More than 18 million Americans have diabetes. providers are finding more and more children and teens with type 2 diabetes, even though the …

LEARNING AND DIABETES
A Resource Guide for Connecticut Schools and Families

Connecticut State Department of Education — 2005

State of Connecticut
M Jodi Rell, Governor

State Board of Education
Allan BTaylor, Chairperson
Janet M Finneran,Vice Chairperson
Beverly R Bobroske
Donald J Coolican
Lynne S Farrell
Tori Hendrix
Theresa Hopkins-Staten
Patricia B Luke
Timothy J McDonald
Callan Walsh

Valerie Lewis ex officio
Commissioner of Higher Education

Betty J Sternberg Commissioner of Education

LEARNING DIABETES:

A Resource Guide for Connecticut Schools and Families

CONTENTS

Introduction Acknowledgments Section 1 Diabetes Overview I Types of Diabetes a Type 1 b Type 2 II Effective Diabetes Management a What is Effective Diabetes Management? b How do Schools Plan and Implement Effective
Diabetes Management
c The Law
d School Plans
e What are the elements?
1 Blood Glucose Monitoring
2 Nutrition 3 Physical Activity
4 Planning Beyond the School Day
5 Social and Emotional Aspects
6 Promoting Student Independence
f Diabetes Management Training
Section 2 Section 3 Section 4 Section 5 Frequently Asked Questions
Suggested Roles and
Responsibilities
Resources
Appendices
v
vii 1
2
2
3
4
4
5 6 7 8 9 16
19 20 21 23 25 27 31 39 49

iii

INTRODUCTION

More than 18 million Americans have diabetes In your work with children and youth in the school setting, it is likely that you already have, or will have, a student with diabetes in your care Diabetes is one of the most common chronic diseases in school-aged children, affecting about 151,000 young people in the United States, or about 1 in every 400 to 500 young people under 20 years of age Each year, more than 13,000 youths are diagnosed with type 1 diabetes In addition, health care providers are finding more and more children and teens with type 2 diabetes, even though the disease is usually diagnosed in adults over the age of 40 Diabetes is the sixth leading cause of death by disease in the United States Longterm complications include heart disease, stroke, blindness, kidney disease, and amputation of the foot or leg Although there is no cure, the disease can be managed and complications delayed or prevented Diabetes must be managed 24 hours a day, 7 days a week For students with type 1 diabetes, and for some with type 2 diabetes, that means
careful monitoring of their blood glucose sugar levels throughout the day and administering multiple doses of insulin therapy — now prescribed for most young people with diabetes As a result, the school health team, which includes the school nurse, teachers, the school administrator and other school staff members, plays an important role in helping students manage their diabetes The school health team, which includes the school nurse, teachers, the school administrator, and other school staff members, plays an important role in helping students manage their diabetes

Effective diabetes management is crucial: for the immediate safety of students with diabetes; for the long-term health of students with diabetes; to ensures that students with diabetes are ready to learn and to participate fully in school activities; and to minimize the possibility that diabetes-related emergencies will disrupt classroom activities

While this manual is dedicated to children with diabetes, many of the recommendations and guidelines would pertain to all children with various health conditions

The information in this manual is general in nature and does not constitute specific medical or legal
advice Readers should consult directly with medical professionals regarding specific questions about care of children with diabetes Readers should consult with legal counsel regarding questions pertaining to the rights and/or responsibilities under state and federal law of any individual or institution receiving or providing care for children with diabetes This manual and future updates will be available on the State Department of Education website: http://wwwstatectus/sde/

ACKNOWLEDGMENTS

This manual was developed through the cooperation of key organizations and individuals committed to improving diabetes care for children in schools throughout Connecticut Connecticut State Department of Education staff members would like to thank them for their collaboration, expertise and perseverance regarding its development Eileen Clark, Parent
Wendy Harwin
Pat Krin, APRN, NCSN
Education Service Specialist
Head Nurse
Cheryl Carotenuti
CT State Department of Education
Newington Public Schools
Health Promotion Consultant
CSDE
CT State Department of
Pat Philipp, RN, BSN
Education CSDE
Cindy Kozak, RD, MPH, CDE
School Nurse
Diabetes Control Unit
Newtown
Public Schools
Faine Gauthier, RN, BSN,
CT Department of Public Health
NCSN
Patricia Vadya, RN, BSN,
Nursing Supervisor
NCSN
Wethersfield Public Schools
Nursing Supervisor
Enfield Public Schools
We are also deeply grateful to those who so graciously reviewed the manual, shared the lessons learned and final products of their school and district policies and manuals These individuals and organizations are listed below:
Joanne Ahern, APRN
Endocrinology
Yale-New Haven Hospital
and Medical Center
Phil Apruzzese
Vice President
CT Education Association
Joseph Castagnola
Superintendent of Schools
Portland, Connecticut
Cathy Castaldi, Parent
William Cross, Parent
Sheila McKay
Connecticut Association of
Boards of Education
Linda Pica
Director of Pupil Services
Bethel, Connecticut
Paul Rossi
Parent
Juvenile Diabetes Research
Foundation

David Larson
Karen Bucci, APRN
Executive Director
Endocrinology Department
CT Association of Public School
CT Childrens Medical Center
Superintendents
National Diabetes Education Program: Helping the Student with Diabetes Succeed: A Guide for School Personnel New York State
Department of Health: Diabetes in Children A Resource Guide for Schools Wisconsin Department of Education: Children with Diabetes: A Resource Guide for Wisconsin Schools and Families

Thanks to the Diabetes Prevention and Control Program at the Connecticut Department of Public Health for the printing of this manual Publication was supported by funds from the Centers for Disease Control and Prevention Award U32-CCU122689-03
vii

viii

SECTION ONE

Diabetes Overview
iabetes is a disorder of metabolism — the way in which the body converts the food you eat into energy The food you eat is broken down by digestive juices into the fuel component you need to survive, including a sugar called glucose Glucose is the bodys main source of energy After digestion, glucose passes into your bloodstream, where it is available for cells to take in and use or store for later use In order for your cells to take in glucose, a hormone called insulin must be present in your blood Insulin acts as a key that unlocks doors on cell surfaces to allow glucose to enter the cells Special cells islet cells produce insulin in an organ called the pancreas, which is about 6 inches long and lies behind your
stomach In people who do not have diabetes, the pancreas automatically produces the right amount of insulin to enable glucose to enter cells In people who have diabetes, the body does not make or properly use insulin If glucose cannot get inside cells, it builds up in the bloodstream The buildup of glucose in the blood sometimes referred to as high blood sugar or hyperglycemia which means too much glucose in the blood is the hallmark of diabetes When the glucose level in your blood goes above a certain level, the excess glucose flows out from the kidneys the organs that filter wastes from the bloodstream into the urine The glucose takes water with it, which causes frequent urination and great 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

Careful monitoring and prompt intervention are necessary to prevent life threatening hypoglycemic episodes and long-term complications

When insulin is no longer made, it must be obtained from another source insulin shots or an 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 Diabetes management balances careful control of diet, exercise, and medication Careful monitoring and prompt intervention are necessary to prevent life threatening hypoglycemic episodes and longterm complications such as heart disease, kidney failure, retinopathy, and serious impairment of circulation that may require amputations 1

DCCT study 1

I Types of Diabetes
Diabetes occurs in several different forms This manual will focus primarily on issues related to type 1 diabetes in children All 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 treatment plan

A Type 1 Diabetes
Type 1 diabetes usually has a very rapid onset It was previously called Juvenile Diabetes because most people develop it as children or teenagers The immune system is the bodys system for fighting infection In people with type 1 diabetes, the immune system attacks the beta cells the insulin-producing cells of the
pancreas and destroys them Why this happens is not fully understood But because the pancreas can no longer produce insulin, people with type 1 diabetes need to take insulin daily to live Type 1 diabetes can occur at any age, but it occurs most often in children and young adults Type 1 Diabetes

Most Common in Children Rapid Onset Pancreas cannot Produce Insulin
Symptoms:

There is no single way to treat type 1 diabetes Each childs life events vary and as such, experienced diabetes teams are necessary to set up individualized treatment plans For treatment plans 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 New information on diabetes management allows people with diabetes to be more liberal with food planning

Increased Thirst and Urination Constant Hunger Weight Loss Blurred Vision Fatigue

Blood glucose monitoring2 is essential to help assess how well the treatment plan is working Most children can perform blood glucose checks by themselves but may need a private place to do so Some children may need supervision to see that the procedure is done properly and results are
recorded accurately How often the child checks or whether he/she checks at school at all are decisions made in conjunction with the child, family, childs diabetes team and school personnel It is the board of educations responsibility to ensure that staff, including nursing staff has adequate training and the updated skills necessary to best assist children with diabetes The school nurse can then recognize when additional training is needed to perform a particular procedure and to help determine where appropriate training can be obtained

Although the terms blood glucose testing and blood glucose checking are also common terms, for the purpose of this manual, the term blood glucose monitoring will be used 2

Symptoms of Type 1 Diabetes
Symptoms usually develop over a short period of time They include increased thirst and urination, constant hunger, weight loss, and blurred vision Affected children also may feel very tired all the time If not diagnosed and controlled with insulin, the child with type 1 diabetes can lapse into a life-threatening condition known as diabetic ketoacidosis KEY-toe-asi-DOE-sis, or DKA

Risk factors
Although scientists have made much progress in
predicting who is at risk for type 1 diabetes, they do not yet know what triggers the immune systems attack on beta cells They believe that type 1 diabetes is due to a combination of genetic and environmental factors Researchers are working to identify these factors and to stop the autoimmune process that leads to type 1 diabetes

B Type 2 diabetes
Type 2 diabetes is the most common form of the disease, representing 90-95 percent of people with diabetes It was previously known as adult-onset or non-insulin dependent diabetes because it most often occurs in overweight adults ages 40 or older Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people To control their diabetes, children with type 2 diabetes may need to take oral medication, insulin, or both The first step in the development of type 2 diabetes is often a problem with the bodys response to insulin, called insulin resistance For reasons scientists do not completely understand, the body cannot use 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 Type 2 Diabetes

Usually more common in overweight adolescents and adults Develops slowly Insulin resistance
Symptoms

Fatigue Increased thirst and urination Nausea Weight loss Acanthosis nigricans

Symptoms of Type 2 Diabetes
Symptoms may develop slowly or quickly, and may be similar to those of type 1 diabetes A child or teen may feel tired, thirsty, or nauseated and urinate often Other symptoms include rapid weight loss, blurred vision, frequent infections, yeast infections, and slow healing of wounds or sores High blood pressure may be a sign of insulin resistance In addition, physical signs of insulin resistance include acanthosis nigricans A-can-tho-sis NIG-reh-cans, where skin around the neck, armpits or groin appears dark, thick, and velvety On the other hand, some children or adolescents with type 2 diabetes show no symptoms at all when they are diagnosed For that reason, it is important for parents and caregivers to talk to their health care providers about screening children or teens at high risk for diabetes

Risk factors
Being overweight and having a family member who has type 2 diabetes are the key
risk factors In addition, type 2 diabetes is more common in certain racial or ethnic groups, such as African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Pacific Islander Americans For children and teens at risk, health care providers can encourage, support, and educate the entire family to make lifestyle changes that may delay or prevent the onset of type 2 diabetes Such changes include reaching and maintaining a healthy weight, and engaging in regular physical activity 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

II Effective Diabetes Management In Schools
A What Is Effective Diabetes Management?
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 control 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 is essential to prevent or delay the
long-term complications of diabetes, such as heart attack, stroke, blindness, kidney failure, nerve
disease, and amputations of a foot or lower limb
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 levels 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

Students with diabetes must monitor 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 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, in rare cases, can be life-threatening, present the greatest immediate danger to people with diabetes see hypoglycemia, page 10
4

The key to
optimal blood
glucose control
is to carefully
balance food, exercise, and insulin or medication

Many students can handle all or almost all of their diabetes care by themselves Others, because of age, developmental level, or inexperience, will need help from school staff The school nurse is the most appropriate person in the school setting to provide care for a student with diabetes However, diabetes management is needed 24 hours a day, 7 days a week and diabetes emergencies can happen at any time More importantly, the school nurse may not always be available Therefore, the board of education should identify appropriate school personnel to be prepared to respond to emergencies at school and at all school-sponsored activities in which a student with diabetes participates In this case,
the school nurse should ensure proper training of appropriate school personnel and provide professional supervision and consultation regarding routine and emergency care of the student

B How Do Schools Plan and Implement Effective Diabetes Management?
Collaboration, cooperation, and planning are key elements in developing and implementing successful diabetes management at school As is true for children with other chronic diseases, students with diabetes are more likely to succeed in school when students, parents, school nurses, principals, teachers, other school personnel, and the students health care providers or personal health care team work together to ensure effective diabetes management Your school probably has similar plans and systems in place for children with other health considerations To work collaboratively, a school team should be assembled that includes people who are knowledgeable about diabetes, the school environment, and federal and state education and nursing laws Team members might include the student, parents/guardian, the school nurse, school food service and other health personnel, administrators, the principal, the students teachers, guidance counselor,
and other relevant staff This team works together to implement the recommendations developed by the students personal health care team and family The team decides who needs to receive appropriate medical information about the child, and who will be trained by the nurse to assist with monitoring and performing certain tasks In addition, the school team should be part of the group that develops and implements the students Individual Health Care Plan, Emergency Care Plan, Section 504 Plan if needed, Individualized Education Program IEP, or other education plan that addresses the students developmental and educational needs so that diabetes can be managed safely and effectively in school The plan is based, in part, on the students medical recommendations, sometimes called a Diabetic Medical Management Plan DMMP as well as recommendations from the team

C The Law
A number of laws address the schools responsibilities to help students with diabetes on a case by case basis Under certain federal laws, any school that receives federal funding must reasonably accommodate the special needs of children with diabetes If found eligible for services, federal law requires an individualized
assessment and reasonable accommodation within the childs usual school setting with as little disruption as possible to the schools and the childs routines, in a way that allows the child to fully participate in all school activities Schools have a responsibility to be knowledgeable about all relevant state and federal laws, and about how they impact policies in this area Brief descriptions of the most relevant federal laws follow The Americans with Disabilities Act ADA prohibits discrimination against any individual with a disability Section 504 of the Rehabilitation Act of 1973 further protects the rights of children with disabilities, requiring reasonable accommodations that allow for the provision of a free and appropriate public education FAPE This legislation applies to all programs and activities receiving federal financial assistance, including public schools Children are eligible for accommodations through Section 504 if they have a physical or mental impairment that substantially limits a major life activity Major activities may include walking, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and performing manual tasks Children with diabetes
are often considered eligible because of their special metabolic and dietary requirements It is not required that the student receive special education services to be eligible for other services The Individuals with Disabilities Education Act of 1976 IDEA provides financial assistance to state and local agencies for educating students with disabilities Children are eligible if they fit one or more of the 13 categories of disability and if, because of the disability, they require special education and related services The category that most often applies to children with diabetes is Other Health Impaired OHI This is defined as having a limited strength, vitality or alertness, including heightened alertness to environmental stimuli, that results in limited alertness with respect to the education environment, that 1 is due to a chronic or acute health problem; and 2 adversely affects a childs educational performance The Family Education Rights and Privacy Act of 1974 FERPA protects the privacy of students and their parents by restricting access to school records in which individual student information is kept This act sets the standard for the confidentiality of student information
FERPA also sets the standards for notification of parents and eligible students of their rights with regards to access to records, and stipulates what may or may not be released outside the school without specific parental consent Within schools, FERPA requires that information be shared among school personnel only when there is a legitimate educational interest

Schools have a responsibility to be knowledgeable about all relevant state and federal laws, and about how they impact policies in this area

Public schools in Connecticut are required to meet standards set by the Occupational Safety and Health Administration OSHA, a regulatory agency within the US Department of Labor These standards include the need for procedures to address possible exposure to blood-born pathogens Under OSHA regulations, schools are required to maintain a clean and healthy school environment Schools must adhere to Universal Precautions designed to reduce the risk of transmission of blood-borne pathogens, which include the use of barriers such as surgical gloves and other protective measures when dealing with blood and other body fluids or tissues These federal laws provide a framework for planning
and implementing effective diabetes management in the school setting School administrators and nursing personnel also should determine whether there are applicable state and local laws that should be factored into helping the student with diabetes

D School Plans
It is recommended that schools to develop a plan for accommodating the health needs of children with diabetes These plans should be, in part, based on the students health care providers medical management plan sometimes called Diabetic Medical Management Plan [DMMP] The DMMP is completed by the students parents/guardians and the health care provider It generally includes how to recognize and treat hypoglycemia and hyperglycemia as well as specific orders for blood glucose monitoring, administration of insulin, and the steps to take in an emergency A written school plan for each students diabetes management helps the student, their families, school staff, and the students health care providers know what is expected of them These expectations should be laid out in writing in the following documents as determined by the team: Individual Health Care Plan IHCP describes how the school intends to meet an individual childs
daily health and safety needs in all contexts, while under the care of the school IHCPs are developed by the school nurse, in conjunction with parents, the student, healthcare providers, and other school personnel IHCPs are usually developed for students with multiple health needs or whose health needs require daily intervention The plan includes a summary of health assessments, a nursing diagnosis, goals, and plans of action covering the range of possible concerns It is also used to document interventions and evaluate outcomes Emergency Care Plan ECP, based on the information provided by the students health care provider, family and school team the ECP describes how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs or symptoms of these conditions are observed The ECP is often part of the IHCP Emergency care plans provide specific directions about what to do in an emergency These written plans assist the school nurse, school personnel and emergency responders react to an emergency situation in a prompt, safe and individualized manner Education plans, such as the Section 504 Plan or Individualized Education Program IEP, explain what accommodations,
education aids, and services might be necessary for each student
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This information should be reviewed, along with the students IHCP and/or 504 Plan, and updated each school year, or upon a change in the students prescribed regimen, level of selfmanagement, school circumstances eg, a change in schedule, or at the request of the student or parents/guardian

The Individual Health Care Plan IHCP and Emergency Care Plans
The following information should be essential in the development of a students IHCP: Date of diagnosis
Current health status
Emergency contact information
Students willingness and ability to perform self-management tasks at school
List of diabetes equipment and supplies
Specific medical orders
Blood glucose monitoring
Insulin, glucagon, and other medications to be given at school
Meal and snack plan
Exercise requirements
Additional monitoring
Typical signs, symptoms, and prescribed treatment for hypoglycemia Typical signs, symptoms, and prescribed treatment for hyperglycemia

Note: See Appendix A for sample plans

E What are the Elements of Effective Diabetes Management in School?
Diabetes management entails monitoring or checking
blood glucose levels throughout the day, following an individualized meal plan, getting regular physical activity, and administering insulin and/or other medications to help keep blood glucose levels in the target range and to help prevent the onset of hypoglycemia or hyperglycemia Additional elements of diabetes management in school include planning for events outside the usual school day, planning for appropriate disposal of materials that come in contact with blood, and dealing with the emotional and social aspects of living with diabetes Each student with diabetes has different needs, but school plans developed for such students are likely to address the following common elements: Where and when blood glucose monitoring and treatment will take place;
Identity of school personnel who are trained to assist the student;
Location of the students diabetes management supplies;
Ensuring free access to the restroom and water fountain;
Discussion of nutritional needs, including provisions for meals and snacks;
Issues related to full participation in all school-sponsored activities and field trips;

Accommodations such as alternative times for academic exams if the
student is experiencing hypoglycemia or hyperglycemia; Permission for absences by the local board of education, without penalty, for doctors appointments and diabetes-related illness; and Maintenance of confidentiality and the students right to privacy

1 Monitoring Blood Glucose Levels
Blood glucose monitoring is a necessary and useful Students usually check tool in the management of diabetes Blood glucose their blood glucose: monitoring is done with a small device called a blood glucose meter Monitoring helps identify patterns in before eating snacks or meals blood glucose fluctuation, as well as help to detect before physical activity acute problems of high or low blood sugar Students when they have symptoms of often monitor their blood glucose every time they eat high or low blood glucose a meal to help them decide how much insulin to take at that time There are numerous brands of monitors available, each with specific features that an individual may find useful Since the school nurse plays an integral role in assisting children with diabetes in their tasks of daily management while at school, he or she must become familiar with the various monitors being used To monitor
glucose levels, a drop of blood is required This can be obtained from fingers, arms, and legs

What should a blood sugar level be? For a person who does not have diabetes, a normal blood glucose level is 70-120 mg/dl Blood sugar levels in a child with diabetes will vary depending on insulin action times, food consumed, activity level, and illness The students diabetes health care professional will advise the childs family on an appropriate target range The goal is for the blood sugar to fall within the target range the majority of the time It is common for children with diabetes to experience fluctuations of their blood sugar levels outside of their target range The childs diabetes care plan should include his/her target range and outline corrective actions when the blood glucose level is outside the target range

Some helpful suggestions:
Most children can perform blood glucose monitoring by themselves This may be done safely in the classroom or the child may prefer to do this in a more private setting The State Commissioner of Education recently released a circular letter regarding the State of Connecticuts guidelines for blood glucose self-monitoring in schools See Appendix
G Allow child to assist in the steps in the monitoring procedure How much involvement will depend upon the age of the child and their capability Even small children can help with some of the steps such as choosing the site or getting the strip out of the container The site for monitoring should be cleaned with warm soapy water and dry before being pricked If hand-washing is not available, use an alcohol wipe and allow to dry Apply adequate amount of blood to the test strip Dont get in the habit of calling blood glucose results good or bad Values are either within range or out of range which can be called high or low Try to use a nonjudgmental approach when a result is abnormal If the blood glucose reading is unusually high or unusually low, you may repeat the test if you suspect a false reading Then, treat for hyperglycemia or hypoglycemia if the second test indicates it is necessary according to the students IHCP If a low blood glucose is suspected, the finger is the recommended site for blood glucose monitoring The Self-Monitoring Checklist See Appendix G can be used by schools to determine if it is appropriate for a child to perform blood glucose self-testing at
school

Understanding HYPOglycemia low blood glucose Hypoglycemia, also called low blood glucose or low blood sugar, is Hypoglycemia one of the most frequent complications of diabetes and can happen very is one of the suddenly Hypoglycemia is a blood glucose level 70 mg/dl This is most frequent the greatest immediate danger to students with diabetes; it sometimes complications cannot be prevented Hypoglycemia occurs when a students blood of diabetes and glucose level falls too low, usually as a result of administering too much can happen insulin, skipping or delaying meals or snacks, not eating enough food as very suddenly prescribed in the meal plan, exercising too long or too intensely, or a combination of two or more of these factors It is more likely to occur before lunch, at the end of the school day, or during or after physical education classes Hypoglycemia usually can be treated easily and effectively If it is not treated promptly, however, hypoglycemia can lead to unconsciousness and convulsions Early recognition of its symptoms and prompt treatment, in accordance with the students IHCP, are necessary for preventing severe symptoms that may place the student in danger The
information contained in the ECP, should be provided to all school personnel who have responsibility for the student with diabetes see Appendix A for a sample plan
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Not all students, especially young children, will recognize the symptoms of hypoglycemia with every episode Therefore, school personnel should be familiar with the symptoms and treatment so that an urgent problem can be handled appropriately Hypoglycemia can impair thinking abilities and sometimes can be mistaken for misbehavior If a student has a sudden change in behavior, becomes lethargic, combative, or unconscious, or is having a seizure or convulsion, presume that the student has hypoglycemia Treat the situation as a hypoglycemic emergency and check the students blood glucose level immediately If a blood glucose meter is not available in the immediate area, or if the blood glucose level is otherwise unknown, treat the student for hypoglycemia The student should never be left alone or sent anywhere alone when experiencing hypoglycemia The student should never be left alone or sent anywhere alone or with another child when experiencing hypoglycemia Symptoms of hypoglycemia are different for each student and may
vary from episode to episode They include: Mild/Moderate Symptoms shaky sweaty hungry pale headache blurry vision sleepy dizzy confused disoriented uncoordinated irritable or nervous changed personality
inability to concentrate
changed behavior
weak
lethargic
slurred speech

Severe Symptoms inability to swallow seizures or convulsions loss of consciousness

What to Do for a Child who is Showing Signs and Symptoms of Mild Hypoglycemia 40-70mg/dl Optimally, check blood glucose before treating a child suspected of hypoglycemia When in doubt, treat If the childs hypoglycemia is above 40 mg/dl, give the child some quickacting sugar 15 grams of carbohydrate, such as one of the following: cup 4 oz of juice;
cup 6 oz of REGULAR not diet soda;
3-4 glucose tablets;
4-5 small jelly beans or gum drops;
1 mini box of raisins; OR
1 cup 8oz low fat or skim milk

What to Do for a Child with Moderate Hypoglycemia less than 40mg/dl but Responsive If the childs blood glucose levels are 40 mg/dl or less and the child is still responsive and able to swallow and follow directions, double the treatment amounts indicated above If the child has
difficulty following directions or eating, but can swallow, administer an entire tube of glucose gel in between his or her cheek and gums and gently rub to be sure the sugar is being absorbed Follow with food In any of the above cases, check blood glucose 15 minutes after treatment If the blood glucose result is still less than 70 mg/dl, or if the child still has symptoms, repeat the quick sugar treatment and blood glucose testing cycle until the child is symptom free and the blood glucose result is above 70 mg/dl This can be summarized as the Rule of 15 Give 15 grams of carbohydrate, wait 15 minutes, and then recheck If still less than 70 mg/dl, repeat the cycle giving another 15 grams of carbohydrate and rechecking in 15 minutes RULE OF 15 Give 15 grams of carbohydrate Wait 15 minutes, and then recheck blood glucose If still less than 70 mg/dl, repeat another 15 grams of carbohydrate Wait 15 minutes and then recheck

When the child feels better and blood glucose levels have risen to above 70 mg/dl, give one of the following if the childs next meal is more than one hour away and/or if the child will be participating in active play or sports: 4 graham cracker squares with
peanut butter or cheese;
6 saltine crackers with peanut butter or cheese; OR
an equivalent combination of carbohydrate 15 grams and protein 1 oz
The child may return to class after the blood glucose is above 70mg/dl and he or she no longer has symptoms What to Do for A Child who is Showing Signs and Symptoms of Severe Hypoglycemia Be sure the child is lying down in a safe area protected from injury Position the child on his or her side Call 9-1-1 and the appropriate emergency contacts, as described in the students Emergency Care Plan ECP Follow steps outlined in the ECP, including use of glucagon or the treatment specified in the medical orders You may also put Instaglucose inside cheeks and rub in Do not attempt to put anything between the teeth As the child regains consciousness, nausea and vomiting may occur Child should be placed on his/her side What is Glucagon? Glucagon is a hormone that causes the liver to release sugar into the blood It is used to raise the blood sugar when a child is unable to take liquids or food by mouth because of severe sleepiness, unconsciousness, or seizure activity Glucagon must be injected with a syringe into the skin, like insulin It
should be administered as soon as possible Glucagon, is the medically endorsed treatment of choice for severe hypoglycemia Other options and alternatives include
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glucose gel or other glucose supplements It is important to remember that the risk of not giving Glucagon is more life-threatening than giving it under these emergency conditions

If Glucagon is ordered in school: One Glucagon Emergency Kit supplied by the family is needed Keep Glucagon at room temperature, and inform the appropriate staff of the storage location Check the date of Glucagon kits on a regular basis Discard if past the expiration date Obtain a refill immediately When possible, practice drawing up Glucagon with an expired kit Glucagon must be mixed as per instructions If Glucagon is part of a childs ECP then a physicians order and parental permission is needed Glucagon injections may only be administered by the school nurse in the school setting In the absence of the school nurse to administer Glucagon, or if glucagon is not ordered, glucose gel may be an appropriate substitute for non-nursing school staff Glycemic effects of glucagons are short lived so once the student is able to swallow, a
carbohydrate liquid ie, juice, low-fat milk should be given Understanding HYPERglycemia High Blood Glucose Hyperglycemia, also called high blood glucose, or high blood sugar, is a serious manifestation of diabetes that may be caused by Increased thirst too little insulin, illness, infection, injury, stress or emotional upset, Frequent ingestion of food that has not been covered by the appropriate urination amount of insulin, or decreased exercise or activity High blood Nausea glucose symptoms include increased thirst, frequent urination, Blurred vision nausea, blurry vision, and fatigue In the short term, hyperglycemia can impair cognitive abilities and adversely affect academic Fatigue performance Over a long period of time, even moderately high blood glucose levels can lead to serious complications, such as heart disease, blindness, kidney failure, and amputations
Symptoms of Hyperglycemia:

Hyperglycemia does not usually result in acute problems If, however, the student fails to take insulin, if a pump malfunctions and delivers less insulin, or if either physical or emotional stress causes the insulin not to work effectively, there will be a breakdown of fat, causing
ketones to form see below At first, ketones will be cleared by the kidneys into the urine, but if there are more than the kidneys can handle, they will build up in the blood and may result in diabetic ketoacidosis DKA This complication will cause a fruity breath odor, nausea, vomiting, stomach pain, and, if untreated, deep breathing and increasing sleepiness Students who use insulin pumps can go into DKA within hours if their pumps stop delivering insulin appropriately
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DKA can be prevented if the students urine is checked for ketones during times of illness, especially if vomiting occurs, or whenever the blood glucose level exceeds the target range provided in the IHCP The test involves dipping a special strip into the urine and comparing the resulting color to a color chart or by blood ketone testing Treatment of hyperglycemia may involve drinking extra water or diet drinks or administering supplemental insulin in accordance with the students healthcare providers recommendations Free and unrestricted access to liquids and the restroom must be provided, as high blood glucose levels increase urination and may lead to dehydration if the student cannot replace the fluids The
students blood glucose level should be monitored closely until it returns to the target range, as outlined in the IHCP If treatment does not lower blood glucose levels and clear the ketones, if vomiting occurs, or if the student is lethargic or experiences breathing difficulties, call the parents/guardian or call for medical assistance, as outlined in the ECP Treatment guidelines for ketones and when to call parents should be listed in the students IHCP/ECP Information about the symptoms and treatment of hyperglycemia, contained in the ECP should be provided to all school personnel who have responsibility for the student with diabetes see Appendix A for a sample plan

Administering Insulin Students with type 1 diabetes, and some students with type 2 Diabetes, require insulin to be given at regular times each day Some students may need additional or corrective dosages of insulin to treat hyperglycemia or to cover a rise in blood glucose levels The IHCP should specify the dosage, delivery system, and schedule for insulin administration, which will differ for each student as prescribed by their health care provider, as well as specify who will administer prescribed insulin and under
what circumstances

Insulin has three characteristics: Onset is how long insulin takes to reach the bloodstream and begin lowering blood glucose Peak time is when insulin is at its maximum strength in terms of lowering blood glucose Duration is the number of hours insulin continues to lower blood glucose levels

Today, new types of insulin and new delivery systems do a better job of keep blood glucose levels within target range These options may require closer monitoring and possibly more assistance for students with diabetes There are several types of insulin that are used in combination to treat people with diabetes These different types of insulin have been manufactured either to have immediate rapid-acting or short-acting insulin, intermediate, or long basal insulin onset and duration of action in the body A coordinated combination of insulin is used to allow for adequate treatment of diabetes at meals, snacks, during periods of physical activity, and through the night See Appendix C for types and characteristics of insulin Opened vials of insulin should be refrigerated or may be left at room temperature for 30 days after opening Unopened vials should be stored in the
refrigerator and are good until the expiration date See Appendix-for insulin storage and substitution

The three most common ways to administer insulin Insulin syringes available today make it easier to draw up the proper dosage, and shorter, smaller needles make injections easier and relatively painless An insulin pen looks like a fountain pen The pen holds a cartridge of insulin, and a needle is screwed onto its tip just before use Insulin pens are convenient and most appropriate when children need a single type of insulin An insulin pump is a Advantages of an Insulin Pump computerized device that looks like a pager and is usually worn on the Most closely mimics the bodys normal students waistband or belt The release of insulin pump is programmed to deliver small, Two types of insulin delivery: steady doses in insulin throughout the 1 Basal: small hourly dose that is day; additional doses are given to preprogrammed cover food or high blood glucose levels The pump holds a reservoir of 2 Bolus: given to cover food or cover insulin attached to a system of tubing high blood sugar called an infusion set Most infusion Pump therapy allows for greater sets are started with a guide
needle, flexibility in food choices and meal then the plastic cannula a tiny, timing flexible plastic tube is left in place, taped with dressing, and the needle is Children who wear pumps can removed The cannula is usually participate in all school activities changed every 2 or 3 days or when the blood glucose levels remain above target range More students are opting for insulin pump therapy to keep blood glucose levels in better control See Appendix C for information on pens and pumps
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Some students who need insulin during the school day are able to administer it on their own; others need supervision; and some need someone to administer the insulin for them The school nurse should provide this help in accordance with the IHCP School personnel who are responsible for the students care should be knowledgeable about the students insulin delivery system and how to respond to an emergency When a school nurse is not available to administer insulin and the student is not able to administer his/her own insulin, alternative plans need to be developed In some circumstances, the parent or other immediate family member such as the grandparent is available to come into school during the
school day to administer his/her own childs insulin When the school nurse or parent is not available to administer the insulin, the plan may identify a school nurse in a nearby school that would be available for both routine administration of insulin or emergencies For students with type 2 diabetes, treatment may commonly involve oral medication and less frequently administration of insulin

2 Nutrition
Nutrition is one of the cornerstone treatments of diabetes The goals of nutrition therapy include an adequate caloric and nutritional intake for growth and development and the balance of food with insulin and activity to achieve target blood glucose levels Children with diabetes have the same nutritional needs as a child without diabetes A meal plan needs to be developed to meet the individual needs of the child, taking into consideration food preferences, cultural influences, family eating patterns and schedules, weight, activity level, and insulin action peaks All family members can benefit from these healthy eating guidelines

Nutrition is one of the cornerstone treatments of diabetes

There are three major nutrients found in the food groups identified on the Food Guide Pyramid
The following information includes a summary of these nutrients protein, carbohydrate and fat, their roles in the body, the food groups that contain them, and their impact on blood glucose Protein builds and repairs body tissues, and is important for normal growth and development Eaten by itself, protein has little effect on blood glucose Over the years, many popular bodybuilding and weight-loss regimens have over-emphasized the role protein plays in a healthy, well-balanced meal plan, and protein supplements in the form of powders or shakes are common However, protein needs for even vigorous athletes can be easily met with everyday food sources For people with diabetes, it is especially important to communicate with a physician or registered dietician if they are considering use of a protein supplement or any nutritional supplement, due to the potential impact on blood glucose levels

Food Group Sources of Protein:
Meat and Others
Milk
Fats carry the flavor of our foods, and are a very concentrated source of energy for the body They also slow the emptying time of the stomach after a meal Eaten alone, fats have very little effect on blood glucose As part of a mixed
meal, fats may slow the absorption of carbohydrate, causing a more gradual rise in blood glucose Food Group Sources of Fats:
Meat and Others
Fats
Sweets
Carbohydrates provide most of the energy we need to move, work and live As such, the majority of calories consumed should come from carbohydrate sources, spaced appropriately throughout the day Of all the food components, carbohydrates have the greatest effect on blood glucose The total amount of carbohydrate consumed has more of an effect on blood glucose than the type of carbohydrate The best way to regulate foods is carbohydrate counting Food Group Sources of Carbohydrates:
Starch/Grain
Fruit
Milk
Sweets
Meal planning for diabetes includes all the principles of good nutrition that are recommended for good health People with diabetes are encouraged to choose a well-balanced diet with a controlled amount of carbohydrate at each meal and snack in order to help manage blood glucose Healthy carbohydrates from starches, fruits and milk are encouraged daily Sweets can be worked into a meal plan occasionally, as long as the carbohydrates they contain are accounted for, keeping in mind they are often sources of
empty calories This is true for any child or adult with or without diabetes Carbohydrate information can be obtained from many sources, including the Food Guide Pyramid, food labels, and any number of books that contain nutrient information on specific foods

Special Nutrition Issues
School Lunch: Children with diabetes may participate in school lunch program Parents/guardians can review the school menu ahead of time and request modifications for their child as needed Parents/guardians may also wish to contact the school food service director if needed for planning meals while in school School lunch programs that use nutrient standard menu planning may be able to provide a breakdown of carbohydrates to assist with meal planning After School: Children should have a convenient snack if staying after school Parents/guardians should notify school personnel that the child may need to eat during the session and are responsible to provide the snack A physicians order may also be necessary School Parties: Children with diabetes should be included in school parties; however, it may require some proper planning before the party Sweets can be eaten on a special occasion such as a
birthday party or Halloween party The carbohydrates should be included as part of the childs meal plan The childs parent/guardian should provide a list of special occasions foods included in their meal plan if the parents/guardians have not supplied an alternate snack for their child Field Trips: Whenever on a field trip, children should carry convenient snacks Bus drivers and chaperones should be notified by the school staff that the child has diabetes and may need to eat a snack during the trip Parents are responsible for providing the snack For information on general guidance for field trips, see page 20

Following an Individualized Meal Plan
The nutritional needs of a student with diabetes do not differ from the needs of a student without diabetes Both should eat a variety of foods to maintain normal growth and development The major difference is that the timing, amount, and content of the food that the student with diabetes eats are carefully matched to the action of the insulin It is recommended that children see a Registered Dietitian, preferably a Certified Diabetes Educator, once a year to create an individualized meal plan based upon carbohydrate counting or an exchange
system The students meal plan is designed to balance nutritional needs with the insulin regimen and physical activity level There are usually no forbidden foods for people with diabetes The meal plan should include 3 meals and 2-3 snacks with a specific amount of carbohydrate The meals and snacks should be timed appropriately with the peak of the childs insulin Each child needs a certain amount of carbohydrate based on age, size, gender and activity level Substitutes or modifications to school meals can only be made with appropriate documentation from the childs physician
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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 See Appendix D on carbohydrate counting
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 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 food groups
are: bread/starchy foods; fruit; milk; vegetables; meat/protein foods; and fats
With some insulin regimens, it is important to maintain consistency
A missed or delayed
in the timing and content of meals and snacks The student should snack could result in
eat lunch at the same time each day Snacks are often necessary for hypoglycemia
a child with diabetes and must be eaten to balance the peak times of insulin action A missed or delayed snack could
result in hypoglycemia The student also must have immediate access to a quick-acting form of glucose, such as juice or glucose tabs or gel

3 Physical Activity
Physical activity is an important part of the overall management of diabetes The benefits of physical activity include cardiovascular fitness, long-term weight control, social interaction and the promotion of self-esteem fostered by team play Additionally, physical activity can help to lower blood glucose Physical activity is a fundamental part of
a healthy lifestyle for all children including those with diabetes Children with diabetes can participate in gym class and after school sports Health care providers may suggest adjustments in medication and food for appropriate blood glucose control Physical education instructors and sports coaches must be able to recognize and assist with the treatment of hypoglycemia Families are encouraged to include more physical activity at home

General Physical Activity Guidelines:
1 2 3 4 5 Drink lots of sugar-free fluids, especially water Have rapid acting carbohydrate sources available Test blood glucose before, during and after physical activity Wear a diabetes ID To avoid low blood glucose, eat more carbohydrate or follow your health care providers recommendations about reducing the amount of insulin prior to physical activity

Carbohydrate Replacement for Physical Activity
Blood glucose should be checked according to the physicians recommendations so that proper measures can be taken to keep the level in the appropriate range The following chart illustrates the action that should be taken to maintain blood glucose safely with physical activity The following chart is guidelines for
students with both Type 1 and Type 2 diabetes requiring insulin for management of their diabetes
Type of Activity: If Blood Glucose Prior to Activity is: Then Eat the Following Carbohydrate Before Activity:

Short Duration Less than 30 minutes

Less than 100 Greater than 100 Less than 100

15 grams carbohydrate No carbohydrate necessary 25-50 grams carbohydrate plus protein source 15 grams carbohydrate No carbohydrate necessary 50 grams carbohydrate plus protein source 25-50 grams carbohydrate plus protein source 15 grams carbohydrate

Moderate Duration 1 hour

100-180 180-240 Less than 100

Strenuous 1-2 hours

100-180 180-240

Note: If Blood glucose is above 240, physical activity should be restricted

4 Planning Beyond the School Day
Meeting the needs of students with diabetes requires advance planning for special events such as classroom parties, field trips, and school-sponsored extracurricular activities held before or after school With proper planning students with diabetes can participate fully in all school-related activities While there are no forbidden foods for children or teens with diabetes, school parties often include foods high in carbohydrates and fats Providing
more nutritious snacks will be healthier for all students and encourage good eating habits The parents/guardian should decide whether the student with diabetes should be given the same food as other students or food the parents provide Parents should be given advance notice of parties to incorporate special foods in the meal plan or to adjust the insulin regimen With proper planning students with diabetes can participate fully in all school-related activities

Students often view a field trip as one of the most interesting and exciting activities of the school year, and students with diabetes must be allowed to have these school-related experiences
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Students with diabetes often need support from an adult on school trips Although it is not unusual to invite parents to chaperone field trips, parental attendance is not a prerequisite for participation by the student with diabetes If the parent does not accompany their child on the field trip, the school nurse needs to determine the level of health care needed on this trip and whether or not it is necessary for a nurse to participate Often a nurse is not needed on the trip; however, school personnel need to be properly trained to
accompany the student with diabetes off-site and ensure that all the students supplies are brought along with the student This includes snacks and supplies to treat hypoglycemia The plan for coverage and care during extracurricular activities sponsored by the school that take place outside of school hours should be carefully set out in the students IHCP, 504 plan, IEP, or other education plan As with field trips, personnel must be trained to ensure student safety and respond to routine and emergency care

Transportation Issues
Similar to other school activities away from the school building, advanced planning is necessary for meeting the needs of a student with diabetes while being transported to and from school School bus drivers need to be aware that they often may have students with health care needs riding the buses and should be educated on diabetes and, in particular, the signs of hypoglycemia School bus drivers also need to understand how to handle an emergency The IHCP and ECP should address how emergencies will be managed on school transportation In most situations, this plan will allow for the student to have access to food on the bus if needed and their supplies and
equipment

5 Social and Emotional Aspects of Diabetes
The diagnosis of diabetes in a child can have a significant impact on the entire family In many cases, the diagnosis of diabetes, like other chronic health diseases, is a major event for both the child and the family Each individual in the family is affected and feelings experienced often follow a similar pattern although all reactions are unique and may occur at different times for different families These feelings may linger for a long time if they are not recognized and expressed Dealing with feelings openly can help the child and the family learn to face the daily challenges and facilitate acceptance of having diabetes as part of their family The feelings described are often present in all families who have a child with diabetes

Denial
This cant really be happening Its not that serious I dont need to take my insulin today No one has to know I have diabetes

The child or family member may find it difficult to even talk about diabetes It may be too painful to face This can interfere with the medical teams ability to educate and treat the child At times, the child or the parent/guardian may try to hide their feelings to be
strong or not to upset the others This denial may make the childs ability to adjust to the daily struggles much more difficult
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Sadness
The child or family member may cry, feel depressed, or hopeless Feeling sad is normal, and brief periods of sadness can occur for years after diagnosis It is important for the child or family member to express their sadness and to openly share their feelings They should be encouraged to seek professional help if they feel depressed or hopeless for a long period of time

Anger
Why me? or Why my child? Why do I have to do it all? It isnt fair Anger may be vented toward nurses, doctors, God, spouse, friends, siblings, teachers, the list is endless Although this also is a normal feeling, it may interfere with the child or the family members ability to adjust to the daily pressures of managing diabetes If it is having a major impact on the child or the family as a unit, individual counseling may be helpful

Fear
What will this mean for my childs life? Whats going to happen? How can we ever leave him alone? There are so many fears that are expressed by the family and the child Parents/guardians fear the increase in responsibility and the expenses
They worry about the future, and doubt their ability to manage diabetes every day Siblings fear they may get diabetes too The child with diabetes fears hospitals, injections, finger sticks, low blood sugars and even death He/she may fear being different from friends All these fears are certainly justified, but can be allayed if they are openly discussed and support is given as needed

Guilt
What did I do to deserve this? If I just hadnt eaten so much sugar The diabetes may have come from my side of the family Parents/guardians commonly feel that they gave their child diabetes This idea often persists even though we know other factors also play a role in the onset of diabetes The child may feel diabetes is a punishment for bad behavior Such feelings are very common at the time of diagnosis As time goes on, the child feels guilty if he/she sneaks extra candy, skips doing blood tests, lies about blood glucose results or does not follow the rules Parents/guardians feel guilty whenever they have to enforce the rules of self-management or deny their child a treat The opportunities to feel guilty are always there Parents/guardians and children need to be supported in their efforts each
day

Acceptance
I dont like having diabetes but I guess I can handle it The shots arent so bad, I just wish I could eat whatever I want This stage may take a long time to reach and some may never come to accept diabetes as part of their life A well-adjusted family learns to cope with the endless demands and struggles diabetes can add to their life They feel more confident and hopeful Sadness and anger may still occur but these periods are temporary The family needs to seek out resources in the community and within their family to ease the burden of daily management Dealing with all of these emotions can be a challenge for the family with diabetes They must come to the understanding that diabetes should not prevent a child from living a full and active life They are not alone There are many resources available in the community and many other families traveling the same road
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Factors Causing Emotional Distress at Diagnosis of Diabetes in a Child
Uncertainty about the outcome of the immediate situation
Feelings of intense guilt and anger about the occurrence of diabetes
Feelings of incompetence and helplessness about the responsibility for managing the
illness Loss of
valued life goals and aspirations because of illness Anxiety about planning for an uncertain future Adults must Recognition of the necessity for a permanent change in living recognize that

6 Promoting Student Independence

While it is very important to provide students with assistance and supervision of their diabetes care as needed, it is equally important to enable students to take on the responsibility of learning diabetes selfmanagement and control Age alone should not be the guideline used to assume that a child is ready to accept responsibility for managing components of diabetes care It is important to realize that children develop at different rates There is no such thing as a magic age when a child suddenly can perform a certain skill or be responsible for their own care

responsibilities related to diabetes depend not just on age, but also on the development of the individual as well as the circumstances at individual schools

Student ability to participate in self-care also depends upon their willingness to do so As students are ready, they can assume more responsibility for their care Children need to be encouraged and supported to gradually assume diabetes self care
as they mature and demonstrate confidence The adult must be sure that when the responsibility is given that the child is willing to take it Keep in mind that a childs ability or desire to perform certain diabetes related tasks might vary from day to day It is normal for the child to regress and depend once again on an adult to handle the responsibility Parents, school nurses, relatives and other reliable adults must be sensitive to the childs needs and be available to take over with no questions asked A students health care provider must provide a written order stating the need and the capability of the student to conduct self-testing Such an order will permit a student to self-test their blood glucose while at school or at school sponsored activities The school nurse and/or other school personnel should collaborate with the student and family to ensure that the personnel should collaborate with the student and family to ensure that the students ability to self-test will result in effective diabetes management and complies with OSHAs Universal Precautions Student competence and capability for performing diabetes-related tasks are determined by the school team and the
parents/guardians Diabetes care depends upon selfmanagement Ultimately, each person with diabetes becomes responsible for all aspects of self-care, including blood glucose monitoring and insulin administration Regardless of their level of self-management, however, all students with diabetes may require assistance when blood glucose levels are out of the target range
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To help determine how much responsibility a student with diabetes can handle, it helps to be aware of different stages in normal childhood development Adults must recognize that responsibilities related to diabetes depend not just on age, but also on the development of the individual as well as the circumstances at individual schools The charts below provide guidelines for determining the average age for assuming diabetes related skills These are general recommendations, but each child must be evaluated individually Independence takes a long time and requires a lot of help and supervision from adults The child who feels that he or she has a network of adults to support and assist with diabetes management will generally maintain better diabetes control

General Guidelines: Age-Appropriate Responsibilities
Age 3-7
years Developmental Characteristics Imaginative/concrete thinkers Cannot think abstractly Self-centered Diabetes-Related Responsibility Parent supervision for all tasks Is generally cooperative for blood glucose tests and insulin shots Inconsistent with food choices Gradually learns to recognize hypoglycemia Not much concept of time Can learn to test blood glucoses At age 10 or 11, can draw up and give shots on occasion Can make own food choices Can recognize and treat hypoglycemia By 11 or 12 years, can be responsible for remembering snack, but may still need reminders Alarm watches may promote independence Capable of doing the majority of shots and blood tests but may still needs some parental supervision and review at times to make decisions about dosage Knows which food to eat Gradually recognizes the importance of good sugar control to prevent later complications May be more willing to inject multiple shots per day

7-12 years

Concrete thinkers Capable of more logic and understanding More curious More social More responsible

12-18 years

More independent Behavior varies Body image important Away from home more More responsible Capable of abstract
thinking

F Diabetes Management Training for School Personnel
Diabetes management training teaches school nurses and staff members how to provide necessary care for students with diabetes during the school day and school-sponsored extracurricular activities Training should occur when a student is diagnosed with diabetes, when a student with diabetes is enrolled in the school, or when appropriate Training should be ongoing and include regular refresher sessions Suggested Components: Introduction to the childs IHCP
Type 1 and 2 diabetes: what it is, how it is managed if not covered at planning meeting
Monitoring tools: blood glucose monitor, written records, etc
Signs and symptoms of hypoglycemia and hyperglycemia
Procedures for routine care of the individual student
Emergency procedures
Overview of universal health and safety guidelines OSHA and disposal of supplies
Monitoring techniques for those who may do finger sticks or arm sticks

Following the initial training, school nurses often provide the ongoing training needs of staff and the student See Appendix A for staff training record

SECTION TWO

Frequently Asked Questions
1 What is the
citation in the law that indicates who can perform nursing tasks and/or administer medications to students?
Section 20-87a of Chapter 378 of the Connecticut general statutes The Nurse Practice Act states that only registered nurses may execute medical regimens Section 20-87c indicates that licensed practical nurses may perform selected tasks and share responsibility under the direction of a registered nurse or advanced practice registered nurse Section 10-212a of Chapter 169 of the Connecticut general statues allows a school nurse or any other nurse licensed pursuant to the provisions of chapter 378 to administer medications to students in schools In addition 10-212a, amended by Public Act 03-211, allows, in the absence of a school nurse, the principal, any teacher, licensed physical or occupational therapist, or coach of intramural and interscholastic athletics of a school to administer medicinal preparations, including such controlled drugs as the Commissioner of Consumer Protection may, by regulation, designate, to any student at such school pursuant to the written order of a physician licensed to practice medicine or a dentist licensed to practice dental medicine in this or
another state, or an advanced practice registered nurse licensed to prescribe in accordance with 20-94a, or a physician assistant licensed to prescribe in accordance with 20-12d, and the written authorization of a parent or guardian of such child 10-212a as amended by PA 03-211 designates the State Board of Education in consultation with the Commissioner of Public Health as the entity to adopt regulations that specify conditions under which a coach of intramural or interscholastic athletics may administer medication to a child participating in such intramural or interscholastic athletics 10-212a as amended by PA 03-211 allows a school paraprofessionals to administer medication to a specific student with a medically diagnosed allergic condition that may require prompt treatment in order to protect the student against serious harm or death

2 Can an LPN provide school health services including diabetic care 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 school nurse The tasks must be part of an individual nursing care plan that is developed, maintained and evaluated by a school
nurse

3 How should school districts handle the issue of medications when students go on field trips or participate in after-school activities?
Connecticut state law allows a number of trained school employees to administer oral, topical and inhalant medications to students who cannot self-administer medications Non-licensed personnel may only administer injectable medication to students who have a medically diagnosed allergic condition For other students who need injectable medications and cannot self-administer, a number of options are available:
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The parent or guardian may attend the activity and administer the medication; or The students health care provider can be consulted and may order the medication time to be adjusted or the dose eliminated; or The school may send a school nurse, substitute school nurse or LPN on the field trip to administer the medication A child may not be prevented from participating in an educational activity, such as a field trip, solely on the basis of a special health need Even if no medication is needed during the field trip, the school must have trained personnel who can respond to an emergency

4 How should school districts handle the need
for nursing procedures when students go on field trips or participate in after-school activities?
When a student is unable to perform a necessary health-related task independently and the task is a nursing procedure, the school nurse has to participate or the school nurse may delegate the task to an appropriate, trained unlicensed person To delegate this task the nurse feels it is appropriate to delegate that particular task for that particular student to that particular staff members, the identified staff member is willing to assume the task and the task does not require nursing judgment

5 Must all children with special health care needs have an individualized health care plan IHCP?
An IHCP, a plan of care for a child with health needs, is not required by law, but is customarily used in nursing practice and is recommended for all students with special health care needs who require care for their health care needs The IHCP may be a stand-alone plan developed by the nurse in consultation with a team that includes a parent or guardian, the health care provider, teachers and others responsible for the student, or it may be a part of an Individualized Education Plan or 504 Plan

6 Are
school districts authorized to employ Emergency Medical Technicians EMTs to provided health care to children with special health care needs in the absence of the school nurse?
No The definition of services that may be provided by EMTs allows these individuals to function as EMTs only when they are working as members of the emergency medical system An EMT may not be hired to provide nursing procedures, including medication administration, to children with special health care needs An EMT who has been hired as a health aide must work within the scope of the health aide job description and be trained as a health aide

7 If a non-licensed individual takes a course that certifies him/her to give medications in the home, can that person give medications in the school setting?
No Medication administration in schools is governed by 10-212a of the CGS
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8 Can a non-licensed person, who receives appropriate training, administer medications?
Yes A full time school employee who meets the criteria of 10-212a and has been appropriately trained by the school nurse for the specific student and medication may administer oral, topical, and inhalant medications

9 Can the school nurse provide
training to non-licensed persons to administer injectable medications in anticipation of an emergency?
According to 10-212a-2e Non-licensed persons may administer injectable medications only to students who have been medically diagnosed with an allergic condition, which may require prompt treatment to protect the student against serious harm or death

10What procedures should be followed when a nurse working in a school building is employed by another agency ie private duty nurse for a child with special health care needs?
Procedures that govern health care for students, including care provided by nurses from outside agencies, should be established by school district policy Procedures should address situations where: 1 there is a school nurse in the building, 2 there is no school nurse in the building If the nurse is hired by the school district there should be a contract with the agency in place The agency is responsible for assuring that the nurse has a valid license and the expertise to perform the functions required The school district should have all the required orders and authorizations in place The agency nurse and school nurse should work together to develop a plan to
assure that the students health needs will be met ie, an emergency However the school nurse should never be expected to substitute for the agency nurse in providing constant care of the student or to supervise a nurse who is not employed by the district Agency nurses should be expected to abide by the health and administrative policies of the district ie, notification to the school nurse or administrator when in the building, evacuation and emergency procedures, etc Procedures should be established for the school nurse to follow if the school nurse determines that an agency nurse is performing a procedure in an unsafe way Agency nurses assigned to care for a specific student should not be expected to substitute for the school nurse

11Where can districts get training information and resources on school health issues?
Many hospitals in the state provide training, information and resources Connecticut Childrens Medical Center, Hospital for Special Care, University of Connecticut John Dempsey Medical Center and Yale University and Hospital may be able to guide school districts in the right direction The State Department of Education is an additional resource Regional Education Service
Centers RESCs can be helpful in providing consultation, technical support and training Some colleges offer continuing education related to school health
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SECTION THREE

Suggested Roles and Responsibilities of School Personnel
The following suggested roles and responsibilities were adopted from Helping the Student with Diabetes Succeed from the National Diabetes Education Program School districts may find them helpful in understanding the roles and responsibilities of the various school personnel who may be involved in creating a safe learning environment for students with diabetes As noted in the introduction, the school health team, which includes the school personnel mentioned in the following pages, plays an important role in helping students manage their diabetes

Actions for the School District Administrator
Superintendent, Director, 504 Coordinator, or other administrative personnel V Provide leadership in developing district policy related to all aspects of diabetes management at school, including staff training, medication administration policy, and blood glucose monitoring V Support implementation of district policy regarding diabetes management, and ensure
ongoing quality improvement V Understand and implement the federal and state laws that apply to diabetes where applicable V Allocate sufficient resources to helping students manage diabetes V Monitor schools attended by students with diabetes for compliance with district policy V Respect the students confidentiality and right to privacy V Learn about diabetes

Actions for the Principal, School Administrator, and/or Designee
V Participate in developing and implementing school policy on diabetes management V Allocate sufficient resources to helping students manage diabetes V Develop and implement a system to inform school health services of the pending enrollment of a student with diabetes V Promote a supportive learning environment for students with diabetes V Meet annually with the school health team, including the student, family, school nurse, teachers and others, to discuss accommodations needed V Identify all staff members who have responsibility for the student with diabetes V Arrange for diabetes management training for the school nurse and other staff with responsibility for students with diabetes V Alert all school-staff members who teach or supervise a student with
diabetes about accommodations and emergency procedures V Alert all substitute personnel and others eg the bus driver so that they are familiar with emergency procedures for the student V Implement school policy on availability of health services V Work with the school health team to implement the students written plans V Respect the students confidentiality and right to privacy V Help to develop and implement on-campus and off-campus emergency protocols V Include diabetes awareness as part of health or cultural education V Support and facilitate ongoing communication between parent/guardians of students with diabetes and school staff V Learn about diabetes V Be able to recognize and respond to signs and symptoms of hypoglycemia and hyperglycemia V Understand federal and state laws where applicable
32

Actions for the School Nurse
V Obtain and review the students current diabetes medical plan from the students physician and pertinent information from the student and family V Facilitate the initial school health team meeting V Conduct a nursing assessment of the student and develop a nursing care plan that incorporates the students diabetes care regimen as prescribed by the students
diabetes medical management plan or healthcare providers orders V Conduct ongoing, periodic assessments of the students with diabetes and update the nursing care plans V Coordinate development of the students Emergency Care Plan ECP and provide copies to staff members who have responsibility for the student throughout the school day eg teachers, counselor, PE instructor, and lunchroom staff V Obtain materials and medical supplies necessary for diabetes care tasks from the parents/guardians and arrange a system for notifying the student or parents/guardian when supplies need to be replenished V Plan and implement diabetes management training for appropriate staff V Participate in diabetes management training V Review information about diabetes in this guide V Perform routine and emergency diabetes care tasks, including blood glucose monitoring, urine ketone testing, insulin administration, and glucagon administration V Practice universal precautions and infection control procedures during all student encounters V Maintain accurate documentation of contacts with students and family members V Collaborate with other co-workers, eg food service and school bus transportation services, as
necessary to provide appropriate health care services V With parental permission, act as liaison between the school and the students health care provider regarding the students self-management at school V Communicate to parents/guardians any concerns about the students diabetes management or health, such as acute hypoglycemia episodes, hyperglycemia, general attitude, and emotional issues V Promote and encourage independence and self-care consistent with the students ability, skill, maturity, and developmental level V Respect the students confidentiality and right to privacy V Act as an advocate for students to help them meet their diabetes health care needs V Provide education and act as a resource on managing diabetes V Assist the classroom teacher with developing a plan for substitute teachers V Assist the PE instructor with managing the students exercise program at school V Be knowledgeable about federal, state, and local laws and regulations that pertain to managing diabetes at school V Assist student with blood glucose monitoring prior to dismissal
33

Actions for the Teacher
V Participate in school health care team meetings V Work with school health team to implement
written care plans V Recognize that a change in the students behavior could be a symptom of blood glucose changes V Be prepared to recognize and respond to the signs and symptoms of hypoglycemia and hyperglycemia V Provide a supportive environment for the student to manage diabetes effectively and safely at school, which includes eating snacks for routine diabetes management and to treat low blood glucose levels, having bathroom privileges and access to drinking water, monitoring blood glucose, and administering insulin and other medications V Provide classroom accommodations for the student with diabetes V Provide instruction to the student if it is missed because of absence for diabetes-related care V Provide information on accommodations and policies, location of supplies, the students emergency care plan and other aspects of diabetes management to substitute teachers V Notify the parents/guardians in advance of changes in school schedule, such as class parties, field trips, and other special events V Communicate with the school nurse, and parents regarding any concerns about the student V Learn about diabetes and if necessary, attend diabetes management trainings V Treat the
student with diabetes the same as other students, except to meet medical needs V Respect the students confidentiality and right to privacy

Actions for the Coach and Physical Education Instructor
V Encourage exercise and participation in physical activities and sports for students with diabetes, as well as for other students V Treat the student with diabetes the same as other students, except to meet medical needs V Encourage the student to have personal supplies readily accessible V Allow the student to check blood glucose levels V Understand and be aware that hypoglycemia can occur during and after physical activity V Recognize that a change in the students behavior could be a symptom of blood glucose changes V Be prepared to recognize and respond to the signs and symptoms of hypoglycemia and hyperglycemia V Provide the student with immediate access to a fast-acting form of glucose to treat hypoglycemia if necessary V Consider taping a fast-acting form or glucose 3 or 4 glucose tablets or hard candies to a clipboard or include it in the First Aid pack V Learn about diabetes V Provide input to the students school health team as needed V Communicate with the school nurse
regarding any observations or concerns about the student V Provide information to substitute PE instructors V Respect the students confidentiality and right to privacy

Actions for the Food Service Manager/Staff, or Lunchroom Monitor
V Obtain a copy of the students written individualized meal plan V Obtain a copy of the students Emergency Care Plan and keep it in a known, yet secure, place in the lunchroom V Provide a lunch menu and lunch schedule in advance to parents If available, also include the nutrition content of menu selections including grams of carbohydrate and fat V Understand and be aware that hypoglycemia can occur before lunch V Encourage student to eat appropriate foods based on the students individualized meal plan V Be prepared to recognize and respond to the signs and symptoms of hypoglycemia and hyperglycemia according to the students emergency care plan V Learn about diabetes V Recognize that a change in the students behavior could be a symptom of blood glucose changes V Learn about the various kinds of diabetes meal and snack plans, and which type of meal plan the student follows V Recognize that eating meals and snacks on time is a critical component of
diabetes management, and that failure to eat lunch on time could result in low blood glucose, especially if a student has missed a morning snack or has had a physically strenuous or otherwise active morning at school V Know where supplies to treat hypoglycemia are kept V Treat the student with diabetes the same as other students, except to meet medical needs V Provide input to the students school health team when requested V Communicate with the school nurse regarding any concerns about the student V Respect the students confidentiality and right to privacy

Actions for the Guidance Counselor or School Psychologist
V Work with school staff to promote a supportive learning environment V Ensure that the student with diabetes is treated the same as students without diabetes, except to respond to medical needs V Be aware of and be prepared to respond to the emotional needs of the student V Recognize that students with chronic illnesses such as diabetes may rebel by discontinuing all or part of their medical regimen V Be aware that some students may not wish to share information about their diabetes with other students or school staff, particularly if it makes them feel different
from others V Promote and encourage independence and self-care that are consistent with the students abilities, skill, maturity, and development V Learn about diabetes V Provide input to the students school health team as appropriate V Communicate with the school nurse regarding any concerns about the student V Respect the students confidentiality and right to privacy

Actions for Parents or Guardians
V Inform the school principal that your child has diabetes V Provide accurate and emergency contact information and ensure it is always up to date V Provide the Diabetes Medical Plan, signed by the physician, to the school nurse V Attend and participate in initial and annual meetings of the school health team V Provide specific information about your childs diabetes V Permit sharing of medical information necessary for the students safety between the school and the students personal health care providers V Inform the school staff of any changes in the students health status V Provide all supplies, equipment, and snacks necessary for implementing your childs diabetes management V Provide and maintain all supplies, equipment, and snacks necessary to accommodate the students long-term
needs in case of an emergency V Inform appropriate school staff when the student plans to participate in school-sponsored activities that take place before or after school so that health care coverage can be coordinated to ensure the health and safety of the student with diabetes V Understand federal, state, and local laws that address the schools responsibilities to students with diabetes

Actions for the Student with Diabetes
V Participate in the school meeting regarding your diabetes management V Always wear a medical alert ID and carry a fast-acting source of glucose V Tell teachers and other school staff members if you feel symptoms of low or high blood glucose, especially if you need help V Work with school staff members if you need help checking your blood glucose, getting insulin, or eating the right amount of food at the right time during the school day V Take charge of your diabetes care at school if your written plans include: checking and writing down blood glucose levels figuring out the right insulin dose giving yourself insulin properly disposing of needles, lancets, and other supplies after use eating meals and snacks as planned treating low blood sugar
carrying diabetes equipment and supplies with you at all times

RESOURCES
American Academy of Family Physicians AAFP The AAFP is the national member organization of family doctors Its website includes articles about the link between obesity and diabetes in young people and how to help children lose weight 11400 Tomahawk Creek Parkway
Leawood, KS 66211
Phone: 913 9066000
wwwaafporg
American Academy of Pediatrics AAP The AAP is a professional membership organization committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults 141 Northwest Point Boulevard Elk Grove Village, IL 600071098 Phone: 847 4344000 wwwaaporg American Association for Health Education AAHE The AAHE serves health educators and other professionals who promote the health of all people through education and other systematic strategies Programming focuses on health promotion in schools K-12, health care, public and community agencies, business/industry, and professional preparation AAHE is one of six national associations within the American Alliance for Health, Physical Education, Recreation and Dance 1900 Association
Drive
Reston, VA 20191
Toll-free: 18002137193, Ext 437
wwwaahperdorg/aahe
American Association of Diabetes Educators AADE The AADE is a multidisciplinary organization for health professionals who provide diabetes education and care The AADE website provides diabetes links, including information about diabetes in children and adolescents 100 West Monroe Street, Suite 400
Chicago, IL 60603
Toll-free: 1800TEAMUP4
18008326874
wwwaadenetorg
American Council on Exercise ACE The ACE is a nonprofit organization that promotes active, healthy lifestyles and their positive effects on the mind, body, and spirit Its programs are directed to youths as well as adults 4851 Paramount Drive San Diego, CA 92123 Phone: 858 5358227 wwwacefitnessorg

American Diabetes Association ADA The ADAs mission is to prevent and cure diabetes and improve the lives of people with diabetes Founded in 1940, the association conducts programs in all 50 states and the District of Columbia, reaching hundreds of communities across the country The ADA is a nonprofit organization that provides diabetes research, information and advocacy The association offers a variety of programs focused on young
people with diabetes 306 Industrial Park Rd 105
Middletown, CT 06457
1-877-639-0385
wwwdiabetesorg
For information about ADAs training curriculum for school personnel:
wwwdiabetesorg/schooltraining
American Dietetic Association ADA The ADA is a member organization for registered dietitians and registered
technicians representing special interests, including public health, sports nutrition, medical nutrition
therapy, diet counseling for weight control, cholesterol reduction, and
diabetes More than 5,000 dietitians now belong to the ADAs specialty group on Diabetes Care and
Education
120 South Riverside Plaza, Suite 2000
Chicago, IL 606066995
Toll-free: 18008771600
Consumer referral: 18003661655
wwweatrightorg
American Heart Association This Web site is filled with important information about type 2 diabetes, insulin resistance, and related cardiovascular risks — as well as ways you can reduce your chances of heart disease and other complications of diabetes Plus, theres special information on our Heart of Diabetes Thrivers Program We even have special sections of Fun Stuff, My Diabetes Tools, and even a Meet Our Celebrity section 7272 Greenville Avenue
Dallas, TX 75231 1-800-AHA-USA1 242-8721 wwwamericanheartorg American Medical Association AMA The AMA is the nations leader in promoting professionalism in medicine and setting standards for medical education, practice, and ethics As the largest physician membership organization in the United States, the AMA is at the forefront of every major development in medicine and is a steadfast and influential advocate for physicians and their patients The AMA works tirelessly to promote the art and science of medicine and the betterment of public health American Medical Association Science, Quality and Public Health Group
515 N State Street
Chicago, IL 60610
Phone: 312 4644908
wwwama-assnorg/

American Podiatric Medical Association, Inc APMA The APMA is the premier professional organization representing the nations Doctors of Podiatric Medicine and is committed to advancing the profession of podiatric medicine for the benefit of its members and the public by ensuring the highest quality foot and ankle care APMA
9312 Old Georgetown Rodad
Bethesda, MD 20814-1621
Telephone: 1-800-FOOTCARE
http://wwwapmaorg
American School Health Association ASHA The mission of the ASHA
is to promote and improve the well-being of children and youth by supporting comprehensive school health programs In addition to a journal, the association produces a book for school nurses and families on managing school-age children with chronic health conditions Route 43, PO Box 708 Kent, OH 44240 Phone: 330 6781601 wwwashaweborg Centers for Disease Control and Prevention CDC The CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States CDC divisions with special relevance to diabetes in students are the Division of Diabetes Translation, the Division of Nutrition and Physical Activity, and the Division of Adolescent and School Health 4770 Buford Highway, NE Atlanta, GA 30341 Toll-free: 1800-3113435 wwwcdcgov Division of Diabetes Translation Toll-free: 1877CDCDIAB 18772323422 wwwcdcgov/diabetes Division of Nutrition and Physical Activity wwwcdcgov/nccdphp/dnpa Division of Adolescent and School Health wwwcdcgov/nccdphp/dash Children with Diabetes This is an on-line community for kids, families and adults with
diabetes It is easy to navigate and provides a wealth of information on the basics, management in school, treatments, research and more wwwchildrenwithdiabetescom Connecticut Association of Diabetes Educators CADE The Connecticut chapter of the AADE is dedicated to improving the quality of diabetes education,
care and services to people with diabetes by enhancing the competence of diabetes educators and
facilitating interaction and communication among diabetes educators
wwwcadeonlineorg

Connecticut Childrens Medical Center CCMC Department of Endocrinology Karen Bucci, APRN 1-860-545-9370 wwwccmckidscom Disability Rights Education and Defense Fund DREDF DREDF is a national law and policy center dedicated to protecting and advancing the civil rights of people with disabilities through legislation, litigation, advocacy, technical assistance, and education and training of attorneys, advocates, persons with disabilities, and parents and children with disabilities 2212 Sixth Street Berkeley, CA 94710 Phone: 510 6442555 wwwdredforg Diabetes Exercise and Sports Association This nonprofit service organization is dedicated to enhancing the quality of life for people with diabetes
through exercise 1647-B West Bethany Home Road
Phoenix, AZ 85015
Toll-free: 18008984322
wwwdiabetes-exerciseorg
Educational Resources Information Center ERIC The ERIC is a federally funded, nonprofit information network designed to provide ready access to education literature for teachers and parents 1307 New York Avenue, NW, Suite 300
Washington, DC 200054701
Toll-free: 18008229229
wwwericedgov
5 A Day for Better Health Program The national 5 A Day for Better Health Program gives Americans a simple, positive message–eat 5
or more servings of fruits and vegetables every day for better health The program is jointly sponsored
by the National Cancer Institute NCI and the Produce for Better Health Foundation PBH, a
nonprofit consumer education foundation representing the fruit and vegetable industry The National
Cancer Institute funds behavior change and communications research to determine strategies that are
effective to increase fruit and vegetable consumption
www5adaygov
The Foundation of the American Academy of Ophthalmology Diabetes Project PO Box 42998
San Francisco, CA 94142-9098
1-800-222-EYES 3937

wwwihsgov/medicalprograms/diabetes

Indian Health Service IHS IHS National Diabetes Program The mission of the IHS is to develop, document, and sustain a public health effort to prevent and control diabetes in American Indian and Alaskan Native communities 5300 Homestead Road, NE Albuquerque, NM 87110 Phone: 505 2484182 wwwihsgov Insulin Pumpers Insulin Pumpers provides information and support for adults and children with diabetes and their families interested in insulin pump therapy There is a special section devoted to children with diabetes and the stories about how an insulin pump has changed their lives wwwinsulin-pumpersorg Joslin Diabetes Center The Joslin Diabetes Center and its affiliates offer a full range of services for children and adults with diabetes, including programs to help youngsters with diabetes and their families manage the disease 1 Joslin Place Boston, MA 02215 Toll-free: 1800JOSLIN1 18005675461 wwwjoslinharvardedu Juvenile Diabetes Research Foundation International JDRF The mission of JDRF is to find a cure for diabetes and its complications through the support of research 120 Wall Street New York, NY 100054001 Toll-free: 1800533CURE 18005332873
wwwjdrforg National Association of Elementary School Principals NAESP The NAESP promotes advocacy and support for elementary and middle level principals and other education leaders in their commitment to all children Linkages to Learning
1615 Duke Street
Alexandria, VA 22314
Toll-free: 180038NAESP 18003862377
wwwnaesporg
National Association of School Nurses NASN The NASN is a nonprofit organization that represents school nurses; it offers continuing education, issues briefs, holds an annual conference, and provides legislative updates and position statements, and other materials 1416 Park Street, Suite A
Castle Rock, CO 80109
Toll-free: 1866NASNSNS 18666276767
wwwnasnorg

National Association of Secondary School Principals NASSP The NASSP is a membership organization of middle level and high school principals, assistant principals, and aspiring school leaders from across the United States and around the world NASSPs motto is promoting excellence in school leadership, and the association provides members with various programs and services to guide them in administration, supervision, curriculum planning, and staff development to achieve that goal 1904
Association Drive Reston, VA 20191 703 8600200 wwwprincipalsorg National Association of State Boards of Education NASBE The NASBE is a nonprofit association that represents state and territorial boards of education NASBEs principal objectives include strengthening state leadership in educational policymaking, promoting excellence in the education of all students, advocating equality of access to educational opportunity, and assuring continued citizen support for public education 277 South Washington Street, Suite 100
Alexandria, VA 22314
Phone 703 6844000
wwwnasbeorg
National Center on Physical Activity and Disability NCPAD The NCPAD provides information about current research, local programs, adapted equipment, recreation and leisure facilities, and many other aspects of physical activity for persons with disabilities, including children and adolescents with diabetes 1640 West Roosevelt Road Chicago, IL 60608 Toll-free: 18009008086 wwwncpadorg National Education Association NEA Health Information Network The NEA Health Information Network is the nonprofit health affiliate of the
National Education Association, the nations largest labor organization representing 23 million
public
school employees The mission of the NEA Health Information Network is to ensure that all public
school employees, students, and their communities have the health information and skills to achieve
excellence in education
1201 16th Street, NW
Suite 521
Washington, DC 200363290
Phone: 202 8334000
wwwneahinorg
National Eye Institute
Nation Eye Health Education Program
Diabetic Eye Disease Public Education Program
2020 Vision Place
Bethesda, MD 20882-3655
1-800-869-2020 to order materials
wwwneinihgov/nehep/dedhtm

National Information Center for Children and Youth with Disabilities This national information and referral clearinghouse on special education and disability-related issues provide information about local, state or national disability groups and gives technical assistance to parents and professionals PO Box 1492
Washington, DC 200131492
Toll-free: 18006950285
wwwnichcyorg
National Institute of Child Health and Human Development NICHD, National Institutes of Health The NICHD conducts and supports laboratory, clinical, and epidemiologic research on the reproductive, neurobiological, developmental, and behavioral processes that
determine and maintain the health of children, adults, families, and populations 31 Center Drive, MSC 2425 Bethesda, MD 208922425 Phone: 301 4965133 wwwnichdnihgov National Institute of Diabetes and Digestive and Kidney Diseases NIDDK The NIDDK conducts and supports research on many of the most serious diseases affecting public health The Institute supports much of the clinical research on the diseases of internal medicine and related subspecialty fields, as well as many basic science disciplines wwwniddknihgov National Diabetes Education Program NDEP The NDEP is a federally sponsored program of the National Institutes of Health and the Centers for Disease Control and Prevention, involving over 200 public and private partners to improve diabetes treatment and outcomes for people with diabetes, promotes early diagnosis and prevention 1 Diabetes Way
Bethesda, MD 20892-3600
Toll-free: 1-800-438-5383
wwwndepnihgov
National Diabetes Information Clearinghouse NDIC The NDIC is a service of the National Institute of Diabetes and Digestive and Kidney Diseases that provides information about diabetes to people with diabetes, their families, health care professionals, and the public 1
Information Way Bethesda, MD 208923560 Toll-free: 18008608747 wwwdiabetesniddknihgov/ National Kidney Foundation The National Kidney Foundation, Inc, is a major voluntary health organization, seeks to prevent kidney and urinary tract diseases, improve the health and well-being of individuals and families affected y these diseases, and increase the availability of all organs for transplantation National Kidney Foundation 30 East 33rd Street New York, NY 10016
45

1-800-622-9010 http//wwwkidneyorg Pediatric Education for Diabetes in School PEDS The PEDS website is designed for both health care professionals and consumers, providing comprehensive information and resources for the management of diabetes in school It contains many tools for schools including Individual Healthcare Plans, numerous procedures, and school staff action tools There are also two online training programs entitled Recommendations for Diabetes Care in Schools and Diabetes Basics wwwpedsonlineorg Pediatric Endocrinology Nursing Society PENS The PENS is a nonprofit professional nursing organization with the goal of advancing pediatric endocrine nursing Its website features articles about diabetes-related topics,
including insulin pump therapy, obesity in children, and development of a pediatric diabetes education program for home health nurses P O Box 2933 Gaithersburg, MD 20886-2933 Phone: Not available All contact is through mail or email Email: Through website under contact PENS wwwpensorg The Presidents Council on Physical Fitness and Sports PCPFS The PCPFS serves as a catalyst to promote, encourage and motivate Americans to become physically active and participate in sports The PCPFS advises the President and the Secretary of Health and Human Services on how to encourage more Americans to be physically fit and active wwwfitnessgov US Department of Agriculture USDA The USDA supports several programs of importance to students with diabetes: the Center for Nutrition Policy and Promotion, the Food and Nutrition Information Center, and the Food and Nutrition Service Center for Nutrition Policy and Promotion wwwusdagov/cnpp Food and Nutrition Information Center wwwnalusdagov/fnic Food and Nutrition Service wwwfnsusdagov/fns U S Department of Education The mission of the Department of Education is to ensure equal access to education and to promote
educational excellence throughout the
nation
400 Maryland Avenue, SW
Washington, DC 20202
Office of Civil Rights OCR Toll-free: 1-800-421-3481, TTY: 1-877-521-2172 wwwedgov/ocr Office of Special Education Programs OSEP Phone: 202205-5507, TTY: 202205-5637 wwwedgov/offices/OSERS/OSEP
46

Yale Program for Children with Diabetes This program, directed by Dr William Tamborlane, holds three half-day sessions per week The sessions are led by a 10 person Diabetes Team 203764-6745

Other resources for teachers, child care providers, parents, and health professionals who care for children with diabetes: Barrett, Jena Clayton 2001 Teaching Teachers About School Health Emergencies The Journal of School Nursing, 176, 316-322 Bierschbach, Judy Laver Bierschbach, Cooper, Leslie, and Liedl, Jennifer A2004 Insulin Pumps: What every school nurse should know The Journal of School Nursing 202,117-123 Blum, Monica 2002 Are School Nurses Using the Recommendations of the Diabetes Control and Complications Trial in the Care of Students with Diabetes? The Journal of School Nursing, 183, 138141 Clarke W 1999 Advocating for the child with diabetes Diabetes Spectrum 12,230236
Complete Guide to Diabetes, Alexandria, VA, American Diabetes
Association, 1999; 1-800-232-6733
Education Discrimination Resources List, Alexandria VA, American Diabetes Association, 2000
Fredrickson L, Griff M: Pumper in the School, Insulin Pump Guide for School Nurses, School Personnel and
Parents MiniMed Professional Education, Your Clinical Coach First Edition, May2000 MiniMed, Inc, 1800-440-7867 Information for Teachers Child-Care Providers, Alexandria, VA, American Diabetes Association, 1999 brochure; available online at: http://wwwdiabetesorg/ada/teacherasp Kolar, Kathryn R, Haynie, Lisa, Wilkerson, Robin and Fisher, Wanda 2002 Type 1 Diabetes in Children and Adolescents: Whats New? The Journal of School Nursing, 183, 144-149 National Association of School Nurses NASN Issue Briefs: Delegation of Care in the School Setting 2004 The School Nurse Role in Accessing Health Care 2002 NASN Position Statements: Blood Sugar Monitoring in the School Setting 2001 Case Management of Children with Special Health Care Needs 2002 Emergency Care Plans for Students with Special Health Care Needs 2004 Individualized Health Care Plans 2003 Medication Administration in the School Setting 2003 Rescue Medications in School 2004 School Nurse Role in
the Care and Management of the Child with Diabetes in the School Setting 2001 The School Nurse and Specialized Health Care Services 2002 NASN Resolution: Access to a School Nurse 2003 All are available online at: wwwnasnorg Barrett, Jena Clayton, Goodwin, Debra K, and Kendrick, Olivia 2002 Nursing, Food Service, and the Child with Diabetes The Journal of School Nursing, 183, 150-156 Pediatric Education for Diabetes in Schools National Version: A Resource Manual for School Nurses 2003 Available through NASN at: wwwnasnorg Quarry-Horn, Jill L, Evans, Barbara J, and Kerrigan, James R2003 Type 2 Diabetes Mellitus in Youth The Journal of School Nursing, 194,195-202 Raising a Child with Diabetes: A Guide for Parents, Alexandria, VA, American Diabetes Association, 2000; 1-800-232-6733
47

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 The Care of Children with Diabetes in Child Care and School Setting video; available from, Managed Design, Inc, PO Box 3067, Lawrence, KS 66046, 785 842-9088 Treating Diabetes Emergencies: What You Need to Know, Alexandria, VA, American Diabetes
Association, 1995 video; 1-800-232-6733 Wizdom: A Kit of Wit and Wisdom for Kids with Diabetes and their parents, Alexandria, VA, American Diabetes Association, 2000 Order information and select resources available at: wwwdiabetesorg/wizdom Your Child Has Type 1 Diabetes: What You Should Know, Alexandria, VA, American Diabetes Association, 1999 brochure; available online at: http://wwwdiabetesorg/main/community/advocacy/type1jsp Your School Your Rights: Protecting Children with Diabetes Against Discrimination in Schools and Day Care Centers, Alexandria, VA, American Diabetes Association, 2000 brochure; available online at: http://wwwdiabetesorg/main/type1/parents_kids/away/scrightsjsp These documents are available in the American Diabetes Associations Education Discrimination Packet by calling 1-800-DIABETES

APPENDIX A:

Sample Health Care Plans
Individualized Emergency School Health Plan for Diabetes 51
Individualized Health Care Plan for Diabetes 53
Individualized Health Care Plan Authorization 55
Individualized Health Care Plan 57
Sample Plans Ridgefield Public Schools 59
Diabetes Student Contract Enfield Public Schools 63
Staff Training Record 65

Individualized Emergency School Health Plan for Diabetes Management
Student Name__________________________________________ Grade________ Date___________

MY PHOTO
I have INSULIN DEPENDENT DIABETES which means I must take insulin every day along with balancing diet and exercise Several times a day, I check my blood sugar levels by using a special meter that I keep with me It is important for you to understand some important things about diabetes while I am in your care

LOW BLOOD SUGAR REACTIONS: Occasionally, my blood sugar may be too low insulin reaction This can be very dangerous A low blood sugar reaction can be a result of receiving too much insulin, skipping a meal or snack or an unusual amount of exercise If you think my blood sugar is low, I may check my blood sugar in the classroom If I go elsewhere to check my blood sugar, someone must accompany me Some symptoms of low blood sugar may be:

Shakiness Sweatiness

Change in personality Feeling low or hungry or tired

Confusion
Looking pale or flushed in the face

If my blood sugar is low, I NEED FAST-ACTING SUGAR QUICKLY
You can give me_________________________________________________________ I should
start to feel better in
10-15 minutes If my blood sugar remains low, call my parents and do the following:
______________
If my blood sugar drops too low, I may become unconscious or have a seizure If this happens: 1 Call 911 2 A Registered Nurse needs to give GLUCAGON by injection 3 Call my parents Glucagon is not life threatening even if it is given when not needed EMERGENCY NUMBERS: _______________________________ Mothers Name _______________________________ Fathers Name _______________________________ Other relationship _______________________________ Health Care Provider ______________ Home phone ______________ Home phone ______________ Home phone ______________ Home phone _____________ Work phone ______________ Work phone ______________ Work phone _______________ Work phone Date prepared____________________ _________________ Cell phone _________________ Cell phone _________________ Cell phone

_____________________________________________________ Preferred hospital

Individualized Health Care Plan for Diabetes Management
Student
School

DOB
Grade Teacher

Date
________

BLOOD SUGAR TESTING Check ALL that apply Will not test at school
Will be done by student
every day at ____________________________________________
Will be done by student when symptoms are present _______________________________
Will need assistance from an adult Physicians Authorization must be signed
Will not need assistance from an adult
Testing supplies will be kept at school in ________________________________________
INSULIN NEEDS Check ALL that apply Will not need insulin at school
Will need insulin at school Physicians Authorization must be signed
Will be using an insulin pump and is self-sufficient in its use
Will be using an insulin pump and will need assistance Physicians Authorization
must be signed
FOOD PLAN Check ALL that apply Will bring daily morning snack of _______ carbohydrates to be eaten at _________am
Will bring daily afternoon snack of ________ carbohydrates to be eaten at ________ pm
Will eat _________ carbohydrate servings or ________ grams of carbohydrates at lunch
On special occasions, student can eat same snack provided to classmates
On special occasions, student will select alternate snack from supply provided by parent
MEALS AND INSULIN NEEDS
Breakfast
Insulin/Carbs

Snack
Insulin/Carbs

Lunch
Insulin/Carbs

Snack
Insulin/Carbs

Supper
Insulin/Carbs

Snack
Insulin/Carbs

TIME:_________

Insulin Type: Blood Sugar

Blood Glucose Target Range:

Sliding Scale S/S ————Insulin Dose mg/dl -units mg/dl -units mg/dl -units mg/dl -units mg/dl -units

Comments: Date Completed:

LOW BLOOD SUGAR SYMPTOMS

Blurred vision Fatigue Irritability Dizziness Headache Personality change Fast heartbeat Hunger Sweating Comments____________________________________________________
If student is experiencing symptoms, TEST BLOOD SUGAR

Trembling Weakness

LOW BLOOD SUGAR TREATMENT TEACHERS: Students with symptoms MUST be escorted to Health Room For blood sugar ________________ give 15 gms fast acting carbohydrate _______________________________ For blood sugar ________________ give 30 gms fast acting carbohydrate _______________________________
If lunch or snack time allow child to eat normal amounts of carbohydrate
If not lunch or snack time repeat blood sugar in 15 20 minutes Repeat treatment as needed
Parent will provide appropriate drinks and/or food Retest blood sugar in __________
minutes If under ____________, repeat above treatment If student is feeling better, s/he can: _______________________________________________________________ LOW BLOOD SUGAR TREATMENT FOR INSULIN PUMP THERAPY: In addition to the interventions listed above, if student who is using an insulin pump becomes unconscious due to a severe low blood sugar, disconnect tubing from insulin pump, call 911 and the childs parent For severe hypoglycemia with loss of consciousness or seizure, call 911, administer Glucagon 1 mg by injection, and call parents Comments: ____________________________________________________________________________ HIGH BLOOD SUGAR SYMPTOMS Blurred vision Frequent urination Nausea/vomiting Drowsiness Heavy, labored breathing Stomachache Extreme thirst Hunger Comments ____________________________________________________________________ Test blood sugar, if over ________________ Student should drink large amounts of water
Test urine ketones if blood sugar is over ____________, or if child is experiencing symptoms of high blood sugar
HIGH BLOOD SUGAR TREATMENT FOR INSULIN PUMP THERAPY: In addition to the interventions listed above, if student is using an insulin
pump and blood sugar is over 240 for two readings in a row, call parent Blood Glucose Target Range: ____________________________ On Insulin Pump Therapy High blood sugar before meals and 2 hours after:

Assess for pump/tubing/site problems if using an insulin pump Blood sugar is greater than __________ give extra insulin by using the Sliding Scale S/S or Insulin Sensitivity Factor ISF as written below Repeat blood sugar within ________ HOURSs if previous blood sugar greater than _______ If repeat blood sugar greater than __________ give insulin by syringe using the S/S or ISF Contact parents and/or health care provider if blood sugar greater than _________ and vomiting, difficulty breathing or lethargy or other symptoms of ketoacidosis Repeat blood sugar every ________ HOURs Give insulin using the S/S or ISF until the blood sugar is less than ____________
Insulin Sensitivity Factor ISF

correction factor

Blood Sugar

1 unit of insulin will bring the blood sugar level down by __________ mg/dl

Sliding Scale S/S Insulin Dose mg/dl mg/dl mg/dl mg/dl mg/dl

units units units units units

Comments:
____________________________________________________________________________
54

Individualized Health Care Plan for Diabetes Management
AUTHORIZATION/SIGNATURES FORM
Student DOB School/Grade Date

Individualized Health Care Plan for: _______________________________________ School/Grade_____________________________________________________________ I have reviewed and approved the Individualized Health Care Plan for Diabetes Management I understand that specialized health care services will be performed by designated school personnel under the training and supervision provided by the School District Nurse This consent shall remain in effect through the end of the current school year unless discontinued or changed in writing Physicians Signature Parent School Nurse Building Administrator Date Date Date Date

Staff Members Signature responsible for implementing the care plan:

Reprinted with Permission from Wisconsin Department of Education Document
55

Individualized Health Care Plan

NAME: ___________________ DOB: ________ SEX: ____ ALLERGIES: ______________________ PHYSICIAN___________________ RELEVANT DIAGNOSIS ES:
____________________________________________________________________________________ DIET: ____________ MOBILITY: __________________________ EQUIPMENT: ___________________________________________ MEDICAL HISTORY: ____________________________________________________________________________________________ MEDICATION/TREATMENT: ____________________________________________________________________________________ SIGNATURE: ________________________ SIGNATURE: _________________________ SIGNATURE: ___________________________ parent student School Nurse HEALTH CARE GOAL DATE HEALTH PROBLEM/ NURSING DIAGNOSIS STUDENT OBJECTIVES INTERVENTION AND RESPONSIBLE PERSON EVALUATION AND TIMELINE

NAME: ____________________________________
DATE HEALTH PROBLEM/ NURSING DIAGNOSIS STUDENT OBJECTIVES INTERVENTION AND RESPONSIBLE PERSON EVALUATION AND TIMELINE

Adapted from Hartford Public Schools for use in Connecticut Department of Education Guidelines for Students with Special Health Care Needs

Student with Diabetes Information Sheet
Date:____________________ Student Name_________________________________Grade_____________DOB_________________ Parent Daytime phone number:
Mother_____________________________________________ Father______________________________________________ Primary health care provider: ______________________________ Phone: ___________________ Diabetes Specialist_______________________________________ Phone: ___________________ INSULIN: AM________________________ Lunch _______________________________ Time-Type-Amount Time-Type-Amount Dinner______________________ Bedtime_______________________________ Time-Type-Amount Time-Type-Amount Will require insulin at school? ________________________ Obtain health care prescriber orders Does student need assistance with insulin administration? _________________________________ DIET: AM Snack ___________________________________________________________________________ Lunch ___________________________________________________________________ PM Snack _______________________________________________________________ Modifications for parties?____________________________________________________ MONITORING: Will require routine glucose monitoring at school? _______ Yes _______ No Obtain health care prescriber orders Will require assistance with monitoring? _______ Yes ________ No Should routinely
check blood glucose at____________ time each day and record results Type of glucometer: ________________________________________________________ Does student check urine for glucose? ________ Yes ______ No Obtain health care prescriber orders Will student needs assisting with urine testing? ________ Yes ______ No Routine time for urine testing is______________________________________

PHYSICAL EDUCATION: Scheduled at______________________________________________________________
Snack required before physical education? _______Yes _________No
Snack given before physical education if:_________________________________________

Management of:

HYPOGLYCEMIA-Insulin Reaction
Students symptoms are____________________________________________________________ Treatment_______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

HYPERGLYCEMIADKA-High Blood Glucose
Students symptoms
are____________________________________________________________ Treatment_______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Sliding Scale Insulin Kept at School: Yes____ No____ yes current Authorization for Medication Administration on file with sliding scale authorized by parent and health care provider

Ridgefield Public Schools

Date: _____________________

Emergency Care Plan for the Student with Diabetes
Name_____________________________________________ Birth Date____________________ Parent/Guardian _________________________________________________________________ Emergency phone home __________________________________________________________ Emergency phone work __________________________________________________________ Primary health care provider ________________________________________________________ Address ______________________________________________________________ Student ID Phone
_________________________________________________ Photo Hospital _______________________________________________________________________ Diabetes Specialists ______________________________________________________________ Address/Phone__________________________________________________________________

Specifics of Management
1 Insulin Dosage: _______________________________________________________________ Times: ______________________________________________________________________ 2 Glucose monitoring: ___________________________________________________________ Location of monitor: ___________________________________________________________ Type of monitor: ______________________________________________________________ Times to monitor: _____________________________________________________________ 3 Diet: _______________________________________________________________________ Snack times: __________________________________________________ ____________ 4 ID bracelet: Yes ______ No______ 5 Time and day of physical education: _______________________________________________ 6 School Lunch/Recess: ___________________________________ ________________

Protocol for Hypoglycemic
Episode
1 General symptoms: hunger, dizziness, sweaty palms or forehead, and change in behavior 2 Signs/symptoms particular to this student_____________________ _____________ _________________________________________________________________________

3 Action to take: ________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
attach additional information if needed 4 Contact Parent/guardian if:______________________________________________________ 5 Cake gel or other substance to be given:____________________________________________ 6 Glucagon ordered: Yes___ No____ if yes current Authorization for Medication Administration on file DO NOT LET STUDENT GO TO HEALTH OFFICE ALONE
CALL 911 IF STUDENT UNCONSCIOUS OR CONVULSING
and GIVE NOTHING BY MOUTH
7 Individual considerations for this particular student____________________________________ _______________________________________________________________________________ 8 Contact parents/guardians if student vomits or has a fever and refer to IHCP 9
Signatures/photocopies to where applicable: Parent/guardian__________________________ Principal_______________________________ Student_________________________________ Teacher________________________________ School Nurse_____________________________ Lunch Aide_____________________________ Physician________________________________ Bus Driver______________________________ Diabetes Educator_________________________ PE Teacher____________________________ Other Education Specialists: Guidance Dept_______________________ Music________________ Art____________________________________ Library_________________________________ Other__________________________________

Ridgefield Public Schools
Adapted from J School Health Nursing, April 1997

Diabetic Student Contract
Students Name: ________________________________________ DATE: __________

School Year
I understand that it is essential to my health that I take proper doses of my insulin daily I understand that I will test my blood sugar in the nurses office daily at ____________ I understand that if I fail to test my blood sugar, I will have to eat lunch in ___________ I understand that I will write my blood sugar results daily in my
notebook kept in the nurses office I understand that it is my responsibility to bring in snacks/juice to be kept I the nurses office I understand the need to report to the nurses office any time I feel low to test and record my blood sugar Students Signature: _________________________________ Parents Signature: __________________________________ School Nurses Signature: _____________________________ Copies to: Student Parent School Nurse Guidance Counselor House Office

Staff Training Record

Diabetes Training Record
Staff Member Name Diabetes Basics Blood Glucose Monitoring Notes

APPENDIX B:

Low/High Blood Sugar Signs and Symptoms:
http://wwwlifecliniccom/WhatsNew/FeaturedArticles/articleViewasp?MessageID1138

APPENDIX C:

Insulin
Administration of Insulin 71
Insulin 72
Insulin Delivery Systems 73
Disposing of Sharps 74

Guidelines for Administration of Insulin

Administration
The school nurse might be responsible for injecting insulin or in assisting a student to draw up and self inject insulin The procedure for administration of insulin is in the box at the right Inspect the insulin Check the expiration date printed on
the label Humalog and Regular insulins are clear, others are cloudy Long and intermediate acting insulins must be gently mixed by rolling the vial between palms There should be no clumping of particulate in the insulin Do not use insulin that is not uniform inconsistency Select injection site Injections may be given in the abdomen, thighs, buttocks or arms Insulin sites should be rotated in order to avoid tissue damage, which results in the poor absorption of the insulin Speed of absorption decreases with each of the following sites: arms, legs and buttocks

Steps for Insulin Injection 1 Get supplies 2 Wash hands 3 Roll bottle to mix Wipe top with alcohol swab 4 Pull plunger down to ______units 5 Push needle into bottle Push plunger up 6 Pull plunger down to _____units 7 Pick injection site Wipe with alcohol swab 8 Pinch up skin Push needle into skin and push plunger in 9 Dispose of syringe per care plan

Care and Storage
Effectiveness of insulin is dependent on its care and storage Date the insulin when it is opened and discard 30 days after opening Check the expiration date on stored insulin regularly Keep refrigerated for longer shelf life If refrigerator is not available a
cool pack may be used Unrefrigerated insulin should be kept as cool as possible Do not let insulin freeze, if it does, discard it immediately Keep insulin away from heat and light Clumping or frosting results from too much shaking or rough handling Discard Insulin may be carried in a fanny pack, or backpack with an ice pack, as long as it is positioned so it does not freeze or get too warm

Adopted from the New York Department of Health

Insulin

Insulin
There are many different types of insulin for different situations and lifestyles

Characteristics
The three characteristics of insulin are: Onset: The length of time before insulin reaches the bloodstream and
begins lowering blood sugar
Peak time: The time during which insulin is at its maximum strength in
terms of lowering blood sugar levels
Duration: How long the insulin continues to lower blood sugar

Storage

Opened vials may be left at room temperature or refrigerated for 30 days after opening Avoid exposure to extreme temperatures Any insulin found frozen cannot be used, and must
be discarded Unopened vials can be stored in the refrigerator until the expiration date Check the manufacturers patient
information insert for storage recommendations for insulin pens

Expiration date
Make sure that the insulin will be used before its expiration date

Types of Insulin by Comparative Action Curves
Action Time Insulin Type Onset Peak hrs Usual Effective Duration hrs Usual Maximum Duration hrs

Rapid Acting

Short Acting Intermediate Acting Intermediate Acting Long Acting

Lispro Humalog Aspart Novolog Regular NPH Lente Ultralente Glargine Lantus

15 minutes 15 minutes 05-1 hr 2-4 hrs 3-4 hrs 6-10 hrs 4-5 hrs

5-15 5-15 2-3 4-10 4-12 None None

2-4 2-4 3-6 10-16 12-18 18-20 24

4-6 4-6 6-10 14-18 16-20 20-24 24

Pre-mixed insulin a mixture of NPH and regular is also available, but is generally not recommended for children Adopted from the Wisconsin Department of Education
72

Insulin Delivery Systems

Syringespumpspensthey all do the same thing deliver insulin These items deliver insulin into the tissue so it can be used by the body This category includes injection aides products designed to make giving an injection easier

Syringes
Todays insulin syringes are smaller and have finer needles and special coatings that work to make injecting as easy and painless as possible When
insulin injections are done properly, most people discover they are relatively painless Points to consider for optimal insulin delivery by syringe: The syringe being used should be the right size for the insulin dose It should be easy to draw up and visualize the dosage devices are available to make this task less complicated Shorter, finer needles are available which allow for ease of administration

Insulin Pens
There is a wide range of insulin pen options available The pens can be an excellent option when children need a single kind of insulin They can make taking insulin mach more convenient Some children find the pen needles make injection more comfortable

Pumps
Insulin pumps are computerized devices, about the size of a beeper or pager, which you can wear on your belt or in your pocket They deliver a steady, measured dose of insulin through a cannula a flexible plastic tube with a small needle that is inserted through the skill into the fatty tissue The needle is removed and the cannula is taped in place Insulin pumps may b worn during most athletic activities The cannula may be placed on one of several sites on the body, including the abdomen, buttocks, thigh, or
arm

Advantages
Pumps most closely mimic the bodys normal release of insulin Pumps deliver insulin in two ways: Basal: small, hourly dose that is pre-programmed Bolus: given to cover food or cover high blood sugar Pump therapy allows for much greater flexibility in food choices and meal timing Children who wear pumps can participate in all school activities

Responsibilities of Pump Wearer
Must be willing to test blood sugar minimum of 4 times/day
Must learn how to make adjustments in insulin, food and exercise in response to those test results
Must respond to blood sugar readings
Must know how to troubleshoot the pump if blood sugars are inexplicably too high or too low
Must keep back-up insulin, syringe or pen, and pump supplies available at school and home in
case of cannula occlusion andor pump failure

Adopted from Wisconsin Department of Education
73

Disposing of Sharps

Disposing of Sharps Safely
Millions of individuals with serious health conditions manage their care at home For example, people with diabetes use syringes to inject their own insulin and lancets to test their blood sugar every day All this creates a lot of medical waste Whats the best
way to handle this waste? The best way to protect trash handlers and sewage treatment workers against disease or injury and avoid attracting drug abusers looking for syringes to reuse is to follow these guidelines for containment and disposal of sharps Containment
Place the sharps in a commercially available sharps container
Once a syringe or lancet is used, immediately put it into a sharps container
Keep the sharps container away from children
When the container is full, follow the manufacturers guidelines on sealing and locking the
container Notify the building and ground staff or appropriate school personnel for removal Disposal There are different options for getting rid of the container of sharps Some cities and towns have more options than others Here are the best bets for safety, health and protection of the environment Do not put the sharps out with the recyclable plastics Sharps are not recyclable Ask your local doctor or clinic, schools medical advisor, public health department, solid waste or streets department or environmental services department about local options Some of them may be registered sharps collection stations Registered sharps collection
stations may charge fees only to recover costs, such as costs for the container, transportation and treatment Some offer the services for free If there are no sharps collection stations in your area, you may take sharps directly to a licensed infectious waste treatment facility or contract with a licensed infectious waste hauler to transport them for you People transporting more than 50 pounds per month must get be licensed Ask your doctor where she or he sends sharps, or look in the yellow pages under waste disposal or medical waste Another option provided by some disposal companies is a mail-in sharps disposal program The company provides containers and packaging that meet US Postal regulations

APPENDIX D:

Nutrition
Individualizing Meal Plans 77 Food Labels 78 Special Nutrition Issues 79 Snack Choices for Physical Activity 80 Emergency Food Supplies 81

Individualizing Meal Plans

Individualizing Meals Plans for Children with Diabetes
It is recommended that children see a Registered Dietician, who is preferable a Certified Diabetes Educator, once a year for an individualized meal plan The meal plan should include 3 meals and 2-3 snacks with a specific
amount of carbohydrate The meals and snacks should be timed appropriately with the peak of the childs insulin Each child needs a certain amount of carbohydrate based on age, size, gender and activity level General Guidelines for Daily Carbohydrate Intake Age 3-10 years 11-13 years 16-18 years Daily Carbohydrate Needs Male/Female [200-275 grams] Male [275-400 grams] Female [275-300 grams] Male [300-475 grams] Female [250-300 grams] Per Meal 50-70 70-90 75-100 Per Snack 15-20 30-45 30-50

This is a generalization; children who have seen a Registered Dietician may have a meal plan individualized for them based on age, gender, activity level etc

Knowing the carbohydrate content of given foods allows for more flexibility in the meal plan One serving from starch/grain, fruit, milk or sweets group contains 15 grams of carbohydrate The following chart illustrates examples of food that contain approximately 15 grams of carbohydrate 15 Grams of Carbohydrate Snack Choices Choose More Often
Choose Less Often

1 cup low fat milk 1 mini bag potato chips
1 mini bag pretzels 1 small cupcake
1 4 ounce juice box 2 small cookies
1 4 ounce jar of canned fruit cup ice cream
1 piece fresh
fruit 1 snack pack pudding
8 animal crackers 1-2 inch square birthday cake
1-1 whole graham crackers
4 peanut butter or cheese crackers

Food Labels

Another way of determining how a food may fit into your daily meal plan is through the nutrition information found on food labels Food labels can help you figure out the appropriate portion size to provide the amount of carbohydrate needed at any given meal or snack Use the food label for pretzel nuggets along with the following instructions to learn how to determine appropriate portion sizes based on carbohydrate needs Look at serving size: 12 pretzel nuggets Look at Total Carbohydrate: 23 grams The sugars listed are included in the Total Carbohydrate amount and therefore should not be added to the total carbohydrate amount To figure out how much carbohydrate in each pretzel nugget: Total carbohydrate divided by serving size: 23g carbohydrate divided by 12 nuggets 19 g/per nugget Therefore there is 19 grams of carbohydrate in each pretzel nugget Next you can figure out how many pretzel nuggets are equal to 15 grams or 30 grams carbohydrate For 15 Grams carbohydrate: 15 Grams divided by 19 approximately 8 pretzel
nuggets containing 15 grams carbohydrate For 30 Grams carbohydrate: 30 grams divided by 19 approximately 16 pretzel nuggets containing 30 grams carbohydrate
Diet Exchanges: 15 Starch
Based on the Exchange Lists for Meal Planning
Copyright 1995 by the American Diabetes Association
and the American Diabetic Association

Nutrition Facts
Serving Size: 1 oz 28g/about 12 nuggets Servings Per Container: 18 Amount per Serving Calories 100 Calories from Fat 0 Daily Value 0 0 17 8 4 Vitamin C 0
Iron 6

Total Fat 0 g Saturated Fat 0g Cholesterol 0 mg 0 Sodium 420 mg Total Carbohydrate 23 g Dietary Fiber 1 g Sugars 1 g Protein 3 g
Vitamin A 0 Calcium 0

Percent Daily Values are based on a 2000 calorie diet
Your daily values may be higher or lower depending on
your calorie needs
Calorie 2000 Total Fat Less than 65 g Sat Fat Less than 20 g Cholesterol Less than 300 mg Sodium Less than 2400 mg Total Carb Less than 300 g Dietary Fiber 25 g Calories per gram: Fat 9 Carbohydrate 4 2500 80 g 25 g 300 mg 2400 mg 374 g 30 g Protein 4

Special Nutrition Issues

School Parties:
Sweets can be eaten on a special occasion such as a birthday or Halloween party The carbohydrates
should be included as part of the childs meal plan See snack list for serving sizes equal to 15 grams of carbohydrate

Field Trips:
Children should carry convenient snacks on the bus and field tip Bus drivers and chaperones should be notified that the child has diabetes and may need to eat a snack on the bus or during the trip

After Care:
Children should have a convenient snack if staying after school Notify school personnel that the child may need to eat during the session

School Lunch:
Children with diabetes may participate in the school lunch program Families can review the school menu ahead of time and modify as needed Families may also wish to contact the school food service director if needed

Snack Choices for Physical Activity
15 Grams carbohydrate:
1 4 ounce juice box 1 cup Gatorade 1 sliced orange or apple 1 small box raisins 6 saltines 1 cup light yogurt cup dry cereal

30 grams carbohydrate:
1 cereal bar 1 8 ounce juice box 2 slices bread 1 small bagel

45-50 grams carbohydrate plus protein:
1 nutrition bar 1 package 6 cheese or peanut butter sandwich crackers plus 4 oz juice

Protein Sources:
Peanut butter
Sliced or String Cheese
Lunch Meat
Egg

Peanuts, Walnuts or Almonds

Adopted from Wisconsin Department of Education

Emergency Food Supplies

Snack Packs or Low Packs

for Low Blood Sugar
Good overall planning and access to carbohydrates ensures that the child with diabetes have the means of obtaining appropriate emergency responses during the school day The family should furnish emergency food supplies to provide the childs preferred choice of food to respond to low blood sugar The food supplies should be in several locations and travel with the child Appropriate locations for low packs might be the health office, physical education office, classroom, school office and school bus A typical low pack would include easy to eat sources of pure carbohydrate such as fruit juice packs or glucose tablets It may also contain foods to be used as a snack after the low blood sugar level has been raised, such as prepackaged cheese or peanut butter

Recommended Foods for Low Packs
Food Immediate Treatment 4 Glucose Tablets 1 Tube glucose gel or cake frosting cup juice
orange, apple, grape or pineapple
cup non-diet soda
cup Kool-Aid
16 15 15 15 15 Grams of Carbohydrate

Follow-up Snack
15-30 minutes following
hypogycemia 1 cup milk Cracker snack pack cheese or peanut butter Granola Bar 12 as listed on food label as listed on food label

APPENDIX E:

Family Resources

Travel, Vacations and Camps 85
Sick Day Guidelines 88

Travel, Vacations and Camp

Travel Guidelines
Prepare Ahead The patients physician should be contacted for the following items: A letter describing patients current medical condition and a list of medications This may be used to verify patients medical status Written prescriptions for all medications including oral agents, insulin, syringes, test strips, other medications taken May also need prescriptions to treat other possible illnesses that the patient may develop on the trip eg antibiotics, meds for diarrhea, motion sickness, etc If immunizations are needed, they should be done at least one month in advance of the trip in the even that an adverse reaction to the vaccine is experienced The local health department is a good resource to inquire about immunizations The patient should always wear a MEDIC ALERT bracelet or necklace and carry an ID card in their wallet or purse detailing the management regimen, physician name and telephone
number The airlines can arrange a diabetes meal plan when called several days in advance If prone to motion sickness, take motion sickness medication or wear Sea Bands acupressure wristbands available at the pharmacy no prescription is necessary prior to the time of travel Diabetes supplies should be taken in a carry-on bag: Food: At least one days supply of food in case of delayed or canceled flights, delayed meals, or restaurants being closed eg packaged cheese and crackers, containers of juice or fruit Quick sugar source: glucose tablets, glucose gel While in Travel
Reduce jet lag and dehydration by drinking adequate amount of fluids Try to maintain some degree of activity, especially on a longer flight; walk about the cabin If taking insulin while in flight, less air will need to be injected into the bottle, due to increased pressure inside the cabin

When you reach your destination
Secure syringes in a locked suitcase Use a small, plastic opaque bottle for disposal of all lancets and syringes While away, watch food intake, activity level and medications Divide meal plan so that something is eaten at least every 4 hours If activity is greater than normal have an extra snack
between meals, preferably protein and complex carbohydrate eg meat sandwich or cheese and crackers Test blood glucose every four hours and be prepared to take supplemental insulin if required When going to the beach: Use sunscreen or lotion Cover arms, shoulders, legs, head and eyes to protect you from the sun Adopted from South Carolina Chapter of the American Diabetes Association
85

Vacations
Diabetes should not interfere with vacations, which are a normal part of life Some extra planning ahead is
required
Pack enough insulin and supplies to last the whole time you are away They may not be available at your
vacation area Make a checklist ahead of time of things to take Double check at the last minute If you are traveling in hot weather, keep lucagons, insulin and blood sugar strips cool If you travel by plane, keep all of your supplies in your carry-on luggage It may freeze in the luggage compartment of get lost Carry a form of sugar with you to treat reactions Have adequate snacks available in case meals are not served on time Get the name of a doctor in your vacation area so you can call him/her if necessary Take your own doctors phone number too He/she knows
your case best, and it may be reassuring to make a long distance phone call when help is needed Visit or call your doctor two weeks before you leave so that you can work out any problems before the last minute Remember to take his/her list of suggestions with you If you expect to be more active on the vacation you may need to decrease insulin dose Discuss this with your doctor or nurse If foreign travel is planned, carry a letter from the physician explaining why insulin syringes and other supplies are being transported through customs When going to a non-English speaking country, the patient should learn phrases in the language of the country to which they will travel: I HAVE DIABETES, I NEED SUGAR OR ORANGE JUICE, I NEED A DOCTOR, and phrases to order meals It is wise to take a bilingual dictionary A traveling companion should be prepared to recognize and treat diabetic emergencies eg Diabetes KetoAcidosis, hypoglycemia The most important advice is HAVE FUN Camp programs for children with diabetes can provide children with role models as well as the opportunity to meet other children their age who have the same challenges Most of the young people who work at diabetes camps
are living very healthy successful lives with diabetes Establishing relationships with them can benefit your childs long term health and self-esteem Community and/or residential camps that are not diabetes camp programs should be able to accommodate your childs needs if provided with appropriate support It is crucial that your childs needs be communicated completely and the camp staff be trained appropriately http://wwwchildrenwithdiabetescom/Used with permission Check List of Items to Take Along on Vacations, Travel, Camp Insulin Syringes Alcohol Swabs Blood Sugar Monitor Blood Sugar Test Glucagon Glucose Tabs or Some Form of Sugar Snacks in Small Easy to Use Packages List of all medications Identification Name, Address, Age Medical Identification Bracelet/Necklace/Card Name and Phone Number of Primary Care Doctor Name and Phone Numbers of Parents when traveling without them
86

Check List for Camp Staff
_______________________________________________________________________________ Childs Name Childs age Amount of Daily Insulin Requirement
Monitor Blood Sugar Level prior to and during exercise/play
Importance of Exercise
Watch for signs of hypoglycemia Low
Blood Sugar please fill in signs for your child
_________________________________________________________________________ _________________________________________________________________________ Watch for signs of hyperglycemia High Blood Sugar Please fill in signs for your child _________________________________________________________________________ _________________________________________________________________________ Nutrition meal requirement
Timing of Meals and Snacks
Check List of Items to Bring on Field Trips please fill in usual items you pack for your child
_________________________________________________________________________ _________________________________________________________________________

Medical Identification Products
Health care and emergency personnel encourage people with diabetes to wear some form of medical identification The reason is obvious: Such identification can save time in an emergency and may save your life Key factors include age, form of identification, costs, and the services provided with the tag: Age: Everyone with diabetes should have a medical identification tag Form: Medical identifications take many forms: wrist or
ankle bracelets, necklace pendants or neck chains with dog tags, watch charms, shoe tags, iron-on tags or wallet cards Service and cost: No matter what the form, medical identifications carry at least three pieces of information your name, medical condition, and an emergency phone number for more information However, some medical identifications carry the emergency number you choose, such as yours or your neighbors, while others carry a number that is staffed by emergency personnel 24 hours a day with your medical records and emergency numbers at hand Adapted from Diabetes Forecast website

Sick Day Guidelines

Effect of Illness/Injury on Diabetes Control
Illness places stress on the body and usually will have the effect of raising blood glucose levels Flu type illness with nausea, vomiting and/or diarrhea can upset the electrolyte balance of the body, causing dehydration and possibly ketoacidosis Injuries like illness, also place a stress on the body and can have the effect of raising glucose levels

Responsibilities of the School Personnel
If possible determine the students blood glucose level
Give comfort measures as you would with any student without diabetes

If the glucose level is low or the student is showing symptoms of hypoglycemia, have the student take
a sip only of regular soda at 5-10 minute intervals Small frequent sips are often tolerated even by a student with nausea or vomiting If the glucose level is high, or if symptoms of hyperglycemia are present the student can be given sips of sugar-free soda If possible and if ordered, check for the presence of urine ketones

If the student is unconscious, unresponsive or uncooperative, or severely injured, notify the appropriate emergency personnel immediately Do not delay getting any emergency squad by first obtaining a glucose level The can be obtained after the emergency squad is called
If respirations are deep and labored, and if the students breath smells fruity or like alcohol, the student may have ketoacidosis Report to the parent, guardian or physician immediately In cases of injury, administer the usual first aid measures as well as determining the blood glucose level Notify the parents/guardian of the students symptoms, injury and glucose level If unable to reach a parent, call the students physician

Adapted from American Diabetes Association

What to Put in Your
Sick Day Cupboard

Keep the following in a box marked For Sick Days A Copy of Sick Day Rules Thermometer Gelatin Sugared and Sugar Free Aspirin-Free Products such as Liquid, Chewables and/or Suppositories Ketone Strips Can of Soup Cans of Soda Sugared and Sugar Free Cans of Concentrated Juice One that does not need refrigeration Glucagon Kit Broth or Bouillon Powdered Fruit Drink Sugared and Sugar Free Pedialyte or Other Rehydration Product for Very Young Children

APPENDIX F:

Tips for Kids with Type 2 Diabetes

What is Diabetes at:
http://wwwndepnihgov/diabetes/pubs/Youth_Tips_Diabetespdf

Stay at a Healthy Weight at:
http://ndepnihgov/diabetes/pubs/Youth_Tips_Weightpdf Eat Healthy Foods at: http://ndepnihgov/diabetes/pubs/Youth_Tips_Eatpdf

Be Active at:
http://wwwndepnihgov/diabetes/pubs/Youth_Tips_Activepdf

Diabetes in Children and Adolescents Fact Sheet at:
http://wwwndepnihgov/diabetes/pubs/Youth_FactSheetpdf

Appendix G:
Connecticut Department of Education Self Blood Glucose
Monitoring Guidelines

Series 2003-2004 Circular Letter: C-19 To: From: Date: Subject: Superintendents of Schools Dr Betty J Sternberg, Commissioner of Education February 6, 2004 Guidelines for Blood Glucose Self-Monitoring in School

Section 7 of Public Act 03-211, effective July 1, 2003, states: a No local or regional board of education may prohibit blood glucose self-testing by children with diabetes who have a written order from a physician or an advanced practice registered nurse stating the need and the capability of such child to conduct self-testing b The Commissioner of Education, in consultation with the Commissioner of Public Health, shall develop guidelines for policies and practices with respect to blood glucose self-testing by children pursuant to subsection a of this section Such guidelines shall not be construed as regulations within the scope of chapter 54 of the general statutes The following guidelines for blood glucose self-monitoring have been developed in response to this legislation The legislation and these guidelines have been developed in recognition of the importance of regular monitoring of blood glucose levels as part of a students diabetes
management plan Research has demonstrated that better blood glucose control greatly reduces the risks of long-term complications of diabetes DCCT, 1993 By developing and implementing policies and procedures that ensure timely monitoring and prompt intervention, students with diabetes will have better short- and long-term outcomes both medically and academically The guidelines for blood glucose self-monitoring were developed by a committee representing a broad range of stakeholders, including school administrators, school nurses, school board members, parents, the medical community, and the Connecticut Departments of Education and Health The guidelines offer school districts a framework for developing policies and procedures that meet the needs of individual students with diabetes and their families, as well as take into consideration the circumstances of school and community Contained in the first three pages of the attached document, the guidelines include the following key components: Development of an Individualized Plan; Communication Needs; Determination of Location; Safety Considerations; Staff Education and Training; and Evaluation of Plans

In addition,
appendices provide information on individualized plans and a list of additional print and webbased resources, describe recommended steps for blood glucose monitoring, and supply sample tools that can be tailored for use by individual districts or schools If you have any questions or need additional information on the guidelines, please contact Cheryl Carotenuti, Health Consultant, 860-807-2108, Cherylcarotenuti@postatectus or Wendy Harwin, SchoolFamily-Community Partnerships Project Coordinator, 860-807-2105, wendyharwin@postatectus

Cc:

School Medical Advisors School Nurse Supervisors

These guidelines were prepared by a statewide committee chaired by Cheryl Carotenuti, Health Promotion Consultant, and Wendy Harwin, Project Coordinator, School-Family-Community Partnerships Project The Connecticut State Department of Education would like to acknowledge the expertise, dedication and time of the following people in the preparation of these guidelines JoAnn Ahern, Yale-New Haven Medical Center; Phil Apruzzese, CEA; Karen Bucci, Connecticut Childrens Medical Center; Louise Butcher, ADA; Joseph Castagnola, Portland Public Schools; Cathy Castaldi, Parent; Susan E Craig, Parent JDRF;
Bill Cross, Parent JDRF; Cindy Kozak, Department of Public Health; Pat Krin, Newington Public Schools; David Larson, CAPSS; Melissa Lopez, DPH; Sheila McKay, CABE; Linda Pica, Bethel Public Schools; Paul Rossi, Parent JDRF; Brendan Sharkey, Connecticut State Representative; Trish Vayda, Enfield Public Schools

Guidelines for Blood Glucose Self-Monitoring in School Introduction Diabetes mellitus is a chronic disease that interferes with the bodys ability to produce or use insulin, impairing the ability to metabolize food Diabetes management balances careful control of diet, exercise and medication Frequent monitoring or checking1 of blood glucose levels is critical to diabetes management Timely blood sugar monitoring and prompt intervention are necessary to prevent life threatening hypoglycemic episodes Equally important, close monitoring to maintain blood glucose levels within a specified range is essential to prevent long-term complications such as heart disease, kidney failure, blindness, and serious impairment of circulation that may require amputations2 The benefits of allowing blood glucose self-monitoring are significant Students learn better when their blood glucose
levels are within the proper range It is important for schools to address the issue of locations of self-monitoring Students who self-monitor in the classroom or in other locations outside the school health office can more readily adjust their blood sugar levels They spend less time out of class and thus lose out on fewer learning opportunities provided to children without diabetes They also gain independence and self-confidence, and experience fewer stigmas when monitoring is treated as a regular occurrence The State Board of Education encourages families, schools and medical providers to work together to develop district policies and procedures These policies and procedures should recognize the capabilities of students to participate in the management of their diabetes, with the ultimate goal of independent management School districts should also recognize that decisions about selfmonitoring must be made on a case-by-case basis, with the participation of the family, school, and medical providers, and with respect for individual needs and preferences regarding privacy and confidentiality The Law Section 7 of Connecticuts Public Act No 03-211 states that [n]o local or regional
board of education may prohibit blood glucose self-testing by children with diabetes who have a written order from a physician or an advanced practice registered nurse stating the need and the capability of such child to conduct self-testing Schools must be knowledgeable of all relevant state and federal laws, and how these laws impact school district policies in this area The most relevant federal laws include: The Americans with Disabilities Act ADA, Section 504 of the Rehabilitation Act of 1973, The Individuals with Disabilities Education Act of 1976 IDEA, and The Family Education Rights and Privacy Act of 1974 FERPA Moreover, public schools in Connecticut are required to meet standards set by the Occupational Safety and Health Administration OSHA, a regulatory agency within the US Department of Labor3 As also required for any simple paper cut or bloody nose, these standards include the need for procedures to address possible exposure to blood-born pathogens4

Although the terms blood glucose testing and blood glucose checking are also common, these guidelines use the term monitoring Please
note that these guidelines cover blood glucose monitoring only, not urine tests for
ketones
2 The landmark Diabetes Control and Complications Trials DCCT demonstrate that better glucose control significantly decreases the risk for long-
term complications For example, risk of diabetic eye disease was reduced by 76; kidney disease by 50; and nerve disease by 60 The results
were so striking that investigators ended the study early so conventionally treated patients could also realize the benefits of intensive diabetes
management
3 OSHA regulates employer/employee conduct, and does not apply to students in schools
4 Schools must adhere to Universal Precautions designed to reduce the risk of transmission of blood-borne pathogens, which include the use of
barriers such as surgical gloves and other protective measures when dealing with blood and other body fluids or tissues

Guidelines All students with diabetes need an individualized plan to address their health and safety needs in school settings This plan may be a Section 504 accommodation plan and/or an Individualized Health Care Plan IHCP with an Emergency Care Plan ECP See Appendix A The State Board of Education recommends that district policies regarding self-monitoring of blood glucose levels
in school settings address the following issues: 1 Determine a process for developing and implementing an individualized plan for the student

Identify a core team to create the plan This team should include, at a minimum, the school nurse; appropriate teachers; the student if appropriate; and parents, guardians or other family members Other possible members include the students health care provider, an administrator and other school staff Obtain current health information from the family and the students health care providers, including how often the child should monitor his or her blood glucose level Based on the students health status, determine the minimum frequency with which health information will be reviewed and updated Clarify the roles and responsibilities of each member of the core team See Appendix B 2 Define expectations for communication between relevant school staff, family and the students health care provider that includes: Documentation by the students health care provider of health needs, which may be included in appropriate authorizations for medications and procedures to be performed at school Written permission for school health staff to communicate with the
childs health care provider regarding diabetes management Clear expectations for minimum frequency of communication

3 Determine appropriate locations for self-monitoring that take into account the individual students needs, level of competence, health status, and independence Location determination should be a team decision Such a determination should also consider the safety of the child with diabetes, other students, and staff Factors which may impact determination of self-monitoring locations include: If self-monitoring locations are outside the health room, completion of a self-monitoring checklist and
documentation of such assessment by the school nurse See Appendix C
Team discussion of the self-monitoring checklist
Completion of a student agreement See Appendix D
The determination of the locations of self-monitoring should address accommodations during field trips,
athletics, and unusual circumstances such as lockdowns or building closures
4 Address safety concerns, including: Specific procedures for disposal of lancets and any material exposed to blood, which meet OSHA Universal Precaution standards4 Procedures for transportation of monitoring equipment;
storage, security and access to monitoring supplies; identification of signs and symptoms of excessively high or low blood sugar levels and appropriate responses; access to food and drink; and replacement of equipment, and supplies
96

5 Establish procedures ensuring that the appropriate people including staff members such as teachers, physical education teacher, custodian, bus driver and substitute staff are familiar with the 504 plan and/or IHCP and ECP, and are properly educated regarding diabetes and the importance of timely treatment This education should include: An understanding of diabetes; the signs and symptoms of high or low levels of blood glucose; familiarity with blood glucose equipment; appropriate locations for self-monitoring; possible adverse effects of high or low blood glucose levels on learning; and OSHA Universal Precaution standards Raising awareness of diabetes and the importance of blood glucose monitoring throughout the school, especially if monitoring is to occur in the classroom However, individual student and family privacy needs and preferences should be considered 6 Ensure periodic assessments of the effectiveness of the individual plan, location
of self-monitoring and student agreement see Appendix D, including review of the students competency level and changes in the school environment Assessments should occur: At least annually with the school team, including the parents or guardians and when appropriate the student More frequently if there are changes in the students diabetes management plan, changes in the self-monitoring abilities of the student, or whenever an adjustment to the plan is appropriate If the IHCP is separate from the Section 504 Accommodation Plan, then the team may make modifications to the IHCP without formal review of the 504 plan

For more information, please contact Cheryl Carotenuti, cherylcarotenuti@postatectus, 860 807-2108, or Wendy Harwin, wendyharwin@postatectus, 860 807-2105

Appendix A: Individualized Plans
Individualized Health Care Plans Individualized Health Care Plans IHCPs are usually developed for students with multiple health needs or whose health needs require daily intervention These plans describe how the school intends to meet an individual childs daily health and safety needs in all contexts, while under the care of the school IHCPs are developed by the school nurse, in
conjunction with parents or guardians, the student, healthcare providers, and other school personnel An IHCP includes: a summary of health assessments; and a nursing diagnosis, goals, and plans of action covering the range of possible concerns

IHCPs should also address student needs outside of the normal school routine Considerations for students with diabetes include: meal times; changes in schedules; lunch and recess times; school transportation; transitions to after school programs; athletic and extracurricular activities; accommodations for test-taking; field trips; and transitions to new schools or school buildings

The IHCP is also used to document interventions and evaluate outcomes IHCPs can and should be updated at least annually, and more frequently, as necessary to keep pace with changing student needs and school environment Emergency Care Plans Children with special health care needs should also have a written Emergency Care Plan ECP that provides specific directions about what to do in a medical emergency or safety emergency such as fire drill or lockdown The ECP is often part of the IHCP This written plan helps the school nurse, school personnel and
emergency responders react to an emergency situation in a prompt, safe and individualized manner ECPs should provide emergency contacts and address what to do: For high and low blood glucose levels; If an insulin pump malfunctions or becomes dislodged; and fire drill

To ensure access to equipment and medication if not carried by student, eg during lockdown or

Appendix B: Sample Core Team Roles and Responsibilities
School Nurses Participate in core team meetings Conduct nursing assessment for Individualized Health Care Plan IHCP Conduct nursing assessment for section 504 accommodation plan, if appropriate Develop section 504 accommodation plan and/or IHCP with the core team Coordinate development of Emergency Care Plan ECP Ensure family provides medical supplies, materials and snacks needed at school Obtain necessary physician orders Conduct periodic and ongoing reviews of student needs, and update IHCP ECP as needed Plan and implement diabetes training for appropriate school staff Work with family and health care providers to reinforce and strengthen student self-management skills, and promote independence Teachers Participate in core team meetings Work with
core team to implement the section 504 accommodation plan and/or IHCP Recognize signs and symptoms of hypoglycemia and hyperglycemia Be prepared to respond to signs and symptoms as identified in the IHCP Provide the student with a supportive classroom environment Provide classroom accommodations as outlined in the section 504 accommodation plan and/or IHCP Participate in diabetes education, as specified in the student plan Communicate with school team as outlined in the section 504 accommodation plan and/or IHCP Administrators Understand state and federal laws Participate in the development of school policy Promote a supportive learning environment for all students Support and arrange for staff training Work with core team to implement the individual plan as needed Respect the students confidentiality and right to privacy Support and facilitate ongoing communication between family, school staff and community members Family Members Notify the school of student health needs Provide written medical documentation, written authorizations, and all necessary medications, equipment, and snacks Work as a full partner with the core team to develop a section 504 accommodation
plan and/or IHCP Educate child in self-management skills and promote independence Review plans with schools at least annually and more frequently as needed

Appendix C: Sample Self-Monitoring Checklist
Student: DOB: Age: Grade: School:

Physical/Behavioral Limitations:

Self-Monitoring Criteria: These criteria are designed to assist the school nurse in making recommendations Answers to the following provide a basis for team discussion of appropriate blood glucose self-monitoring locations

X
A Medical Provider has provided written documentation that student is competent to self-monitor blood glucose level Comments if any: B

Student knows what equipment to use to conduct blood glucose self-monitoring Comments if any:

C Student is familiar with individual health care providers instructions or recommended steps for blood glucose monitoring see Appendix E, and demonstrates the ability to self-monitor blood glucose levels Comments if any:

E Student understands how to dispose of contaminated equipment, eg at home or in the health office Comments if any:

Student understands what locations are appropriate for blood glucose self-monitoring Comments if any:

100

Student is able to identify appropriate action if blood glucose level is not within normal range: Comments if any:

H Student knows how to access assistance, and when it is needed Comments if any:

I: An Individual Health Care Plan and Emergency Care Plan has been developed to monitor and evaluate the students health status

Based on Checklist: Student has successfully demonstrated competence in independent self-monitoring Student is not a candidate for blood glucose self-monitoring outside the health room at this time, but the following steps will be taken to help the student move toward independence: Comments if any:

School Nurse Signature: Date: Date of next assessment:

101

Appendix D: Sample Agreement Concerning Blood Glucose Self-Monitoring
Determination of locations for blood glucose self-monitoring is made in accordance with an Individualized Health Care Plan IHCP and/or section 504 accommodation plan, and [Name of School Districts] procedures Once locations for self-monitoring are determined, the following guidelines apply: 1 2 Self-monitoring shall be performed in the designated locations The student shall be responsible for disposing of lancets, strips, and
any other material exposed to blood either in the health office or at home The parent or guardian and student have knowledge of and agree to comply with OSHAs Universal Precautions If, after monitoring the student is not within his/her target range, the student should notify the appropriate school personnel in accordance with the students IHCP The parent or guardian shall be responsible for maintaining the equipment and supplies needed for self-monitoring in the school

The above information has been reviewed by the IHCP Team, the parent or guardian, and the student The above procedures have been agreed upon by: _____________________________ Parent/Guardians signature _____________________________ Students signature _____________________________ School Nurses signature _____________________________ School Administrators signature ___________________ Date ___________________ Date ___________________ Date ___________________ Date

102

Appendix E: Recommended Steps for Blood Glucose Monitoring
1 Gather supplies
2 Wash hands with warm soapy water
3 Load device with lancet
4 Wipe finger or other target area with warm soapy water Let dry Use alcohol swabs only if warm
water
is not available
5 Hold lancet device to the side of the fingertip or other area, and press button to puncture skin
6 Turn finger or area of punctured skin down to get a full drop of blood If a larger drop is necessary,
squeeze the area around the puncture
7 Put full drop of blood on strip pad
8 Follow directions for use of monitor or read the result on the bottle of strips
9 Record results on log sheets provided by parent or guardian

Adapted from: cite Provided for general information only Students should follow the instructions of their individual health care providers

103

Appendix F: Additional Resources Resources on the law
American School Health Association, 2000 Guidelines for Protecting Confidential Student Health Information American Diabetes Association, 2000 Your School Your Rights: Protecting Children with Diabetes Against Discrimination in Schools Day Care Centers http://wwwdiabetesorg/main/type1/parents_kids/away/scrightsjsp Champion, C 1999 Occupational Exposure to Blood-Borne Pathogens: Implementing OSHA Standards in a School Setting Connecticut State Department of Education, 2003 A Parents Guide to Special Education in Connecticut
Available at http://wwwstatectus/sde/deps/special/ParentGuidepdf Connecticut State Department of Education, 2000 Section 504 of the Rehabilitation Act of 1975: Procedural Safeguards Available at http://wwwstatectus/sde/circ/circ00-01/c-9pdf Connecticut Department of Labor, Division of Occupational Safety and Health CONN-OSHA http://wwwctdolstatectus/osha/oshahtm The US Department of Education website has a wealth of information about FERPA, IDEA, etc Go to http://wwwedgov, and type the relevant acronym into the search window

Sample IHCPs and ECPs
American Diabetes Association, 2001 Diabetes Care, 24 supplement 1 Care of Children with Diabetes in the School and Day Care Setting S108-112 Rapone, K Brabston, L, 1997 Journal of School Nursing, 13 No 2 Nursing Practice Management: A Health Care Plan for the Student with Diabetes 30-37 Haas, M ed, 1993 The School Nurses Source Book of Individualized Healthcare Plans Volume I Arnold, M Silkworth, C, eds, 1999 The School Nurses Source Book of Individualized Healthcare Plans Volume II

Print
American Diabetes Association, 2003 Diabetes Care, 26 supplement 1 Care of Children with Diabetes in the School and Day Care Setting S131-135
American Diabetes Association Diabetes Forecast To subscribe to this monthly magazine: 1-800diabetes American School Health Association, 2002 Health in Action A recent issue of this journal focuses on Diabetes and the School Community It is available online at http://wwwashaweborg/healthinactionhtml Diabetes Interview: To subscribe to this monthly magazine: 1-800-488-8468 US Department of Health and Human Services, 2003 Helping the Student with Diabetes Succeed: A Guide for School Personnel Available online at http://ndepnihgov/materials/pubs/schoolguidepdf

104

Websites American Association of Diabetes Educators: http://wwwaadenetorg American Diabetes Association: http://wwwdiabetesorg Children with Diabetes: http://wwwchildrenwithdiabetescom Juvenile Diabetes Research Foundation International: http://wwwjdrforg National Association of School Nurses, 2001 Position Statement: Blood Sugar Monitoring in the School Setting http://wwwnasnorg/positions/bloodsugarhtm National Diabetes Education Program: http://wwwndepnihgov National Diabetes Information Clearinghouse, a service of the National Institute of Diabetes and Digestive and Kidney Diseases at NIH, offers a wide range of
resources in English and Spanish on treatment, complications, statistics and research, including on the landmark Diabetes Control and Complications Trial at http://diabetesniddknihgov/dm/pubs/control/indexhtm

105

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Connecticut State Department of Education
Division of Teaching and Learning Programs and Services
George A Coleman
Associate Commissioner
Deborah Koval
Publications and Web Content Coordinator

Bureau of Health and Nutrition Services
and Child/Family/School Partnerships
Charlene Russell-Tucker
Bureau Chief

School Health Services
Cheryl Ann Carotenuti
Project Manager
Bonnie Edmondson
Susan Fiore
Bob Lichtenstein
Scott Newgass

It is the policy of the Connecticut State Board of Education that no person shall be excluded from participation in, denied the benefits of, or otherwise discriminated against under any program, including employment, because of race, color, religious creed, sex, age, national origin, ancestry, marital status, sexual orientation, mental retardation or past/present history of mental disorder, learning disability or physical disability

Source:uchsc.edu

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