Struggling with T1DM mgmt in school. :(

[erinsbigsister, BSN, RN]

Hello All!

I am in my first role as a school nurse and have 2 students with type 1 diabetes (grade 2 and grade 3) in my school of about 400 children (Pre-K, Grades 2-4). The parent of one of these children has requested that I call her every time I see her child to review what I am doing. Unfortunately, when I do this, she typically wants to make an adjustment that is beyond what I would have done, such as administering a little more insulin that I would have and/or adjusting the basal rate on the pump (I.e. "give him this much extra insulin and increase his temp basal rate by 100% for an hour"). I have been deferring to her because of course she is the expert on her child and I respect that she knows him so well AND, while I am not a new nurse, I do feel like a novice in many ways as this is my first time working with children (other than raising my own, etc.) and also my first time in the school setting...so I am in the thick of it with acclimating to my role. Two weeks in over here!

Long story short, 2 days ago I followed her instructions and ended up having the front desk cover my clinic so I could run out to the child as his BG rapidly dropped at recess. (He was not symptomatic but I can monitor with a tablet and he was in the 90s with double arrows down when I first started out and in the 70s when I got there). (We did double check with fingerstick.) The next day I did not call her and things went OK - no lows but some higher BGs. She did not like that so when we talked, I agreed to call her even if I was confident in what I was doing as she would like more contact while he is adjusting to the new school setting (he was in a different school last year). Today, I had to drop everything and get to him twice. He was dropping and she requested I have him eat a fourth of his Clif bar vs the 15g fast carbs I had with me (Gogo Squeeze or juice). She said he could eat a little more of the bar if needed. He was not coming up after 15 mins and I let him eat the rest of the Clif bar. Another 5-10 mins went by and the CGM gave me a warning of urgent low of 55 in 20 mins. I was getting very uncomfortable and just gave him a juice when he hit 68. He did come up quickly after the juice and I was able to get back to my clinic which was PACKED with kids (everyone had a sore throat today). One of my fellow school nurses is feeling protective of me over this and said that it is not realistic for mom to expect me to be able to use a Clif bar vs juice and sit with him for this much time. Mom can keep him lower and wait for him to slowly come back up but the nurse with 400 other kids is another story. She also does not think I should have to be making all of these calls and adjusting the basal rate multiple times t/o the day. I was honest with mom and apologized to her for the extra juice, and just explained my discomfort. She told me that she remembers feeling the same way and explained that he can be slow to come up and it's just something I'll get used to. (Mom is not worried when he is low. She prefers lows over highs.) My coworker says NOPE..NOT OK.

By the way, this low was about an hour or so before lunch and he was in the 130s before lunch. He ended up dropping again after lunch/recess. It was just a DAY.

We will be scheduling a 504 and my coworker is going to join me for support. I thought about this and researched all weekend (while also trying to complete course work for grad school...fun wkd). I realized that what I have for him is a DMMP from LAST year. What they gave me this year is a Diabetes Road Map. The Road Map is not signed by the physician and does not state parents may make changes. It does have instructions for an adjusted correction scale between 2-3 hours after last insulin dose. Mom states that is too long to wait. She wants a correction if he is not down in an hour since last injection. I tried to do a correction on the pump today - 2.5 hours after previous and it offered nothing for that (I think he was 206 at the time). If the pump is not offering a correction, mom has had me enter in the amount of carbs needed to get the pump to give the amount of insulin she wants him to have in the past (before I realized I needed updated orders for her to be making changes). 

Today, Mom yelled at me and told me I cared more about my license than her child. It was awful. Admin did meet with her and they told me she will be apologizing but I am just feeling shaken. I want to have a good relationship with mom and for her to feel supported. Dad is the opposite of mom (they are separated) so we need to all get on the same page. I want the student to be safe and need to feel confident in my care of him. I want to be able to be there for all the kids. Today (and last week) was ROUGH on me as I adjust to this role. 

My other little one went low last week, too. She popped in after hearing her CGM alarm before I even had time to find her (which was great). I contacted mom and dad just to let them know I was on it, treated her with a Gogo squeeze and she came right up, then had a snack and she was picked up (end of day).

Any words of wisdom? Feel free to tell me what I did wrong or give any feedback or advice!

How low should be be trying to keep the student during the day? My coworker feels like 180s is a decent place and he is sort of just up and down throughout the day. 

Thank you in advance for any help with this. Super-super stressed. 😞

[RatherBHiking, BSN, RN]

Oh my I can't imagine! I'm not sure how it is everywhere but in our district we have Dr orders that we are required to follow with a rule we do not take orders from parents. Secondly, I never would have had time to call my diabetic parents every single time I saw their child. If the parent can't trust a medical professional to take care of their child in school then they either need to homeschool or hire a private nurse they can boss around. You are there for the entire school, not that one child. This needs to stop. Sure you may have questions and that's OK to call the parent to clarify but to call the parent to ask what to do is too much. I'd come up a plan where you will promise to call or message if you're worried and let her know each day through note or message what the day's sugars and treatments were. She will probably calm down on the micromanaging once she sees you're competent. 
 

Do you have Dr orders with step by step what to do for highs and lows? Make sure you have those and explain to the mom you cannot just change the basal rate all day long unless the Dr writes that. Some pumps have a setting you can change for like gym and recess and you can pause it when they're dropping but to constantly change it is not common practice. 
 

Kid's blood sugars do go up and down frequently. Some kids are very well controlled and others not so much. You'll eventually learn how much of a snack is needed to get the kid back up and how long it will take. You'll start noticing what their sugars do depending on what they have for breakfast or lunch, when they have gym, recess etc and can adjust accordingly based on your own critical thinking. Each child is different.

Just assuming that the mom knows what's best for her child is not the best practice. I've met many a diabetic parent who like their kids in the 200-300's all the time or freaks out if it gets above or below a certain number and over or under corrects. The Dr orders we had would have us treat if below 70 but one student, if he had two arrows at 100 I knew if I didn't treat and wait until he got to 70 he'd drop to 40 and take forever to get back up with many snacks then go high so I would give him a small snack at 100. The orders also specified when to check the blood sugars and when to treat and how much insulin. It's normal for it to up after lunch and then come down a little and stabilize. We usually checked 2 hours after lunch. It's whatever the Dr wrote. In the afternoon unless it was over 300 we didn't usually give extra insulin. That's what the basal rate is for-to try and keep it steady. If it's always being changed the Dr can't make corrections on what it should be. 
 

So get the detailed orders and then explain to mom how it's going to go from here on out. One of the quickest things as a school nurse you need to learn is how to stand up to parents. They'll walk all over you and make your life miserable if you don't. Good luck!

 

[k1p1ssk, BSN, RN]

I agree with everything said above. Nurses take orders from doctors, not parents.

I'll admit that I was extremely lucky with my first diabetic student as not only was his mom super chill (he'd been diagnosed for 7 years already when I got him) but she also worked in the building! The only time I would contact her was if he wasn't feeling well and his numbers were good or if he needed a pod/cgm sensor change - and that was only the first year as it was new equipment for them as well. 

I initially was spending a lot of time with him, but once I figured out how different carbs affected him, I was able to use my nursing judgement to alter how many carbs I covered for - but his DMMP was clear that we were never to change his basal rate without calling the diabetes nurse line at his endo's office and receiving verbal orders. 

You need actual clear orders ASAP and to make it clear to mom you will call only during certain times - like if he's low/high and you cannot get him back to normal within 30minutes or something like that. 

Good luck!

 

[erinsbigsister, BSN, RN]

Thank you, both!

Mom came in again the next morning and did NOT apologize. She questioned what I wrote in the book the day before and we found out the child made a mistake when he told me how many pieces of fruit he was going to eat. By the way, it turns out she HAD given me the DMMP but it was buried in my stack of papers to be filed! Not my finest moment! 😬 I had already obtained a new copy when I realized that (after she said she remembered giving it to me). 

I'm not sure I regret that the DMMP got buried though because I may not have questioned things as much if I had had it, since it says parents may adjust +/- 50%. I had a great talk with the endo RN who also talked with mom and advised against the temp basal changes. Mom was NOT happy about this. Anyway, that day, I called her for the routine adjustments just to honor her request but refused to do any temp basal changes. At lunch, I gave him his meal bolus. The pump wanted to account for IOB by giving a little less than that but she told me that he had to get the full meal bolus. She does not understand that the pump is avoiding stacking insulin and she frequently corrects him when they are just home together. He was in the 180s and I agreed to her adjustment. Then she said, "just so you know, this is when I would also increase his temp basal for 30 mins." I said I couldn't do that but I would watch him. A couple of hours later he was 120, then 15 mins after that 81 and dropping. When I got to his classroom his CGM said 68 but his fingerstick was 44. We did the juice, then complex carbs after he came up (15 mins later). He was fine the rest of the day. 

Mom says it's too early to see a pattern but she is being a bit more cordial now. This afternoon she allowed me to account for IOB and not override the bolus and things went fine. He came in at 326 this morning after having a bagel and jelly for breakfast. If he was 326 for me, she would be storming the school! He also came in with a temp basal increase for an hour which she told me I could cancel if he came down to 150. We have a 504 meeting tomorrow that may be tense. Admin will be telling her she cannot walk into the school to have a meeting with me every morning and we plan to end the routine phone calls. 

Thanks for the feedback and support! Speaking with endo was also so helpful and I can reach out to them whenever needed. The endo RN said she suspects we'll be checking in every 10 days or so. 

Thanks again! Have a great rest of the week! 😊