Managing Type 1 Diabetes

[HyzenthlayLPN]

I have also posted this in the Diabetes specialty group...

One of the students in our district (5th grade) has Type 1 diabetes. It does not seem to be very well controlled so I have been called several times to go to his school and monitor him, usually because his FSBS is high. (I am the only nurse in the district and I am with the schools 16-20 hours each week).

My question is really this: in absence of a written plan from his physician, does he need to remain in the school office under close supervision of a nurse or a staff member who is trained to assist him with managing his diabetes (i.e. who can supervise him in checking his blood sugar and his self-administration of insulin and has basic education re: s/sx of hyper and hypoglycemia and how to manage both) when his blood glucose is high?

(the written management plan from his doctor does not address whether or not he needs to be in the office or sent home or can stay in class...it only addresses how much insulin he should take/when and what to do on days when he is sick)

I'm asking because his fasting FSBS was 291 today when he arrived at school. He took a correction dose and coverage for his breakfast (he doesn't write things down so I am relying on his memory-hours later). His blood glucose reportedly peaked at either 256 or 380 something depending on who you are talking to and then dropped to either 42 or 56 (again depending on who you are talking to) all before lunch. I was called in this afternoon...and his FSBS was 174. His parents were called at 0930 and were coming to get him asap...he was still at the school at 1415 when I left.

I can understand wanting to keep him in the office when his blood sugar is low...but what about when it is "high"? His parents sent him to school with a 291 FASTING FSBS...he went straight to the office and never left. I know he feels bad (headache, etc) when his blood sugar is high...but he isn't going to feel any better or benefit in any way (that I can see) by sitting in the office rather than being in class...

What do you think? I have no experience with Type 1 diabetes. I've tried to educate myself because of this on going situation but I'm starting to wonder if this child has discovered that he can get out of class/be sent home if his blood sugar is high and he says he feels bad...He was dx'd last school year so this is new...he is currently an advanced student but I am concerned that if he continues to spend 25% of his school time in the office, he is going to fall behind.

Any insight/information would be very helpful. Thank you!

[grammy1]

If they are low, we have to keep them in the clinic till they are over 70. We've had them back in class at 400 after they've corrected, and they come back to recheck (or check in class) q2h if they're high. However, if they have moderate to large ketones and are that high, they go home. We have a great children's endo clinic that we are in contact with frequently with our kiddos. They are pretty much responsible for checking their own BG and doing their own corrections at the jr. high level. It's very rare I give the insulin, unless the endo clinic tells us to give a shot instead of using their pump, or to give it in the arm since most of them use their abdomen or thighs (sometimes they hit scar tissue and don't absorb well). Occasionally (and they never know when it's going to happen), I'll ask to see their meter or have them show me their pen or pump before they inject/infuse, just to make sure they're not playing any games...and yes, they know how to adjust their insulin to get out of class and go home!

Edited to add:

I would definitely get clarification from his doctor regarding going back to class, etc. You really need it for PE instructions too. Truthfully, I've never kept anyone in the clinic with a 291. Special note to carry a water bottle, BR privileges and back to class.

[kidzcare]

If they are low, we have to keep them in the clinic till they are over 70. We've had them back in class at 400 after they've corrected, and they come back to recheck (or check in class) q2h if they're high. However, if they have moderate to large ketones and are that high, they go home. We have a great children's endo clinic that we are in contact with frequently with our kiddos. They are pretty much responsible for checking their own BG and doing their own corrections at the jr. high level. It's very rare I give the insulin, unless the endo clinic tells us to give a shot instead of using their pump, or to give it in the arm since most of them use their abdomen or thighs (sometimes they hit scar tissue and don't absorb well). Occasionally (and they never know when it's going to happen), I'll ask to see their meter or have them show me their pen or pump before they inject/infuse, just to make sure they're not playing any games...and yes, they know how to adjust their insulin to get out of class and go home!

Edited to add:

I would definitely get clarification from his doctor regarding going back to class, etc. You really need it for PE instructions too. Truthfully, I've never kept anyone in the clinic with a 291. Special note to carry a water bottle, BR privileges and back to class.

Yes to what I bolded! Sneaky, sneaky kids!! During my first 2 months as a school nurse I had a 12 year old lying left and right about her blood sugars so she could come in and have snacks. Then she would leave and bolus from her pump. This student had a rough home life and I felt bad having to be so firm with her and she did not take kindly to me insisting on seeing her glucometer to confirm what she was telling me or checking through the history. She would come into school most mornings in the 400-600 range and telling me she had pop tarts for breakfast, I would call mom who was sleeping still and would ask me what I expected her to do about it. This was several years ago, but I think of this student every so often. If I'm doing the math right, she would be a Junior in HS now I think. Last I'd heard, mom had lost custody of her r/t the student's medical needs.

I agree also that you need very specific written orders from the student's doctor. When to keep in office, how many carbs to give for low sugar, ect.

[KKEGS, MSN, RN]

I would definitely want some type of written plan for what to do in those situations! My three diabetics all have written plans including their goal range, how much insulin to cover how many carbs, correction doses and what to do when they're low. They each have their own 3 ring notebook in the health office to record their blood sugars.

Just curious why there are no written plans for them from their endocrinologists?!?