handling a willful child

[basketball13]

Let me give you a quick background. My county only ever employed 1 school nurse at a time. They finally added a second school nurse (me!) a few months ago. There is a diabetic student in 4th grade. She gets insulin around lunch time. THere is no set sliding scale as to how much coverage she gets. It's up to the parents and at school it's up to the school nurse to decide how much she gets. She also gets rechecked at the end of the day and if her number is over a certain number, she gets 1 to 2 more units. Her blood sugar can be very unpredictable at times but I have gotten her fairly figured out.

Here are my issues. When I am checking her blood sugar and deciding on how many units to give her at lunch I have a hard time getting her to do what I ask her to do. Whether it be to actually check her blood sugar, to actually take her insulin, how much insulin to take, to tell me what she had for lunch, etc. Sometimes she will argue with me about how many units she needs (and I do listen to her and her rationale and there have been a couple times that I wanted to give say 3 units, but she wanted 4 so I did go with 4, but then she was a little bit low at the end of the day so I rarely do what she wants unless it's in agreement with me anyways,) I spend a good 5-10 minutes at lunch time arguing with her about how much insulin to take. The thing is, she is almost always a good number in the afternoon so I don't understand why she always argues with me at lunch time anyway.

This was the big kicker last week though. On wednesdays I am at another school at the end of day and only come back over if she is above that certain number and needs covered. The teachers text me her number. Last week though she lied to her teacher and said she was 127 (no coverage or intervention) which was texted to me. However, the next day at lunch I came in and looked back at her blood sugars and saw it was ACTUALLY 280 (requiring 1 unit of insulin). I questioned her about it and called her out on it (explaining how dangerous doing stuff like this is for her) and talked to her teachers. She had lied (though she claims the meter is just wrong blah blah blah). Anyway, I told her from now on she had to show her number to her teachers which made her mad and she tried arguing with me AGAIN. I spoke to the principle as well and we called the parent to explain what had happen and also explained the trouble I've had with her. I don't think anything was said or done to her though at home. However, she is incredibly angry at me still today and argued with me again over everything and again argued about how much insulin to take today at lunch. I was incredibly firm with her, even raised my voice (something I don't really do. I am an easy going person), etc. I'm at a loss. She likes to say "the other nurse doesn't do this or that." The other nurse is in her 40s and I'm young and in my 20s so I don't know if that's part of the issue? Or if she just got so used to the other nurse and doesn't know how to take me? The other nurse and I switch schools every month so I only have to handle her a month at a time, but I just don't know what to do with her. Any advice??? Sorry for rambling and I hope that made sense? lol I'm just so frusterated, and don't want something bad to happen related to all this.

[mmc51264, BSN, MSN, RN]

I have 2 w T1. They are 12 and 15. They have no input. They have a pump. and a CGM. This child might do well on this. Either way, there needs to be more doctor involvement.

1 unit for 280? That is not very much. Scary. Especially since my 12 yo just had a bout of dka and almost died.

[ohiobobcat]

If the current orders are not giving her the blood sugar control she needs, then she needs new orders. Do you have permission to speak directly with the diabetes center/doc? I follow the orders for my kiddos almost to a T and if those orders aren't sufficient to control her blood sugar consistently, then the doc needs to evaluate and provide new orders. What is her A1C?

I have had a couple of kids who lied about their blood sugars on a regular basis. I visualized their meters and pump settings (when applicable) every time they checked with me. You lied? That's the consequence of your actions. Your "meter malfunctioned"? Well, gosh, the nurse better see your meter every time to make sure that doesn't happen again.

And a blood sugar of 280 is only 1 unit for this child? Where does her coverage start? My kids tend to start coverage anywhere from 130-180.

Those were my thoughts when I read your original post. I am sorry she is being such a stinker for you. Stay firm and consistent with her.

[tining, BSN, RN]

Arguing with a child is futile. I would call for a 504 meeting to discuss situation and place consequences. If unable to do a meeting then as soon as the situation turns heated I would step back (child present), call mom and state "Hi mom, this is Nurse Basketball13, I just want to tell you that cupcake and I are having a conversation in which we disagree (state the issue, state your knowledge of the correct actions) what would be your advice?" This (hopefully) will show the child that you are not tattling, but having a respectful conversation and meeting of the minds - put mom on the speaker if you want all parties clear on the final choice and the reasoning behind. Do this everyday until everyone is tired of fighting.

[AdobeRN]

If the current orders are not giving her the blood sugar control she needs, then she needs new orders. Do you have permission to speak directly with the diabetes center/doc? I follow the orders for my kiddos almost to a T and if those orders aren't sufficient to control her blood sugar consistently, then the doc needs to evaluate and provide new orders. What is her A1C?

My thoughts also....I rarely deviate from the doctor orders and if I find I am starting to need to or parents are requesting me to do so on a consistent basis I will request updated orders - I have also called the doctor on few occasions when I wasn't able to get anywhere with the parents.

[JenTheSchoolRN, BSN, RN]

If the current orders are not giving her the blood sugar control she needs, then she needs new orders. Do you have permission to speak directly with the diabetes center/doc? I follow the orders for my kiddos almost to a T and if those orders aren't sufficient to control her blood sugar consistently, then the doc needs to evaluate and provide new orders. What is her A1C?

I have had a couple of kids who lied about their blood sugars on a regular basis. I visualized their meters and pump settings (when applicable) every time they checked with me. You lied? That's the consequence of your actions. Your "meter malfunctioned"? Well, gosh, the nurse better see your meter every time to make sure that doesn't happen again.

And a blood sugar of 280 is only 1 unit for this child? Where does her coverage start? My kids tend to start coverage anywhere from 130-180.

Those were my thoughts when I read your original post. I am sorry she is being such a stinker for you. Stay firm and consistent with her.

^all of this.

1 unit seems very low, but I did work with a T1D student that was very sensitive to insulin, then boom! puberty started and her insulin needs tripled very quickly. I worked with her mom and providers to try and find a good balance on her pump.

4th grade is on the younger end of puberty starting, but is possible for girls. And those hormones can mess with glucose control.

As for the student herself, ugh. I feel you, OP. I had a very, very similar situation with an older student. Did not want anything to do with diabetes, had to stalk her for BG checks and coverage. Mom worked a lot and was trying so hard, but the student was stubborn and A1C 10+. Student argued coverage. Student had a 504 plan and every year when we re-evaluated it, I talked frankly to her and Mom and made her cry every time. I was bad cop. But bad cop was the only thing that worked. So I stuck with it, thankfully with Mom's blessing.

[basketball13]

I have 2 w T1. They are 12 and 15. They have no input. They have a pump. and a CGM. This child might do well on this. Either way, there needs to be more doctor involvement.

1 unit for 280? That is not very much. Scary. Especially since my 12 yo just had a bout of dka and almost died.

I myself have wondered if a pump for her would be more beneficial for her. She can be fairly unpredictable at times. She actually did go into DKA over the summer. She had gotten a bad case of mono which caused her spleen to enlarge etc. and she went into DKA. I agree with the more doctor involvement. The whole family has type 1 so I think perhaps they don't always see it as a real big deal.

At the end of the day (245 pm) if she is above 250, she gets 1 unit (per doctor order). That actually is usually okay because she gets home around 4 and eats dinner at this time so she gets checked and covered at that time. The one unit usually helps keep her number reasonable when she gets home. However, if she is up in the 300 range, I go ahead and give 2 sometimes 3 units. She's been known to drop in the afternoon though which is why the order (1 unit) is so low. I rarely have to cover her in the afternoon though. She's usually in the 150 range.

Lol, when I first got into school nursing and learned about how to manage her diabetes at school I was in shock. I mean I came from the hospital setting where there is a set sliding scale. A blood sugar below 150 at meal times would not get any coverage (not counting any scheduled insulin). The first day I had her, her blood sugar was 85 at lunch. I was thinking she didn't need any, but the other nurse told me to give her at least 2 units. We were having pepperoni rolls that day and she rose to around 350 by 2:30!

[JenTheSchoolRN, BSN, RN]

I myself have wondered if a pump for her would be more beneficial for her. She can be fairly unpredictable at times. She actually did go into DKA over the summer. She had gotten a bad case of mono which caused her spleen to enlarge etc. and she went into DKA. I agree with the more doctor involvement. The whole family has type 1 so I think perhaps they don't always see it as a real big deal.

At the end of the day (245 pm) if she is above 250, she gets 1 unit (per doctor order). That actually is usually okay because she gets home around 4 and eats dinner at this time so she gets checked and covered at that time. The one unit usually helps keep her number reasonable when she gets home. However, if she is up in the 300 range, I go ahead and give 2 sometimes 3 units. She's been known to drop in the afternoon though which is why the order (1 unit) is so low. I rarely have to cover her in the afternoon though. She's usually in the 150 range.

Lol, when I first got into school nursing and learned about how to manage her diabetes at school I was in shock. I mean I came from the hospital setting where there is a set sliding scale. A blood sugar below 150 at meal times would not get any coverage (not counting any scheduled insulin). The first day I had her, her blood sugar was 85 at lunch. I was thinking she didn't need any, but the other nurse told me to give her at least 2 units. We were having pepperoni rolls that day and she rose to around 350 by 2:30!

School nursing gives you a real picture of T1D in the real world. And each kid is different, but you start to learn how each student responses. I had one MS student that sometimes was 70 right before lunch, where she was eating 120 carbs. 70 is in her orders as her borderline "low" mark if you follow to the letter (it also allows for some school nurse judgement slight adjustments), but in reality, if you didn't treat it like a "low" her lunchtime insulin coverage would drop her to 55-60 by 2 PM.

Also, puberty. It really affects glucose control. It can be a constant up/down adjustment, even with a pump. Same student has had basal rate adjusted 5 times in the last year, and carb ratio adjusted at least 3.

[NanaPoo]

I think there was a little offense taken because you said, "the other nurse is in her 40's and I'm am young..." I can see where that might be slightly offensive.

Anyway, as far as argumentative kids go, and not necessarily diabetic ones, firmness is always required. Give them their options and, if they don't like them, I say "see ya later, back to class it is." I have a guy who also happens to be in 4th grade who LOVES to argue and he hates that I won't take part in it. I actually have lots of kids who come with complaints then refuse all offered treatments to which I reply, "then there is no pleasing you!"

But my 4th grade guy will always reply that my treatments either don't work OR actually make the problem WORSE. Imagine! Then he starts making up crazy stuff like his Adam's apple is hurting or argues with me that he has some rare diagnosis that he heard about on TV. I just tell him again what his options are in my clinic and, if he doesn't want those, tell his parents his problem so he can go see a doctor for his possible rare condition. :sigh:

[ohiobobcat]

At the end of the day (245 pm) if she is above 250, she gets 1 unit (per doctor order). That actually is usually okay because she gets home around 4 and eats dinner at this time so she gets checked and covered at that time. The one unit usually helps keep her number reasonable when she gets home. However, if she is up in the 300 range, I go ahead and give 2 sometimes 3 units. She's been known to drop in the afternoon though which is why the order (1 unit) is so low. I rarely have to cover her in the afternoon though. She's usually in the 150 range.

Lol, when I first got into school nursing and learned about how to manage her diabetes at school I was in shock. I mean I came from the hospital setting where there is a set sliding scale. A blood sugar below 150 at meal times would not get any coverage (not counting any scheduled insulin). The first day I had her, her blood sugar was 85 at lunch. I was thinking she didn't need any, but the other nurse told me to give her at least 2 units. We were having pepperoni rolls that day and she rose to around 350 by 2:30!

Ah!! I see now. I have some of those wonky things that I do with my students with T1D because I know they trend a certain way (with OK from parents of course) at a certain time of day. I agree with Jen-E. It has been a real eye opener to see the struggles of T1D on a day to day basis,

especially the hormonal ones.

Someone said something about a group meeting with all involved- I think that would be essential so everyone is on the same page. Then I still think a firm approach is the best with this kiddo. Someone get control over this kid NOW before she becomes a teenager!!

[foggnm]

She gets insulin around lunch time. THere is no set sliding scale as to how much coverage she gets. It's up to the parents and at school it's up to the school nurse to decide how much she gets.

This makes no sense. You can't be giving medication at school without orders. That is a violation of your license. I think you might be trolling though.

[MrNurse(x2), ADN]

This makes no sense. You can't be giving medication at school without orders. That is a violation of your license. I think you might be trolling though.

OP has posted appropriately on other occasions and this situation is not unheard of. This is real world nursing, not acute care. We are the nurses station for school nursing, coming in and throwing grenades when uninvited is pretty rude. Come on in, hang, but please be kind. Want to be mean, click on "nurses" up there and spew all the venom you want. Thanks.

[djh123]

Sorry, just have to jokingly (well, not entirely...) comment that sometimes I have willful children who are 90+ to deal with.