7. When a new diabetic student comes to your site . . .
Contact your School Nurse if she is not already aware of it.
Your School Nurse will . . .
have specific paperwork that must be completed before Diabetic Care Procedures can be available for the new student.
develop an Individualized Health Care Plan for the student.

8. Diabetes Management at School

9. Much of the information in this training was taken from:
Diabetic Care Tasks at School: What Key Personnel Need to know. Powerpoint presentation from The American Diabetic Association.
Mary Zombec, RN, MS, CPNP. P.E.D.S., Pediatric Education for Diabetes in Schools. Copyright June 2001 PADRE Foundation in Partnership with the California State Dept. of Education.

10. Diabetes is a Complex Disease and . . .
occurs when special cells in the pancreas produce inadequate or no insulin.
is influenced by diet, exercise, general health, emotions and other factors.
often managed by oral or injectable medications, depending on the type and severity of the diabetes.
can be one of two types.

11. Type 1 and Type 2 Diabetes Type 1*
Develops when person’s own immune system destroys pancreatic cells that make insulin.
Usually occurs in childhood or young adulthood.
Medical help sought because people are seriously ill from sudden symptoms of high blood sugar.
Usually treated with insulin replacement.
Episodes of low blood sugar are common
Cannot be prevented.
*Cited from US Centers for Disease Control and Prevention. National Diabetes Fact Sheet, Atlanta: US Dept. of Health and Human Services
Type 2*
Develops when cells do not properly use insulin.
Body does not make an adequate amount of insulin.
May not have symptoms before diagnosis.
Usually discovered in adulthood, but is being found in increasing number of children.
Associated with obesity and inactive lifestyle.
Can be prevented or delayed with healthy lifestyle – diet, weight control & exercise.

12. Goal of Diabetic Management
To keep blood glucose levels within an individual’s TARGET RANGE.
This range is determined by the physician, based on each individual’s condition and lab results.
Any glucose levels outside this range indicate the need for treatment.

13. HYPOglycemia

14. Learning Objectives Participants will learn:
Symptoms of low blood glucose
Short and long term risks
Treatment of low blood glucose
Prevention of low blood glucose
Our objectives are to learn:
Why blood glucose is monitored.
When blood glucose should be monitored
How to perform a blood glucose check

15. Vocabulary Glucose HYPOglycemia Quick-acting glucose
Glucose tablets or gel
Glucagon
Carbohydrate
a simple sugar found in the blood. the fuel that all body cells need to function.
a LOW level of glucose in the blood.
foods containing simple sugar that raise blood glucose levels.
There are a few vocabulary terms related to hypoglycemia:
Glucose is a simple sugar found in the blood. It is the body’s main source of energy. The terms “glucose” and “sugar” are commonly used interchangeably.The same for “blood glucose” and “blood sugar”.
Hypoglycemia. A low level of glucose in the blood..
Quick-acting glucose. Foods containing simple sugar that are used to raise blood glucose levels quickly during hypoglycemia.
Glucose tablets or gel. Special products that deliver a pre- measured amount of pure glucose. They are a fast-acting form of glucose used to counteract hypoglycemia.
Glucagon. A hormone that raises the level of glucose in the blood. Glucagon, given by injection, is used to treat severe hypoglycemia.
Carbohydrate. Carbohydrates are one of three main classes of foods and a source of energy for the body. Foods high in carbohydrates raise blood glucose levels.
special products that deliver a pre-measured amount of pure glucose.
they are a fast-acting form of glucose used to counteract hypoglycemia.
a hormone given by injection that raises the level of glucose in the blood.
source of energy for the body.

16. HYPOglycemia = LOW sugar
Onset: Sudden.
May be caused by too little food, too much insulin or extra physical exercise.
May quickly progress to unconsciousness if not treated.
Can result in brain damage or death if not treated.
Hypoglycemia = low blood glucose levels. Hypoglycemia is a low level of glucose in the blood.
Onset: Sudden, usually mild, but may progress to unconsciousness if not treated and result in brain damage or death
The Diabetes Medical Management Plan (DMMP) should specify signs and action steps for each student at each level of severity of hypoglycemia:
Mild
Moderate
Severe

17. Hypoglycemia: Possible Signs and Symptoms
Moderate Symptoms
Yawning
Irritability/Frustration
Extreme tiredness/fatigue
Confusion
Restless
Dazed Appearance
Sudden Crying
Severe Symptoms
Unable to Swallow
Seizures
Combative
Unconsciousness
Mild Symptoms
Hunger
Sleepiness
Shakiness
Changed Behavior
Weakness
Increased Heart Rate/Palpitations
Sweating
Pale Color
Anxiety
Blurry Vision
Dilated Pupils

18. Hypoglycemia: Risks & Complications
Greatest immediate danger
Impairs cognitive and motor functioning
Early recognition and intervention can prevent an emergency
Not always preventable
Hypoglycemia is the greatest immediate danger to students with diabetes. Students can quickly get to a state where they cannot reliably help themselves. In this case, they are dependent on others to recognize that they are experiencing a low blood glucose level, and also to know what to do to treat the low. Left untreated, hypoglycemia can lead to: unconsciousness, seizures, and may even be life-threatening.
Hypoglycemia is one of the most frequent complications of diabetes. It can happen very suddenly and is not always preventable.
Hypoglycemia impairs cognitive and motor functioning. Even a student who knows s/he needs to eat might not be able to problem-solve how to get the food, or may not have the fine motor skills to screw off a juice lid or open a cracker package. Some students may become combative and hypoglycemia may be mistaken for misbehavior.
However, while a hypoglycemia episode is an urgency, it need not become an emergency. Most hypoglycemic episodes are quite mild; with students responding to eating a quick acting carbohydrate such as fruit juice, or crackers within minutes. Recognizing early symptoms and always having access to appropriate foods are the surest way to prevent an emergency.

19. Mild Hypoglycemia: What to do
Goal: To raise blood glucose level
Intervene promptly.
If a meter is available, test blood glucose immediately and minutes after treatment.
When in doubt, always treat!
Treat by having student eat or drink 15 gm. fast acting carbs.
Repeat treatment if blood glucose level remains low or if symptoms persist.
If symptoms continue, call parents per plan.
Never leave a student with suspected low blood glucose unattended.
Intervene promptly when hypoglycemia is mild to prevent the progression to severe symptoms. The steps for intervening with each student will be outlined in his/her DMMP.
General steps are as follows:
First, verify with blood glucose test when available. (Some students confuse low & high symptoms.)
However, if no meter is available, treat for hypoglycemia.
WHEN IN DOUBT, ALWAYS TREAT FOR LOW BLOOD SUGAR as per DMMP:
Treatment involves the following steps:
Have student eat or drink fast acting carbohydrates (15g)
Test blood glucose minutes after treatment
Repeat treatment if blood glucose level remains low
If symptoms continue or blood glucose levels do not increase, call parents as specified in DMMP

20. Quick Acting Glucose for HYPOglycemia
Treatment for Lows: One of the following choices provides 15 gm. of carbohydrates
4 oz. fruit juice
15 gm glucose tablets (2-3 tablets)
1 tube of glucose gel
4-6 small hard candies
1-2 tablespoons of honey
6 oz. regular (not diet) soda (about half a can)
Any quick-acting glucose can be used to treat hypoglycemia. Be careful not to overdose on the treatment or the student will be too high later. Treatment may need to be repeated at about 15 minute intervals (based on continued low test results or poor symptom response), but each treatment dose should be 15g unless otherwise stated in the student’s DMMP. Some quick-acting forms of glucose include:
4 oz. fruit juice
3 or 4 glucose tablets
1 tube of glucose gel
4-6 small hard candies
1-2 tablespoons of honey
6 oz. regular (not diet) soda (about half a can)

21. Severe Hypoglycemia: What to do
Rare, but life threatening, if not treated promptly:
Inject Glucagon, if ordered by M.D. and you have been trained by your School Nurse.
Call 911, then parent/guardian.
If Glucagon is not ordered, call 911 immediately.
Never attempt to give food or put anything in the student’s mouth if they are unconscious or having a seizure.
Remain with the student until help arrives.
Procedures for intervening with severe hypoglycemia will be covered in more detail in another unit on glucagon administration.
Remember the steps for intervening with a specific student will be outlined in his or her DMMP.
This slide describes the general steps in intervention.
Severe hypoglycemia is rare, but life threatening, if not treated promptly:
Place student on his or her side
Inject glucagon if provided for in the student’s DMMP.
Never attempt to give food or put anything in the student’s mouth
Call 911, and then call parents/guardians
The student should respond to the glucagon in 15 to 20 minutes.
Remain with the student until help arrives.

22. A Note About Glucose Gel
It is the only fast-acting oral carbohydrate source you might use for an unconscious person if Glucagon is not available or no one is trained to give the injection.
It can only be done if it is ordered by the doctor on the Physician’s Authorization form under “Emergency Care of Severe hypoglycemia.”

23. Procedure for Using Glucose Gel
What to do:
Perform procedure with extreme caution/use gloves.
Turn the unconscious person on their side.
Place the tip of the tube in the cheek that is down.
Squirt the gel between the cheek & teeth.
Massage outside of cheek to help glucose penetrate into the gums.
Allow the saliva/gel to drain out on a towel.
To avoid aspiration, keep person on their side until they regain consciousness.

24. Prevention of Hypoglycemia
Follow individualized diabetic management plan regarding eating, glucose testing, insulin coverage and exercise.
ALWAYS keep a quick acting sugar source on hand.
Treat at first sign of symptoms.
Ensure that carbs in food match insulin dose.
Watch for picky eaters.
Consult with parent before class parties.

25. HYPERglycemia

26. Learning Objectives Symptoms of high blood glucose
Participants will learn:
Symptoms of high blood glucose
Short and long term risks
Treatment of high blood glucose
Prevention of Hyperglycemia
Our objectives are to learn:
Why blood glucose is monitored.
When blood glucose should be monitored
How to perform a blood glucose check

27. Vocabulary Hyperglycemia: too high a level of glucose in the blood.
Ketones (ketone bodies) Acidic chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy.
Diabetic ketoacidosis (DKA) the build up of ketones in the body that can lead to serious illness and coma.
Ketone testing a procedure for measuring the level of ketones in the urine or blood.
There are a few key vocabulary terms related to hyperglycemia.
Hyperglycemia is the medical term for “high blood sugar”. It occurs when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy.
Ketones (ketone bodies). Chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy.
Diabetic ketoacidosis (DKA). The build up of ketones in the body that can lead to serious illness and coma.
Ketone testing. A procedure for measuring the level of ketones in the urine or blood.

28. HYPERglycemia = HIGH Sugar
Onset: Severe hyperglycemia is usually slow to develop
Too much glucose in the blood
Too little insulin to transfer glucose into cells
If left untreated, may lead to diabetic ketoacidosis, a serious illness.
Hyperglycemia is a high blood glucose level in the blood. Yet the irony is that with all the glucose floating around in the blood the body cells are actually starving because glucose cannot get in.
Generally the onset of hyperglycemia is slow. An isolated high blood glucose reading is cause for concern, but not alarm. It is especially important to recognize that blood glucose is expected to be higher following a meal or snack. Hyperglycemia can occur more rapidly in students with insulin pumps if a pump malfunctions or delivers less insulin.
If there is insufficient insulin due to pump malfunction, failure to take insulin or insulin not working effectively, there maybe a breakdown in fat, causing ketones to form, ketones may build up in the blood and may result in diabetic ketoacidosis (DKA).
Hyperglycemia becomes an increasing concern when several consecutive readings have been high, or when accompanied by vomiting. The student’s DMMP should determine precisely what actions should be taken at each level of severity of hyperglycemia.

29. Hyperglycemia: Possible Signs and Symptoms
Mild Symptoms
Thirst
Frequent Urination
Flushed Skin
Lack of Concentration
Fatigue/Sleepiness
Blurred Vision
Increased Hunger
Moderate Symptoms
Dry Mouth
Stomach Cramps
Vomiting
Nausea, Stomach Pain
Weakness
Dry, warm skin
Weight Loss
Sweet, Fruity Breath
Severe Symptoms
Labored Breathing
Very Weak
Confused
Unconsciousness

30. HYPERglycemia: Risks & Complications
Interferes with a student’s ability to learn and participate, they chronically feel lousy.
Hyperglycemia due to inadequate insulin can lead to coma or death .
Serious long term complications develop when glucose levels remain above target range over time or are recurring. (Blindness, lost limbs, stroke, heart attack, shorter life span.)
There are several important reason that to learn the signs, treatment, and prevention strategies for hyperglycemia.
If left untreated for an extended period, hyperglycemia due to insufficient insulin can lead to “diabetic ketoacidosis” (DKA) and/or coma and death. The onset is more rapid for students who wear insulin pumps.
High blood sugar can affect a student’s general well-being. Students who do not feel well are less able to learn and participate in school activities.
When glucose levels remain high over time or are recurring, serious life-limiting complications of diabetes develop. Diabetes is the leading cause of adult blindness, lower limb amputations, and kidney failure. It can also cause heart disease and stroke.
Many students with diabetes will not experience symptoms from high glucose levels until the level is far above target range. Therefore, routine glucose testing is needed to identify otherwise undetectable high glucose levels.
The good news is that, treating high glucose levels in accordance with the student’s DMMP,
enables students to participate fully in their education now and enhances their health and
well-being in the future.

31. Hyperglycemia: Possible Causes
Too little insulin
Expired insulin
Too many carbs for insulin dose
Decreased physical activity
Illness, infection, injury
Stress
Other hormones
Menstrual periods
The first four items in this list - too little insulin, expired insulin, food, activity-are the main players. Keeping these three in balance is generally what keeps blood glucose from going too high OR too low.
Adding insulin or exercise generally lowers blood glucose and adding food generally increases blood glucose. So considering these three, hyperglycemia can be caused by too little insulin, too much food, or too little physical activity. Let’s talk about this list in a little more detail.
Too little insulin - Forgetting to “cover” a meal or snack with short-acting insulin can happen. Of greater concern is when students have not taken their long-acting insulin. Students on pumps are especially vulnerable to high blood glucose, if their infusion site pulls out or occludes, preventing insulin delivery.
Expired or “spoiled” insulin: Sometimes insulin that is beyond expiration or has been stored improperly can lose it’s potency and can cause hyperglycemia.
Too much food or food that is not covered by insulin. This may be inadvertent – not realizing how carbohydrate-rich a particular food is. For example, a student who is used to eating grocery store bagels at home, may not realize that some shop bagels are two time as rich in carbohydrates.
Decreased exercise or activity.
Other factors may also play a role:
Illness, injury – an otherwise “unexplained” high glucose reading may be a sign of onset of illness.
Stress. Other hormones, such as glucagon, growth hormone, adrenaline, cortisol
Menstrual periods

32. Hyperglycemia: What to do
Goal: lower the blood glucose to target range.
Check urine for ketones if ordered.
Depending on the amount of ketones, give 8 oz. of water per instructions on Algorithms form.
Licensed nurse to administer insulin per established care plan (student may self-administer if determined to be self-sufficient).
Recheck blood glucose per care plan.
The goal in the treatment of hyperglycemia is to lower the blood glucose level to within a student’s target range.
Always follow the individual child’s DMMP.
Generally, the action steps for hyperglycemia are:
First of all, verify status with a blood-glucose test as specified in the DMMP.
Secondly, check ketones as specified in the DMMP.
Allow free use of bathroom and access to water
Administer insulin as specified in the DMMP.
Recheck blood glucose per DMMP.
The parents should be notified immediately when the conditions for contact are present as specified in the DMMP.

33. Prevention of Hyperglycemia
Avoid “over treating” low blood sugar reactions. Give only 15 gms. of quick acting glucose at a time.
Contact School Nurse or parent if a self-administered insulin dose is missed or pump malfunctions.
Consult with parents if meal or exercise times need to be changed.
Discourage binge eating

34. BLOOD GLUCOSE MONITORING

35. LEARNING OBJECTIVES Participants will learn:
Why blood glucose is monitored
When blood glucose should be monitored
How to perform a blood glucose check

36. What is blood glucose monitoring?
It is a procedure that is done to obtain a small amount of blood to test a person’s blood glucose level.

37. Blood Glucose Monitoring
GOAL: Maintain blood glucose within target range
Immediate Benefit:
Maximize learning & participation in school
Prevent lows and highs
Long-Term Benefit:
Decrease risk of long-term complications
Maximize health
Challenge: Many variables can impact blood-glucose levels
Role of the School
Facilitate blood glucose monitoring
Know target blood glucose results and how to act on them
Provide monitoring data to parent or guardian to give to the MD

38. When to Check Routine monitoring before meals and snacks
Regularly scheduled checks on individual basis:
Routine monitoring before meals and snacks
Before, during and/or after exercise
Extra checks may be necessary:
Periods of stress or illness
Hypoglycemia or hyperglycemia symptoms
Change in diabetes management
Blood Glucose Checking
Regularly Scheduled checks
Routine monitoring before meals and snacks
Before, during, and after exercise

39. Any Time, Any Place Monitoring
Blood Glucose Testing may be done at any time or any place the student is having any symptoms of hypo or hyper gycemia and a Glucose Monitoring Kit is available.
What are the advantages of checking blood glucose levels any time and any place?
The student can achieve better blood glucose control to prevent long-term complications of high blood glucose and complications of acute low blood glucose levels.
It is safer for student because less time is lost between recognizing symptoms, confirming low blood glucose, and obtaining treatment with a fast-acting sugar source followed by a snack or meal.
The student gains independence in diabetes management when the blood glucose meter is easily accessible and checks can be conducted as needed.
The student experiences less stigma as blood glucose monitoring loses its mystery when handled as a regular occurrence.
Students with diabetes who check their blood glucose levels in the classroom spend less time out of class.

40. Equipment and Procedure

41. Lancing Devices Lancets Pen-type Lancing Devices
The basic tool for drawing blood for a glucose check is the lancet, a very sharp steel blade in a plastic case. There are many types of lancets and lancet devices.
Many students will use a lancing device, a pen-shaped lancet holder that "launches" the blade with a spring and controls the depth of the puncture. Some lancing devices (like the one pictured at the bottom of the screen) have several depth settings to allow for the difference between sensitive fingers and callused fingers. Some come with two caps for the end that touches the finger to adjust the depth of puncture. In addition, the pressure of the finger on the cap determines how deep the puncture will go. It should be deep enough to provide an adequate amount of blood, but not be so deep as to cause bruising or pain.
Lancets should be disposed of after use in a sharps disposal container as per student’s education plan and local ordinances.

42. Know the Meter Features vary:
Ease of use
Sample size needed
Wait time
Alternate-site testing capacity
Ability to reapply, if insufficient sample
Become familiar with the operation of each student’s meter. Read the manual!
There are many reliable meters on the market. Each has a unique set of features and operating procedures.
A number of features vary from meter to meter. Some of the features are convenience-based. Others can be critical to accuracy in test results.
Ease of use
Sample size needed
Ability to reapply, if insufficient sample
Wait time
Alternate-site testing capacity
Become familiar with the operation of each student’s meter

43. Preparation Gather blood glucose monitoring supplies:
-Lancing Device and Lancet
-Meter
-Test strips
Wash hands (if student performs test, have them thoroughly wash and dry their hands).
If assisting or performing for student, put on disposable gloves and observe Universal Precautions.
Instructions:
1. Gather blood glucose monitoring supplies:
lancet,
test strip,
meter,
2. Wash hands.
3. If assisting or performing for student, put on disposable gloves.

44. Readying the Meter Insert strip to activate meter.
Check code # on vial of strips.
Code # on meter should match.
Instructions:
4. Turn the meter on
5. Check code number that appears on meter with the code number found on the container of the test strips. Correct meter code if codes do not match.
6. Insert a strip into the meter (some meters turn on automatically when the strip is inserted).

45. Lancing the Finger
Hold the lancet device to the side of the finger and press the button to stick the finger.
Instructions:
7. Hold the lancet device to the side of the finger and press the button to stick the finger.

46. Applying Blood to Strip
Follow instructions included with the meter if different from instructions below.
Place tip of strip in drop of blood on finger.
Blood is automatically sucked up into strip.
Meter will indicate if amount of blood is sufficient.
Instructions:
8. How blood is applied to the strip is a little different from meter to meter. Follow instructions included with the meter in how to apply the blood sample. This slide shows three different kinds of strips to illustrate some things to keep in mind.
With the first type of meter & strip, on the left: Be sure to drop, do not smear the blood onto the strip.
With all meters and strips, be sure to completely cover the test strip window.
The picture on the right illustrates that some strips actually suck the blood onto the strip by capillary action upon contact with the drop of blood on the finger (or other alternate site).

47. 5 3 Results 250 Wait until blood glucose results are displayed.
Dispose of lancet.
Record blood glucose results on log & take action per plan.
250
5 3
Instructions:
9. Wait. Blood glucose results will be displayed on the meter. Meter processing times vary. Most will take from 15 seconds to one minute.
10. Dispose of the lancet in sharps container as per student’s education plan and local ordinances. Test strips may be discarded in a regular trash can.
11. Record blood glucose result and take action as per DMMP.

48. What does the number mean?
Refers to the glucose level in the blood
May vary throughout day.
When compared to the Target Range, it is an indicator of which treatment, if any, is needed.
Guidelines for treatment are found on the Algorithms for Blood Glucose Results form. (next slide)
In responding to and communicating about a specific reading, there are several things to keep in mind.
Reaction to blood glucose testing results should always consider the student’s target range as it has been specified in the DMMP.
Not all children will have the same target range.
Even for an individual child, the target range may be somewhat different at different times of the day.
Take action for blood glucose levels that fall outside of students target range as per DMMP.
Avoid referring to the numbers as “good” or “bad,” both to the student and to others. The fact that the blood sugar is being checked is good, no matter what the results are. Refer to numbers as "in target", or "out of target“ or “below target” or “above target”.

50. Documentation Document the results on the Diabetes Monitoring Log.
After each entry on the Monitoring Log, place your initials in the appropriate box.
Whenever new Monitoring Log is started, remember to sign/initial in one of the designated areas on bottom of sheet. (Sample documentation following).

52. What does the display mean?
Meters do not only display numbers.
Some display “Lo” or “Hi” for out of range readings.
Some of them also display specific “error codes” that may indicate problems like an insufficient blood sample or that the temperature is out of range. You will need the meter manual to respond to these error codes.
You can get information about a specific meter and test strips from several different sources.
A copy of the manufacturer’s manual for the meter should be provided by the parent/guardian and kept in the health office for troubleshooting.
The user manual (and in some cases the meter itself) will include a toll free number in case you have questions or problems.
Also, most meter companies now have their manuals available for download on their websites.
Check manual
Contact manufacturer by phone or website
Note:
At this point in the training the instructor should demonstrate how to use one or more meters.
Have participants practice using meter.

53. Practical Implications for Educators
Students with hyperglycemia or hypoglycemia often do not concentrate well.
During academic testing:
Check blood glucose before and during testing
Allow access to food/drink and restroom.
If a serious high or low blood glucose episode occurs, students should be excused with an opportunity for retaking tests.
Eliminate barriers and provide adequate time for taking medication, checking blood glucose, and eating.
A few practical implications for educators related to the prevention
and/or intervention of hyper- and hypoglycemia:
Students with hyperglycemia or hypoglycemia often do not concentrate
very well; students may need to have information repeated.
During academic testing:
Students should test blood glucose before and during testing, if specified in their educational plan.
Students should have access to food/drink and restroom during the testing period
Students should be excused from testing with an opportunity for retake later, should a serious high or low blood glucose episode occur.
Students should be given adequate time for taking medication, checking blood glucose levels, and eating snacks or completing meals.

54. Glucagon
Administration

55. Learning Objectives Participants will learn: What glucagon is
How glucagon should be stored
When glucagon is used
How to administer glucagon

56. What is Glucagon? Naturally occurring hormone made in the pancreas.
A life-saving, injectable hormone that raises blood glucose level .
Treatment for severe hypoglycemia.
Can save a life.
Cannot harm a student.
Glucagon for injection is a prescription medication.
Glucagon is a hormone that occurs naturally in the body. It is produced in the pancreas and raises blood glucose levels by causing the release of glycogen (a form of stored carbohydrate) from the liver that raises blood glucose levels.
Glucagon injections are used to treat serious hypoglycemia. If it is specified in the student’s Diabetes Medical Management Plan (DMMP), glucagon should be used when the student is unconscious, experiencing convulsions, or cannot eat or drink safely. Severe hypoglycemia can cause brain damage or death.
Although it may cause nausea and vomiting when the student regains consciousness, glucagon is a life-saving treatment that cannot harm a student.

57. Comparison of Insulin and Glucagon
Hormone normally secreted by the pancreas.
Essential for the metabolism of blood glucose.
In certain diabetics, it is an injectable med given daily at specified times & doses to lower blood glucose levels.
Doses are determined and regulated by patient’s doctor according to each individual.
Given only by licensed health care providers.
Glucagon
Hormone normally secreted by the pancreas.
Functions to raise blood glucose levels when needed.
Used as an emergency injectable med for diabetics to raise extremely low blood glucose levels.
May be given in an emergency by non-licensed persons trained by a licensed RN or physician.

58. Glucagon Kit Storage Store at room temperature
Expiration date: Monitor
After mixing, dispose of any unused portion.
The glucagon kit should be stored in a place designated in DMMP and may be kept with the student.
Glucagon should be stored at room temperature.
Expiration date should be checked. Do not administer if expired, discolored, or does not dissolve well.
After mixing the contents, dispose of any unused portion.
Expired glucagon emergency kits can be used for future training sessions.

59. Emergency Kit Contents:
1 mg of freeze-dried glucagon (Vial)
1 ml of water for reconstitution (Syringe)
This photo shows the inside of a glucagon emergency kit. Glucagon must be injected.
Instructions are included in package
In addition to participating in this training, instructions inside the kit should be reviewed.
Within the glucagon kit are:
a syringe pre-filled with a saline and
a vial of powdered glucagon.
Combine the glucagon for injection immediately before use by following the instructions that are included with the glucagon kit.
Combine immediately before use

60. When to Give Glucagon
If authorized by the student’s Health Care Plan and if student exhibits:
Unconsciousness, unresponsiveness
Convulsions or seizures
Inability to safely eat or drink
When hypoglycemia is severe, the school nurse or trained diabetes personnel must respond immediately.
Regardless of whether glucagon is to be given or not, emergency personnel should be summoned by calling 911 or emergency response personnel as soon any of the following are exhibited:
Unconsciousness, unresponsive
Convulsions, seizures, or jerking movements
Inability to safely eat or drink
If student is seizing, unconscious, or having difficulty swallowing, do not attempt to give food or a drink or to put anything in his or her mouth because it could cause the student to choke.

61. Procedure: Act Immediately
Position student safely on side for comfort and protection from injury
Call 911, parents, school nurse
Position student safely – Be sure that the student is lying on his or her side in a clear, safe area protected from head and bodily injury.
Do not leave student alone.
School nurse or other trained diabetes personnel should give glucagon as soon as possible after discovering that the student is unconscious or unable to swallow.
A second person should call 911, then parents and school nurse as per DMMP.

62. Preparation Flip cap off glass vial containing dry powder
Remove cap from syringe
1. Flip the plastic cap off the glass vial of powdered glucagon.
2. Remove the plastic cap off the syringe needle. Do not remove plastic clip from syringe as it prevents the rubber stopper from being pulled out.

63. Mixing Solution
Inject entire fluid in syringe into the bottle containing powder
Shake gently or roll to mix until all powder is dissolved and solution is clear.
3. Take the fluid filled syringe in the glucagon emergency kit and inject the fluid into the bottle containing the glucagon powder.
4. Shake gently or roll to mix until all powder is dissolved and solution is clear.

64. Drawing out Inspect. Solution should be clear and colorless.
Draw prescribed amount of glucagon back into syringe. Check the doctor’s orders.
5. Inspect medication for color, clarity, and presence of lumps. Solution should be clear and colorless.
6. Draw a prescribed amount of glucagon back into syringe. Amount is per DMMP. General guidelines are as follows:
If child weighs > 45 lbs., inject the full vial of glucagon (1 cc) using the buttocks, thigh, or arm.
If child weights < 45 lbs., inject 1/2 of the solution.
Do not recap syringe. Discard sharp in appropriate container.

65. Dosing and Injecting Clean site if possible
Inject needle at 90° angle into the muscle of one of the following sites:
Largest part of thigh is preferred site
Middle of deltoid muscle in upper arm
Very slightly pull back on plunger to check for blood.
If no blood, inject solution
Remove needle and massage site w/ cotton ball
Dispose of needle in puncture-proof container.

66. After Injecting
Turn student on side as he/she may vomit – prepare for this to happen.
May take 15 – 20 minutes for student to regain consciousness.
Check blood sugar level.
Give sips of fruit juice or regular soda – only if student is awake and able to drink.
Document under “comments” on the Diabetes Monitoring Log.
It may take minutes for student to regain consciousness. Check blood sugar minutes after administering glucagon.
Give sips of fruit juice or regular soda once student is awake and able to drink.
Follow with concentrated sugar with snack containing proteins and carbohydrates such as peanut butter sandwich or cheese crackers to keep blood sugar levels elevated to normal levels and to prevent recurrence.
Document blood glucose level and glucagon dosage as per DMMP.

68. Don't be surprised if. . .
Student does not remember being unconscious, is incoherent or has a headache
Blood sugar becomes very high (over 200)
Nausea or vomiting occurs
Don’t be surprised if …..
Student does not remember being unconscious, incoherent or has a headache.
Blood sugar becomes very high (over 200)
Nausea or vomiting occurs
Note: At this point, the instructor demonstrates administration of glucagon and participants practice.

69. Ketone Monitoring

70. Learning Objectives Participants will learn: What ketones are
Why ketones are monitored
When ketones should be monitored
How to perform a ketone test

71. Why test for ketones?
Ketones(acids) are produced when the body burns fat for energy. Ketones can build up and result in diabetic ketoacidosis (DKA)
What is DKA?
Acids that build up in body and cause student to feel ill
Emergency state, can lead to coma, death
Common symptoms include fruity odor to breath, nausea, vomiting, drowsiness
Number one reason for hospitalizing children with diabetes
Testing for ketones results in early detection and treatment of DKA and prevents hospitalizations
Reasons for testing for ketones
It is important to test for ketones (acids) because they can build up in the body and result in one of the two emergencies of diabetes, diabetic ketoacidosis, often referred to as “DKA”. DKA is a condition that occurs due to insufficient insulin in the body. This can be due to illness, not enough insulin/medication doses or omitting insulin injections.
Common symptoms include fruity odor to breath, nausea, vomiting, drowsiness.
If the test shows medium or large ketones to be present, extra insulin may be needed, if specified in the student’s Diabetes Medical Management Plan (DMMP) to reduce the level of ketones.
If the ketones are not detected early, particularly during illness, they will build up in the body and DKA may result.
DKA is the number one reason for hospitalizing children with diabetes in the U.S.
It is the early detection of ketones and treatment with insulin that prevents hospitalizations for DKA.

72. When to test for ketones?
Ketones are usually checked when the blood sugar is high – how high is determined on an individual basis.
Check the doctor’s orders to determine if ketones are to be checked and at what glucose level.
Follow the instructions on the Algorithms for Blood Glucose Results Form.

74. How to test urine for ketones
Gather supplies
Student urinates in clean cup
Put on gloves, if performed by someone other than student
Quickly dip the ketone test strip in the cup containing urine
Wait seconds
Read results at designated time
Record results, take action per Health Care Plan
Urine Ketone Testing Instructions:
1. Gather supplies:
vial of ketone strips,
urine cup
2. Student urinates in clean cup.
3. Put on gloves, if performed by someone other than student.
4. Dip the ketone test strip in the paper cup containing urine.
5. Wait seconds, as indicated on the directions printed on the bottle label.
6. Read the results at the designated time by comparing the color on the strip to
the color chart printed on the label on the bottle.
7. Record results and take action per DMMP.

75. Test Results: Color code
no ketones
trace
small
moderate
large ketones present
When recording results record the descriptor from color coding on the packaging.
Record both the word and numerical result labels.
Note: At this point in the training the instructor of training demonstrates checking of urine ketones and how to read results when compared to color coding on packaging.

76. Documentation
Record your findings on the Diabetes Monitoring Log under the column “Ketones.”
Under “comments” record what actions you took.
Your actions should correspond to the instructions on the Algorithms for Blood Glucose Results form.