handling a willful child

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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.

Specializes in Geriatrics, Dialysis.

Kid or not, why on earth are there no sliding scale orders? Unless her and her parents happen to be diabetes educators why are any of them just told to decide on their own how much insulin to take? I've never heard of such a crazy thing and I can't imagine any provider telling them to give how ever much insulin they feel like giving. This seriously needs clarification.

Of course I work with the elders instead of kids and have very limited experience with T1 diabetics so maybe this just deciding on your own insulin coverage is a thing that is done? If so I'm glad I don't have to deal with that. I can't imagine any 8-9 year old kid having the ability to make that decision correctly with any consistency.

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Specializes in ED, School Nurse.
Kid or not, why on earth are there no sliding scale orders? Unless her and her parents happen to be diabetes educators why are any of them just told to decide on their own how much insulin to take? I've never heard of such a crazy thing and I can't imagine any provider telling them to give how ever much insulin they feel like giving. This seriously needs clarification.

Of course I work with the elders instead of kids and have very limited experience with T1 diabetics so maybe this just deciding on your own insulin coverage is a thing that is done? If so I'm glad I don't have to deal with that. I can't imagine any 8-9 year old kid having the ability to make that decision correctly with any consistency.

This is a direct quote from one of my TID student's orders.

"At the Diabetes Center we encourage parents to take an active role in their child's disease management. Parents are encouraged to look for blood glucose patterns and make adjustments to their child's insulin accordingly. Parents may make adjustments for illness/activity/other factors affecting BG values (+/- 50%)."

I have high school students who will adjust their basal rate right here at school (on a pump) if they are trending high/low for a period of time. I will call a parent and say Hey- Joey has been running high all day- I'd like to add an extra unit to his lunch coverage- what do you think? Parent and I will confer, and I will add that extra unit most often with good documentation. Parents know their kid, and are often (not always) who I consider an expert on their kid's diabetes. I even get a good idea about how students trend here at school. I don't typically call the doctor unless I am seeing a trend over a period of time that I feel the parent isn't addressing. That "contingency" in the orders gives the parent (and I by extension) a little room to play with if a kid is having a rough diabetes day for whatever reason.

Oh, and the OP clarified in a further post that this student is on a sliding scale, with some room to make adjustments, which is where the OP is running into trouble with this student.

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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.

First, like I clarified earlier.... There is a dr.'s order on file for the insulin. There is a sliding scale ordered. HOWEVER, there is a clause in the order stating that the insulin may be adjusted based upon the parents' and school nurses' discretion. (For example, if she had pepperoni rolls and is not going outside for recess, etc., then she would get maybe a unit or 2 more than she would if she had say salmon and was going outside for recess even though her blood sugar was the same before lunch both times.) I really was just trying to shorten the original post so I didn't explain this in the original post. Clearly, this was a mistake due to the backlash I am getting instead of advice on how to handle this willful child from so many of those who replied. I am far too paranoid and anxious of a person to violate my license.

2nd what in the world does "trolling" mean? I mean really?

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Specializes in Cardiology, School Nursing, General.

You need doctor's orders and fast. As well, tell her if she doesn't listen, you will call her mother. If your school has a discipline system, give her discipline, you have the right. We give points and the more good points you get, you get rewards. If they misbehave in my office, I give them DPS, stat.

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

lol too funny! I understand that. I worked on a psych geriatric unit before I started this job, and some of those sweet, geriatric patients sure were a handful sometimes! I loved it though.

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Specializes in School nursing.
This is a direct quote from one of my TID student's orders.

"At the Diabetes Center we encourage parents to take an active role in their child's disease management. Parents are encouraged to look for blood glucose patterns and make adjustments to their child's insulin accordingly. Parents may make adjustments for illness/activity/other factors affecting BG values (+/- 50%)."

I have high school students who will adjust their basal rate right here at school (on a pump) if they are trending high/low for a period of time. I will call a parent and say Hey- Joey has been running high all day- I'd like to add an extra unit to his lunch coverage- what do you think? Parent and I will confer, and I will add that extra unit most often with good documentation. Parents know their kid, and are often (not always) who I consider an expert on their kid's diabetes. I even get a good idea about how students trend here at school. I don't typically call the doctor unless I am seeing a trend over a period of time that I feel the parent isn't addressing. That "contingency" in the orders gives the parent (and I by extension) a little room to play with if a kid is having a rough diabetes day for whatever reason.

Oh, and the OP clarified in a further post that this student is on a sliding scale, with some room to make adjustments, which is where the OP is running into trouble with this student.

THIS. Again, we are talking T1D in the real world. The real world is a crazy place, especially with puberty hormones in play. I never adjust anything without talking with a parent, we're in this together. The beauty of helping a T1D student manage at school is that you see trends. I always ask what breakfast glucose was (and the pumps made it easy to check if student doesn't remember), and manage lows keeping units on board in mind, along with timing of last bolus.

In the hospital, sliding scales exist because the pump can be removed and there may be several others factors at play. In school, I use carb ratios, which pumps are programmed to calculate automatically, which does make things easier. (Though being able to do the math is good - I have caught errors when students read me back the units the pump calculates, usually when the student types something like 12 carbs vs the 120 carbs they meant to enter.)

OP, I do wonder if a pump is something to explore with this student. I have seen students take a more active approach to their own management with it because the pump itself is some control that they have a part in, vs. going to nurse to check and having the nurse give the insulin. I use the pump as a teaching tool. Sure, the student I mentioned above was an exception (and they happen, these are kids and teens), but others I've worked with love their pump. Omipod in particular.

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Sigh, see above.... There IS a doctor's order... I've clarified this a couple of times. If I knew how to edit the original post, I would. I'm a new user on here.

I have called the mother, but this doesn't seem to scare her... probably because she's got this same bossy attitude at home and doesn't face much consequence at home regardless. The discipline system at this particular school is to go to the principle's office pretty much. I've never actually done this, but perhaps I should go this route? I don't know.. I just feel weird sending a kid to the principle's office...

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Some Clarifications:

1. There is a doctors order for the insulin. There is a sliding scale ordered. However, there is a clause in the order that says the parents and school nurse may adjust it if needed. For example, I may adjust it based upon what she had to eat, if she is going outside for recess, whether or not she has gym, etc. I document everything related to this. I also look at how her blood sugar's been running the past few days and her reaction to the insulin. Some have suggested that if I see patterns then the doctor should be notified and he should adjust accordingly. That would be fine, but these trends do not last for long periods of times. That is what kind of makes it difficult. A trend may last a few days, but then it changes again. I've looked back at her blood sugars and insulin and there is no real pattern. There have been times when I've given 5 units for a blood sugar of 80 at lunch and in the afternoon her sugar was in the mid 100s. At other times I've given just 2 units for the same blood sugar and her afternoon blood sugar was still in the mid 100s. There is never a pattern or trend that lasts more than a few days at a time. I think a pump would be beneficial, but the parents aren't really on board with that at this time anyway. THe child plays contact sports and I think that may be why they're hesitant.

2. As for my comment regarding describing the other nurse as "older in her 40s," and me "younger in my 20s," I just meant that I wondered if part of my issue in taking care of this child has to do with the fact that the student see the other nurse as more of a mother type figure (therefore, listens better to her) and sees me more as a teenager (therefore, doesn't listen to me as well... also she has a sister who is around my age who the student bosses at home too). I was just attempting to describe the situation.. and why I may be having difficulty with the student..... It's kind of like when you work in a hospital and are in report and describe a patient as an "80 year old female with heart failure..." It was just a description of what is going on. Why is being told your "older" offensive anyway? It's a state of being. But I digress, and won't do it again.

3. Thank you to everyone who has given me advice about how to handle the child. And thank you to those who KINDLY gave advice and shared their experience in managing her blood sugar and insulin. I never expected to get backlash for this post. I just feel like my original post was picked apart, and to be honest I feel a little torn down. So extra thanks to those who stuck up for me.

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Thank You to everyone who was encouraging and kindly gave advice to my original question. And a special thanks to the ones who even stuck up for me!

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Specializes in School Nurse.

Have the principal meet you at the specific time she comes in to observe your interaction. If she behaves inappropriately then she/he is there to back you up. If she behaves appropriately then you can tell her I have brought the principal in to help with our disagreements on you T1D care. That may shake her up. If it does not help I wouldn't engage with her. Say something like I understand that you prefer this way. In my __ years of nursing, I am required to do it this way. If there is a compromise I am willing to listen, but I have to follow the orders that your mother and doctor signed.

I completely understood this was a behavior question and not an order question. ;)

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Have the principal meet you at the specific time she comes in to observe your interaction. If she behaves inappropriately then she/he is there to back you up. If she behaves appropriately then you can tell her I have brought the principal in to help with our disagreements on you T1D care. That may shake her up. If it does not help I wouldn't engage with her. Say something like I understand that you prefer this way. In my __ years of nursing, I am required to do it this way. If there is a compromise I am willing to listen, but I have to follow the orders that your mother and doctor signed.

I completely understood this was a behavior question and not an order question. ;)

THankyou!!

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If you are comfortable with the order and do not feel it needs clarification, proceed with a 504 meeting ) to outline any mods in classroom and discuss with parent and student the policies of your office(admin should be present and aware of your policies). Then stick to your policies, orders, etc. Engaging with a noncompliant child is fruitless. It is her health, but she is not yet showing the maturity to get a say. Your office, your rules. Otherwise, I would invite mom to come take care of all of her diabetic needs.

I have a student who might be this child's sibling! Been dealing with her for 4 years and she has gotten worse, not better. That said, she does what she is to do at school. I call her mother, if needed and will not hesitate to track her down and pull her out of class. I stay on her so she is not DKA, again. We have a relationship, she knows I care and have higher expectations than she has at home. She rises to those expectations (most days). :cat:

Best of luck!

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