SLO 1: Analyze learning needs to patients and care providers

Case Study – School Nurse: Middle School Student with ADHD, T1D, SDOH Social History You are a nurse practicing in the school setting in a rural title one community. It is the beginning of the school year and one of your 7th grade students on your caseload is a 13-year-old student named Aiden. Aiden is an only child in a single parent household. Aiden’s grandmother was living with Aiden and his mom until she passed away in July. Aiden’s mom is a local retail grocery assistant manager and works evenings and weekends. Aiden receives free and reduced meals and eats both breakfast and lunch at school daily. His breakfast is at 7 am and his lunch at noon. Aiden is an overall strong student and very social and has a specific learning disability called dyscalculia. Medical History and Current Health Status Aiden is an otherwise healthy child who is fully vaccinated and diagnosed with both Attention Deficit Hyperactivity (ADHD) and Type 1 Diabetes (T1D) in early elementary school. Aiden is able to provide a lot of self-care with his diabetes management and you have delegated some of his daily care to an unlicensed assistive personnel (UAP). Aiden has an insulin pump and a continuous glucose monitor (CGM). His pump has a basal insulin level set at home and he receives meal time boluses at school. Aiden’s mealtime insulin cover ratio is 1 unit per 12 grams of carbs. His blood sugar correction dose is 0.5 units of insulin for every 50 mg/dL over 150 mg/dL. Aiden also takes his methylphenidate 30 mg PO at breakfast and 20 mg PO at lunch. History of Present Situation You have only worked with Aiden one year previously and his glycemic control had been fairly stable. Last September when you checked in with mom with the start of the year care planning, his HbA1c was 7.0. You recall that the end of the school year was a little less stable when his grandmother was placed on hospice and Aiden missed a lot of school and had to be reminded to report for medications before meals several times. You have noticed since school started this year that his blood glucose has been elevated each morning, despite having a continuous glucose monitor (CGM) with alarms. Present Situation It is Monday morning and you receive a call from your delegated caregiver that was supervising Aiden’s breakfast insulin bolus and Aiden’s CGM is reading over 400 with a trend of increasing. He denies abdominal pain or nausea. You advise that his bolus is administered as you are just walking into the health room. You begin interacting with Aiden; you have him double his blood glucose. With a finger stick his reading is almost 500. You have him check his ketones, as per his school diabetic orders, which are trace. He continues to deny any symptoms other than a slight headache. You double check Aiden’s insulin pump and his pump and tubing is intact and patent and his basal insulin is running. Upon further assessment you find that Aiden has been estimating his carbohydrates for his dinner bolus every night based on “about whatever my lunchtime carbs were” stating that he “never really go the hang of counting carbs, because my grandma always did it for me”, and they were always calculated at school. Aiden further states that his mom is working most evenings and sometimes he forgets about his dinner dose completely. He states he is unsure if he took any insulin last night. When you ask about his alarms on his CGM, he states that he silences them often because they are annoying. After speaking with Aiden for a bit his blood glucose is trending downward and he is drinking clear liquids and continues to be asymptomatic. You have him go eat breakfast and tell him you would like him to come back to the office after breakfast so you can talk further. He agrees. When you call his mom, she states that things have been very stressful since her mom passed away and bereavement leave was only a few days and states they do not have any additional family here. She also notes that Aiden and his grandma were really close, but he doesn’t share his feelings. She states that Aiden is forgetful and that “he doesn’t like math, but should be able to calculate his own carbohydrates!” She further said “the doctor just talked to him about this!” When you call his endocrinologist, she shares that Aiden’s hemoglobin A1c was checked last month and was 12. She is concerned about the family and discusses further support. Instructions Use the information in the case study to address the following questions. Be sure to include your reference information. Questions Question Answer Reference 1. What further assessment questions might you ask Aiden when he returns? 2. What patient problems are immediately identifiable in this situation? 3. How would you prioritize addressing these problems and why? 4. How might these problems impact long term health outcomes? 5. What does Aiden’s dose of methylphenidate suggest about his ADHD? 6. What potential social determinants of health or environmental factors are identifiable in this case study? 7. Given Aiden’s environment, diagnoses and biological age, what are some possible contributors to his deviation from his care? 8. What are some evidence based tools that can be used to support Aiden in improving self-efficacy? 9. What are some family centered interventions that can be employed? 10. What are some potential patient centered education topics to address with Aiden? 11. Who are important individuals to coordinate with on care planning for Aiden? 12. What immediate interventions can you implement to assist Aiden with glycemic control? 13. What is at least one other intervention you can provide to Aiden for health promotion and maintenance? 14. What are two ways you can measure outcomes for Aiden?

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