dansingrn

Lantus is a basal insulin. Basal insulin is NOT adjusted for PO intake, rather, the rapid acting insulins are adjusted based on the carbohydrate content of the meal or snack. Lantus is adjusted based on a pattern of morning glucose readings. If the pattern is low morning BGs, then the bedtime Lantus may be lowered, usually by about 10% (3.5 units in this case). A morning BG of 87 is excellent. The range of human BG is the same for everyone. We don't think in terms of "low" for a particular person. If a person is symptomatic of hypoglycemia at 90, which is actually an in-range BG, then that usually means they have been running overall high BGs recently. To "re-set" their autonomic response that brings on symptoms of hypoglycemia, they need to have their average BGs in range for a period of time. This can be done by gradually lowering the BGs over time (ie gradually increasing insulin) so that they aren't so symptomatic. Running the BGs consistently too high to avoid a feeling of hypoglycemia is not proper BG management and ultimately leads to all the sequelae of hyperglycemia.

I'm thinking if the child requires overnight home health and TPN/lipids, he may not be in a situation where he can be responsible for his T1DM care...

Glucose levels that high are definitely not dawn phenomenon. The child needs more insulin overall; I would contact the physician for sure. You mentioned that he gets Novolog per the bolus wizard, he should also be getting a basal infusion. Those rates need to be adjusted, and only the physician or NP can do that. It is usually fairly easy to control BGs when on TPN and lipids, as the carbohydrate content is constant. There are many things to consider, most important is whether the child is developing ketones during his hyperglycemia. There is a meter than can test for this in the blood much sooner that can be detected in the urine. Additionally, the pump tubing and subcu catheter must always be checked for occlusion - the reason you don't treat extreme hyperglycemia through the pump.

I am a pediatric nurse practitioner working in an Integrative Pain Management department at a children's hospital. We do use Western medicine, but also incorporate massage, aromatherapy, diet, stress management, self-hypnosis, relaxation/meditation techniques, yoga therapy and acupuncture. It never ceases to amaze me how these complementary modalities seem to make all the difference, and how effective they are for chronic pain management. A BONUS - the benefits affect many aspects of our patients lives, not just chronic pain :)

I went to a (mostly) online NP program. It required a GRE and a master's thesis before a panel of tenured faculty. The program was through a state university, and the professors were from the university's school of nursing, all PhD nurses. I don't understand why the OP assumes that online equates to simulated patients and "easy" courses. OF COURSE we learned pelvic exams/PAPs on real humans, the very same "professional patients" the med students learn with. OF COURSE we must complete as many clinical hours doing actual patient care with qualified preceptors that the B&M institutions require. An ENORMOUS benefit of online NP schools is that there are many more clinical opportunities when arranged for individual students. My university is in a smaller city with far fewer hospitals, clinics and especially pediatric opportunities (I'm a PNP) than the larger cities can offer. If every NP student left their lives (families, jobs, etc) to move to this small college town for 2-3 years, there simply would not be enough quality clinical experiences to go around for the students. At the graduate level, and as an experienced nurse, I took responsibility for my own learning with regard to the content. There were many creative ways to experience lectures that did not require sitting in a classroom (I won't mention them all here, those of us familiar with current technology are already familiar). I must add that online courses that have rather stringent criteria for frequency and quality of postings (student interactions) can be extremely challenging and time consuming. I started my NP program at a B & M, and was put off by the poor teaching, poor student support, and students sitting in the back, unprepared and nonparticipatory. I transferred to an online program that was far more rigorous. In order to get a grade in an online program, there are standards for participating online, including references for post every post. Not AT ALL saying that online is "better" than B&M, just feeling a bit defensive at the assumption I hear all the time that online programs at the graduate level are inferior and "easy."

It's fine to prefill syringes with NPH, home health nurses have been prefilling for their patients who are blind or have dexterity problems for eons. It's important to remember with NPH that the suspension must be mixed as evenly as possible before filling syringes or the concentration will not be uniform. NEVER shake NPH vials, but roll between the palms, then tip upside down/right side up several times until fully suspended. When using the pre-filled syringes, warm by rolling between your palms or let come to room temp, then tip the syringe several times to let the precipitate suspend again. This will prevent clogging of the needle, and ensure that all the suspension is delivered and none is left in the syringe.

This is a question that even the insulin manufacturers struggle with. There are several factors, such as number of injections per day (number of times the rubber stopper is penetrated), temperature, sterility, etc. that can affect (however slightly) the potency of opened insulin. The most practical answer we give our pediatric patients is to use opened insulin pens or vials within 30 days, or monthly. This allows a new pen to be taken to school on the same day of the month each month. There is no practical difference in potency between the 28th and 30th (or 31st) day. Hope this helps. Here is a link with more details: http://care.diabetesjournals.org/content/26/9/2665.full

Omitting insulin causes the body to use fat rather than glucose for an energy source. Fat metabolism creates ketones (acids in the blood). Ketones cause nausea and vomiting, so that be one cause of nausea with missed insulin doses. Rapidly changing glucose levels can "feel like" highs or lows, regardless of the actual glucose level. If you took rapid acting insulin after missing the Lantus, the drop in glucose can feel like a low, even if you are still hyperglycemic, like if you drop from 500 to 300.

blood glucose 2,217

Finished my NP at 49. And I was not the "oldest kid in the class" by a longshot!!! Do it!

Standard sick day management is to treat the hyperglycemia, adding even more insulin if ketones are present (even if NPO, even if vomiting!). Definitely needs insulin in presence of infection, so clarification with the provider is indicated here.

np2b - Do you have peds RN experience? PM me . . . I have a lead on a PNP position in your general region if you are willing to consider a subspecialty in a children's hospital.

I'm an NP in chronic disease management. I work in peds with type 1 diabetes. (The answer is NOT ALWAYS fnp!!) The time to work on preventing complications is at diagnosis. Therefore, working in peds (as a peds specialist, not the broader fnp) hopefully addresses these very issues. Proud to be a PNP

Try University of Missouri (Columbia) Sinclair School of Nursing.

Absolutely this tech cannot be required by an employer to revert to injections! Contact the American Diabetes Association for details regarding discrimination against persons with diabetes.

I too am "peds through and through". Many advised me to go FNP for broader opportunities, but when looking at FNP curriculae I couldn't even get excited. When looking at PNP programs, I couldn't wait to take all of it. Although the FNP prepares you to see children, it obviously doesn't specialize in peds. If you want to be a pediatric specialist, follow your heart! The FNP program will certainly be focused on adults, there will be some peds courses and clinicals, but you will not focus on peds. In the institution where I work, there are many PNP opportunities. There are FNPs, but certainly there is a preference for hiring PNPs (its a children's hospital). I don't think my previous peds RN background (my entire RN career) actually made the difference, believe it or not! I think that for the most part, when you are applying for an NP position, they are looking at your NP education/experience, and not putting much by your RN background. Others may have more to add here. It is true that I don't feel there are lots and lots of peds opportunities for me outside my institution. But in the end, I don't want to ever do anything but peds anyway. Follow your heart and you will not go wrong here! Get the best training you can for the job you want, not the "backup" training for the job you can't imagine doing! Pour your efforts into what you want to do, and go out there and get your dream job! Your specialized expertise will show through in your enthusiasm for peds! (just my little pro-peds soapbox!)

I'm peds all the way. No white lab coats.

I finally solved my own organization problem with a small zippered "document case" made by Samsonite. Found it at TJ Maxx for 5 bucks, and its great! Currently in the case: iPhone, keys, calculator, pens, script pad, lip balm, business cards. There is a belt loop on the back, (of course i don't wear it!) but I clip my pager on the belt loop. I carry the case around in clinic, but its very small, flat, and very organized inside. I have eliminated the problem of realizing my (name needed item) is back home in yesterday's pockets.

Type 1 DM is an autoimmune disease, and can be diagnosed at any age. Just because a patient takes insulin, even from the beginning, does not make them necessarily type 1. Autoimmune beta cell destruction is type 1 diabetes. Many type 2s need insulin to control their BGs. Type 2s CAN go into DKA, especially at diagnosis. It is important to do thorough testing at diagnosis ( C-peptide, insulin, several auto-antibodies) to differentiate between the two in many cases. I have a 5 y/o patient with type 2 DM, and many pre-teens. It is not uncommon at all to have hypoglycemic episodes before the diagnosis of type 1 DM. Think of the islet cells as still producing some insulin, just not nearly as efficiently as they should. When the BG is high, signaling the pancreas to secrete insulin, it may not react quickly and with precision. Then, when it does react, it secretes an imprecise amount (too much) resulting in hypoglycemia.

Another option that is very popular with my pediatric patients is to place the site on the back of the upper arm with the tubing pointing toward the underarm. The tubing goes down the inside of the shirt, and the pump clips on the waistband. The tubing is completely under the shirt. The taller teenagers usually get the 42 inch tubing instead of the 23 inch for this method. I know several nurses who clip a small hole in the pocket as suggested by other posters. The tubing is not likely to kink this way. The tubing is very flexible, actually tubing inside the outer tubing, so its difficult to kink. There is a small round device especially made for coiling up the excess pump tubing, it clips onto the tubing right at the top of the pump. I can't remember who makes it, but I saw it demonstrated at a couple of diabetes conferences. I haven't actually used those in practice. The majority of our patients coil the tubing loosely around a finger, then tuck it behind the pump. Hope this helps!

In my institution, we have PNPs as well as a few FNPs, but the preference is definitely PNP. When I was asking myself "FNP or PNP" my only vote for FNP was the "marketability." In the end, I went with my heart and chose PNP and am so glad I did. Even though FNPs technically have the scope of practice, the focus of the program is adult care, not peds. There are some peds clinicals, but with the PNP its ALL peds obviously. The entire program is specifically focused. When I looked at curriculae for both programs, the peds program made me excited; the FNP program did not. Go with your heart, and you won't go wrong. Get the education for what you really want to do, whichever that is, not what you might do for a back-up. Good luck and enjoy your program!

I have copied/pasted the required practice experience section from the NCBDE, the body who gives the CDE exam below. NTPinky, you are correct, one must have 1000 hours and 2 years experience in a position whose job description is specifically "diabetes education" to even apply for the exam. Professional Practice Experience All professional practice experience is defined as employment for compensation as a diabetes educator in the United States or its territories within the past five years. Employment for compensation means to hold a job in which one is actively engaged in diabetes self-management education and for which paid income is comparable to other diabetes educators in the same area or region of the country. Only experience occurring AFTER completing the Discipline requirement can be counted toward the Professional Practice Experience requirement. After meeting the Discipline requirement and before applying for the Examination, all (A through C) of the following requirements must be met: A minimum of two years (to the day) of professional practice experience in diabetes self-management education. AND A minimum of 1,000 hours of diabetes self-management education experience. AND Current employment in a defined diabetes educator role providing diabetes self-management education a minimum of four hours per week, or its equivalent, at the time of application.

To work with pregnant women and deliver babies, certified nurse midwife is the track. CNM opportunities can be limited depending on what part of the country you are in. Family nurse practitioners can see all age ranges. If you really truly want to work with children, pediatric nurse practitioner is more focused (obviously) with all pediatric specific assessment, pharmacology, pathophysiology and clinical hours. One can obtained a master's degree with any of the above specialty tracks, and then obtain a post-master's certificate in an additional track. For example, a FNP could obtain a post-master's certificate CNM. OR become an FNP and obtain certificate in PNP for the additional focused training. Its all in the goal . . .

Why a 90 degree angle with Lantus? Just curious. Loved your thorough answer, and thoroughly agree with all of it. I was too tired to post all that, but I was thinking about it when I read the original post! Saw a type 1 new onset in DKA last month (definitely not HHS) with a 2224 BG, certainly the record for me! I have only seen 2000 3 times in 12 years and DM is all I do . . .

It seems strange that the FNP requirement is 500 hours for the entire lifespan. Can that be correct? My PNP program was 700 hours for birth to 18 (including an OB/sexual health rotation for adolescents). Seems as if the FNP would be at least that many?