Non compliant Diabetic Students

nursekoll, BSN, RN · Apr 25, 2018

Could you work with the cafeteria monitor or cooks to require the diabetic students to hand in a nurse pass to them before they eat lunch, showing that they have already checked in with you?

High school students should be encouraged toward more self- independence as able. What could motivate them to remember more consistently? An alarm on their phone, a reward for a full week of no missed check-ins maybe? Find out what motivates them.

Parents should be aware of the issue, I would call them to report what is happening, what is expected as per the health plan, and see if they have ideas for motivating the student.

Also, insulin dosed after lunch and not based on a fasting sugar level would be inaccurate. I see this as a safety issue and it's behavior- based. What does your school do for other irresponsible or unsafe behaviors in regard to discipline?

grammy1 · Apr 25, 2018

I'm in a junior high, but it all honesty, our students are pretty independent. The only one who isn't is one who was newly diagnosed a few weeks ago, but it won't be long till she can be on her own. Others check in their classrooms, give their insulin, then just check in with me at the end of the day, before getting on the bus. Until I get to know them, I have them call me from the classroom before they give their dose so I can check their calculations, but once I know they are able to take care of it they usually don't call anymore. At then end of the day, they give me their numbers and dosages and they never know when I am going to ask for their meters to check and make sure what they are telling me is true. The children's endo clinic here likes them to be as independent as possible.

They do come to me if they are having trouble with a site, figuring out a dose, or sometimes they just don't want to have to deal with everything and will come and ask me to give their injection. If their BG is high enough to need a ketone check, they automatically come to me for that.

ruby_jane, BSN, RN · Apr 25, 2018

Sounds like it's a behavioral issue, and should be treated as such.

Here's the other thing- are they actually checking/correcting on their own? Are they better served to be independently managed?

I would have a conversation with the diabetic nurse at the doctor's office. They may be able to shed light on whether the practice thinks independent management is possible. Next, conversation with the parent.

Finally...it's a discipline issue just as surely as skipping class is. Apply some consequences. And when you talk with their AP make sure you tell them about the missed content time.

JenTheSchoolRN, BSN, RN · Apr 25, 2018

Sounds like it's a behavioral issue, and should be treated as such.
Here's the other thing- are they actually checking/correcting on their own? Are they better served to be independently managed?
I would have a conversation with the diabetic nurse at the doctor's office. They may be able to shed light on whether the practice thinks independent management is possible. Next, conversation with the parent.
Finally...it's a discipline issue just as surely as skipping class is. Apply some consequences. And when you talk with their AP make sure you tell them about the missed content time.

This.

It the issue is they manage on their own and hate the attention paid to them for having to go to the nurse's office to check, then work with it. None of my diabetics in HS come to me unless there is an issue (high/low/etc) - I am a MS and HS nurse and we transition to this goal in 8th grade. It has worked very well.

(Also I love CGMs if any of your students have them - great way to troubleshoot if needed.)

No, if they are just non compliant UNLESS they check and dose with you, that is a different story. I have been there as well. I had the call that student down every time. And sometimes they refused. I let the parent know and documented. Parent was equally frustrated about non-compliance at home. We had to think more out of the box for that one and work with a consequence plan.

Supernrse01, BSN · Apr 25, 2018

I would absolutely involve the parents. I'm not convinced they are actually forgetting. I go through this frequently with my DM kiddos. They all hit a point where they don't want to differ from their friends. They don't want to interrupt their lunch, class, break, etc... to check their sugar or bolus. I've had an issue with this every year, since I started. (Not the same kids, but the same DX)

I normally give the parents a call to let them know where we are and what I have attempted to do help find a solution. It definitely has to be a team effort on this one, where other faculty and staff are monitoring and redirecting too. I once had a student ask if her friend could come with her, so they could still have their break together. I was OK with that.

nmr79 · Apr 25, 2018

I have one DM student who is honestly forgetful (She's good about AM and pre-lunch checks, but forgets the 2PM pre-gym class check). I've started emailing her at 1:55, and she responds with her number (as long as it's normal- if it's high or low, she comes here for intervention). I'm at a middle school, and the students have iPads, so she can check her school email discreetly. She has a google sheet that she keeps track on, which I have access to as well (she puts her normal readings on there for morning and lunchtime). She has an omnipod and dexcom, and does her own insulin.

Avill, BSN, RN · Apr 25, 2018

Do you have "fragile" diabetics? mine come in 5-10 minutes before lunch, test, look at menu, counts carbs ect. That way by the time the bell rings they are set to go to lunch. I've had a talk with my students letting them know that it is in their diabetic management plan for them to come in, and they NEED to be compliant or else they cannot be in the school.... last resort type of thing.

But I would talk to the parents first then threated. lol, but it's true!

Rubor · Apr 25, 2018

I have 15 and all but 2 are independent. A call definitely to parents to figure out maybe even that they can become independent and get the orders rewritten. How old are these students?

Have Nurse, ADN, RN · Apr 25, 2018

I am a high school nurse and I'm having a bit of an issue with my some of my diabetic students (I have 5).. they are frequently forgetting to report to my office for their 'before lunch' accuchecks, they all require supervision, and insulin coverage to be administered for carbs to be eaten + a sliding scale.
The kids are getting out of class 5 min early before lunchtime, so they can be the first to get their meal and then are supposed to report straight to my office..
I have reminded them daily to do so, I have sent out messages to the teachers so they know to release them early before lunch, and even sometimes I preemptively call the teacher and tell them to ensure they come here (and even then sometimes they no-show!).
It is happening too frequently, and I then need to pull them out of their 5th period and have them miss class to test and they have then already eaten.
I'm not sure if it is time to involve parents? Calls? Letters home?
What would you do in this situation? Any tips or help would be much appreciated.

You bet it's time to involve the parents!!

RobotechTD · Apr 27, 2018

I substituted in a school that had eleven students with diabetes and about 20 daily medications to be given at lunch time. There was no time to look for students who forgot to come to the health office for treatment and medications at lunch time. This is also a busy time for the frequent fliers because they use the innocent lunch volunteers to come to the health office. The nurse made an agreement with administration to give lunch detention to those who did not come to the health office for meds and treatment, including those students with diabetes.

ButterflyRN90, ASN, RN · May 2, 2018

STOP.

From what I see and have read, you have treated diabetics and even live with one. It's NOT the same as being one.

Let me explain a bit. I'm a Type 1 diabetic who was diagnosed at the age of 7 in 1997. I had the same exact rules implemented at my school. I didn't care. I wanted to grab my lunch and eat with my friends. I didn't want to drink disgusting sugar-free drinks (still don't). I didn't want to stop playing at recess because my body was feeling "low". I didn't want to go to the nurse's office every day, 4x a day. I threw away my meters when they showed a high blood sugar. I avoided injections because they hurt. I skipped classes to avoid being present during an early release (3 month blood draw for A1c). This was not a life I chose and that was elementary school.

Middle school: I had more freedom and the same rules. I still avoided it. Boys I had crushes on didn't like me because they thought they'd catch diabetes from me. I had my friends and didn't want to be singled out.

High school: I hid soda bottles in my room. I bought snack cakes and juices before class. High BGs make us lethargic plus growing is tiring so I slept in every class until lunch. I had an insulin pump by then. I would eat my meal and forget to bolus. I got very sick. I still rebelled. I was depressed.

College: I would go weeks without checking and just give insulin. I'd lose weight. Had frequent UTIs and slow healing wounds. I had a boyfriend who I met in high school (he's now my husband) who saw me deteriorate. I couldn't stay in a dorm. I couldn't experience college the way I wanted to (not the partying or sleeping around portion). I was always too tired, too sick, or too depressed.

Nursing school: I found out about a diabetes program for adults which I'm going to again in May. When I walked into that building and saw 90 other Type 1s with the same illness it clicked for me. I was not alone. Nursing school didn't teach me about complications or treatment modalities for diabetic patients, but it did give me a different perspective.

Going to parents may work...temporarily. More often than not they will find ways around it. I did.

Tricks used by former and current non compliant (rebellious/depressed) diabetics:

-control solution

-change date/time and check BG 20-30x making it look like they've been checking consistently throughout the week.

-checking their friend's BG "just for fun"

-I used my dog (I still can't believe I did that)

-write in different pen ink for the month

-Coke

-Inject insulin after checking with another meter and using main meter to record only "good" BGs

-Drop of blood on counter. Let it sit. Use. Value drops about 30 pts while open to air (I don't know how but it did for me back in the day)

You got a long road ahead. Usually though, it gets better with age. Just DO NOT:

-take pt to dialysis center

-take child to funeral home

-ask child what color coffin they want (was done to me by my mother. I was 9)

-spank child when BG is elevated (done to me too)

-punish child for not coming in for BG checks

This was hard enough as a kid and a teen without adding puberty, peers, and the instinct to be "normal". Talk to them. Teach them about diabetes camps (I went to Camp Winona) for kids. They may feel ostracized. They aren't alone.

Good luck. :)