Can you please give me an idea of what a typical day your students with T1D looks like? When are they coming to see you, when are they getting insulin, etc.
Many here know I have been dealing with a first grader since September who is very poorly managed, almost consistently in the 300-400 range. His endo clinic is of little help.
He was out yesterday and mom just dropped him off and there were papers in his folder "for the nurse" that were discharge papers from our local ER, Diagnosis "hyperglycemia" No answer from mom when I call her. I am waiting for the endo clinic to open so I can inform his resource nurse and ask about a plan.
I am feeling very lost in terms of support from anyone really. The last time I reached out to his endo nurse she scolded me saying he is a six year old kid and should be allowed to eat like a six year old kid. Very frustrating all around.
Right now, my instructions from the endo clinic are to just check him before lunch and then 20 minutes after, give him his insulin based on BG and carb count. That's it! Obviously if he is showing any signs of being low (has b=never happened) he gets checked, but I used to check him mid-morning and the nurse questioned why I was "giving him an extra stick"!?! It seems crazy to think that he should only be checked once before lunch. He is not on a pump by the way. He was supposed to be on one as of October and mom keeps failing the pump training appointments.
Anyway, would just love to hear from others and get a sense of what goes on with your students with Type 1.
Specializes in ICU/community health/school nursing.
No one other than the attending, who I have paged the one time he had 1.1 ketones and neither mom or his endo nurse were reachable.
He is currently in school, BG 280 about 30 minutes ago and "feels well". I will re-check him before lunch and see how he is doing. I seem to be the only one concerned about his management, including the endo clinic.
BSG of 280 after breakfast when the bolus insulin is still chipping away at breakfast carbs is probably OK. Assuming there was breakfast insulin, and a Lantus or similar given at the appropriate time at home. If not....you'll know it by lunch time! Hang in there. It is hard when a nurse is dismissive - especially when you know the kid. It's hard when the kid is a first grader -they will compensate and compensate until they crash, and then crash hard.
Specializes in Cardiology, School Nursing, General.
No one other than the attending, who I have paged the one time he had 1.1 ketones and neither mom or his endo nurse were reachable.
He is currently in school, BG 280 about 30 minutes ago and "feels well". I will re-check him before lunch and see how he is doing. I seem to be the only one concerned about his management, including the endo clinic.
I would call the attending, because this is ridiculous. That's not a little hyperglycemia, that kid will be super sick one day, and guess who they'll blame? Not you! Because you did your job properly.
I have a 9th grade T1D who was diagnosed 2 years ago, and on an Omnipod pump. She is generally late to school, because mom stops and gets her fast food for breakfast. She eats a Fruit Roll-Up for lunch, and drinks water during the day. Her BG is always in the 100s range, but she has frequent clinic visits for headaches, or feeling low. Her only scheduled visit is before lunch and before her bus ride home. I've tried talking to the student and the mom about the importance of eating protein, as well as eating an adequate lunch, but haven't gotten anywhere with either one of them. Mom just says she's picky.
My experience with elementary diabetic students is that each one has a plan that is very specific based on what the parents want. I have had kids visit the health office as many as 7 times a day (on arrival, before snack, before lunch, after recess, before and after gym and end of day). I have had kids that I see once a day at lunch and that's it. Otherwise it's a combination of before lunch, when they are feeling symptomatic (or their CGM is alarming high or low), before gym or before they get on the bus at the end of the day. I have kids where we automatically deduct 15 carbs from their lunch or kids who have a couple of crackers before gym no matter what their BG says. No plan is the same.
Since parents aren't being helpful I guess I would try to have a frank conversation with the endo clinic. Explain where you are coming from and ask for more detailed orders.
Wow, what a horrible job on that Endo's part. Sounds like the family likes him because they aren't challenged, meanwhile the child will probably die in his 20's, so sad. Do you live in a rural area? Hate to bring it down to this, but that bottom of the class in med school has to go somewhere, and they normally go where there is little competition and patients are the sad victims. Happened to my father.
Same story here, unfortunately. I've had several T1D's come and go, and only 1 is consistent with diet carbs, checking BG, and dosing insulin. Whaddaya know, she's also the only one with consistent numbers in the 70-150 range! I have heard from several different endo clinic nurses that they let the kids eat like they want, "so they feel like normal kids". HOWEVER, most still give me target carbs per meal. The last one was supposed to keep meal time carbs between 45-90. I get it, the idea is to teach these kids how to count carbs and manage their diabetes in the real world where food is not tailored to diabetics. We can still do our part to educate the kids and their parents on good nutrition, choosing proteins and healthy carbs for every meal.
My T1D's vary in ability to be responsible and perform their own tasks. I have 1 that tests on her own in the classroom, then comes in if high or low and otherwise only comes in for lunch insulin. Another that is *supposed to* come in three times daily for BG checks and corrective insulin. (average is once daily though) Ketones are checked if over 300. I don't hesitate to call parents with abnormals. If parents are unreachable I'll call the clinic. I had one clinic suggest a call to CPS for negligent home care, as student often would have missed lantus dose and morning insulin. Totally noncompliant on the parents and kid's part. That one transferred out the next day :-/
Keep doing what you know is right and document, document, document! You're doing a good job!
Nurse from diabetes clinic actually returned my call for once. She was very dismissive and said too me "He's totally fine, just a little hyperglycemia. Mom is great about calling me when she is worried, so if mom is not worried, I am not worried". I don't consider vomiting with high ketones and a BG in the 500s "just a little hyperglycemia", but ok thank you wise endo nurse. She drives me nuts- so condescending to me, like I am "just" a school nurse and know nothing about this family.
I have a 1st grader who is T1D as well. I test him in the morning before breakfast, at 11:15 am before lunch and at 1:50 pm before dismissal. I have orders based up carb count, that we do together when he shows me what he is eating for both meals. (our district provides free breakfast and lunch to all). He is very rarely high, he tends to go more low, if he doesn't eat what he says he is going to eat for lunch (he eats a huge breakfast)(his eyes are bigger than his stomach!).
I cant believe how the clinic is treating you! I think it is awful! They should be WAY more caring and involved than they are, his is going to blow his kidneys and then who will they blame? I am sorry you are going thru this! I would keep calling them!
My son is a Type 1 diabetic. School routine for elementary school was to come down and do blood test (and insulin if needed) at lunchtime. If at other times he felt that he was low or the teacher/staff noted a marked beligerance (a sign his bg was going down), he'd get another test.
By high school, I had lobbied long and hard that he be able to keep his meter and glucose tabs with him. Only needed to come to the office if he needed insulin or further assistance.
Specializes in orthopedic/trauma, Informatics, diabetes.
I am a parent of 2 type 1s. Both of mine wear pumps and with the CGMs they don't need to see a nurse. At all. When my youngest was little (he was diagnosed @ 2) he was at day care and they just tested before meals/snacks. covered carbs and BG. In NC, we are lucky if the nurse in each school one day a week.
For that child that is 500, vomiting and has ketones? that is a trip to the ED via ambulance. Parents have has CPS called on them for not managing their child's diabetes and it sounds like that kid needs some intervention (and a new endo) I'd hate to see her A1c. SO very sad.
I would have reached through the phone and choked the nurse that said 500 no big deal
As parents we fight SO FREAKIN hard to get people to understand and y'all sound like the nurses I would want for my kids. I couldn't do it. I end up doing something that would have me lose my license or put me in jail.
No answer from mom when I call her. I am waiting for the endo clinic to open so I can inform his resource nurse and ask about a plan.
ruby_jane, BSN, RN
3,142 Posts
BSG of 280 after breakfast when the bolus insulin is still chipping away at breakfast carbs is probably OK. Assuming there was breakfast insulin, and a Lantus or similar given at the appropriate time at home. If not....you'll know it by lunch time! Hang in there. It is hard when a nurse is dismissive - especially when you know the kid. It's hard when the kid is a first grader -they will compensate and compensate until they crash, and then crash hard.