Students with diabetes — Individual health plans diabetes, subject to the following conditions: diabetes educators who are nationally certified. …

Appendix A

APPENDIX A RCW 28A210330 Students with diabetes — Individual health plans — Designation of professional to consult and coordinate with parents and health care provider — Training and supervision of school district personnel 1 School districts shall provide individual health plans for students with diabetes, subject to the following conditions: a The board of directors of the school district shall adopt policies to be followed for students with diabetes The policies shall include, but need not be limited to: i The acquisition of parent requests and instructions; ii The acquisition of orders from licensed health professionals prescribing within the scope of their prescriptive authority for monitoring and treatment at school; iii The provision for storage of medical equipment and medication provided by the parent; iv The provision for students to perform blood glucose tests, administer insulin, treat hypoglycemia and hyperglycemia, and have easy access to necessary supplies and equipment to perform monitoring and treatment functions as specified in the individual health plan The policies shall include the option for students to carry on their persons the necessary
supplies and equipment and the option to perform monitoring and treatment functions anywhere on school grounds including the students classrooms, and at school-sponsored events; v The establishment of school policy exceptions necessary to accommodate the students needs to eat whenever and wherever necessary, have easy, unrestricted access to water and bathroom use, have provisions made for parties at school when food is served, eat meals and snacks on time, and other necessary exceptions as described in the individual health plan; vi The assurance that school meals are never withheld because of nonpayment of fees or disciplinary action; vii A description of the students school day schedules for timing of meals, snacks, blood sugar testing, insulin injections, and related activities; viii The development of individual emergency plans; ix The distribution of the individual health plan to appropriate staff based on

Guidelines for Care of Students with Diabetes

May 2005

the students needs and staff level of contact with the students; x The possession of legal documents for parent-designated adults to provide care, if needed; and xi The updating of the individual health plan at
least annually or more frequently, as needed; and b The board of directors, in the course of developing the policies in a of this subsection, shall seek advice from one or more licensed physicians or nurses or diabetes educators who are nationally certified 2a For the purposes of this section, parent-designated adult means a volunteer, who may be a school district employee, who receives additional training from a health care professional or expert in diabetic care selected by the parents, and who provides care for the child consistent with the individual health plan b To be eligible to be a parent-designated adult, a school district employee not licensed under chapter 1879 RCW shall file, without coercion by the employer, a voluntary written, current, and unexpired letter of intent stating the employees willingness to be a parent-designated adult If a school employee who is not licensed under chapter 1879 RCW chooses not to file a letter under this section, the employee shall not be subject to any employer reprisal or disciplinary action for refusing to file a letter 3 The board of directors shall designate a professional person licensed under chapter 1871, 1857, or 1879 RCW as it
applies to registered nurses and advanced registered nurse practitioners, to consult and coordinate with the students parents and health care provider, and train and supervise the appropriate school district personnel in proper procedures for care for students with diabetes to ensure a safe, therapeutic learning environment Training may also be provided by a diabetes educator who is nationally certified Parentdesignated adults who are school employees are required to receive the training provided under this subsection Parent-designated adults who are not school employees shall show evidence of comparable training The parent-designated adult must also receive additional training as established in subsection 2a of this section for the additional care the parents have authorized the parentdesignated adult to provide The professional person designated under this subsection is not responsible for the supervision of the parent-designated adult for those procedures that are authorized by the parents [2002 c 350 2] NOTES:

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Findings — 2002 c 350: The legislature finds that diabetes imposes significant health risks to students
enrolled in the states public schools and that providing for the medical needs of students with diabetes is crucial to ensure both the safety of students with diabetes and their ability to obtain the education guaranteed to all citizens of the state The legislature also finds that children with diabetes can and should be provided with a safe learning environment and access to all other nonacademic school-sponsored activities The legislature further finds that an individual health plan for each child with diabetes should be in place in the students school and should include provisions for a parental signed release form, medical equipment and storage capacity, and exceptions from school policies, school schedule, meals and eating, disaster preparedness, inservice training for staff, legal documents for parent-designated adults who may provide care, as needed, and personnel guidelines describing who may assume responsibility for activities contained in the students individual health plan [2002 c 350 1] Effective date — 2002 c 350: This act takes effect July 1, 2002 [2002 c 350 5]

RCW 28A210340 Students with diabetes — Adoption of policy for inservice training for school staff The
superintendent of public instruction and the secretary of the department of health shall develop a uniform policy for all school districts providing for the inservice training for school staff on symptoms, treatment, and monitoring of students with diabetes and on the additional observations that may be needed in different situations that may arise during the school day and during schoolsponsored events The policy shall include the standards and skills that must be in place for inservice training of school staff [2002 c 350 3] NOTES: Findings — Effective date — 2002 c 350: See notes following RCW 28A210330

RCW 28A210350 Students with diabetes — Compliance with individual health plan -Immunity A school district, school district employee, agent, or parent-designated adult who, acting in good faith and in substantial compliance with the students individual

Guidelines for Care of Students with Diabetes

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health plan and the instructions of the students licensed health care professional, provides assistance or services under RCW 28A210330 shall not be liable in any criminal action or for civil damages in his or her individual or marital or governmental or corporate or
other capacities as a result of the services provided under RCW 28A210330 to students with diabetes [2002 c 350 4] NOTES: Findings — Effective date — 2002 c 350: See notes following RCW 28A210330

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Appendix B

APPENDIX B INDIVIDUAL HEALTH PLAN SECTION 504 PLAN
Student: Birthdate: Address: Physician: Contact number: School: Grade: Phone: Mother: Home: Work: Pager/Cell Phone: Father: Home: Work: Pager/Cell Phone:

Effective date: Parent-designated adult: Home phone: Cell phone: Brief History:

Age of onset: Dates of recent hospitalizations: Concurrent illness or disability:

Results and date of Hemoglobin A1C test: Related social/emotional factors:

PLAN:

Blood sugar monitoring: Time: Location: Additional tests: as needed when having symptoms of low blood sugar Insulin injection:
Time: Location: Lunch eaten at time: PE days and times: Notify parents of shortened school day

Parents to establish plan with the school nurse and with HCP orders

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1 In event of field trips, all diabetes supplies are taken and care is provided: By accompanying parent or parent-designated adult According to procedure developed prior to field trip According to low/high blood sugar school plans Notify parent prior to planned field trip 2 In event of classroom/school parties, food treats will be handled as follows: Student will eat treat Replace with parent supplied alternative Modify the treat as follows: Schedule extra insulin per prearranged plan 3 Scheduled after school activities: List: Low/high blood sugar after school plan to: Supervisor with instruction Parent-designated adult 4 Attach copies of High Blood Sugar School Plan and Low Blood Sugar School Plan NEVER SEND A CHILD WITH LOW OR HIGH BLOOD SUGAR ANYWHERE ALONE 5 Activities student can self manage: Totally independent management OR A Blood sugar monitoring: Student monitors independently Student monitors with verification of number on meter by designated staff
Student needs help with monitoring and/or to be done by school nurse or parent-designated adult Monitoring needs to be done by nurse or parent-designated adult B Insulin injection: Administers independently Student self injects with verification of number on insulin pen by designated staff Student self injects syringe or pen with school nurse supervision and/or administration by nurse or parent-designated adult Administration by nurse or parent-designated adult C D E F Self treats mild hypoglycemia Monitors own snacks and meals Monitors and interprets own ketones Student implements universal precautions when lancing finger and disposing of lancets/syringes

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6 Equipment and Supplies: EQUIPMENT AND SUPPLIES PROVIDED BY PARENT Blood Sugar Meter Kit includes all blood monitoring supplies for school Low Blood Sugar Supplies: ___________________________ ___________________________ For Example: Fast-acting carbohydrate drinks: apple juice and/or orange juice and soda pop regular, not diet6 pack Glucose tablets Glucose gel product Gel Cakemate not frosting 19gm Mini-purse size Pre-packaged snacks such as cracker/cheese;
crackers/peanut butter, etc times 56 Daily Snacks: for am/pm snack times:________________ ___________________________ 7 School bus driver instruction: Call parent to pick up student if a low blood sugar episode occurs 30 minutes or less prior to departure regardless if sugar returns to normal reading Student to eat snack on bus if part of care plan or if having signs of low blood sugar and able to swallow Driver to call for special directions Date of next plan review: Must be reviewed before the next school year unless there is a change requiring earlier revision Disaster Supplies check x: Food supply for 3 days stored in:______________ Low blood sugar supplies Medication and medical supplies stored in:________ ________________________ Insulin pen and needles Insulin and syringes

Other Supplies specify:___ ________________________ ________________________ Disaster Plan attached

____________________________________ Parent Date ____________________________________ Student Date

______________________________________ School Nurse Date ______________________________________ Physician optional Date

_____________________________________________________________________________
Parent-designated adult if one has been assigned Date

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INDIVIDUAL HEALTH PLAN SECTION 504 PLAN Independent Management
Student: Birthdate: Address: Physician: Contact number: School: Grade: Phone: Mother: Home: Work: Pager/Cell Phone: Father: Home: Work: Pager/Cell Phone:

Effective date: Parent-designated adult: Home phone: Cell phone: Brief History:

Age of onset: Dates of recent hospitalizations: Concurrent illness or disability:

Result and date of Hemoglobin A1C test: Related social/emotional factors:

Level of Independence attach copy of HCP Orders for Children with Diabetes in Washington State Schools Appendix K PURPOSE: To promote student self management of diabetes, recognize signs of high and low blood sugar, and provided appropriate assistance and/or emergency care Daily Diabetes Routines Blood sugar monitoring: Time: Location: Additional tests: as needed when having symptoms of low blood sugar Insulin injection: Time: Location: Lunch eaten at time: Notify parents of shortened school day 1 Scheduled after school activities: List: 2 Attach copies of High Blood Sugar School Plan and Low Blood Sugar School Plan 3
Student is: Totally independent in management of their diabetes

PLAN:

Parents to establish plan with school, the nurse, and with HCP orders NEVER SEND A CHILD WITH LOW OR HIGH BLOOD SUGAR ANYWHERE ALONE

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4 Equipment and Supplies: EQUIPMENT AND SUPPLIES PROVIDED BY PARENT Blood Sugar Meter Kit includes all blood monitoring supplies for school Low Blood Sugar Supplies: ___________________________ ___________________________ For Example: Fast-acting carbohydrate drinks: apple juice and/or orange juice and soda pop regular, not diet6 pack Glucose tablets Glucose gel product Gel Cakemate not frosting 19 gm mini-purse size Pre-packaged snacks such as cracker/cheese; crackers/peanut butter, etc times 56 Daily Snacks for am/pm snack times:________________ ___________________________ Disaster Supplies check x: Food supply for 3 days stored in:_____________ Low blood sugar supplies Medication and medical supplies stored in:_______ ________________________ Insulin pen and needles Insulin and syringes

Other Supplies specify:___ ________________________ ________________________ Disaster Plan attached

5 School bus driver
instruction: Student is independent in managing low blood sugars during bus transportation Unless displaying symptoms of moderate to severe low blood sugar, follow instructions for low blood sugar page 14

Date of next plan review: Must be reviewed before the next school year unless there is a change requiring earlier revision ____________________________________ Parent Date ____________________________________ Student Date ______________________________________ School Nurse Date ______________________________________ MD/DO/PA/ARNP Date

_____________________________________________________________________________ Parent-designated adult if one has been assigned Date

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INDIVIDUAL HEALTH PLAN/SECTION 504 PLAN TRAINING DOCUMENTATION
NAME/POSITION TRAINING PROVIDED DATE TRAINER/TITLE

Plan distributed to the following:____________________________________________________ Received entire IHP/Section 504 Plan:_______________________________________________ Received High Blood Sugar School Plan and Low Blood Sugar School Plan:_________________

NAME/POSITION

A/B

DATE

Date of next plan
review:__________________________________________________________ Must be reviewed before the next school year unless there is a change requiring earlier revision __________________________________ Parent Date __________________________________ Student Date _______________________________________ School Nurse Date _______________________________________ MD/DO/PA/ARNP Date

A Received entire IHP/Section 504 plan B Received High Blood Sugar School Plan and Low Blood Sugar School Plan

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Appendix D

APPENDIX D DIABETES CHECKLIST FOR SCHOOL NURSES DATES ______ 1 School nurse is notified that student with diabetes will be attending school ______ 2 Call or arrange meeting/home visit with parent/care provider a Discuss parent/student expectations of diabetes care while at school b Discuss details of diabetes management plan and potential accommodations c Determine the equipment and supplies needed for school and obtain prior to admittance d Determine supplies needed for Disaster Kit see Appendix N and obtain prior to admittance e Discuss plans for communication with parent and HCP f Discuss role of health services, personnel, and
parent-designated adult if indicated g Have parent sign an exchange of medical information h Obtain parent/guardian request for care and other legal documents as needed ______ 3 Meeting with parents, school nurse, and other significantly involved members of the school staff Typical accommodation issues: a Management of low blood sugar 1 Who? 2 Where? 3 When? 4 When and how to communicate to parents? b Management of high blood sugar 1 Who? 2 When? 3 How? 4 When and how to communicate to parents? c Blood testing 1 Who? 2 Where? 3 When? 4 What to do with results? 5 When and how to communicate to parent? d Insulin administration 1 Who? 2 Where? 3 When? 4 Who determines dose within the HCP/doctor orders? 5 When and how to communicate to parent? 6 Manufacturers instructions for insulin pen or pump supplied by parent e Meals and snacks 1 Who? 2 Whats too much or too little/monitoring? 3 When and who to notify? 4 Where location? 5 Replacement 6 Special occasions parties, field trips
Guidelines for Care of Students with Diabetes 55 May 2005

f Bathroom privileges g Access to drinking water h Transportation 1 Who? 2 What route? 3 When? i After-school activities 1 When? 2 Where? 3 Orders? j
Identify and obtain legal documents for consent and authorization of treatment and exchange of information k Identify and obtain legal document for parent-designated adult if needed ______ 4 Review school day schedule and assess level of independence ______ 5 Identify potential issues requiring accommodations ______ 6 Clarify specifics of treatment using HCP Orders form and authorization by HCP Appendix K ______ 7 Develop IHP/Section 504 plan Appendix B, Low and High Blood Sugar School Plan, Appendix P and Q and Disaster Preparedness plan Appendix O ______ 8 Determine which staff will be trained and arrange for education dates prior to students admittance Arrange for back-up personnel or system ______ 9 Notify and educate personnel working with student secretary, lunchroom and playground personnel, principal, transportation, coaches Maintain diabetes training record of who received the entire IHP/Section 504 plan and who received only the High and Low Blood Sugar School plans ______10 Classroom education if requested by parent or child a By whom? ______11 Monitor staff and student ______12 Annual review of IHP/Section 504 plan and/or revise as needed

Adapted with permission from
form of the Orange County Department of Education, Costa Mesa, CA and the Orange County School Nurses Association

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Appendix E

APPENDIX E Required District Policies and Sample Policy School District Responsibilities Districts are directed to seek the advice from one or more licensed physicians, nurses, or diabetes educators who are nationally certified in the course of developing the policies A The policies must address: The acquisition of orders from a HCP prescribing within the scope of their prescriptive authority for monitoring and treatment at school You may refer to Appendix K of the Guidelines for Care of Students with Diabetes, May 2005 for a sample form The provision for storage of medical equipment and medication provided by the parent The provision for students to perform blood glucose tests, administer insulin, treat hypoglycemia and hyperglycemia, and have easy access to necessary supplies and equipment to perform monitoring and treatment functions as specified in the IHP/Section 504 plan The option for students to carry on their persons the necessary supplies and equipment The option to perform monitoring
and treatment functions anywhere on school grounds including the students classrooms, and at school-sponsored events as explained in the Guidelines for Care of Students with Diabetes The exceptions to school policy necessary to accommodate the students needs to: 1 Eat whenever and wherever necessary 2 Have easy, unrestricted access to water and bathroom use 3 Participate in parties at school when food is served 4 Eat meals and snacks on time 5 Other necessary exceptions as described in the IHP/Section 504 plan The assurance that school meals will not be withheld because of nonpayment of fees or disciplinary action The inclusion of a description in the IHP/Section 504 plan of the students school day schedules for timing of meals, snacks, blood sugar testing, insulin injections, and related activities The development of individual emergency plans The distribution of the IHP/Section 504 plan to appropriate staff based on the students needs and staff level of contact with the students The districts possession of legal documents for the PDA to provide care, if needed The updating of the IHP/Section 504 plan at least annually or more frequently, as needed The Seattle School District
policy is included as a sample

It is suggested that school district administrators consult with their attorney when developing district policy
Guidelines for Care of Students with Diabetes 58 May 2005

Diabetic Students

H 5800 Adopted 2003 Page 1 of 1

POLICY It is the policy of the Seattle School Board that students with diabetes be afforded a safe learning environment and access to all academic and non-academic activities All students with diabetes shall have an Individual Health Care Plan Such plan shall be created pursuant to the requirements outlined in the attached Diabetes Procedure, H 5801

Reference: Cross Reference:

RCW 28A210330–350 Diabetes Procedure H 5801 Life-Threatening Policy H 5900 Life-Threatening Procedure H 5901 Medications at School Policy H6005
59 May 2005

Included with permission from Jill Lewis, Seattle Public Schools, Student Health Services
Guidelines for Care of Students with Diabetes

BOARD ADOPTED PROCEDURE I Individual Health Care Plan IHCP All students known to have diabetes must have an IHCP in place at school The plan must be distributed to appropriate staff, and must include the following information: a Provisions for the
storage of medical equipment and medication provided by the parent; b Provisions for the student to perform tests and treatments anywhere on school grounds including in the classroom and at school-sponsored events, to have easy access to necessary supplies and equipment, and to carry necessary supplies and equipment on his or her person; c A description of the students school day schedule for the timing of meals, snacks, blood sugar testing, insulin injections, and related activities; d An individualized emergency care plan that plans for both a health emergency for the student and a school emergency such as an earthquake; e Legal documents allowing a parent-designated adult to provide care, if the parent has designated such a person f Any parent requests and instructions, as well as orders from licensed health professionals If the student needs medications/treatments while at school, a Medication at School Authorization Form must be completed for each medication/treatment The IHCP must be updated at least annually, or more frequently if necessary II Food and Drink Students with diabetes must be allowed to eat or drink whenever and wherever necessary, including on the bus or in
other areas where food and drink are generally prohibited Students with diabetes must have unrestricted access to water and bathroom use Food or water shall never be withheld as a disciplinary action or because of nonpayment of fees
Guidelines for Care of Students with Diabetes 60 May 2005

III Parent-Designated Adult PDA A PDA is a volunteer, who may be a school district employee, who receives additional training from a health care professional or expert in diabetic care selected by the parents, and who provides care for the student consistent with the students IHCP To be eligible to be a PDA, a school employee who is not a licensed nurse must file a voluntarily written letter of intent with the school nurse The letter must be dated, and shall be valid for not longer than one year An employee who is not a licensed nurse and who wants to act as a PDA must file a valid letter of intent each year No employee who refuses to file such a letter shall be subject to reprisal or disciplinary action No employee may be coerced into filing such a letter A non-employee may become a PDA by filing a letter of intent with the school nurse and by completing the non-school employee training as
outlined below PDAs must receive training as indicated below The Nursing Supervisor or nurse designee is not responsible for the supervision of the PDA for those procedures that are authorized by the parents IV Training–School Employees Inservice Training In schools attended by diabetic students, all school employees must undergo an inservice training on symptoms, treatment, and monitoring of students with diabetes and on the additional observations that may be needed in different situations that may arise during the school day and during school sponsored events Specific Training All school employees who have responsibility for diabetic students must complete training in proper procedures for care of students with diabetes Either the Nursing Supervisor or his or her nurse designee will offer such training Such training must include information on individual students IHCP requirements, as well as information on symptoms, treatment, and monitoring of students with diabetes
Guidelines for Care of Students with Diabetes 61 May 2005

The Nursing Supervisor or nurse designee shall train school employees

V Training–PDAs PDAs who are school employees must undergo both the Inservice and
the Specific trainings, as outlined above PDAs who are not school employees must show evidence of comparable training Additionally, all PDAs must receive training from a health care professional or expert in diabetic care selected by the parents This additional training is required to allow the PDA to provide the additional care the parents have authorized the PDA to provide

VI Indemnity State law provides that a school district, school district employee, agent, or PDA who, acting in good faith and in substantial compliance with the students IHCP and the instructions of the students licensed health care professional, provides assistance or services under RCW 28A210330 shall not be liable in any criminal action or for civil damages in his or her individual or marital or governmental or corporate or other capacities as a result of the services provided under this law

Reference: RCW 28A210330–350 Cross Reference: Diabetes Policy H 5800 Medications at School Policy H 6005 Life-Threatening Conditions Policy H 5900 Life-Threatening Conditions Procedure H 5901

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Appendix F

APPENDIX F AUTHORIZATION FOR EXCHANGE OF MEDICAL
INFORMATION This appendix contains a sample form for Authorization for Exchange of Medical Information School districts will require parents to sign this form or one developed by the school district to obtain access to the students health records Districts may also require parents to sign a consent form for the district staff to provide healthcare, treatments, and special healthcare procedures These forms will be provided by the individual school district and conform to district policy and requirements

Guidelines for Care of Students with Diabetes

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Authorization for Exchange of Medical Information
SECTION I–INFORMATION REQUESTED FROM
NAME/AGENCY NAME OF PERSON DISCLOSING INFORMATION

ADDRESS

TITLE

Name of Student Specific nature of information to be disclosed:

Birth Date

Date

SECTION II–AUTHORIZATION I hereby authorize the release of medical information as described in section I to the individuals who are affiliated with the school/agency indicated in section III This authorization expires 90 days after the date it is signed This authorization expires on:

Parent Signature Student Signature

Date Date

If the student is a minor but is authorized to consent
to health care without parental consent under federal and state law
only the student shall sign this authorization form Students Consent: HIVAIDS status, diagnosis, treatment–14 years of age Family Planning/Abortion–no age limit Alcohol/Drug Treatment–13 years of age Mental Health Services–13 years of age SECTION III–AGENCY RECEIVING INFORMATION
NAME/AGENCY

ADDRESS

This information disclosed to you is protected by state and federal law You are prohibited from releasing it to any agency or person not listed on this form without specific written consent of the person to whom it pertains A general authorization for release of medical or other information is not sufficient See chapter 7002 RCW

Name of School Psychologist

Envelope shall be marked CONFIDENTIAL
Name of School Nurse Name of Other indicate position title IP 113 7/98 Guidelines for Care of Students with Diabetes

May 2005

Appendix G

APPENDIX G Notice of Parent/Guardian and Student Rights Under Section 504 This is a notice of your rights under Section 504 These rights are designed to keep you fully informed about the districts decisions about your child and to inform you of your rights if you disagree with any
of those decisions You have the right to: 1 Have your child participate in and benefit from the districts education program without discrimination based on disability 2 An explanation of your and your childs rights under Section 504 3 Receive notice before the district takes any action regarding the identification, evaluation, or placement of your child 4 Refuse consent for the initial evaluation and initial placement of your child 5 Have your child receive a free appropriate public education This includes your childs right to be educated with nondisabled students to the maximum extent appropriate It also includes the right to have the district provide related aids and services to allow your child an equal opportunity to participate in school activities 6 Have your child educated in facilities and receive services comparable to those provided to nondisabled students 7 Have your child receive special education services if she/he needs such services 8 Have evaluation, educational, and placement decisions for your child based upon information from a variety of sources, by a group of persons who know your child, your childs evaluation data, and placement options 9 Have your child be
provided an equal opportunity to participate in nonacademic and extracurricular activities offered by the district 10 Have educational and related aids and services provided to your child without cost except for those fees imposed on the parents/guardians of nondisabled children 11 Examine your childs education records and obtain a copy of such records at a reasonable cost unless the fee would effectively deny you access to the records 12 A response to your reasonable requests for explanations and interpretations of your childs education records 13 Request the district to amend your childs education records if you believe that they are inaccurate, misleading or otherwise in violation of the privacy rights of your child If the district refuses this request, you have the right to challenge such refusal 14 Request mediation or an impartial due process hearing to challenge actions regarding your childs identification, evaluation, or placement You and your child may take part in the hearing and have an attorney represent you Hearing requests can be made to the districts 504 coordinator 15 Ask for payment of reasonable attorneys fees if you are successful on your claim 16 File a local
grievance or a complaint with the US Department of Education Office for Civil Rights The person in this district who is responsible for ensuring that the district complies with Section 504 is:

A Parent Educator Guide to Free Appropriate Public Education Puget Sound ESD, Office of Special Services, November 2002 Available online at http://wwwk12waus/HealthServices/pubdocks/504ManualFinalpdf Guidelines for Care of Students with Diabetes 67

Revised 2004

May 2005

Appendix H

APPENDIX H Uniform Staff Training Policy: Students with Diabetes RCW 28A210340 requires that inservice training on diabetes be provided by all school districts for school personnel The superintendent of public instruction and the secretary of the department of health shall develop a uniform policy for all school districts providing for the inservice training for school staff on symptoms, treatment, and monitoring of students with diabetes, and on the additional observations that may be needed in different situations that may arise during the school day and during school sponsored events The policy shall include the standards and skills that must be in place for inservice training of school staff 1 Local
School Board Responsibility All local school boards shall designate a professional person licensed as a RN, ARNP, MD, DO, or a nationally certified diabetes educator to provide inservice training for school staff on symptoms, treatment, and monitoring of diabetes Due to the changing nature of diabetes management, it is advised that the licensed professionals be competent in current diabetes management techniques 2 Parent-Designated Adult Responsibility Parent-designated adults who are school employees are required to receive the training in symptoms, treatment, and monitoring of diabetes provided by the school district Parent-designated adults who are not school employees must show evidence of training in symptoms, treatment, and monitoring of diabetes that is comparable to what the school district provides It is recommended that parent-designated adults who are not school district employees participate in the school district training for school personnel directly involved with students with diabetes All parent-designated adults must receive additional training from a healthcare professional or expert in diabetes care, selected by the parent, for the additional care the parents
have authorized the parent-designated adult to provide, which is included in the Individualized Health Plan IHP Appendix I of these Guidelines for Care of Students with Diabetes 2005 have been revised to reflect that a parent-designated adult may be a paid school staff member

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APPENDIX H Uniform Staff Training Policy: Students with Diabetes 3 Training Guidelines Training in symptoms, treatment, and monitoring of diabetes and related standards and skills are to be guided by the most recent edition of the Guidelines for Care of Students with Diabetes The use of these Guidelines is not intended to replace clinical judgment or individualized consultation with medical care providers Refer to attached chart on how to use the guidelines for training, and for detailed topics to be included in both brief and intensive training curricula 4 Training Levels General training in symptoms, treatment, and monitoring of diabetes is designed for school personnel indirectly involved with students with diabetes School personnel that may be included are office staff, athletic personnel/coaches, bus drivers, custodians, cooks, teaching staff,
paraprofessionals, and others Intensive training in symptoms, treatment, and monitoring of diabetes is designed for school personnel directly involved with the students with diabetes This training may include teachers, coaches, a parent-designated adult who is or is not a school employee, and others who are appropriate for the training The Individual Health Plan directs both the content to be included and the personnel 5 Frequency The optimal training time is prior to the first day of school each school year Additional training of select personnel may need to occur during the school year if: –A new student transfers into the school district –An enrolled student is newly diagnosed –Treatment changes occur 6 Resource Guidelines for Care of Students with Diabetes May 2005 Available from the Office of Superintendent of Public Instructions Web site: wwwk12waus To order the document, call 1-888-59 LEARN Refer to document number 050013 Refer to the law in Chapter 350, Laws of 2002 C350L02

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APPENDIX H Uniform Staff Training Policy: Students with Diabetes Guidelines for Care of Students with Diabetes Recommended Standards and
Skills

This table will serve as a guide to the Guidelines for Care of Students with Diabetes The content necessary to include in the training for symptoms, treatment, and management of diabetes for both the brief inservice for all school personnel and the comprehensive training is included This table refers to the Guidelines dated August 2004 Comprehensive training will be individualized according to the Individual Health Plan that is developed by the school nurse with the parent and the student

Topic as found in Guidelines table of contents General page in Guidelines

Overview of rationale for Individual Health Plan IHP Detailed process for completing the IHP with samples Overview of diabetes Insulin action, delivery and storage specific to child Blood sugar testing rationale and brief process Diabetes supplies Low blood sugar High blood sugar, illness, ketones Overview of nutrition/meal planning/snacks and balancing with insulin and activity Specific meal plan for child while at school Exercise and sports Personnel guidelines for care Suggested accommodations the law Health care provider orders Parent-designated adult Questions and concerns raised by parents Disaster
preparedness

67 67 8 12 14, 22 15, 23 1619

Intensive: Teacher and ParentDesignated Adult page in Guidelines App B App B 8 911 12 13,App O 14, 22, App P 15, 23, App Q 1619, App R, App S 17 20 2125 2627 App K App I, App V 2831 App O

20 2627 App I 2831

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Appendix I

APPENDIX I Parent-Designated Adults RCW 28A210330 through 350 allows parents to designate an adult through proper legal procedures to assist the student in managing his or her diabetes see Appendix A The statute defines a Parent-Designated Adult PDA as a volunteer, who may be a school employee, who receives additional training from a healthcare professional or expert in diabetes care selected by the parents, and who provides care for the child consistent with the individual health plan Parents, rather than the school, are responsible for the training of the PDA The new statute requires districts to provide an individual health plan IHP for each child with diabetes As a part of an IHP, parents may choose to designate an unrelated adult, or PDA, to provide care such as blood sugar monitoring and/or insulin administration that would otherwise be performed by a
health professional licensed under RCW 1879 The volunteer PDA may be a school district employee If a PDA is a school employee, the district must keep on file a voluntarily written, current, and unexpired letter of intent from the employee to act as a PDA This letter must be filed without coercion from the employer Additionally, the letter must state the employees willingness to be a volunteer PDA Included in this appendix is a model document to meet this requirement School district employees may not be subject to any reprisal or disciplinary action for refusing to file a letter Furthermore, school districts should keep on file documentation of the required additional training that all PDAs must receive for the additional care the PDA may provide as authorized by the parent, such as insulin or glucagon injections and blood glucose monitoring procedures Again, a model form for documentation is included in this appendix RNs and ARNPs may not delegate procedures such as blood glucose monitoring and insulin injections to unlicensed staff Thus, the new law provides that the designated licensed professional is not responsible for the supervision of the PDA for those procedures that cannot
be delegated and are authorized by the parent for the PDA to provide Parents responsibilities in regards to PDAs Provide written authorization for a PDA to provide additional care, specifying the additional care so authorized This may include blood glucose testing and injections Coordinate with the district-designated licensed professional to ensure that the additional care authorized for the PDA to provide is consistent with the childs IHP Arrange for a healthcare professional or an expert in diabetes to provide training for the additional care that the parent authorizes the PDA to provide A health professional licensed under RCW 1879 would otherwise perform this care
73 May 2005

Guidelines for Care of Students with Diabetes

Parent-Designated Adult Responsibilities Voluntarily submit to the school district a written, current, and unexpired letter of intent This letter must state the employees willingness to be a volunteer PDA and must be submitted at least annually Schedule appointments with school staff Attend school district training offered for staff directly involved in care of student with diabetes The PDA, if not a district employee, may provide documentation of
comparable training in lieu of attending district offered training Complete and provide documentation of training for additional care authorized by the parents Deliver care consistent with the IHP

Liability A school district, school district employee, agent, or PDA is not liable in any criminal action or for civil damages in his or her individual, marital, governmental, corporate, or other capacities as a result of the services provided if he or she: Acts in good faith Acts in substantial compliance with the students individual health plan, and the instructions of the students licensed healthcare professional Provides assistance or services as outlined in this new law

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MODEL VOLUNTARY PARENT-DESIGNATED ADULT NOTICE OF INTENT Washington State requires public school districts to address the medical needs of students with diabetes The school district uses this document to certify that a person intends to serve or continue to serve as a volunteer parent-designated adult pursuant to Chapter 350, Laws of 2002 which added sections to RCW 28A210 For the purposes of this form, parent-designated adult means: a volunteer, who
may be a school district employee, who receives additional training from a healthcare professional or expert in diabetic care selected by the parents, and who provides care, if needed, for the child consistent with the individual health plan The additional training is for care that would otherwise be performed by a health professional licensed under RCW 1879 A parent-designated adult, acting in good faith and in substantial compliance with the students individual health plan and the instructions of the students licensed healthcare professional, that provides assistance, or services shall not be liable in any criminal action or for civil damages in his or her individual or marital or governmental or corporate or other capacities as a result of the services provided to a student with diabetes Information Name: ______________________________________________________ Birthdate: ___________________ Address:___________________________________________________________ Phone: _____________ Alternate Phone: _________________________ Statement of Intent I, _________________________________, certify that I voluntarily will serve or continue to serve as a Name parent-designated adult for
________________________________ and will provide diabetes related healthcare Students Name to the best of my ability, consistent with the students individual health plan I further certify that: _________I have had the individual health plan training provided by the district _________I have completed training comparable to the district-provided training necessary to act as a parentdesignated adult _________I have completed additional training for the additional care that I am authorized by the parent to provide prior to any acts that I perform as a parent-designated adult Additional language if PDA is a school employee: As a school district employee, I understand that I am not required to serve as a PDA, but choose to do so voluntarily I have not been coerced by my employer to sign and file this Notice of Intent and I understand that my refusal to do so cannot be a basis for disciplinary action ________________________________________________ Signature
Guidelines for Care of Students with Diabetes 75

__________________ Date
May 2005

MODEL DESIGNATION OF A PARENT-DESIGNATED ADULT Washington State requires public school districts to address the medical needs of students with
diabetes Pursuant to Chapter 350, Laws of 2002, which added sections to RCW 28A210, the school district uses this document to allow the parent to designate a parent-designated adult who can provide care, if needed, for a student with diabetes For purposes of this form, parent-designated adult means: a volunteer, who may be a school district employee, who receives additional training from a health care professional or expert in diabetic care selected by the parents, and who provides care, if needed, for the child consistent with the individual health plan The additional training is for care that would otherwise be performed by a health professional licensed under RCW 1879 By law, a school district, school district employee, agent, or a parent-designated adult, acting in good faith and in substantial compliance with the students individual health plan and the instructions of the students licensed health care professional, that provides assistance or services shall not be liable in any criminal action or for civil damages in his or her individual or marital or governmental or corporate or other capacities as a result of the services provided to my child with diabetes Information Name
of Child: __________________________________________ Birthdate: Address: __________________________________________________ Phone: School Year: ______________________ School: ____________________________ M/F: Name of PDA: ______________________________________ Birthdate: Address: ____________________________________________ Phone: Alternate Phone: ____________________ Relationship to Child: Grant of Permission As a parent or guardian of _________________________________, a child with diabetes, I hereby acknowledge Students Name that I have read and understand this form and agree to the following: I hereby authorize ____________________________________________, to be a Parent-Designated Adult Parent-Designated Adults Name PDA for the above named student and empower him/her to provide diabetes related health care to my child I further agree that if the PDA is not a district employee and does not participate in the district individual health plan training, I will arrange for the PDA to receive comparable training I further agree to arrange for the PDA to receive additional training for the additional care I authorize the PDA to provide, including:
__________________________________________________________________________________________ ______________________________________ _____________ ____________________ _____________ Signature of Parent/Guardian Date Work Phone Home Phone PLEASE SIGN AND RETURN THIS FORM TO YOUR SCHOOL OFFICE If no form is on file, it will be assumed that permission for a PDA has not been granted and there will be no Parent-Designated Adult designated for your child
Guidelines for Care of Students with Diabetes 76 May 2005

Appendix J

APPENDIX J Type 2 Diabetes

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 the 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 used to be found mainly in adults who were overweight and age 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 Type 2
Diabetes is also more common in certain racial and ethnic groups, such as African-Americans, American Indians, Hispanic/Latinos, and some Asian and Pacific Islander Americans To control their diabetes, children with Type 2 Diabetes may need to take oral medication, insulin, or both

Symptoms Type 2 Diabetes develops slowly in some children, but quickly in others Symptoms may be similar to those of Type 1 Diabetes A child or teen can feel very tired, thirsty, or nauseated sick to the stomach, and have to urinate often Other symptoms may include weight loss, blurred vision, frequent infections, and slow healing of wounds or sores Some children or adolescents with Type 2 Diabetes may show no symptoms at all when they are diagnosed For that reason, it is important for parents and caregivers to talk to a healthcare provider about testing children or teens who are at high risk for the disease Risk Factors Being overweight, being older than 10 years of age, experiencing puberty, and having a family member who has Type 2 Diabetes are risk factors for the disease Certain populations, as noted above, are at higher risk In addition, physical signs of insulin resistance, such as acanthosis
nigricans A-can-tho-sis NIG-reh-cans, may appear: the skin around the neck or in the armpits appears dark, thick, and velvety High blood pressure also may be a sign of insulin resistance For children and teens at risk, healthcare 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 lifestyle changes include keeping at a healthy weight and staying active

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Appendix K

APPENDIX K

HEALTHCARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS

OVERVIEW This form is intended to help standardize information for students with diabetes It has been designed to cover situations that may apply to the student while at school In most cases, the majority of the blank space will not need to be filled in or the answer may be similar to the previous space Generally, the plan should be worked out between the parent and the school nurse and then submitted to the Healthcare Provider HCP to authorize The following is a brief description of each section: Hypoglycemia low blood sugar The blank lines are for treatment plans
for various situations The information in parenthesis are guidelines that can either be used or crossed out if another treatment is desired Blood Sugar and Insulin Dosage Various situations are supplied Not all require a response with an injection of insulin Many situations will have the same response Other is for the new forms of insulin that may soon be available The last two lines of this section are included to allow the school nurse and the parent/guardian some degree of flexibility under the HCPs supervision and written orders Although ketone testing is recommended, cross out check ketones if this test will not be done In this situation, do not fill in If urine ketones Disaster Insulin Dosage This includes doses of insulin that are normally not given at school, but that during a disaster situation may be needed Since the food supply may be limited, it is recommended that the usual dosage be reduced to 80 percent A copy of this order form should be included in the Disaster Kit Alternately, the disaster dose can be recorded on the form found in Appendix O Disaster dosages must be reviewed and updated anytime the students insulin requirements change Self Care The intent is to
document agreement as to the extent to which the student can manage her or his own care and to clarify to what degree the school is responsible for care If the student is totally independent, the first statement only needs to be initialed The blank at the bottom of this section allows for other situations that might arise regarding the students diabetes management Signatures and Start/Termination Dates Each person involved in verifying the students ability to participate in self-care should sign and date the form Start and review termination dates must be noted

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HEALTH CARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS
STUDENTS NAME__________________________________Students birthdate___/___/___School______________Grade___ Emergency numbers for parents phone _____-_____-_____ Cell contact 2 _____-_____-_____ //Cell _____-_____-_____ Doctors phone number_____-_____-______ Other contacts________________________________, _____-_____-______

HYPOGLYCEMIA fill in individualized instructions on line or use those in parenthesis Unconscious–____________________________________________phone 911 Blood sugar
60 and symptomatic _______________________juice, pop, candy Blood sugar 100 and symptomatic _______________________crackers/cheese Blood sugar 80 and asymptomatic ______________________feed partial meal Blood sugar 100 and symptomatic _______________________feed partial meal Blood sugar at which parent should be notifiedlow ____________ high ___________

Other orders___________________ _______________________________ _______________________________ _______________________________

BLOOD SUGAR AND INSULIN DOSAGE prior to lunch R is regular and H is lis-pro, _______________ any other insulin requested Blood sugar Blood sugar Blood sugar Blood sugar Blood sugar Blood sugar Blood sugar Blood sugar 100 100149 150199 200249 250299 300349 350399 400 ____________ units R - H - other __________________ see hypoglycemia above ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________
check ketones check ketones check ketones check ketones

Licensed medical personnel allowed to give _____ units minimum of insulin to _____ units maximum of R, H, other _________ insulin after consultation with the parent/guardian Other insulin instructions ie, CHO counting:______________________________________________________ If urine ketones trace, small, moderate, large call parents circle one or more

DISASTER INSULIN DOSAGE-in case of disaster how much insulin should be given? Recommend 80 of usual dose AM __________ units R - H - other _______________ units Lente NPH Ultralente Lantus other Noon PM __________ __________ units R - H - other units R - H - other units R - H - other _______________ units Lente _______________ units Lente _______________ units Lente NPH NPH NPH Ultralente Lantus other Ultralente Lantus other Ultralente Lantus other

Bedtime __________

Parent HCP School Nurse STUDENTS SELF-CARE ability level Initials of: ___________ ____________ ____________ Totally independent management or 1 Student tests independently or ___________ ____________ ____________ student needs verification of number by staff or ___________ ____________ ____________ assist/testing
to be done by school nurse ___________ ____________ ____________ 2 Student administers insulin independently or ___________ ____________ ____________ student self-injects with verification of number or ___________ ____________ ____________ student self-injects with nurse supervision or ___________ ____________ ____________ injection to be done by school nurse ___________ ____________ ____________ 3 Student self-treats mild hypoglycemia ___________ ____________ ____________ 4 Student monitors own snacks and meals ___________ ____________ ____________ 5 Student tests and interprets own urine ketones ___________ ____________ ____________ 6 Student tests and interprets own blood ketones ___________ ____________ ____________ 7 Student carries own supplies ___________ ____________ ____________ HCP _______________________________print/type _________________________signature _____/_____/_____ date Parent ______________________________print/type _________________________signature _____/_____/_____ date School Nurse _________________________print/type _________________________signature _____/_____/_____ date Start date: ____day ____mo ____yr Termination date: _____day _____mo _____yr or End
of school year: _____ Must be renewed at beginning of each school year

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Appendix L

STATEOF WASHINGTON DEPARTMENT OF HEALTH 1300 Sf Quince St PO Box 47864 Olympia, Washington 98504-7864
March 15,2000

Ms Judy Maire, RN, MSN Office of the Superintendent of Public Instruction 600 S Washington Olympia, W A 98504 Dear Ms Maire, This letter is in response to the questions raised by the school nurse members of the Diabetes in the Schools Task Force, which has recently authored the guidelines to be used by school personnel to assist with the planning of care for students with diabetes Specifically, there are concerns about how to handle the issue of insulin injections and blood glucose monitoring in the event of an unforeseen disaster, when nurses may not be available to assist students The practice conunittee of the Nursing Care Quality Assurance Commission discussed this issue at its meeting on March 3, 2000 The diabetes guidelines are based on individual care planning with the goal of self-management by each student, with assistancewhen needed by appropriate school personnel or family members The Conunission understands that
comprehensive planning includes provisions for disaster situations Each students plan of care should contain specific detailed instructions and diagrams which could be easily understood by other adult school personnel who could assist the student if a nurse or other licensed, knowledgeable individual were unavailable Because registered nurses are not permitted by statute to delegate piercing of the skin ie insulin injections and obtaining samples for blood glucose monitoring, the Conunission would not reconunend that individuals be trained in the tasks ahead of time Instead, resource people within the school could be identified who could help the student with these tasks, and simple instructions could be included with the students supplies and required food The Commission would like to reassure registered nurses and licensed practical nurses working in school settings that charges against their licenses would not be filed if an unforeseen disaster situation caused them to teach or coach another individual to assist a student with activities involving piercing of the skin Other individuals would not be held liable for practicing without a license in a true emergency However, it
seems impractical and potentially risky for the nurse to train a group ofpersons to do these tasks ahead of time In addition to the fact that competency would have to be periodically verified, there is no provision which allows the nurse to and delegate these tasks unless it is an unforeseen emergency Thank you for your concerns regarding these issues and for your leadership in school health

Sincerely, 1\A

Shannon Fitzgerald,RN, MSN, ARNP Member,Nursing CareQuality Assurance Commission

;;i? ExecutiveDirector, HPQA, Secti/:

–

II ,J

RECEIVED
MAR 24 2000

HEALTHSERVICES

APPENDIX L WASHINGTON STATE NURSING CARE QUALITY ASSURANCE COMMISSION ADVISORY OPINIONS

Intensive therapy for students with diabetes has resulted in questions relating to nursing practice Most schools do not have full-time health services in the building, and, therefore, many of the practice questions have related to the involvement of nonnurse school staff in the care of students with diabetes In July 2002, a new law, RCW 28A210330-350, came into effect in Washington State designed to address the care of students with diabetes attending public schools One component of the law allows for
parent-designated adult PDA to participate in certain procedures, including blood sugar monitoring and injections of medications Please note that this law is not part of the Law Relating to Nursing Care the nurse practice act, rather it is part of the education statutes The new ruling has not changed any of the previously issued advisory opinions relating to the care of children with diabetes The new law specifically exempts school districts and their personnel including registered and licensed practical nurses from liability if they are acting in substantial compliance with the students IHP Comments intended to clarify this new law as it relates to nursing practice appear in italics in this Appendix, which contains the advisory opinions of the Nursing Care Quality Assurance Commission Several advisory opinions have been issued by the Washington State Nursing Care Quality Assurance Commission, the regulatory authority for nursing, in response to questions about how to manage the care of students with diabetes in the face of dangerously high school nurse-to-student ratios Advisory opinions are, by law, intended to provide guidance for the requesting parties only However, opinions
issued by the commission can be helpful in the care planning process The committee responsible for developing this guide asked for technical assistance from the commission so that nurses could successfully use the opinions to plan for staffing of schools with appropriate personnel The Nursing Commission encourages each nurse to consider the care of each student with diabetes as a unique opportunity to apply the nursing process; the Personnel Guidelines for Care of Students with Diabetes chart, pages 24 and 25, may assist nurses with these individual decisions Other resources include the Law Relating to Nursing Washingtons Nurse Practice Act and school health staffing guides provided by the Office of Superintendent of Public Instruction Role of the school nurse/registered nurse Registered nurses are responsible for assessing the status and identifying the needs of the child with diabetes Input from the family, primary healthcare providers, specialty healthcare providers, teachers, and other school professionals is included in the

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assessment and care planning process Comprehensive care planning reflects the individual
needs of students, and considerable nursing judgment is used in each case Once care is planned, registered nurses are ideal persons to teach others in the school setting about diabetes, including the essential facts listed in this guide The registered nurse is an ideal resource for questions, demystifying the care of students with diabetes, and the creation of plans to allow a seamless transition from home to school for the student RCW 28A210330350 which addresses accommodations for students with diabetes, recognizes the importance of the registered nurse RNin school settings by directing school districts to designate a professional person licensed under RCW 1871 [medical doctors], RCW 1854 [doctors of osteopathy], or RCW 1879 as it applies to RN and the Advanced Registered Nurse Practitioner ARNPs to consult and coordinate with the students parents and healthcare provider to help coordinate and plan care for students If a PDA is identified by the parents, for purposes of carrying out selected tasks, the registered nurse in the school retains the responsibility for overall care planning for the student The registered nurse is not and cannot delegate tasks to the PDA; such tasks are
directed by the parents to the designated adult However, any PDA is required by the new law to participate in school district student specific training If the PDA is not a district employee, they may show proof of comparable training Furthermore, every PDA must complete and provide documentation of training for the additional care authorized by the parent This additional training must be conducted by a healthcare professional or an expert in diabetes selected by the parent RNs and ARNPs may not delegate procedures such as blood glucose monitoring and insulin injections to unlicensed staff Thus, it is recommended that the school nurse not provide this additional training It is the school nurse who delegates specific aspects of care to appropriate school staff, trains and supervises those individuals, and retains responsibility for the quality of nursing care the student receives Suggested parameters for nurses following physician orders and other plans for care include: All orders must be originated and signed by the physician or authorized prescriber and must be individualized for the child Faxed orders are acceptable if the nurse is able to verify by telephone or other means
that the order is from the physician Nurses involved in intensive therapy for diabetes must have adequate education about its long-term benefits, risks, and theory of its use, as it differs significantly from traditional diabetes treatment Emergency plans must be ordered by the physician, ideally in cooperation with school personnel, and must be easily accessed and understood by nurses and other school personnel Inclusion of parents in the planning of care is necessary for the 24-hour management of diabetes

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The term standing order is not recommended because it implies that the treatment plan or orders could be used for other patient care situations and could be seen as a circumvention of the necessary prescriber-patient relationship Nursing judgment is necessary to make adjustments within the sliding scale, and therefore, the decisions relating to dosage adjustment and interpretation of blood glucose measurements may not be delegated to unregulated individuals Parents may be involved See advisory opinion dated September 19, 1997 page 91

Advisory Opinions The following is a summary of the questions asked by interested
parties of the Nursing Commission related to diabetes care Complete copies of the opinions, including questionnaires completed by the requestors, are available by request from the Washington State Nursing Care Quality Assurance Commission, PO Box 47864, Olympia, WA 98504-7864 Any opinion issued by the commission is advisory and intended for the guidance of the requesting parties only The opinion is not legally binding and is not intended to be seen as a declaratory ruling of the commission, a promulgated regulation, or as exempting your facility from any applicable federal or state requirements

Issue: Supervision of other nursing personnel Advisory opinion of November 13, 1998a response to a school nurse with questions about supervision: Note: Several school districts have opted to hire LPNs, supervised by RNs, to assist with the care of students with diabetes The following opinion relates to supervision Recently you wrote to the Nursing Commission with several questions related to nursing services in schools, supervision requirements for LPNs, and questions related to liability for services rendered To streamline the responses, your questions have been reworded slightly Question:
How is indirect supervision defined? Answer: According to the Law Related to Nursing, WAC 246-840-01011e: Indirect supervision shall mean the licensed registered nurse is not on the premises but has given either written or oral instructions for care and treatment of the patient, and the p atient has been assessed by the licensed registered nurse prior to the delegation of duties to any caregiver not licensed as a nurse

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School nurses who are responsible for more than one school typically use this type of supervision Services rendered to children in school vary according to their needs For instance, supervision of medication administration by school staff per RCW 28A210260 and RCW 28A210270, the oral medication statute in schools could be accomplished by teaching a group of individuals and reviewing the individual plans for care Under this statute only RNs can delegate oral medication administration to unlicensed school staff In contrast, direct and immediate supervision is defined in WAC 246-840-01011: Direct supervision shall mean the licensed registered nurse is on the premises, is quickly and easily available and the
patient has been assessed by the licensed registered nurse prior to the delegation of duties to any caregiver Immediate supervision shall mean the registered nurse is on the premises and is within audible and visual range of the patient and the patient has been assessed by the registered nurse prior to the delegation of duties to any caregiver Complex care for a medically fragile student may require that the RN delegate most of the care to an LPN or other individual In such a case, the RN might use direct or immediate supervision, depending on the needs of the student In any case, the determination about what to delegate and to whom is a matter of professional nursing judgment Question: What are the supervision requirements for LPNs? Answer: LPNs use specialized knowledge, skill, and judgment to carry out selected aspects of the designated nursing regimen under the direction and supervision of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, physician assistant, osteopathic physician assistant, podiatric physician and surgeon, advanced registered nurse practitioner, or registered nurse RCW 1879060 LPNs are fully licensed health professionals and are
accountable for their own actions at all times LPNs may give medications in school settings, including injections, without direct RN supervision WAC 246-840-705 describes the functions of a LPN In summary, an LPN recognizes and meets basic client needs in routine nursing situations, which are defined as situations which are relatively free of scientific complexity involving stable and predictable client conditions LPNs also function in more complex nursing care situations, and in these cases an LPN would function as an assistant to the registered nurse or physician As stated above, indirect supervision by an RN who is not on school premises is within the standard of care, as long as the LPN is providing care for students in routine, noncomplex situations and as long as the supervisory role of the RN has been

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established Periodic review of the plan and RN availability for questions are recommended components of school health services Question: What should a certificated school nurse consider in terms of supervision and liability when a noncertificated school nurse is employed in the district? Answer: Each registered nurse
is responsible for his or her own clinical practice If a certificated nurse is the supervisor of the other registered nurses, typical conventions for personnel supervision would apply At no point would the certificated school nurse be responsible for the clinical decisions made or actions taken by other registered nurses employed by the district There is no statutory requirement that a nurse hold a school nurse certificate The commission has no authority to require that registered nurses obtain the 30 clock hours of instruction involved in the school nurse certification process Professionally, the acquisition of this additional education would assist the nurse functioning in a school setting Impact of RCW 28A210330-350, 2002: Registered nurses and LPNs are not the supervisors of parent-designated adults who may be performing certain tasks contained within the students overall plan of care The Nursing Commission has no jurisdiction over nonlicensed individuals The new law exempts school district employees from liability for the actions of PDAs Issue: Involvement of nonnurse personnel with insulin injections using traditional syringes Note: Piercing of the skin is seen by various
practice acts and state law as a regulated activity which must be specifically allowed Unless specially authorized, as in community-based long-term care facilities, RNs and LPNs cannot delegate this activity to unlicensed persons With regard to medication administration, injectable medications may not be delegated to unlicensed persons by either RNs or LPNs Family members or designated adults as defined earlier in this document can perform these activities Advisory opinion dated April 25, 1997: Question: May an RN delegate the health task of double-checking the dose of a selfdrawn syringe of insulin by a student to unlicensed school staff? Answer: The answer to your question is no, because the process involves assistance and potential decision making with nonoral medication and there is no provision to allow unlicensed/unregulated school personnel to assist with or administer injectable medications except for emergencies related to serious allergies The commission recognizes that self-management of diabetes and tight control of blood glucose levels are treatment goals for diabetics of all ages Your question involves the

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2005

entire process of student self-medication In the situation you have described, it would be most appropriate for the school nurse to assess the childs ability to:

Verbalize the process for self-testing blood glucose Verbalize her or his understanding of the use of the sliding scale for insulin, including whether or not this process involves telephoning a parent to make the dosage decision Demonstrate her or his ability to draw up the correct amount of medication and to inject it appropriately

Our suggestion is to involve parents as partners in this nursing assessment and plan for care If the student is able to self-medicate as outlined above, there should be no need to involve school staff in the process If the student is unable to complete the process independently, plans should be developed to ensure that a licensed professional is able to be present to assist the student with insulin administration Impact of RCW 28A210330-350, 2002: Registered nurses are not delegating tasks relating to injections to PDAs Parents are, in effect, supervising such care The advisory opinion as written still applies in any situation in which tasks in the care plan for the student are not
assigned to a PDA As stated in the introductory section, the school nurse is responsible for the overall care plan, which in this case would involve discussions with parents, PDAs, and the students healthcare providers in order to ensure safety at school Issue: Use of glucagon injections for emergencies related to insulin reaction Advisory opinion dated November 1, 1996: Question: May a registered nurse, in the event of unresponsive hypoglycemia in a child with known diabetes, delegate the injection of glucagon to an unregulated person or persons? Answer: The answer is no The procedure for administering glucagon injection for unresponsive hypoglycemia involves blood sugar testing, patient assessment, and plans for follow-up and cannot be delegated to an unregulated person Management of unresponsive hypoglycemia through the use of glucagon injections by unregulated persons in an unmonitored, outlying setting such as a school is seen by the commission as outside the usual standard of care You have described an emergency situation that would require the specialized knowledge and skills of the registered nurse, based on a nursing assessment Your plan, consistent with the Superintendent
of Public Instructions guidelines for school emergencies, is sound The emergency plan submitted includes the use of oral glucose gel, tablets, or juice for hypoglycemic

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reactions and activation of the 911 system for diabetic emergencies Glucagon injections could be administered by the registered nurse on an individual basis in consultation with the childs medical providers Impact of RCW 28A210330-350, 2002: Registered nurses are not delegating tasks relating to injections to PDAs Parents are, in effect, supervising such care The advisory opinion as written still applies in any situation in which tasks in the care plan for the student are not assigned to a PDA As stated in the introductory section, the school nurse is responsible for the overall care plan, which in this case would involve discussions with parents, PDAs, and the students healthcare providers in order to ensure safety at school Issue: Use of insulin pen injector devices as an alternative to syringes Advisory opinion dated May 29, 1998: Addendum for the 2005 Guidelines: Current diabetes care planning includes the use of pumps for children, and may, in the
future, involve other devices Verification of numbers on such devices by unlicensed school personnel, at the direction of the registered nurse, is consistent with the rationale for previous advisory opinions by the Washington State Nursing Care Quality Assurance Commission and the Scope of Practice Decision Tree Question: May an RN delegate to an unlicensed person in a school setting the task of double-checking a dose of insulin for a student ordered by a physician which is contained in a dial-a-dose pen injector system? In such a situation, the student selfinjects the insulin The unlicensed persons sole function is to verify the number reading on the pen injector system, which does not involve handling the actual syringe Answer: You have asked whether a registered nurse in a school setting may delegate to an unlicensed person the task of double-checking a dose of insulin for a student, as ordered by a physician which is contained in a dial-a-dose pen injector Additionally, your question proposes that unlicensed school personnel would not be involved with mechanical assistance with blood glucose monitors, would not handle any drugs or syringes, and would not be involved with any
clinical decisions, including the interpretation of orders The Nursing Commission believes that under certain circumstances, and with limitations, a school nurse may include, as part of a treatment plan for a student who is self-managing insulin-dependent diabetes, participation in the plan by unlicensed school personnel for the sole purpose of confirming numbers The commission does not view this practice of delegation of medication administration as inappropriate delegation of other nursing tasks because the act of confirming numbers does not constitute specialized or clinical judgment

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However, the nurse must first ensure that this practice does not violate the policies and laws that apply to the school district and that:

The students physician or other authorized prescriber has ordered such treatment The parent, physician, or person authorized to prescribe, and the school nurse have evaluated and approved the students ability to self-manage blood glucose monitoring and insulin administration The parent has requested that school personnel verify numbers on the glucometer or dial-a-dose pen injector as part of
the students treatment plan The parent agrees to provide for and be responsible for all equipment necessary for the care of diabetes in school The parent, parents authorized representative, or a school nurse is available by telephone or other means to directly confirm the dosage of insulin, to answer other questions, or to assume responsibility for the entire process if necessary The unlicensed school personnel have agreed to the plan and that the school nurse has provided any necessary education about the process The unlicensed individuals role is strictly limited to confirming for the student the numbers on a glucose monitor and dial-a-dose pen injector

Clarification: School nurses at the task force meetings had further questions about whether a nurse would need to make the decision about whether a child should eat in response to a low blood sugar reading This advisory opinion related only to insulin doses and orders related to that task The commissions intent in the use of the phrase interpretation of orders referred to medications and piercing of the skin The assumption is that the school nurse would have completed a full assessment of the students ability to perform the
various tasks related to comprehensive diabetes management and that the nurse would devise a plan of care for each individual child Part of the nurses care planning process would involve teaching the unlicensed school staff about the need for food and its timing This would include teaching the teachers, aides, bus drivers, and anyone else involved with the child that low blood sugar, however it is verified, requires that the child eat The plan of care should spell out what the child should eat, along with the requirement that the parents provide the food Such a plan would help to prevent staff and other adults from allowing the child to eat more or less than she or he should in such situations which could lead to problems with blood sugar maintenance later in the day or that evening Impact of RCW 28A210330-350, 2002: Registered nurses are not delegating tasks relating to injections to PDAs Parents are, in effect, supervising such care The advisory opinion as written still applies in any situation in which tasks in the care plan for the student are not assigned to a PDA As stated in the introductory section, the school nurse is responsible for the overall care plan, which in this
case would involve discussions with parents, PDAs, and the students healthcare providers in order to ensure safety at school

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Issue: Involvement of the parents in the determination of insulin doses Note: By law, RNs and LPNs may accept orders for medications from physicians, ARNPs, and others; orders received directly from parents are not considered legitimate orders Advisory opinion dated September 19, 1997: Question: May registered nurses, and licensed practical nurses under the supervision of registered nurses, use a physician-ordered sliding dosage scale for insulin injections, which may, also at the direction of the physician, require the input of parents for dosage adjustment throughout a given school day? Answer: Yes, in situations in which frequent blood glucose measurements and a sliding dosage scale for insulin injections are used to manage diabetes in children, it is within the current accepted standards of care for nurses to include parents in the decisions related to insulin dosages, provided that such a treatment program is ordered by a physician for an individual child and provided that certain conditions
are met Plans for care must be individualized, must clearly specify a range of dosages for the child based on a 24-hour, comprehensive plan for diet, blood glucose monitoring, and activity level and the physician or authorized provider must clearly state that parents are to be consulted for daily dosage adjustments within the sliding scale range Provisions must be made for emergency situations or unexpected outcomes, including methods for the nurse to contact the physician or other authorized healthcare provider to modify the plans for care if consultation is necessary based on the nurses professional judgment Parents may not order treatments or changes to treatment plans independently as they are not authorized prescribers Question: What types of parameters should be included when nursing practice guidelines and protocols for care are developed? Answer: Practice guidelines or protocols for care are generally developed to establish standard procedures, to improve and streamline quality of care, and to ensure safe, consistent practice Such guidelines assist nurses to provide care, which is within the scope of nursing practice Practice guidelines are not to be used to develop
policies that allow nurses or other healthcare providers to practice outside their scope For instance, practice guidelines may not be used to allow nurses to prescribe treatments and medications, since registered nurses and licensed practical nurses are not authorized prescribers The situation in the advisory opinion relating to the use of a sliding scale for blood glucose monitoring and insulin injections refers to one child with a set of orders from a physician As the nursing care plan for this child is developed, a practice guideline for

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the care of children with diabetes may be used to assist the school nurse in meeting the needs of the child throughout the school day Suggested parameters include:

All orders must be originated and signed by the physician or authorized prescriber and must be individualized for the child Faxed orders are acceptable if the nurse is able to verify by telephone or other means that the order is from the physician Nurses involved in intensive therapy for diabetes must have adequate education about its long-term benefits, risks, and theory of its use as it differs significantly
from traditional diabetes treatment Emergency plans must be ordered by the physician, ideally in cooperation with school personnel, and must be easily accessed and understood by nurses and other school personnel Inclusion of parents in the planning of care is necessary for the 24-hour management of diabetes The term standing order is not recommended because it implies that the treatment plan or orders could be used for other patient care situations and could be seen as a circumvention of the necessary prescriber-patient relationship Nursing judgment is necessary to make adjustments within the sliding scale, and therefore the decisions relating to dosage adjustment and interpretation of blood glucose measurements may not be delegated to unregulated individuals

Impact of RCW 28A210330350, 2002: Registered nurses and LPNs are not the supervisors of parent-designated adults who may be performing certain tasks contained within the students overall plan of care The Nursing Commission has no jurisdiction over nonlicensed individuals The new law exempts school district employees from liability for the actions of PDAs

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Appendix
M

APPENDIX M BLOODBORNE PATHOGENS STANDARD AND STUDENTS WITH DIABETES WAC 296-823 Ocupational Exposure to Bloodborne Pathogens of the Washington Industrial Safety and Health Act WISHA requires the school district employer to develop a written exposure control plan to eliminate or minimize employee exposure to bloodborne pathogens such as hepatitis B and HIV The Department of Labor and Industries enforces the requirements of this WAC There are many required elements to the exposure control plan These requirements apply to all school settings, including playgrounds and school buses as well as to school sponsored activities where employees might be exposed to bloodborne pathogens The elements of the plan universal precautions specific to employees exposed to treatments required for students with diabetes are: 1 Personal protective equipment gloves 2 Handwashing facilities If not available, the employer provides antiseptic hand cleanser and clean cloth/paper towels or antiseptic towelettes to be followed by handwashing with soap and water when available 3 Proper protection from and disposal of contaminated sharps 4 Procedures and equipment/supplies to minimize splashing, spattering,
etc, of blood 5 Procedures and equipment/supplies to decontaminate work surfaces 6 Proper removal, replacement, storage, and disposal of any protective covering plastic wrap that may be used 7 Disposal of all contaminated waste according to specifications of the regulation The complete WAC 296-823 Occupational Exposure to Bloodborne Pathogens is available by contacting the Washington State Department of Labor and Industries at 1/800-4BE-SAFE 1/800-423-7233 or online at http://wwwlniwagov/wisha/rules/bbpathogens/PDFs/823-Completepdf

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Appendix N

APPENDIX N NUTRITION GUIDELINES FOR SCHOOL SNACKS School specific policy and food provision will be determined by the health planning team and recorded in the students IHP/Section 504 plan 1 Planned snacks are an important part of the nutritional management of most children with diabetes Snacks help prevent low blood sugar hypoglycemic reactions which can occur when food and insulin are unbalanced; for example, when there is too little food for the amount of insulin present or there is extra activity 2 Discuss with parent/guardian when the student has snacks during the day If
possible, arrange in advance of school when and where the student will eat planned snacks Most elementary school-age children will have a mid-morning snack Middle school or high school students may have eliminated the mid-morning snack due to changes in their insulin regime 3 Children may need an afternoon snack at school Usually afternoon snacks are eaten at home, but if the child has an early lunch, PE class late in the day, a long ride home on the bus, or an after school sports practice or other activity, an afternoon snack at school may be needed 4 Parent/guardian is responsible for providing planned snacks 5 Snacks should be eaten on time Delaying snacks can result in low blood sugar 6 Most snacks will include one to two carbohydrate choices and a meat/protein choice This will provide about 1530 grams of carbohydrate, 7 grams of protein, and 5 grams of fat Smaller or less active children need smaller snacks than larger or more active children 1 carbohydrate choice 1 starch 1 fruit 1 milk 15 grams carbohydrate Examples: 6 saltine crackers, 3 graham cracker squares, 5 vanilla wafers, bagel, 1 slice bread, 1 small apple, orange or banana, 4 ounces apple juice, pint milk, 1
cup light yogurt, 3 cups popcorn, cup ice cream Dixie cup, 2 small cookies 1 meat/protein choice 1 ounce meat 1 ounce cheese 2 tbsp peanut butter 1 egg 1/4 cup peanuts 7 grams protein 510 grams fat Examples: 1 string cheese stick, 1 ounce slice cheese, 1 ounce slice bologna or turkey, 1 hotdog, 1 hard-cooked egg, 1 stick pepperoni, 1 small bag peanuts, 2 tbsp peanut butter 7 An extra snack may be needed before extra activity This may include an unusually active PE class, a field trip, extra recess, or sports practice If possible, alert the parent/guardian to these occasions so that extra food can be sent to school

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8 An unplanned snack may be needed if hypoglycemia occurs If low blood sugar occurs, treatment with a fast-acting, simple sugar such as two glucose tablets or 4 oz juice will be required If a meal is not scheduled within the next half hour, a snack containing carbohydrate and protein should be eaten 9 Ask the parent/guardian to provide an emergency snack box to keep at school to use when unplanned snacks are needed Included items might be prepackaged snacks such as a cheese or peanut butter and cracker
packet, granola bar, small box of raisins, or small package of peanuts

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Appendix O

APPENDIX O DISASTER PREPAREDNESS: THREE-DAY EMERGENCY READINESS Include these pages along with copies of Low and High Blood Sugar Plan Appendix P and Q with Disaster Kit The primary needs for the child with diabetes would be the requirements for food and insulin Safety is the goal, so slightly higher than normal blood sugar levels are preferable Basically, the child needs enough food to prevent serious short-term problems of low blood sugars hypoglycemia and sufficient insulin to prevent ketoacidosis from continually increasing high blood sugars The goal of sound diabetes management requires the balancing of food intake with insulin administration and level of activity We believe that a child being kept at school during a disaster situation would likely have less activity and less readily available food for an extended period Therefore, the childs insulin requirements would decrease INSULIN Orders for insulin amounts to be given during a disaster should be included in the Disaster Kit Insulin orders can be documented using the Disaster
Insulin Dosage form, page 104 of this Appendix or the Healthcare Provider HCP Order Sheet Appendix K Instructions on how to administer insulin can be found in this Appendix These insulin instructions are specifically designed to allow an adult, in an emergency situation, to supervise the child who performs this skill It must be noted that a child with diabetes cannot survive without insulin In a disaster situation, it may be necessary for a nonlicensed person to use these instructions to draw up and administer the insulin that a young child may not be able to administer on her or his own Registered nurses are not permitted by statute to delegate procedures requiring piercing of the skin For further information on the issue of nonlicensed persons performing such skills in a disaster situation, refer to the letter dated March 15, 2000, to Judy Maire from the Nursing Care Quality Assurance Commission, Appendix L Parents may designate a PDA to provide care that a registered nurse may not delegate, such as insulin injections see Appendix I Even so, there may be a disaster situation in which an adult who is not a PDA would need these instructions BLOOD SUGAR CHECKS AND KETONE CHECKS A
means of checking blood sugar levels should be available Either an extra meter that can be left at school or visual test strips may be used Directions for use of the visual strips are on the container In a disaster situation, the nonlicensed person may need to assist the child with this skill However, it should be noted that even very young children are often able to perform or assist in the blood sugar check
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It is also important to have ketone test strips available to measure urine ketones This should be done if the blood sugar level is over 240 or if the child has been running higher than normal blood sugar levels Ketones should also be checked if the child is not feeling well If the child runs moderate or large ketones, a doctor should be notified as soon as possible Attach a copy of the students High Blood Sugar School Plan Appendix Q Instructions for blood sugar and ketone checks can be found in this Appendix NUTRITION Orders regarding the amount of food and/or number of meals and snacks must be obtained from the dietitian and HCP and should be included in the Disaster Kit 1 Try to offer three meals along with a
mid-morning snack, an afternoon snack, and a bedtime snack at the usual meal/snack time 2 If possible, include a carbohydrate food and a protein food at each meal and bedtime CARBOHYDRATE FOODS Bread Crackers Cereal Cereal/granola Bar Chips/pretzels Fruit/canned fruit Dried fruit Juice Milk 3 If protein foods are not available, then offer carbohydrate foods every two to three hours 4 If the child is required to spend the night at school, the child should be given a bedtime snack consisting of a carbohydrate food and protein food or a bedtime snack bar such as Nite-biteTM LOW BLOOD SUGAR If a childs blood sugar is less than 70, she or he should be given a quickly absorbed sugar source such as 48 oz of juice, one-half of a can of regular pop, one to two packets of sugar, one packet of honey, or four to five hard candies A serving of carbohydrate and protein food, such as cheese and crackers, half of a sandwich, or cereal and milk, should follow Attach a copy of the students Low Blood Sugar School Plan Appendix P PROTEIN FOODS Cheese/cheese foods Meat/dried meat Canned tuna/meat Peanuts Peanut butter

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SUPPLIES It is
recommended that the parents provide a three-day supply of the following at the beginning of the school year:

Blood sugar meter with instructions and meter strips or visual strips Ketone strips Insulin: may be stored in refrigerator but refrigerator may not be accessible during a disaster Insulin at room temperature may begin to loose potency after one month Label with date that it is brought to school and date when actually opened Insulin syringes Lancets Antiseptic wipes or wet wipes Small logbook to record insulin dose/blood sugar results Bedtime snack bar, such as Nite-biteTM, if used Low blood sugar reaction food supplies: quick-acting sugar and carbohydrate/protein snacks Send enough supplies for two to three episodes Schools are generally prepared for inclement weather with food for one or two meals on hand If a student needs specialized food, her or his parents should work with the HCP and/or dietitian and the food service manager to plan for emergency situations

It is suggested that the diabetes supplies be replaced during the winter holiday season This way what has been kept at school can be used before its expiration It is important that supplies such as
meter and all testing strips be kept at room temperature, as extreme heat or cold may impair function

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SKILLS INSTRUCTION: Blood Sugar Checks, Ketone Checks, Insulin Administration Registered nurses are not permitted by statute to delegate procedures requiring piercing of the skin For further information on the issue of nonlicensed persons performing such skills in a disaster situation, refer to the letter dated March 15, 2000, to Judy Maire from the Nursing Care Quality Assurance Commission, Appendix L TO CHECK BLOOD SUGAR 1 2 3 4 Wash and dry hands Obtain drop of blood with lancet Place drop on meter strip per meter instructions or on ChemstripTM if reading visually Record result TO CHECK KETONES 1 2 3 4 5 6 Obtain a urine sample Dip test strip into urine and tap off excess against edge of container Read color change in exactly the number of seconds indicated on strip bottle or box Compare with color chart Notify a medical doctor if ketones are moderate or high as soon as possible If a medical doctor is not available: a Encourage student to drink as much sugar-free fluid eg, water as possible b Ensure that student
rests c Ensure student gets scheduled insulin TO ADMINISTER INSULIN TO DRAW INSULIN Clear Regular, Humalog or Novolog insulin and cloudy NPH, Lente, or Ultralente insulin can be mixed in one syringe Lantus insulin must never be mixed with any other insulin A new syringe is needed The following instructions 2 through 5 outline the steps If the person drawing up the insulin feels uncomfortable with mixing the two types, each insulin could be drawn up and injected separately In this case follow steps 1, 2 or 3, and 5 1 2 3 4 Clean top of vials with alcohol swab if available Roll NPH, Lente, or Ultralente to mix insulin Be sure there are no clumps Be sure that Regular, Humalog, or Novolog insulin is clear Insert syringe into Regular, Humalog, or Novolog draw back on plunger to fill the syringe to the number of units of Regular, Humalog, or Novolog insulin needed Since there is only one kind of insulin in the syringe, you may go beyond line needed and gently push back to get rid of air bubbles if necessary 5 Pull syringe out of the Regular, Humalog, or Novolog vial and put the needle into the NPH, Lente, or Ultralente vial and draw back on plunger to obtain the total number of units to
be given Be careful to not draw too far If you go beyond the unit you want, squirt the insulin into the sink and start over 6 Pull the syringe out of the vial and cap loosely 7 If only one type of insulin such as Regular, Humalog, Novolog, NPH, Lente, Ultralente, or Lantus is to be given, simply insert the syringe into the appropriate insulin vial, invert, and draw the correct amount Since there is only one kind of insulin in the syringe, you may go beyond line needed and gently push back to get rid of air bubbles if necessary
Guidelines for Care of Students with Diabetes 102 May 2005

THE AIR BUBBLES WILL NOT HURT THE CHILD IF INJECTED, BUT THEY DISPLACE INSULIN AND THEREFORE ALTER THE DOSE TO GIVE INJECTION 1 Wash site if possible 2 Pinch up fat layer on thigh or back of upper arm 3 Inject with quick dart-like motion between a 45 and 90-degree angle Older kids go straight infor younger children with less body fat, use angle If using an Ultrafine II syringe with a very short needle, then always use a 90-degree angle 4 Push plunger to inject insulin 5 Release pinch and remove syringe CHILDS NAME:____________________________________

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DISASTER INSULIN DOSAGE It is prudent to decrease the childs insulin dosage during a disaster to prevent low blood sugar A general guideline is to give 80 percent of the childs usual dose during a disaster The following can be used as an order if the Health Care Provider HCP signs it Alternatively, the Healthcare Provider HCP Order Sheet for Students with Diabetes in Washington State Schools Appendix K can be used to record the disaster dosage attach Disaster dosages, wherever recorded, must be updated as the students insulin requirements change THE CHILDS INSULIN DOSE USING THE 80 PERCENT GUIDELINE IS: Time of Day PLEASE SPECIFY TYPE AND DOSE Units of NPH, Lente, Ultralente, or Lantus 08 X usual dose PLEASE SPECIFY TYPE AND DOSE Units of Regular, Humalog, or Novolog 08 X usual dose

Breakfast Lunch Evening meal Bedtime Other

USE THIS SPACE FOR OTHER SPECIFIC INSULIN ORDERS:

HCP: Signature:

Print/type:

Start date:____day____mo____yr Termination date:____day____mo ____yr or end of school year ____ Must be renewed at beginning of each school year

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Appendix P

APPENDIX P LOW BLOOD SUGAR SCHOOL
PLAN Name: ________________________________________________ Grade/Teacher: _________________________________________ Date: _________________________________________________
CAUSES
Too much insulin Missed food Delayed food Too much exercise Unscheduled exercise

PICTURE

ONSET
Sudden

SYMPTOMS

MILD Hunger Dizziness Shakiness Sweating Weak Drowsy Sweaty Pale Anxious Irritable Unable to concentrate Personality change Other: Circle students usual symptoms

MODERATE Headache Behavior change Poor coordination Confusion Blurry vision Weakness Slurred speech Other: Circle students usual symptoms

SEVERE
Loss of consciousness Seizure

ACTION NEEDED
Notify School Nurse If possible, check blood sugar per plan But always, when in doubt, TREAT

MILD Treats self 23 glucose tablets or 48 oz Juice or 48 oz Regular soda or Glucose gel product Or 38 Lifesavers Wait 1015 minutes Repeat food if symptoms persist or sugar less than Follow with a snack of carbohydrate and protein, ie, crackers and cheese Communicate with parents/parentdesignated adult

MODERATE Someone assists Insist on child drinking quick sugar source per MILD guidelines Wait 1015 minutes Repeat food if symptoms persist or sugar less
than Follow with a snack of carbohydrate and protein, ie, crackers and cheese Communicate with parents/parent-designated adult

SEVERE Dont attempt to give anything by mouth Call 911 Position on side, if possible Contact parents/parentdesignated adult

School Nurse:_______________________________ Nurse Contact Number:________________________ Never send a child with suspected low blood sugar anywhere alone
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Appendix Q

APPENDIX Q HIGH BLOOD SUGAR SCHOOL PLAN Name: _____________________________________________________ Grade/Teacher: ______________________________________________ Date: ______________________________________________________
PICTURE

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

ONSET
Over time several hours or days

SYMPTOMS

MILD
Thirst Frequent urination Fatigue/sleepiness Increased hunger Blurred vision Weight loss Stomach pains Flushing of skin Lack of concentration Sweet breath

MODERATE
Mild symptoms plus Dry mouth Nausea Stomach cramps Vomiting

SEVERE
Mild and moderate symptoms and labored breathing Very weak Confused Unconscious

ACTION NEEDED

MILD/MODERATE
Treats self Drink zero-calorie fluids ie, water Check ketones, if student able Decrease activity if ketones present Student may need to use bathroom frequently A water bottle in the classroom may encourage the intake of fluids Communicate with parents/parentdesignated adult Other:

SEVERE
Call 911 Contact parents/parent-designated adult Notify school nurse

School Nurse:_____________________________ Nurse Contact Number:_____________________ Never send a child with suspected high blood sugar anywhere alone
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Appendix R

APPENDIX R
NUTRITION GUIDELINES FOR SCHOOL PARTIES AND/OR UNPLANNED EATING School-specific policy and food provision will be determined by the health planning team and recorded in the students IHP/Section 504 plan School parties are usually a celebration of a particular holiday or occasion eg, Valentines Day, a childs birthday, or a special achievement by the class Many of the following suggestions for parties are a good idea for all children, since many parents would like their children to eat less sweets and junk food 1 Send the party menu home in advance If possible, decide on the menu for the party and
send this home with the children in advance Adults at home can help the child with diabetes decide which food choices are appropriate and in what amounts Set the time of the party at the usual snack or lunchtime of the child with diabetes For example, if the party is timed toward the end of the school day, the food eaten can be counted as the usual after-school snack If this isnt possible, try to encourage some active games after eating that will help burn up extra blood sugar or have the party just before PE class Substitute party foods for usual snack or lunch foods Consult with parents on the childs meal plan The following substitution guidelines may be used: Carbohydrate choice 1 starch 1 fruit 1 milk Examples of 1 carbohydrate choice or 15 Grams are: may also include protein fat 1 small cupcake no frosting 2 tablespoons frosting small 2-inch square brownie 1 slice thin crust pizza 1/8th of a 10 pizza 1 fun size Snickers or Milky Way bar cup regular ice cream 2 regular Chips-Ahoy cookies 1 medium 3-inch diameter sugar cookie cup regular gelatin cup regular punch or juice 3 cups popcorn buttered is okay 1 small apple, banana, orange, or 15 grapes 1 small plain cake donut
1 flour tortilla 6 inch or 2 corn taco shells 1 cup no-sugar-added flavored yogurt cup sugar-free or cup regular pudding Use foods that will not raise blood sugar very much These foods include free foods that have less than 20 calories and 5 grams of carbohydrate per serving and foods from the meat/protein group and the fat group Examples include: Meat Group cup peanuts 1 stick pepperoni 1 stick beef jerky 2 tablespoons peanut butter cup taco meat 1 ounce cheese cubes 1 string cheese 1 gobble stick turkey cup tuna fish cup cottage cheese Fat Group 5 olives 2 tablespoons Cool Whip 1/8 avocado cup guacamole 1 tablespoon cream cheese 2 tablespoons ranch dressing 2 tablespoons 1,000 Island dressing

Free Foods sugar-free gelatin or jello jigglers carrot and celery sticks dill pickles Free Cool Whip salsa lettuce, radishes sugar-free popsicles diet soda Crystal Light sugar-free flavored seltzers or wafers sugar-free gum 56 sugar-free candies eg, gummi bears or hard candies limit foods with sorbitol as may have a laxative effect

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Appendix S

APPENDIX S: EXCHANGE
LIST FOR MEAL PLANNING CARBOHYDRATE CHOICES Starch Choices: 15 grams Carbohydrate, 3 grams Protein, 01 grams Fat, 80 Calories Bread Dried Beans, Peas, Lentils
Whole wheat or white 1 oz or 30 grams Light bread 40 cal/slice Bagel English muffin Hamburger or hotdog bun Tortilla 6 Pita 6 Plain small roll Pancake batter Low fat waffle 4 Bran flakes Grapenuts Cooked cereals Unsweetened cereal Puffed cereal Cooked pasta Cooked rice Cornmeal and flour Shredded wheat 1 slice 2 slices 1 oz 1 1
1/3 C

Cooked beans and peas Cooked lentils Baked beans Corn Corn on the cob 6 Lima beans Mixed veg w/corn/peas/pasta Green peas Baked or boiled potato 1 small Mashed potato no fat added Winter squash Yam or sweet potato Animal crackers Graham crackers Popcorn no fat added Pretzels Rye crisps Saltines Whole wheat crackers Rice or popcorn cakes

C C 1/3 C C 1 ear
2/3 C

Starchy Vegetables

Cereal, Grains, Pasta

1 C C C C 1 C C
1/3 C

1C C 3 oz C 1C C 8 3 sq 3C oz 4 6 oz 2 lrg

Crackers and Snacks

3 Tbsp C or 1 lrg Biscuit

Apple 2 Applesauce Apricots Banana Blackberries or Blueberries Canned fruit Cantaloupe Cherries Figs Fruit cocktail Grapefruit Grapes Honeydew melon Kiwi Mandarin orange Mango
Nectarine 2 1/2 Orange 2 1/2 Peach 2 3/4 Pear Plum 2 Raspberries Strawberries Tangerine Watermelon

Fruit Choices: 15 grams Carbohydrate, 60 Calories Fresh, Frozen or Unsweetened Canned Fruit
1 C 4 1 sm C C 1C 12 2 C 17 1C 1 lrg
2/3 C

Apple juice/cider Cranberry juice Low-cal cranberry Grapefruit juice Grape juice Orange juice Pineapple juice Prune juice

Fruit Juice

C 1C C 1/3 C C C 1/3 C 4 rings 8 3 med 1 3 med 2 Tbsp
1/3 C

Dried Fruit

1 1 1 1 sm 2 1C 1 C 2 1 C

Apples Apricots Dates Figs Prunes Raisins

Skim, nonfat, 1 Evaporated skim Nonfat yogurt light Buttermilk

Milk Choices: 12 grams Carbohydrate 8 grams Protein, 03 grams Fat, 90 Cal Skim/Very Low Fat Milk
1C C 1C 1C

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Vegetable Choices: 5 grams Carbohydrate, 2 grams Protein, 25 Calories 1 choice cup cooked or 1 cup raw vegetable Starchy vegetables are listed under Starch Choices:
Artichoke Asparagus Bean Sprouts Beets Broccoli Brussels Sprouts Cabbage Carrots Cauliflower Celery Chinese Cabbage Cucumber Eggplant Endive Escarole Green Onion Green Pepper Greens: Beet Chard Collards Dandelion Kale Mustard Turnip Hot Peppers Lettuce Mushrooms Onions Parsley
Radishes Rhubarb Rutabaga Sauerkraut Spinach String Beans green or wax Squash Tomatoes Tomato Juice Turnips Vegetable Juice Zucchini

Soups
Bean Cream made w/ water Split Pea Tomato made w/ water Vegetable Beef Chicken Noodle 1 C 1 carb, 1 meat 1 C 1 carb, 1 fat C 1 carb 1 C 1 carb 1 C 1 carb 1 C 1 carb

Combination Foods
Tuna casserole, lasagna, spaghetti w/meatballs, chili w/beans, mac and cheese 1 C 2 carbs, 2 meats Chow mein no rice/noodles C 1 carb, 2 meats Cheese pizza, thin crust 10 2 carbs, 2 meats 1 fat Meat pizza, thin crust 10 2 carbs, 2 meats 2 fats 1

Other Carbohydrate Choices: Examples of choices that may occasionally be substituted into your Meal Plan
Angelfood Cake Small unfrosted brownie 2 square Plain cake donut 1 Unfrosted cake 2 square Potato chips 1 oz Tortilla chips 1 oz Sugar/fat free cocoa 1 C Arrowroot cookie 4 Fat free cookie 2 sm Gingersnaps 3 Vanilla Wafers 5 Cranberry sauce C 2 carbs 1 carb, 1 fat 1 carbs, 2 fats 1 carb, 1 fat 1 carb, 2 fats 1 carb, 2 fats 1 carb 1 carb 1 carb 1 carb 1 carb, 1 fat 2 carbs Sugar/fat free frozen desserts C Fat free granola bar Ice cream C Frozen yogurt C Jam/jelly/fruit spread 1Tbsp Fruit pie, double,
crust 1/6 pie Pumpkin or custard pie 1/8 pie Sugar/fat free pudding C Sherbet/sorbet C Canned spaghetti sauce C Light syrup 2 Tbsp Low fat yogurt 1 C 1 carb 2 carbs 1 carb, 1 fat 1 carb, 1 fat 1 carb 3 carbs, 2 fats 1 carb, 2 fats 1 carb 2 carbs 1 carb, 1 fat 1 carb 3 carbs, 1 fat

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Very lean beef, lamb, veal, and pork well trimmed with little marbling; round steak, rump roast, center cut ham , etc Low fat cottage cheese Cheese low or no fat w/less than 55 calories/oz Grated Parmesan cheese Fresh or frozen fish Clams, oysters, shrimp Canned salmon or crab Canned tuna in water Fat free hot dogs Poultry skinless chicken, turkey, Cornish hen

Meat Choices: Weight after cooking with bone and excess fat removed Very Lean/Lean High Fat 7 grams Protein, 03 grams Fat, 3555 Calories 7 grams Protein, 8 grams Fat, 100 Calories
1 oz 1 oz C 1 oz 2 Tbsp 1 oz 5 sm/1 oz 1 oz 1 oz 1 oz 1 oz Beef 2030 fat ground beef, sirloin, etc Lamb or veal breasts Pork spareribs, country ham, sausage Cheese regular or processed Luncheon meats Duck, goose Light hot dogs Old-fashioned peanut butter Nuts 1 oz 1 oz 1 oz 1 oz 1 oz 1 1 Tbsp cup

Medium
Fat 7 grams Protein, 5 grams Fat, 75 Calories

Lean beef or pork rib eye, 15 fat ground beef, sirloin, etc Creamed cottage cheese Cheese 5680 cal/oz Large egg Egg substitute Liver, heart, kidney Poultry w/skin or ground Tofu

1 oz C 1 oz 1 C 1 oz 1 oz C

Fat Choices: 5 grams Fat, 45 Calories Polyunsaturated Fats
Safflower, sunflower, corn, or cottonseed oils Margarine made from above oils Diet margarine 50 cal/Tbsp French or Italian dressing Walnuts Seeds pine nuts, sunflower Mayonnaise Light mayonnaise Low fat mayonnaise Fat free mayonnaise 1 tsp 1 tsp 1 Tbsp 1 Tbsp 4 halves 1 Tbsp 1 tsp 2 tsp 2 Tbsp 3 Tbsp

Monounsaturated Fats
Avocado 4 Canola, olive, peanut oils Olives Almonds Pecans Peanuts-Spanish Virginia Other mixed nuts

1/8 1 tsp 8 lrg 6 whl 2 lrg 20 10 6 sm

Regular marg Butter Crisp bacon Cream Light Heavy Sour cream Low fat sour cream Cream cheese Low fat cream cheeses Gravy Low fat creamy salad dressing

Saturated Fats

1 tsp 1 tsp 1 Slice 2 Tbsp 1 Tbsp 2 Tbsp 3 Tbsp 1 Tbsp 2 Tbsp 1 Tbsp 1 Tbsp

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Fat Free or Reduced Fat Foods: Less than 20 calories per serving Check labels carefully Use no more than 1
serving per meal 3/day
Sugar free hard candy Catsup Fat free cream cheese Liquid nondairy creamer Powdered nondairy creamer Low-sugar/light jams or jellies Fat free margarine Low fat margarine Light mayonnaise 1 piece 1 Tbsp 1 Tbsp 1 Tbsp 2 tsp 2 tsp 4 Tbsp 1 tsp 1 tsp Low fat mayonnaise Fat free salad dressing Salsa Fat free/low fat sour cream Soy sauce Sugar free syrup Taco sauce Regular or light whipped topping2 Tbsp Fat free mayonnaise 2 tsp 1 Tbsp C 1 Tbsp 2 Tbsp 2 Tbsp 1 Tbsp

1 Tbsp

Free Foods Drinks
Broth, bouillon, consommé Coffee, decaf coffee, tea Sugar free drink mixes Sugar free hot cocoa/cider 20cal/pkt Sugar free soft drinks

Seasonings
Extracts Garlic Tabasco/hot pepper sauce Pimento Herbs Black, red, white peppers Wine used in cooking Worcestershire sauce Salt Spices Garlic/Onion salts Lemon pepper

Other
Sugar free gelatin Unflavored gelatin Sugar free gum Nonstick pan spray Sugar substitutes

Condiments
Horseradish Lemon/lime juice Mustard Dill pickles Vinegar

High in Vitamin A Eat at least 1 per day High in sodium High cholesterol foods

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Appendix T

APPENDIX T MEAL SERVICE FOR STUDENTS WITH
DIABETES

Will the food service department provide meals to students with diabetes? The food service department will provide meals if a diet order is prescribed by a licensed medical authority The diet order must be very specific and describe foods and portion sizes Who pays for meals? All food and labor used to prepare the food for school lunches and breakfasts can be paid for from food service revenue If the school participates in the National School Lunch Program NSLP and/or the School Breakfast Program SBP, lunch and/or breakfast will be available in the school Free and reduced-priced meals are available to student based on family size and income In general, free meals are available to students from families whose income is at or below 130 percent of the federal income poverty guidelines Reduced-price meals are for families with incomes between 130 percent and 185 percent of this guideline Schools will have applications available for families to fill out Who pays for snacks? If the student has an individual education program IEP that requires a meal that is generally not provided eg, an afternoon snack, the food service department will provide this snack In this instance the
snack and time to prepare it can be paid for from special education funds if the student qualifies for special education Disaster or emergency situations Schools are generally prepared for inclement weather with food for one or two meals on hand If a student needs specialized food, his or her parents should work with the HCP and/or a dietitian and the food service staff to plan for emergency situations Meals that are withheld or delayed as a disciplinary measure Withholding meals as a disciplinary measure is not allowed in the NSLP or SBP The school must use some other means to discipline its students Meals that are withheld because of nonpayment This is a school or school district issue We recommend that the school district or school develop a policy that addresses a way for students to receive meals when they have no cash The most common method is a petty cash fund that a student can borrow from Using food service staff to prepare and portion meals Food service staff can prepare and serve meals to students with diabetes based on predetermined diet orders They can and do portion food based on diet orders Using food service staff to monitor students with diabetes at meal times Food
service employees are hourly workers with very specific tasks Their jobs are to prepare food, serve meals, and clean up the kitchen They are seldom in the cafeteria area except to clean tabletops The use of food service employees to monitor student mealtime is not an appropriate use of scheduled hours

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Appendix U

APPENDIX U SPECIAL EDUCATION IF PARENTS AND SCHOOL STAFF DONT AGREE When a child is eligible for special education, the child is guaranteed by federal and state law a free appropriate public education FAPE through individualized special education services Because services are individualized, parents and school districts must work together to determine exactly which services the child needs and how services will be delivered Sometimes parents and school staff do not agree about what is appropriate for the childs educational program When parents and school staff do not agree about the educational program for an eligible special education student, the first step is to consider whether additional IEP meetings would assist in achieving a program that is agreed to by the IEP team Ultimately, however, it is the
districts obligation to offer a free appropriate educational program for the student If differences cannot be resolved through IEP meetings, procedural safeguards give parents and schools several options for making decisions about an educational program for an eligible special education student Section 504 also provides parents with similar procedural safeguards Mediation: Mediation is a voluntary process to help parents and school personnel work out their disagreements about a childs educational program A trained, neutral mediator helps both parents and school personnel clarify issues at no charge to either party Together they develop mutually acceptable agreements about the educational program for the child with a disability Because mediation is voluntary, either party can terminate the mediation process at any time, if the parties do not reach agreement While mediation is an alternative to starting a due process hearing; it cannot be used to deny or delay a due process hearing For more information about special education mediation services, call Sound Options at 1/800-692-2540 or Washington State Relay Service at 1/800-833-6388 TTY, or 1/800-833-6384 voice Due process hearing: A
due process hearing is the formal legal action designed to resolve disagreements between parents and educators about the appropriateness of a childs educational program or other matters involving the students eligibility for special education Parents and school districts are usually represented by lawyers who know special education law The due process hearing is conducted by an impartial neutral administrative law judge who will make a decision on the case A parent or school district may start a due process hearing at any time to resolve differences Both parties have the right to file an appeal to state superior or federal court within 30 calendar days of the decision Citizens complaint: A citizens complaint may be filed when a parent believes that a school district has violated state or federal special education laws or regulations The complaint must be filed with the Office of Superintendent of Public Instruction The complaint will be investigated and a written response developed within 60 calendar days after the complaint is received Discrimination complaint: Anyone who believes that an educational institution that receives federal financial assistance has discriminated against
a person with a disability
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may file a complaint with the Office for Civil Rights OCR A complaint must be filed within 180 days of the alleged discrimination unless the time for filing is extended by OCR for good cause Procedural safeguards: Procedural safeguards protect the parents rights to participate meaningfully in decisions about the childs educational program Procedural safeguards give parents and school staff a set of tools to help them solve problems and settle disagreements about the educational program of a special education student Both your local school district or the Office of Superintendent of Public Instruction have copies of the notice of procedural safeguards The safeguards address many issues including, prior written notice, consent, access to and confidentiality of records In addition, copies of the notice should be given to parents at specific times Your school district should be able to go over the procedural safeguards and address any questions regarding them Prior written notice: School districts must provide parents with written notice each time they propose or refuse to start or change services
for an eligible special education student Services means any action to identify, evaluate, place, or provide FAPE to a child with a disability Consent: School districts must get parental consent for evaluation, for initial placement in special education, and for reevaluation with certain exceptions of a child Districts have the right to request a hearing to determine a childs need for services when parents will not give consent Parents also have the right to appeal such action Access to records: Parents have the right to review all educational records kept by the school district about their child as guaranteed by the Family Educational Rights and Privacy Act of 1974 FERPA When a parent requests such information, the district must provide it without unnecessary delay within 45 calendar days and before any meeting about the childs IEP or due process hearing If parents find an educational record is inaccurate or misleading, they may request changes or corrections Schools and education agencies must promptly respond to these requests Confidentiality: FERPA also protects confidentiality A parents consent is usually needed before personally identifying information is given One exception
is when information is given to school officials who have a legitimate educational interest A school official includes school administrators, supervisors, instructors, consultants, therapists, or support staff including health or medical staff and law enforcement personnel Generally, school officials have legitimate educational interest if they need to review an educational record to fulfill their professional responsibilities Another exception is to the officials of the school where the child seeks or intends to enroll

___________________________ Family/Educator Guide, Special Education, OSPI, July 2002, pages 5562, OSPI Available on OSPI Web site: http://wwwk12waus/specialed/Publications/family_educator_guide/family_educator_guide_200 2pdf Family/Educator Guide is also available in a variety of languages

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Appendix V

APPENDIX V SKILLS CHECK LIST FOR PARENT-DESIGNATED ADULT For Additional Care Authorized by Parent This skills check list is a sample of what could be used in training a volunteer PDA who may or may not be a district employee The skills included here are for additional care authorized by the parent A
health professional licensed under RCW 1879 would otherwise perform this care The training for these tasks is to be provided by a healthcare professional or expert in diabetes selected by the parent It is recommended that the trainer obtain a copy of the students individual health plan and/or communicate with the school nurse This will enable the trainer to provide training consistent with the students individual health plan for school The educators initials go in the Instruction Provided and Assessment boxes Objectives that are not applicable should be crossed out Individual objectives may be added Blood Sugar Monitoring Instruction Provided Discussion/ Demonstration Assessment Returned demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies supplies: Meter, strips, lancets, lancet device, cotton ball or Kleenex, Zip lock baggie for strip disposal optional, log book, if needed Describes steps in monitoring: 1 Calibration needed and current strips 2 How to load the strip and when to change 3 How to load the lancet device 4 Preparation and choice of extremity to be poked 5 Poke forearm vs finger 6 Correct way to operate meter 7 How to read the
blood sugar reading, ie, what does high mean? 8 Storage and disposal of strips Demonstrates obtaining blood sample and running the meter

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Insulin Instruction Provided Discussion/ Demonstration Assessment Returned demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies supplies: Insulin or insulins, syringe, site rotation plan Sliding scale or decision process for amount of insulin to be given, syringe disposal container Demonstrates administration of insulin: 1 Insulin action–general and child specific 2 Site preparation 3 Determine what and how much insulin is to be given 4 Syringe size 5 Air replacement 6 Draw up insulin 7 How to mix insulins 8 Expulsion of air 9 Choose area to inject 10 Injection of insulin 11 Check site for leakage after injection 12 Disposal of syringe and storage of insulin Insulin Pen Instruction Provided Discussion/ Demonstration Assessment Returned demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies supplies: Insulin pen-specific to child, pen needles, cartridge Describes pen operation: Priming of pen with new
cartridge and each time usage Demonstrates administration of insulin: 1 Insulin actions–child specific 2 Site preparation
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3 Determine what and how much insulin to be given by sliding scale or decision process for amount of insulin to be given 4 Dial dose needed 5 Choose area to be injected 6 Inject insulin 7 Check site for leakage after injection 8 Disposal of pen needle and storage of pen and insulin Insulin Pump Special training outside the normal parent-designated adult instruction is needed The training must be pump specific Instruction Provided Discussion/ Demonstration Assessment Returned, demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies supplies: Complete change of reservoir and infusion set only if trained by specific pump trainer for that specific pump Demonstrates and describes giving bolus: 1 Understand function of bolus 2 Calculate amount of insulin to be given 3 Give bolus Site change: Will need specific instruction by the pump trainer for the specific set insertion and device used Describes trouble shooting pump: 1 Call parents 2 Know how to respond to and treat
high blood sugars 3 Symptoms of diabetes ketoacidosis due to failure of insulin delivery or other pump problem

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Glucagon Instruction Provided Discussion/ Demonstration Assessment Returned, demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies supplies: Current dated Glucagon kit Demonstrates administration of Glucagon: 1 When to use 2 Proper mixing and administration 3 Choose site: Intramuscular IM or subcutaneous SQ child specific 4 Be sure 911 and parents have been called Describes follow up: 1 Roll child to side in case vomiting occurs 2 Monitor blood sugar see skills section for blood sugar monitoring Low blood sugar Hypoglycemia Instruction Provided Discussion/ Demonstration Assessment Returned, demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Describes: 1 Low blood sugar per IHP/Section 504 plan 2 Signs and symptoms for this child 3 Possible causes of low blood sugar 4 Treatment of mild, moderate, and severe low blood sugar

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High blood sugar Hyperglycemia Instruction Provided
Discussion/ Demonstration Assessment Returned, demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Describes: 1 High blood sugar per IHP/Section 504 plan 2 Signs and symptoms for this child 3 Possible causes of high blood sugar 4 Treatment of high blood sugar, and when to test for ketones Ketone Testing Instruction Provided Discussion/ Demonstration Assessment Returned, demonstration, or verbalized understanding

Learning Objectives/Content

Comments

Identifies Supplies: Ketone test strips properly stored and dated, containers to collect urine, watch/clock for timing Describes: 1 When to test 2 Test procedure Identifies that color blindness, especially in males, will interfere with test interpretation Date of instruction:______________ Childs Name:_______________________________ Childs Date of Birth:__________________________ I have received training and understand what has been taught This instruction is valid for ____________, unless changes have been made in the childs regimen PDA:___________________________ Instructor:__________________________________

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Appendix W

APPENDIX W
RESOURCES: PRODUCTS Below is a list of companies categorized by products Please refer to the following pages for the phone numbers and Web sites of the various companies This list of products is not meant to be any type of endorsement or to be all-inclusive Every attempt has been made to assure accuracy at time of press Most product packaging includes the 1/800 number and these numbers should be called for questions or information INSULIN DELIVERY Insulin Aventis Pharmaceuticals Eli Lilly and Company Novo-Nordisk Pharmaceuticals, Inc Syringes Abbott Laboratories Becton-Dickinson UltiMed, Inc Insulin Pens and Pen Needles Disetronic Medical Systems Eli Lilly and Company Owen Mumford, Inc Becton-Dickinson Novo Nordisk Pharmaceuticals, Inc Insulin Pumps Animas Corporation Dana Diabecare USA Deltec Corporation Disetronic Medical Systems, Inc Medtronic Minimed BLOOD GLUCOSE SUGAR MONITORS Abbott Laboratories Bayer Corp, Diagnostics Division Home Diagnostics, Inc Hypoguard Lifescan, Inc Quest Star Medical, Inc Roche Diagnostics Smith Medical MD,Inc Therasense
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Abbott Laboratories 100 Abbott Park Road Abbott Park, IL 60064-6048
1/800-255-5162 wwwabbottdiabetescarecom Animas Corporation 200 Lawrence Drive West Chester, PA 19380 1/877-937-7867 wwwanimascorpcom Aventis Pharmaceuticals 300 Somerset Corporate Blvd PO Box 6977 Bridgewater, NJ 08807-0977 1/800-981-2491 wwwaventiscom Bayer Corporation Diagnostics Division 511 Benedict Avenue Tarrytown, NY 10591 1/800-348-8100 wwwascensiacom Becton-Dickinson One Becton Drive Franklin Lakes, NJ 07417-1883 1/800-BD-CARES wwwBDdiabetescom Dana Diabecare USA 541 Julia Street New Orleans, LA 70130 1/866-342-2322 wwwtheinsulinpumpcom Disetronic Medical Systems, Inc 11800 Exit 5 Parkway Fishers, IN 46038 1/800-280-7801 wwwDisetronic-USAcom

Eli Lilly Lilly Corporate Center Indianapolis, IN 46285 1/800-545-5979 wwwlillydiabetescom Home Diagnostics, Inc 2400 North West 55th Court Ft Lauderdale, FL 33309 1/800-342-7226 wwwthesmartchoicecom Hypoguard USA, Inc One Corporate Center IV 7301 Ohms Lane Edina, MN 55439 1/800-818-8877 wwwhypoguardcom Lifescan, Inc 1000 Gibraltor Drive Milpitas, CA 95035-6312 1/800-227-8862 wwwlifescancom Medtronic Minimed 18000 Devonshire Street Northridge, CA 91325 1/800-Mini Med wwwMiniMedcom Novo Nordisk Pharmaceuticals, Inc 100 College Road
West Princeton, NJ 08540 1/800-727-6500 wwwnovonordiskcom Owen Mumford, Inc 1755-A West Oaks Commons Court Marietta, GA 30062 1/800-421/6936 wwwowenmumfordcom

Quest Star Medical, Inc 10180 Viking Drive Eden Prairie, MN 55344 1/800-525-6718 wwwqueststarmedicalcom Roche Diagnostics 9115 Hague Road PO Box 50457 Indianapolis, IN 46250-0457 1/800-858-8072 wwwrochecom wwwaccu-chekcom Smith Medical MD, Inc 1265 Grey Fox Road St Paul, MN 55112 1/800-826-9703 wwwcozmorecom Therasense 1360 South Loop Road Alameda, CA 94502 1/888-522-5226 wwwtherasensecom Ultimed, Inc 287 East Sixth Street St Paul, MN 55101 1/877-ULTIMED wwwdiabetes-carecom

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Appendix X

APPENDIX X RESOURCES For questions or concerns regarding this document and school health services: Gayle Thronson, RN, MEd Health Services Program Supervisor Office of Superintendent of Public Instruction Old Capital Building PO Box 47200 Olympia, WA 98504-7200 360/725-6040 Email: gthronson@ospiwednetedu Web site: wwwk12waus For questions or concerns regarding nursing practice: Washington State Nursing Care Quality Assurance Commission PO Box 47864 Olympia, WA 98504 360/236-4725
https://fortresswagov/doh/hpqa1/HPS6/Nursing/defaulthtm For questions on diabetes, treatment, support groups, and programs: American Diabetes Association ADA Seattle Area Office 557 Roy Street, Lower Level Seattle, WA 98109 1/800-628-8808 http://wwwdiabetesorg/homejsp Juvenile Diabetes Research Foundation 1200 Sixth Avenue, Suite 605 Seattle, WA 98101 1/800-925-5533 http://wwwjdrforg/ Washington Association of Diabetes Educators WADE 206/282-4616, ext 50 http://wwwwadepageorg/ Additional resources: Staff Model for the Delivery of School Health Services http://wwwk12waus/HealthServices/publicationsaspx A Parent Educator Guide to Free Appropriate Public Education under section 504 of the Rehabilitation Act of 1973 http://wwwk12waus/HealthServices/resourcesaspx Family/Educator Guide, Washington State Special Education Services http://wwwk12waus/SpecialEd/publicationsaspx

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A Parent Educator Guide to Free Appropriate Public Education under section 504 of the Rehabilitation Act of 1973: Puget Sound Educational Service District, November 2002 Taking Diabetes to School: Training Nurses, Teachers, Administrators, and Support
Staff How to Care for a Child With Diabetes at School, Woodinville Pediatrics, 1999–Video Available to check out through OSPI, Health Services To order a copy you may call 425/483-5437 Helping the Student with Diabetes Succeed: A Guide for School Personnel A joint program of the National Institutes of Health and Centers for Disease Control and Prevention US Department of Health and Human Services, June 2003 Available online at: wwwndepnihgov/resources/schoolhtm

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