Diabetes Awareness, Training, and Action

 Program Developed by:Wake Forest Baptist Hospital Diabetes Care Center

&American Diabetes Association

&Nursing Education Department

Eastern Area Health Education CenterPart of the North Carolina AHEC Program

 

This Program is Supported by:

Training Curriculum

This training curriculum was originallydeveloped for the North Carolina Public SchoolSystem in response to the NC Session Law 2002

103, Care of School Children with Diabetes.

This version will serve as an update to version 2.0 whichwas developed in 2005

Review of the 2008 Diabetes School Bill Data Collection Survey

2003 State Board Guidelines

• An individualized diabetes care plan be developed by the parent/guardian, the child’s diabetes care team

• At least two school personnel be intensively trained in schools where students with diabetes are enrolled to provide direct care for students

• All staff be trained in generalized care (recognizing highs and lows) regarding diabetes

2003 State Board Guidelines

• Children have immediate access to diabetes supplies at all times, including glucagon

• Children be allowed to monitor their blood sugar anywhere in school or during any school activity

2003 State Board Guidelines

• Children be allowed to eat a snack anywhere, including the classroom and school bus, to prevent or treat hypoglycemia

• Children be allowed to use the restroom and have access to fluids as necessary

2003 Training Results

2008 Data Collection Survey

• Survey developed in cooperation with the State Board of Education

• State Board Chair sent to all 115 Local Education Agencies

• State Board Liaison sent to more than 2500 Principals/Directors

• Regional school nurse consultants worked with school nurses to improve response rate

2008 School Bill Data Collection Survey Response Rates

Survey Results

• 93.2% had an identified diabetes care manager, and 82% conduct annual staff training

• Need for better communication between schools, parents, providers

• 43% response rate

Overview of Senate Bill 911“Care of School Children

with Diabetes Law”

Overview of Senate Bill 911

• Procedures for the development of diabetes care plans when requested by the parent

• Procedures for regular review of the plan

Diabetes Care Plans Should Include:

• Responsibilities and staff development for teachers and other school personnel

• Development of an emergency care plan

• Identification of allowable actions to be taken

• Extent of student participation in care plan

Local Boards of Education Responsibilities

• Ensure that guidelines are implemented in all schools which have students with diabetes enrolled

• Provide necessary information and resources for staff development to support diabetes care plan requirements

State Board of Education

• North Carolina State Board of Education delivered a progress report to the General Assembly in September 2003

• Original guidelines were implemented at the start of the 2003-2004 school year

• Guidelines were updated in 2005

G.S. 115C-375.3

• House Bill 496 states that local boards of education shall ensure that guidelines for the development and implementation of individual diabetes care plans are followed. Local boards are to make available necessary information and staff development in order to support and assist students with diabetes in accordance with their individual diabetes care plans.

Forms to Facilitate Diabetes Care

• Diabetes Care Plan Request

• Diabetes Care Plan

• Responsibilities of Parent and School

• Quick Reference Plan

American Diabetes Association (ADA) Recommendations

• Guidelines for diabetes care adopted in every school in North Carolina must meet or exceed the recommendations of the ADA

Diabetes Care Plan…Who Should be Involved?

• Medical Care Provider

• Parent/Family Member

• School Personnel

Federal Acts

• Diabetes is considered a disability and is covered under the following Federal Acts:

– Section 504 of the Rehabilitation Act of 1973

– Individuals with Disabilities Act of 1991

– Americans with Disabilities Act

504 Plans…Required?

• A 504 Plan MAY be written but is not required

– Base decision on how the management of a student’s diabetes impacts his/her ability to learn

No Child Shall Be Discriminated Against For Having Diabetes!

Senate Bill 738Signed into Law on August 28, 2009

• Requires

– All North Carolina Charter Schools to comply with The Care of School Children with Diabetes Act

– Local Boards of Education and Board of Directors of Charter Schools to report to the State Board of Education their compliance with “Care of School Children with Diabetes Act” and whether or not they have enrolled students with diabetes

Senate Bill 738 Continued

• Reporting due by August 15

• Reporting done annually

Annual School Nurse Report

• 2009-2010 school year report will include four additional questions on diabetes

• These questions will collect the necessary reporting data for LEAs and Charter Schools

• Reporting this collected data to the SBE will meet the SB 738 reporting requirement

Reporting Back

• Who is responsible?– Local Boards of Education– Boards of Directors of Charter Schools

• Who to report to?– Paula Hudson Collins, Senior Policy Advisor for

Healthy Responsible Students, State Board of Education Office

Training Materials

• Include the original templates and forms for compliance

• Background and all necessary information on all aspects of SB 911 and SB 738

 Diabetes Overview

Diabetes Defined:

“Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia (high blood sugar) resulting from defects in insulin secretion, insulin action, or both.” (Diabetes

Care, Supplement 1, 26:1, January, 2003, p. S5)

Diabetes Overview continued…

• Insulin is a hormone produced in the beta or islet cells of the pancreas.

• In order for glucose or sugar to be used as energy, it must be transported by insulin.

• Glucose is necessary to keep the cells in the body healthy.

Diabetes Overview continued…

Type 1:

• Has been called Juvenile-Onset or Insulin Dependent Diabetes in the past.

• Results from the autoimmune destruction of the beta or islet cells of the pancreas which produce the hormone, insulin.

• Insulin is required for glucose metabolism (using blood sugar for fuel in the cells).

• A person cannot live without insulin.

Diabetes Overview continued…

Type 2:

• Has been called Adult-Onset or Non-Insulin-Dependent Diabetes.

• Characterized by insulin resistance that develops into relative insulin deficiency.

• Central abdominal obesity is directly related to insulin resistance.

• Type 2 diabetes is a fast-growing epidemic in our young population.

• Type 2 diabetes is related to family history of diabetes, weight gain, and sedentary lifestyle.

Diabetes Overview continued…

• Insulin resistance means that insulin is produced, but the body is not using it correctly.

• This resistance causes the blood sugar to rise; thus, type 2 diabetes develops.

• Insulin resistance is also related to the shape of the body.

• An apple-shaped body is more resistant than a pear-shaped body.

Diabetes Overview continued…• Reasons for Control: Diabetes is

– the 7th leading cause of death in the United States.

– the major cause of blindness, nontraumatic amputations, and kidney failure leading to dialysis and the need for a kidney transplant.

– a major cause of heart attacks and strokes.– a possible cause of lack of normal growth and

development if not controlled prior to puberty.

Diabetes Overview continued…

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

• Effective diabetes management is needed to prevent the immediate dangers of blood glucose levels that are too high or too low.

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

Diabetes Overview continued…

• Diabetes management means monitoring or checking blood glucose levels throughout the day.

• Planning for events outside the usual school day is very important.

• Dealing with the emotional and social aspects of living with diabetes is a key element to effective management.

Diabetes Overview continued…

The Good News:

The “Diabetes Control And Complications Trial”(DCCT) of 1993, clearly demonstrated that goodDiabetes control with blood glucose readingsclose to normal, prevents and postpones diabetescomplications. The results of this study changedthe direction of diabetes treatment to moreaggressive care for most everyone with diabetes.

Treatment Foundations:

Type 1 diabetes:

• Occurs in approximately 1:400 children (10% of the diabetes population.

• Often presents as an acute illness and results in diabetic ketoacidosis (DKA) due to lack of insulin.

• Requires insulin either by injection into subcutaneous tissue or by Intravenous (IV).

• Other routes of insulin delivery are under development.

Treatment Foundations:

• Currently, most students are taking insulin by syringe, pen device, or insulin pump.

• The insulin pump is a type of injection using a very small catheter under the skin.

Treatment Foundations:

• The amount of insulin taken has to be balanced with food intake (specifically carbohydrates) and physical activity.

• The outcome of all this is measured by self-monitoring of blood sugar and keeping a written log or computer

program.

• Ketone testing is also necessary when the blood sugar is very high or if the child complains of a stomach ache.

Treatment Foundations:

Type 2 diabetes: • Most often occurs in the adult population.• Accounts for 90% of the diabetes population in the

world. • Is a rising epidemic in the young obese person. • Can be present for months or years before diagnosis. • Has as a goal to develop and maintain a healthy lifestyle

involving physical activity and weight loss. • Usually improves with weight loss which decreases

insulin resistance. • May require medication if diet and exercise don’t

improve blood sugars.

Necessary Tools for Diabetes Management

• Self-Monitoring of Blood Sugar:– Is important for anyone with diabetes.– Currently is done by placing a very small

drop of blood on a test strip in a blood glucose meter.

– Takes from 5-45 seconds, depending on the meter.

– Should be recorded in the child’s log book as well as school log.

Blood Sugar Monitoring

• If you need to assist a child with blood sugar monitoring, please follow these steps:

– Make sure the child’s hands are warm, clean, and dry. (Hand washing is fine, alcohol to prep the finger is not necessary.)

– Use exam gloves to cover your hands. (Universal Precautions.)– Set up the meter with the test strip. (Most meters today turn on when

you place the strip in.)– Make sure the meter is coded for the test strip used.– Insert the lancet into the lancing device and pull it back to cock.

Necessary Tools Continued…

Blood Sugar Monitoring continued…

• Prick the fleshy part on the side of the fingertip (may use any finger.)

• Gently squeeze to get a small drop of blood and add to the test strip.

• The meter will automatically begin counting down and then read the sample.

• If you did not get enough blood on the strip, often the meter will read “Error” and you will need to repeat the test.

• Please note: One lancet can be used for the entire day as long as no one other than the student uses it or it becomes otherwise contaminated.

Blood Sugar Monitoring continued…

• If the school has a meter that is kept in the office for various students to use, the following must be addressed:

• How often are control tests done to verify accuracy?

• Single-Use Only lancets must be available.• Who takes care of replacing the sharps container

when needed?• Who is assigned to clean the meter and check

supplies?• The meter must be approved for multi- person use.

Necessary Tools continued…

• Carbohydrate Counting and the Meal Plan– Students with Type 1 diabetes may practice carb

counting in order to balance insulin with food and activity.

– Students with Type 2 diabetes may also use carb counting as a way to regulate their carb intake which is also a weight management strategy.

– Every person with diabetes should undergo Medical Nutrition Therapy (MNT) with a Registered Dietitian or receive Diabetes Self Management Education (DSME) with a Certified Diabetes Educator (CDE).

“Learn to Make Healthy Food Choices”

Insulin Action and Administration

• Most students take at least two injections of insulin a day.

• Some students are on intensive insulin therapy or wear the insulin pump.

• A combination of different insulins is most often used.

• It is important to remember that insulins have different “peak” times. These are times when insulin is working hardest to lower blood sugar.

What is an insulin pump?• A battery operated device about the size of a pager

Insulin Action

• Insulin types are categorized as rapid-acting, fast-acting, intermediate-acting, long-acting or basal.

• Each type has a different onset, peak and duration.

Rapid -Acting

Fast- Acting

Intermediate-Acting

Basal

Insulin Action

Insulin Administration

• After carefully drawing up the correct amount of insulin, cleanse the injection site with an alcohol swab and wait for it to dry.

• For most students, a short-needle syringe is used.

• Insulin should be administered in subcutaneous (or fatty) tissue under the skin. This tissue is approximately the depth of the short needle when injected at a ninety degree angle.

Insulin Administration Continued…

• After pushing the plunger on the syringe, count slowly to five and remove the needle.

• Do not massage the area of the injection.

• If the needle on the syringe is one of the longer needles, the angle of insertion should be approximately 45 degrees.

• Injection sites are the outer area of the upper arm, abdomen, outer aspect of the thigh, or upper outer quadrant of the buttock.

Calculation

(Current Blood Sugar) – (Target Blood Sugar) = 

the dose to be given to correct

Insulin sensitivity factor – a high blood sugar

Carb Counting, Insulin to Carb Ratios

• Many students are now using an algorithm instead of a sliding scale for an elevated blood sugar.

• For example, a student with a blood sugar of 347 may have a correction algorithm of BG-120/55. To determine the correct amount for administration using this formula, subtract 120 (the target blood sugar) from 347 (BG) and divide the product by 55 (insulin sensitivity—one unit will lower the blood sugar by this amount). 347-120 = 227 ÷ 55 = 4.1 units of insulin to correct the blood sugar to the target of 120.

Insulin to Carb Ratio

• In an effort to match insulin to carbohydrate eaten, an insulin to carb ratio is developed.

• Example: Haley is planning to have 57 grams of carb at lunch. Her established ratio is one unit of insulin for every 8 grams. 57 ÷ 8 = 7.1 (If given by syringe, this amount would be rounded to 7 units.)

Combining the Two

• In order to correctly determine the amount of insulin needed before a meal, it is necessary to add the amount to cover the carbs to the amount to return the blood glucose to target. In our examples just given, the two amounts ( 4.1 units and 7 units) would be added for a total injection amount of 11 units of insulin.

Insulin to Carb Ratios and the Insulin Pump

• Most insulin pumps today are far more sophisticated than those of only three to four years ago.

• Pumps are able to calculate the amount of insulin needed by the student when the blood glucose and grams of carb are programmed into the pump.

• The ratios and correction calculations are pre-programmed into the pump so that calculations are done by a mini computer contained in the pump. Counting grams of carbohydrate is very important for successful application of pump therapy.

• Dosages are capable of being given in micro amounts.

Oral Meds for Kids With Type 2 Diabetes

• The preferred method of treating Type 2 diabetes in young people is through physical activity and healthy food choices.

• Most often, Type 2 diabetes requires the child to eat a certain amount of carbohydrate at each meal.

• Oral medications would be an option if Type 2 diabetes is not controlled with the measures mentioned above.

Oral Meds

• The most frequently used medication for increasing insulin sensitivity in Type 2 diabetes in kids is metformin or Glucophage™.

• Metformin works by preventing the liver from releasing glucose into the system and does not cause low blood sugars or promote weight gain.

Oral Meds

• It is important to note that some kids with Type 2 diabetes may at times require insulin. This does not indicate worsening of their diabetes.

• Taking insulin does not mean this student has Type 1 diabetes.

• The regimen will vary according to the needs of the child.

Acute Complications of Diabetes

• Hyperglycemia – (High Blood Sugar)

• Hypoglycemia – (Low Blood Sugar)

High Blood Sugar

“Hyperglycemia”

Hyperglycemia

• High blood glucose (hyperglycemia) occurs when the body gets too little insulin, too much food, or too little exercise.

• Hyperglycemia may also occur when a child has an illness such as a cold.

• Hyperglycemia may occur when a child is under extreme stress.

Definition: High Blood Sugar

• Target Blood Sugar

– <6 years: 100-160 mg/dL pre-meal and bedtime

– 6-12 years: 80-160 mg/dL pre-meal and bedtime

– >12 years: 80-140 mg/dL pre-meal; <160 mg/dL 2 hours after start of meal

Definition: High Blood Sugar

• Most health professionals view a blood sugar greater than 240 as “hyperglycemia.”

Signs & Symptoms of Hyperglycemia

• Frequent Urination• Extreme Hunger• Extreme Fatigue• Unusual Thirst• Irritability• Blurred Vision

High Blood Sugar“Hyperglycemia”

• For the school age child, a blood sugar greater than 240 mg/dL requires an additional check half an hour later. Two consecutive blood sugars greater than 240 mg/dL requires ketone testing.

• A single blood sugar greater than 300 mg/dL requires ketone testing.

• Insulin injections for high blood sugar should be given according to the student’s IHP or Diabetes Care Plan.

Ketostix®

• Directions must be followed exactly.– Dip reagent end of strip in FRESH urine and

remove immediately.– Draw the edge of strip against rim to remove

excess urine.– Exactly 15 seconds later, compare to color chart.

Negative Trace Small Moderate LARGE

If a student’s ketone level is greater than “trace” but less than “large”, refer to that student’s IHP for information on steps to take to prevent Diabetic Ketoacidosis. This plan usually requires administration of insulin and drinking lots of water.

• In the event of moderate to large ketones, treat as an emergency situationaccording to the student’s IHP.

• In all cases of high blood sugar, if the student is able, he should drink calorie-free, caffeine-free liquids such as water.

• If the student is unable to drink liquids because of nausea or vomiting, you should seek medical attention immediately according to the student’s IHP.

Diabetic Ketoacidosis-DKA

If untreated over a period of time, high blood sugar can cause a serious condition called

“diabetic ketoacidosis” (DKA.)

DKA is characterized by nausea, vomiting, and a high level of ketones in the blood and urine.

Diabetic Ketoacidosis

• For students using insulin infusion pumps, lack of insulin supply may lead to DKA more rapidly.

• Insulin infusion pumps use only rapid acting insulin.

• Lack of insulin causes the breakdown of body fat for energy which releases “ketones” into the bloodstream.

Diabetic Ketoacidosis

• Ketones in the bloodstream cause the pH of the blood and body fluids to be lower and more acidic.

• DKA can be life-threatening and thus requires immediate medical attention.

• IV fluids and an insulin drip along with hospital admission are necessary in severe cases of DKA.

Low Blood Sugar

“Hypoglycemia”

What Is Hypoglycemia or Low Blood Sugar?

• Sometimes called an insulin reaction• Occurs when blood sugar is below the target

range (under 70-80)• Can be caused by too much insulin, unplanned

increased activity, eating too few carbohydrates

• Happens when the body does not have enough sugar in the blood

Lows Happen When Insulin and Blood Sugar Are Out of Balance.

• People without diabetes do not usually get hypoglycemia.

• When we have enough insulin our body stops releasing insulin automatically.

• But, people with diabetes have to figure out how much insulin their bodies will need.

• Low blood glucose levels, which can be life-threatening, present the greatest immediate danger to people with diabetes.

Signs and Symptoms of Low Blood Sugar

Hunger Shakiness Dizziness Sweating

Fast heartbeat Drowsiness

Feeling irritable, sad or angry Nervousness

Pallor

More Signs and Symptoms of Low Blood Sugars

• Feeling sleepy• Being stubborn• Lack of coordination• Tingling or numbness of the tongue• Personality change• Passing out• Seizure

Recognizing Low Blood Sugar

• It is important to recognize a low blood sugar as soon as possible so that it does not progress to a severe reaction.

• Early signs are caused by the release of the hormone epinephrine.

• Our bodies make this hormone when we are excited or stressed.

Frequent Causes of Low Blood Sugar

• Meals that are late or missed

• Extra exercise or activity

• An insulin dose which is too high

• Unplanned changes in school schedule

What To Do When Hypoglycemia Occurs

• If possible always do a blood sugar check first.

• If meter is unavailable and the child feels sick, treat as a low.

• Eat or drink about 15 grams of fast-acting carbohydrate.

• Wait 15 minutes and check blood sugar.

• If blood sugar remains lower than 70 or below target for individual child, treat again.

Hypoglycemia Busters

• 2-4 glucose tablets• 4 ounces of juice• 4-6 ounces of regular

soda• 2 tablespoons of

raisins

• 3-4 teaspoons of sugar or syrup

• 1 cup of low fat milk• 1 tube of cake gel

Catch Low Blood Sugar Early

• Be alert for any symptoms and times when a low blood sugar is likely to occur.

• Check blood sugar if there is any doubt.

• Fast acting carbohydrate or sugar should always be available.

• Treat low blood sugar promptly or it can turn into severe hypoglycemia.

Treating Severe Hypoglycemia

• When severe hypoglycemia occurs, not enough sugar is in the brain.

• The student may lose consciousness and/or have convulsions.

• At this time the student will need the assistance of someone else.

What Happens when the Child is Unconscious?

• Drinking soda or eating glucose tablets is not possible and would be dangerous when the child is unconscious.

• Glucagon injection may then be necessary.

• Glucagon is a substance or hormone that makes the liver release sugar into the blood stream.

Using Glucagon

• Glucagon should be administered promptly if the person is unable to swallow, loses consciousness or becomes combative. Call 9-1-1.

• Glucagon can be stored at room temperature. • Glucagon comes in a bottle and needs to be mixed

with a diluting solution immediately before using.• Glucagon is injected into the front of the thigh or

upper arm muscle.

In order for school staff to use Glucagon, orders for its use must be included on the child’s IHP or

Diabetes Care Plan and staff must be specifically trained in its administration

Safety and Fairness for Children with Diabetes

Our Mission

• Ensure that all children with diabetes are medically safe at school

• Children with diabetes have the same educational opportunities as their classmates.

Statement of Principles

• All staff members who have responsibility for a child with diabetes should receive diabetes training

• The school nurse holds the primary role but a small group of staff members should receive training as well

• Students possessing the necessary skills and maturity to do so should be permitted to self-manage

What we’re doing Locally!

• Safe at School – DATA Trainings• Safe at School Superstars Program• Parent Workshops• School Walk for Diabetes

Safe at School – DATA Trainings

• Ongoing follow up• ADA as a resource• Establishment of a partnership

Safe at School Superstars

• Will acknowledge schools in our state that are adhering to the Care of School Children with Diabetes Law by meeting/exceeding the needs of students with diabetes.

• Included in your binder– Information for Schools– Application Form

Parent Workshops

• ADA will provide an expert who will speak about diabetes care challenges and legal protections for families with school-aged children.– 2-3 events a year– Family Night – January 2010

School Walk for Diabetes

• School Walk for Diabetes is ADA's signature school-based event. It is an educational, school fund-raising program that promotes community service, school spirit and healthy living to students.

• Participants learn about diabetes and ways to prevent the disease by eating right and exercising regularly. Students raise money for diabetes research, information and advocacy.

Resources

• Safe at School CD• Safe at School Brochure• Safe at School Website

– http://www.diabetes.org/advocacy-and-legalresources/discrimination/school/safeschool.jsp

• PlanetD: – http://tracker.diabetes.org/index.php

• Family Resource Network:– http://www.diabetes.org/family-link/about-family-link.jsp

Thank you for keeping children with diabetes…..

Demonstration/Skills Stations

BLOOD GLUCOSE MONITORING

• Why blood glucose is monitored

• When blood glucose should be monitored

• How to perform a blood glucose check

• Required equipment

Participants will be able to understand:

Role of the School

In accordance with DMMP:

• Facilitate blood glucose monitoring

• Act on blood glucose check results

• Document results of blood glucose monitoring when assistance or supervision is provided

• Communicate blood glucose results to parent/guardian or school nurse to monitor for trends

DMMP specifies for an individual student

Regularly scheduled checks:• Routine monitoring before meals and snacks

• Before, during and/or after physical activity

When to Check?

• Hypoglycemia or hyperglycemia symptoms

• Change in diabetes management• Periods of stress or illness• Prior to academic tests• Early or delayed release from school• Continuous Glucose Monitoring

(CGM) alarms

• Hypoglycemia or hyperglycemia symptoms

• Change in diabetes management• Periods of stress or illness• Prior to academic tests• Early or delayed release from school• Continuous Glucose Monitoring

(CGM) alarms

When to Check?

Lancing Devices

Lancets MultiClix

Pen-type Lancing Devices

Know the Meter

• Features vary:- Sample size- Wait time- Alternate-site testing capacity- Communication with other devices – pumps, continuous glucose monitors

• Become familiar with operation of meter 1-800 number on back of meter

Preparation1. Gather blood glucose

monitoring supplies: - Lancet

- Test strips

- Meter

2. Student washes hands and dries thoroughly

3. If assisting or performing for student, put on disposable gloves

Readying the Meter

4.Turn the meter on

5.Check code # (if required)

6. Insert a strip into the meter

7.Hold the lancet device to the side of the finger and press the button to stick the finger.

• Alterative site (per DMMP) the school nurse and/or parent/guardian will give further instructions which sites are appropriate

• Note: In the case of suspected hypoglycemia, only the finger should be used for blood glucose sampling

Lancing the Finger

Applying Blood to Strip8. Follow instructions included with the meter when

applying blood to strip

Some strips wick blood

onto the strip

Cover ALL of test strip window

Results

9. Wait until blood glucose results displayed

10. Dispose of lancet and strip

11. Record blood glucose results, take action per DMMP

25053

• Reference student’s target range- Individualized for student- May vary throughout day- Take action per DMMP

• Communicate sensitively

• Recognize value may vary according to time since eating, insulin, or physical activity

What Does the Number Mean?

INSULIN

• Participants will be able to understand:Where on the body to inject insulinPreparation steps for insulin pen and vial/syringe

injection

• Participants will be able to demonstrate:How to dose with an insulin pen and vial/syringeHow to inject with insulin pen and vial/syringe

Insulin Pens

• Techniques for dosing and insulin delivery are similiar for both types of pen devices: ─ Prefilled pens

─ Reusable (cartridge) pens

• Both long-acting or basal insulin and rapid-acting or bolus insulin are available in pens

• Most students will only take rapid-acting or bolus insulin in school

Where to Give Insulin:  On Target!

• Inject into fat layer under skin

• Rotate sites• Student should choose site

• Common sites: abdomen, thigh buttocks, upper arms

Insulin Pen: Preparation

1. Gather supplies. Verify insulin type─ pen device (with cartridge)─ pen needle─ alcohol wipe─ sharps container

2. Wash hands

3. Apply gloves

4. Have student chose injection site

5. Clean injection site

6. Screw on pen needle

Insulin Pen: Dosing

7. Prime: Dial “2” units. If the pen is being used for the first time, prime 4-6 units as per manufacturer’s instruction

8. Hold upright. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows at end of needle

9. Dial number of units to be administered as per DMMP

Insulin Pen: Injecting

10. Pinch up the skin

11. Push the needle into the skin at 90 12. Release pinched skin

13. Push down on the plunger

14. Count to “5”

15. Remove and dispose of pen needle

16. Document time, dose, site, and blood glucose value

INSULIN BY SYRINGE AND VIAL

• Insulin Syringes

• Sizes – 30, 50, 100 units

• Disposal– Do not reuse– Do not recap

Syringe & Vial: Preparation

1. Get Supplies– Insulin (Verify type of insulin) – Syringe– Alcohol wipe– Disposable gloves– Sharps container

Syringe & Vial: Preparation

2. Wash hands and apply gloves

3. Clean the insulin vial

Syringe & Vial: Preparation

4. Have student select injection site

5. Clean the injection site

Syringe & Vial: Preparation

6. Check the insulin dose

7. Remove the cap from syringe

Syringe & Vial: Dosing

8. Pull the plunger down to number of units to be administered

9. Inject air into bottle

Dose units

Dose units

Syringe & Vial: Dosing

10. Draw out prescribed number of units of insulin as per DMMP

Check Dose

Syringe & Vial: Injecting11. Pinch up the skin12. Push needle into skin at 9013. Release pinch14. Push the plunger in15. Count to “5”16. Remove needle and dispose of syringe17. Document time, dosage, site, and blood glucose

value

Glucagon Administration

Participants will be able to identify:• What glucagon is

• How glucagon should be stored

• When glucagon is used

Participants will be able to demonstrate:• How to administer glucagon

What Is Glucagon?• Naturally occurring hormone made in the

pancreas

• A life-saving,injectable hormone, Glucagon/GlucaGen that raises blood glucose level by stimulating the liver to release stored glucose

• Treatment for severe hypoglycemia

• Life-saving, cannot harm a student – cannot overdose

Glucagon or GlucaGen Kit Storage

• Place: As designated in DMMP accessible to school personnel • Store at room temperature• Expiration date: Monitor• After mixing, dispose of any unused portion within one hour

Emergency Kit Contents:

 1 mg of freeze-dried glucagon (Vial) 1 ml of water for reconstitution (Syringe)

Combine immediately before use

When to Give Glucagon/GlucaGen

If authorized by the student’s DMMP and if student exhibits:

• Unconsciousness, unresponsiveness

• Convulsions (seizures)

• Inability to safely eat or drink

Procedure: Act Immediately• If possible check blood glucose, don’t delay

• If in doubt, always treat

• Position student safely on side for comfort and protection from injury

• School nurse or trained personnel notified to give glucagon in accordance with DMMP or emergency care plan

• Call 911, parent/guardian, school nurse as per DMMP or emergency care plan

Preparation

1. Flip cap off glass vial containing dry powder

2. Remove cap from syringe

3. Put on gloves if available

Mixing Solution

4. Inject entire fluid in syringe into the bottle containing powder

5. Shake gently or roll to mix until all powder is dissolved and solution is clear

Dosing and Drawing Out

6. Inspect. Solution should be clear and colorless

7. Draw prescribed amount of glucagon back into syringe

Injecting

7. Clean site if possible

8. Inject at 90° into the tissue of cleansed area (may administer through clothing if necessary)

• buttocks • thigh• arm

After Injecting

9. May take 10-20 minutes for student to regain consciousness

10. Check blood glucose

11. Give sips of fruit juice or regular soda, once student is awake and able to drink

12. Advance diet as tolerated

13. Document as per DMMP

14. Do not recap syringe. Discard sharp in appropriate container

Considerations• The time to complete recovery from a severe

hypoglycemic episode varies according to how low the blood glucose level was and for how long prior to treatment

• Some signs and symptoms, such as headache, may persist for several hours, although the blood glucose level is satisfactory

• Continued monitoring is important

• Student may need to be transported via EMS or go home with parent/guardian

Don't Be Surprised If. . .

• Student does not remember being unconscious, incoherent or has a headache

• Blood glucose becomes very high (over 200)

• Nausea or vomiting may occur

INSULIN BY PUMP

Participants will be able to understand:

• Basic types and features of insulin pumps

• What pumps do

• Essential information and skills for key school personnel who might perform or assist in entering data or delivering insulin with a pump

• Battery operated device about the size of a pager

• Reservoir filled with insulin

• Computer chip with user control of insulin delivery

• Worn 24 hours per day

• Delivers only rapid-acting insulin

What Is an Insulin Pump?

Dosing with an Insulin Pump

Insulin Pump Therapy

• Based on what body does naturally - Small amounts of insulin all the time (basal

insulin)

- Extra doses to cover each meal or snack (bolus insulin)

• Precision, micro-drop insulin delivery

• Flexibility

• Ease of correction for high blood glucose levels

What Pumps Do

“Bells and Whistles”• Many pumps will calculate bolus dosages• Some pumps communicate with blood glucose

meters, or continuous glucose monitors

• Tracking active insulin• Temporary basal rates

Limitations:• Pumps rely on input from humans to calculate

dosing; the user can override pump-calculated doses

What Key Personnel Need to Know About an Insulin Pump

• How to deliver routine boluses for carbs and high blood glucose

• Signs/symptoms that pump site may need to be changed

• When an injection by pen or syringe is indicated

• How to disconnect or “suspend” the pump– In the event the student becomes unconscious or seizes

– If instructed by the parent/guardian/diabetes care provider (i.e. during P.E.)

Sampling of Pumps

Pump Supplies at School• Infusion set• Reservoir• Insulin• Skin prep items• Alcohol wipes• Syringe (in case of malfunction)• Pump batteries• Inserter (if used)• Manufacturers manual, alarm card

In cases where the pump is disconnected (for example in PE) it should be placed in a secure place as designated in the student’s written plan.In cases where the pump is disconnected (for example in PE) it should be placed in a secure place as designated in the student’s written plan.

Internet Resources

• http://www.animascorp.com/sites/default/files/lms/module_2/animas.html

• http://www.infusion-set.com/

• http://www.childrenwithdiabetes.com/pumps/

• http://www.barbaradaviscenter.org/

• http://www.diabetes.org/for-parents-and-kids.jsp

• http://www.joslin.org/1317_2667.asp

http://www.barbaradaviscenter.org/

• Understanding Insulin Pumps & Continuous Glucose Monitorsby H. Peter Chase, MD

• Barbara Davis Center for Childhood DiabetesProfessor of PediatricsUniversity of Colorado Denver

• The newest edition of Understanding Insulin Pumps & Continuous Glucose Monitors can be purchased for US$15.00 (includes postage) from the Children's Diabetes Foundation at Denver. Bulk discounts available. Please call the CDF at Denver for information on bulk discount prices. You may also download the order form in .pdf format and mail in your order with payment. Download the order form here or order online here at the CDF Web site.

• The links below lead to Adobe .pdf files. You must have Adobe Acrobat Reader version 7.0 or better to view these files (dowload here). You will NOT be able to print the .pdf files, due to copyright restrictions.

Diabetes Training Toolbox•  Diabetes DVD• Hypo/Hyper Card• Insulin Syringes• Saline Vials• Insulin Pens (saline)• Pen Needles• Injection Pads• Alcohol Swabs• Calculator• Blood Glucose Meter, Strips and Lancets• Glucagon Injection Demo• Glucagon Training DVD• Glucose Tablets• Urine Ketone Sticks with Color Chart• (Please use a sharps container to dispose of all sharps)

Additional Resource Slides

SB-911

Overview of SB 911: Care of School Children with Diabetes

• Federal & State Support and History of the Law:Diabetes is considered a disability and is covered under the

following Federal Acts:– Section 504 of the Rehabilitation Act of 1973– Individuals with Disabilities Education Act of 1991– Americans with Disabilities Act

Overview of SB 911 continued…

• State Board of Education Policy # GCS-G-006 Special Health Care Services (1995)– Shall make available a registered nurse for

assessment, care planning, and on-going evaluation of students with special health care service needs in the school setting…

Overview of SB 911 continued…

• The bill passed unanimously in the House and Senate in August, 2002 and on September 5, 2002, the bill was signed into law by Governor Easley.

Overview of SB 911 continued…

• Implications for NC Schools

– Guidelines adopted in every school in the state must meet or exceed American Diabetes Association recommendations.

Overview of SB 911 continued…

• Section 1 of SB 911– Procedures for the development of a diabetes care plan if requested

by parent– Procedures for the regular review– Included should be:

– Responsibilities and staff development for teachers and other school personnel

– Development of an emergency care plan– Identification of allowable actions to be taken– Extent of student’s participation in diabetes care

Overview of SB 911 continued…

• Section 2 of SB 911– Local Boards of Education must ensure that guidelines are

implemented in schools in which students are enrolled.– Local Boards of Education will make available necessary

information and staff development in order to support care plan requirements for students with diabetes.

– Section 3 of SB 911• The NC State Board of Education delivered a progress

report in September, 2003.– Section 4 of SB 911

• The guidelines were implemented by the beginning of the 2003-2004 school year.

• Guidelines were updated August, 2005.

Overview of SB 911 continued…

Overview of SB 911 continued…

• Please refer to your copy of the ADA Standards.

– An Individual Health Plan (IHP) should be developed by the parent/guardian, the student’s diabetes care team, and the school nurse.

– At least 2 school personnel in each school should be trained in diabetes care and emergencies. (Diabetes Care Managers/DCM)

Overview of SB 911 continued…

– Children should have immediate access to diabetes supplies and diabetes treatments as defined in the IHP.

– Roles and responsibilities of the parents/guardians and the schools are defined.

– DCM roles are also defined.

G.S. 115C-375.3April 28, 2005

• House Bill 496 states that local boards of education shall ensure that guidelines for the development and implementation of individual diabetes care plans are followed. Local boards are to make available necessary information and staff development in order to support and assist students with diabetes in accordance with their individual diabetes care plans.

Forms to Facilitate Implementation of the Law

–Diabetes Care Plan Request–Diabetes Care Plan –Responsibilities of Parent & School–Quick Reference Plan–Health Identification Form

Role of the Master Trainer(One RN and One 504 Coordinator from each Local Education Agency (LEA)

• Participate in regional intensive training sessions.

• Set up general information sessions for 504 Contact Person or other person from each LEA.

• Set up the intensive training session for the DCMs from each school in the LEA.

• Coordinate continuing education for the DCMs.

Communication- Role of Nurse• With student, parent & school staff• SB-911 Diabetes School Act• Provide forms• Provide training• Act as a resource• Continuing Education for diabetes

management

Communication

• With student and parent before school year begins

• By phone, meeting at the library, by mail

• Ask questions about self care

• Get to know the student

Communicate: Self Care

• Procedures done at school• Equipment kept at school• Diabetes care recommendations may change during

the school year • Whom to tell about having diabetes• Determine student’s level of maturity• Diet issues:

• Meals• Snacks• Emergency snacks

Communicate: Parent Responsibilities

• Phone numbers– Home, work, cell, pager

• Supplies• Snacks• School absences• Care Plan request• Care Plan• Student’s self-care capabilities• Medication forms• Diet form• Student photo• Medic alert ID

Customize: Parent Request Form

• No MD signature required• Request for Care Plan to be

implemented• Consent for release of

information• Trained staff in place• Require annual review

Communicate: Parent Responsibilities

• Student, parent or 9-1-1 may have to assume responsibility for diabetes care until the Care Plan is signed and returned.

• A new Care Plan is needed annually.• Communicate on regular basis with school

staff and bus driver either verbally or written.

Role of the DCMDiabetes Care Managers in Each School

• Participate in the Intensive training session.• Obtain certificates of course completion and

maintain documentation as proof of completion.• Participate in IHP conferences.• Have ready access to the student’s IHP.• Be readily reached in case of a diabetes emergency.

DCM Roles continued…

• Communicate with teachers/substitute teachers/student/parents/health care team as indicated or as necessary.

• Assist the student with diabetes care as indicated in the IHP.

• Be available to go with the student on field trips or to school-sponsored extracurricular activities as indicated.

• Attend continuing education sessions as needed.

Role of the 504 Contact in Each School

• Attend general information session instructed by the 504 Coordinator Master Trainer for the LEA.

• Provide a general information session for all personnel within his/her school.

• Develop communication and emergency protocol with the school administration and the DCMs.

• Attend review sessions when organized by the 504 Coordinator for their LEA.

Guidelines for PE Teacher and Coach

• Encourage exercise and participation in sports and physical activities for students with diabetes.

• Treat the student with diabetes the same as other students except to meet medical needs.

• Encourage the student to have blood glucose equipment and treatment for low blood sugar available.

• Understand and be aware that hypoglycemia can occur during and after physical activity.

• Recognize any changes in student’s behaviors which could be a symptom of a low blood sugar.

Guidelines for Bus Drivers• At the beginning of the school year, identify any students on

the bus who have diabetes. Be familiar with their IHP.• Be prepared to recognize and respond to the signs and

symptoms of a low blood sugar.• Parents should consider giving bus driver their daytime contact

numbers.• Student may carry monitor, insulin, glucagon and snacks on bus.• The student, teacher & parent should communicate with bus

driver.• Bus driver may consider carrying extra snacks in case of bus

breakdown, traffic jam, etc.

Actions for Food Service Staff or Lunchroom Monitor

• Provide a lunch menu and lunch schedule in advance to parents along with nutrition information including grams of carbohydrate and fat.

• Be aware of your students’ diabetes meal plans and snack plans.

• Treat the student with diabetes the same as other students except to respond to medical needs.

• Understand that hypoglycemia can occur before lunch.

Role of School Administration

• Work with the LEA Master Trainers to identify at least 2 school personnel to serve as the school’s DCMs.

• Provide support for DCMs to attend the intensive training session.

• Identify new DCMs as turnover occurs.

Role of School Administration continued…

• Notify the Master Trainers for the school when such turnovers occur during the school year so individual training can be planned.

• Set up communication and emergency protocols for access to DCMs.

• Support the general information sessions for staff and all school support personnel.

Liability Concerns and Issuesfor DCMs

• How do I prevent liability situations from occurring?– Be very familiar with the student’s IHP and refer

to it often.– If the student needs assistance with administering

insulin, make sure the most recent dosage schedule is available for your use.

Liability Concerns and Issues

– Remember, a vial of insulin kept at room temperature is discarded 30 days after opening. Some insulin pens must be discarded 15 days after it is first opened even if insulin remains.

– Check expiration dates on insulin and glucagon to make sure they are in date.

– Triple check yourself when drawing up a dose of insulin. Double check the student’s dose if he/she is drawing up the insulin.

Liability Concerns and Issues continued…

• What happens if there is an occurrence?

– Most incidents occur when we are in a rush. Think carefully about what you are doing and if the situation doesn’t make sense, question it!

– If an incorrect dosage is given, document the procedure you take to keep the child safe.

Liability Concerns and Issues continued…

• If you give too much insulin– Notify the student’s health care team to let them

know. They may have special instructions for this situation.

– Test blood sugar more frequently or according to the Individual Diabetes Care Plan for the rest of the school day.

– Notify the parent/guardian of the procedure you have taken.

– Make sure the child has extra food/juice to consume.

– Alert the teacher.

Liability Concerns and Issues continued…

– If you give too little insulin, an additional shot can be given to make up the missed amount if you discover the mistake quickly. Document your actions.

» Quickly – within 15 minutes – If the child refuses the extra shot, document the

occurrence and notify the parent .– Generally there is not much you can do if insulin

leaks at the site. Blood sugars may run a little higher that day.

– If insulin leaks are a common problem, take a little more time with the injection and count 10 seconds before withdrawing the needle.

Liability Concerns and Issues continued…

• But how am I protected from litigation?

– The State of NC now has SB911 in place with directives for adoption by all public schools in the state.

– Many State Agencies have organized this training program.– You are now going through the training and will receive a

certificate of completion once the training has satisfactorily been completed.

– You will maintain up to date knowledge through continuing education.

– You will have resources to call upon if questions or problems arise.

Liability Concerns and Issues continued…

• Do I have any other protections?

– NC General Statute 90-21.14 adopted in 1975:• Provides immunity for rescuers.• Provides immunity for acquirers and enablers.• Encourages/requires CPR & AED training.

– G.S. 115-C-375.1

This is the “Good Samaritan Law”

Liability Concerns and Issues Continued…

• So what needs to happen in my school?

– You as DCM, should be known by administration and staff throughout the school. Communication is essential.

– You should make sure an emergency communication protocol is set up and is followed.

– You should have easy access to the child’s IHP and be included in any IHP conferences or revisions.

• You should be notified when special events or conferences occur for the child in order to include this in your schedule.

Liability Concerns and Issues continued…

• So what about sharps, blood, carrying medication around the school?

– Self-monitoring of blood sugar should be supported. – The lancet should not be removed from the lancing

device.– Insulin pumps cannot be removed except to quick

release in certain instances. – Students injecting insulin with pens or syringes should

be provided a safe place for injecting.– Students using insulin pens are to discard their used pen

needles in an approved sharps container.– Insulin pens should not be carried with needles

attached.

Continued

– Glucose Tabs are not medication.– Other discipline problems should not interfere with the

self-management rights of the student with diabetes.