insulin pump

Well, every student's orders are different, so the plan for your student might be different, but in general

- students should not exercise when they have ketones, so I would not have sent her to PE with trace/small ketones

- My diabetic student can have a snack if she feels she needs it (she does not have scheduled snacks, however) as long as she is given insulin to cover it.

- Are there parameters as to when you bolus insulin? I have never had a student with a pump, so I may be way off, but I cannot imagine them getting a bolus every time they have a high reading. A high after lunch is not out of the norm, as long as the insulin she was given with lunch brings it down, it should be ok. In your case since she showed up later with a higher reading and ketones, perhaps her lunch dose was off?

At the very least, you need to have a sit down meeting with the parent and student and make sure everyone is on the same page as far as her plan of care. I would get the name and number of her diabetic educator and give that person a call if the MD is hard to get ahold of, but you also need to speak to one of her providers.

Since you state the student is non-compliant, you are going to have to develop a very strong relationship with the parent and providers, and hopefully with the student, although there may also be some resentment there if you are holding her feet to the fire. Hang in there...you will get the hang of it!

monday was the student's first day of school and i spoke to the mother serveral times on the phone because the student came into school without testing her bg in the morning before getting on the bus and without even turning on her pump to receive insulin. i would like to sit down with the mother and the student together but it seems that that may be an impossibility because the mother is wheel chair bound with MS and cannot come to the school (the school is about 45 minutes away from where she lives.) as far as the parameters to bolus insulin, she is supposed to get a bolus before lunch and a bolus PRN if her bg is greater than 250 with ketones present and the last time she received a bolus was at least an hour before. the doctor's orders say to keep her out of gym if the initial bg is lower than 60 but does not say anything about keeping her out of gym with hyperglycemia with or without ketones. i know i have to get into contact with the doctor or the diabetes educator but they were all unavailable today and did not return my phone calls. i am becoming very nervous with this student because although she understands how to use the pump (she is 17) she is very flippant about the situation and couldn't care less.

I would have followed what the care plan said. Remember, you can't keep bolusing her, or you'll be "correcting the correction". One of my diabetics on the pump has "scheduled" snacks, timed to be approximately 2 hrs. after meal. That's when we give a bolus dose to cover carbs (along with lunchtime). As as been said, the child shouldn't run if urine shows ketones. This is clearly stated on his care plan. This sounds like somewhat of a mess. A teleconference with Mom, the principal, the guidance counselor and your district (or supervising) nurse would be in order. I would be very uncomfortable unless I had everything in writing and I understood exactly why I was doing what I was doing. Don't be afraid to ask questions and require clarification before moving forward. I'd rather feel stupid than accidently overdose someone, as I'm sure you would too!

Good luck,

mc3

I will not comment on the insulin pump, because I am not familiar with it. I will tell you I had a iddm start at the begining of this school year. I was scared sh*tless :) (also new nurse @ first job, yr 3) After i called and spoke with the nurse at the school she came from, my feelings were confirmed. I have managed to get the "this kid is gonna crash on me, or go into a coma" under control. I really had no choice since I have ~ 500 other students to take care of. I will tell you it gets better, I PROMISE :)

thanks for all the support!!! i was scared to even post about this situation because i feel pretty embarrassed about it. the student is scheduled for a snack at 10:30 AM and after doing some research on other school district's policies, i am going to give her the snack as scheduled because she is receiving a continuous dose of insulin (basal rate is 1.5 U/h) from her pump. also, i will keep in mind to keep her from gym if her urine shows ketones again; however, her care plan does not specifically state this unless the ketones are moderate to large. i work for a small private school so i don't have a district nurse i can turn to, unfortunately. i am going to follow the care plan's instructions to give a bolus of insulin prior to lunch.

i'm really just having a lot of anxiety about this student and i think i need to relax and stop over analyzing everything and just follow the care plan.

Four years ago I too faced a huge learning curve with type 2 and insulin pumps-but since we had 6 type 2 diabetics last year-I am not alone-there is another nurse, I have come a long way! Since she is on the pump, I would think that she can generally eat as long as she covers it-as far as putting the numbers in-any active insulin is always subtracted out from the correction factor so technically you are not correcting the correction. However, that being said I have not corrected through a bolus when I felt like the student had received a lot. I know you are in a private school but I think a 504 plan would help to specifically state the accomodations for the student and who is responsible for them as well as a medical care plan signed by you, Mom and physician. Generally, the diabetic nurse educator will help you a ton and a rep from the insulin pump will also come out if you request it.

I would never withhold a snack. If the student has an elevated bs & wants a snack, they simply the high blood sugar & carbs by entering it into the pump. What kind of snack does the student have? I've found snacks that are high in protein (peanut butter, soy butter, or chocolate milk) are nice, stabalizing snacks.

Your care plan should give parameters for PE & when to exclude (with too high or too low of a blood sugar, or if (+) ketones.

I would not have student bolus for every low reading, especially if they are in checking frequently. You might end up with hypoglycemia instead.

Take a deep breath. Relax. Talk to the student's mom & her diabetic educator/ or the physician's nurse. Priority #1 for me would be to get the orders/ parameters you need clarified ASAP!

Hope your tomorrow is better. Hugs to you.

thanks so much

If its 'snack time' she can certaintly eat the snack. 182 is perfectly fine for her to have a snack. She shouldn't be kept from doing what everyone else is doing. Now, being 17, do they actually have a snack time? Is it breakfast? Begin on a pump allows freedom, one of those freedoms is not having to eat on a schedule, so she doesn't HAVE to eat a snack, unless low, but she also shouldn't be excluded if its something everyone else is doing at that time, regardless of her blood sugar level.

The pump is programed with all her personal information. Her carb ratios, her correction factor, her basal rates and her blood sugar targets. This is different from every person and it may be different on a day to day basis. You can not stack insulin while using an insulin pump (unless your pump isn't programed right). The pump keeps track of the corrections you are giving. If she was 300, and it gave her 10u, she checked again in 30min (which isn't even time to even see a difference as most insulin don't start working for 20-30min, so checking in 30min isn't going to give you useful information) and her bg was 330, the pump will NOT give her another 10u.. it may not give her any, depending on her correction factor. ALso, the difference between 300 and a 330 is nothing, its well within the 20% margin of error that is allowed with blood glucose meters.

There should be no restriction on gym unless there are large ketones present. Make sure she's drinking plenty of water during that time. She may not feel well and will likely be very thirsty.

Is this student newly diagnosed? If not, at age 17, I would think she'd be doing most of this on her own.

thanks for all the info arnu. she has a scheduled snack time at 10:30 AM by her physician. she comes in and asks for a snack and i give her the snack. i thought that i was wrong to give her the snack the other day but i realize now that it is okay and i will continue doing so. the insulin pump is definitely proving to be a learning curve for me but i am beginning to understand it and today went much more smoothly. i have a lot of anxiety about this, as she is the first diabetic i ever dealt with, so the jump from 300 to 330 just kind of scared me but thanks for explaining that it is really nothing.

the student is not newly diagnosed; however, she was sent to my school, which is a private school for special needs students, specifically because she is non-compliant with checking her glucose and programming her pump correctly (even though she knows how.)

anyway, thanks again for sharing your advice. i really appreciate it more than you know!

Glad you are getting more comfortable. I totally understand now why she's coming to see you. There is a lot to learn with pumps, insulin and type 1 diabetes in general. I have several kids in my school. Plus my friend has a child with type 1, who happens to be friends with my daughter, so she sleeps over a lot.