Diabetes is a chronic disease in which the body does not make or properly diabetes occur in teens and young adults who develop diabetes during childhood. …

Care of the Endocrine System
Diabetes Medical management plan Blood glucose testing Glucagon Urine ketones Insulin Insulin pump therapy Resources

Diabetes
Overview
Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone needed to convert sugar, starches, and other food into energy People with diabetes have increased blood glucose sugar levels because they lack insulin, have insufficient insulin, or are resistant to insulins effects High levels of glucose build up in the blood and spill into the urine; as a result, the body loses its main source of fuel When insulin is no longer made, it must be obtained from another source–insulin shots or insulin pump When the body does not use insulin properly, oral medications may be taken instead of, or in addition to, insulin shots Neither insulin nor other medications, however, are cures for diabetes: they only help control the disease Taking care of diabetes is important If not treated, diabetes can lead to serious health problems The disease can affect the blood vessels, eyes, kidneys, nerves, gums, and teeth, and it is the leading cause of adult blindness, lower limb amputations, and kidney
failure People with diabetes also have a higher risk of heart disease and stroke Some of these problems can occur in teens and young adults who develop diabetes during childhood The good news is that research shows that these problems can be greatly reduced or delayed by keeping blood glucose levels near normal

Types of Diabetes Type 1 Type 1 diabetes mellitus T1DM is a complex metabolic disease In people with
T1DM, the immune system attacks the beta cells the insulin-producing cells of the pancreas and destroys them Because the pancreas can no longer produce insulin, people with type1 diabetes need to take insulin daily to live T1DM can occur at any age, but it begins most often in children and young adults T1DM can not be prevented Symptoms Increased thirst and urination Constant hunger Weight loss Blurred vision Fatigue Risk Factors Genetics Environment

Type 2 The first step in the development of type 2 diabetes mellitus T2DM is often a
problem with the bodys response to insulin, or insulin resistance For reasons scientists do not completely understand, the body cannot use its insulin very well This means that the body needs increasing amounts of insulin to control
blood glucose The pancreas tries to make more insulin, but after several years, insulin production may drop off

T2DM used to be found mainly in overweight adults ages 40 or older Now, as more children and adolescents in the United States become overweight and inactive, T2DM occurs more often in young people To control their diabetes, children with T2DM may need to take oral medication, insulin, or both The risk of getting T2DM can be decreased by avoiding obesity through healthy diet and plenty of exercise Symptoms

Fatigue Increased thirst and urination Nausea Rapid weight loss Blurred vision Frequent infections Slow healing of wounds or sores

Risk Factors Being overweight greater than 85th percentile for height/weight Having a family member who has type 2 diabetes Being African American, Hispanic/Latino American, Native American, Asian American or Pacific Islander American

Understanding Diabetes and Ketoacidosis
The pancreas makes enzymes and hormones Insulin is a hormone secreted by the beta cells of the pancreas Insulin goes straight into the blood and enables glucose to enter other cells of the body Enzymes help digest or breakdown the food into glucose
Glucose is a simple sugar that is present in the blood and is used by the body for energy When someone has diabetes, the pancreas doesnt make enough insulin When there is not enough insulin, glucose cannot enter the cells Body cells need to have glucose to provide the energy to do their jobs When glucose cannot be used for energy the level of glucose builds up in the blood stream When excess glucose builds up in the blood, the kidneys filter it out into the urine In the process the body uses and loses a lot of water This causes increased thirst Hunger is another symptom of diabetes caused by the body losing calories as a result of its inability to utilize the glucose from food that is consumed This leads to weight loss and fatigue When the body cant use glucose, it uses its own fat and muscle tissue for energy Ketones are acids that are left in the blood when fat is used for energy Symptoms of nausea, vomiting, and eventually, coma occur This is called diabetic ketoacidosis The body will try to get rid of ketones through the kidneys and lungs The ketones will show up in the urine and will also cause the breath to smell fruity

Management of Diabetes
The goal of effective diabetes
management is to control blood glucose levels by keeping them within a target range that is determined for each child Optimal blood glucose helps to

promote normal growth and development and allows for optimal learning Effective diabetes management is needed to prevent the immediate dangers of blood glucose levels that are too high or too low As noted earlier, research has shown that maintaining blood glucose levels within the target range can prevent or delay the long-term complications of diabetes, such as heart attack, stroke, blindness, kidney failure, nerve disease, and amputations of the foot or leg The key to optimal blood glucose control is to carefully balance food, exercise, and insulin or medication As a general rule, food makes blood glucose go up, and exercise and insulin make blood glucose levels go down Several other factors, such as growth and puberty, mental stress, illness, or injury also can affect blood glucose levels With all of these factors coming into play, maintaining good blood glucose control is a constant juggling act–24 hours a day, 7 days a week

Monitoring Blood Glucose
Students with diabetes usually TIDM must check or test their blood glucose
levels throughout the day by using a blood glucose meter The meter gives a reading of the level of glucose in the blood at the time it is being checked Monitoring involves pricking the skin with a lancet at the fingertip, forearm, or other test site to obtain a drop of blood and placing the drop on a special test strip that is inserted in a glucose meter If blood glucose levels are too low hypoglycemia or too high hyperglycemia, students can then take corrective action, such as eating, modifying their activity level, or administering insulin Low blood glucose levels, which can be life-threatening, present the greatest immediate danger to people with diabetes Health care providers generally recommend that students check their blood glucose during the school day, usually before eating lunch or snacks, before physical activity, or when there are symptoms of hypoglycemia or hyperglycemia In young children, symptoms may be subtle; blood glucose should be checked whenever symptoms are suspected Many students can check their own blood glucose level; others will need supervision; and others will need to have the entire task performed by a school nurse or trained diabetes personnel Students
who can self-check can be allowed to do so whenever they need to and at any school location Being able to do so can help achieve better glucose control, independence in managing their diabetes, less stigma, and less time out of class Frequency, supervision, and implementation of testing should be covered in the students individualized health care plan Possible Causes of Hypoglycemia Low Blood Glucose Too much insulin Too little food Extra physical activity

Signs of Hypoglycemia–Low Blood Glucose
Mild Symptoms Hunger Shakiness Weakness Paleness Blurred vision Increased heart rate/palpitations Moderate to Severe Symptoms Yawning Irritability/frustration Extreme tiredness/fatigue Inability to swallow Sudden crying Sleepiness Changed behavior Sweating Anxiety Dilated pupils

Confusion Restlessness Dazed appearance Having a seizure or convulsion Unconsciousness/coma

Possible Causes of Hyperglycemia High Blood Glucose Too little insulin Expired insulin Food not covered by insulin Decreased physical activity Illness, injury Stress or emotions Other hormones Menstrual periods

Signs of Hyperglycemia–High Blood Glucose
Mild Symptoms Increased thirst
Increased urination Dry mouth Fatigue Numbness or tingling Agitation, fidgetiness, irritability Moderate Symptoms Decreased appetite Nausea Abdominal pain Severe Symptoms Continued vomiting Sleepiness Coma or unconsciousness Increased hunger Nausea Blurred vision Weakness Lack of concentration

Vomiting Sunken eyes Weight loss Very weak Deep breathing, fruity smell Possible ketones

Nutrition Planning
Although students with diabetes have the same nutritional needs as other students, there are special considerations for the school setting Structured meals and snacks contribute to optimal glucose control and assist in preventing hypoglycemia Timing of snacks is based on peak insulin action times when the insulin is most effective in lowering the blood glucose Therefore snacks must be allowed according to pre-scheduled daily snacks and/or for treatment of hypoglycemia Students with diabetes usually have an individualized meal plan based upon carbohydrate counting or an exchange system All meal plans are nutritionally sound and encourage the daily calorie requirements needed for optimal growth and development Carbohydrate counting involves calculating the
number of grams of carbohydrate or choices of carbohydrate the student eats This information, which can be obtained from nutrition information on food labels, is used to determine the amount of insulin the student needs to control blood glucose for any given meal or snack Carbohydrate counting is the preferred method for determining food choices and portion sizes The exchange system groups foods in six different lists, each with a set nutritional value A meal plan is prepared that recommends several exchanges or servings from each food group for each meal and snack The exchange list ensures that the meal plan is consistent in portion size and nutrient content while offering a wide variety of foods from each group Students using this approach consume a prescribed number of exchanges at meal and snack times The exchange lists include the following food groups: 1 bread/starch, 2 fruit, 3 milk, 4 vegetables, 5 meat/protein foods, and 6 fats The exchange system is not usually recommended for use in T1DM It is important for school personnel working with students who have diabetes to realize that any food eaten that contains carbohydrate must be worked into the meal plan, even if it is
labeled sugar free Also, some sugar substitutes add carbohydrates They can make blood sugar rise if they are not eaten as part of a meal plan

Physical Activity
Exercise and physical activity are critical parts of diabetes management Everyone can benefit from regular exercise, but it is even more important for a student with diabetes In addition to maintaining cardiovascular fitness and controlling weight, physical activity can help to lower blood glucose levels Students with diabetes should participate fully in physical education classes and team sports To maintain blood glucose levels within their target ranges during extra physical activity, students may make adjustments in their insulin and food intake To prevent hypoglycemia, they also may need to check their blood glucose levels more frequently while engaging in physical activity General guidelines for blood glucose levels before exercise should be over 100 and under 250 When the blood glucose level is over 300, a test for ketones should be done if authorized by the health care provider before exercising If ketones are positive, the student should not exercise

The student with diabetes should eat prior to exercising if
it has been more than two hours since the student has eaten It is best to exercise or take physical education classes 30-60 minutes after a meal to allow time for food to be absorbed A person with diabetes always needs to have a fast-acting sugar and a complex carbohydrate readily available for treatment of low blood sugar, along with plenty of water Physical education instructors and sports coaches should be able to recognize and assist with the treatment of hypoglycemia Exercise increases the flow of blood in general, but especially to the muscles that are being used the most Insulin is absorbed faster when there is increased blood flow to the exercising muscles For example, if the insulin is injected in the arm before a run or swim, it may be absorbed quickly and cause a low blood sugar Muscles use stored energy while exercising and after exercise, the muscles need to replace this stored sugar They do this by taking glucose out of the blood and this may continue for up to 12 hours after exercising Students using pumps may disconnect from the pump for sports activities If they keep the pump on, they may set a temporary, reduced rate of insulin while they are playing The students
individualized health care plan should include specific instructions for physical activity

Implications for Education
Students with diabetes should have adequate time for taking medication, checking blood glucose, and eating and school personnel should help eliminate barriers to these activities Students with hyperglycemia or hypoglycemia often do not concentrate well and blood glucose may need to be checked before and during academic testing Students also may need to have additional access to food or drink and the restroom If a serious high or low blood glucose episode occurs, a student may need to be excused with an opportunity for retake

Planning for Disasters and Emergencies
In the event of natural disasters or other emergency situations, students may need to stay at school The family, therefore, must provide an emergency supply kit containing a 72 hour supply of the following items as appropriate: Blood glucose meter, testing strips, lancets and batteries for meter Urine ketones strips Insulin and supplies Insulin pump and supplies, including syringes Other medications Antiseptic wipes Fast-acting source of glucose Carbohydrate-containing snacks Hypoglycemia food
supplies for 3 episodes: quick-acting sugar and carbohydrate/protein snacks Glucagon emergency kit

Parents must provide similar snacks and supplies for daily use

Potential Settings
As with all medical conditions, every effort should be made to protect the students privacy It is important for students to be able to check their blood glucose levels and respond to levels that are too high to too low as quickly as possible Accordingly, if recommended by the health care provider, students may be permitted to check their blood glucose level and respond to the results at any school location or at any school activity Taking immediate action is important so that the symptoms dont get worse and students dont miss time in the classroom Blood glucose monitoring does not present a danger to other students or staff members when there is a plan for proper disposal of lancets and other materials that come into contact with blood The family and the school should agree on the plan, which should be consistent with Standard Precautions and local waste-disposal laws The individualized health care plan should specify the level of supervision needed for testing and treatment

Staff Preparation
The
Code of Virginia Section 221-274 requires that if one or more students are diagnosed with diabetes, at least one or two school employees depending on the size of the school must be trained to administer insulin and glucagon The medical provider and parent must give written consent for any employee who is not a registered nurse, nurse practitioner, physician, or physician assistant to assist with the administration of insulin or glucagon If a registered nurse, nurse practitioner, physician, or physician assistant is present, no other school employee may administer insulin or glucagon All students with diabetes will need help with emergency medical care All school staff members, including bus drivers, who have responsibility for students with diabetes should receive training that provides a basic understanding of the disease and the students needs, how to identify medical emergencies, and whom to contact in case of an emergency Students also need a transportation plan

Components of the Individualized Health Care Plan
Each students IHCP must be tailored to the individuals needs Students also need a transportation care plan The following section covers procedures for diabetic
management as well as possible problems and emergencies that may arise The National Diabetes Education Program recommends developing a plan with three components: 1 the Diabetes Medical Management Plan DMMP, which contains the prescribed diabetes health care regimen, 2 a Quick Reference Emergency Plan describing how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs of these conditions are observed, and 3 an education plan explaining what accommodations, education aids, and services are needed A sample DMMP and Quick Reference Emergency Plan follow this section They may be copied and used to develop a plan for each student For a student with diabetes, the following items should receive particular attention: Diabetes Medical Management Plan Date of diagnosis Current health status

Emergency contact information Students willingness and ability to perform self-management tasks at school Lists of diabetes equipment and supplies with schedule for quality control checks of equipment Specific medical orders o Blood glucose monitoring o Insulin, glucagon, and other medications to be given at school o Meal and snack plan o Exercise requirements o
Additional monitoring, such as testing for ketones Typical signs, symptoms, and prescribed treatment for hypoglycemia Typical signs, symptoms, and prescribed treatment for hyperglycemia Latex allergy alert Standard precautions Anticipating the tasks to be done, the risk involved, and the personal protective equipment needed will enhance protection of both the caregiver and student

Quick Reference Emergency Plan Symptoms of hypoglycemia and hyperglycemia Actions to take when hypoglycemia or hyperglycemia occur Emergency contact information and phone numbers Education Plan Where and when blood glucose monitoring and treatment will take place Location of students diabetes management supplies Identification of trained diabetes personnel who can conduct blood glucose checking, insulin and glucagon administration, and treatment of hypoglycemia and hyperglycemia Unrestricted access to the restroom and water fountain Nutritional needs, including provisions for meals and snacks Full participation in all school-sponsored activities and field trips, with coverage by trained diabetes personnel Alternative times for academic testing if student is experiencing hypoglycemia or
hyperglycemia Flexible policies regarding absences for doctors appointments and diabetes-related illness Maintenance of confidentiality and the students right to privacy
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining

US Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Date of Plan:_______________________

Diabetes Medical Management Plan
Effective Dates:______________________
This plan should be completed by the students personal health
care team and parents/guardian It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel Students Name: _________________________________________________________________________ Date of Birth: ______________________________Date of Diabetes Diagnosis: ______________________ Grade: ____________________________________Homeroom Teacher: ____________________________ Physical Condition: Contact Information Mother/Guardian:_________________________________________________________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________________ Telephone: Home ___________________________Work _______________ Cell _____________________ Father/Guardian: _________________________________________________________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________________ Telephone: Home
____________________________Work _______________Cell ____________________ Students Doctor/Health Care Provider: Name: _________________________________________________________________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________________ Telephone: __________________________________Emergency Number: __________________________ Other Emergency Contacts: Name:__________________________________________________________________________________ Relationship: ____________________________________________________________________________ Telephone: Home ___________________________Work _______________ Cell _____________________ Notify parents/guardian or emergency contact in the following situations: Diabetes type 1 Diabetes type 2

________________________________________________________________________ ________________________________________________________________________
28

Diabetes Medical Management Plan Continued
Blood Glucose Monitoring Target range for blood glucose is 70-150 70-180 Other__________________________

Usual times to check blood
glucose __________________________________________________________ Times to do extra blood glucose checks check all that apply before exercise after exercise when student exhibits symptoms of hyperglycemia when student exhibits symptoms of hypoglycemia other explain: Can student perform own blood glucose checks? Yes No

Exceptions: _____________________________________________________________________________ Type of blood glucose meter student uses: ____________________________________________________ Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog /Regular insulin at lunch circle type of rapid-/short-acting insulin used is _____ units or does flexible dosing using _____ units/ _____ grams carbohydrate Use of other insulin at lunch: circle type of insulin used: intermediate/NPH/lente _____ units or basal/Lantus/Ultralente _____ units Insulin Correction Doses Parental authorization should be obtained before administering a correction dose for high blood glucose levels Yes No _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to
_____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl Can student give own injections? Yes No Can student determine correct amount of insulin? Yes No Yes No Can student draw correct dose of insulin? _____ Parents are authorized to adjust the insulin dosage under the following circumstances:_____________ _______________________________________________________________________________________ For Students With Insulin Pumps Type of pump: _____________________________Basal rates: _____ 12 am to _____ _____ _____ to _____ _____ _____ to _____ Type of insulin in pump: ___________________________________________________________________ Type of infusion set: ______________________________________________________________________ Insulin/carbohydrate ratio:________________ Correction factor: ___________________________________ 29

Diabetes Medical Management Plan Continued
Student Pump Abilities/Skills: Needs Assistance Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Count carbohydrates Bolus correct amount for carbohydrates consumed Calculate and administer corrective bolus Calculate and set basal profiles Calculate and set temporary basal rate Disconnect
pump Reconnect pump at infusion set Prepare reservoir and tubing Insert infusion set Troubleshoot alarms and malfunctions For Students Taking Oral Diabetes Medications Type of medication: ___________________________________________ Timing: ____________________ Other medications: ____________________________________________ Timing: ____________________ Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? Meal/Snack Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner Snack before exercise? Snack after exercise? Time ____________________ ____________________ ____________________ ____________________ ____________________ Yes Yes No No Yes No

Food content/amount _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________

Other times to give snacks and content/amount: ________________________________________________ Preferred snack foods: _____________________________________________________________________ Foods to avoid, if any:
_____________________________________________________________________ Instructions for when food is provided to the class eg, as part of a class party or food sampling event: _______________________________________________________________________________________ _______________________________________________________________________________________ Exercise and Sports A fast-acting carbohydrate such as___________________________________________________ should be available at the site of exercise or sports Restrictions on activity, if any: ______________________________________________________________ Student should not exercise if blood glucose level is below ____________ mg/dl or above _________ mg/dl or if moderate to large urine ketones are present 30

Diabetes Medical Management Plan Continued
Hypoglycemia Low Blood Sugar Usual symptoms of hypoglycemia:___________________________________________________________ _______________________________________________________________________________________ Treatment of hypoglycemia: ________________________________________________________________ _______________________________________________________________________________________
Glucagon should be given if the student is unconscious, having a seizure convulsion, or unable to swallow Route_______, Dosage_______, site for glucagon injection: _______arm, _______thigh, _______other If glucagon is required, administer it promptly Then, call 911 or other emergency assistance and the parents/guardian Hyperglycemia High Blood Sugar Usual symptoms of hyperglycemia: __________________________________________________________ Treatment of hyperglycemia: _______________________________________________________________ Urine should be checked for ketones when blood glucose levels are above _________ mg/dl Treatment for ketones: ____________________________________________________________________ Supplies to be Kept at School _______Blood glucose meter, blood glucose test strips, batteries for meter _______Lancet device, lancets, gloves, etc _______Urine ketone strips _______Insulin vials and syringes Signatures This Diabetes Medical Management Plan has been approved by: ____________________________________________________ Students Physician/Health Care Provider ___________________________ Date _______Insulin pump and supplies _______Insulin pen, pen needles, insulin
cartridges _______Fast-acting source of glucose _______Carbohydrate containing snack _______Glucagon emergency kit

I give permission to the school nurse, trained diabetes personnel, and other designated staff members of ______________________________ school to perform and carry out the diabetes care tasks as outlined by ________________s Diabetes Medical Management Plan I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my childs health and safety Acknowledged and received by: ___________________________________________________ ___________________________________ Students Parent/Guardian Date _______________________________________________________________________________________ Students Parent/Guardian Date
Source: US Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217, pages 49-52

Source: US Department of Health and Human Resources, National Diabetes Education
Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217, pages 53, 54

Procedure for Blood Glucose Testing
Note: Parent provides necessary equipment and supplies 1 Review directions for blood testing meter if not familiar with it 2 Wash hands 3 Assemble equipment: Alcohol prep pad Finger lancing device Blood glucose testing meter for example, Accucheck Advantage, Bayer Elite, Lifescan UltraOne Touch, Therasense Freestyle, etc Blood testing strips for specific electronic meter Tissue or cotton balls or spot bandage Gloves Student log 4 Wash hands and area to be tested with soap and water If the caregiver is performing the procedure, put on gloves Washing students hands and test site is sufficient for prepping the site; however, alcohol may be used for further prepping The site selected must be dry before pricking Alcohol may cause toughening of the skin or burning sensation If moisture water or alcohol remains on the skin it may alter test results 5 Place glucose testing strip into electronic meter according to manufacturers instructions 6 Prepare lancing device according to manufacturers instructions If school
personnel are performing the procedure, then a disposable lancing device must be used Some of the new meters allow testing on forearms The lancet device used for forearm testing is not disposable; therefore, the child may only use the forearm if independently able to use the lancing device 7 Select a site If using finger, use the top sides of fingertips Hang the arm below the level of the heart for 30 seconds to increase blood flow The tips of the fingertips may be more sensitive 8 Puncture the site with the lancing device Gently squeeze the finger in a downward motion to obtain a large enough drop of blood to cover the test pad on the test strip Avoid squeezing the site excessively because excess squeezing can contaminate the sample with tissue fluid and causes hemolysis of sample and trauma to the site 9 Place blood on testing strip and complete instructions according to manufacturers instructions Compress lanced area with tissue or cotton ball until bleeding stops 10 Dispose of test strip and tissue or cotton ball in lined wastebasket Dispose of lancing device in Sharps container 11 Remove and dispose of gloves Wash hands 12 Record results in student log Refer to students
individualized health care plan for actions Refer to the Quick Reference Emergency Plans on the preceding two pages for sample actions
Sources: American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Mild or Moderate Low Blood Glucose
Mild Symptoms Hunger Shakiness Weakness Paleness Anxiety Irritability Sweating Drowsiness Personality change Inability to concentrate Dizziness Moderate Symptoms Headache Behavior change Poor coordination Blurred vision Slurred speech Confusion

1 Observe/Recognize signs of low blood glucose Ask student to describe how he/she feels Refer to students individualized health care plan, if possible If student is unable to swallow, combative, uncooperative, unconscious, or having a seizure, proceed immediately to Procedure for Severe Low
Glucose Factors Which Can Lead to Low Blood Glucose Too much insulin Too little food Extra physical activity To prevent hypoglycemia: ALWAYS keep a fast-acting carbohydrate source with the student Treat low blood glucose at the onset of symptoms Eat, take insulin, test blood glucose, and exercise at the prescribed times Have an up-to-date individualized health care plan from students health care provider Ensure that food eaten matches insulin dosing Watch picky eaters Provide information to families about school meals, as well as snacks and classroom activities involving food Monitor blood glucose variations on gym days because an extra snack may be required hour before physical education or during prolonged vigorous exercise Never leave a student unattended when low blood glucose is suspected 2 Test blood for glucose See Procedure for Blood Glucose Testing If no blood glucose meter is available, treat immediately When in doubt, always treat If moderate symptoms, provide immediate adult supervision during testing 3 If blood glucose is below 80: Have student eat or drink one of the following fast-acting carbohydrates: 4 oz 1/2 cup fruit juice 2-4 glucose tablets chewed
thoroughly before swallowing 6 ounces of regular not diet soda about half a can 1 tube of glucose gel or cake decorating frosting 35

4 5

6 7 8 9

4-6 small hard candies 1-2 tablespoons of honey Treat on the spot The student should never be left alone or sent anywhere alone when experiencing hypoglycemia Students should be permitted to carry source of glucose with them at all times If blood glucose is above 80 and student is not feeling well, repeat test to verify results Observe for 10-15 minutes, then recheck blood glucose If blood glucose is over 80 and student is feeling better: Provide extra carbohydrate and protein snack if over 1 hour until lunch or snack time, if ordered in students individualized health care plan Resume classroom activities if fully recovered Repeat food if symptoms persist or blood glucose is less than 80 If no improvement, call school nurse and family If pupil becomes unable to participate in care, proceed immediately to Emergency Procedure for Severe Blood Glucose Document actions

Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American
Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining US Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Emergency Procedure for Severe Low Blood Glucose
Hypoglycemia/Insulin Reaction 1 Verify signs of severe low blood glucose: Unable to swallow Unconscious Combative Uncooperative Having seizures Signs are so severe that student cannot participate in care Factors Which Can Lead to Low Blood Glucose Too much insulin Too little food Extra physical activity To prevent hypoglycemia: ALWAYS keep a fast-acting carbohydrate source with the student Treat low blood glucose at the onset of symptoms Eat, take
insulin, test blood glucose, and exercise at the prescribed times Have an up-to-date individualized health care plan from students health care provider Ensure that food eaten matches insulin dosing Watch picky eaters Provide information to families about school meals, as well as snacks and classroom activities involving food Monitor blood glucose variations on gym days because an extra snack may be required hour before physical education or during prolonged vigorous exercise 2 Have someone call emergency medical services 911 in most areas, school nurse, and family Student should not be left unattended If seizure occurs, follow procedure for Managing a Seizure 3 Place student on side or in upright position if restless/uncooperative If on side, maintain head position to one side to prevent aspiration 4 Do not attempt to give food or put anything in the students mouth Student may aspirate or choke 5 Give glucagon injection, if ordered in students individualized health care plan See Procedure for Giving Glucagon on next page 6 If student becomes alert after receiving glucagon, stay with student until emergency services arrive Student may be given sips of fruit juice or regular soda
once awake and able to drink 7 Document in student log
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Glucagon
Definition
Glucagon is a hormone that occurs naturally in the body It is produced in the pancreas and raises blood glucose levels by causing the release of glycogen a form of stored carbohydrate from the liver that raises blood glucose levels

Purpose
Glucagon injections are prescription medications used to treat serious hypoglycemia If it is specified in the students individualized health care plan, glucagon should be used when the student is unconscious, having seizures, or cannot eat or drink safely Severe hypoglycemia can
cause brain damage or death Although it may cause nausea and vomiting when the student regains consciousness, glucagon is a life-saving treatment that cannot harm a student

Storage
The glucagon kit should be stored at room temperature in a place designated by the students individualized health care plan It may be kept b y the student The expiration date should be checked and it should not be administered if expired, discolored, or does not dissolve well It should not be mixed until it needs to be given Combine the glucagon for injection immediately before use by following the instructions that are included with the glucagon kit Expired glucagon kits can be used for training sessions
Source: American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining

Procedure for Giving Glucagon for Severe Hypoglycemia
Note: Parent provides necessary equipment, supplies, and medications 1 Verify signs of severe low blood glucose: Unable to swallow Unconscious Combative Uncooperative Having seizures Signs are so severe that student cannot
participate in care 2 Have someone call emergency medical services 911, school nurse, and family Student should not be left unattended If seizure occurs, follow procedure for Managing a Seizure 3 Place pupil on side or in upright position if restless/uncooperative If on side, maintain head position to one side to prevent aspiration 4 Obtain glucagon kit Wash hands if possible and put on gloves

5 Flip cap off glass vial bottle containing dry powder Remove needle cover from syringe

6 Take the fluid-filled syringe in the glucagon emergency kit and inject the fluid into the vial containing the glucagon powder Shake gently or roll to mix until all powder is dissolved and solution is clear Inspect medication for color, clarity, and presence of lumps Solution should be clear and colorless

7 Hold vial upside down and withdraw a prescribed amount of glucagon back into the syringe The prescribed amount should be specified in the students individualized health care plan Withdraw needle from vial Generally, if the student weighs 45 pounds, the full vial 1 cc of glucagon may be injected If the child weighs 45 pounds, inject of the solution 8 When possible, the injection site should be
exposed and cleaned However, glucagon can be administered through clothing, if necessary Suggested sites include the outer thigh, upper outer buttock, or arm 9 Inject needle straight into muscle of site and inject glucagon 10 Withdraw needle and press site with cotton ball or wipe Massage injection site for 10 seconds; apply bandage if needed 39

11 Do not recap syringe Put used syringe in sharps container 12 Stay with student It may take 15-20 minutes for student to regain consciousness 13 Recheck blood sugar Follow students specific instructions for response to results Some students may have a second injection of glucagon ordered if glucose remains low 14 Student may be given sips of fruit juice or regular soda once awake and able to drink May follow with snack containing proteins and carbohydrates such as peanut butter sandwich or cheese crackers to keep blood sugar levels elevated to normal levels and to prevent recurrence 15 Dont be surprised if student does not remember being unconscious, incoherent or has a headache Blood sugar may also rise over 200 and nausea or vomiting may occur Glucagon can cause nausea/vomiting 16 When emergency services arrive, student to be
transported for medical care 17 Document in student log
Sources: American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for High Blood Glucose
Hyperglycemia 1 Observe/Recognize signs of high blood glucose, although student may frequently be asymptomatic: Mild Symptoms Increased thirst Increased urination Dry mouth Fatigue Numbness or tingling Agitation, fidgetiness, irritability Hunger Nausea Blurred vision Weakness Moderate Symptoms Decreased appetite Nausea Abdominal pain/stomach cramps Vomiting Sunken eyes Weight loss Dry mouth Severe Symptoms Continue vomiting Sleepiness Coma or unconsciousness Deep breathing, fruity smell Possible ketones Factors Which Can Lead to High Blood Glucose hyperglycemia: Too little insulin Illness, injury Expired insulin Stress or
emotions Too much food for insulin taken Other hormones Decreased physical activity Menstrual periods Any combination of the above To prevent hyperglycemia: Eat, take insulin, test blood glucose, and exercise at the prescribed times Have an up-to-date individualized health care plan from students health care provider Ensure that food eaten matches insulin dosing Monitor food intake Report binge eating 41

2 3

4 5

6 7 8 9

Provide information to families about school meals, as well as snacks and classroom activities involving food Consult family when snack, meal, or exercise times must be changed and prior to extra snacks Take appropriate action if a missed dose is suspected or if an insulin pump malfunctions Avoid overtreating low blood sugar reactions Respect the student; realize their limits Test blood glucose See Procedure for Blood Glucose Testing Initiate care per health care providers orders for high blood glucose This may include insulin administration, checking for ketones, and possibly activity restriction exercising when ketones are present may elevate blood glucose levels even further Insulin administration during hyperglycemia may be referred to as a
sliding scale insulin order Refer to students individualized health care plan Check urine ketones if blood glucose 250 See Procedure for Testing Urine Ketones on next page Encourage student to drink water, generally 16-24 ounces over 2 hours or 8 ounces per hour Allow unrestricted use of the bathroom If student resumes classroom activities, he/she may need to use a water bottle in class to ensure adequate fluid intake If student is feeling okay, he or she may resume classroom activities If student does not feel well nausea, lethargy, headache, then the family should be called Recheck blood glucose according to students individualized health care plan If the student develops severe stomach pains, vomiting and/or rapid breathing, call emergency medical services, school nurse, and family immediately Document care in student log

Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at
wwwdiabetesorg/schooltraining US Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Testing Urine Ketones
When the body cant use glucose, it uses its own fat and muscle tissue for energy Ketones are acids that are left in the blood when fat is used for energy Symptoms of nausea, vomiting, and eventually, coma occur This is called diabetic ketoacidosis, also referred to as DKA, and may occur with hyperglycemia The body will try to get rid of ketones through the kidneys and lungs The ketones will show up in the urine and will also cause the breath to smell fruity Other symptoms include nausea, vomiting, and drowsiness If testing for urine ketones shows medium or large ketones present, extra insulin may be needed, if specified in the students
individualized health care plan, to reduce the level of ketones If ketones are not detected early, particularly during illness, they will build up in the body and DKA may result DKA is the number one reason for hospitalizing children with diabetes Early detection of ketones and treatment helps to prevent hospitalizations for DKA 1 Review directions for urine ketone testing if not familiar with it Wash hands 2 Assemble equipment: Bottle of ketone strips Urine cup 3 Saturate the test strip with urine by one of the following methods: Student urinates in cup, and then test strip is dipped into urine Student holds test strip in urine flow If assisting the student, wear disposable gloves during this procedure 4 Dip the ketone test strip in the cup containing urine 5 Wait the exact amount of time for test strip to develop, per directions on test strip bottle usually 15-60 seconds 6 Compare color of strip to chart on bottle Results will be read as negative, small, moderate, or large Refer to students individualized health care plan for actions Generally, if results are moderate or large, student should not engage in physical activity and family should be called to take student home for
observation and/or medical care If urine ketone results are trace or small, increase fluid intake 7 Record results in student log
Sources: American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Insulin
Definition
Insulin is a hormone constructed of proteins that is normally produced by the pancreas Synthetically manufactured insulin is produced for the person with diabetes who lacks this hormone Several days without insulin can cause a life-threatening condition of ketoacidosis, coma, and eventually death

Storage
Insulin can be affected by extremes in temperature, which can denature the protein and decrease or eliminate its effect Insulin remains stable at temperatures between 40-75 degrees Once insulin is opened, the date should be written on the vial Refer to students individualized health care
plan for instructions regarding storage Opened vials of insulin are sometimes left at room temperature for 30 days after opening, but will keep for 3 months if refrigerated Some health care providers recommend storing any opened insulin in the refrigerator and using for one month Unopened vials that are stored in the refrigerator are good until the expiration date Refer also to manufacturers instructions to ensure proper storage

Dosage and Administration
Insulin doses are measured in units There are 10 milliliters in one vial of insulin, which is equivalent to 1000 units One unit of insulin can alter a blood glucose level; therefore, it is imperative that the ordered dosage be EXACT The number of insulin units to be given is ordered by the childs licensed health care provider-physician or nurse practitioner The amount or dose of insulin will depend on several factors: body size, blood glucose levels, meal plan, and exercise A sliding scale may be used, that is, the number of insulin units to be given is based on the blood glucose reading Insulin injections are given subcutaneously area between the skin and the muscle Sites should be rotated to avoid scar tissue or fatty cell
growth under the skin

Types of Insulin
Insulin can be classified as rapid-acting, short-acting, intermediate-acting, or long-acting The different types vary in onset of action length of time the insulin takes to start working, peak action when the insulin has its strongest effect, and duration of action the length of time the insulin usually lasts Rapid-acting and short-acting insulin can be used for meal coverage or spot dosing and correction doses doses given in order to decrease an elevated blood glucose If an extra dose of rapid or short-acting insulin is given, the blood glucose should be checked approximately 30 minutes to 2 hours later, or as specified in students individualized health care plan Correction or spot doses should not be given closer than 2 hours apart Some insulin orders may call for the mixing of a short-acting insulin with a longer-acting insulin, but are usually not given during school hours See chart below for insulin action times:

Insulin Action Times Type Names of Insulin Rapid-Acting Short-Acting IntermediateActing Long-Acting Lispro Humalog Aspart Novolog Regular NPH Lente Ultralente Glarine Lantus

Onset of Action how long
before it starts to
work

Peak Action
when the insulin has the strongest effect

Duration of Action
how long the insulin usually lasts

5-15 minutes 5-15 minutes 30-60 minutes 2-4 hours 3-4 hours 6-10 hours 1 hour

30-90 minutes 1-3 hours 2-3 hours 6-10 hours 6-12 hours 10-16 hours peakless

2-4 hours 2-4 hours 3-4 hours 10-18 hours 12-20 hours 18-24 hours 24 hours

Insulin Delivery Systems
Insulin delivery methods include syringes, insulin pens, or insulin pumps In addition, syringes can be attached to several types of spring-loaded aids which make injection easier See procedure sections for insulin pens and insulin pumps for more information

Interactions with other Medications
The school nurse should be notified if additional medication is being used by the student Other medications can increase or decrease the effect of insulin
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining US
Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Insulin Administration by Syringe
Injection of Regular or Humalog/Novolog Insulin - no mixing with other insulins Staff training must be done by a registered nurse preferably a certified diabetes educator or physician preferably an endocrinologist Note: Parent provides necessary equipment, supplies, and medications 1 Wash hands 2 Assemble equipment: Vial of insulin Syringe with needle only use an insulin syringe Alcohol prep pad Cotton balls or spot bandage optional Gloves if done by anyone other than student Sharps container 3 If insulin is cold, warm in the palm of hand to room temperature Injecting cold insulin can cause pain and may affect absorption 4 If this is a new bottle of insulin,
remove the flat, colored cap Do not remove the rubber stopper or the metal band under the cap Check expiration date of the vial of insulin 5 Clean the rubber top of the insulin vial and let dry for a few seconds 6 Remove the cap from the syringe Fill the syringe with air equal to the number of units of insulin needed Inject air into Regular or Humalog/Novolog insulin bottle with syringe remaining in bottle, invert and pull plunger back beyond the number of units desired Keeping the syringe in an upright position, clear any air by pulling plunger back and tapping syringe to raise air bubbles to the top Push plunger to desired amount of units, ensuring that no air bubbles remain and withdraw the syringe Air is always injected into the vial to prevent creating a vacuum inside the vial as insulin is removed Air bubbles left in the syringe can alter the desired dose 7 Slip needle back into cap without touching cap or needle see procedure for One-Handed Needle Recapping if syringe must be recapped Select the site to be used and prep with alcohol and let dry If area is dirty, wash with soap and water and dry Any subcutaneous tissue can be used for injection sites The best absorption is in
the lower abdomen, followed by the upper, outer arms, tops of the thighs and lastly the upper areas of the buttocks Exercise and heat like the warmth from a heating pad or whirlpool also hastens absorption of an injected area 8 Pinch up skin and tissue with one hand With the other hand, hold the syringe, with the eye of the needle pointing upward, like a pencil Dart the needle into the soft pocket area that lies directly in front or in back of the pinched up skin at a 90 degree angle Inject insulin in one to five seconds Do not aspirate or pull back the plunger Release pinched up skin and remove needle while applying gentle pressure at the injection site for 10-15 seconds This will help to prevent leakage from the site Take care to avoid injecting into the muscle, as it will hasten absorption Do not massage the area as it irritates the tissue and hastens absorption 9 Dispose of syringe with needle intact into a sharps container Recapping a needle can result in a needlestick injury 10 Document in student log

Sources: American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To
Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Insulin Administration by Syringe
Injection of Two Types of Insulin Together Staff training must be done by a registered nurse preferably a certified diabetes educator or physician preferably an endocrinologist Note: Parent provides necessary equipment, supplies, and medications 1 Wash hands 2 Assemble equipment: Vials of insulin Syringe with needle use only an insulin syringe Alcohol prep pad Cotton balls or spot bandage optional Gloves if done by anyone other than student Sharps container 3 If insulin is cold, warm in the palm of hand to room temperature Injecting cold insulin can cause pain and may affect absorption 4 If this is a new bottle of insulin, remove the flat, colored cap Do not remove the rubber stopper or the metal band under the cap Check expiration dates of the vials of insulin 5 If NPH or Lente is used, it will require mixing Gently roll the bottle between the palms
or turn the bottle over from end to end a few times Do not shake If any clumps are visible, do not use Shaking can cause the protein to denature and decrease the potency Clumps are an indication that the protein has been denatured 6 Clean the rubber top of the insulin vial and let dry for a few seconds 7 Remove the cap from the syringe Fill the syringe with air equal to the number of units of intermediate or long-acting insulin needed Keep the bottle upright and inject air into the intermediate or long-acting bottle Pull empty syringe out of the bottle Air is always injected into the longer acting insulin first Air is always injected into the vial to prevent creating a vacuum inside the vial as insulin is removed 8 Inject air into Regular or Humalog/Novolog insulin bottle with syringe remaining in bottle, invert and pull plunger back beyond the number of units desired Keeping the syringe in an upright position, clear any air by pulling plunger back and tapping syringe to raise air bubbles to the top Push plunger to desired amount of units, ensuring that no air bubbles remain and withdraw the syringe Regular/Humalog/Novolog insulin is always drawn up first This avoids potential
contamination of longer acting insulin into the short acting which could delay the action time of regular insulin Air bubbles left in the syringe can alter the desired dose 9 Inject needle into intermediate or long-acting insulin bottle and withdraw exact number of units to be given Total number of units must equal the Regular/Humalog/Novolog unit dose plus the intermediate/long-acting insulin dose Example: 5 u Regular and 10 u NPH equals 15 total units If there is any air in the syringe after withdrawing the needle, attempt to clear If any insulin is inadvertently pushed out, the entire dose should be discarded and redrawn Avoid pushing the plunger up in the intermediate/long-bottle to rid air This could inadvertently push regular insulin up in to the intermediate/long-acting bottle and alter the entire dose 48

10 Slip needle back into cap without touching cap or needle See Procedure for OneHanded Needle Recapping if syringe must be recapped Select the site to be used and prep with alcohol and let dry If area is dirty, the wash with soap and water and dry Any subcutaneous tissue can be used for injection sites The best absorption is in the lower abdomen, followed by the upper,
outer arms, tops of the thighs and lastly the upper areas of the buttocks Exercise and heat like the warmth from a heating pad or whirlpool also hastens absorption of an injected area 11 Pinch up skin and tissue with one hand With the other hand, hold the syringe, with the eye of the needle pointing upward, like a pencil Dart the needle into the soft pocket area that lies directly in front or in back of the pinched up skin at a 90 degree angle Inject insulin in one to five seconds Do not aspirate or pull back the plunger Release pinched up skin and remove needle while applying gentle pressure at the injection site for 10-15 seconds This will help to prevent leakage from the site Take care to avoid injecting into the muscle, as it will hasten absorption Do not massage the area as it irritates the tissue and hastens absorption 12 Dispose of syringe with needle intact into a sharps container Recapping a needle can result in a needlestick injury 13 Document in student log
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with
Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining US Department of Health and Human Resources, National Diabetes Education Program June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Insulin Pen Delivery System
An insulin pen is an insulin delivery system that has the visual appearance of a writing pen; it consists of a cartridge holder insulin must be purchased in prescribed cartridges, a piston rod this is a screw mechanism that adjusts the desired dose, a dose indicator window dose is indicated by visual numbers, a push button this delivers the insulin, and a pen encasement The purpose if an insulin pen is to provide insulin with a convenient and accurate device at school Insulin pens will assist in preventing dose
errors that may occur with a syringe and vial Some pens can be purchased with the insulin cartridge already in place these are considered disposable pens and other pens require loading of a specific insulin cartridge Storage of cartridges may or may not require refrigeration Specific manufacturers instructions regarding handling and storage of insulin cartridges must be followed Staff training must be done by a registered nurse preferably a certified diabetes educator or physician preferably an endocrinologist Note: Parent provides necessary equipment, supplies, and medications 1 Obtain a blood glucose reading prior to insulin administration 2 Determine insulin dose with health care providers orders 3 Wash hands 4 Assemble equipment: Insulin pen device Pen needle Alcohol prep pad Cotton balls or spot bandage optional Gloves if done by anyone other than student Sharps container 5 Check insulin type/brand This must match health care providers orders 6 Check the level of insulin remaining in the insulin cartridge Cartridges are made for multiple doses Ensure that enough insulin remains in the cartridge for accurate dosing 7 Attach new needle Remove outer plastic cap and plastic
needle cap Place outer cap on a flat surface with open end facing up This will assist in needle disposal after insulin is given 8 Dial in two units of insulin to perform an air shot to prime the pump Insulin should appear at needle tip If it does not, repeat procedure Change in temperatures can cause air intake This procedure ensures that any accumulated air will be released, thereby ensuring accurate insulin dosage 9 Dial in prescribed dose 10 Cleanse skin with alcohol and allow to dry before injecting 11 Pinch up the skin at selected area and dart the needle into the soft pocket at a 90 degree angle The soft pocket lies directly in front of or in back of the pinched up skin 12 Inject insulin at a steady rate 13 Count slowly to three or five and then remove the needle Some pen manufacturers require a longer count 14 Grasping the pen, place the needle into plastic needle cap that was left upright on a flat surface Unscrew the needle tip and carefully discard into a sharps container 50

Do not lift the cap up with fingers to cover needle tip Leave cap on the counter and use the pen to place the needle into the cap to avoid possibility of fingerstick injury see Procedure for
One-Handed Needle Recapping The needle must be changed after each injection, as leaving the pen needle attached leaves an OPEN passageway into the insulin and contamination may occur 15 Document in student log Information about different insulin pens, along with contact information for their manufacturers can be found at wwwpedsonlineorg
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Insulin Pump Therapy
Definition
Insulin Pump Therapy is also referred to as Continuous Subcutaneous Insulin Infusion CSII The pump is worn outside the body and is about the size and weight of a pager It holds a reservoir of insulin inside the pump and is
programmed to deliver the insulin through a thin plastic tube called an infusion set The infusion set is inserted via a needle that is covered by a cannula just below the skin Once inserted, the needle is removed and the cannula stays in place for two to three days When it is time to change the infusion set, a new infusion set is inserted into a different site

Purpose
The goal of Insulin Pump Therapy is to achieve near normal blood glucose levels over 24 hours per day The use of CSII has been shown to improve growth in children, decrease the incidence of hypoglycemia, and decrease the incidence of long-term diabetes complications The advantages of CSII are that it affords more flexibility of lifestyle with less variability of insulin absorption, more precise insulin administration matched with food intake and activity levels, and overall close attention to diabetes management

Type of Insulin
The pump uses rapid-acting insulin such as Humalog or Novolog as opposed to conventional injections, which typically combine short and longer-acting insulins Insulin Pump Therapy combines a continuous basal rate of insulin for 24 hours and a bolus dose for meal or snack times and times of
high blood glucose Basal rate: Amount of insulin required when no food is eaten; a pre-programmed feature measured in units per hour U/H; can be altered based on the pumpers daily needs; can be temporarily changed for alteration in schedule activity, illness or food When the pump is programmed to give a dose of insulin for meals, snacks and /or for correction of elevated blood glucose

Bolus:

Pump Operation and Maintenance
The specific pump manufacturer instructions must be followed Manuals, booklets, and videos are usually available free of charge by calling the number listed on the back of the pump If the supply of insulin is interrupted due to mechanical pump failure, dislodgment of the cannula, accidental severing of the tubing, or clogged or obstructed tubing, the blood glucose level can rise quickly In case one of these incidents should occur, it is necessary for extra supplies to be kept at school to prevent or limit the subsequent hyperglycemia and possible ketoacidosis can occur in as little as 3 hours The pump can be disconnected using a quick release set This is usually done during water activities or contact sports 52

A card with the students name, pump model and
serial number, and the pump manufacturers help line phone number should be readily available in the health office for any problems that might occur A wallet-sized programming card and an alarm card or manufacturers instructions should also be available in the health office for reference

Insulin Pump Skills
Assessment of the following skills can be used in determining a students ability to independently manage Insulin Pump Therapy: Appropriately counts carbohydrates Calculates appropriate correction dose based on health care provider orders Calculates total dose based on health care providers orders for carbohydrate consumption and correction dose Programs appropriate bolus Adjusts temporary rate for exercise Disconnects and reconnects tubing Inserts new infusion set Uses standard precautions Fills reservoir and primes tubing Trouble shoots alarms appropriately Appropriately identifies high and low blood glucose levels Actions/responsibilities of student and/or parent when student independently manages Insulin Pump Therapy: Provide equipment, appropriate information, and medical provider orders to school Proper needle/catheter preparation and insertion Programming the
pump functions Reporting to school personnel school nurse any pump malfunctions dead batteries, high pressure alarm, no delivery, etc Delivering appropriate insulin amount based on blood glucose testing values, anticipated exercise and planned food consumption Caring for skin site Inserting a new set if tubing becomes dislodged Using standard precautions, including proper disposal of sharps and contaminated wastes Ensuring pump/tubing safety during physical activities If student chooses a quickrelease set during activities, he/she will ensure that normal blood glucose is maintained as much as possible checking blood glucose before, during, and after activities and taking extra carbohydrates as needed
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The
Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Hypoglycemia with Pump Therapy
1 Follow Procedure for Low Blood Glucose and student-specific instructions for low blood glucose while receiving insulin pump therapy Follow pump-specific directions if pump therapy must be suspended Even students who usually function independently may require assistance during hypoglycemia due to mental status changes School personnel working with diabetic students need to be able to recognize signs of low blood glucose and when to obtain assistance The pump can be programmed to suspend function during exercise so hypoglycemia can be avoided or extra carbohydrates can be consumed for every 30 minutes of exercise 2 If problems continue, notify the school nurse School nurse will notify family and/or health care provider according to students individualized health care plan 3 Document actions
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational
Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Procedure for Hyperglycemia with Pump Therapy
1 Check site for leakage, cannula dislodgement, redness and/or tenderness If any of these are present, have student change the site or call family to change the infusion set immediately Notify school nurse Redness and/or tenderness at the site may indicate obstruction The blood glucose can rise quickly since the delivery of short-acting insulin has been interrupted and there is no longacting insulin in the body 2 If student changes site, he/she must assemble equipment, prime tubing, prep the insertion site, and insert the infusion set using an insertion tool The cannula can be inserted using an insertion tool Some pump wearers use an infusion set such as Silhouette or Tender Twos that is inserted at an angle with a longer cannula This is used for those who have less body
fat The Sof-serter cannot be used with these sets 3 If student cannot change site and family is not available, then a back-up plan for insulin administration must be provided Refer to students individualized health care plan 4 Follow Procedure for High Blood Glucose previous section Student or parent may program a bolus to correct the hyperglycemia 5 Check blood glucose 30 minutes 2 hours after inserting a new infusion set and/or any correction bolus to ensure that blood glucose is responding to insulin It may be necessary to continue checking blood glucose levels periodically to prevent potential hypoglycemia 6 Document actions
Sources: American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at
school Available at wwwpedsonlineorg

Procedure for Pump Alarms
1 Troubleshoot alarms Follow manufacturers instructions for alarm indication A reference card can assist with troubleshooting steps of the manufacturers 800 number can be called listed on the back of the pump LOW BATTERY NO DELIVERY Insert new batteries according to instructions Check insulin reservoir If empty, have student or family refill it If cannula becomes obstructed or kinked, new infusion set must be inserted

2 If unable to restart pump function or troubleshoot pump, call school nurse so student can be monitored closely and receive appropriate care An injection of short-acting insulin may be ordered 3 Follow Procedure for High Blood Glucose if necessary 4 Document any incidents in student log Keep school nurse and parents informed of any issues at school Contact information for companies that manufacture insulin pumps: Animas 877 937-7867 http://wwwanimascorpcom Disetronic Medical Systems 800 280-7801 http://wwwdisetronicusacom MiniMed 800 646-4633 http://wwwminimedcom 24-hour clinical service phone line 800-826-2099
Source: Zombeck, Mary, in partnership with the California Department of Education and the
PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Resources for Teachers, Child Care Providers, Parents, and Health Professionals
American Diabetes Association 2003 Care of Children with Diabetes in the School and Day Care Setting Position Statement Diabetes Care 26: S131-S135 American Diabetes Association 2003 Children with Diabetes: Information for Teachers ChildCare Providers Alexandria, VA: American Diabetes Association brochure order code 5958-01 Available online at http://wwwdiabetesorg/uedocuments/C-ren-wdiabetes-brochure-caregiverspdf American Diabetes Association 2004 Diabetes Care in the School and Day Care Setting Position Statement Diabetes Care 27:S122-S128 American Diabetes Association 2004 Sample Section 504 Plan Diabetes Medical Management Plan for a student with diabetes Available online at http://wwwdiabetesorg/advocacy-andlegalresources/discrimination/school/504planjsp American Diabetes Association, 2000 Wizdom: A Kit of Wit and Wisdom for Kids with Diabetes and their parents Alexandria, VA: American Diabetes Association Available online at
wwwdiabetesorg/wizdom American Diabetes Association 2002 Your School Your Rights: Protecting Children with Diabetes Against Discrimination in Schools and Day Care Centers Alexandria, VA: American Diabetes Association brochure order code 5958-01 Available online http://wwwdiabetesorg/main/type1/parents_kids/away/scrightsjsp American Diabetes Association, in partnership with Metropolitan Educational Cooperative Service Unit 2003 Diabetes Care Tasks At School: What Key Personnel Need To Know Available at wwwdiabetesorg/schooltraining American School Health Association 2002 Health in Action: Diabetes and the School Community Available online at http://wwwashaweborg/minieditionpdf Copies can be obtained by contacting ASHA at 1-800-445-2745 Clarke W: Advocating for the child with diabetes Diabetes Spectrum 12:230236, 1999 National Diabetes Education Program, US Department of Health and Human Resources June 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel NIH Publication No 03-5217 Available at http://wwwndepnihgov/resources/schoolhtm Tappon D Parker M, Bailey W: Easy As ABC, What You Need to Know About Children Using Insulin Pumps in School Disetronic Medical
Systems, Inc, 1-800-280-7801 Virginia Department of Education Office of Special Education and Student Services 1999 Manual for Training Public School Employees in the Administration of Insulin and Glucagon Available online at http://wwwpenk12vaus/VDOE/Instruction/Health/insulin-glucagonpdf Zombeck, Mary, in partnership with the California Department of Education and the PADRE Foundation April 2002 The Diabetes School Resource Guide: A guide for managing students with diabetes at school Available at wwwpedsonlineorg

Source:doe.virginia.gov

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