour, take Vicodin at school for the oral surgery they had thas morning. Give me a break! I am all for keeping kids in class but at some point.......

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Specializes in DD, PD/Agency Peds, School Sites.

Thank you for this, OP. Many of us are dealing with the same thing and it's always great to read the comments. I believe that some parents see certain emergency situations as "normal" for their kid, but that's not my normal as a school site nurse. CGYK = "come get your kid."

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Specializes in ED, School Nurse.

I agree, Mimi. I think mom has seen theses elevated blood sugars with her student so many times that she thinks we should all be OK with treating a blood sugar of 500 + with elevated ketones at school. My favorite part was "Maybe she can walk around the gym for a bit." Uh, who, pray tell, is going to supervise our sweet (get it? haha) princess while she ambles around the gym to bring her blood sugar down?

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