Diabetes Training GuidelinesHelping the Keene ISD Diabetic Student Succeed

Updated 2017Developed by Keller ISD

Edited by EMS ISDShared with Keene ISD

Used by Permission

Keene ISD Diabetes Contact Information

Kathy M. Coker, RNBelinda Chacon, LVN

Keene ISD Health Services817-774-5327

Diabetes is a chronic disease (endocrine disorder) in which the body (pancreas) does not make or properly use insulin, a hormone needed to convert sugar, starches, and other food into energy.

The pancreas is a gland that produces insulin for glucose (sugar) absorption. Without insulin, glucose remains in the bloodstream and causes elevated glucose values; glucose values that are not in the normal range can cause damage to major organs and blood vessels.

HB 984, passed in 2005, requires that in each school in which a student with diabetes is enrolled, the school principal shall:

▶ seek school employees who are not health care professionals to serve as unlicensed diabetes care assistants (UDCAs) to care for students with diabetes, and

▶ make efforts to ensure that the school has at least 1 UDCA if a full-time RN is assigned to the school, and at least 3 UDCAs if a full-time RN is not assigned to the school.

▶ HB amended Subtitle H, Title 2, Texas Health and Safety Code by adding chapter 168. The Texas Health and Safety Code does not require that all schools have a school nurse assigned to a campus.

House Bill 984

Parents cannot be required to come to school to care for their student with diabetes.

Chapter 168 requires schools to have trained staff available to care for students with diabetes.

The Health and Safety Code does not require that a student go to the nurses’ office to care for his/her condition. If the IHP specifies that a student with diabetes go to the nurse’s office, and the parents agree, then that is permissible. However, a student that self-manages his/her care (according to physician, parent and IHP) cannot be required to go to the nurse’s office to have a snack, administer insulin, or check blood glucose values.

•Diabetes cannot be cured, only managed.•In Diabetes, the blood sugar can either be too low or too high. Therefore, diabetics must carefully balance food, medications and activity levels to keep blood sugar level as close to normal as possible.•It is not possible to look at a person with diabetes and tell that they have the disease. The disease is diagnosed by a blood test.

Type 1● Most common type in

school-age children● Pancreas does not

produce/secrete insulin properly

● Must receive insulin through injections or pump

● Diagnosed at any age, but mostly before age 19

Type 2● Body does not secrete

enough insulin or use insulin properly

● May be managed with diet and exercise

● Injections/oral meds may be required

Gestational Diabetes● Diagnosed during

pregnancy

Types of Diabetes (3 Types)

What is effective diabetic management?

Diabetes Management means monitoring or checking blood glucose levels throughout the day, following an Individualized Health Plan (IHP), getting regular physical activity and administering insulin and/or medications to help keep blood glucose levels in the target range. Diabetics must also follow a regular eating plan and see a healthcare provider routinely.

Every student with diabetes will have an IHP developed by a Registered Nurse (RN) from information obtained from the parent/guardian and physician.

▶ Be as healthy as possible▶ Avoid complications associated with diabetes▶ Fully participate in all academic and extracurricular

activities▶ Keep blood glucose levels within an acceptable range

Goal of Diabetes Management

Collaboration, cooperation and planning arekey elements in developing and implementingsuccessful diabetes management.

It is the responsibility of the nurse, student and teacher to ensure testing and medications are done on time.

School Health Team

▶ A list of all of the medicines the student is to take while at school

▶ A schedule of when medicines are to be administered▶ Doses of medicines that will be taken at school▶ Ranges of glucose values and steps to take when the values

are out of range▶ When and how often the student is to have snacks▶ Name and phone number of treating physician▶ Additional information as required

Individual Healthcare Plan (IHP)

▶ If the IHP specifies, the student shall be permitted to attend to his/her own care in the classroom or at any school sponsored activity.

▶ Student must have free access to water and restroom.

▶ The student may require a quick acting sugar to be available at all times.

▶ Some students will have an insulin pump- which automatically administers calculated amounts of insulin.

What could diabetes management involve?

Caused when the body gets too much insulin, too little food, a delayed meal, or more exercise than usual

Symptoms:-Shaky-Dizzy-Sweaty-Hungry-Pale-Headache-Irritable-Confused-Weak-Changed personality-Inability to

concentrate

Hypoglycemia(Low Blood Sugar)

Hypoglycemia can cause unconsciousness or seizures and must be treated per student’s IHP.

Hypoglycemia, which cannot be prevented, is the greatest immediate danger to students with diabetes.

▶ There are many things to do before a person’s blood sugar gets so low that they become unconscious….

▶ However, it could be the case that a student does not realize their own symptoms of low blood sugar and are found in a bathroom or on the playground unconscious or seizing.

▶ While there are physical symptoms of hypoglycemia, the only way to definitely know if a student has mild to moderate hypoglycemia is to test the blood glucose.

Important Facts

Mild/Moderate Symptoms: -Check Blood Sugar-Treat according to IHP, which could include any of the following: 15 grams

of carbohydrate (such as 4 oz juice, 6 oz regular soda, or 3 glucose tablets)-Check blood sugar in 15 min and repeat treatment per IHP-Can administer glucose gel if student unable to chew

Severe Symptoms: (unconscious, unresponsive, unable to swallow) -Position student on his/her side-Contact the school nurse or trained diabetic personnel-Administer glucagon, as prescribed-Call 911-Call parents/guardian

How To Treat Hypoglycemia

What is Glucose gel?-Glucose gel is a small tube of what looks like cake icing.-The gel is readily absorbed in the mucous membranes.-This will help to raise the blood sugar.

How to use Glucose gel:-Put on gloves-Squeeze two inches of gel into the mouth, between the cheek

and gums-Rub the outside of the cheek to help the gel absorb -Retest the BS in 10 min and follow the student’s IHP

Glucose Gel

Glucagon is a hormone that raises blood glucose levels by causing the release of glycogen (a form of stored carbohydrate) from the liver.

It is administered in an emergency situation such as when the student’s blood glucose level gets so low that the student passes out, experiences seizures, or cannot swallow.

-Should be supplied by parent-Glucagon can be stored at room temperature-Located in the nurse’s office unless otherwise specified.

-Comes in an individual case for each diabetic student.-The medication is pre-measured-Administer as prescribed by physician-The directions for giving the shot are right there for

you to review!-It comes in a powder form that must be mixed.

Glucagon

Glucagon Emergency Kit

*DESIGNATE SOMEONE TO CALL 911*

1. Prepare the Glucagon -Remove vial cap -Remove needle cover -Inject contents of syringe into vial (held upright) -Remove needle from vial. Handle safely. -Swirl vial gently until dissolved and clear

Glucagon Administration

2. Syringe Preparation -Once solution is clear: Hold vial upside down and

withdraw all solution into syringe. Remove needle. -Hold syringe upright and tap gently to remove air

bubbles.

3. Clean the Skin -Expose injection site (upper, outer area of arm or

thigh) -Hold syringe safely, use other hand to clean injection

site with alcohol

Glucagon Administration continued:

4. Inject the Glucagon -“Pinch up” skin/muscle -Insert needle straight into skin/muscle of arm or

thigh -Push plunger in to inject Glucagon5. Removal of Syringe -Remove syringe while pressing gently with alcohol

wipe or cotton ball at injection site -Do not recap the needle -Massage site for 10 seconds, apply Band-aid if

necessary -Carefully dispose in Sharps container

Glucagon Administration continued:

6. Care after Administering -Keep the student on his/her side -Maintain an open airway -Feed the patient as soon as he/she awakens and is

able to safely swallow -Wait for EMS to arrive and continue to monitor

student

Glucagon Administration continued:

Symptoms: -Increased thirst -Frequent urination -Blurry vision -Drowsiness -Irritability -Ketones in urine -Nausea -Fatigue -Sweet breath -Disorientation -Labored breathing

Hyperglycemia(High Blood Sugar)

Occurs when too little insulin, too much food, or too little exercise. May also be caused by stress, emotional upset, illness and injury.

Hyperglycemia is determined by blood glucose values. It may be treated by administering insulin, per the IHP.

Hyperglycemia can cause the body to produce ketones. Ketones are chemicals that the body makes when there is not enough insulin in the blood and the body must breakdown fat for its energy.

Ketones are detectable in the urine.

According to the IHP, it may be necessary to test for ketones.

Testing for Ketones: - Gather supplies-Student urinates in clean cup-Put on gloves, if performed by someone other than

student-Dip ketone strip in the cup containing urine-Wait 15-60 seconds-Compare color of strip to chart on bottle-Record results.

How to test for Ketones

Testing for Ketones

*******REFER TO STUDENT’S IHP*********Example of treatment protocol:↖ Test BS. If above 250, check urine for ketones↖ If small, trace or no ketones, encourage student to drink

extra fluids…water.↖ If moderate to large ketones, notify parent or physician’s

office.

If the student has any ketones, they should not participate in activity such as PE, but they may attend class if they are feeling okay.

Treatment for Hyperglycemia(High Blood Sugar)

Blood Glucose Testing

1. Gather supplies -Gloves -Alcohol -Finger lancing

device/lancets -Blood glucose testing

meter -Test strips

Blood Glucose Testing

2. Wash Hands3. Put on gloves4. Clean area to be tested

(usually a fingertip) Make sure finger is dry before testing5. Prepare lancing device

according to manufacturer’s instructions

6. Prepare Meter- There are different styles of meters. Please familiarize yourself with your student’s meter.

-Turn on the meter -Check code # (Code on meter must match test strip

bottle) -Insert test strip in meter

Blood Glucose Testing

Blood Glucose Testing

7. Lancing the finger -Hold the lancing device firmly

onto the side of the fingertip -Puncture the site with the

lancing device -Gently squeeze the finger in a

downward motion to obtain a large enough drop of blood to cover the test strip

Blood Glucose Testing

8. Place blood onto testing strip and follow meter

instructions according to manufacturer

9. Wait until blood glucose results are displayed10. Dispose of lancet in sharp’s container11. Take action according to student’s IHP

A student with diabetes must dispose of his/her sharps (including lancets, syringes, empty pens, insulin vials, insulin cartridges, and pump infusion sets) into a safe container/sharps container. Small containers may be brought by the student.

The nurse’s office also has a sharps container in the clinic.

Sharps should never be thrown away in the regular trash.

Disposal

Insulin is a hormone produced by the pancreas that helps the body use glucose for growth and energy.

Different types of insulin:

- immediate (rapid-acting or short-acting insulin) - intermediate or long acting(basal insulin) Describes the onset of action and duration of action in the body.

A coordinated combination of insulin is used to allow for adequate treatment of diabetes at meals, snacks, during periods of physical activity and through the night.

Insulin

Delivery Methods-Syringe-Insulin pen-Insulin pump

When to Administer-Administer according to

Individual Health Plan (IHP)-Generally:▶ Before meals (dosage based

upon insulin to carbohydrate ratio)

▶ Blood glucose level significantly above the target range (correction factor)

▶ Increased ketones

Delivery Methods/When to Administer Insulin

Insulin Administration

Steps to follow for insulin administration:1. Gather supplies▶ Insulin▶ Syringe▶ Alcohol/cotton ball▶ Sharps▶ Gloves

Steps to follow for insulin administration:

2. Wash hands, apply gloves

3. Clean the top of insulin vial with alcohol

4. Have the student select injection site

5. Clean the injection site with alcohol/cotton ball

6. Check the insulin dose, according to IHP7. Remove the cap from syringe8. Pull down the plunger to units needed

9. Draw out prescribed number of units according to IHP/physician’s orders ** VERIFY CORRECT DOSAGE WITH ANOTHER KISD EMPLOYEE

Steps to follow for insulin administration

Check Dose

Steps to Follow for insulin administration

11. Pinch up the skin.12. Push needle into skin at

90°. 13. Release pinch.14. Push the plunger in.15. Count to “5”.16. Remove needle and

dispose of syringe.17. Document Care

An insulin pen looks like a fountain pen and can be pre-filled or a cartridge

Preparation: 1. Gather supplies (pen device, alcohol, needle, sharps) 2. Verify type of insulin/dose 3. Wash hands 4. Choose site 5. Clean site with alcohol 6. Apply needle to pen

Insulin Pen

7. Prime with “2” units of insulin8. Remove air by pressing the plunger. Repeat prime if no insulin shows.9. Dial units of insulin as prescribed/IHP10. Pinch skin and push needle into skin11. Release skin and push plunger12. Count to “5” 13. Remove and dispose of needle in sharps

Insulin Pen (cont)

-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)

-Rapid or Short-Acting Insulin

-Precision, micro-drip insulin delivery

-Flexibility

Insulin Pumps

-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 one type of insulin

What is an Insulin Pump?

Types of Insulin Pumps

-Infusion set-Reservoir-Insulin-Skin prep-Alcohol/cotton balls-Syringe (in case of malfunction)-Batteries-Manufacturer Manual

Training for students with pumps will beconducted on an individual basis

Pump Supplies at School

The student’s meal plan is designed to balance the student’s nutritional needs with his/her insulin routine and physical activity.

There are usually no forbidden foods, however, the content of the food is carefully matched to the action of the insulin.

A person with diabetes can have foods that contain sugar; should know how to count carbohydrates in those foods and then adjust his/her insulin accordingly.

Nutrition and Diabetes

The family and personal health care team create an individualized meal plan based upon carbohydrate counting or an exchange system.

Carbohydrate counting involves calculating the number of grams of carbohydrates the student eats. This information, which can be obtained from nutrition information on food labels, is used to determine the amount of insulin the student needs to control blood glucose for any given meal or snack.

Nutrition and Diabetes

Exchange System groups food in six different lists, each with a set nutritional value. A meal plan is prepared that recommends several exchanges or servings from each food group for each meal and snack. The exchange list ensures that the meal plan is consistent in portion size and nutrient content while offering a wide variety of foods from each group. Students using this approach consume a prescribed number of exchanges at meal and snack times. Bread/starch, fruit, milk, vegetables, meat/protein, and fats are food groups included in the exchange list.

The Meal Plan is an important part of the IHP. Please refer for individual meal/snack plans.

Nutrition and Diabetes

With some insulin regimens, it is important to maintain consistency in the timing and content of meals and snacks. The student should eat lunch at the same time each day.

Snacks are often necessary for a child with diabetes and must be eaten to balance the peak times of insulin action.

A missed or delayed snack could result in hypoglycemia.

Nutrition Info to Remember

▶ Exercise and physical activity are critical parts of diabetes management.

▶ Students with diabetes may participate fully in physical activity

▶ Physical activity may help to control weight, maintain cardiovascular fitness, lower blood glucose levels and increase

insulin sensitivity

Physical Activity and Diabetes

▶ Physical education instructors and sports coaches should be able to recognize and assist with the treatment of hypoglycemia.

▶ A quick-acting source of glucose should be available, along with plenty of water.

▶ A student with diabetes that participates in physical activity should closely monitor his/her blood glucose levels.

Physical Activity and Exercise cont.

▶ Meeting the needs of students with diabetes requires advanced planning for special events such as classroom parties, field trips and extracurricular activities scheduled during the school day.

▶ A trained diabetes care provider must accompany the student and carry a copy of the student’s IHP.

▶ Refer to the IHP for specific guidelines to follow.

Special Events, Field Trips and Extracurricular ActivitiesScheduled During School Day

▶ Understand the student’s IHP▶ Understand how to respond in an emergency

situation▶ Learn about Diabetes▶ Communicate with your school nurse▶ Respect the student’s confidentiality▶ Be available for student▶ Provide support and encouragement to student▶ Help ensure that the student has a supportive

learning environment

Actions for Trained Diabetes Personnel

Thank you for your attendance and participation today.

If you have any questions, please consult with a Nurse on your campus.

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