ONLINE TRAINING FOR Diabetes Management in School

This training will cover the following Diabetic Care Tasks: Signs and Symptoms of Hypo and Hyper

glycemia Blood Glucose Testing Glucagon Injections Ketone Monitoring Documentation Please read through each section. There is a post-test at the end. Print the test and answer the questions. Contact your school nurse for an appointment to go over the test and perform return demonstrations on glucose testing and glucagon administration.

When a new diabetic student comes to your site . . . Contact your School Nurse if she is not

already aware of it. Your School Nurse will . . .

have specific paperwork that must be completed before Diabetic Care Procedures can be available for the new student.

develop an Individualized Health Care Plan for the student.

Diabetes Management at Diabetes Management at SchoolSchool

Much of the information in this training was taken from: Diabetic Care Tasks at School: What Key Personnel

Need to know. Powerpoint presentation from The American Diabetic Association.

Mary Zombec, RN, MS, CPNP. P.E.D.S., Pediatric Education for Diabetes in Schools. Copyright June 2001 PADRE Foundation in Partnership with the California State Dept. of Education.

Diabetes is a Complex Disease and . . .

occurs when special cells in the pancreas produce inadequate or no insulin.

is influenced by diet, exercise, general health, emotions and other factors.

often managed by oral or injectable medications, depending on the type and severity of the diabetes.

can be one of two types.

Type 1 and Type 2 DiabetesType 1*

Develops when person’s own immune system destroys pancreatic cells that make insulin.

Usually occurs in childhood or young adulthood.

Medical help sought because people are seriously ill from sudden symptoms of high blood sugar.

Usually treated with insulin replacement.

Episodes of low blood sugar are common

Cannot be prevented.

*Cited from US Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. Atlanta: US Dept. of Health and Human Services

Type 2* Develops when cells do not

properly use insulin. Body does not make an

adequate amount of insulin. May not have symptoms before

diagnosis. Usually discovered in

adulthood, but is being found in increasing number of children.

Associated with obesity and inactive lifestyle.

Can be prevented or delayed with healthy lifestyle – diet, weight control & exercise.

Goal of Diabetic Management

To keep blood glucose levels within an individual’s TARGET RANGE.

This range is determined by the physician, based on each individual’s condition and lab results.

Any glucose levels outside this range indicate the need for treatment.

HYPOHYPOglycemiaglycemia

Learning ObjectivesParticipants will learn:

Symptoms of low blood glucose

Short and long term risks Treatment of low blood

glucose Prevention of low blood

glucose

VocabularyGlucose

HYPOglycemia

Quick-acting glucose Glucose tablets or gel

Glucagon

Carbohydratesource of energy for the body.

a simple sugar found in the blood. the fuel that all body cells need to function.

a LOW level of glucose in the blood.

foods containing simple sugar that raise blood glucose levels.

special products that deliver a pre-measured amount of pure glucose.

they are a fast-acting form of glucose used to counteract hypoglycemia.

a hormone given by injection that raises the level of glucose in the blood.

HYPOglycemia = LOW sugarOnset: Sudden.

May be caused by too little food, too much insulin or extra physical exercise.

May quickly progress to unconsciousness if not treated.

Can result in brain damage or death if not treated.

Hypoglycemia:Possible Signs and Symptoms

Mild Symptoms Hunger Sleepiness Shakiness Changed Behavior Weakness Increased Heart

Rate/Palpitations Sweating Pale Color Anxiety Blurry Vision Dilated Pupils

Moderate Symptoms Yawning Irritability/Frustration Extreme tiredness/fatigue Confusion Restless Dazed Appearance Sudden Crying

Severe Symptoms Unable to Swallow Seizures Combative Unconsciousness

Hypoglycemia: Risks & Complications

Greatest immediate danger

Impairs cognitive and motor functioning

Early recognition and intervention can prevent an emergency

Not always preventable

Mild Hypoglycemia: What to doGoal: To raise blood glucose level Intervene promptly. If a meter is available, test blood glucose immediately

and 10-15 minutes after treatment. When in doubt, always treat! Treat by having student eat or drink 15 gm. fast acting

carbs. Repeat treatment if blood glucose level remains low or if

symptoms persist. If symptoms continue, call parents per plan. Never leave a student with suspected low blood glucose

unattended.

Quick Acting Glucose for HYPOglycemia

Treatment for Lows: One of the following choices provides 15 gm. of carbohydrates

4 oz. fruit juice 15 gm glucose tablets (2-3 tablets) 1 tube of glucose gel 4-6 small hard candies 1-2 tablespoons of honey 6 oz. regular (not diet) soda (about half a can)

Severe Hypoglycemia: What to doRare, but life threatening, if not treated

promptly: Inject Glucagon, if ordered by M.D. and you have

been trained by your School Nurse. Call 911, then parent/guardian. If Glucagon is not ordered, call 911 immediately. Never attempt to give food or put anything in the

student’s mouth if they are unconscious or having a seizure.

Remain with the student until help arrives.

A Note About Glucose Gel

It is the only fast-acting oral carbohydrate source you might use for an unconscious person if Glucagon is not available or no one is trained to give the injection.

It can only be done if it is ordered by the doctor on the Physician’s Authorization form under “Emergency Care of Severe hypoglycemia.”

Procedure for Using Glucose Gel

What to do: Perform procedure with extreme caution/use gloves. Turn the unconscious person on their side. Place the tip of the tube in the cheek that is down. Squirt the gel between the cheek & teeth. Massage outside of cheek to help glucose penetrate into

the gums. Allow the saliva/gel to drain out on a towel. To avoid aspiration, keep person on their side until they

regain consciousness.

Prevention of Hypoglycemia

Follow individualized diabetic management plan regarding eating, glucose testing, insulin coverage and exercise.

ALWAYS keep a quick acting sugar source on hand. Treat at first sign of symptoms. Ensure that carbs in food match insulin dose. Watch for picky eaters. Consult with parent before class parties.

HYPERHYPERglycemiaglycemia

Participants will learn:

Symptoms of high blood glucose

Short and long term risks

Treatment of high blood glucose

Prevention of Hyperglycemia

Learning Objectives

VocabularyHyperglycemia: too high a level of glucose in the blood.

Ketones (ketone bodies) Acidic chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy.

Diabetic ketoacidosis (DKA) the build up of ketones in the body that can lead to serious illness and coma.

Ketone testing a procedure for measuring the level of ketones in the urine or blood.

HYPERglycemia = HIGH Sugar Onset: Severe hyperglycemia is usually

slow to develop Too much glucose in the blood Too little insulin to transfer glucose into

cells

If left untreated, may lead to diabetic ketoacidosis, a serious illness.

Hyperglycemia:Possible Signs and Symptoms

Mild Symptoms Thirst Frequent Urination Flushed Skin Lack of Concentration Fatigue/Sleepiness Blurred Vision Increased Hunger

Moderate Symptoms Dry Mouth Stomach Cramps Vomiting Nausea, Stomach Pain Weakness Dry, warm skin Weight Loss Sweet, Fruity Breath

Severe Symptoms Labored Breathing Very Weak Confused Unconsciousness

HYPERglycemia: Risks & Complications

Interferes with a student’s ability to learn and participate, they chronically feel lousy.

Hyperglycemia due to inadequate insulin can lead to coma or death .

Serious long term complications develop when glucose levels remain above target range over time or are recurring. (Blindness, lost limbs, stroke, heart attack, shorter life span.)

Too little insulin Expired insulin Too many carbs for insulin dose Decreased physical activity Illness, infection, injury Stress Other hormones Menstrual periods

Hyperglycemia: Possible Causes

Hyperglycemia: What to doGoal: lower the blood glucose to target range.

• Check urine for ketones if ordered. • Depending on the amount of ketones, give 8 oz. of

water per instructions on Algorithms form.• Licensed nurse to administer insulin per established

care plan (student may self-administer if determined to be self-sufficient).

• Recheck blood glucose per care plan.

Prevention of Hyperglycemia

Avoid “over treating” low blood sugar reactions. Give only 15 gms. of quick acting glucose at a time.

Contact School Nurse or parent if a self-administered insulin dose is missed or pump malfunctions.

Consult with parents if meal or exercise times need to be changed.

Discourage binge eating

BLOOD GLUCOSE BLOOD GLUCOSE MONITORINGMONITORING

LEARNING OBJECTIVES

Participants will learn: Why blood glucose is monitored When blood glucose should be

monitored How to perform a blood glucose

check

What is blood glucose monitoring?

It is a procedure that is done to obtain a small amount of blood to test a person’s blood glucose level.

Blood Glucose Monitoring GOAL: Maintain blood

glucose within target range Immediate Benefit:

Maximize learning & participation in school

Prevent lows and highs

Long-Term Benefit: Decrease risk of long-term

complications Maximize health

Challenge: Many variables can impact blood-glucose levels

Role of the School Facilitate blood

glucose monitoring Know target blood

glucose results and how to act on them

Provide monitoring data to parent or guardian to give to the MD

When to CheckRegularly scheduled checks on individual basis:

Routine monitoring before meals and snacks

Before, during and/or after exercise

Extra checks may be necessary:

Periods of stress or illness

Hypoglycemia or hyperglycemia symptoms

Change in diabetes management

Any Time, Any Place Monitoring

Blood Glucose Testing may be done at any time or any place the student is having any symptoms of hypo or hyper gycemia and a Glucose Monitoring Kit is available.

Equipment and ProcedureEquipment and Procedure

Lancing Devices

Lancets

Pen-type Lancing Devices

Know the Meter250

53250

53

Features vary:– Ease of use– Sample size needed– Wait time– Alternate-site testing capacity– Ability to reapply, if insufficient sample

Become familiar with the operation of each student’s meter. Read the manual!

Preparation Gather blood glucose monitoring

supplies:

-Lancing Device and Lancet

-Meter

-Test strips

Wash hands (if student performs test, have them thoroughly wash and dry their hands).

If assisting or performing for student, put on disposable gloves and observe Universal Precautions.

Readying the Meter

Insert strip to activate meter.

Check code # on vial of strips.

Code # on meter should match.

Lancing the Finger

Hold the lancet device to the side of the finger and press the button to stick the finger.

Applying Blood to Strip

•Place tip of strip in drop of blood on finger.

•Blood is automatically sucked up into strip.

•Meter will indicate if amount of blood is sufficient.

Follow instructions included with the meter if different from instructions below.

2505

3

Results Wait until blood

glucose results are displayed.

Dispose of lancet.

Record blood glucose results on log & take action per plan.

What does the number mean?

Refers to the glucose level in the blood

May vary throughout day.

When compared to the Target Range, it is an indicator of which treatment, if any, is needed.

Guidelines for treatment are found on the Algorithms for Blood Glucose Results form. (next slide)

ALGORITHMS FOR BLOOD GLUCOSE RESULTS

Revised 8/13/07 JM (N Drive: Forms-Diabetes)

Student’s Name: __________________________ School: _________________________________ School Nurse: ____________________________ Nurse Contact Number: ____________________ Parent’s Phone Number: Home: _____________ Work: _____________ Cell: ________________

Check ketones (if ordered) 1. Give fast acting sugar source.* 2. Observe for 10 - 15 minutes. 3. Retest blood glucose, if less than 70

repeat sugar source.* 4. If over 70 give carbohydrate and

protein snack (ie. crackers and cheese) or if within one hour to next meal, feed early.

5. Notify school nurse if student has two or more episodes in one week.

If Student Becomes Unconscious, Seizures, or is Unable to Swallow: 1. Call 911. 2. Maintain open airway 3. Turn student on side to prevent

aspiration 4. Give Glucose Gel and/or Glucagon

per MD orders 5. Notify parents and school nurse

1. If student feels OK, may resume school activities.

2. If student does not feel OK, retest blood glucose.

3. If glucose < 70 then follow directions on the left.

If glucose > 300 & Ketone check is ordered, follow instructions on the right. If no orders, contact school nurse.

Student Does Not Feel OK - Ketones Mod.-

Large 1. Consult with

school nurse. Notify parents.

2. Provide 1-2 glasses of water every hour.

If at any time student vomits, becomes lethargic, and/or has labored breathing -CALL 911

Student Feels Ok – Ketones Neg. –Small

1. Give 1-2 glasses of water every hour.

2. Insulin/exercise per MD orders & IHCP

3. Notify parents if small ketones are present.

4. Notify School nurse if two or more episodes occur in one week.

Below: ___70__

Target Range From: 70 To: 300

Above: 300

STUDENT’S PHOTO

To Physician Please make desired modifications to the standard procedure above and insert number for personal algorithms for this child in the boxes provided. Please list any additional needs for special considerations for this child. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________Physician’s Signature __________________________________________

Check Blood Glucose

*FAST ACTING SUGAR SOURCES:

15 gm. Glucose Tabs (3 – 4 Tabs) 4 oz. Apple Juice 15 gm. Glucose Gel 4 oz. Grape Juice 1/3 c. Regular Soda (Not Diet) Tube of Cake Mate Gel 4 oz. Orange Juice 3 tsp. sugar in water

Documentation

Document the results on the Diabetes Monitoring Log.

After each entry on the Monitoring Log, place your initials in the appropriate box.

Whenever new Monitoring Log is started, remember to sign/initial in one of the designated areas on bottom of sheet. (Sample documentation following).

Vista Unified School District Vista, CA 92084

DIABETES MONITORING LOG

Student’s Name: Johnnie Jones Birthdate: 1/22/99 Teacher: Grade:

Doctor: Phone: Parent: Phone: School Nurse: Cell:

Date Time Blood Glucose Level

Time/Re-check of Glucose

Level

Ketones Insulin Dose

Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action taken, document the response of the student, and document any phone calls made).

Initials

5/20/09 11:30 110 Within target range. Ate 45 carbs for lunch TT 5/21/09 11:30 55 Gave 4 oz. apple juice. 11:45 Rechecked glucose level TT 11:45 70 Up to target range – ate 47 carbs for lunch TT

Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials

Terry Tech TT

What does the display mean?

Check manual Contact manufacturer by phone or website

Practical Implications for EducatorsPractical Implications for Educators Students with hyperglycemia or hypoglycemia often

do not concentrate well.

During academic testing: Check blood glucose before and during testing Allow access to food/drink and restroom. If a serious high or low blood glucose episode occurs,

students should be excused with an opportunity for retaking tests.

Eliminate barriers and provide adequate time for taking medication, checking blood glucose, and eating.

GlucagonGlucagon

AdministrationAdministration

Learning ObjectivesParticipants will learn: What glucagon is How glucagon should be stored When glucagon is used How to administer glucagon

What is Glucagon? Naturally occurring hormone made in the

pancreas.

A life-saving, injectable hormone that raises blood glucose level .

Treatment for severe hypoglycemia.

Can save a life.

Cannot harm a student.

Comparison of Insulin and Glucagon

Insulin Hormone normally secreted by

the pancreas. Essential for the metabolism of

blood glucose. In certain diabetics, it is an

injectable med given daily at specified times & doses to lower blood glucose levels.

Doses are determined and regulated by patient’s doctor according to each individual.

Given only by licensed health care providers.

Glucagon Hormone normally secreted by

the pancreas. Functions to raise blood

glucose levels when needed. Used as an emergency

injectable med for diabetics to raise extremely low blood glucose levels.

May be given in an emergency by non-licensed persons trained by a licensed RN or physician.

Glucagon Kit Storage

Store at room temperature Expiration date: Monitor After mixing, dispose of any unused portion.

1 mg of freeze-dried glucagon (Vial) 1 ml of water for reconstitution (Syringe)

Emergency Kit Contents:

Combine immediately before use

When to Give Glucagon

If authorized by the student’s Health Care Plan and if student exhibits:

Unconsciousness, unresponsiveness

Convulsions or seizures

Inability to safely eat or drink

Procedure: Act Immediately Position student safely on side for comfort

and protection from injury

Call 911, parents, school nurse

Preparation

Flip cap off glass vial containing dry powder

Remove cap from syringe

Mixing Solution

Inject entire fluid in syringe into the bottle containing powder

Shake gently or roll to mix until all powder is dissolved and solution is clear.

Drawing out

Inspect. Solution should be clear and colorless.

Draw prescribed amount of glucagon back into syringe. Check the doctor’s orders.

Dosing and Injecting

Clean site if possible Inject needle at 90° angle into the muscle of one of the

following sites:• Largest part of thigh is preferred site• Middle of deltoid muscle in upper arm

Very slightly pull back on plunger to check for blood. If no blood, inject solution Remove needle and massage site w/ cotton ball Dispose of needle in puncture-proof container.

After Injecting Turn student on side as he/she may vomit –

prepare for this to happen.

May take 15 – 20 minutes for student to regain consciousness.

Check blood sugar level.

Give sips of fruit juice or regular soda – only if student is awake and able to drink.

Document under “comments” on the Diabetes Monitoring Log.

Vista Unified School District Vista, CA 92084

DIABETES MONITORING LOG

Student’s Name: Johnnie Jones Birthdate: Teacher: Grade:

Doctor: Phone: Parent: Phone: School Nurse: Cell:

Date Time Blood

Glucose Level

Time/Re-check of Glucose

Level

Ketones Insulin Dose

Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action taken, document the response of the student, and document any phone calls made).

Initials

4/30/09 10:30 30 Johnnie was carried in by custodian – collapsed outside classroom. Unconscious. 911/parents called.. Administered Glucagon 1 mg IM in right Thigh. As he was turned on his side, vomited small amount. As paramedics arrived, Johnnie started to revive. Parents arrived – Johnnie transported to Tri- City Hospital FA

Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials

Fantastic Annie FA

Don't be surprised if. . . Student does not remember being

unconscious, is incoherent or has a headache

Blood sugar becomes very high (over 200)

Nausea or vomiting occurs

Ketone MonitoringKetone Monitoring

Learning ObjectivesParticipants will learn: What ketones are Why ketones are monitored When ketones should be

monitored How to perform a ketone test

Why test for ketones? Ketones(acids) are produced when the body burns fat for

energy. Ketones can build up and result in diabetic ketoacidosis (DKA)

What is DKA? Acids that build up in body and cause student to feel ill Emergency state, can lead to coma, death Common symptoms include fruity odor to breath, nausea,

vomiting, drowsiness Number one reason for hospitalizing children with diabetes Testing for ketones results in early detection and treatment of

DKA and prevents hospitalizations

When to test for ketones?

Ketones are usually checked when the blood sugar is high – how high is determined on an individual basis.

Check the doctor’s orders to determine if ketones are to be checked and at what glucose level.

Follow the instructions on the Algorithms for Blood Glucose Results Form.

ALGORITHMS FOR BLOOD GLUCOSE RESULTS

Revised 8/13/07 JM (N Drive: Forms-Diabetes)

Student’s Name: __________________________ School: _________________________________ School Nurse: ____________________________ Nurse Contact Number: ____________________ Parent’s Phone Number: Home: _____________ Work: _____________ Cell: ________________

Check ketones (if ordered) 1. Give fast acting sugar source.* 2. Observe for 10 - 15 minutes. 3. Retest blood glucose, if less than

______ repeat sugar source.* 4. If over ______, give carbohydrate

and protein snack (ie. crackers and cheese) or if within one hour to next meal, feed early.

5. Notify school nurse if student has two or more episodes in one week.

If Student Becomes Unconscious, Seizures, or is Unable to Swallow: 1. Call 911. 2. Maintain open airway 3. Turn student on side to prevent

aspiration 4. Give Glucose Gel and/or Glucagon

per MD orders 5. Notify parents and school nurse

1. If student feels OK, may resume school activities.

2. If student does not feel OK, retest blood glucose.

3. If glucose < ______, then follow directions on the left.

If glucose > ______ & Ketone check is ordered, follow instructions on the right. If no orders, contact school nurse.

Student Does Not Feel OK - Ketones Mod.-

Large 1. Consult with

school nurse. Notify parents.

2. Provide 1-2 glasses of water every hour.

If at any time student vomits, becomes lethargic, and/or has labored breathing -CALL 911

Student Feels Ok – Ketones Neg. –Small

1. Give 1-2 glasses of water every hour.

2. Insulin/exercise per MD orders & IHCP

3. Notify parents if small ketones are present.

4. Notify School nurse if two or more episodes occur in one week.

Below: _____

From: ________ To: _________ Above: ________

STUDENT’S PHOTO

To Physician Please make desired modifications to the standard procedure above and insert number for personal algorithms for this child in the boxes provided. Please list any additional needs for special considerations for this child. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________Physician’s Signature __________________________________________

Check Blood Glucose

*FAST ACTING SUGAR SOURCES:

15 gm. Glucose Tabs (3 – 4 Tabs) 4 oz. Apple Juice 15 gm. Glucose Gel 4 oz. Grape Juice 1/3 c. Regular Soda (Not Diet) Tube of Cake Mate Gel 4 oz. Orange Juice 3 tsp. sugar in water

How to test urine for ketones Gather supplies Student urinates in clean cup Put on gloves, if performed by

someone other than student Quickly dip the ketone test strip in

the cup containing urine Wait 15 - 60 seconds Read results at designated time Record results, take action per

Health Care Plan

Test Results: Color code

no ketones trace small moderate large ketones present

Documentation

Record your findings on the Diabetes Monitoring Log under the column “Ketones.”

Under “comments” record what actions you took.

Your actions should correspond to the instructions on the Algorithms for Blood Glucose Results form.

Vista Unified School District Vista, CA 92084

DIABETES MONITORING LOG

Student’s Name: Johnnie Jones Birthdate: Teacher: Grade: 4th

Doctor: Phone: Parent: Phone: School Nurse: Cell:

Date Time Blood

Glucose Level

Time/Re-check of Glucose

Level

Ketones Insulin Dose

Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action taken, document the response of the student, and document any phone calls made).

Initials

5/6/09 11:30 350 Trace 3u Novalin Assisted Johnnie in testing urine for ketones, gave him 8 oz. water per care plan & verified insulin dosage per sliding scale before he self- administered insulin in right upper arm. AG

Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials

Alice Good AG