GUIDELINES FOR CARE OF STUDENTS WITH DIABETES
Washington State Task Force for Students with Diabetes
GUIDELINES FOR CARE OF STUDENTS WITH DIABETES Washington State Task Force for Students with Diabetes DISCLAIMER In 1998, the Office of Superintendent of Public Instruction OSPI and the American Diabetes Association ADA joined together in trying to create the Washington State Task Force for Students with Diabetes WSTFSD They recruited a number of persons from a variety of areas including physicians, diabetes educators, nurses at schools, hospitals and medical offices, dietitians, representatives from the Washington State Attorney Generals Office and the Office for Civil Rights, a parent, psychologist and school administrator This document represents the outcomes of many meetings in which the suggested guidelines have been negotiated and does not represent the specific opinion of any individual or any institution in which they have been either previously employed or are employed at the present time Information in these Guidelines is provided as a courtesy by the WSTFSD The Guidelines as posted on the OSPI website are provided as a courtesy by facilities that were part of the WSTFSD,
specifically Childrens Hospital and Regional Medical Center Childrens, Mary Bridge Childrens Hospital and Health Center MBCHC, Woodinville Pediatrics and their related organizations The Guidelines are posted on the OSPI website with the understanding that WSTFSD, Childrens, and MBCHC, and Woodinville Pediatrics are not rendering medical advice or other professional services for the readers The Guidelines are not intended to replace clinical judgment or individualized consultation with medical care providers Persons accessing this information assume full responsibility for its use and understand and agree that the WSTFSD, Childrens, MBCHC and Woodinville Pediatrics are not responsible or liable for any claims, loss or damage arising from use of the information References to specific products, processes, resources, websites, or services do not constitute or imply recommendations or endorsement by the WSTFSD, Childrens, MBCHC or Woodinville Pediatrics The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of
human error or changes in medical sciences, neither the WSTFSD, nor Childrens, MBCHC or Woodinville Pediatrics nor any party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information Readers are encouraged to confirm the information contained herein with other sources and to seek the care of a healthcare professional if medical care or advice is needed
TABLE OF CONTENTS
List of Appendices3 Acknowledgements4 Introduction5 Developing an Individual Health Plan/Section 504 Plan: THE TEAM APPROACH6 Overview of Diabetes7 Insulin8 Blood Sugar Testing10 Diabetes Supplies11 Low Blood Sugar Hypoglycemia12 High Blood Sugar Hyperglycemia13 Diabetes Nutrition and Meal Planning: The Basics14 Exercise/Sports17 Personnel Guidelines for Care of Students With Diabetes in the School Setting18 Suggested Accommodations for the Student With Diabetes23 Questions and Concerns Raised by Parents24 Living With Diabetes28 Bibliography30
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APPENDICES
A Diabetes Checklist for School Nurses 31
B Individual Health Plan/Section 504 Plan 34 C Sample Health Care Provider HCP Order Form for Students With Diabetes40 D Low Blood Sugar School Plan 43 E High Blood Sugar School Plan 45 F Individual Health Plan/Section 504 Plan: completed example 47 G Bloodborne Pathogens Standard and Students With Diabetes 54 H Meal Service for Students With Diabetes 56 I J Washington State Nursing Care Quality Assurance Commission Advisory Opinions 58 Parent-Designated Adult Care Provider 67
K Authorization for Exchange of Medical Information 69 L Nutrition Guidelines for School Snacks72 M Nutrition Guidelines for School Parties and/or Unplanned Eating 74 N Disaster Preparedness/Three Day Emergency Readiness 76 O Special Education/If Parents and Staff Dont Agree 82 P Parent/Student Rights in Identification, Evaluation, and Placement 85 Section 504 of the Rehabilitation Act of 1973 Q Resources: Products 88 R Resources: Questions about Diabetes? 91
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ACKNOWLEDGEMENTS
This guide provides an overview of diabetes and its management as well as information for providing optimal care in the school setting While it is recognized that each child has specific needs, the use of consistent guidelines
promotes compliance, efficient use of resources, and a comprehensive school care plan The Washington State Task Force for Students With Diabetes developed this guide during a series of collaborative meetings This task force involved professionals from a variety of facilities and agencies, both local and state Editing for this guide was provided by Teresa Gauthier, RN, MSN, CDE The task force gratefully acknowledges her very significant contribution to this guide as well as to students with diabetes and their families in Washington State WASHINGTON STATE TASK FORCE FOR STUDENTS WITH DIABETES Laurie Anderson RN, BSN Michelle Cameron, RN, BSN, CDE Becky Deeter, RN, MN Alison Evert, RD, CDE Shannon Fitzgerald, RN, MSN, ARNP Teresa Gauthier, RN, MSN, CDE Martin Goldsmith, MD Joanne Hanson, RN Anne Hendon, RN, MEd, CDE Debby Jackson, RD, MEd, CDE Chris Ladish, PhD Judith Maire, RN, MN DeAnna Martin Rick Mauseth, MD Jim Rich Frederick Streeck, MSW Shirley Vacanti, RN, CDE Heidi Williams Jan Wisner, RN, BSN Bellingham School District, School Nurse Organization of Washington SNOW, representative Mary Bridge Childrens Hospital South Kitsap School District, SNOW representative Woodinville
Pediatrics Nursing Care Quality Assurance Commission Mary Bridge Childrens Hospital Pediatrics Northwest Woodinville Pediatrics Parent Mary Bridge Childrens Hospital Mary Bridge Childrens Hospital Office of Superintendent of Public Instruction American Diabetes Association Woodinville Pediatrics Special Education Consultant Dieringer School District Childrens Hospital and Medical Center American Diabetes Association Bellingham School District, SNOW representative
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INTRODUCTION
The purpose of this educational guide is to provide families of students with diabetes, school personnel, and health care providers HCPs to include physicians and nurse practitioners ARNPs, with the information and procedures necessary to provide such students with a safe learning environment and access to all other nonacademic school-sponsored activities These guidance and training materials are based on the belief that for children with diabetes to be successful in school, a comprehensive plan must be cooperatively developed by the families, school personnel, and the HCP Through this cooperative effort, plans that are reasonable and appropriate for implementation in the public school setting can be
developed to meet the individual needs of these students and their families This educational guide: 1 Gives general information for school personnel about the management of diabetes 2 Provides consistent care guidelines in the school setting for students with diabetes 3 Provides guidelines that ensure a learning environment that is safe and therapeutic for the student 4 Provides forms to document individualized information about students
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DEVELOPING AN INDIVIDUAL HEALTH PLAN IHP/SECTION 504 PLAN
THE TEAM APPROACH To ensure a safe, therapeutic, learning environment for the student with diabetes, parents and the student should plan to meet with school officials and the school nurse to develop the individual health plan IHP/Section 504 plan Appendix B prior to the student attending school, upon returning to school after an absence related to the diagnosis, and any time there are changes in the students treatment plan The IHP/Section 504 team will consist of at least the school nurse and parents Others members will be added as needed eg, teachers The school nurse must be involved in these initial and ongoing discussions since it will be the nurse who establishes the school treatment
and disaster and emergency plans, coordinates the nursing care, and trains and supervises school staff in the monitoring and treatment of symptoms Appendix A The school nurse is ultimately accountable for the quality of the health care provided during the school day to students with diabetes She or he has the responsibility of consulting and coordinating with the students parents and health care provider HCP to establish a safe, therapeutic learning environment The following activities should occur:
Obtain parent-signed release to access information from the students HCP and permission to evaluate the student, secure HCP Orders Appendix C for monitoring and treatment at school, provide parents copy of the districts explanation of parent/student rights A sample is contained in Appendix P 2 Secure medical equipment and medication Parents must provide all supplies Districts must provide appropriate, secure storage as needed 3 Establish school policy exceptions as needed to accommodate page 22 the students potential needs to: Eat whenever and wherever necessary, including having food at his or her desk Have easy, unrestricted access to water and bathroom use Have provisions made
for parties at school when food is served Eat meals and snacks on time and, if requested, be monitored by staff as to whether the student finishes food 4 Ensure that school meals are never withheld because of nonpayment of fees or disciplinary action 5 Discuss students school day schedule for timing of meals, snacks, blood sugar testing, etc 6 Develop disaster preparedness plans 7 Review need and establish plan for inservice training to staff on symptoms, treatment, and monitoring of students with diabetes and the additional observations that may be needed in certain situations eg, at recess or when student is ill This training should include the student and parents, as appropriate, and should be provided by an individual with training in current diabetes management 8 Secure legal documents for parent-designated adults Appendix J who are neither relatives nor school staff to provide care, if needed 9 Initiate discussion of the Personnel Guidelines for Care of Students With Diabetes in the School Setting pages 1721 Decisions will be made by parents, district administrators, school nurse, and perhaps the HCP based on the students ability to assume varying degrees of responsibility
in his or her care Such decisions may relate to: Should the student carry her or his own blood glucose monitoring equipment and syringes/insulin pen? Where/when should the student perform blood glucose testing? Where/when should the student administer insulin? When is school staff verification and notification of parents necessary and for what activities eg, do parents want to be notified when the student receives treatment for low blood sugar? 10 When the students IHP/Section 504 plan has been developed, the school nurse should obtain parent and HCP written approval to implement the students plan of care IHP/Section 504 plans and/or individual education programs IEPs require parental notice prior to implementation 1
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OVERVIEW OF DIABETES
Diabetes is a chronic illness that results from failure of the pancreas to make a hormone called insulin Insulin helps the body utilize food by converting sugar or glucose into energy Without insulin, sugar accumulates in the blood stream and will cause symptoms Most children with diabetes have Type 1 Diabetes Diabetes is not contagious and cannot, at this time, be cured However it can be managed and treated Treatment consists of taking
multiple injections of insulin, testing blood sugar several times during the day, eating nutritious meals and snacks, as well as following a regular exercise program A balance between insulin, food, and exercise must be maintained to prevent blood sugar levels from being either too low hypoglycemia or too high hyperglycemia Research has shown that maintaining good control of blood sugar levels can prevent long-term complications of diabetes The Diabetes Control and Complications Trial DCCT was a nationally sponsored study involving more than 1,400 persons with Type 1 Diabetes at 29 medical centers in the US and Canada Patients were randomly assigned to an intensive or standard treatment group and both groups were regularly examined for the presence or progression of diabetes complications The patients in the intensive group who kept their blood sugar levels close to normal by frequent blood monitoring, several daily insulin injections, and lifestyle changes including exercising and healthy eating had a combined 60 reduction in the development and progression of complications of the eye retinopathy, kidneys nephropathy, and nervous system neuropathy These benefits were achieved
despite the fact that average blood sugar levels were still above the normal range in this intensive group Although children under the age of 13 were not included in the study, it is believed that promoting blood sugar levels close to normal for all age groups is important It should be noted that there may be different target ranges for blood sugar in the various age groups and that the HCP and the parent establish this target range Goals of Diabetes Management in Children: 1 To promote normal childhood/adolescent growth and development 2 To promote healthy emotional well-being 3 To maintain a balance between insulin, food, and exercise Children with diabetes can and should participate in all school activities School staff should refer students to parents and HCP for recurrent illness, frequent or recurrent low blood sugar hypoglycemia, frequent requests to be excused from class, and frequent absenteeism as these may indicate a need for a change in the established treatment plan
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INSULIN Insulin is a hormone that can only, at this time, be taken by multiple injections or insulin pump Insulin lowers blood sugar The various kinds of insulin work for differing lengths of time Most
children take a combination of insulin at different times of the day The types and amount of insulin the student needs must be ordered by the HCP Appendix C INSULIN ACTION CHART NAME ONSET OF ACTION Hours How long before it starts to work 025 PEAK ACTION Hours When the insulin has the strongest effect 0515 DURATION OF ACTION Hours How long the insulin usually lasts 5 35
RAPID-ACTING Humalog Lispro SHORT-ACTING Regular INTERMEDIATEACTING NPH INTERMEDIATEACTING Lente LONG-ACTING Ultralente
0510
24
48
14
68
1215
24
612
1824
46
815
1824
The following special points should be considered: 1 All insulins lower blood sugar but peak at different times 2 Rapid-acting Humalog starts to work very quickly and leaves the body quickly The meal must be eaten immediately after injecting this insulin 3 Short-acting regular takes relatively longer to work and is ideally injected approximately 30 minutes before eating 4 Most students are on a sliding scale that allows the dosage of rapid-acting or short-acting insulin to be adjusted according to the blood sugar level See HCP Orders For Students With Diabetes in Washington State Schools Appendix C 5 The onset and duration of insulin may
vary Consult manufacturers guidelines
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Insulin Delivery Methods Insulin delivery methods include a syringe, an insulin pen, or an insulin pump Students who are able to self-administer insulin may use a syringe or pen The pen differs from the syringe in that it contains a prefilled cartridge containing insulin Insulin pens, if used properly, can be easier to handle and present less potential for error Nonlicensed school personnel may not assist with the syringe, but may, with instruction and supervision from the school nurse, verify the number shown in the window on the insulin pen Appendix I The insulin pump delivers a continuous low dose of insulin basal insulin and allows for bolus doses as needed Children who wear the external pump must be well versed in its use and maintenance and as such should be independent in testing blood sugar and administering a bolus The school nurse needs to be informed that the student is wearing the pump and information on the pump should be included in the students IHP/Section 504 plan The school nurse will be knowledgeable about the pump and how to disconnect or inactivate it in the unlikely event that a severe low blood sugar occurs Severe low
blood sugar is treated in the same manner whether a student is wearing an insulin pump or not If the school nurse is not available, the pump should be left intact and 911 should be alerted to its presence Storage of Insulin It is important to label the insulin bottle with the opening date Insulin can be stored at room temperature for one month After the first month the potency will be diminished Insulin can also be stored and will last longer in the refrigerator To avoid discomfort, insulin should be at room temperature before injection Storage guidelines for insulin pens that contain Regular or Humalog insulin are the same as noted above Usually pens are stored at room temperature
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BLOOD SUGAR TESTING Blood sugar testing is recommended for individuals with diabetes The procedure involves pricking a finger and placing a drop of blood on a test strip Appendix G Although some strips can be read visually, most are inserted into a glucose meter to obtain the test result or reading The result is then evaluated and recorded Nonlicensed school staff, trained and supervised by the school nurse, may in selected situations verify the reading Appendix I Blood sugar testing is often
performed three to four times daily The level of blood sugar guides treatment decisions and insulin dosage Benefits of blood sugar testing at school: 1 Provides the student with an immediate test result 2 Allows for adjustments in the insulin dose prior to meals 3 Provides the student as well as the health care team with important information regarding the effects of insulin, food, and exercise 4 Confirms low hypoglycemia or high hyperglycemia blood sugar Common problems causing inaccurate blood sugar test results: 1 Finger not clean and dry 2 Poor technique, including inadequate blood drop not enough blood 3 Code on test strip does not match code on meter 4 Outdated or incorrectly stored test strip 5 Machine dirty, often with dried blood 6 Product malfunction
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DIABETES SUPPLIES Parents are responsible for providing all diabetes supplies The following is a list of typical supplies: Insulin 1 2 3 4 5 6 7 Insulin bottles 1 Insulin syringes Alcohol wipes/antiseptic wipes optional or Insulin pens with cartridge loaded 1 Pen needles Logbook to record amounts of insulin and blood sugar Pump supplies, if needed, and manufacturers operating instructions
Blood Sugar Testing Supplies
Blood glucose meter and manufacturers instructions Test strips with code information, if needed 1 Finger-poking device Lancets Cotton balls Logbook to record blood sugar and amounts of insulin Protective covering eg, plastic wrap as needed
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Food
Snack foods Low blood sugar hypoglycemia supplies: glucose tablets, juice and carbohydrate/protein snack
Parents of students on an IEP and/or free and reduced priced meals program may supply food or work with the food service manager at the school to plan and supply meals that meet the childs needs A diet or meal plan from a licensed medical authority is required It must identify specific foods and portion sizes The provision of snacks is addressed on page 19 as well as Appendix H Ketone Testing
Urine ketone test strips
Disaster Preparedness/72 Hour Emergency Readiness See APPENDIX N
1 2
Assure contaminated waste and sharps are properly disposed Appendix G Parents are responsible for periodic quality control testing of meter and strips as well as providing meter manufacturers operating instructions 11
LOW BLOOD SUGAR HYPOGLYCEMIA
Low blood sugar hypoglycemia is defined as a blood sugar level tested less than 60 mg/dl The
student may feel low and show any of the symptoms below A low blood sugar episode does not feel good and may be frightening for the student Low blood sugar can develop within minutes and requires immediate attention Never send a child with suspected low blood sugar anywhere alone Appendix D contains a form to be completed based on the students IHP/504 plan Causes Late food or too little food Too much exercise Too much insulin A planned or unplanned activity without additional food
Symptoms/Signs
Mild Hungry Shaky Dizzy Sweaty Pale Increased heart rate Anxiousness Irritability Weakness, tiredness Inability to concentrate Personality change
Moderate Headache Behavior changes Poor coordination Confusion Blurry vision Weakness Slurred speech
Severe Loss of consciousness Seizure
Symptoms can vary per student as well as per hypoglycemic event, particularly at different ages Often children will not have an awareness of low blood sugar symptoms until they are 7 or 8 years of age Management Mild Student treats self Ingests quick sugar source such as: 23 glucose tabs or 48 oz juice or Glucose gel or 48 oz regular not diet soda or 38 Lifesavers Moderate Someone assists Insist on child
swallowing quick sugar source as listed under mild management Severe Call 911 Position on side, if possible Dont attempt to give anything by mouth
Follow-up management for mild or moderate low blood sugar: Wait 1015 minutes Repeat food if symptoms persist or blood sugar remains less than 60, if known Follow with snack of complex carbohydrate and protein eg, crackers and cheese if it is more than one-half hour until the next meal If You Have A Way To Check Blood Sugar, Do So BUT ALWAYS, WHEN IN DOUBT, TREAT Send for help if unsure of what to do If student is unconscious or unable to swallow, DO NOT try to feed Place on side and call 911 After 911 has been called, the office should contact parents
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HIGH BLOOD SUGAR HYPERGLYCEMIA
High blood sugar hyperglycemia is defined as a blood sugar level greater than 240 mg/dl It occurs over time, hours and days, and indicates the need for evaluation of management Students who will be checking their blood sugars at various times during the day are generally able to self-treat However the student may require occasional assistance Note that undiagnosed children may exhibit some or all of the following signs, including weight loss Appendix E
contains a form to be completed based on the students IHP/504 plan Causes Too much food Too little insulin Decreased activity Illness Infection Stress
Symptoms/Signs
Mild Thirst Frequent urination Fatigue/sleepiness Increased hunger Loss of concentration Blurred vision Sweet breath Urine ketones varies 1 from 0 to small
Moderate Dry mouth Nausea Stomach cramps Vomiting Urine ketones moderate to 1 large
Severe Labored breathing Very weak Confused Unconscious Urine ketones 1 moderate to large
Management
Mild Drink zero-calorie fluids ie, water Decrease activity, if ketones present Check urine ketones, if 1 test strips available
Moderate Drink zerocalorie fluids, as tolerated Check urine ketones, if test 1 strips available Decrease activity Call doctor Antinausea suppository, if prescribed
Severe Call 911
Student may need to use the bathroom frequently AND should be allowed to do so High blood sugar is characterized by excessive thirst It is important to drink plenty of water and it may be helpful for the student to use a water bottle in the classroom School district or classroom policy may need to be amended for these accommodations
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Urine ketones may be checked at school
based on the students IHP/Section 504 plan 13
DIABETES NUTRITION AND MEAL PLANNING: THE BASICS
Structured meals and snacks help promote optimal blood glucose control and help prevent the incidence of low blood sugar hypoglycemia levels during the school day The students IHP/Section 504 plan will dictate the role of the student, family, and school personnel in managing the meal plan Meal Plan Guides A meal plan is not a diet, but a guide to assist children/families with diabetes in choosing ageappropriate meals and snacks The registered dietitian usually develops an individualized meal plan designed to meet the childs unique nutritional needs School staff must know the students meal plan requirements during the school day The meal plan is based on: Age Weight Height Activity level for a 24-hour period Usual eating habits
Children with diabetes are children first and their nutritional needs and favorite foods will be similar to brothers, sisters, friends, and classmates who do not have diabetes All children like the taste of sweet foods Blood Glucose Response To Major Nutrients Carbohydrate Most important aspect of the meal plan Carbohydrate foods include bread and starches,
fruit, and milk Main source of blood glucose Approximately 90100 of dietary carbohydrate enters the blood stream as glucose within 15 minutes to onetwo hours Greatest determinant of amount of insulin needed to control the blood glucose after meals Consistency in amounts eaten at each meal and snack makes it easier to fine-tune insulin doses and timing Protein Approximately 50-60 of the dietary protein is converted to glucose and released into the bloodstream This process occurs between two to five hours following the meal/snack Protein foods include meat, fish, poultry, eggs, peanut butter, cheese, and meat alternatives Adds staying power to the meal A protein food at breakfast may reduce the incidence of low blood sugar before lunch A protein food is recommended at lunch Fat Negligible less than 10 effect on the blood sugar levels Delays/slows the digestive process Children with diabetes do not have to be placed on strict low-fat diets However, heart-healthy foods are recommended for children with diabetes as they have a greater incidence of heart disease as adults Consumption may need to be monitored more closely in situations of co-existing childhood
obesity
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Sugar Is Okay, Sugar Is Not a Poison Small or calculated amounts are acceptable in a diabetes meal plan Research does not support the long-held theory that ingestion dramatically elevates blood sugar levels Foods containing sugar can be substituted for part of the carbohydrate foods allowed in the childs meal plan It is recommended that these empty calorie foods do not replace healthy foods on a regular basis Matching Food/Insulin Action Children generally need three meals and two-three snacks each day Eating four to five hours apart with snacks two to three hours after the previous meal almost always matches the peak times of insulin action Usually one meal/snack is covered by each of the insulins acting during the day Almost all children with diabetes receive a combination of quick-acting insulin regular or Humalog and an intermediate-acting insulin NPH or Lente or long-acting insulin Ultralente before breakfast Various combinations of insulin are received at the evening meal and/or at bedtime Many children are now receiving an injection of quick-acting insulin regular or Humalog before lunch to achieve a more optimal level of blood glucose control Insulin
action: Morning Humalog insulin covers the carbohydrate foods consumed at breakfast Morning Regular insulin lasts from breakfast to lunch Morning NPH or Lente insulin lasts from lunch to just before dinner Morning Ultralente lasts from lunch into the evening Lunchtime Humalog insulin covers the carbohydrate foods consumed at lunch Lunchtime Regular insulin lasts from lunch to dinner If a student with diabetes eats school meals, the parents, HCP, or school nurse may need to contact the schools food service dietitian/supervisor to ensure appropriate school participation in 1 the students meal plan In no instance should a meal be withheld because of lack of payment If there is a party at school, work with the parents to make accommodations as determined by the IHP/Section 504 plan so that the student can participate Appendix M
1
In order for appropriate modifications to be made in the schools menus, the parent must supply a meal plan signed by a licensed medical authority 15
Meal Planning Approaches Many children with diabetes use either the exchange lists or carbohydrate counting as part of their meal plan Exchange Lists Commonly eaten foods are grouped into six different
exchange groups The exchange lists groups include the following: Bread/starch Fruit Milk Vegetables Meat/protein foods Fats
Each exchange within a group is an amount of food with set nutritional value Therefore, foods in each specific exchange list can be substituted or exchanged with other foods from the same list The exchange list approach allows for a meal plan guide to be consistent while offering a wide variety of food choices A child using this approach has a prescribed number of exchanges to be consumed at meal and snack times Substitutions between exchange groups can be made to increase flexibility For example: one bread exchange can be substituted for one fruit exchange or one milk exchange Carbohydrate Counting The carbohydrate counting approach is a simpler approach used frequently with children This approach emphasizes the carbohydrate content of the childs food intake Parents and children are taught how to determine the carbohydrate choices and/or the grams of carbohydrate in foods This information is obtained from the exchange lists and from the nutrition information on food labels Carbohydrate counting provides increased flexibility in meal planning while
keeping the amount of carbohydrate consistent from day to day Foods in the meat and fat group contain little carbohydrate and therefore are not used in this approach 1 carbohydrate choice 1 starch exchange 15 grams of carbohydrate 1 fruit exchange 1 milk exchange Tips For Healthy Eating To Achieve Optimal Blood Sugar Management Eat lunch and snacks at regular times every day Be consistent: Eat about the same amount of food at lunch and snacks each day Sugar can fit occasionally into a diabetes meal plan when substituted for other carbohydrate foods Appendix M Low blood sugar hypoglycemia can occur in the absence of regular meals and snacks Many children require a snack prior to physical education class, extra activity, extra recess, or a field trip Appendix L
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EXERCISE/SPORTS
Organized sports and other forms of active play are a great way for a child to stay in shape, spend time with friends, build self-confidence, have fun, and help blood sugars stay within an acceptable range Children and young adults with diabetes should be encouraged to participate in exercise Specific requirements are in the students IHP/Section 504 plan The following are a few guidelines at
school:
High blood sugar hyperglycemia: If blood sugar level is above 240, the urine may be checked for ketones as determined in the students IHP/Section 504 plan If the ketone check is negative, it should be okay to play If ketones are anything above trace, the student may need to clear the ketones with extra insulin and zero calorie fluids before being physically active Contact parent when ketones are present and/or the blood sugar is above 240 Low blood sugar hypoglycemia: Every coach/PE teacher and teacher should be aware of the signs, symptoms, and management of low blood sugar hypoglycemia page 12 and Appendix D
Suggestions for Exercising Child should be allowed to check blood sugar before, during, or after exercising see students IHP/Section 504 plan Eat before intensive exercising Have extra snacks available during exercise to prevent low blood sugar hypoglycemia Gatorade, 4 to 8 oz, for every 30 minutes of vigorous exercising can be used Foods such as cheese and crackers provide a longer-acting carbohydrate Always have quick-acting sugared food/beverages available for managing low blood sugar hypoglycemia Suggestions include: Juice 48 oz Glucose tablets Glucose
gel Regular not diet soda Treat low blood sugar hypoglycemia Recheck blood sugar to ensure it is in normal range before additional exercising If ketones are present, intensity and duration of exercise may need to be modified Refer to students IHP/Section 504 plan Drink plenty of water, especially in hot weather
After-School Activities Parents or guardian will need to inform the school whether the student will require an insulin injection and/or a substantial snack before participating in a preplanned after-school activity The students IHP/Section 504 plan should include this information
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PERSONNEL GUIDELINES FOR CARE OF STUDENTS WITH DIABETES IN THE SCHOOL SETTING
This section describes who may assume responsibility for activities in the IHP/Section 504 plan as determined by statute, regulation, Nursing Care Quality Assurance Commission guidelines Appendix I or best practice While they are guidelines only, it is strongly recommended that they be followed in order to maintain safety and quality of care Determinations that relate to these guidelines become part of the students IHP/Section 504 plan A table pages 21 and 22 summarizes these guidelines Blood Sugar Test Blood
sugar testing, if ordered, will be provided before meals not including snacks The student, parent, family member, designated adult Appendix J, or licensed staff RN or LPN may perform this procedure A HCPs order is needed if blood sugar testing is being done by a licensed school health professional Assessment of the students ability to independently perform this procedure will be determined by the parent, school nurse, and HCP Supervision of the student may be needed due to the students developmental ability, level of independence, proximity to initial diagnosis, and/or age Such supervision can only be provided by a parent, family member, designated adult, or licensed personnel Based on an advisory opinion from the Nursing Care Quality Assurance Commission, this procedure and necessary student supervision cannot be delegated to nonlicensed personnel Appendix I Verification of the number on the meter by nonlicensed school personnel for a student independent in the management of his/her self-testing can be performed after training, supervision, and delegation by the school nurse Appendix I The test can be done at most locations with planning for blood containment, clean up, and lancet
disposal in the physical setting where the testing will occur Appendix G It will be necessary to establish a plan with the student, parent, and school nurse in advance Provisions for storage of supplies must be made Blood sugar testing for symptoms of low hypoglycemia or high hyperglycemia blood sugar will be done by the student if able, the parent, family member, or designated adult The school nurse, if available and with a HCP order, can also perform it The same provisions, as stated above, for containment of blood and sharps must be applied In special circumstances such as extended day, field trips, and after-school sports or activities, blood sugar testing can be performed by the student, licensed staff member, parent, family member, or designated adult Provisions for containment and clean up of blood and sharps disposal must be available Appendix G Also, provisions for safe storage of supplies and equipment must be made
Insulin Injection
An insulin injection prior to meals may be needed to treat elevated blood sugars A HCPs written order stating the sliding scale ranges for the amount and type of insulin to be injected is required Appendix C Adjustments in the
daily dosage amount of insulin can be made by consultation with the parent as long as the parents recommendations are within a range ordered on the HCPs written sliding scale The HCP must also clearly state that parents may be consulted for daily dosage adjustments Parents may not order treatments or changes to treatment plan independently as they are not authorized prescribers Appendix I Assessment of the students ability to independently perform this procedure will be determined by the parent, school nurse, and HCP If licensed staff perform the procedure, the HCP order is necessary Supervision that may be needed due to the students developmental ability, level of independence, proximity to initial diagnosis, or age can only be provided by a parent, family member, designated adult, or licensed staff member 18
Verification of the amount dialed by the student on the insulin pen by nonlicensed school personnel for a student who is independent in the management of her or his self-injecting can be performed after training, supervision, and delegation by the school nurse Appendix I Drawing up of insulin, verification of dose, and injection can be done only by the student if able, a
parent, a family member, a designated adult, or licensed staff RN or LPN The injections can be done at any location where privacy is provided, with planning for blood containment, clean up, and lancet disposal, in the physical setting where the injections will occur Appendix G It will be necessary to establish a plan with the student, parent, and school nurse in advance Provisions for storage of medication and syringes must be made If extra insulin injections are needed, the student, parent, family member, designated adult, or school nurse can perform the procedure Extra injections are those needed as determined by testing done other than before meals These injections can occur anywhere as long as provisions are made for blood containment, clean up, sharps disposal, and storage of medication
Low Blood Sugar Hypoglycemia Treatment
The school nurse, parent, and HCP should determine a plan that includes the individual students symptoms and treatment of low blood sugar Blood glucose determination can be done by the student, nurse or parent, if available Treatment, however, should not be withheld if testing is not available and the student is symptomatic If there is ever a
doubt that the student is experiencing low blood sugar hypoglycemia symptoms, treatment should be given immediately Treatment should be a food snack that the parent has provided The snack needs to be a quick acting carbohydrate fruit juice, glucose tablets, glucose gel, etc A more substantial follow-up snack may be needed All snacks should be readily available Low blood sugar hypoglycemic episodes and snack usage should be reported to the parent Please note that glucose tablets and food are not considered to be medication Anyone can treat the student who is experiencing symptoms of low blood sugar If the student is excused from class to seek treatment at another location, she or he needs to be escorted to that location It is important to treat symptoms immediately Document and inform parents as noted in the students IHP/504 plan Treatment for low blood sugar can occur anywhere For this reason, it is important for the student and the adult in charge to know where the students emergency food supplies are stored
Severe low blood sugar hypoglycemia occurs when the student is unconscious and cannot safely swallow food or liquid School staff should be trained in emergency response for
this situation: If the student is unconscious or unable to take food or drink safely by mouth, call 911 Place the student on his or her side to prevent aspiration School personnel must remain with the student until medical help arrives It is extremely helpful to have the students medical information available for the paramedics treating the student Parents should be contacted after 911 has been called
19
Glucagon Glucagon 1 mg injected intramuscularly or subcutaneously may be administered by licensed staff, parents, family members, or designated adults only Note that the dosage should be 05 mg for children weighing less than 44 lb 20 kg The dosage for any particular student must be ordered by the students HCP Licensed staff may not be available to administer the Glucagon injection In this case the protocol for severe low blood sugar should be followed A written HCPs order and parental agreement is needed in order to give Glucagon by licensed staff Even when Glucagon is administered, 911 must always be called
High Blood Sugar Hyperglycemia Treatment A plan for high blood sugars hyperglycemia should be developed with parents and HCP that sets parameters for treatment as
necessary Depending on the ability and independence of the student, parents may need to be contacted when blood sugars reach a predetermined level Parents and students are responsible for treatment of high blood sugars if an insulin shot is needed outside of the pre-meal testing and injection Accommodations for the student may include availability of bathroom, fluids, and exercise restrictions The parent should supply ketone test strips for urine testing if needed and ordered by the students HCP Testing should take place in the health room or designated private bathroom Licensed staff may not be available to help with this testing but the school nurse may delegate to, train, and supervise designated nonlicensed staff
Snacks Parents should supply a ready supply of snacks with some method of communication that notifies them when the supply is low or out In no instance should a meal/snack be withheld because of discipline or lack of payment Snacks may be supplied by the school food service if designated in the students IEP
Illness If a student has a temperature 100F and/or vomiting, parents should be contacted to come and get the student Observe for symptoms of low blood sugar
hypoglycemia
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PERSONNEL GUIDELINES FOR CARE OF STUDENTS WITH DIABETES IN THE SCHOOL SETTING SKILL/TOPIC WHO CAN DO IT WHERE LOCATION
Designated Adult Designated Staff I BLOOD GLUCOSE TEST Parent/Family Licensed Staff Any School Staff Can occur at any preapproved location eg, classroom, health room as long as plan in place for blood containment/clean up and sharps disposal This must comply with infectious disease control plan and with WISHA bloodborne pathogen standards Appendix G The procedure should not be disruptive of class routine or other students Provision for easy access storage of supplies must be made Same as above Same as above Can occur at any preapproved location eg, classroom, health room as long as plan in place for blood containment/clean up and sharps disposal This must comply with infectious disease control plan and with WISHA bloodborne pathogen standards Appendix G The procedure should not be disruptive of class routine or other students Provision for storage of medication and supplies must be made Same as above
1 Test to be performed prior to meals not snacks 2 The following can be performed by those marked with an X: a Piercing skin/performing blood
sugar monitoring b Verifying number on meter c Interpreting results Appendix I 3 Test if symptomatic high or low blood sugar, if possible 4 Test during special events extended day, field trips, sports, band, etc II INSULIN INJECTION 1 Prior to meals Requires HCP order Sliding scale can be adjusted by nurse/parent consultation within ordered HCP parameters per NCQAC opinion Appendix I 2 The following can be performed by those marked with an X: a Drawing up syringe and administering insulin
X
Student
X
X
X
X X X X
X X X X
X X X X
X X X X
X
Licensed staff may not be available X X X X Licensed staff may not be available
X
X
X
X
X
X
X
X
b Verifying dose on syringe not an insulin pen c Verifying number on insulin pen syringe Appendix I
X X
X X
X X
X X X
3 Extra injections: Those needed as determined by testing done other than before meals
X X X X Licensed staff may not be available
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PERSONNEL GUIDELINES FOR CARE OF STUDENTS WITH DIABETES IN THE SCHOOL SETTING SKILL/TOPIC WHO CAN DO IT WHERE LOCATION
Designated Adult III Designated Staff X X LOW BLOOD SUGAR HYPOGLYCEMIA Parent/Family Licensed Staff
IV
1 Mild and Moderate: Follow treatment plan 2 Severe:
If unconscious or unable to swallow: CALL 911 HIGH BLOOD SUGAR HYPERGLYCEMIA 1 Extra insulin to be determined by HCPs order for sliding scale 2 Urine ketone test if supplied by parent and ordered by HCP and part of students IHP/Section 504 plan
X X
X X
X X
X X
X X
Any School Staff Can and must be treated anywhere Can and must be treated anywhere and follow IHP/504 plan Same as for insulin injections II Health room or designated private bathroom X As needed where needed X
X X X X For extra injections see II, No 3 X X X X X Licensed staff may not be available
V
SNACKS 1 Parent provided 2 School provided if student has an IEP ILLNESS 1 Per Infectious Disease Control Guide for school staff If vomiting, monitor for low blood sugar hypoglycemia Call parents X X X X X
VI
X
Student
X
X
X
X
Students Developmental Ability: The student possesses the cognitive, emotional, behavioral, motor skills, and physical maturity necessary to perform the required activity and can demonstrate it consistently and across multiple settings A release should be included that is signed by the parent, HCP, and school nurse Appendix C Parent/Family: Includes parent, guardian, or designated
family member If the family member is less than 18 years of age, the parents, HCP, school administrators, and school nurse should determine if it is appropriate and safe for the family member to provide the care Licensed Staff: Must be a RN or LPN A HCPs order is required for licensed person to test or inject Designated Adult: Cannot be a school employee Adult must have legal authority power of attorney for health care and hold harmless statement with district Appendix J Designated Staff: School employee trained and supervised by RN who has delegated the tasks such as verifying numbers on glucose meter and/or insulin pen A release should be included that is signed by the parent and school nurse
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SUGGESTED ACCOMMODATIONS FOR THE STUDENT WITH DIABETES
THE LAW AND DIABETES
Diabetes is considered a disability under federal law Under Section 504 of the Rehabilitation Act of 1973, it is illegal to discriminate against a person with a disability Children with diabetes must have full access to all activities, services, or benefits provided by public schools Any school receiving federal funds must accommodate the special health care needs of its students with disabilities in order
to provide them with a free appropriate public education Such accommodations should be documented in an appropriately developed Section 504 plan or, if the child also needs special education services, in an individualized education program IEP These accommodations must be developed with parental input and cannot be implemented without parental consent The school district has a legal obligation to ensure that these accommodations are provided as described in the plan The Individual Health Plan and the 504 plan may be the same document For procedural safeguards and parent/student rights under Section 504, see Appendix P For procedures specific to a student with diabetes and IEP, see Appendix O
The following is a list of suggested accommodations for students with diabetes: 1 School nurse, parents and student should mutually determine the most appropriate location for blood sugar glucose monitoring and insulin administration Determining factors may include: Student age, developmental level and possibility of negative effects in classroom Student desire for privacy Length of time since diagnosis Student knowledge of diabetes and degree of independence Student ability to demonstrate
blood sugar glucose monitoring procedure and insulin administration, correctly, over time Awareness of safety issues surrounding needles, lancets, and blood, including proper disposal of waste and storage of diabetes equipment Plus, any other special circumstances Student may have permission to do blood sugar testing in the classroom This procedure should take only a few minutes and be nondisruptive to the class Student may also need to check sugar on field trips or during special events Blood sugar testing is usually done before meals per HCPs order Parents are responsible to supply snacks for school; students should have at least one additional snack readily available everyday for emergency consumption Parents should be notified when the emergency snack is consumed if this is part of the students IHP If student has an IEP and a meal plan from a licensed medical authority, snacks will be provided after consultation with food service manager, parents, and HCP Appendix H Student needs to be allowed to snack when and where necessary low blood sugar/hypoglycemia to maintain adequate blood sugar levels This includes school transportation as well as the classroom, gymnasium, etc A
student who does not respond to a snack and/or exhibits signs of low blood sugar hypoglycemia, needs to be accompanied to the health room, or a call for assistance should be made from the classroom DO NOT SEND ALONE if dizzy, sweating, pale, trembling, crying, drowsy, nauseated, or if complaining of abdominal pain, blurred vision, headache, and/or displaying out of character behavior A student with a high blood sugar hyperglycemia is to receive insulin per HCP order This may include going to the health room to self-inject insulin or notifying school nurse, parent, family member, or designated adult to administer The student may be allowed to self-inject in the classroom or health room, if appropriate, and permission is given by the school nurse1 A student must be allowed to drink water or other sugar free fluids in the classroom, as needed, to dilute high blood sugars A student needs to be allowed extra bathroom privileges as high blood sugars hyperglycemia results in increased urine output Parents should be given at least a one-day notice of extra events such as parties or field days
2 3
4 5
6
7 8 9
1
Permission is granted to test or self-inject in the classroom after
demonstrating to the school nurse appropriate procedure and disposal of waste Amount of classroom disruption is also a consideration Students wishing privacy, confidentiality, or supervision shall have permission to come to the health room for blood sugar testing or insulin injection
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QUESTIONS AND CONCERNS RAISED BY PARENTS
1 Who will monitor the health of my child during the school day? Your school nurse is the best person to contact She or he will assist you, your HCP, the building staff, and your child with developing an accommodation plan This IHP/Section 504 plan will establish the guidelines of what needs to be done for your child during the day This plan also serves as a teaching tool that your childs teachers will need It is helpful to make these contacts; it raises awareness to your childs special needs and identifies who will be performing certain tasks Refer to the Suggested Accommodations for the Student with Diabetes page 23 as well as Personnel Guidelines for Care of Students with Diabetes in the School Setting pages 1822 2 How can I reach my childs teacher? Most teachers prefer to be contacted during their work hours When both parents work, it is sometimes
difficult to reach the teacher and be available when she or he is able to talk Often communication via a note in the backpack can be a viable solution Address this issue as soon as possible at the beginning of the year or as soon as your child is diagnosed 3 Will my child be labeled as that diabetes kid? The individual self-worth of every student is important in a learning environment Most teachers are well trained and sensitive enough to avoid this type of stereotyping The individuals own self-perception and how she or he manages his or her own illness will most likely be the measuring stick that classmates will use with each other when interacting If your child appears to have difficulty accepting or living with diabetes, seek out resources such as a counselor or a diabetes educator to help address the issues Decide with the school nurse whether or not classmates should be taught about diabetes It may be useful for your child to have a friend or classmate monitor symptoms and/or behavioral indications of low blood sugar and assist your child in seeking adequate help 4 Will my childs new teacher know anything about diabetes? Maybe and maybe not It would be advisable for you to
request an IHP/Section 504 plan meeting prior to each school year Most teachers are very receptive to parental involvement Since teachers are very busy at the beginning of the year, they may need some time You need to be patient and available to educate, particularly in the area of low blood sugar hypoglycemia management Your childs IHP/Section 504 plan should ensure that all staff that come in contact with your child is involved: substitute teachers, other teachers, playground monitors, cafeteria workers, and bus drivers Transition to next year can be addressed in a childs IHP/Section 504 plan Be sure to maintain a good working relationship with the staff and dont forget your sense of humor 5 What about snacks at school? Snacks need to be where your child is Your childs IHP/Section 504 plan should include a snack plan Extra snacks can be kept in your childs backpack, in the main classroom, the gymnasium, as well as the health room Your child needs to know where the snacks are stored If your child does not remember snack times, the teacher may be able to remind him or her Alternatively, your child could wear a watch with an alarm that can alert him or her to snack time or testing
time Some schools will not allow juice boxes because of spills on carpet, etc Be sure to work out acceptable snack foods in advance when developing your childs IHP/Section 504 plan to avoid problems Ask the teacher and health care worker to notify you when the snack supply is low
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6 What about the diabetes supplies? Dont forget to periodically restock insulin, blood monitoring supplies, and low blood sugar and emergency supplies Your childs IHP/Section 504 plan should address who should notify you when the diabetes supplies are low You are responsible for cleaning and quality control checking of your childs meter and insulin pen and ensuring that the insulin supply is fresh 7 I am concerned that if my son leaves his insulin pen at school, the insulin will become outdated and have to be wasted This insulin is expensive I feel that my 11-year-old son is responsible and should be allowed to carry his insulin pen instead of storing it at school The school districts policy and your sons level of independence will be important factors in the solution to this question Most school districts have policies that surround the safety of sharps and bloodborne pathogens If your son has
demonstrated that he is responsible in the usage of his insulin pen, it might be very possible to establish a plan for him to carry his insulin pen in a secured place This matter should be addressed in your childs IHP/Section 504 plan 8 What will happen when there are special occasions such as school parties, field trips, etc? There are a variety of ways these problems can be addressed Discuss these issues at your childs IHP/Section 504 plan meeting If the party is a surprise often these occur at the end of the day, the parent could cover the elevated blood glucose reading with extra insulin at home At preplanned parties with a known menu, the child could select one to two favorite treats to eat and take the rest home Alternately, the parent could provide a special treat for the child If an opportunity to act as a homeroom parent arises, do it Teachers that are informed can assist other parents in choosing food treats Field trips are less frequent events They are almost always preplanned If it is possible for you to make arrangements in your schedule and be one of the chaperones, this is the best solution A number of variables need to be considered when planning for the trip: the
level of independence your child may have with his or her diabetes, the availability of licensed personnel joining the trip, the length of time the trip will last, the necessity to test, the need to take insulin, and the potential for low blood sugar during the trip The details should be addressed at your childs IHP/Section 504 plan meeting 9 Can the teacher or secretary just look at the syringe to be sure the right amount of insulin that the child drew up is correct? Personnel Guidelines for Care of Students With Diabetes in the School Setting on pages 1721 is a guide to assist school districts in identifying the needs of these students and who can be responsible to help meet those needs Appropriate staff assignments are based on Washington State laws, regulations, and guidance from the Nursing Care Quality Assurance Commission There is a difference between an insulin syringe and an insulin pen A dose of insulin delivered via an insulin syringe requires verification by a licensed health professional However, a designated, trained school employee can legally verify the number of units of insulin shown on the insulin pen Please note that this is a 1998 Nursing Care Quality Assurance
Commission opinion Appendix I
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10 I have been told that the more normal my daughters blood sugars are, the better her chances are for fewer health complications from diabetes How can the necessary checks be done at school? The 1993 Diabetes Control and Complication Trial demonstrated that patients with type 1 diabetes who experienced intensive management regimens developed fewer diabetes complications This decrease was achieved despite the fact that average blood sugar levels were still above the normal range Schools recognize that students with diabetes have some special needs that may need to be accommodated in order to facilitate education and diabetes management Some students with diabetes may require accommodations such as preferential seating, a shortened day, a mid-morning or afternoon snack, an injection, or a blood sugar test When a student is independent in monitoring and insulin-administration skills, there are few requirements of school employees When the student is less independent, school staff will need to be more involved It is important to establish a realistic plan regarding monitoring of students symptoms, testing of blood sugar, and administration of insulin
Communication with the school nurse will facilitate this goal The demands on specialized school personnel are high If a parent feels that the amount of monitoring by school personnel is insufficient, she or he should request an IHP/Section 504 plan meeting to discuss her or his concerns 11 My high school-aged child wont tell anyone that she has diabetes She ended up passing out on the volleyball court before someone realized that she had a problem How do you get kids to share such important information? Once a student begins to realize that she or he has different requirements for her or his body, it is not uncommon to want to hide the fact as a means to be the same as others It is important to remember that kids are kids first and they all share similar developmental needs Family attitudes teach early lessons in the precautions that someone with diabetes needs to take A young person can learn that her daily routine is just a part of her personal responsibilities and care Your childs IHP/Section 504 plan should ensure information is confidential and will be shared with staff only to the extent they need to know in order to monitor your childs health The age that the diagnosis was
made may have an impact on how she accepts or denies the fact that she has diabetes If the denial is such that important details are being ignored, a referral to a counselor may be necessary Your HCP, endocrinologist, diabetes educator, and school nurse are all appropriate referral sources 12 A parent support group would really have helped to keep me from rediscovering the wheel What are the possibilities of that being developed? An excellent resource is the American Diabetes Association Your hospital, your diabetes educator, and your HCP are other resources to connect your family with support groups Within the school district it will be very individual If there are parents of children with diabetes that are willing to share phone numbers, this can be a marvelous help line The districts school nurse is the most appropriate contact for this kind of assistance The nurse can inquire if other parents are willing to share their thoughts and phone numbers Due to confidentiality issues, it cannot be assumed that individuals would be willing to share such information
26
13 How does the school address the difference between special education issues and a student with diabetes who
experiences multiple high and low blood sugar readings that might impact his or her educational performance? Diabetes is always a disability under Section 504 plan and in most cases requires accommodations within the school setting However, for a student with diabetes to be eligible for special education, he or she must be determined to have a health impairment that substantially limits learning and requires special education When a student is failing in the classroom and the school district suspects that this failure may be the result of a disability, the district has an obligation to determine if the student needs to be evaluated to determine if she or he has a disability and needs special education or accommodations under Section 504 plan If the district determines that an evaluation is necessary, it must get parent permission prior to conducting the evaluation and it must involve the parents in the eligibility determination meeting It is during this evaluation process that the district and family must differentiate between the need for special education learning assistance and the diabetes medical management issues A student experiencing multiple high and low blood sugar
readings and having no specific learning problems would not qualify for special education but would be eligible for accommodations under Section 504 plan 14 What will happen if a disaster ie, an earthquake occurs while my child is at school? The Washington State Military Department/Emergency Management Division recommends that schools in Washington develop a disaster plan for each of their buildings Students that have special needs will require additional planning in the form of available first aid kits A disaster preparedness/three day emergency readiness plan has been developed for students with diabetes Appendix N It outlines the supply and food needs as well as provides information about how to draw up and administer insulin As a parent, you will be responsible for providing the emergency food, insulin, and supplies for the disaster preparedness kit 15 What do I do if my childs recess or PE class comes just before lunch? Depending on what kind of insulin your child is on, she or he may need a small additional snack before exercise to prevent low blood sugar An additional blood sugar test may be helpful as sometimes a little activity will bring them into the target range and
decrease the need for lunchtime insulin These preparations should be part of the students IHP 16 Can my child go to her or his neighborhood school? Maybe and maybe not It may depend upon whether the childs IHP/Section 504 plan, jointly developed by parents and the school nurse with responsibility for care of the student during the school day, states the child needs to be at a school with a school nurse 17 What if I am unhappy with some aspect of my childs IHP/Section 504 plan? Request an IHP/Section 504 plan meeting to discuss the matter or consult Appendix P, Parent/Student Right in Identification, Evaluation, and Placement to determine how to challenge the IHP/Section 504 plan
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LIVING WITH DIABETES
Living with diabetes is a challenge met not only by the child newly diagnosed, but also by his or her family parents and siblings, school system teachers, nurses, counselors, coaches, physical education instructors, HCP, and other individuals caring for her or him Meeting the challenge of living with this diagnosis is thus a team effort that hinges on the skills of communication, creativity, flexibility, adaptability, and consistency While no one can predict the unique challenges
faced by every child or family, specific challenges are always to be expected These include: 1 2 3 Physical challenges taking place in the childs body as it deals with the manifestations of high and low blood glucose Emotional challenges as the child and his or her family confront the continual frustration and struggles imposed on them by this new illness and the reality of a lifelong chronic illness Practical challenges imposed by the need for and inconvenience of multiple daily insulin injections and blood sugar testing, nutrition and exercise management, and other routine schedule changes Systemic challenges as the childs illness impacts his or her family, school system, day care, peer, and other environments
4
Despite these multiple challenges, perhaps THE BIGGEST CHALLENGE met by the newly diagnosed child is her or his need and desire to be no more unique, different, or special than any other child in the classroom, day care, or family environment Maintaining sensitivity to this fact, particularly at the time of diagnosis, is critical in creating an atmosphere of understanding, emotional privacy and safety, and acceptance Several key principles are provided below and are
intended as general guidelines that may be helpful in meeting the challenge of living with diabetes within multiple settings 1 DO NOT ASSUME THE CHILD WANTS OR DOES NOT WANT OTHERS TO KNOW OF HIS/HER DIAGNOSIS Despite visible equipment, insulin injections, snacks, trips to the office, etc, which are easily viewed by other children, children with diabetes generally prefer to keep their diagnosis private Always communicate with the child to assess her and his need or yours to give others knowledge of the childs diagnosis and if they want their classmates to be given instruction about diabetes or a classmate to become a special buddy for monitoring activities and symptoms The parents of the special buddy would need to be involved CHILDREN AT DIFFERENT AGES HAVE VARYING LEVELS OF UNDERSTANDING ABOUT THEIR DIAGNOSIS Use developmentally appropriate language when speaking to children about their diabetes and other issues NEEDS FOR INDEPENDENCE AND ASSISTANCE MAY VARY WITH AGE AND LIFE CIRCUMSTANCES Frequent check ins with a child regarding her or his need for independence or assistance are very helpful in keeping feelings of anxiety and frustration to a minimum and help reduce the risk of
complication due to oversight or lack of knowledge If uncertain of what level of assistance a child requires for appropriate management, dont assume: ASK CHILDREN COME WITH FAMILIES, TEACHERS, FRIENDS, AND OTHERS Thus, treatment of the system is critical in creating consistency of treatment for the child It is also important to recognize that the childs illness is also affecting the system, not just the child Take care to assess the emotional needs of parents, siblings, schoolteachers, and others who care for the child
2
3
4
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5
WHEN WORKING TOWARD INDEPENDENCE, MAKE EXPECTATIONS CLEAR TO THE CHILD If you are uncertain if a child can reliably demonstrate a skill related to her or his diabetes management, have him or her demonstrate it for you PREPARE FOR EMERGENCIES Having extra supplies on hand at several locations is critical and should not be overlooked Create a checklist of needed supplies, snacks, emergency numbers, etc Check and update it regularly PLAN AHEAD Children require assistance with field trips, overnight stays, and other events Looking ahead can easily prevent the likelihood that an emergency may occur and can decrease the number of events that a child must
miss due to diabetes Be creative Be flexible SEEK HELP WHEN HELP IS NEEDED Do this early and often If you wait for a crisis before allowing others to help, you are modeling this behavior to the child PUT IT IN WRITING Make an informal agreement This can be helpful in preventing miscommunication between parents and children, school personnel, and others Have all necessary parties sign, including the child Keep the agreement visible and review and change as needed The IHP/Section 504 plan is an ideal means of putting it in writing COOPERATE, COMMUNICATE, AND CREATE Use these concepts as your guiding force in maximizing the childs opportunities for success This is a lifelong illnessdont forget to smile and laugh along the way
6
7
8 9
10
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BIBLIOGRAPHY
A Core Curriculum for Diabetes Education, 3 Edition, American Association of Diabetes Educators, Chicago 1998 Care of Children with Diabetes in the School and Daycare Setting ADA: Clinical Practice Recommendations Diabetes Care, Supplement 1, 1999, S94-S97 Chase, H Peter Understanding Insulin-Dependent Diabetes, 9 Edition, Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, 1999 Guidelines
for Implementation of Hepatitis B and HIV School Employee Training: State of Washington, OSPI, May 1992 The American Diabetes Association 1999 Resource Guide: Supplement to the Diabetes Forecast The Diabetes and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus New England Journal of Medicine 1993; 329:977-986
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Source:americanhealthways.com
