“Helping the Student with Diabetes Succeed, A Guide for School Personnel”, U.S. Purpose: The Diabetes in Schools Workgroup was formed to identify information …

MAINE

GUIDELINE FOR SCHOOLS

Tools for Schools Who Have Students with Diabetes

August 2004

Preface: The Maine Guideline for Schools is intended to supplement two
important manuals for schools to address the needs of students with
diabetes:
Helping the Student with Diabetes Succeed, A Guide for School
Personnel, US Department of Health and Human Services, National
Diabetes Education Program NDEP, a joint program of the National
Institutes of Health and Centers for Disease Control and Prevention
2003 and found at http://ndepnihgov/materials/pubs/schoolguidepdf
and,
Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in
2001, with information on the web at http://wwwpedsonlineorg This
document is available for purchase or can be borrowed from the Maine
Health Education Resource Collection The web site is
wwwlibraryumaineedu/lmc/herc
Most
of the materials used in the Maine Guidelines for Schools are taken
from these sources It is expected that these two manuals will be the
schools primary sources for process and procedure in the management of
students with diabetes in a school setting The Maine Guideline excerpts
the most useful tools school nurses will need in order to manage students
at school It also provides additional guidance not covered by the two
Guidelines

Purpose: The Diabetes in Schools Workgroup was formed to identify
information and tools to assist schools in creating a safe environment for
students with diabetes The Workgroup intended that the information in the
Guideline will:
Assist students to achieve academically to their full potential,
Enhance opportunities for student to fully participate in school
activities,
Improve the quality of health care,
Provide standardization of care,
Support students as they move toward independence and self-management
of care, and
Encourage collaboration between school, family, student, and provider

Diabetes in Schools Workgroup Members:
Richard Aronson MD - Bureau of Health, Augusta
Marla Blake RN, MEd - School
Nurse, Mt Ararat High School, Topsham
Susan Chaffee RN - School Nurse, Penquis Valley High School, Milo
Barbara Dee - Special Education Director, Portland Public Schools
Kathy Hayes RN - School Nurse, Lincoln School, Augusta
Maurie Hill MS, RN, CDE - The Maine Center for Diabetes and Department of
Nursing Resources, Maine Medical Center, Scarborough
Mary Moody - Education Specialist, Department of Education, Augusta
Elaine Ouellette RN, PA - School Nurse, Van Buren District Secondary School

Pat Patterson MD - Department of Pediatrics, Barbara Bush Childrens
Hospital, Portland
Bonnie Stone RD, CDE - Mayo Regional Hospital, Dover-Foxcroft

Staff:
Lucinda Hale MS, RD, CDE - Bureau of Health, Diabetes Prevention and
Control Program
DeEtte Hall RN, MN - School Nurse Consultant, Department of Education

For information contact DeEtte Hall 207-624-6688 deettehall@mainegov or
Lucinda Hale 207-287-2907 lucindahale@mainegov

A special thank you to Donna Collins, Department of Education, who helped
prepare this document

Table of Contents

Diabetes
Overview
5

Actions for the School Nurse
7

Developmental Abilities in Diabetes Care
by
Age10

Expectations of the Student in Diabetes Care by Grade Level
11

Developmentally Age Appropriate Skills Check List for Diabetes
Care 12

Equipment and Supplies Checklist for Parents
13

Individualized Plan of Care for Students with Diabetes Instructions
15

Individualized Plan of Care

Individualized Plan of Care for Students with Diabetes Sample
17

Diabetes in School Care Plan /IHP
18

IHP for Student with Diabetes
19

Health Services Contract

IEP Sample Plan

Section 504 Student Accommodation
Plan 24

Suggested Accommodations for the Student with Diabetes
26

Delegation Oversight of Health Tasks to LPNs and Unlicensed School
Personnel 27

Frequently Asked Questions
27

Decision Tree for Nurse Delegation
29

Bus Driver Plan for Student with
Diabetes 30

Training Agreement for School
Staff 31

Outline for the Level of Care Needed to Perform Diabetes Procedures in
School 32

Checklist: Training School Personnel in Blood Glucose Testing
33

Emergency Guide for School Staff: Low Blood Glucose Management
Algorithm34

Procedure for Mild or Moderate Low Blood Glucose - For School
Nurses35

Emergency Procedure for
Hypoglycemia36

Checklist: Training
Unlicensed Staff in Hypoglycemia
37

Checklist: Training Unlicensed Staff in Glucagon Injection
38

High Blood Glucose Management for School Staff
39

Procedure for High Blood Glucose
40

Procedure for Blood Ketone Testing
41

Hyperglycemia Skills Checklist Training Record
42

Insulin Action Times

Insulin Pump
Therapy
44

Student Pump Skills Checklist
45

Student Independent Performance of Blood Glucose Testing and Insulin Admin

Sample Health Service Contract
46

Sample Health Services Contract - Insulin Pump
47

Daily Blood Glucose Tests Chart
48

Diabetes Monitoring Log for the Year
49

Blood Glucose Monitoring Log for the Year
50

School/Home Diabetes Monitoring Log for Insulin
Pump 51

Checklist: School Nurse with New Student with Diabetes in School
52

Resources
53

Diabetes ——- Overview

Diabetes is a disorder of metabolism - a chronic disease in which the
body does not make or properly use insulin, a hormone needed to convert
food into energy Because individuals with diabetes lack insulin, they
have increased blood glucose Glucose is the bodys main source of energy
After digestion, glucose passes into the blood stream, where it
is
available for cells to take in and use or store for later use
Insulin, produced by special cells in the pancreas, enables the cell
surfaces to allow glucose to enter the cells
In people who do not have diabetes, the pancreas automatically produces
the right amount of insulin to enable glucose to enter the cells Without
insulin, blood glucose levels rise The buildup of glucose in the blood
hyperglycemia is the hallmark of diabetes When the glucose level in
blood goes above a certain level, the excess glucose flows out from the
kidneys as it filters wastes from the bloodstream, into the urine The
glucose takes water with it, which causes frequent urination and extreme
thirst These two conditions - frequent urination and unusual thirst - are
usually the first noticeable signs of diabetes Weight loss often follows,
resulting from the loss of calories and water in urine A summary of
common symptoms of diabetes and factors that can affect blood sugar levels
in people with diabetes follows

Symptoms of High Blood Sugar that Characterize Diabetes
frequent urination including during the night
unusual thirst
extreme hunger/weakness
unexplained weight
loss
extreme fatigue
blurred vision
irritability
itchy skin
slow healing of cuts and bruises
frequent infections of skin/gums/vagina/bladder

Types of Diabetes
There are two main forms of diabetes This Guideline will focus
primarily on issues related to type 1 diabetes in children

Type 1 Diabetes
Type 1 diabetes is an auto immune disease that occurs during childhood
The immune system attacks the beta cells the insulin-producing cells of
the pancreas destroying them Daily insulin is necessary for survival
Food intake, activity levels and insulin control diabetes Approximately 5-
10 of all people with diabetes have type 1 diabetes, translating to
approximately 1 student per 400
An individualized plan of care must be developed for each student as
each childs status and life events vary For the plan of care to be most
successful, an insulin regimen will be tailored to the needs of the child,
as will a meal plan and recommendations for physical activity Diabetes
management allows people with diabetes to be more liberal with food
planning than in the past Individuals who have good control are less
likely to experience complications from
diabetes
Children with diabetes must be allowed to participate fully in all
school activities They need the cooperation and support of school staff
members to help them with their plan of care
Blood glucose monitoring is essential to help assess how well the plan
of care is working Most children can perform blood glucose checks by
themselves but may need supervision to see that the procedure is done
properly and results are recorded accurately The child must have a meter
at school so their blood glucose can be checked when needed How often the
children check their blood or whether they check at school at all are
decisions made in conjunction with the child, family, health provider and
school personnel
It is the school administrations responsibility to ensure that staff
members, including nursing staff have adequate training and updated skills
in order to assist students with diabetes The school nurse must recognize
when he/she needs additional training to perform a particular procedure and
can help determine where the appropriate training can be obtained

Type 2 Diabetes
Type 2 diabetes is the most common form of the disease, representing 90-
95 of people with
diabetes This form of diabetes is a result of the
bodys inability to use insulin well The body needs increasing amounts of
insulin to control blood glucose Although type 2 diabetes is most often
found in individuals after age 40, recent trends are finding Type 2
diabetes in children, adolescents and young adults

The Path Toward Type 2 Diabetes
In adults, one of the greatest risk factors for type 2 diabetes is
excess weight The same is likely true for children Science is pointing
to multiple factors as reasons for the increase, such as, higher calorie
intake and less physical activity As an individual gains weight, the
extra weight causes the cells of the body to become resistant to the
effects of insulin The pancreas responds by producing more and more
insulin, which eventually begins to build up in the blood High levels of
insulin in the blood, a condition called insulin resistance, may cause
problems such as high blood pressure and harmful changes in the levels of
different fats cholesterol in the blood Insulin resistance, is the
first step on the path to type 2 diabetes
The second step to type 2 diabetes is a condition called impaired glucose
tolerance Impaired
glucose tolerance occurs when the pancreas becomes
exhausted and can no longer produce enough insulin to move glucose out of
the bloodstream into cells Glucose begins to build up in the blood It
if is not diagnosed and not treated, this gradual rise in glucose often
leads to type 2 diabetes, high blood pressure, and heart disease
While all these harmful activities are going on inside the body, the
affected individual may feel perfectly fine Type 2 diabetes is considered
a silent disease because it works its destruction over many years without
causing any noticeable symptoms Thats why half of the people who have
type 2 diabetes dont know it

Clarification - For the purposes of this Guideline, references to Primary
Care Provider PCP includes diabetes specialists, who provide medical care
for the students diabetes

ACTIONS for the School Nurse

Obtain and review the students current diabetes individualized
care of plan from their health care provider and pertinent
information from the family

Facilitate the initial school health team meeting to discuss
implementing the students individualized plan of care and
refer to
and participate in the development and implementation of the
students 504 Plan, IEP, or other education plan, as appropriate
Monitor compliance with these plans and facilitate follow-up
meetings of the school health team to discuss concerns, receive
updates, and evaluate the need for changes to the students plans,
as appropriate

Conduct a nursing assessment of the student and develop an
Individual Health Plan Many school nurses already have systems
set up to develop nursing care plans for students with a chronic
diseases The plan for students with diabetes is based on
assessment of the student, input from the parents/guardian and the
student, and the diabetes medical management plan For example,
the Individual Health Plan will identify specific functional
problems, establish a goal to overcome each problem, and delineate
tasks or interventions to help reach the goals

Conduct ongoing, periodic assessments of students with diabetes and
update the Individual Health Plan

Coordinate development of the students Quick Reference
Emergency
Plan and provide copies to staff members who have responsibility
for the student throughout the school day eg, teachers, coach,
PE instructor, lunchroom staff, and bus driver in compliance with
the students rights of confidentiality Review the Emergency Plan
with substitute teachers, bus drivers and school nurses

Obtain materials and medical supplies necessary for diabetes care
tasks from the parents/guardian and arrange a system for notifying
the student or parents/guardian when supplies need to be
replenished Also consider frequent daily if appropriate
communication with parents depending on the students developmental
age

Plan and implement Diabetes Management Training for the school
nurses and staff members with responsibility
for the student with diabetes who require such training Ensure
that all those mentioned in the 504 Plan, IEP, or other education
plans, know their roles in carrying out the plan, how their roles
relate to each other, and, when and where to seek help

Participate in Diabetes
Management Training provided by health care
professionals with expertise in diabetes and attends other
continuing education offerings to attain and/or maintain knowledge
about current standards of care for children with diabetes The
certified school nurse assigned to the school or school district,
is the key school staff member who coordinates the provision of
health care services for a student with diabetes at school and at
school-related activities When notified that a student with
diabetes is enrolled in the school, annually or more often as
necessary, the school nurse will:

o Review the information about diabetes in current guidelines
Helping Students with Diabetes Succeed and Pediatric
Education for Diabetes in Schools See information in
preface

o Distribute the Diabetes Primer Guide to all school personnel
who have responsibility for students with diabetes Found in
Helping Students with Diabetes Succeed

o Train or oversee training of, assess competence, and
monitor trained
diabetes personnel in carrying out the health
care procedures defined in the Individual Health Plan, 504
Plan, IEP, or other education plan

o Perform routine and emergency diabetes care tasks, including
blood glucose monitoring, urine ketone testing, insulin
administration, and glucagon administration

o Practice universal precautions and infection control
procedures during all student encounters

o Maintain accurate documentation of contacts with students and
family members; communications with the students health care
provider; and direct care given, including medication
administration; and the training and monitoring of trained
diabetes personnel

o Collaborate with other co-workers eg, food service and
agencies eg, outside nursing agencies, school bus
transportation services as necessary to provide health care
services

o Act as liaison between the school and the students health
care provider, with signed Health Insurance Portability and

Accountability Act parental permission, regarding the
students health care and self-management at school

o Communicate to parents/guardian any concerns about the
students diabetes management or health, such as acute
hypoglycemia episodes, hyperglycemia, general attitude, and
emotional issues

o Promote and encourage independence and self-care consistent
with the students ability, skill, maturity, and development
level

o Respect the students confidentiality and right to privacy

o Act as an advocate for students to help them meet their
diabetes health care needs
o Provide education and act as a resource on managing diabetes
at school to the student, family, and school staff
Establish and maintain an up-to-date resource file of
pamphlets, brochures, and other publications for school
personnel

o Assist the classroom teacher with developing a plan for
substitute teachers

o Be knowledgeable about federal, State, local laws,
and
regulations that pertain to managing diabetes at school

Helping the Student with Diabetes Succeed a Joint Program of the National
Institutes of Health and the Centers for Disease and Prevention, US
Department of Health and Human Services, 2003

Developmental Abilities in Diabetes Care

By Age

Age 4 - 5

Knows likes and dislikes
Can tell where injection should be
Can pinch skin
Collects urine for ketones
Turns on meter
Helps with recording
Identifies with high and low reading

Age 6 - 7

Can begin to tell carbohydrate content of
food
Knows which ones to limit
Can begin to help with aspects of injection
Can prick finger
Needs many reminders and supervision

Age 8 - 10

Can select food according to criteria
Knows if food fits diet plan
May begin to do own shots
Can do blood tests with supervision
Can keep records
Can do own urine test with supervision
Needs many reminders and supervision
Understands only immediate consequences
of diabetes control, not long term
Scientific mind developing-intrigued by

Age 11 - 13

Helps plan meals and snacks
Can see blood test
results forming a pattern
Still needs help with interpreting urine test
May be somewhat rebellious
Concerned with being different
Peer pressure influencing decisions

Age 14

Able to identify appropriate foods and
portion sizes
Can mix two insulins
Can begin to use test results to adjust insulin
Knows consequences of poor diabetes control but often has feelings of
immortality
Independence and self-image important
Rebellion continues
Strong peer pressure
May be resistant to testing for urine ketones

tests

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Expectations of the Student in Diabetes Care

by Grade Level

Children should be able to participate with parental consent in their
diabetes care at school to the extent that is appropriate for the childs
development and his/her experience with diabetes The extent of the
childs ability to participate in diabetes care should be agreed upon by
the school personnel, the parent/guardian, and the health care team, as
necessary

1
Preschool and day care:
The preschool child is usually unable to perform diabetes tasks
independently By 4
years of age, children may be expected to generally cooperate in
diabetes tasks

2 Elementary school:
The child should be expected to cooperate in all diabetes tasks at
school By age 8
years, most children are able to perform their own fingerstick blood
glucose tests with
supervision

3 Middle school or Junior High school:
The student should be able to perform self-monitoring of blood
glucose under usual
circumstances when not experiencing a low blood glucose level By 13
years of age,
most children can administer insulin with supervision

4 High school:
The student should be able to perform self-monitoring of blood
glucose under usual
circumstances when not experiencing low blood glucose levels In high
school, most
adolescents can administer insulin with supervision

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Developmentally Age Appropriate Skills Check List for Diabetes Care

School
_______________________________

Student _______________________________ Date ___________________

This checklist is part of the school nurses assessment that will be
completed with the parent/care provider Tasks that the student is
able to complete are checked off School personnel can be trained to
observe tasks using this checklist as a resource

Blood Glucose Testing:

____ Turns on meter
____ Able to code meter, if required
____ Inserts testing strip into meter
____ Operates lancing device
____ Lances finger or forearm
____ Places blood onto strip
____ Disposes of testing strip properly
____ Records blood glucose reading

Ketone Testing:

____ Collects urine in a cup for ketone test
____ Dips testing strip into urine
____ Interprets color of strip
____ Records result

Insulin Administration:

____ Selects appropriate injection site
____ Cleans site
____ Draws up insulin
____ Pinches up skin for injection
____ Injects needle
____ Pushes plunger in
____ Uses blood glucose test
results to adjust insulin

Nutrition:

____ Knows when to eat snacks
____ Eats snacks promptly
____ Knows carbohydrate content of food
____ Aware of foods to limit or restrict
____ Selects appropriate food on meal plan

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001

Equipment and Supplies Checklist for Parents

Student: _______________________________________ DOB: _________________
School: ________________________________________ Grade: ________________

Equipment and Supplies to be Provided by Parent

Parent Signature _____________________________________________ Date
__________

Daily Snacks for AM/PM snack times: Specify:
___________________________________

Extra Snacks for before, after, and/or during exercise Specify type of
snacks:
____________________________________________________________________________

Glucose Meter Kit Brand/Model:
_______________________________________
Includes meter, testing strips, lancing device with lancet, cotton balls,
spot bandages

Low Blood Glucose Supplies Provide item from
selected category - 5 day
supply preferable
o Fast acting carbohydrate drinks: Apple juice and/or orange juice,
sugared soda -NOT diet
o Glucose tablets: 1-2 packages preferred
o Glucose gel products: Insta-Glucose, Monogel or Glutose/25 - 31gms
1-2 preferred
o Gel Cakemate:not frosting, 19 gm, mini-purse size, 1-2 preferred
o Prepackaged snacks: such as crackers with cheese or peanut butter,
Nite-Bite, etc
High Blood Glucose Supplies Check those that apply
o Ketone test strips/bottle or meter kit
o Urine cup
o Water bottle
Note: Timing device may be wall clock or watch worn by pupil or personnel
Insulin Supplies
o Insulin pen
o Insulin and syringes
o Extra pump supplies, such as infusion set
o Vial of insulin, syringes
o Pump cartridge
o Batteries
o Tape
o Insertion device
Insulin supplies storage location:
_________________________________________________

Emergency Supplies
o Glucagon kit stored:
___________________________________________________
Expiration date of glucagon vile:
_____________________________________

Recommended 3 Day Disaster Diabetes Supplies
Check those that apply
o Vial of insulin; 6 syringes, or
o Insulin pen with cartridge and needles
o Blood glucose testing kit testing strips, lancing device with
lancets - if authorized
o Glucose gel product and glucose tablets
o Glucagon kit
o Food supply include daily meal plan stored as follows:
________________________
o Ketone strips/plastic cup - if authorized
o Pump supplies, as listed above
o Extra battery for pump
o Other Supplies - specify:
_____________________________________________________________

Date Form sent home ________________
Date Form returned to school __________
School will include a copy of the IHP for diabetes management with the
disaster supplies
Stored as follows:
____________________________________________________________________________

____________________________________________________________________________
_______________

Individualized Plan of Care for Students with Diabetes
Instructions

Every student with diabetes must provide a written order from their
physician/health provider for the school nurse to carry out the plan of
care The
Individualized Plan of Care for Students with Diabetes is
suggested as a standard plan to be used for all students with diabetes

Instructions:
The plan of care is to be developed by the physician/health provider and
updated as needed but at least annually

The adjustments for illness/activities provides an order for the school
nurse to change the insulin dose to accommodate the students need for dose
adjustment during illness or changes in physical activity Although this
is a physician order for the school nurse, it is recommended that changes
in insulin dose be made in consultation with the parent/guardian

The school nurse is responsible for actions taken to carry out the plan

If the school nurse has concerns or questions in providing care to the
student, contact should be made with the provider or diabetes center

Possible Side Effects
Insulin - Possibility of low blood sugar

Glucagon - The student may vomit following Glucagon administration If
unconsciousness, turn child on side to protect the airway If student is
seizing, do not attempt to put anything in their mouth

INDIVIDUALIZED PLAN OF CARE FOR STUDENTS WITH DIABETES

|Home and School Care Instructions
|

Name: ______________________________________________ Date:
______________________

Weight: ______ Height: _______ DOB: _________ School
___________________________________

School Nurse __________________________________________ School Fax
________________________

PLAN: Multiple Daily Injections: ____ Pump: ____ Adjustment
for illness / activity / other
factors affecting BG
values /- 50

Basal Bolus: Base Dose
Basal Bolus: Base Dose or
or Insulin to Carb Rato
Insulin to Carb
Ratio
Breakfast___________________________________________________________________
__________
AM
Snack_______________________________________________________________________
______
Lunch
____________________________________________________________________________
____
PM
Snack_______________________________________________________________________
______
Supper
____________________________________________________________________________
___
Bedtime_____________________________________________________________________
__________

Pump Basal Rates: Time Units/hr Time Units/hr
12 MN ______ 12 MN
______________
_____ ______ _____
______________
_____ ______ _____
______________
_____ ______ _____
______________
_____ ______ _____
______________
_____ ______ _____
______________
Total Basal ______units Total Basal
________________units

Supplemental Correction
Scale:
Day
____________________________________________________________________________
___
Evening and 2-3 AM
__________________________________________________________________
Other
____________________________________________________________________________
__

Blood sugars need to be checked before: Brkfst Bus AM
Snack Lunch
PM Snack PE Getting on the bus Supper
Bedtime Other

Meal Plan Optional: Urine Ketones:
Target Blood Sugar:

I authorize the school nurse to carry out the orders defined in the plan of
care
Physician/Provider Signature: _____________________________________ Date:
________
Phone: __________ Fax:__________ Next Appt: _______________ Other:
___________________________

INDIVIDUALIZED PLAN OF CARE FOR STUDENTS WITH DIABETES

|Home and School Care Instructions |

Name: ______James Smith_______________________
Date:
______9/4/04___________________

Weight: ___60 Kg_______ Height: __140 cm__ DOB: __11/14/93 School
__George E Jack_______
School Nurse ____________________________________________ School Fax
_______________

PLAN: Multiple Dose Injection: _X__ Pump: ____ Adjustments for
illness/activity/other
factors affecting BG values
/- 50
Basal Bolus Basal Bolus
Breakfast ______________8 units Novolog_____________________/- 4
units____________________
AM Snack ______________0 units Novolog ____________________/-
0________________________
Lunch ______________7 units_Novolog ____________________/-
35_______________________
PM Snack ______________3 units_Novolog____________________/- 15_ grms
CHO____________
Supper 15 units Lantus__8 units Novolog _____/- 75 unit
L_____/- 4_________________________
Bedtime ______________2 units Novolog ____________________/-
1_________________________
Low blood sugar is a possible side effect of giving insulin

Pump Basal Rates: 12 MN _09, 12 MN 045 -
135

3 AM 12 3 AM 06 - 18

7 AM 12__ 7 AM 06 - 18
11 AM 10__ 11 AM 05 - 15
5 PM 11__ 5 PM 055 -
165
10 PM 09__ 10 PM 045 - 135
Total Basal: _24 units___ Total Basal 12 -
36 units

Supplemental Correction Scale:
Daytime _1 unit/40mg/dl_ 200_____________________________________/-
20/dl____________________
Bedtime and 2 - 3 AM__Unit/40 mg/dl
200________________________NA___________________________
Other
____________________________________________________________________________
________

Blood Sugar checked before: Brk AM Bus AM Snack Lunch
PM Snack PE PM Bus Supper Bedtime Other

| |Total Carbs |
|Breakfast |45 g |
|AM Snack |15 g |
|Lunch |60 g |
|PM Snack |30 g |
|Dinner |75 g |
|HS Snack |30 g |

Meal Plan: Urine Ketones Target Blood
Sugar:

I authorize the school nurse to carry out the orders defined in the
Individulized Plan of Care
Physician/Provider Signature:
______________________________________________________ Date: ________
Phone: _______________________ Fax: ___________________ Next App;t:
______________

Individual Health Plan for Student with Diabetes in School

Every student with diabetes should have a written Individual Health Plan
that includes an Emergency Care Plan The IHP should be developed by the
school nurse in collaboration with the student, family, and providers
Developing the plan prior to the students attendance at school is
preferable The plan should be changed as needed and reviewed at least
annually Information from the plan is intended to be shared, with
permission from parents/guardian or eligible student, with school staff who
need the information to assure the health and safety of the student The
students health provider must sign medical orders at least yearly

According to the Nurse Practice Act, registered
professional nurses may
only accept medication orders from the health providers licensed to
prescribe medication This includes diabetes specialist licensed to adjust
medications Adjustment in medication orders must be made by the provider
and can not be accepted from the parent/guardian or other unlicensed
individual

The school nurse is accountable for the quality of the health care he/she
provides and for the training and supervision of unlicensed staff
performing health tasks The preparation of the health plan will help
assure quality of care The school nurse has the responsibility of
counseling and coordinating with the students parents, primary care
provider, student and teacher to assure a safe learning environment

When the student has a substitute teacher or attends a field trip,
appropriate information about the students health needs and how to respond
to an emergency situation, must be provided to responsible staff to assure
the safety of the student The students bus driver should also be aware
of the students health needs and be informed of their responsibility

Helping the Student with Diabetes Succeed provides an overview for
training unlicensed staff and
information on the roles of school personnel
with students with diabetes

SAMPLE

Individual Health Plan IHP for Students with Diabetes
School Year _________________________

Name of Student ___________________________________ School
_______________________________ Date _________
To be completed by parent/health care team and reviewed with necessary
school staff Copy should be kept in school health record and in the
classroom
Date of Birth _________ Grade ______ Teacher
_________________________________ Date of Diagnosis ____________
Classroom Teacher
____________________________________________________________________________
_________
Contact Information:
Parent/Guardian 1 __________________________________ Address
__________________________________________
Telephone: Home _______________________ Work _______________________ Cell
Phone ________________________
Parent/Guardian 2 __________________________________ Address
__________________________________________
Telephone: Home _______________________ Work _______________________ Cell
Phone ________________________
Students Doctor
______________________________________ Phone
___________________ Fax ___________________
Address
____________________________________________________________________________
__________________
Diabetes Educator ____________________________________ Phone
___________________ Fax ____________________
Other Emergency Contact ______________________________________________
Relationship _____________________
Telephone: Home ______________________ Work ________________________ Cell
Phone ________________________
Notify parent/guardian in the following situations:
__________________________________________________________
____________________________________________________________________________
__________________________
Blood Glucose Monitoring
Target range for blood glucose: _____ mg/dl to _____ mg/dl Type of
blood glucose meter __________________________
Times to routinely check blood glucose:
_____________________________________________________________________
Times to do extra tests check all that apply ______ Before Exercise
______ With signs of hyperglycemia
______ After Exercise ______ With
signs of hypoglycemia

______ Other explain
_________________________________________
Can student perform own blood glucose tests? Yes No Exceptions
___________________________________
_____ No blood glucose testing at school
School personnel trained to monitor blood glucose level
________________________________________________________

Insulin/Diabetic Medication
Times, types and dosages of insulin injections/Medications:
Given at
Time Name of Insulin/Medication Dosage Home
School
_____ _________________________________________ __________________
__________ __________
_____ _________________________________________ __________________
__________ __________
_____ _________________________________________ __________________
__________ __________
_____ _________________________________________ __________________
__________ __________
School personnel trained to assist with insulin injections
_______________________________________________

Can student give own injections? Yes No
Can student determine correct amount of insulin? Yes No
Can student draw correct dose of insulin?
Yes No
____________________________________________________________________________
________________
Meals and Snacks Eaten at School The carbohydrate content of the food is
important in maintaining a stable blood glucose level
Time Amount of Carbs Number of Grams

Breakfast _________
_________________________________________________________________

AM Snack _________
_________________________________________________________________

Lunch _________
_________________________________________________________________

PM Snack _________
_________________________________________________________________
Individual Health Plan Continued

For Students with Insulin Pumps Only

Type of Insulin Pump
____________________________________________________________________

Basal Rates: 12 AM to _________ _________

_________ _________ to _________ _________

Type of Infusion
set:
____________________________________________________________________

Insulin/ Carbohydrate ratio:
_______________________________________________________________

Correction Factor:
_______________________________________________________________________

Student Skills with pump ______ ________________
Needs Assistance

1 Counting carbohydrates _____Yes
_____No

2 Can Bolus correct amount for carbohydrates consumed
_____Yes _____No

3 Can Calculate and administer corrective bolus
_____Yes _____No

4 Can Calculate and set temporary basal rates
_____Yes _____No

5 Able to Disconnect pump _____Yes
_____No

6 Able to Reconnect pump at infusion set
_____Yes _____No

7 Able to Prepare reservoir and tubing
_____Yes _____No

8 Able to Insert infusion set _____Yes
_____No

9 Can Troubleshoot alarms and malfunctions _____Yes

_____No

10 Can Troubleshoot causes of high Blood Sugar
_____Yes _____No

Snacks: ____Mandatory ____At students discretion

Circumstances under which student should disconnect
pump________________________________________
____________________________________________________________________________
_____
Back-up battery given to School Nurse - Yes [ ] No [ ]
Supply of insulin, syringes, and ketone sticks available if pump fails -
Yes [ ] No [ ]
Other information the school nurse needs to be aware of in dealing with
pump
_______________________________________
____________________________________________________________________________
__________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________

Physical Education
1 Time and Days PE Scheduled
________________________________________________________
2 Is snack needed before PE Class? YES NO If Yes, give
_______gram of carbs
3 Is a snack needed before any other exercise? YES NO If Yes,
give _______grams of carbs
4 Is a snack needed after exercise? YES NO If Yes,

give _______grams of carbs
A snack such as
________________________________________________________should be available
at the site of exercise or sports Preferred snack foods:
___________________________________________________________
Foods to avoid if any:
___________________________________________________________________
Restrictions on activity, if any:
____________________________________________________________
Instructions for class parties:
______________________________________________________________
____________________________________________________________________________
__________
Student should not exercise if blood glucose below ___ mg/dl or above___
mg/dl or if ketones are present

Hypoglycemia Low Blood Sugar
Usual symptoms of hypoglycemia?
_________________________________________________________
____________________________________________________________________________
__________

TO TREAT LOW BLOOD SUGAR:
___Self treatment of mild lows If Glucose _______________Give
____________________________
___Assistance for all lows If Glucose _______________Give
____________________________

Glucagon should be given if the student is unconscious, having
a
seizureconvulsion or unable to swallow If required, glucagon should be
administered promptly and then Call 911, parents and School Nurse
Glucagon Dose ____05mg ____1mg
School personnel trained to administer glucagon and dates of training:
_____________________________

Hyperglycemia High Blood Sugar
Usual symptoms of hyperglycemia?
_________________________________________________________
____________________________________________________________________________
__________

TO TREAT HIGH BLOOD SUGAR
If Glucose _____to _____ Give ______units of ___________ Check for
Ketones if glucose above _____
If Glucose _____to_____ Give ______units of ___________ If Ketones
positive, call parent

Location of supplies: Blood glucose monitoring equipment
__________________________________
Insulin administration supplies ______________________ Glucagon Emergency
Kit __________________
Ketone testing supplies ____________________________Snack Foods
_________________________
Personnel trained in the symptoms and treatment of low and high blood sugar
and dates of training:
____________________________________________________________________________
__
Bus Transportation: _____
Blood glucose test not required prior to
boarding bus _____
Test blood glucose 10-20 minutes before boarding bus IF glucose is
_______mg/dl give 15 gm of carbs

This Diabetes Medical Management Plan has been approved by:

__________________________________________ __________________
Students Health Care Providers Signature
Date
I give permission to the school nurse, trained diabetes personnel and other
designated staff members to perform and carry out the diabetes care tasks
as outlined by this medical management plan I also consent to the release
of the information contained in this Individual Health 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 I
will notify the school nurse if there is any change in my childs health
status and provide copies of any changes in doctors orders
Acknowledged/received by: ______________________________________
__________________
Parent/Guardian Signature
Date
Reviewed by: _______________________ _________
_________________________ __________

School Nurse Date School
Principal Date

I agree to allow the school nurse to communicate with my childs health
care providers regarding my childs diabetes

___________________________________________________
_______________________
Parents Signature
Date

HEALTH SERVICES CONTRACT
A copy of this contract will be attached to the Individualized Healthcare
Plan

STUDENT: __________________________________________________ DATE:
___________

School ___________________________________________

The initials of the parties signed below indicate specific individual
responsibilities in agreement to:

____ the student will:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________
____ the parent
will:
____________________________________________________________________________
____________
____________________________________________________________________________
____________________________________________________________________________
________________________
____ the school nurse will:
____________________________________________________________________________
____________
____________________________________________________________________________
____________

____________________________________________________________________________
____________
This contract is good for one year and will be reviewed for renewal
A review may occur if any party is non-
compliance or there is a change in status Any party may call for an
immediate review

The undersigned are in agreement of the above contract

_______________________________________
____________________________________
Student Signature Date Parent/Guardian
Signature Date

__________________________________ _______________________________
School Nurse Signature Date School Administrator Signature

Date

_______________________________________________
____________________________________________
Designated Staff Signature Date Designated Staff
Signature Date

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001

Individualized Education Plan IEP - Sample

STUDENT: Jane Doe SCHOOL:
Sugar Pine Intermediate________

DOB: 6-11-87 DATE: September 13,
2003_____________

GOAL: Independent Health Care Maintenance with regards to
diabetes_______________

OBJECTIVE: By June 2004___ STUDENT WILL be able to operate meter
independently, lance finger and place blood onto strip
__________________________________________________________
____________________________________________________________________________
_________

ACHIEVED: 6/04__ NOT ACHIEVED: _____

OBJECTIVE: By June 2004__ STUDENT WILL: be able to make snack choice
independently based on
blood glucose
level_______________________________________________________
____________________________________________________________________________
_________
____________________________________________________________________________
_________
ACHIEVED: 6/04_ NOT ACHIEVED: ___

OBJECTIVE: By: June 2004__ STUDENT WILL: take responsibility for leaving
weekly snacks in the health office refrigerator on Monday AM; including
carrots, celery, juice, fruit, cheese and
crackers___________________________________________________________________
____________________________________________________________________________
________
ACHIEVED: 6/04_ NOT ACHIEVED: ___

OBJECTIVE: By June 2004__ STUDENT WILL: attend a peer support group
meeting on a regular
basis____________________________________________________________________
_____________________________________________________Continue goal until
June 2005
ACHIEVED: _ NOT ACHIEVED: _X_

PERSON RESPONSIBLE: Julie Smith school nurse __
DATE OF REVIEW:
June 30, 2004

COMMENTS: Jane says she has refused to go to the meetings because she is
embarrassed about sharing her feelings A meeting will be scheduled with
the school psychologist to assist Jane in dealing with these feelings and
to facilitate attendance at the support group meeting The school
psychologist will contact the support group leader in an attempt to hook
Jane up with another peer who attends these
meetings___________________________________________________________________
__________
____________________________________________________________________________
_________

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Section 504 Student Accommodation Plan

THE LAW AND DIABETES

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 Diabetes is recognized as a disability under federal law
Students with diabetes may be referred to a 504 Team to determine whether
they would be qualified under 504 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 included in the same document If a
student with diabetes is found eligible, a 504 plan for that student would
be developed to provide full accessibility to all activities, services, or
benefits provided by public schools If a student is found eligible for
504 the following apply

Under Section 504 of the Rehabilitation Act of 1973, it is illegal to
discriminate against a person with a disability The 504 section of the
Federal Registry indicates that no qualified handicapped person shall, on
the basis of handicap, be excluded from participation in, be denied the
benefits of, or otherwise be subjected to discrimination under any program
of activity which receives or
benefits from Federal financial assistance
Section 504 defines an individual with a disability as any person whom:
has a physical or mental impairment which substantially limits
participation in one or more major life activities such as caring for
oneself, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning, and working

Type 1 diabetes is a physiological disorder that affects the endocrine
system, placing the individual at risk for hypoglycemic and hyperglycemic
episodes related to this metabolic dysfunction Potential fluctuations in
blood glucose impact the individuals major life activities as described in
the 504 document Historically, Section 504 and ADA have covered students
with diabetes Reasonable accommodations can be planned and documented in
a 504 plan by a designated 504 coordinator in each school district

If parents have concerns about the identification, evaluation, programming,
placement, or the provisions of a free and appropriate education, there are
procedural safe-guards that parents can access

A sample 504 plan for a student with diabetes follows

Helping the Student with Diabetes Succeed a Joint Program of the
National
Institutes of Health and the Centers for Disease and Prevention, US
Department of Health and Human Services, 2003
Section 504 Student Accommodation Plan - Sample

School: _______________________________________ Teacher:
________________ Grade: _______

Student Name: _____________________________ DOB:
______________________

Parent Name:
__________________________________________________________________

Address:
_______________________________________________________________________

Home Phone: ______________________________ Work Phone:
__________________________

Case Manager: _____________________________ Date of Meeting:
________________

1 Describe the nature of the concern leading to this referral:
Include a statement of the 504 eligible condition Possible loss of
cognitive ability if blood
sugar is too low or too high Possibility of seizure if blood sugar
is too low Long-term
vascular implications if blood sugar remains high for extended
periods

2 Describe the basis for the
determination of disability:
Medical diagnosis Type I Diabetes Is insulin dependent and is
currently
receiving X injections per day as needed to keep blood sugar at
optimal levels

3 Describe how the disability limits major life activity:
Blood sugar must be monitored and maintained at an optimal level to
maintain above stated
health status

4 Describe the reasonable accommodations that are necessary:
Providers
Assistance with and privacy for blood glucose testing and insulin
injections Health Clerk
Snacks and meals whenever/wherever necessary
Teacher
Free access to water and toilet
Teacher
Full participation in extra-curricular programs
Coach
Scheduling physical education around meal times
Teacher
Allowances for increased absences
Administration
Implementation of the IHP
School Nurse

Review/Reassessment Date: must be
completed:
_____________________________________

Participants Signature and Title:

_______________________________________
__________________________________________

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001

SUGGESTED ACCOMMODATIONS FOR THE STUDENT WITH DIABETES

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
Any other special circumstances
1 Student may have permission to do blood sugar testing in the
classroom This procedure should take only a few minutes and not
disrupt the class Student may also need to check blood glucose on
field trips or during special events Blood glucose testing is
usually done before meals per primary care providers PCP order
2 The school lunch menu for the week will be available to the students
family a week in advance The carbohydrate content of school lunches
may be made available on request
3 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 Individual Health
Plan IHP
4 Student needs to be allowed to snack when and
where necessary low
blood sugar/hypoglycemia to maintain adequate blood glucose levels
This includes school transportation as well as the classroom,
gymnasium, etc
5 A student who does not respond to a snack and/or exhibits signs of low
blood glucose 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
6 A student with a high blood glucose hyperglycemia is to receive
insulin per PCP 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 nurse 1
7 A student must be allowed to drink water or other sugar free fluids in
the classroom, as needed, to dilute high blood glucose
8 A student needs to be allowed extra
bathroom privileges as high blood
glucose hyperglycemia results in increased urine output
9 Optimally, parents should be given at least a three-day notice of
extra events such as parties or field trips

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

Guidelines for Care of the Students with Diabetes: Washington State Task
Force for Students with Diabetes
Delegation and Oversight of Health Tasks to LPNs and Unlicensed School
Personnel

It is often difficult for school nurses to decide if it is safe to allow
other school personnel to assume health tasks in caring for students with
diabetes This is particularly challenging for school nurses serving
multiple schools, especially when they have young students with diabetes
who require significant care The SCHOOL NURSING ROLE DEFINITION IN
DELEGATION OR COORDINATION AND OVERSIGHT assists the school nurse
in
understanding how the Maine Nurse Practice Act governs the nurses ability
to delegate task to a LPN or oversee a health task of a non-licensed
person That document can be found in the Maine School Health Manual at
wwwstatemeus/education/sh/contentshtm Another tool to assist school
nurses with decisions is the Decision Tree for Nurse Delegation
following frequently asked questions, below

Frequently Asked Questions
About Roles and Responsibilities in Relation to Nursing Procedures and
Health-related Activities for all Children in the School Setting

1 What is the citation in law that relates to performing nursing task,
including administration of medication to students requiring
assistance with their care?
Section 2102 2 C of The Nurse Practice Act states that registered
professional nurses may delegate selected nursing services to licensed
practical nurses when the services use standardized protocols and
procedures leading to predictable outcomes The Maine Board of
Nursing Rule Chapter 6, allows nurses to coordinate and oversee
unlicensed health care assistive personnel for specific tasks
for
specific students consistent with student safety The registered
professional nurse may not coordinate or oversee unlicensed health
care assistive personnel for health counseling, teaching or any task
that requires independent, specialized nursing knowledge, skill or
judgment

Title 20-A 254 5 B requires schools to have a written local
policy and procedure for administering medication, which must include
that unlicensed personnel who administer medication receive training
before receiving authorization to do so

2 Can a LPN provide school health services as long as supervision is
provided?
Yes LPNs may be hired to perform nursing tasks permitted in the LPN
scope of practice under the direction of a certified school nurse,
physician or dentist The tasks must be part of an individual nursing
care plan that is developed, maintained and evaluated by a certified
school nurse Supervision need not be on site, but evidence of
adequate supervision which must include, at a minimum, availability
of the school nurse, physician or dentist by telephone is essential

3 What are
the minimum criteria for considering a student to be able to
provide self-care?
Determination as to whether a student should be considered able to
provide self-care should be based on the students cognitive and/or
emotional development rather than age or grade Factors such as age
of reason and mental/emotional disability are some additional
considerations to be looked at in determining a childs ability to be
self-managed Guidelines for considering a student to be able to
provide self-care are if he/she is consistently able to do all of the
following:
Identify the correct medication eg, color, shape, label
Identify the purpose of the medication eg, to maintain blood
glucose in normal range
Determine that the correct dosage is being administered eg,
amount of insulin to be injected
Identify the time the medication is needed during the school day
eg, lunch time, before/after lunch
Describe what will happen if medication is not taken eg,
increase in blood glucose resulting in feeling ill and unable to
complete school work

Refuse to take medication, if student has any concerns about its
appropriateness
Student individualized health care plans should always address ways to
make the student more independent in the management of their health
needs Goals should be established that would enable children to be
able to provide self-care regardless of age or grade

4 How should school districts handle the issue of medications or needed
health care procedures when students go on field trips or participate
in after-school activities?
Most students can be taught to administer their own medications For
procedures addressing the administration of medication, refer to the
School Health Manual guidelines, Administration of Medications in
Schools For field trips or after-school activities, teachers or
other school staff must be provided with instructions on medication
administration or directions on the specific health care task The
responsible school staff should appropriately transport the students
medication and/or supplies and allow students to take their own
medication at the appropriate time,
administer medications or assist
with the health care procedure for those students that need
assistance, according to the students health care plan If it is
determined that a students need for health care is such that the task
can not be given to an unlicensed school staff, the certified school
nurse, other RN, or licensed practical nurse must accompany the
student on the field trip as identified on the 504 plan to
administer medication or carry out the nursing procedures
Alternatively, a parent may accompany the child if they so desired

A student may not be prevented from participating in an educational
activity, such as field trip, solely on the basis of a special health
need

5 What if neither the certified school nurse nor the parent is available
to attend a field trip with a student with special health needs who is
not able to provide self-care?
A district must provide appropriately licensed nurses to provide
necessary nursing services if it is determined that the health task
cannot be given to an unlicensed staff This can be accomplished by
reassigning school nursing
staff from other sites within the district,
contracting with neighboring school districts, contracting with nurses
employed by outside agencies, or by actively recruiting an adequate
nursing staff to serve as substitute

6 Must all children with special health needs have an individualized
health plan IHP?
An IHP, a plan of care for a child with health needs, is developed for
students with special health needs Schools are eligible to receive
MaineCare reimbursement for skilled nursing services for MaineCare
eligible students only if an IHP is a part of a students cumulative
health record and such services are included in the students
individualized education plan IEP - an educational plan for students
who have been identified by the Committee on Special Education as
having a disability

7 What is the districts responsibility for ensuring that a school nurse
has received appropriate training if he/she does not know how to
perform certain procedures that a child will need? What is the
nurses responsibility?
It is the school administrators responsibility to ensure that staff,

including nursing staff, is adequately trained and has updated skills
It is the registered nurses responsibility to recognize additional
training he/she may need to perform a particular procedure and to help
determine where the appropriate training may be obtained
DECISION TREE FOR NURSE DELEGATION

This decision tree is to assist Registered Nurses in determining if it is
appropriate to delegate a particular nursing task in a particular setting
to an Unlicensed Assistive Personnel UAP

It is assumed that a nurse has assessed the student and situation
completely in order to answer the questions in this decision tree

Yes

NO No

Yes

Bus Driver Plan for Student with Diabetes

Please notify students parents if you are going to have a substitute
bus
driver

Before student gets on the bus, parents/student should:
Test blood sugar to make sure it is in normal range,
Give a snack before boarding the bus if blood sugar is low
Assure student has necessary snack and glucose gel with him/her at
all times

If on the bus, student complains of feeling as if he/she is experiencing
low blood sugar:
Have student eat food right away and notify the school via radio;
the school will notify students parent,
If you can, drive student directly home or to the school,
Parent or other emergency contact person per IHP or emergency
contact card will be at bus stop or school nurse or other school
staff should be waiting at school

ALLOW STUDENT TO EAT ANYTIME AND ANYPLACE

Symptoms of Low Blood Sugar

Sweating beads of sweat on nose - sweaty forehead causing hair to become
wet
HUNGER TIRED BLANK STARES SPACEY
PALE WEAK FLUSHED DIZZY
DROWSY WEEPY REFUSES TO DO THINGS
PERSONALITY CHANGES

If student becomes confused, give instant glucose under tongue or in cheek
and call 911

Bus Driver should know where in
students backpack the glucose gel is kept

If student becomes unconscious, call 911

If you need to evacuate the bus for ANY reason, students backpack NEEDS to
go with the student

Training Agreement for School Staff

I ________________________________________________ have read, been trained,

print name of trained personnel
and understand the following procedure for
_________________________________________
____________________________________________________________________________

____________________________________________________________________________

Initials in the space provided indicate agreement for the following:

____ I understand I will need to maintain my skills and will be observed on
an ongoing bases by the
School Nurse

____ I have had the opportunity to ask questions and received satisfactory
answers

_____________________________________________ _________________
Signature of
trained personnel Date

Supervising signatures:

_____________________________________________ _________________
School Nurse signature Date

_____________________________________________ _________________
Principal signature Date

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Outline for the Level of Care Needed to Perform Diabetes Procedures In
School
Complete in accordance with State laws - provide copy to school
administrator

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001

Checklist: Training School Personnel in Blood Glucose Testing
Instructor: ____________________________Person Trained:
________________________
____________________________________________________________________________
_________

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Emergency Procedure for Hypoglycemia
Low Blood Sugar
GLUCOSE GEL FOLLOWED BY GLUCAGON INJECTION

Student: _____________________ Grade _____ School _______________ Date
_______

1 Verify signs of severe low blood glucose:
a Have someone call 911, parents and school nurse
b Place on side or in upright position
2 If ABLE to swallow and combative, uncooperative, unable to participate
in care:
a Place one of the following in cheek pouch closest to ground and
massage:
i 15 gms glucose gel: ___ 15 gm tube Insta-Glucose, or
___ 15 gm pkt Monogel
or Glutose
Maintain head position to side for aspiration prevention
3 If UNABLE to swallow, UNCONSCIOUS, combative, uncooperative or
seizures:
a Give glucagon injection
b When able to swallow, give sips of regular soda till paramedic
arrives

4 Procedure
for SUBCUTANEOUS Glucagon Injection SN may give IM if
desires
a Gather the Glucagon kit that should include alcohol swabs, emesis
basin, syringe and
medication
b Remove seal from the bottle
c Wipe the rubber stopper of the bottle with alcohol swab
d Remove the cap from the syringe, not touching the needle
e Plunge needle into bottle, pushing all the fluid from the syringe
into the bottle Without
withdrawing the needle, gently shake the bottle until the powder
is dissolved
f Turn the bottle upside down and withdraw the medicine as directed
g Remove the syringe from the bottle, remove the air from the
syringe and recap the syringe
h Clean a 2-inch area on the upper arm with the alcohol swab
i Remove the syringe cap
j Gently grasp the arm around the cleaned area with the opposite
hand from which you will
administer the medication
k Insert the needle at a 90-degree angle and push in all the
medication
l Count to 10 and remove the needle
m Have the student lie on side with emesis basin and expect the

student to vomit
n Monitor for seizures and breathing
o When fully awake, feed fast acting foods such as regular soda
5 Document in Individual Student Record

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Checklist: Training Unlicensed Staff in Hypoglycemia
Low Blood Sugar
Person Trained: _______________________________
Instructor: _______________________________

|Essential Steps: |
|1 Test blood glucose per procedure |
|2 Initiate care per Authorized Health Care Provider as identified on students |
|IHP This may include insulin
|
|administration and checking for ketones and possibly activity restriction |
|3 If student is thirsty or has dry mucous membranes, provide water as tolerated|
| |
|4 If student is feeling OK resume classroom activities |
|5 If student does not feel well nausea, lethargy, headache then the parents |
|should be called to take the child home |
|6 If student develops severe stomach pains, vomiting and/or rapid breathing, |
|call paramedics, school nurse and |
|parent immediately |
|7 Document care on procedure log |

|Key Points Precautions: |
|Exercising when ketones are present may elevate blood glucose levels even |
|further |
|Test for Ketones see below |
|If student resumes classroom
activities, he/she may drink water in class for |
|symptoms of thirst and/or |
|dehydration |
|Notify the school nurse so follow-up care can be ensured |
|School nurse or parent will notify the healthcare provider |
|Consider use of ketodia sticks for students 10 years and older |

Standard Procedure for Testing Urine Ketones

|Essential Steps: |
|1 Saturate the test strip with urine by one of the following: |
|__ Student to hold test strip in urine flow |
|__ Student to urinate in cup/jar, then strip is dipped into urine |
|2 Wait for test strip to develop per directions on test strip bottle |
|3 Compare color of strip to chart on bottle Results will be read as negative, |
|small, moderate, or large |
| If results are moderate or large, call parent to take pupil home for
|
|observation and/or medical care |
|4 Record results on Procedure Log |

|Key Points Precautions |
|If assisting the student, wear disposable gloves during this procedure |

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 200125

Procedure for Blood Ketone Testing

GENERAL INFORMATION
1 Testing the blood for ketones is considered to be more accurate than
urine testing for ketones Blood ketone
testing reflects time accuracy whereas urine ketones reflects a time
delay The monitoring of blood ketone levels
can assist in proper management of diabetes
2 Follow manufacturers guidelines for ketone ranges negative or normal
limits, moderate and large or at risk for possible ketoacidosis

ESSENTIAL STEPS

|EQUIPMENT AND SUPPLIES |
| Alcohol prep pad |
| Finger
lancing device |
| Blood ketone testing meter such as Precision Xtra with strips |
| Blood testing strips for specific electronic meter |
| Tissue or cotton balls |
| Gloves |
| Log Book |
| Spot bandage |
|PROCEDURE |
|1 Wash hands with soap and water Put gloves on Students hands must be washed |
|as well This is sufficient for |
|prepping the site, however, alcohol may be used for further prepping The site |
|selected must be dry before |
|pricking |
|2 Place ketone testing strip into electronic meter according to manufacturers |
|instructions
|
|3 Prepare lancing device according to manufacturers instructions |
|4 Select a site on the top side of any fingertip Hang the arm below the level |
|of the heart for 30 seconds to |
|increase blood flow |
|5 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 strip 3/16 to 1/32 in diameter |
|6 Place blood onto testing strip and complete procedure according to |
|manufacturer instructions |
|7 Dispose of test strip and tissue or cotton ball in lined wastebasket Dispose |
|of lancing device in Sharps container |
|8 Remove and dispose of gloves, wash hands |
|9 If results are small, notify school nurse and parent If results are |
|moderate or large, call parent to take |
|student home for
close observation and/or medical care; notify school nurse |
|10Document results in Student Health Record |

|KEY POINTS AND PRECAUTIONS |
|Alcohol may cause toughening of the skin or burning sensation If moisture water|
|or alcohol remains on the |
|skin it may alter test results |
|If school personnel are performing the procedure then a disposable lancing |
|device should be used |
|The tops of the fingertips may be more sensitive |
|The sides of the fingers have less blood flow |
|Compress lanced area with tissue or cotton ball until bleeding stops or apply |
|spot bandage |
|Refer to Standard Procedure for Hyperglycemia for specific treatment |

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in
2001

Hyperglycemia Skills Checklist Training Record

Person Trained: ___________________________
Instructor: ___________________________

Adopted from: PEDS Pediatric Education for Diabetes in Schools, A
Curriculum for Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP,
published in 2001

Insulin Pump Therapy

Student Requiring Supervision

|General Information |
|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 |
| |
|The goal of Insulin Pump Therapy is to achieve near normal blood glucose |
|levels over 24 hours per day The use of insulin pumps 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 insulin pumps are that it affords more flexibility of |
|life-style with less variability of insulin absorption, more precise insulin|
|administration matched with food intake and activity levels, and overall |
|close attention to diabetes management |
| |
|The pump uses short acting insulin as opposed to conventional injections, |
|which combine |
|short and long-acting insulin |
| |
|Insulin Pump Therapy combines a continuous basal 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 |
|Bolus: when the pump is programmed to give a dose of insulin for meals, |
|snacks |
|and/or for correction of elevated blood glucose |
| |
|F 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 rapidly 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 |
| |
|I A 3×5 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 |
| |
|J A wallet sized programming card and an alarm card or manufacturers |
|instructions should be
|
|available in the health office for reference |

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001

Student Pump Skills Checklist

This form is to be completed by the school nurse with input from the
parent/guardian/care provider The school nurse must directly assess
specific skills for competency if independent performance is desired
Document student competency on skills, which are in accordance with
standard procedure and the students IHP

PEDS Pediatric Education for Diabetes in Schools, A
Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 200130
Sample Health Service Contract
Student Independent Performance of
Blood Glucose Testing and Insulin Administration

This contract will be attached to the Individualized Healthcare Plan

Student: ________________________________________ Date:
___________________

The following statements delineate specific individual responsibilities and
will be initialed by the appropriate party to indicate agreement:

____ The student will:
Independently perform blood glucose testing in accordance with written
procedures
Keep daily records of blood glucose test and insulin dose as agreed
upon by parent and school nurse
Seek help from designated school staff if any problems with their
diabetes should occur
Keep parent informed of diabetes issues
Treat hypoglycemia per written procedure
Determine insulin dose based on the physicians order
Self-administer insulin per written procedures
Follow Universal Precautions change lancet device at home, dispose of
needle and syringe in a designated sharps container, place
cotton ball
over lanced skin until bleeding stops or use a spot bandage to cover
area

____ The parent will:
Provide necessary equipment such as: blood glucose testing kit, juice,
snacks, glucose product, syringes and insulin
Within 24 hours, inform the school nurse, in writing, of any changes
in the students health status, medication, or treatment regimen and
provide order change from health provider
Provide signed consents

____ The school nurse will:
Ensure that the student has the necessary skills, maturity and
competence for blood glucose testing and independent administration of
insulin
Evaluate Blood Glucose Testing records; consult student and parent
with any concerns regarding interventions or contract compliance
Inform, by phone, the physician and/or parent/guardian of any unusual
circumstances
Arrange to have the parent contacted, by phone, when supplies or
insulin are running low

____ The health clerk/designated staff will:
Intervene as instructed for low blood glucose in accordance with
written procedure
Record the date and time of insulin administration on
the students
Medication Log
Provide a copy of this log to the physicians office as directed
Notify the school nurse of any unusual circumstances

This contract is good for one year and will be reviewed for renewal If
non-compliance or a change in status occurs any party may call for an
immediate review

_______________________________________
_____________________________________
Student Signature Date Parent/Guardian
Signature Date
______________________________________________
____________________________________________
School Nurse Signature Date School Administrator
Signature Date

______________________________________________
____________________________________________
Designated Staff Signature Date Designated Staff
Signature Date
PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Sample Health Service Contract
Insulin Pump
This contract will be attached to the Individualized Healthcare Plan

Student:
______________________________________ DOB: __________________
Date: _________

The following statements delineate specific individual responsibilities and
will be initialed by the appropriate party to indicate agreement:

____ The student will:
Be responsible for needle/catheter site preparation and insertion
Be responsible for programming the pump functions
Immediately report to appropriate school personnel any pump
malfunctions dead batteries, high pressure alarm/no delivery, etc
Deliver the appropriate bolus based on blood glucose values and
planned food consumption
Use Universal Precautions when discarding pump tubing, needles, and
cannulas
Notify parents of any pump incidents
Ensure pump/tubing safety during physical activities If the student
chooses to use a quick-release set during activities he/she will
ensure that euglycemia normal glucose concentration in blood is
maintained as much as possible checking blood glucose before and
after activities, taking extra carbohydrates as needed, re-connecting
the pump after completion of activities, etc
Take care of any skin site problems
bleeding, tenderness, itching,
oozing, etc If the pump tubing becomes dislodged at school the
student will report immediately to the health office and insert a new
set or supplement with insulin

____ The parent will:
Be responsible for keeping an extra set of pump batteries, tubing,
tape Tegaderm, Op-Stie, etc, insulin, syringe, and solutions
needed to prep skin sites alcohol swabs, betadine, etc on the
school site in case it is needed

____ The school nurse will:
Inform by phone, the physician and/or parent/guardian of any unusual
circumstances

____ The health clerk/designated staff will:
Notify the school nurse of any unusual circumstances

This contract is good for one year and will be reviewed for renewal If
non-compliance or a change in status occurs any party may call for an
immediate review

______________________________________________
____________________________________________
Designated Staff Signature Date Designated Staff
Signature Date

Signature of Staff providing Care Initials
Signature of Staff providing Care Initials Signature
of Staff providing Care Initials
| | | | | | |
| | | | | | |

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
BLOOD GLUCOSE MONITORING LOG FOR THE YEAR

Student Name: School:
Grade: Teacher: Room

Record blood glucose results and your initials in the box Place initials
and signature once on lines at bottom
Document treatment for low and high blood glucose results on the back or in
students health record

| |MON |TUE |WED |THR |FRI |MON
|TUE |
| | | | | | |
| | | | | | |

PEDS Pediatric Education for Diabetes in Schools, A Curriculum for
Diabetes Care in Schools, Mary Zombek, RN, MS, CPNP, published in 2001
Checklist for School Nurse with New Student with Diabetes in School

1 _____ Meet with parents and student to develop IHP Individual
Health Care Plan - Have parent sign plan
2 _____ Obtain parental release of information HIPAA Compliance
Release to communicate with physician
3 _____ Obtain parental release of information to provide information
to school staff that need to know
4 _____ Obtain physician orders
5 _____ Parent signs consent form for glucagon and insulin as
appropriate
6 _____ Familiarize yourself with diabetes, insulin pump if
appropriate
7 _____ Conduct school health team meeting with teachers, principal,
and other school staff involved in the care of the student with
diabetes
8 _____
Evaluate eligibility for and complete a 504 Plan
9 _____ Coordinate the development of a Quick Reference Emergency
Plan that is to be placed in an confidential spot in the
classroom
This plan should include when to contact the School Nurse, and
signs/symptoms/treatment of hyper- and hypoglycemia
10 _____ Plan and implement Diabetes Education Training for all staff
including the childs bus driver
11 _____ Prepare Log Sheet for glucose testing monitoring
12 _____ Train unlicensed staff in:
a _____ hypoglycemia and hyperglycemia recognition,
b _____ their actions and responsibility with hyper- or hypoglycemia,
c _____ glucagon administration,
d _____ standard procedure for ketone testing,
e _____ insulin pump therapy if appropriate,
f _____ documentation

13_____ Obtain a book on Carbohydrate Counts if needed
14_____ Prepare Health Services Contract for student and parent to
sign as appropriate
15_____ Complete Outline for Level of Care Needed to Perform
Diabetes Procedures in School
16_____ Continually monitor the diabetes care plan and make

adjustments as needed

From: Van Buren High School

Resources

American Diabetes Association - wwwdiabetesorg/homejsp

The Center for Health and Health Care in Schools -
wwwhealthinschoolsorg/sh/diatesesasp

Helping the Student with Diabetes Succeed -
wwwndepnihgov/diabetes/pubs/Youth_SchoolGuidepdf

MCH Diabetes in Children and Adolescents -
wwwmchlibraryinfo/knowledgePaths/Kp_diabeteshtml

National Diabetes Information Clearinghouse -
http://diabetesniddknihgov/dm/pubs/type1and2/whathtm

PEDS - wwwpedsonlineorg

———————–

For the school nurse to complete

Do not delegate

Is appropriate supervision available?

1 Is the task within the registered nurses scope of practice?

Do not delegate

2 Are there any specific laws, rules or institutional/agency policies
prohibiting the delegation?

3 Can the task be performed without observations or critical decision-
making that requires nursing knowledge, skills and judgment?

Do not delegate

4 Can the task be safely performed according to clear, unchanging
directions?

Do not delegate

5 Are the outcomes of the task reasonably
predictable?

Task itself is generally appropriate for nurse delegation/oversight

Follow the Delegation Guideline and school policies/procedures

PICTURE

ONSET

Sudden

CAUSES

Too much insulin
Missed food
Delayed food
Too much exercise
Unscheduled exercise

SYMPTOMS

MODERATE

Sleepiness
Erratic behavior
Poor coordination
Confusion
Slurred speech

MILD

Hunger Dizziness
Irritable Pallor
Shakiness Sweating
Weak Drowsy
Sweaty Crying
Anxious Headache

Unable to concentrate
Numbness of lip tongue
Other: _______________

SEVERE

Unable to swallow
Combative
Unconscious
Seizure

ACTION NEEDED

Notify School Nurse

If possible, check blood glucose per plan
But, always when in doubt
TREAT

SEVERE

Call 911
Give Glucagon, if ordered
Position on side
Contact parents school nurse

MILD

Provide sugar source:
2-3 glucose tablets or
4 to 8 oz Juice or
4 to 8 oz Regular soda or
Glucose gel product
Wait 10 minutes
Provide sugar source if symptoms
persist or blood glucose less than 70
Provide a snack of carbohydrate
protein, ie crackers and cheese
Communicate with parents

MODERATE

Provide Glucose source:
3 Glucose tablets or
15 gm Glucose gel
Wait 10 minutes Repeat glucose if
symptoms persist or blood glucose
less than 70
Follow with a snack of carbohydrate
protein, ie crackers and cheese

Notify parents

Never send a child with suspected low blood sugar anywhere alone

PICTURE

ONSET

Over-time several hours or days

CAUSES

Too much food
Too little insulin
Decreased Activity
Illness, Infection Stress

SYMPTOMS

Early symptoms: Symptoms progressively become worse:
Thirst/dry mouth Sweet breath
Frequent urination Weight loss
Fatigue/sleepiness Facial flushing
Increased hunger Dry, warm skin
Blurred vision Nausea/stomach pains
Lack of Vomiting
concentration Weakness
Confusion
Labored breathing
Unconsciousness/coma

ACTION NEEDED

Check blood glucose per IHP

IF STUDENT IS NOT FEELING WELL
Call parents to pick up student
Provide water if student is

thirsty
Provide additional treatment
per IHP ketone check, insulin
Notify school nurse if there are
further immediate concerns or
questions Document action
and provide copy to school
nurse

FOR VOMITING WITH CONFUSION LABORED BREATHING AND/OR COMA

call 911

Contact school nurse

Notify parents

IF STUDENT IS

FEELING OK

Provide water if student is thirsty
Allow liberal bathroom
privileges
Provide additional treatment per
IHP ketone check, insulin as appropriate
May resume classroom activities
Document action and provide
copy to school nurse

REVIEW OF BLOOD GLUCOSE
MONITORING RROCEDURE
Date Student/Staff Reviewed by
____ ________________ _______________
____ ________________ _______________
____ ________________ _______________
____ ________________ _______________

I authorize the exchange of information about my childs diabetes between
the Physicians Office and the school nurse
Parent signature: ____________________________________________
Date:
________________

Parent/Guardian Signature _________________________________ Date
___________

Check for urine ketones if Blood Sugar is 240 or if child is ill
Contact parent if Moderate to
Large ketones

Before Meals ____ - ____

2 Hours After Meals/snacks and/or Correction ___ - ___

3 Hours After Meals/snacks and/or Correction ___ - ___

Glucagon: Dose: Route: Call parent immediately after
giving

XYZ[]ciw- U
-
q
?

ì
ô
ãä
?-ÈÜãi{|ævñëåØËÇÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃ?h
5?CJ\?h
CJCheck for urine ketones if Blood Sugar is 240 or if child is ill
Contact parents if Moderate to Large ketones

Glucagon: Dose: 1 mg Route: SC Call Parent immediately after
administering
Possible side effect: Child may vomit following Glucagon administration
If unconscious, turn child on side to protect airway If child is seizing,
do not attempt to put anything in childs mouth

I authorize the exchange of information about my childs diabetes between
the Physicians Office and the School Nurse Parent Signature
_______________________________________ Date _______________

Source:state.me.us

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