Conflict with the nurse, help

Hi

I am new to the pump. I just recently got it for a month.
The nurse set a new carb ratio and basal rate for me, but it is really not enough and bg goes really high, around 13-17 everyday.

I adjust my carb ratio and told the nurse about the change. the bg was beautiful that week, average of 5.7. I emailed the nurse about the result later that week. However, my nurse warn me to let her make the change and let me to change the ratio back to the way to set it.

Have you had any conflict with the nurse? How did you deal with it

Thank you

At first I let mt Endo make the calls. They always err on the side of caution. About 4 to 5 months into it I was making my own adjustments and emailing them to him. I am in my 32nd month of pumping.

Most docs and nurses are comfortable letting T1’s tweak their own doses.

Heck, they taught me how to tweak doses when I was a kid diagnosed 30 years ago.

But other docs/nurses simply are not willing to give up micromanagement, and believe they have to be the one making any dosage changes. Personally I think that went out of style 30 or 40 years ago but obviously it still is living on today. Heck, there is a huge chunk out there that still think that “sliding scale” is the best thing since sliced bread. Don’t get me started on sliding scale!

Read your page where I coment back to you. I’ve never had that problem. I’m sorry you do.

It’s your disease and you should be the one making the changes since you actually live with your diabetes :slight_smile:
It is good to consult with your nurse and Endo and discuss any major changes you’re going to make, but things like changing your carb ratio or adjusting basal rates… these are minor things that you are capable of doing because you know the best what suits you based on your everyday readings and doses.
You should let the nurse know you are an adult person :slight_smile: she would not want you to call her every time you bolus to get her approval, right? :slight_smile:

My way of approaching things is to have a conversation about it with the nurses. My 4 yr old son will be going on the pump Aug 24/2010 and the nurses have forewarned me that they have a procedure to follow and they want to err on the side of caution in the beginning and they hope I can let them take the lead until they calculate the best basal, etc rate for him. I suspect that I will be frustrated but they were proactive in telling me how things will work so I will give them time to do their thing knowing full well that I can do my own thing later AND I keep a good relationship going which is very important.

That being said… I gave the hospital 3 months of their way upon initial diagnoses a year ago, threw it all out and did my own thing anyway. Can’t say my way is working perfectly but their way wasn’t working at all, at least not to the level I would like. Now that I am moving Payton to the pump, I am going to try to have an attitude that this is a mini vacation from deciding how much insulin to give him and see what I can learn from it. I hope I can keep my frustration down to a minimum.

I used to always make my own changes, but switched to a good doctor who prefers that we make changes together. So now I try to consult with her on all changes. The reason is that I would be ready to make changes with too little data. She prefers to be sure that we see a pattern before we make changes. I think that it has often worked out that she was right. So now I tend to wait, but I find it really tempting to make changes on my own.

It sounds like you made a good decision. Are you able to call her or send her your numbers when you want to make a change? This might be a reasonable compromise.

Diabetes is the only major chronic disease where the patient is responsible for the vast majority of the daily medical decisions. This is in total opposition to all the rest of medical practice where doctors make all the decisions and the patients are expected to just follow the doctors decision.

This can be very difficult for some practitioners who are loath to turn over this stuff to the patient. You will always have to deal with making your medical team feeling slightly uncomfortable with your ability to make these decisions and some of them may well be quite conservative. You need to demonstrate a competence to make these decisions. One way that you can do this is to slowly showing your knowledge of what changes are to be made while keeping your nurse in the loop to monitor your progress. Defer to her desire to make the changes or approve things, but seek gradual independence. You will be in the decision loop anyway. No nurse is going to follow you around to count you carbs for you.

Just look on this as a transition process.

I would agree with Kristin. Fine tuning your basal and carb ratios is a team effort. Like yourself, I also recently started on an insulin pump. I thought that changing the “carb ratio” would be the right thing to do. But after disscussing and consideration from my CDE it was my Basal rated that needed adjustment.

As months pass I have made only minor changes. I had to determine if there was a change in my daily activity, therefore effecting my basal. Or was it a pattern or change in my eating habits. I wish you the best of luck.

Medical professionals are more concerned with the immediate danger of lows than with the long-term effects of highs. Liability.

I’m on MDI & change my basal/bolus doses/ratios constantly. You clearly had success changing your ratio. Someone shouldn’t be arguing with success & insist you go back to readings of 13-17.

Changes should be made conservatively, but I wouldn’t let my BG hover that high while waiting for permission.

Have you read Pumping Insulin by John Walsh?

The most important person responsible for my health on my team is me. I don’t feel like I have a team anyway. I see several doctors like most diabetics, but it’s not like they’re consulting with each other on a master plan. Honestly, I’ve never understood the whole team thing.

Amy,
The nurse is fearful that you do not have the background for changing. From her standpoint, she simply needs to see that you’re handling changes well. Remember, she hopefully knows that most patients do not need as much insulin on the pump. She is afraid that you will go hypoglycemic… She knows that the change to less insulin goes on for a couple months. she also knows that gradual settling of the BG is to be preferred over rapid descent.
Show her that your changes result in great BG, not too low BG, and over time you will convince her that your changes are just fine!
I know I sound optimistic about the nurse.
My optimism is due to the fact that I think nurses are too busy to bother unless there’s reason to be cautious. So she’s thinking ‘CAUTION’.
So I haven’t told you how I deal with conflicts with nurses. Happily, the Endo has gone to bat by ensuring I never come in contact with them.
I overwhelm them with data and they don’t want to deal with me anymore.
But in your situation, new with the pump, take care to keep the nurse on your side. Do not get too low and have a need for her.

I know endo’s office and CDE do adjust in the beginning. But if high, they should adjust the dose so you get more insulin.

The nurse is being cautious and trying to avoid lows IMHO. I don’t think she’s being a control freak.

I haven’t had this experience, but why let that stop me from giving advice?

You did a wise thing to keep her informed of what you did and showing her the results. If changing back to the original settings results in more highs, I think you should go ahead and adjust it yourself. Keep the nurse informed of what you’ve done, and why, and show her the results.

You want to try to bring her on board as a member of the team and assume control without creating a conflict.

Make only minor adjustments and show her they’ve been successful. Emphasize that you’re avoiding lows, assuming that’s true. Next adjustment, tell her BEFOREHAND so you can try to get her to buy into the change. Remind her that the last adjustment was successful, acknowledge that you know she’s looking out for you, promise to keep her updated. If she won’t go for what you suggest, try a compromise number until she buys into it. Repeat as necessary.

Good luck,

Terry

The bottom line is that the nurse is part of YOUR diabetes management team; you’re the team manager and get to decide upon the roles of the other participants in your team. I hope you reach an understanding with this nurse; otherwise she can be replaced.

But im using the minimed pump, and it has a carelink which is a device that i use to upload my data to the computer, so the nurse can see everything, including the carb ratio and basal rate

how does eating habit affect the carb ratio? the nurse told me the carb ratio should not be changed because it will always stay the same, the only thing to change is the basal rate.
How do you know when you should change basal or carb ratio

Big Sister is watching!

Thanks everyone
I have another question, this is a bit unrelated to this topic
if you guys have high bg for about 3 days, do you change the basal rate or carb ratio?
do you guys think frequently changing the basal rate or carb ratio is a bad thing to do?

I do when there’s a pattern of highs or lows that can’t be attributed to anything else like unusual stress, illness, hormones, different exercise, etc. I make small changes & keep it at that rate for 3-4 days.

Did you adjust doses yourself before the pump?

I change the basal rate after doing a basal rate test & seeing that the basal rate is high without food and boluses. That doesn’t mean I do the entire 3 days of testing basals. I look at my BG when I haven’t eaten for 4 hours around the clock and shortcut, since I’m already in good control.
I think changing basals frequently can impede knowledge of actual need of cells of the body over the 24 hrs.
If my basal rate is too high, and I have evidence to show it, my next dose of basal will be changed. Then I stay there for 3 days. I need to know I can depend on my basal rate since the bolus needs to get me back to my target zone after carbs.
Perhaps target zone is best put at 110, 6.1-6.2, for awhile? Not too low.
About changing the carb ratio, you may find that, after basal rate is established, your carb ratio can be fine tuned according to the time of day. Remember carb ratio may change over the 12 hour eating day.
The need for insulin goes down gradually over a two month period after switching to the pump. I think everyone needs Pumping Insulin and Think Like a Pancreas! Me, too!