Ok, so I'm a school contract nurse through a home health agency working with a very young diabetic patient. The school is great, couldn't be more supportive of my role and continuously praise my efforts at keeping the client's blood sugar levels within range. That being said, the parents are much less than cooperative, downright non-compliant mostly. They have the "feed whatever whenever and cover with insulin" mentality, and cannot seem to understand why I won't jump on board with their dangerous, and if I'm honest, abusive behavior. After a particular incident occurred recently in which the client's blood sugar was well above the MD's range for the client, I refused to give the client a sugary, carb-filled treat with the client's classmates. I discussed the situation with my supervising RN as well as the school principal and we all agreed that adding fuel to the fire was a big no-no for BS levels, regardless of the fact that everyone else was going to have the treat. The client's parents were informed well ahead of the event that the class would have said sugary treat and could have brought in a diabetic-friendly alternative but did not do so. Furthermore, the parents called my employer after I clocked out to inform them that they were furious with me denying their child the sugary treat since everyone else had it (I took my client onto the playground so nobody ate in front of client) and since BS was high and I had to treat with insulin anyways why couldn't I just give the kid the treat?! Well, after much griping, my RN mgr decided to call me and determined it would be best if I were to take the next day off-without pay!!!- to let everyone cool down. So, what can I do about this whole situation? Keep my mouth shut and poison the kid next time like they wanted me to do so I don't get suspended without pay? ~feeling like a flamin' bag o' poo after being stomped on a few times right now
I hate to be blunt here, but the endo wrote that very clearly. 300 AND ketones. This right here tells you that the endo is not concerned until you have 300 AND ketones and I think this is the crux of the issue. Endos teach things really differently to parents than what you learn in nursing school and to be honest that is a big, big part of the problem. That I sympathize with nurses on.
And usually drunken behavior is from low blood sugars not highs. It can make your more irritable, but I have never seen drunkenness as a description for high blood sugars. As I said earlier, I would be not be surprised if this kid has a secondary behavioral issue. I think often people associate things to diabetes that are actually secondary problems.
Furthermore, from NCBI's article on hyperglycemic crises in adults, please see below regarding altered mental status and severe hyperglycemia:
"Occasionally, the entire symptomatic presentation may evolve or develop more acutely, and the patient may present with DKA with no prior clues or symptoms. For both DKA and HHS, the classical clinical picture includes a history of polyuria, polydipsia, weight loss, vomiting, dehydration, weakness, and mental status change. Physical findings may include poor skin turgor, Kussmaul respirations (in DKA), tachycardia, and hypotension. Mental status can vary from full alertness to profound lethargy or coma, with the latter more frequent in HHS." (Kitabchi, Abbas E. et al. Hyperglycemic Crises in Adult Patients With Diabetes.†Diabetes Care 32.7 (2009): 1335–1343. PMC. Web. 30 May 2015.) web address for full article: Hyperglycemic Crises in Adult Patients With Diabetes
This client does exhibit lethargy, cognitive difficulties, and combative behavior when BS spikes dramatically. Had I given the treat then the BS would've spiked to over 300 and ketones would be present (they almost always are every time this client has BS over 300) and then the parents would want to know why I intentionally caused the client to have ketones, and the MD would be yelling at me for doing something that would cause ketones, etc.
The order didn't say to give the treat and cover even if the BS was over their set parameters either though. And I'll reiterate that I offered a non-carb protein snack so that the client could at least participate in the celebration in lieu of the treat but the client didn't want that so the school/my supervisor decided to remove the client from the situation and offer a different sort of treat (recess as the client loves recess).
And extremely high BS do alter the client's behavior/mood (yes, secondary issues are at play in this case and are triggered/worsened by these high BS's b/c they make the client feel ill) so I had to take that in to account as well since the teacher still had lessons to complete for the day after the celebration. Had the client been given the treat, even though I'd cover with insulin for both high BS and insulin-ratio coverage, their BS would still have spiked severely high during the remainder of the school day and they would not have been able to function/think clearly in order to learn, which is why they were at school to begin with, right?
I will sort of agree with that, but did any of the other kids have expressed permission to have an extra treat? If the parents did not give expressed permission for an extra treat then I might side with you. There are equally spazzy parents that would freak out if you gave them food that they didn't approve of.
If it were me I would stick with this point and this point only for your argument and get clarification from the endo and the parents on how to handle extra snacks in the future.
there are a couple of parents in her grade level that are persnickety regarding certain treats being given out and they will write back on the note, please do not give this, please give XYZ treat instead, please don't give any treat, etc. And there are a few that have dental problems and the parents have expressed to the teachers that they would prefer sodas not be given, or gum/sticky treats, things of this nature d/t those dental issues but that other treats are ok. There are also a couple parents that have asked that their child not have sweets on religious grounds, but those children are not in this client's class. Going forward, I will clarify every last detail with a client's endo at the beginning of the acceptance of the shift for similar client's so that I know exactly what that client's endo wants done and then will discuss with the school contacts and have them discuss with the parents if the endo's POC clashes with the parents wishes. And I will also require a full 48hrs notice ahead of these types of celebrations so that I have time to contact the endo and the school has time to contact the parents if need be.
I'm just going to drop this little nugget of information here because it directly pertains to the client in question.
"As most people with diabetes already know, insulin helps transfer glucose out of the bloodstream and into the body's cells. It is produced by a group of cells in the pancreas called beta cells. But beta cells secrete more than just insulin; they also secrete amylin. People with Type 1 diabetes, whose beta cells have been destroyed by the body's immune system, secrete no amylin at all. And people with Type 2 diabetes who have progressed to the point of needing insulin injections (or infusions from a pump) have limited beta cell capacity and thus produce insufficient amylin.
So why all the fuss about amylin? Those of us with diabetes have survived for years without it. But the goal, of course, is more than just survival. It is to manage blood glucose levels effectively so that we feel good, can perform our daily routines, and live long, healthy, productive lives. The natural hormone amylin, as well as its synthetic equivalent, pramlintide (available since 2005 under the brand name Symlin), helps improve blood glucose control after meals." (Amylin, October 7, 2010 by Gary Scheiner, MS, CDE, Amylin - Diabetes Self-Management)
In the case of the client I was working with, it has been documented numerous times that when certain sugary substances were consumed by my client there would be a very rapid and very high rise in client's BS that lasted approx 3-4 hours, depending on whether it was a larger portion or smaller, but with correlating increases regardless. In this instance, knowing that the client already had a BS of 250+, and knowing that I cannot give insulin until after client had eaten said sugary substance, PER MD ORDERS, and that it can take the client upwards of 45-60mins to eat, I still feel it would have been negligence on my part had I given said sugary substance, which is why I sought guidance from my supervisor and the school principal. I did contact the client's endo but they didn't call me back until after 5:30pm, hours after the fact. So, if there is no Amylin in client's system (as evidenced by multiple previous FSBS checks WNL 1-2 hours after eating a nutritious and balanced meal/snack vs. multiple previous FSBS well above 400+ 1-2 hours after eating a carb heavy/starchy meal/snack) and I willingly give the client said snack when they're already above MD's set parameters (cutoff of 200), and there are no WRITTEN orders telling me that I MUST GIVE starchy/carby snacks regardless, and I have instructions from the school and my super (who sign my paycheck), how exactly am I the one in the wrong? If you know someone is drunk at a bar and you see them reach for their keys to drive home, would you let them drive drunk? NO, OF COURSE NOT! When the client has BS spikes over 300 (which ABSOLUTELY would have occurred had I given said treat) the client DEMONSTRATES severe changes in behavior and mood comparable to someone who is drunk, this is known. If you wouldn't let a drunk drive home or even continue to drink for that matter (ie bartender says call a taxi man you're drunk and cuts drinker off), then why am I being bashed for "cutting off" the carbs to prevent severe BS spike, changes in behavior/mood, and bodily harm to the client?! I don't understand some of the responses on here bashing my decision from a medical standpoint.
Plenty of patients with type 1 diabetes have fine management without supplemental Amylin/Symlin. It certainly sounds like this child has some room for improvement in his control. It sounds like he's fairly newly diagnosed from your other posts? This can be managed with insulin Pre-bolusing (giving the insulin a chance to work before the food kicks in) and increasing the dose.
I do however, understand the viewpoint of removing from the party/celebration what-have-you, and that in the long run it may damage their psyche, and I am truly sorry for not considering that POV. Had I been informed of the party beforehand I would have bought some D@@@@@ sugar-free icecream myself and brought it in just in case it was needed so that they could celebrate with the class and no one would be the wiser because nothing was labeled. Sadly, I was not informed of the celebration until that very morning, so there was nothing that I could do to provide an alternative SF treat.
Gaaaahhhh. SF snacks HAVE CARBS. Carbs raise blood sugar. SF snacks also have the fine side effect of having diarrhea since the use sugar alcohols to sweeten, which are essentially laxatives. Sugar alcohols raise blood sugar, but often over a longer period of time, which actually makes it harder to match insulin doses to them than just eating the real thing.
I apologize if, in my OP on this thread, that my attitude towards the parents came across as odious, unpleasant, or disrespectful as that was not my intention, nor is it my general view of the parents. I believe that my shock over the entire situation was still affecting my post, and the fact that I would be suspended without pay for trying to ensure the overall safety and well being of the client came across more than anything in the OP. I have the utmost respect for the client's parents because I know that it is downright misery at times trying to adjust your lifestyle around a child with an illness, much less one with multiple illnesses that is also not the only child in the family, and overall they do a great job with the client and try really hard. It was just that I felt (and that may be where the problem was, I'll admit feelings played a part) that if we exchanged one reward (sugary treat) with another reward (extra recess time with other school friends which the client loves) there would be "no harm no foul", and it was an opinion shared by my super and the principal. From a parent's POV, or T1D's POV, I can see how it could be more harmful than good because it may make the client feel like they are being punished for their Dx. Here again, I will say that this is just a sh@tty situation where I had to choose between a rock and a hard place and I guess I chose wrong.
I have asked to be removed from this case so I will no longer be put in a situation like this in the future.
Again, I am sorry that that happened to you, and I DO feel it was an overreaction on your supervisor's fault to suspend you. It seems like an understanding could have been come to if a meeting was held after things calmed down a bit. Best of luck in your future endeavors. You do seem like a very caring nurse.
Again, I am sorry that that happened to you, and I DO feel it was an overreaction on your supervisor's fault to suspend you. It seems like an understanding could have been come to if a meeting was held after things calmed down a bit. Best of luck in your future endeavors. You do seem like a very caring nurse.
Furthermore, from NCBI's article on hyperglycemic crises in adults, please see below regarding altered mental status and severe hyperglycemia:
"Occasionally, the entire symptomatic presentation may evolve or develop more acutely, and the patient may present with DKA with no prior clues or symptoms. For both DKA and HHS, the classical clinical picture includes a history of polyuria, polydipsia, weight loss, vomiting, dehydration, weakness, and mental status change. Physical findings may include poor skin turgor, Kussmaul respirations (in DKA), tachycardia, and hypotension. Mental status can vary from full alertness to profound lethargy or coma, with the latter more frequent in HHS." (Kitabchi, Abbas E. et al. Hyperglycemic Crises in Adult Patients With Diabetes.†Diabetes Care 32.7 (2009): 1335–1343. PMC. Web. 30 May 2015.) web address for full article: Hyperglycemic Crises in Adult Patients With Diabetes
This client does exhibit lethargy, cognitive difficulties, and combative behavior when BS spikes dramatically. Had I given the treat then the BS would've spiked to over 300 and ketones would be present (they almost always are every time this client has BS over 300) and then the parents would want to know why I intentionally caused the client to have ketones, and the MD would be yelling at me for doing something that would cause ketones, etc.
Your intentions were clearly good, although there seemed to be a misunderstanding on your part as to what the patient's rights are.
It is certainly beneficial to avoid ketosis, particularly for purposes of learning, but withholding snacks actually has nothing to do with avoiding ketosis. Ketone production occurs when the cells cannot use the available glucose in the blood due to lack of insulin. The amount of glucose in the blood really has nothing to do with it, it's all amount the amount of insulin available. Whether there is just enough glucose in the blood to meet metabolic demands, or way too much, if the cells don't have sufficient insulin to utilize the amount of glucose they need then they will trigger energy production through fat metabolism, which releases ketones.
If the medical management of the child is appropriate, then they shouldn't be having severe, prolonged spikes in their BG levels, even after having some ice cream.
Trying to deal with insufficient insulin coverage by reducing intake is actually what's most likely to result in ketone production, and the altered mental state that goes along with it.
I think it was a little much for you to be suspended...
But at the same time I don't agree with taking the kid outside while the rest of the kids were having an ice cream party.
Let the kid be a kid and have some dang ice cream with his/her classmates.
I think sometimes as nurses we need to think about the little things and appreciate the morale of the child. You can argue this child should or should not have had the ice cream...
But at the end of the day would the ice cream have killed him or her? No.
Ah yes...the same parents who would want this nurse's head and license on a platter if the kid ate 3 cupcakes and had a BG related episode.
Obviously not since they were apparently upset the kid didn't get the snack along with the other kids.
Is there really confusion out there among nurses about whether upholding a patient's right to refuse is more or less of a threat to your license than denying someone their right to refuse?
Specializes in Complex pedi to LTC/SA & now a manager.
Since this is private duty agency work were you pulled from the case for a day due to conflict (most definitely not uncommon in private duty pediatrics. If off you don't get paid. If client doesn't go to school you are off without pay. If a client is hospitalized you are off without pay....
Did your supervisor say you were suspended without pay OR were you pulled from the case for the next shift or going forward due to parental conflict. The latter is extremely common in 1:1 private duty pediatric nursing. I was pulled from a case because I requested a child's bus seat be changed for a high safety risk--the child was seated next to the emergency exit and spent the entire 90 minute bus ride obsessively opening the emergency exit latch and setting off alarms. The bus team didn't want to rearrange seats and complained to the agency. I was actually relieved as the only preventative measure was physical restraint which was NOT part of the plan of care.
I think you are over complicating the situation to some degree and becoming too emotionally involved (high risk in this specialty) it's clear that you are a caring, educated nurse but in non-hospital/non-facility nursing environments the plan of care is very different. Going forward if not you personally the clinical nursing supervisor must be in contact with the parents to ensure a mutually agreeable plan of care is in place and all parties involved are in agreement.
I work quite a few cases where I'm contracted by the district via my agency to provide 1:1 care at school. Other cases in home care is extended to the school day (paid for by district) but I already have a rapport with the family. In no case am I prohibited from contacting family/parents. However I work cooperatively with the school building nurse and my agency clinical nurse supervisor. Most parent contacts are done by school nurse or my clinical supervisor.
Since this is private duty agency work were you pulled from the case for a day due to conflict (most definitely not uncommon in private duty pediatrics. If off you don't get paid. If client doesn't go to school you are off without pay. If a client is hospitalized you are off without pay....
Did your supervisor say you were suspended without pay OR were you pulled from the case for the next shift or going forward due to parental conflict. The latter is extremely common in 1:1 private duty pediatric nursing. I was pulled from a case because I requested a child's bus seat be changed for a high safety risk--the child was seated next to the emergency exit and spent the entire 90 minute bus ride obsessively opening the emergency exit latch and setting off alarms. The bus team didn't want to rearrange seats and complained to the agency. I was actually relieved as the only preventative measure was physical restraint which was NOT part of the plan of care.
I think you are over complicating the situation to some degree and becoming too emotionally involved (high risk in this specialty) it's clear that you are a caring, educated nurse but in non-hospital/non-facility nursing environments the plan of care is very different. Going forward if not you personally the clinical nursing supervisor must be in contact with the parents to ensure a mutually agreeable plan of care is in place and all parties involved are in agreement.
I work quite a few cases where I'm contracted by the district via my agency to provide 1:1 care at school. Other cases in home care is extended to the school day (paid for by district) but I already have a rapport with the family. In no case am I prohibited from contacting family/parents. However I work cooperatively with the school building nurse and my agency clinical nurse supervisor. Most parent contacts are done by school nurse or my clinical supervisor.
I was wondering if this was a true suspension or more a matter of request for a different nurse and OP not re-scheduled as of yet. I can't imagine being actually suspended over a complaint like this. Disccusion on how to handle differently but not suspension.
farmernurse26
31 Posts
Furthermore, from NCBI's article on hyperglycemic crises in adults, please see below regarding altered mental status and severe hyperglycemia:
"Occasionally, the entire symptomatic presentation may evolve or develop more acutely, and the patient may present with DKA with no prior clues or symptoms. For both DKA and HHS, the classical clinical picture includes a history of polyuria, polydipsia, weight loss, vomiting, dehydration, weakness, and mental status change. Physical findings may include poor skin turgor, Kussmaul respirations (in DKA), tachycardia, and hypotension. Mental status can vary from full alertness to profound lethargy or coma, with the latter more frequent in HHS." (Kitabchi, Abbas E. et al. Hyperglycemic Crises in Adult Patients With Diabetes.†Diabetes Care 32.7 (2009): 1335–1343. PMC. Web. 30 May 2015.) web address for full article: Hyperglycemic Crises in Adult Patients With Diabetes
This client does exhibit lethargy, cognitive difficulties, and combative behavior when BS spikes dramatically. Had I given the treat then the BS would've spiked to over 300 and ketones would be present (they almost always are every time this client has BS over 300) and then the parents would want to know why I intentionally caused the client to have ketones, and the MD would be yelling at me for doing something that would cause ketones, etc.