How Do You Handle the Student Who Wants Last Year's School Nurse Back?

[MotherRN]

Hi!

In general, the kids are working with me well in the Health Office. I am having trouble with one of my diabetic kids. I think he might have a crush on the former nurse. He's in high school and she looks like she is too, even though she is in over thirty.

Basically, everything I say is wrong and he doesn't want to take his insulin coverage for lunch time meals or snacks. He tells me things like, "I'm not eating today." Then I discover him with a plate of about 100 carbs!!! worth of food!!! Or, he will tell me he is only getting a snack- Gatorade and Doritos- and his doctor says to not cover these. And, when 30 days had passed and it was time for a new bottle of novolog to be dropped off, he told me last year the nurse let him keep the same bottle month after month, because he barely uses it! More than three weeks went by before I could convince mom to drop off another bottle. During this time, he did not get any coverage because I would not give him expired insulin.

I feel like Ms. X put me in this position by mismanaging his treatment last year. She basically took him telling her he was not eating and gave him no coverage (when he was surely eating the whole time or else he would have dropped at least a pound or two!!!) Plus, the not requiring him to drop off insulin monthly is crap! He doesn't believe the stuff expires.

I have told the principal when I first found out he does eat (and lies to take no coverage), she talked to him. It was fixed for about two days. This Monday, he came in like a loaded gun looking to go off! So, I had to tell the principal again. And, this time I had to put him in his place because he was tossing things around and being really disrespectful. I refused to let him storm out after that behavior and told him he would stay put and behave respectfully in my office. He is a junior in high school. He will also speak loud enough to be hear and stop this game he is playing where he mutters and refuses to make eye contact like a spoiled child!

I called mom as well. I requested she call his doctors to see if they want to change his orders in any way. I explained I have to follow the orders given to me in the health office in order to be compliant.

This kid does not run high. He is below 100 when he comes in. I don't want him to refuse to eat, then drop, because he is often at 72-82 and his lunch is early. He is still on campus for another 3.5 hours after lunch.

I'm rambling. I'm just so frustrated. Here I am, actually following the rules of diabetic management and his orders safely, and I'm the bad guy! Today, he told me, "I can't work with you! I want Ms. X!"

Suggestion?

[chrisrn24]

Could he be playing you? Or do you believe him? Clearly he lies about eating so who knows what else he lies about.

Document, document! Keep educating son and mom. Maybe schedule a family conference with yourself, the principal and the family.

[SaoirseRN]

Shouldn't a high school student be managing his own insulin? I can understand why not in younger children but at this age? I imagine it's a policy or something but it seems counter productive to me to have a teenager have to see the nurse for his insulin when he is old enough to manage himself -- or should be anyway.

[morte, LPN, LVN]

Maybe he is, perhaps he has supplies on his person?

Shouldn't a high school student be managing his own insulin? I can understand why not in younger children but at this age? I imagine it's a policy or something but it seems counter productive to me to have a teenager have to see the nurse for his insulin when he is old enough to manage himself -- or should be anyway.

[mycsm]

gently Guide him into the prinicapls office to test and cover for his carbs. And do this everyday until he gets aggravated, and when he gets aggravated then insist the mother come in everyday to observe her prcious baby's behavior. There is no reason why you need to be on his tough guy train every day.

[Nurse ABC]

I would ask for a conference with student, parent, and principal. Then figure out a solution together and a plan for when/if student doesn't adhere to it. Also, I agree, a high school student should be responsible enough to manage own care with indirect supervision but until you can trust him... I'd make that a goal in the student's plan-will become self-sufficient after proving he can.

We had a student (6th gr) who the former nurse said he wasn't bringing his tray for her to see what he ate and then wasn't telling accurately what he ate, etc so I had a meeting with the mom and student and said I hear this is a problem, let's figure out a way for me to know what you ate that you're comfortable with. Low and behold, the student has been compliant every day and we didn't even change anything. I think the student just knowing I was willing to work with him plus feeling like he had some control helped.

When he says he wants the old nurse back because she let him...it's no different than him saying he liked his old teacher better because she let him do whatever that he's not allowed to do now. So what. He needs to grow up. It's more of an authority issue (power struggle) than anything else. Unless you have proof the former nurse did this than don't blame her. He should be respectful enough of you (an authority figure and nurse there to help him) that he would do whatever you asked. He's playing you against the old nurse like a 5 yr old plays mom against dad. Stand your ground. Have your meeting ASAP. Document well. That's what I'd do. Good luck!

[Flare, ASN, BSN]

yep, no different then him wanting last year's math teacher... but i'll bet he still does his assignments like he's supposed to. The difference here is that if he decides to skip out on a few assignments, he just loses a grade, but monkeying around with his diabetes care like this could cost him much much more.

Granted. He's 16 years old. It is very possibly that he has the typical attitude of a 16 year old - 10 feet tall and bulletproof. He doesn't realize what consequenses his actions could have, especially if he hasn't really experienced any real emergencies or highs or lows because of it yet.

If it were my office, I'd call for a meeting - student, parents, maybe even telephone on speaker with doctor or diabetes nurse that covers his care if possible. Let him know that there is a new sheriff in town. That you don't really care what last year's nurse did - that this year's nurse is doing things her way. Novolog will be changed out monthly. Carbs will be covered. Gatorade and doritos (which are chock full of carbs, last time i checked ) will also be covered. This young man needs a wake up call before he lands himself in the hospital or worse.

[MotherRN]

Thank you for the replies. I've had him upfront with his meds in the principal's office (my office is isolated in the back of the school). Today he pulled a stunt. His blood sugar was below 70 and he said he would eat. We observed him, and he was not eating. So, we sent his teacher to check him. The teacher said the student said to "Stop spying on me." I told the principal he wouldn't eat so we agreed he had to go home. We called mom and he got picked up.

The good news is it made mom made enough that she finally called the diabetes educator. And, since mom was impossible to understand, the diabetes educator asked for permission to call me directly. So, we sorted it out. Basically, if his sugar is around 72-80 each morning, then she feels it's too low and they need to adjust his meds. And, if it's below 100, she wants him to eat at school and not Gatorade and chips. So, the principal has told me to inform the cafeteria to not sell these items to him. That was he will have to actually eat lunch. If he chooses to not eat lunch, then we will have to send him home, if he's below 100. He's still on campus for 3.5 hours after. I think I finally got through to administration what a liability to the district this is and how much it concerns me personally.

Administration is going to check with the lawyers to see what we do with a teen who will not allow us to treat him according to our medical orders. He's still too young to refuse. And, oh so dangerous to have on campus untreated. Plus, mom has to drop off the meds monthly. It's not a choice.

We will be having a conference with mom and student in the near future about the issue. They wanted to hear back from district first. I sincerely hope we can hammer out a clear course with clear consequences that are clearly enforced! That is what it will take to solve this issue! Stop babying this teen and help him grow up! Hold him accountable!

[chrisrn24]

Thank you for the update!

At my work we have these protein drinks we use for low blood sugars. Maybe he would drink a little of that? Or some protein powder mixed in milk?

[KelRN215, BSN, RN]

Having last year's nurse back is not an option. This child is 16 or 17 years old and he knows that/can rationalize it. This isn't a first grader. I think you have laid out a good plan- he needs to comply with his treatment while at school or he will be sent home.

[MotherRN]

Suffered a set back today. Discovered the administration is not going to do the right thing. They were doing lip service to it for the benefit of the clinical student who was with us that day and listening. I can still hear, "We're going to do everything we can to support you." in my head. Well, basically, they don't care if he's disrespectful, they don't believe he is a threat. I am to start taking him in the back because he is "shy" and doesn't like being made to come up front. Also, I have been told to not monitor if he eats. Okay. But, they made me do it today because he couldn't stay on campus with his blood sugar at 70 for 3 hours more and not eat something. They did cut him off of snacks, but I bet he'll be back on that soon as well. So, he refused to eat. They said they would send him home if he did that. Instead of calling his bluff, she made me monitor lunch to see if he did eat. He did not. When I told her so at the end of lunch, she called him out of class to "talk" to him. Yes, he got special treatment and all kinds of attention. She called to tell me he had eaten. SO not the way to go with this. Why are you babying this child? You aren't helping him live up to his potential! You are telling him instead he's a baby and needs extra special attention. If he whines, you are going to give him what he wants. I am so mad I could spit right now.

The bottom line is this: I am new. They know him. He's like the school pet. Every refers to him as a sweet heart. Hey, how about teaching him to be a man??

It's also a double standard. I have another diabetes kid. He gave last years nurse trouble so she started giving him his insulin up front. They butted heads. I have no problem with this kid. I have a problem instead with the kid she did get along with.

Now, the one from last year, the teachers don't like because he's ADHD and not on meds. So, if I were having a problem with that kid this year, they would be more than willing to expel him like they did last year. But, because it's their darling, I'm the one who better tow the line.

[MotherRN]

Because I basically spoke my mind and told the assistant principal I did not agree, I did not feel supported, I felt if it were the other kid, they would be supporting me, I told them I felt it was a double standard that last years nurse was allowed to bring a student upfront when she felt uncomfortable but why was I not allowed to do the same? I speculated that it was because it was the well-like student and not last years problem child.

So, basically, I am on thin ice!

In the bigger picture, I know my license is worth more than this job. But, in the short run, I will be bankrupt without it.

So, my question is now this: I need all the documentation advice I can get on how I cover my behind when I am being put in this position?

Because I said all those things above, the assistant denied them and agreed that if I his sugar is low, and he won't eat, call mom to pick him up. Well, here we are, right back where I thought we were. But, what is going to happen is as soon as I do this, the principal is going to hit the roof. She's the one who didn't let it happen today. She and the assistant can't agree on anything! One will give me permission while the other is away ( which is the case until Tuesday now), then I will get blamed for following an unpopular order!

Believe it or not, my lead nurses response was "Quit worrying. Let him be noncompliant. When he passes out, call EMS, give him the shot." Seems like REALLY BAD ADVICE to me. In the end, I would be the one held responsible by his parents, doctors etc for delay of care. Thoughts on this item??

Is it enough to document refused care, called parent, notified principal, strongly recommended student be sent home, denied. student remained on campus.

BTW we do have new orders now. If they get his sugar up in the morning, then he can safely not eat lunch on campus. Still not a good idea.

Anyone been in the position where the principal makes it impossible to follow orders?

Now that I have written it, I am very concerned about the 'delay of care' issue.