care of the child with diabetes at school •compare type 1 vs. type 2 diabetes - differences in...
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Care of the child with diabetes at school
MaryKathleen Heneghan MD
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Objectives • Compare Type 1 vs. Type 2 diabetes -
differences in management
• Discuss nutrition considerations
• Review administration and dosing of insulin
• Discuss monitoring of blood glucose and
treatment of hypoglycemia/hyperglycemia
• Describe sick day management
• Answer questions and facilitate discussion of
diabetes cares in a school setting
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Signs & Symptoms of diabetes
• Increased thirst
• Increased urination
• “accidents” – daytime or nighttime
• Weight loss
• Abdominal pain
• Nausea / emesis
• Headaches
• Blurry vision
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Diagnosis of diabetes
• Fasting blood glucose 126 mg/dL
• HgbA1c 6.5%
• Symptoms of hyperglycemia and plasma
glucose 200mg/dL
• OGTT: plasma glucose 200mg/dL 2 hours
after glucose load
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T1DM vs T2DM • Type 1 diabetes mellitus
– Autoimmune in nature
– Requires insulin administration from time of
diagnosis
• Type 2 diabetes mellitus
– Typically related to obesity
– May be treated with diet, oral medications or
insulin therapy
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A typical day for a child with diabetes
- Wake up
- How do I feel? – do I need to check my BG
- Get ready for school
- Time for breakfast - What am I going to eat?
- How many carbs is it?
- Will I eat it all?
- What is my blood sugar?
- How much insulin do I need?
- Where am I giving my shot today?
- Got my shot
- Time to eat
- Repeat at morning snack, lunch, before gym class,
afterschool snack, dinner and bedtime
- Is it bedtime yet??? I am exhausted
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Type 1 diabetes mellitus • A lot of a child’s diabetes cares will take place
at school
• Illinois has in place the Care of Students with
Diabetes Act
– Provides requirements school must meet in
regards to care of diabetes
– Difficult for many schools to have required
training and personnel available
• A partnership between nurse, students,
parents and medical home
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Diabetes Care Plan • Also known as a diabetes medical
management plan (DMMP)
• Provides direction for diabetes cares at
school
• Per Diabetes Care Act a DMMP is required: – “upon enrollment, as soon as practical following a student's
diagnosis; or when a student's care needs change during the
school year. Parents shall be responsible for informing the
school in a timely manner of any changes to the diabetes care
plan and their emergency contact numbers.”
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Diabetes Care Plan • Also known as a diabetes medical
management plan (DMMP)
• Provides direction for diabetes cares at
school
• Per Diabetes Care Act a DMMP is required: – “upon enrollment, as soon as practical following a student's
diagnosis; or when a student's care needs change during the
school year. Parents shall be responsible for informing the
school in a timely manner of any changes to the diabetes care
plan and their emergency contact numbers.”
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Diabetes Care Plan • Provides information on:
– Monitoring of blood glucose
– Dosing of insulin
• Authorization for insulin use
– Treatment of hypoglycemia
• Authorization for glucagon use
– Treatment of hyperglycemia
– Use of insulin pump
– Physical activity and sports
– Nutrition
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Nutrition Considerations
• Type 1 diabetes – Focus is on healthy diet
– Carbohydrate counting is required
– Few limitations to patient’s diet although ALL carbs consumed need to be counted and dosed for
– Goal is healthy lifestyle
• Type 2 diabetes – Focus is on healthy diet
– Carbohydrate counting MAY be required
– Limitations should be present
• No sugar sweetened beverages
• Avoid high fat / high carb foods
– Typical goal is weight loss and healthy lifestyle
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Nutrition Considerations • Determining amount of carbohydrates
– Most families are taught to count carbohydrates in grams (few families are still using diabetic exchanges)
– Request carb counts on lunches and food items from parents • Encourage parents to include a list in school lunch of grams of carbs in
each item so if a child does not want something it can easily be subtracted out
– Contact food vendors for hot lunches to provide carb counts for “hot lunches”
• Resources: – Calorie King (also available as an app)
– Allrecipes.com (recipes can be entered)
– The Daily Plate (foods by brand can be entered)
– Go Meals
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Nutrition Considerations
• Food Label
– Serving size • Measurement vs weight
– Servings per container
– Total Carbohydrates • Dietary fiber
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Treatment Regimens • Basal – Bolus
– Uses multiple daily injections (MDI) or continuous
subcutaneous insulin infusion (CSII)
• Must be able to count carbs, monitor BG levels and
perform the necessary calculations
– Attempts to replicate normal insulin secretion
through use of long acting insulin and rapid acting
insulin
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Treatment Regimens
Diabetes Education Online Diabetes Teaching Center at the University of California, San Francisco
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Treatment Regimens • Conventional Regimens (70/30 and fast acting)
– administration of an intermediate-acting
insulin twice a day with a rapid-acting insulin
two or three times a day
– regimen is fixed so the patient and family
must adjust their lifestyles so that meals (time
and quantity) and vigorous physical activity
occur on a relatively fixed daily schedule
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Insulin Delivery: Syringe
http://www.diabeticlivingonline.com How to Inject Insulin By Terri Peiffer, RN, BSN, CDE
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Insulin Delivery: Pens
• More accurate
dosing
– Dose is dialed in
• Convenient
• Small needle size
• Requires priming
• Administration
slightly different from
syringe
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Insulin Delivery: Pens
http://www.diabeticlivingonline.com How to Use an Insulin Pen
By Terri Peiffer, RN, BSN, CDE
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Continuous Subcutaneous Insulin Infusion
• Insulin pumps or pods – Provides a continuous dose of
fast acting insulin
– A basal dose is preset into device
and is constantly providing insulin
– A bolus dose is entered into
device and given at each meal
(calculations done by device)
– MUST be able to change out
device at school if failure occurs
– MUST have extra supplies
available
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Dose calculations
• Parents are responsible to make school team
aware of current doses
• Dose of insulin at a meal consists of:
– Carbohydrate dose
– correction dose
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Dose Calculations
• Example:
– 1 unit per 8 grams of carbs (carb ratio)
– correction of 1:40 over target (target of 120)
• If a student is eating 84 grams at lunch their food dose is
10.5 units (84 grams of carb / 8)
• If their BG is 215 the correction dose is 2.375 units (
215-120 / 40)
• The total dose the student is to receive is 12.875 which
rounds to 13 units
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Dose calculations • Some students may have a dose chart or
dose grid for dosing food, correction of a
combination of both
Number of Carbs (grams)
Blood Sugar 0-11 g 12-19 g 20-25 g 26-34 g 35-40 g 41-49 g 50-55 g 56-64 g 65-70 g 71-79 g 80-85 g 86-94 g 95-100 g 101-109 g 110-115 g 116-124 g
from up to 0 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8
80 120 0 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8 9 10 11 12 13 14 15
120 160 1 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9 10 11 12 13 14 15 16
160 200 2 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10 11 12 13 14 15 16 17
200 240 3 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11 12 13 14 15 16 17 18
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Blood glucose monitoring • When to be done
– Before meals or snacks
– Before activitity (per parents)
– Before leaving for the day (per parents)
– When a student feels symptomatic
– When a teacher notices a difference in student
• Should be performed on finger-tip
• Record on log and communicated to parent
as discussed in DMMP
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Continuous glucose monitoring • Student wears a
glucose sensor under
skin
– Typically on stomach
or hips
• A receiver displays a
blood glucose value
every few minutes
– Will demonstrate trends
– Alarms with low or high
blood sugar
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Hypoglycemia • Blood glucose value <80
• Symptoms of hypoglycemia
NEED to be confirmed with a
check of glucose and only
treated if truly a low blood
sugar
• Causes include: •Not finishing meal
•Over-assessment of insulin
•Change in schedule
•Change in activity
• illness
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Treatment of hypoglycemia
• Treat with 15 grams of fast acting sugar
(glucose tabs, 4oz juice, fruit snacks etc..)
• Recheck in 15 minutes
• If still low repeat with another 15 grams
• After treatment work to discover the cause
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Severe hypoglycemia
• NOT a defined blood glucose
• Low blood glucose at which patient can not
safely eat or drink to raise blood glucose
• GLUCAGON must be used
• THIS IS A MEDICAL EMERGENCY AND
RESPONSE CAN NOT BE ONLY CALLING
911
• All staff to be trained on use of Glucagon
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Glucagon • Hormone produced by pancreas
which acts opposite insulin
• Given IM
• Raises blood glucose quickly but
only a temporary fix
• Can cause nausea and emesis
• If administered EMS is typically
called as student may require
additional source of sugar
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Hyperglycemia • Blood glucose value >300
• Can vary by patient
• Causes include:
• Skipped doses
• Eating food without
dosing
• Miscalculation of
carbohydrates
• Miscalculation of
insulin dose
• Illness
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Treatment of hyperglycemia
• Contact parents (per plan)
• Check ketones
• Push fluids (water and non-sugar sweetened)
• Correction dose per parents
– Should be at least 2 hours since last correction
dose of insulin
• Does not always mean the student needs to
go home
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Ketones
• Trace / Small – Push fluids
• Moderate / Large – Push fluids and need
extra insulin
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Sick Day Management at School • What to do if a student with diabetes becomes ill
at school?
– Worrisome signs include abdominal pain, emesis or
change in respirations (fruity odor to breath)
– Contact parents for instructions
– Check ketones
• Ketones represent a deficiency of insulin
• Bodies ways to provide energy (using fat) when
carbohydrates can not be used
• If trace or small push fluids
• If moderate or large needs fluids and additional insulin
– Fluids need to be water or non-sugar containing
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Thank you Now on to the discussion…