suspended for doing the right thing...

MunoRN, RN · May 28, 2015

@meanmaryjean-so you would not take into account that the blood sugar was already elevated, and that, per MD orders, insulin is only to be given after the client eats, which would cause a severe spike in blood sugar before the insulin had a chance to kick in? Furthermore, because of extenuating circumstances around client's mental status, had I caved and said yes to said sugary treat the client would not have been satisfied with a smaller portion in order to help keep the spike down, but would have "razed cane" until they had the same amount (approx 30g cho) as everyone else. Isn't that considered to be neglect at best, and abuse by-proxy at worst?

30 grams of carbs is equivalent to one banana, and no it's considered neglect to allow a diabetic kid to have a banana.

Proper insulin coverage should include a calculation for the person's BG level just prior to eating (correctional) as well as the amount needed for what they are about to eat (nutritional dose).

I'm not sure that you get that you essentially punished the kid, essentially for just being diabetic,which in my view is totally unacceptable, regardless of whether or not his desire to be normal threatened his achievement of perfect BG control. That sort of intervention should be reserved for avoiding excessive danger, which it doesn't appear this situation warranted.

In all medical conditions, there is the rigid medical ideal for how it should be treated and how the patient should comply with that ideal, which is why nurses exist; to properly coordinate those medical theoretical goals with the fact that we're applying those ideals to actual people, who have goals and priorities that are not limited to just the medical ideal.

Emergent, RN · May 28, 2015

I remember having the opposite problem. The teacher, whom I otherwise adored, liked to give candy as a reward. I objected politely. She ignored my request. I had suggested cheap toys, you could buy them at the thrift store for 25 cents.

My point being, sweets are bad for everyone. And, parents should make the decisions. I chose not to make a stink, since the teacher was so wonderful, but she was wrong.

I vote for backing off, and advocating for fewer sweets for everyone.

farmernurse26 · May 28, 2015

@JulesA: I conferred with both my supervising RN and the school principal before moving forward with removal of said treat. The parents have been educated repeatedly over the course of many moons regarding proper nutritional choices and were asked to bring in healthy alternatives.

Here's my dilemma: if a child with a food allergy cannot have the same sugary treat and their parents don't provide an alternative then the school simply would omit said treat, correct? Yet, if a diabetic child has insulin handy go head and give it to them and just cover, regardless of the fact that said treat will do damage to their body the same way that a food allergy will do damage to the other child's body. Rationale for this: both conditions require medical intervention to keep the child from imminent harm, ie the food allergy needs epinephrine and the diabetic needs insulin so where is the difference?

caliotter3 · May 28, 2015

Regardless of whether you were actually right or wrong, it would be best to find another case, now, while you have a say in the matter.

Jules A, MSN · May 28, 2015

@JulesA: I conferred with both my supervising RN and the school principal before moving forward with removal of said treat. The parents have been educated repeatedly over the course of many moons regarding proper nutritional choices and were asked to bring in healthy alternatives.
Here's my dilemma: if a child with a food allergy cannot have the same sugary treat and their parents don't provide an alternative then the school simply would omit said treat, correct? Yet, if a diabetic child has insulin handy go head and give it to them and just cover, regardless of the fact that said treat will do damage to their body the same way that a food allergy will do damage to the other child's body. Rationale for this: both conditions require medical intervention to keep the child from imminent harm, ie the food allergy needs epinephrine and the diabetic needs insulin so where is the difference?

I would hope it doesn't fall on the family to bring in a snack for their child if others have snacks provided to them by the school. I don't understand why the school didn't have had an alternative snack for him since his parent's forgot if that was the plan? I'm guessing the school wasn't so supportive after all if they suspended you which regardless of whether I agree with your decision wouldn't sit well with me and would have me exploring my options to be paid for that day since they initially supported the plan.

I'd disagree that it is the same as a child with an allergy because they both require medical intervention. Unfortunately I think there are times when you need to pick your battles and if you are going to take a hard line on this topic the family or school or whoever is paying you to be this child's 1:1 will likely replace you.

mmc51264, BSN, MSN, RN · May 28, 2015

regardless of the fact that said treat will do damage to their body the same way that a food allergy will do damage to the other child's body

Are you kidding me?????? Letting a diabetic child, that CAN cover for carbs, have a cupcake is NOTHING like a child who will go into anaphylaxis from a peanut. If the parents were not giving insulin, that is neglect. What is this child's A1c?? That is how to tell whether the child's diabetes is being managed properly.

I am going to have to walk away from this discussion. As I have experienced over and over again, most of the health profession knows less about type 1 diabetes than my 11 year old child does. You should not be caring for this child. "A healthy alternative" What do you deem a healthy alternative? Like PP said, a banana has as much carbs as a cupcake. If the child is otherwise healthy, I don't see what the big deal is. Every holiday is food driven. Try living through: Halloween, Thanksgiving, Christmas, Valentine's Day, St Patrick's Day, Easter, the end of the school year, Billy's b-day, Annie's b-day, pizza parties, ice cream parties. It is an endless list. We pick and choose our food battles. When you take too much away, the end of having eating disorders, hoarding food, sneaking food. You just have NO idea.

farmernurse26 · May 28, 2015

Yes, I am a contracted 1:1 nurse for that child only

Gooselady, BSN, RN · May 28, 2015

Resign from this case. When it gets down to this (a ******* match, basically) it's time to admit you and this child/family are a bad mix.

I've been doing hone care since January (1:1 with peds patient) and if there is tension with the family, where you (the generic you) are calling them abusive and so critical of them, lord knows what they think of you, there's no way you are going to be able to do your job they way you see fit.

I grudgingly had to admit the parent is the boss in 1:1 home care with peds. If they are abusive, notify the company you work for and sign off the case. You've done your bit. Now you've gotten into a power struggle and nurses NEVER WIN power struggles LOL. Never.

farmernurse26 · May 29, 2015

mmc51264: unfortunately one of my siblings is type 1 and so i do know first hand what growing up diabetic is like, and i also know that different foods/carbs are broken down in the body differently. Also, this child has a hoarder mentality stemming from long before T1D Dx and I do advocate quite vocally at every "event" that there be either SF alternative or fewer carbs provided, not just for the client but for all children at this school b/c there is A LOT of sugary treats there. The A1C at Dx of the elementary-aged child was just over normal and happened to be Dx by accident during a regular checkup, but at the 6-month checkup the A1C was at 10, so yeah, this is a day-in, day-out struggle to educate the parents while at the same time try to prevent long-term damage to the child's body. And, we have documented behavioral and emotional changes related to large spikes in the kid's BS, including an episode where the kid busted their head open running into something while BS was elevated, and episodes of "drunkenness"-esque behavior from extremely high (450+) BS's.

Been there,done that, ASN, RN · May 29, 2015

The parent's call the shots regarding .. denial or acceptance of the physician order.. not YOU.

jaycam, RN · May 29, 2015

As an adult with diabetes, this just makes me sad. For both you and the parents. Both sides in this story seem to have extreme points of view, both OP and the we don't give them sugar and the whole just give them insulin to cover parents. If what you are saying is true, the only one suffering is the child. I know I'm just a student, but one thing I've learned already is that you have to work with the client and the family, not against them. If they are truly negligent towards their child, report them, but if it's not, then how is it helpful to be at ends with them. A treatment agreed upon is more likely to be followed.

farmernurse26 · May 29, 2015

@Gooselady, I'm starting to realize that even though I had the client's best interests at heart, and only the best intentions, nobody really cares. I truly care for this child and do not want to see them lose limbs like several of my older, non-compliant diabetic friends, and that was my motivation. All anyone cares about is the here and now, instant gratification (oh how different is a cupcake vs a banana), without caring about how that cupcake that *you didn't need* provided no nutritional value then, and contributed to your *now failing* sight and loss of limbs 15-20yrs down the road. Forgive me for having a heart in the nursing field; I guess I forgot to ditch it when I got my license like some others (oh just document, do your best, advocate on paper, blah blah blah).