Uncooperative Diabetic Question - page 3

Alright nurses! Help me figure this one out! Having issues with this student and family on multiple fronts. 4th grade boy with type I diabetes. Diagnosed 1 year ago. Has the Dexcom G5 CGM and... Read More

  1. by   KKEGS
    Quote from Cattz
    KKegs- How is today going with this situation. This is alarming on so many levels. One day this family will look back and realize what a great advocate you have been for this child. ( I am guessing it will be something like when our own kids grow up to be adults/parents- they realize just how smart we really have been all along!)
    Haven't heard a word yet. My office is in a different building. I'm checking in with the building nurse. Conferences are tonight.
  2. by   Have Nurse
    Be direct but respectful. This is a "learned" behavior he is displaying. He is making your job more difficult than it needs to be. He is old enough to know right from wrong.

    Part of nursing is educating those involved. It is perfectly acceptable to "educate" his parents regarding his behavior.

    But don't assume it will be taken happily. Be ready for the backlash.

    He can't be given the care he needs if all are not on board. Document everything including what you are trying to do to fix it.
  3. by   hppygr8ful
    We have a fair number of adolescent and preadolescent type 1 diabetics on pumps who end up at the psych hospital. I find then scary as heck because our facility does not require the pump to e removed and so they have in their possession the ability to give themselves a fatal dose of insulin at any time. The struggle for autonomy at this age plus adjusting to the knowledge that they have a life time chronic disease diagnosis leads many of these patients to have suicidal thoughts. Most of it is passive suicidality but the physician's feel it is important for these young people to have some level of control as they will be doing this for the rest of their lives. Because they are in-patient our dietary department counts the carbs and the kids administer their own insulin as they would do at home. They keep a written journal which they present to the nursing staff twice a day which tells how much insulin they have given themselves and how many carbs they are eating. If the suicidal thoughts are persistent the pump is removed. But these kids are going to have to learn how to manage their disease on their own and perhaps this boy's non compliance in more likely pre-teenage acting out to prove his autonomy more than anything else. From psych perspective and with a teenage boy myself I can see how embarrassed he might feel to be walked to the nurses office every time his BS falls outside the low/high norms and needs correction. It's a heck of a conundrum because you as the school nurse are responsible for his safety. I am not sure how you address this as I only deal with the kids who ultimately can't or won't manage their pump properly. No easy solutions except to call the parents every time an episode of non-compliance occurs and go from there.

    Hppy
  4. by   JenTheSchoolRN
    Oh, KKEGS, catching up on this thread after a snow day and firstly, just ::hugs:: We have all had a family like this this, one that insists we are doing everything wrong and yet doesn't provide us with the tools to do everything right and have one communication volume (LOUD).

    I have always felt drained after having to communicate with a family like this. But fortunately (or unfortunately) I have gotten better at nodding and listening and remaining calm and going through my rehearsed script in my head. I suppose this is one area that I grateful that I am a theater person for .

    And dosing off the Dexcom without access to the Dexcom? Wow. Does the student's doctor know that a) the student nurse doesn't have access to the Dexcom? and b) that parents are also not sharing data from the Dexcom?

    And as others have said, I haven't had a doctor write that is was okay to give insulin off Dexcom numbers but I can treat a low from them. This year is the first year I've been working in depth with a student that has one (I have access to the data and a great relationship with the parents thankfully) and frankly, the numbers have been off a few more times that I expected going in. A high has been about 40-60 off (i.e. saying 310 when sugar is 370) and that definitely impacts insulin dosing. I do love its use to alert me and the student though.
  5. by   ruby_jane
    Quote from hppygr8ful
    We have a fair number of adolescent and preadolescent type 1 diabetics on pumps who end up at the psych hospital. I find then scary as heck because our facility does not require the pump to e removed and so they have in their possession the ability to give themselves a fatal dose of insulin at any time. The struggle for autonomy at this age plus adjusting to the knowledge that they have a life time chronic disease diagnosis leads many of these patients to have suicidal thoughts. Most of it is passive suicidality but the physician's feel it is important for these young people to have some level of control as they will be doing this for the rest of their lives. Because they are in-patient our dietary department counts the carbs and the kids administer their own insulin as they would do at home. They keep a written journal which they present to the nursing staff twice a day which tells how much insulin they have given themselves and how many carbs they are eating. If the suicidal thoughts are persistent the pump is removed. But these kids are going to have to learn how to manage their disease on their own and perhaps this boy's non compliance in more likely pre-teenage acting out to prove his autonomy more than anything else. From psych perspective and with a teenage boy myself I can see how embarrassed he might feel to be walked to the nurses office every time his BS falls outside the low/high norms and needs correction. It's a heck of a conundrum because you as the school nurse are responsible for his safety. I am not sure how you address this as I only deal with the kids who ultimately can't or won't manage their pump properly. No easy solutions except to call the parents every time an episode of non-compliance occurs and go from there.

    Hppy
    I always appreciate your perspective, Hppy. Thank you!
  6. by   OldDude
    Well, how were things when the smoke cleared last night?
  7. by   Flare
    catching up after 2 days of snow filled fun... yay...
    the whole family needs more education about t1d. The dexcom needs to accompany the child to school so that trends can be tracked throughout the day. The argument that the child does meantime fingersticks is invalid. I have a child that has a libre and still occasionally does fingersticks. they don't always agree.
    If the child wants to put his own number into his pump, then that's fine, but it can't be completely unsupervised. He has to have the nurse on duty check and record his numbers prior to him hitting the go button. If another student comes in, during that time, my rule is that unless it's life and limb, it has to wait, my diabetics and their numbers are important. I tell the staff and the students all the time not to distract me during the times that i'm recording.
    I know you already had your meeting and I hope it went well. I hope you armed yourself with a copy of his orders and explained to them the importance of the school knowing fully what is going on with his and his disease for the third of the day that he is in your care. A lot can happen in that time. I hope that you did explain to them that he is not being compliant. Because it's so easy for the small lacks in compliance now to turn into big issues later - not coming all together, then disregarding carbs, then skipping insulin doses. He's got to learn to keep his treatment tight.
  8. by   Cattz
    Wow. This thread is so intriguing to me. What a tough spot for you Kkegs. My hubs is T1 and I have treated more of his very scary lows than I want to remember. I can't imagine being responsible for someone's child and not have all the information and tools to manage safely. Still sending hugs to Kkegs!
  9. by   KKEGS
    Quote from OldDude
    Well, how were things when the smoke cleared last night?
    Well the meeting went much better than I thought it would. Parents stayed calm. I reassured them that we are following the plan that we established in the fall. Dad said the student doesn't like to check his sugars or do anything regarding his diabetes at home so dad "ass"umed he wasn't doing it at school either. Myself and the school social worker, who is our backup Diabetes Trained Personnel confirmed that we do nothing beyond observing and recording his numbers. That seemed to help. And I was honest about his lack of cooperation but this seems to be a pattern of behavior in other areas of his life as well so...I am pleased with how we left things.

    And we hired a new nurse for that building who I am confident will be in for the long haul so that should make the parents happy as well.
  10. by   MrNurse(x2)
    Quote from KKEGS
    And I was honest about his lack of cooperation but this seems to be a pattern of behavior in other areas of his life as well so...I am pleased with how we left things.
    So this is the crux of the matter. Back in the 70's and 80's, this little one would have had no power in his defiance. Today, students call the shots. They are allowed to rage when things don't go their way. They get plans to allow further disrespect. This would have never been seen as a favorable outcome a generation ago. We ask why events happen, maybe we need to look at little things like this and realize our generation has allowed it.
  11. by   WineRN
    Quote from hppygr8ful
    The struggle for autonomy at this age plus adjusting to the knowledge that they have a life time chronic disease diagnosis leads many of these patients to have suicidal thoughts. Most of it is passive suicidality but the physician's feel it is important for these young people to have some level of control as they will be doing this for the rest of their lives.
    Hppy
    I have never heard of a connection between type one and psych dx/suicidal idolization before but it makes perfect sense. Thanks for sharing!

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