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
The OP mentioned that the child's BS was already higher than the doc's given parameters at the time. I think what she did was appropriate given that she was concerned about the BS getting even higher. I understand what you mean about the importance of snacks for a diabetic, but you also have to go by the person's baseline and recommended parameters.
Chronic high blood sugars are extremely damaging to the kidneys and vascular system. I think another important thing to mention about this is that this child is depending on his/her parents and the school RN to teach him/her how to form healthy eating habits to keep them from developing health complications later on.
It was wrong for the RN to be punished for what she did. What is this society coming to when the school would rather cater to the parents whims than what a medical professional knows is the right thing to do?? I'm sure these are truly caring and loving parents who wanted their child to have the same privilege as the rest of the class, but the school nurse had a responsibility to give medically appropriate care. Furthermore, the parents should have provided a diabetic-friendly snack (as advised by the school) so their child could have been able to safely participate with the rest of the class and not feel left out.
Here again. Most patients on a diabetic unit are going to have type 2 diabetes, where carb restricted diets are a common part of treatment.
Fun fact: ADA developed the exchange system, but never recommended any specific diet and doesn't like having ADA 1800, ADA 2000, etc, named after them.
Well...way back then Type 2 Diabetes wasn't nearly as rampant as it is now. It was mostly type 1 ' s I dealt with (lifelong diabetics who had developed complications).
And they most certainly were all on special diabetic diets. Trust me...that I remember well!
It's kind of the whole judgemental attitude toward the family the OP had, calling them neglectful and abisive, and overall lack of knowledge of how type 1 DM is treated that's the issue here, which is literally the OP's only job.
So , while the child is in school, the doctor's orders trump the parent's wishes?
Homeschooling, here I come.
I can tell by the fact you refer to the parent's direction as "whims" , that you don't think much of them.
I think maybe you are misunderstanding my point.
If the parent wants me to do something that doesn't agree with the doctor's order, I won't do it. This relates to how much insulin to give related to his blood sugar; how many carbs to give when student is low. It relates to what the doctor wrote as the ranges, what his definition of "low" or "high" is. His/her actual orders. If the doc says give 15 grams of carbs for a BG below 80 and the parent doesn't want me to do that or the parent wants him to have 30 carbs, I won't do it. If the doctor says check ketones for a BG over 300 but the parent doesn't want me to do that, I will have the parent take the child home.
If the parent decides to give the child a cupcake - I won't fight with that because the doctor's order doesn't say NO CUPCAKES.
I'm just giving examples of what I mean; not what these parents have ever done. They are great parents and very involved in the care and education of their family regarding their son. He's as smart as a whip too.
Funny, today the 2nd & 3rd grade students walked to a local park and played games and then had a picnic. All the food was high carb - chips, cookies, cake, and fruit. All the drinks were high carb juices. No plain old water.
My student picked out two of the store-bought cookies and saved them for his lunch so I could add those carbs into his lunchtime carbs. (He knew he had to pick the store-bought ones because it is difficult to be exact about homemade cookies).
He and I ended up talking today about how proud I was of him for saving those cookies for lunch and not eating them with the rest of the kids. He went out onto the field and played football with some of the kids instead.
Specializes in NICU, PICU, Transport, L&D, Hospice.
Yes! The nurse in question is starting to see the bigger picture, thanks to education from all of you!Education was what she needed, not suspension (again my point).
Like I said; the nurse was advocating for the health interests of her patient.If she had been a police officer and had shot him dead she would at least be suspended WITH pay until the employer said it was an honest mistake.
If the parent decides to give the child a cupcake - I won't fight with that because the doctor's order doesn't say NO CUPCAKES.
Are you saying that even if the doctor did write an order that said "no cupcakes" you would prevent the child from being able to eat a cupcake? Even if the child and their parents were refusing the order?
Specializes in Psych, Addictions, SOL (Student of Life).
I am the one-on-one nurse for this client; I monitor their every bite, record, check blood sugars, and treat accordingly for both as, due to their impaired mental function, they cannot do it themselves. That is why I am in a conundrum over this whole situation.
Are you saying that you are the 1 to 1 for this child because the parents lack the cognitive (as implied by impaired mental function) of understanding the needs of their child. That's a whole different thing than willful non-compliance. What is the mandate of your contract? Were you hired to be a food cop or to monitor, treat and provide education within a physician's orders? In which case this question should have been run by the physician before the child was deprived and excluded from a normal childhood/school Activity. The school should be providing an alternate option. However when I had a DD client with NIDDM I can tell you that regardless of Blood Sugar we always allowed exceptions for special occasions such as birthdays and holidays. To make that child sit and eat a smaller portion or fruit cup while everyone around them ate cake and ice cream is cruel. I imagine part of the goal here is to allow this child to have a mainstream experience. If you are as you say monitoring every bite of food intake there should not be big excursions in BS - Something is missing from this equation.
Are you saying that even if the doctor did write an order that said "no cupcakes" you would prevent the child from being able to eat a cupcake? Even if the child and their parents were refusing the order?
No. I'm saying the physician's order gives you the information regarding kind of medication, doses of medication related to the ranges of blood glucose, and the carb:insulin ratio.
The emergency orders related to low or high BG. The timing of giving glucagon. Etc.
The actual physician orders. I won't counter those with what the parent wants.
The nurse has to follow physician orders. I'm not sure why people are arguing about that.
No. I'm saying the physician's order gives you the information regarding kind of medication, doses of medication related to the ranges of blood glucose, and the carb:insulin ratio.
The emergency orders related to low or high BG. The timing of giving glucagon. Etc.
The actual physician orders. I won't counter those with what the parent wants.
The nurse has to follow physician orders. I'm not sure why people are arguing about that.
But that's the point. Did the physician's orders say to withhold food? It didn't. That's why the parents are upset. If the physician's orders said withhold food then nobody would be having this argument.
There should be a written plan that says what to do if a blood sugar is high, what to do if a blood sugar is low. There should be orders that say at what number the kid needs to go home. There should be orders that say to check for ketones if it is above a certain number. If it was appropriate to withhold food there would be a doctor's order for it. There wasn't. The treatment for high blood sugars is not to withhold food. It isn't in the hospital. The treatment for high blood sugars is insulin. Have you ever seen a doctors order that says if blood sugar is above x number withhold food? No, there's a sliding scale to give insulin to adjust it. There are times where NPO would be appropriate, but that would be in a hospital situation and that would not be something a nurse should be treating in a school setting. If the number was truly too high for a cupcake then it was something that the kid probably should have gone home as ill for the day.
No. I'm saying the physician's order gives you the information regarding kind of medication, doses of medication related to the ranges of blood glucose, and the carb:insulin ratio.
The emergency orders related to low or high BG. The timing of giving glucagon. Etc.
The actual physician orders. I won't counter those with what the parent wants.
The nurse has to follow physician orders. I'm not sure why people are arguing about that.
I think what people are arguing that the nurse doesn't actually have to follow all physician orders, and sometimes they can't follow physician orders. A competent patient or their decision maker, such as parents, can refuse any physician order, in which case the nurse's responsibility is to abide by the patient's refusal, not the order. A patient can't make their own medication orders, for instance, such as refusing the Physician's order for 10 units of insulin and have the nurse give 15, in that case the nurse either has to follow the order or give no insulin at all. But patient's can refuse MD orders, such as "no cupcakes", in which case the nurse cannot prevent the patient from having a cupcake even though there is an MD order to not let the patient have a cupcake.
I've worked with a nurse who not only lost their license but was charged with a felony because they thought their responsibility was to always enforce the doctor's orders, in this case it was for a fluid restriction. The patient was competent and refused the order, yet the nurse continued to prevent the patient from receiving more water than the order allowed.
Right, patients still have a right to autonomy, provided they can competently understand the effects of their decisions. In the case of a minor, the parent has the right to make autonomous decisions that don't grossly endanger the child (and no, even with high bg, a cupcake doesn't qualify). As nurses, it's our job to advocate for these rights.
Specializes in orthopedic/trauma, Informatics, diabetes.
. We follow the physician order; not the parent's whim.
I promise you that a parent of T1 that "overrrides" a doctor's order is not doing so on a whim. I reiterate, the parents of a T1 know more about their child than ANYONE and a great deal of the ped endos will use language that gives the parents latitude to make "whim" decisions. There are SO many variables that cannot be listed. There have been days that no matter what I feed my child, I can't get his BG up and days I cannot get it down.
Sirene77
6 Posts
The OP mentioned that the child's BS was already higher than the doc's given parameters at the time. I think what she did was appropriate given that she was concerned about the BS getting even higher. I understand what you mean about the importance of snacks for a diabetic, but you also have to go by the person's baseline and recommended parameters.
Chronic high blood sugars are extremely damaging to the kidneys and vascular system. I think another important thing to mention about this is that this child is depending on his/her parents and the school RN to teach him/her how to form healthy eating habits to keep them from developing health complications later on.
It was wrong for the RN to be punished for what she did. What is this society coming to when the school would rather cater to the parents whims than what a medical professional knows is the right thing to do?? I'm sure these are truly caring and loving parents who wanted their child to have the same privilege as the rest of the class, but the school nurse had a responsibility to give medically appropriate care. Furthermore, the parents should have provided a diabetic-friendly snack (as advised by the school) so their child could have been able to safely participate with the rest of the class and not feel left out.