Medication Administration Sign In

Medication Administration Sign In

Welcome Thank you for all the juggling you do!!!

Santa Rosa City Schools
Presented by District Nurses Cheryl Closser, RN, MSN, PHN Beth Munns, RN, BA, BSN, PHN Jennifer Rodriguez, RN, BSN, PHN Nicholo Concordio Atup, III, RN, MAN Sangmo Witzman, RN, BSN October 17th and 18th 2016

Presentation Contents:
Welcome and Introduction Medication Administration Training Caring for Medically Fragile Students Other Important Health Tasks Immunizations/CAIR First Aid For Common Injuries Head Injury/Concussion Anaphylaxis Asthma Seizure Disorder Fainting Heart Conditions/AED Diabetes Questions & Concerns

Purpose of Medication Administration Training:
 Allows designated school personnel to administer medication to pupils as allowed by law. (California Code of Regulations, Title 5, Education Code )  Prior to administration, parent must provide: ◦ Order from a healthcare provider stating name of student, birth date, medication name, health condition for which it is prescribed, route (method of administration), dose, time/frequency, possible side effects and whether or not the student is allowed to carry an emergency medication. Form must be filled out completely including signatures from parent and doctor with dates. ◦ A written statement from parent or guardian consenting for assistance regarding medication administration as stated by healthcare provider ◦ Medication delivered to school in the original, labeled container

Accepting Medication Confirm that the name of the drug and dosage matches the physicians orders. Carefully check the contents of the container to verify that the description of the dosage on the prescription label is a match to the physician's written orders. Check the expiration date on medication. Accurately count the number of pills in the prescription container and record the total amount on the master log (MAR) with parent.

Accepting Medication Copy of doctors orders must be placed in 1) health file, 2) med book, 3) with medication (disaster preparedness). Tag new order in medication binder with sticky note. The same rules apply to all medications: including over the counter, supplements, herbs and alternative treatments, etc. Ensure medication is locked up immediately!!

Medication Administration 7 Critical Rights
Right Student Right Medication Right Dose Right Route Right Time Right Documentation Right Response Example asthma symptoms gone

See nurse website for Medication Administration Authorization Form

Medication Administration Record (MAR)
Documentation of the administration of medication is done on a medication administration record, also referred to as the MAR. Not only does the MAR document med. admin., but it serves as a safety measure to ensure the right medication is given to the right student.

MAR-Completion Must Include
Student’s Name Date Time Name of the person administering the medication which must be identifiable and neatly recorded on the MAR

MAR & Documentation Continued
Complete log in ink, with time, and your initials, when you assist or observe student using medication. Sign and initial bottom of medication log. If student takes meds regularly, document reason for any missed doses. i.e.. Student is absent. Print a list of the students who take medication at school on a regular basis in the front of the medication binder. You can also place a list of those taking emergency medications.

Time Initials If student takes meds regularly, must mark reason for any missed dose Explain the MAR: -Top box for time and bottom for initial -W: if med was dropped or tossed away and “*” and put the date/time/med that was ACTUALLY administered. -If student takes meds regularly, need to mark reason (A or P or D) for missed dose For meds dropped or tossed away. Document on reverse side. Then also document the medication was given.

Count pills when medication is dropped off
-Drop off med, need to be logged in back, need to count pills, need 2 people to verify the number of pills If student needs to take medication more than once, put “*” and write in date, time, med, and initial on the reverse side

Medication Documentation (cont.):
All prescription medications must be counted and the number documented on the reverse side of the Medication Administration Record (MAR). Two adults (parent) count the number of pills (without touching them) and both adults sign for the medications that have been brought in. To protect yourself: if you find an incomplete order, document and date what you are doing to resolve the problem.

MAR-Mistakes Never white out or scribble over documentation
If a documentation error is made, simply line out the single line and initial the mistake you made, then add the correct information.

Errors and Discontinued Meds:
Report errors immediately: Site administrator School nurse Parent/Guardian Document error on MAR and medication error form. Fill out incident report (RESIG) if student was injured as a result. Discontinued/Outdated Attempt to return. When disposing of medication (with school nurse or site administrator) place in blue container. There are now three containers: red for sharps, blue for meds, and black for narcotics. Error: wrong time (or missed dose), wrong student, wrong dose, etc. Write explanation on back of MAR next to “*” in regards to what happened

Medication Admin Changes
Any changes must be in writing from the physician. Changes may be brought into school by parent or faxed, but physician and parent must still sign. Notify District Nurse of Changes and New Medication Orders.

Medication storage Must be stored in centrally located, LOCKED cabinet. Do not allow student access to med cabinet. Refrigerators for med storage must be locked and reserved only for meds! Never leave unlocked medication unattended.

Medication Binder Organization:
Insert Medication Administration Record (MAR) and Emergency Care Plans alphabetically by last name, please use alphabetical file tabs. If student has a separate binder/folder, a copy of the Emergency Care Plan must also be placed in the medication binder. A list of students taking daily medication should be placed in the front of the binder. For field trips it is helpful to have a list of all students taking medication at your school site. Especially elementary schools!

Communication with School Nurse
Label on medication container and medication authorization form must match, notify your school nurse immediately if they do not. Notify District Nurse of Changes and New Medication Orders by placing sticky note in binder. Any problems or questions….contact your school nurse!

Time to take a Test, Are you ready?

Medically Fragile Students
These are students that require emergency care plans (ECPs) and/or Individualized Student Health Plans (ISHP). For example, students with Seizure Disorder, Diabetes, Anaphylaxis, or other genetic disorders, etc. Make sure in an emergency to check the med alert triangle or emergency card for pre-existing conditions.

Medically Fragile Students-Forms
Please give a copy of a blank “preformatted” form for Seizure Disorder, Anaphylaxis, Asthma, and Diabetes to parents and/or students with known diagnosis. Must be completed, signed, and returned before student starts school. When plan is returned, tag with sticky note in binder, staple to emergency card, and notify school nurse via or call, depending on urgency.

Medically Fragile Students-How to Access Forms
Forms are available on the SRCS nurse website To access: Go to SRCS website Click on District at top Scroll down left column, click special services Scroll down left column, click nurses

Medically Fragile Students-Forms for Staff/Teachers:
Elementary schools should have a red binder in the staff room with completed care plans for staff to review. Teachers should keep copies of student’s emergency plans in their classrooms (red binder/folder). The purpose is for teachers and substitute teachers to be aware. This information must be kept confidential.

Medically Fragile Students Forms-Continued
Keep existing ECPs and ISHPs in medication administration binder until new plans are received. When new plans are received, place in binder, place old forms in student’s health file. If plan is already in file send a copy to the shredder. We only need one copy in the health file.

Ensuring Confidentiality & Privacy:
Be aware of surroundings when speaking about students and any medical conditions. Keep paper work and files confidential; please do not post private information on walls. Do not allow student access. Please review s before sending. On s be aware when carbon copying, replying to one vs. all etc.

Entering Information in eSchools:
Enter emergency card information ASAP! Enter diabetes under diabetes not other mod. Problem. Use categories. Please add your initials and date to med alert entry. Ask your nurse about any med alert questions Notify staff of any urgent matters i.e. PE restrictions, MD notes addressed to staff. Generate health problem list and distribute to appropriate staff. Example: Food allergy list for kitchen. Asthma list for PE teacher, etc. Notify nurse of any serious health conditions. Doctors notes can now be scanned and ed to all teachers/staff on a need to know basis. This is very important because the district nurse may not see these notes until weeks/months later.

Maintaining the Health Office:
Ensure all equipment is functioning correctly. ie. Refrigerator, ice maker. Supplies are stocked, organized and accessible. Health office is clean, there should not be any food in the office. Example: Clean bed after every use. Ensure Emergency First Aid bag is ready to go, along with student medications, logs and emergency cards for disasters. Get a cart to place supplies for emergency disasters. Earthquake drills. Contact your administrator!

Field Trips: Tell staff at your school that they must give you two weeks notice before field trips. You will give the trained staff a COPY of the medication authorization form and the medication on the day of the trip. Instruct teacher to document the time the medication was given. Assist with official documentation when medication is returned. Add documentation of trained staff in the back of the med binder. Picture: archive.longislandpress.com

Immunization Information:
New State Law SB266 Began July 1, 2016: No longer permits immunization exemptions based on personal beliefs for children in childcare, public, and private schools. Permits personal belief exemptions submitted before January 1, 2016 to remain valid until a pupil reaches kindergarten or 7th grade.

What this means? No personal belief exemptions accepted after December 31, 2015. Medical exemptions are still acceptable. Records must be checked for Kindergarten and 7th grade. i.e. You do not have to go through every record of every student 1st - 6th to determine whether or not they have their immunizations. New students must also be reviewed.

What else? Removes immunization requirements for:
Students in home based private schools Students enrolled in an independent study program who do not attend classes at school. Students receiving IEP services “ONLY” on campus i.e. speech, occupational therapy. Note: Immunizations are required for students with IEPS that attend classes on campus. Our administrators/legal counsel recommends allowing them to come to school but records must be checked every 30 days and parents reminded to bring in their child’s records.

Additional Information
Students need to provide immunization records to their schools before entry! Schools must report to the California Department of Public Health the immunization status of all students at the Pre-school, Kindergarten, and 7th grade levels annually.

How to report immunizations
Go to shotsforschool.org After choosing grade level and school site, passwords are located on the website, towards the bottom. Complete state reports for K and 7th grade Notify your school nurse when complete Notify nurse if you have any questions or concerns. Show them how to report!

Conditional admittance
He/she is missing a dose(s) in a series, but the next dose is not due yet. Refer to California Code of Regulations at for specific questions. Has a temporary medical exemption to certain vaccine(s) and has submitted an immunization record for vaccines not exempted. Awaiting records for transfers from within California or from another state. Allow 30 days before exclusion. See page 9 of § School/Child Care Facility Immunization Record. e) For pupils transferring between schools within California or from a school in another state to a school in California, if the mandatory permanent pupil record or other immunization record has not been received at the time of entry to the new school, the governing authority of the school may admit the pupil for a period of up to 30 school days. If the mandatory permanent record or other immunization record has not arrived by the end of this period, the governing authority shall require the parent or guardian to present a written immunization record, as described in Section 6065, documenting that all currently due required immunizations have been received. If such a record is not presented, the pupil shall be excluded from further attendance until he or she comes into compliance with the immunization requirements, as outlined in Sections 6020, 6035, and 6065.

Conditional admittance cont’d
When transferring into a new school a student who is homeless or in foster care may be admitted immediately if the student arrives without immunization records. Schools should utilize their resources to make sure these students have received all required immunizations as soon as possible. Note: Students from out of the country must have their records to start school. Conditional admittance does not apply if you are not waiting for records.

Maintaining records Maintain a list of unimmunized children (exempted or admitted conditionally), so they can be excluded quickly if an outbreak occurs. Notify parents of the deadline of missing doses. Use the forms listed on the SRCS website or contact your school nurse for exclusions. Once the exclusion form has been sent they have 10 school days. Review records every 30 days until all required doses are received.

CAIR: (California Immunization Registry)
Please review form; add and school Promise of CONFIDENTIALITY Password and User Name Contact if you need to access CAIR CAIR web information

Questions? http://eziz.org/assets/docs/IMM-1080.pdf

Basic First Aid: Provide as much privacy as possible.
Follow universal precautions. Document all visits to the Health Office (in pen) may use paper or computer log. To maintain confidentiality document students individually. Ensure 911 is called if situation warrants, and notify administration, parents and school nurse.

Universal Precautions:
Wash hands before and after first aid treatment and before and after giving medication. Wear gloves when in contact with blood and other body fluids. Also, if touching meds. Call janitorial staff for clean up of excess bodily fluids Wipe down beds after each use, if blankets are used wash between uses. Keep health office area clear of food and beverages.

Nose Bleeds Sit upright, lean slightly forward.
Pinch soft part of nose above nostrils, 10 minutes, repeat if needed. May use ice on bridge of nose if needed. To prevent re-bleeding, advise students not to blow/pick nose or bend down for several hours. If nosebleed lasts more than 20 minutes, or follows an accident, fall or head injury call parent and/or 911.

Head Injury vs Concussion
Injury to the skull, scalp or brain. Injury may range from a minor bump or scrape on the head to a more severe brain injury Concussion a type of brain injury that changes the way the brain normally works. Is caused by a bump, blow, or jolt to the head. Can also occur from a fall or blow to the body that causes the head and brain to move rapidly back and forth.

Head Injury: All head injuries must be taken seriously.
Use concussion checklist (concussion checklist) as an informational tool. Severe symptoms usually develop within 24 hours but can occur several weeks later. Always notify parents and give head injury form (on website) with signs & symptoms and when to seek care. If a student is diagnosed with concussion, doctor’s note required for student’s return to school.

Basic First Aid for a Head Injury:
Ice for head or neck Provide darkened, quiet room Ask simple questions, use concussion checklist (what is your name, where are you?) Observe body language, personality, balance Do not leave student alone and monitor for worsening of symptoms Keep in health office and re-evaluate student at 15 and 30 minutes A visit to the doctor is needed anytime mild symptoms persist.

In case of severe head trauma:
If found unconscious assume the neck is injured and stabilize. DO NOT MOVE! Call 911. Stop any bleeding with pressure unless you suspect a skull fracture, no direct pressure. Open airway, watch for breathing. CPR if needed. If severe head trauma occurs: Keep the person still. Until medical help arrives, keep the injured person lying down and quiet in a darkened room, with the head and shoulders slightly elevated. Don't move the person unless necessary and avoid moving the person's neck. Stop any bleeding. Apply firm pressure to the wound with sterile gauze or a clean cloth. But don't apply direct pressure to the wound if you suspect a skull fracture. Watch for changes in breathing and alertness. If the person shows no signs of circulation (breathing, coughing or movement), begin CPR. 48

Common Symptoms of Concussion
Appears dazed, stunned, and/or confused Loses consciousness (even briefly) Memory, behavior or personality changes Balance problems or dizziness Double or blurry vision Headache and/or sensitivity to light or noise Feels tired, sluggish, hazy, foggy or groggy Nausea and/or vomiting Just not feeling right or feeling down Requires a hospital visit! Need doctor’s note to return to school.

When is Head Injury a Medical Emergency? Call 911 if…
Blood or clear fluid in the ears or nose Loss of consciousness Increasing confusion Worsening headache Drowsiness or cannot be awakened Persistent vomiting or nausea Unusual behavior Difficulty breathing One pupil larger than the other Mood changes Loss of balance Weakness, numbness, and/or decreased coordination Speech problems Severe head/facial bleeding Seizures 50

What is Severe Allergy/Anaphylaxis?
A severe and potentially life-threatening allergic reaction which can occur within seconds or minutes of encountering an allergic trigger.” (Ed. Code Section 49414) In some cases reaction may be delayed for 1 to 3 hours. Or symptoms may go away, but then return a few hours later. Anaphylaxis is always a medical emergency Act immediately, You can save a student’s life! Students with asthma & allergies have a higher risk of complications with breathing.

New Law (SB 1266): “Schools shall be provided epinephrine auto-injectors (Epi-Pens) in order to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an anaphylactic reaction.” SB1266

Who can administer? School Nurses
Trained volunteer employees This is voluntary; there will be an annual call for volunteers to learn EpiPen administration and identify serious allergic reactions. “each employee who volunteers under this section will be provided defense and indemnification by the school district, county office of education, or charter school for any and all civil liability…” SB 1266

Symptoms of Anaphylaxis:
Eyes: red, puffy Nose and mouth: swollen lips, swelling and/or itching of tongue, metallic taste Stomach: nausea, vomiting, cramping and diarrhea Skin: rash, itching, redness, hives, swelling of any body part

Symptoms of Anaphylaxis cont’d
Head: confused, disoriented, sense of pending doom Heart: pale, weak, dizzy, faint, loss of consciousness, shock Lungs and Throat: difficulty breathing in and out, hoarseness, swelling of throat, change in voice, asthma symptoms, i.e. shortness of breath, wheezing, repeated coughing, difficulty walking, talking

What Kids Could Say: Look I have small red bumps
I’m really itchy all over I feel like throwing up My stomach hurts My heart is beating really fast My throat hurts I can’t swallow I can’t breathe I’m scared I’m dizzy

Common Anaphylaxis Triggers:
Nuts Shellfish Latex Insect Sting/Bee Variety of Foods Medication/Chemical Reaction Plants Exercise Other Unknowns See nurse website for Severe Allergy/Anaphylaxis Care Plan

What is an Epinephrine Auto-Injector (Epi-pen)?
Epinephrine is an injectable form of adrenaline used to treat life-threatening allergic reactions. Adrenaline is a hormone produced by the body.

When do you give an Epi-pen?
1) Once there are sign(s) or symptom(s) of anaphylaxis and/or 2) It is suspected or known that student has had exposure to an allergen

Two strengths: Above 66 lbs. = 0.3 mg (yellow)
33-66 lbs. = 0.15 mg (green) . According to the California School Nurses Organization, “when in doubt administer adult dose”

How to Administer Epi-Pen:
 Form a fist around the Epi-pen. Pull off the Safety Cap.  Never put thumb, fingers, or hand over the black/orange tip.  Swing and jab the tip firmly into the OUTER THIGH at a 90 degree angle. Hold the leg still, prevent movement.(Can be injected through clothing.)  You will hear a click. Hold the EpiPen in place for 3 seconds (count slowly) Remove & massage the injection area for several seconds. (After the injection, they may feel their heart pounding. This is normal.)  Check the black/orange tip: If the needle is exposed the dose was delivered, if not repeat above steps.

How to Administer Epi-pen (cont.):
 Give epi-pen while someone calls 911. If alone, give epipen first, then call 911. Do not leave student alone.  Epi-pen may only last minutes. If symptoms return give 2nd Epi-pen minutes after first dose. - For severe allergic reaction, do NOT give Benadryl first because it takes minutes to work.  If insect sting, remove stinger/apply ice to sting area. Scrape stinger out, do not pull out.  Give used Epi-pen to paramedics Always call 911. Some individuals will have an anaphylactic reaction that goes away and returns a few hours later. Therefore, after exposure or a serious reaction observation in the hospital is necessary.

How to Administer Epi-pen (cont.):
Observe for signs of shock (i.e. clammy skin, sweating, agitation, shallow breathing, nausea/vomiting, etc.) Cover with blanket if cold, raise legs if possible. Encourage student to remain calm & still. Watch breathing. Begin CPR as needed. Document the incident and send a copy to your school nurse and administrator.

Side Effects of Epinephrine
Anxious feeling Fast heartbeat Nausea Headache Pale Shaky Let the person know these are common side effects and will go away. Remain calm. Provide reassurance.

Care of Epinephrine Auto-Injectors:
Stock Epi-pens will be kept in a prominent location, to be determined at each site. They should not be locked up. They are to be stored at room temperature – never refrigerated. Solution should be colorless, replace if not. When one is used or expired, contact your School Nurse or Health Services within 24 hours and it will be replaced within 2 weeks. If a specific student has an Epi-Pen, it should only be used by that student, and it should be taken on field trips with its owner. The stock Epi-Pens stay at school and do not go on field trips. Document the date, number, and type of auto injectors, lot number, and expiration dates of auto-injectors received.

Resources American Academy of Allergy, Asthma and Immunology (AAAAI)
American Academy of Pediatrics (AAP) California Department of Education California Department of Public Health California Medical Association (CMA) California School Nurses Organization (CSNO) Emergency Medical Systems Authority (EMSA) Food Allergy Research and Education National Association of School Nurses CPR training: American Heart Association American Red Cross

Epi-pen Quiz Time

What is Asthma?

Asthma Triggers Allergens (mold, dust, pollen, animals etc.)
Chemicals (sulfites, aspirin, etc.) Emotions (stress, crying, excitement) Exercise Irritants (perfume, cleaning fluids, smoke) Respiratory Infections (cold, flu, sinus) Seasonal/Time (day vs. night) Smoking Image Retrieved from:

Asthma Symptoms May Include:
Wheezing Frequent Cough Chest Tightness Shortness of Breath Difficulty Walking or Talking

Asthma Medications Three Types: Please call nurse if unsure of the type of inhaler provided. Rescue Maintenance Steroid Reversing Medication

Rescue Inhaler Rescue Inhaler/Symptom Relieving: FOR SCHOOL
Example: Albuterol/Ventolin/Pro Air HFA

Maintenance Inhaler Maintenance/Preventative: Home Use
Example: Advair, Q Var, Dulera No inflammation=no muscle irritation=no tightening of the breathing tubes.

Steroid Flare Up Reversing Medication Example: Prednisone

Asthma Medication Side Effects:
Rapid Heart Rate Tremors or Shakiness Nervousness Headache

3 Steps for Asthma Episode
Help to sit upright; stay calm and reassure Follow Emergency Action Plan &/or Doctors order for use of rescue inhaler Get help from school nurse or notify parent if student has any of the following:  Inhaler not helping  Breathing hard and fast  Can’t walk or talk well  Call 911 if needed

Call 911:  Struggling to breathe (hunched over, ribs show, etc.) or not breathing  Unconscious  Lips are blue  Other signs of distress Always notify Parent/Guardian, Administrator, and District Nurse

Asthma Inhaler Use Remove the cap and hold the inhaler upright.
Shake the inhaler Tilt your head back slightly and breathe out. Press down on the inhaler to release the medicine as you start to breathe in slowly. Breathe in slowly for 3 to 5 seconds. Hold your breath for 10 seconds to allow medicine to go deeply into your lungs. Repeat puffs as directed. Wait 1 minute between puffs to allow the second puff to get into the lungs.

Six Ways to Administer Medication:

Asthma Action Plan: Please have parents and/or doctor complete the plan for students that have significant difficulty with their asthma See nurse website for Asthma Action Plan

What is Epilepsy/Seizure Disorder?
A brief, excessive discharge of electrical activity in the brain that alters one or more of the following: Movement Sensation Behavior Awareness Most Seizures are NOT medical Emergencies!

Types and Signs of Seizures:
Generalized Seizures: (seizures involving the entire brain) *Tonic-Clonic (generally last 1 to 3 minutes; sudden, loss of consciousness, convulsions, stiffening and/or jerking of extremities) *Absence Seizures(generally last 1 to 10 seconds, lapse of awareness, blank stare, pause in activity) Partial Seizures: (seizures involving only part of the brain) *Simple/Complex Partial (awareness maintained and/or impaired, psychic/sensory symptoms, inability to respond)

Epilepsy/Seizure Disorder Treatments:
Anti-epileptic drugs (i.e. keppra (oral), diastat (rectal), etc. Surgery Vagus nerve stimulation implant Ketogenic diet – a high fat, low carbohydrate diet

Possible Seizure Symptoms

Seizure Triggers and Precipitants:
Flashing lights and hyperventilation can trigger seizures in some students with epilepsy Factors that might increase the likelihood of a seizure in students with epilepsy include: Missed or late medication (#1 reason) Stress/anxiety Lack of sleep/fatigue Hormonal changes Illness Alcohol or drug use Drug interactions (from prescribed or over the counter medicines) Overheating/overexertion Poor diet/missed meals

What to do during a Seizure:
Remain calm Time seizure Ensure safety Clear the area Cushion head, remove glasses Turn on side, loosen any tight clothing Nothing in mouth; don’t hold down Protect privacy After: reassure and stay with them

When is a Seizure an Emergency? Call 911:
Convulsive (tonic-clonic) seizure > 5 minutes Please refer to individual student health plan & consult with your nurse. First Time Seizure Repeated seizures without regaining consciousness Injured or other medical condition Breathing difficulties Possible pregnancy

See nurse website for Seizure Action Plan
For further information: Epilepsy Foundation Information and Referral. (800)

Fainting-Vasovagal Syncope:
Student faints in response to trigger i.e. sight of blood, heat, lack of food or water, fear of injury, standing for a long time If a student loses consciousness, call 911 Student should be checked by MD, especially if it is a first occurrence. If known history follow health care provider’s orders. Hearbeat slows blood vessels in legs relax causing drop in BP leading to brief LOC

Heart Conditions and AEDs:
AED can save a life AED awareness training must occur annually at your school sites. At least one person on site at all times must be CPR certified. AED’s must be registered at Coastal Valley EMS Place device in visible location for anyone to use.

Monthly AED Readiness Check
Date Functional (green light) Adult Padpak Exp. date Ped Padpak Exp. date Signature

Stretch Break

Diabetes Management in Schools

What is Diabetes? In diabetes: Insulin is needed to:
Body does not make or properly use insulin Insulin is needed to: Move glucose from blood into cells for energy If insulin isn’t working, high blood glucose results: Energy levels are low Dehydration Complications Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy by moving glucose from blood into the cells. People with diabetes have increased blood glucose (sugar) levels for one or more of the following three reasons: Either Little or no insulin is being produced, Insulin production is insufficient, and/or The body is resistant to the effects of insulin. As a result, high levels of glucose build up in the blood, and spill into the urine and out of the body. The body loses its main source of fuel and cells are deprived of glucose, a needed source of energy. High blood glucose levels may result in short and long term complications over time.

Type 1 Diabetes Autoimmune disorder Insulin-producing cells destroyed
Daily insulin replacement necessary Age of onset: usually childhood, young adulthood Most common type of diabetes in children and adolescents Type 1 Diabetes Type 1 diabetes is an auto-immune disorder. In type 1 diabetes, the immune system attacks the beta cells, the insulin-producing cells of the pancreas, and destroys them. The pancreas can no longer produce insulin, so people with type 1 diabetes need multiple daily administrations of insulin to live. Type 1 diabetes can occur at any age, but the disease develops most often in children and young adults. Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States.

Type 2 Diabetes Insulin resistance – first step Age at onset:
Most common in adults Increasingly common in youth overweight inactivity genes ethnicity Type 2 Diabetes Type 2 diabetes is the most common form of diabetes. In type 2 diabetes, either the body does not produce enough insulin or the cells ignore the insulin. In Type 2 diabetes, either the pancreas is unable to make enough insulin or the body cells have become less responsive to insulin, a condition called insulin resistance. With insulin resistance the body needs increasing amounts of insulin to control blood glucose. In response, the pancreas tries to make more insulin, but sometimes cannot make enough. Type 2 diabetes used to be found mainly in adults who were overweight and over age 40. Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people. Many people with type 2 diabetes are overweight.

Diabetes is Managed, But it Does Not Go Away.
GOAL: Maintain target blood glucose Diabetes is managed with medication, nutrition, physical activity and glucose monitoring, but there is NO cure. When the body doesn’t produce insulin, it must be obtained from another source. All people with type 1 diabetes must take insulin by injection to live. Many people with type 2 diabetes take glucose-lowering medications which can be taken orally or by injection. Many youth with type 2 take insulin, often in addition to other glucose lowering medications. People with both types of diabetes also need to manage their diet and physical activity. Neither insulin nor other medications, however, are cures for diabetes: they only help control the disease. With both type 1 or type 2 diabetes, the goal of effective diabetes management is to control blood glucose levels by keeping them within a target range that is individually determined for each child. Optimal blood glucose control is essential to: Promote normal growth and development and allow for optimal learning. Prevent the immediate dangers of blood glucose that is either too high or too low. Additionally, research has shown that maintaining blood glucose levels within the target range can: Prevent or delay the long-term complications of diabetes such as heart attack, stroke, blindness, kidney failure, nerve disease, and amputations of the foot or leg.* *While it is important for school personnel to be aware of the potential for these serious life-limiting or life threatening complications, it is not appropriate for school personnel to discuss risks for complications with individual students.

Diabetes Management Constant Juggling - 24/7
Insulin/ medication with: Physical activity BG BG BG Maintaining good blood glucose control is a juggling act, 24 hours a day, 7 days a week. The key to optimal diabetes control is a careful balance or juggling of food, physical activity, and insulin and/or oral medication. As a general rule: Insulin/oral medication and physical activity makes blood glucose levels go down. Food makes blood glucose levels go up. Several other factors, such as stress, illness or injury, also can affect blood glucose levels. and Food intake

Diabetes Management Routine Care:
Many students will be able to handle all or almost all routine diabetes care by themselves Some students will need school staff to perform or assist with routine diabetes care Emergency Care: ALL students with diabetes will need help in the event of an emergency situation The need for performance of or assistance with diabetes care tasks will vary from student to student. Routine Care: Many students will be able to handle all or almost all of their routine diabetes care by themselves – they can check their own blood glucose, and they can dose and give their own insulin or medication, keeping it in balance with physical activity and food intake. Some students, because of age, developmental level, or inexperience, will need help from school staff, including performing tasks like insulin administration, blood glucose monitoring, or carbohydrate counting. Emergency Care: ALL students with diabetes will need help in the event of an emergency situation. The level of care and assistance will be outlined in the Diabetes Medical Management Plan (DMMP) agreed upon by the health care provider, parent/guardian, school nurse and student.

Diabetes Medical Management Plan (DMMP)
Basis for all school-based diabetes care plans Developed by student’s personal health care team and parent/guardian Signed by a member of student’s personal health care team Individualized Implemented collaboratively by the school diabetes team: School nurse Student Parent/guardian Other school personnel The Diabetes Medical Management Plan (DMMP) is the foundation for the development of any and all school-based care plans. The DMMP is the medical basis for an Individual Health Care Plan (IHP) written by the school nurse, a Section 504 Plan or Individualized Education Program (IEP), as well as a Quick Reference Emergency Plan. A DMMP should be implemented for every student with diabetes. (This type of plan may have a different name in some school districts, or by some health care providers.) The DMMP is developed and signed by the student’s personal health care team and parent/guardian with the specific needs of an individual student in mind. It should detail all the elements of care and assistance for that student. Once the DMMP has been provided to the school, it is implemented collaboratively by the school diabetes team, which includes the school nurse, student, parent/guardian, and other school personnel. Details regarding how, when, where and by whom the elements of the DMMP will be implemented should be documented in writing. Many school districts have their own individual health plan forms where the school nurse documents information on diabetes care. Additionally both health and academic accommodations related to diabetes should be included in broader education plans for students with disabilities. For example, under Section 504 of the Rehabilitation Act of 1973, a federal law, students with diabetes are entitled to reasonable accommodations to ensure equal access to public education. A 504 plan should be written to document diabetes-related accommodations needed by an individual student. Some students with diabetes will also be eligible for special education. For these students, diabetes care needs should be documented in the Individualized Education Program (IEP) that is required by another federal law, the Individuals with Disabilities Education Act (IDEA). Information and a sample DMMP and 504 plan can be found on the American Diabetes Association Website at:

Quick Reference Emergency Plan
Summarizes to how to recognize and treat hypoglycemia and hyperglycemia Based on information from DMMP Distributed to all personnel who have responsibility for student with diabetes The Quick Reference Emergency Plan summarizes how to recognize and treat hypoglycemia and hyperglycemia. Based on information from student’s DMMP Developed by school nurse with input from parent/guardian Distributed to all personnel who have responsibility for a student with diabetes. A sample Quick Reference Emergency Plan for the recognition of hyperglycemia and hypoglycemia is available in the National Diabetes Education Program’s (NDEP) Guide Helping the Student with Diabetes Succeed: A Guide for School Personnel. This guide can be viewed and downloaded from Some schools may have their own emergency care plan forms – and will vary in what they call the forms. However, regardless of what the form is called, it should include the basics as set out in the NDEP manual.

Diabetes Monitoring Log
For the supervision of diabetic students at school. Let your nurse know if you have a student that requires supervision.

Vocabulary-Hypoglycemia
Glucose - simple sugar found in the blood; fuel that all body cells need to function HYPOglycemia - a LOW level of glucose in the blood Quick-acting glucose - sources of simple sugar that raises blood glucose levels, like juice, regular soda, glucose tabs or gel, hard candy 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 Carbohydrate - source of energy for the body which raises blood glucose level Glucagon - hormone given by injection that raises level of glucose in the blood 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. 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. Glucagon - a hormone given by injection that raises the level of glucose in the blood.

HYPOglycemia = LOW Glucose (sugar)
Onset: sudden, must be treated immediately may progress to unconsciousness if not treated can result in brain damage or death DMMP should specify signs and action steps at each level of severity: mild moderate severe Hypoglycemia = low blood glucose level. Hypoglycemia is a low level of glucose in the blood. Onset: Sudden, usually mild, but will progress if not treated. May even progress to symptoms of unconsciousness and seizures and if not treated, can lead to 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

Hypoglycemia: Risks & Complications
Early recognition and intervention can prevent an emergency Greatest immediate danger Not always preventable Impairs cognitive and motor functioning While a hypoglycemia episode is an urgency, it need not become an emergency. Most hypoglycemic episodes are mild, with students responding to eating a quick acting carbohydrate such as fruit juice or regular soda within minutes. Recognizing early symptoms and always having access to appropriate foods are the surest way to prevent an emergency. Hypoglycemia is the greatest immediate danger to students with diabetes. Most often students will be able to recognize and treat the early symptoms of hypoglycemia. Occasionally, however, a student might miss the early symptoms. When this happens, 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 be life-threatening. Hypoglycemia is one of the most frequent complications of diabetes. It can happen very suddenly and is not always preventable. Hypoglycemia can impair 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 or soda lid. Some students may become combative and hypoglycemia may be mistaken for misbehavior.

Hypoglycemia: Possible Causes
Too much insulin Too little food or delayed meal or snack Extra/unanticipated physical activity Illness Medications Stress Hypoglycemia or “lows” occur whenever there is too much insulin in the body for the amount of glucose. This imbalance can happen for three main reasons: Too much insulin has been administered Too little food has been eaten Extra/unanticipated physical activity Illness Medications Stress A student may have gotten too little food for a variety of reasons: The student may have not finished a meal or snack The student may have overestimated the amount of carbohydrate in a food or snack A meal may have been delayed or skipped altogether. There are no restrictions on physical activity for students with diabetes. However, when students are more active than usual at insulin peak times, they may experience low blood glucose.

Hypoglycemia: Possible Signs & Symptoms
Mild Symptoms Hunger Sleepiness Shakiness Changed behavior Weakness Sweating Paleness Anxiety Blurry vision Dilated pupils Increase heart rate or palpitations Moderate to Severe Symptoms Yawning Confusion Irritability/frustration Restlessness Extreme tiredness/fatigue Dazed appearance Inability to swallow Unconsciousness/coma Sudden crying Seizures The symptoms of hypoglycemia vary from one individual to another. Also, they may vary for one individual, from one episode to another. The symptoms of mild hypoglycemia are the first alert that the body is in a state of sugar deficiency. Symptoms may include the following: Extreme hunger  Shakiness Tremors  Dizziness Lethargic  Headache Increased heart rate/palpitations  Dilated pupils Pallor  Clammy skin Sweating  Anxiety Changed personality Mild hypoglycemia can usually be treated easily and effectively. Most episodes of hypoglycemia that will occur in the school setting are of the “mild” type. However, if not treated promptly a mild hypoglycemic reaction can quickly progress to a severe state or condition which may be characterized by: Yawning  Irritability/frustration Behavior/personality changes  Extreme tiredness/fatigue Sudden crying  Restlessness Confusion  Inability to swallow Dazed Appearance  Seizures, convulsions Unconsciousness/coma jerking movements Remember, onset and progression can happen very quickly. Each student will have his/her own set of symptoms that characterize hypoglycemia. These should be listed in the DMMP. The important thing to remember is that early recognition and intervention is the best strategy to prevent progression to more severe symptoms.

Mild/Moderate Hypoglycemia: What to do
Intervene promptly; follow DMMP: Check blood glucose if meter is available. If no meter is available, treat immediately, on the spot. NEVER send a student with suspected low blood glucose anywhere alone When in doubt, always treat. If untreated may progress to more serious events. Consider “Rule of 15” Intervene promptly when hypoglycemia is mild/moderate 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 check when available. Some students confuse low and high blood glucose symptoms. Students may have symptoms when their blood glucose level is dropping rapidly so treatment must be immediately given. However, if no meter is available, treat for hypoglycemia on the spot. If untreated, low blood glucose may progress to more serious events. NEVER send a student with suspected low blood glucose anywhere alone When in doubt, always treat for low blood sugar. The DMMP will specify treatment for each student. However, the treatment plans for many students will follow closely with the “Rule of 15” as we’ll consider in the next slide.

“Rule of 15” General guidelines, follow DMMP for each student:
Have student eat or drink fast acting carbs (15g) Check blood glucose minutes after treatment Repeat treatment if blood glucose level remains low or if symptoms persist If symptoms continue, call parent/guardian per DMMP “RULE of 15” Have student eat or drink fast acting carbohydrates (15g). May be fewer grams for young, small students. Check blood glucose minutes after treatment Repeat treatment of 15 grams if blood glucose level remains low and recheck at another 15 minutes If symptoms continue or blood glucose levels do not increase, call parent/guardian as specified in DMMP.

Quick Acting Glucose for Mild/Moderate Hypoglycemia
Treatment for Lows: 15 g Carbohydrate 4 oz. fruit juice 15 g. glucose tablets (3-4 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) 3 tsp. table sugar One-half tube of cake mate Any quick-acting glucose can be used to treat hypoglycemia. Limit intake to 15 grams (or other amount as specified in the plan) or the student will experience a high blood glucose later. The goal is to bring the blood glucose back to the target range. Remember: Treatment may need to be repeated at about 15 minute intervals (based on continued low test results or poor symptom response.) 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) 3 teaspoons of table sugar (dissolved in water) One small tube of cake mate gel Younger or very small students might be directed to take 8g of carbohydrate, or about half of the amounts listed on the slide.

Severe Hypoglycemia Symptoms
Convulsions (seizures) Loss of consciousness Inability to swallow Severe hypoglycemia symptoms: Loss of consciousness Convulsions Inability to swallow

Severe Hypoglycemia: What To Do
Rare, but life threatening, if not treated promptly: Place student on his or her side Lift chin to keep airway open Inject glucagon, per student’s DMMP Never give food or put anything in student’s mouth Call 911, then parent/guardian Student should respond in 10 to 20 minutes 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 Lift chin to keep airway open Inject glucagon if provided for in the student’s DMMP Never attempt to give food or put anything in the student’s mouth Identify someone to call 911, and then call parent/guardian The student should respond to the glucagon in 10 to 20 minutes Remain with the student until help arrives When the student is awake and able to swallow, give juice or other quick acting form of glucose followed by a snack while waiting for EMS. Student may become nauseated and vomit after the glucagon injection.

Hypoglycemia: Prevention
Physical activity, insulin, eating, checking BG, per schedule. Keep a quick-acting sugar source with the student. ALWAYS. Treat at onset of symptoms Ensure reliable insulin dosing, per DMMP. Ensure insulin dosing matches food eaten. Watch picky eaters Provide nutritional information to parent/guardian DMMP may specify after-meal dosing The onset and progression of hypoglycemia happens quickly. Knowing and following the basics of prevention is vitally important to a student’s health, learning capacity, safety and feeling of security. Keep a quick-acting source of sugar with the student. ALWAYS. During school hours, extracurricular activities, field trips and exams. Treat promptly at the onset of symptoms. Preventing high or low blood glucose levels is all about keeping the balance between insulin, food, and physical activity. TIMING is very important in all aspects of diabetes management. Eat on time, take insulin on time, check blood glucose on time and physical activity on time. Eating on time will include snacks for some students. Ensure that insulin dosing is accurate, in accordance with the DMMP. The DMMP should specify what assistance, if any, is needed. The same kind of accuracy in “dosing” needs to happen with food as well. With some (especially young) students this may mean supervision and monitoring what is actually eaten. Picky eaters need monitoring. Nutritional information should be provided to students and/or parent/guardian for all school snacks/meals. Some students, especially picky or unpredictable eaters, may have give insulin after eating. The timing of insulin administration will be specified in the DMMP.

Hypoglycemia: Prevention
Consult with parent/guardian or school nurse when snack, meal or physical activity times must be changed. Monitor blood glucose variations on gym days. An extra snack may be required ½ hour before gym or during prolonged vigorous physical activity per DMMP. A student should never be unattended when a low blood glucose is suspected. Maintain adult supervision. A few more prevention strategies: Changes in the timing of snacks, meals, or physical activity should only be made after consultation with parent/guardian and/or health care provider. Monitor blood glucose variations on gym days, an extra snack may be required ½ hour before gym or during prolonged vigorous physical activity per DMMP. A student should never be alone when low blood glucose is suspected. Maintain adult supervision. Don’t over-rely (or under-rely) on the student with diabetes for management information. Consult the DMMP. Remember, many kids with diabetes seem like experts, but their expertise has limits, especially when they are low.

Information for Teachers
Students with hyperglycemia or hypoglycemia often do not concentrate well. Students should have adequate time for taking medication, checking blood glucose, and eating. During academic testing, provide accommodations as per 504 plan or IEP Check blood glucose before and during testing, per plan Access to food/drink and restroom If a serious high or low blood glucose episode occurs, students should be excused with an opportunity for retake 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. Students should have adequate time for taking medication, checking blood glucose, and eating. During academic testing: Students should check blood glucose before and during testing, if specified in their 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.

Vocabulary - Hyperglycemia
Hyperglycemia - too high a level of glucose in the blood 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) - An acute metabolic complication of diabetes characterized by excess acid in the blood which can be life threatening Ketone testing - a procedure for measuring the level of ketones in the urine or blood Glucose - a simple sugar found in the blood. The fuel that all body cells need to function Let’s review a few vocabulary terms related to hyperglycemia: Hyperglycemia - too high a level of glucose in the blood. 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) -Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by excess acid in the blood which can be life threatening. Ketone testing - a procedure for measuring the level of ketones in the urine or blood. Glucose - a simple sugar found in the blood. The fuel that all body cells need to function.

HYPERglycemia = HIGH Glucose (Sugar)
Onset: Usually slow to develop to severe levels More rapid with pump failure/malfunction, illness, infection Can mimic flu-like symptoms Greatest danger: may lead to diabetic ketoacidosis (DKA) if not treated DMMP will specify signs and action steps at each level of severity: Mild Moderate Severe Hyperglycemia is a term that refers to 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. An isolated high blood glucose reading is cause for concern, but not alarm. For example, blood glucose is expected to be somewhat higher following a meal or snack, but it should also drop once insulin starts to work. However, it is also important to note that hyperglycemia can occur more rapidly in students with insulin pumps if a pump malfunctions or delivers less insulin. Illness or infection can also contribute to a more rapid escalation of hyperglycemia. Hyperglycemia becomes an increasing concern when several consecutive readings have been high, or when accompanied by vomiting. As hyperglycemia progresses, the student may be nauseous or be dehydrated and listless – often it looks flu-like. Any student with diabetes who presents with flu-like symptoms should immediately perform a blood glucose check, contact the school nurse and/or parent/guardian as directed by the student’s DMMP. Hyperglycemia most often does not appear to be as dramatic as does low blood glucose – so it is perceived as less threatening. Yet untreated, high blood glucose presents a much greater threat, especially for those students who are dependent on insulin. If there is not enough insulin for any reason - 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). Fortunately, the onset of hyperglycemia and progression to DKA is usually pretty slow. The student’s DMMP should determine precisely what actions should be taken at each level of severity of hyperglycemia.

Hyperglycemia: Possible Signs & Symptoms
Severe Symptoms Labored breathing Confusion Profound weakness Unconscious Moderate Symptoms Dry mouth Vomiting Stomach cramps Nausea Mild Symptoms Lack of concentration Thirst Frequent urination Flushing of skin Sweet, fruity breath Blurred vision Weight loss Increased hunger Stomach pains Fatigue/sleepiness The onset of severe hyperglycemia and progression to DKA is usually pretty slow. As a result, the recognition and treatment of mild hyperglycemia is vitally important. These symptoms vary somewhat from individual to individual, or from episode to episode and can include: Thirst Blurred vision Lack of concentration Weight loss Frequent urination Sweet, fruity breath Fatigue/sleepiness Stomach pains Increased hunger Flushing of skin The following symptoms indicate that hyperglycemia has escalated. Mild symptoms plus: Dry mouth Nausea Vomiting Stomach cramps Sweet, fruity breath This last group of symptoms indicate severe hyperglycemia, and probable ketoacidosis. Mild and moderate symptoms plus: Labored breathing Profound weakness Confusion Unconscious The important thing to remember is that intervention at any of these levels will prevent progression to more severe symptoms.

Hyperglycemia: Risks & Complications
Hyperglycemia, which if untreated can lead to DKA and potentially to coma and/or death (mainly in type 1) Interferes with a student’s ability to learn and participate Serious long-term complications develop when glucose levels remain above target range over time or are recurring There are several important reasons to learn the signs, treatment, and prevention strategies for hyperglycemia. If left untreated for an extended period, hyperglycemia resulting from 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 glucose 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, kidney failure, 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, 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 and enhances their health and well-being in the future.

Hyperglycemia: What to do
Goal: lower the blood glucose to target range. Action steps, following DMMP Verify with blood glucose check Check ketones Allow free use of bathroom and access to water Administer insulin Recheck blood glucose Call parent/guardian Note any patterns, communicate with school nurse and/or parent/guardian To prevent progression, action needs to be taken at the first signs of hyperglycemia, in accordance with the student’s DMMP. 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 student’s DMMP. Generally, the action steps for hyperglycemia are: First of all, verify status with a blood glucose check 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 parent/guardian should be notified immediately when the conditions for contact are present as specified in the DMMP. Note patterns and need for bathroom or water access and communicate with student, school nurse or parent/guardian as specified in DMMP.

Hyperglycemia: Possible Causes
Late, missed or too little insulin Food intake exceeds insulin coverage Decreased physical activity Expired or improperly stored insulin Illness, injury Stress Other hormones or medications Hormone fluctuations, including menstrual periods Any combination of the above The first four items in this list – late, missed or too little insulin, expired or improperly stored insulin, food, physical activity-are the main players. Keeping these in balance is generally what keeps blood glucose from going too high OR too low. Let’s talk about these factors in a little more detail. Too little insulin - Forgetting to “cover” a meal or snack with rapid-acting insulin can happen. A concern is when students have not taken their long-acting or basal insulin. Students on pumps are especially vulnerable to high blood glucose, if their infusion site pulls out or occludes, preventing basal insulin delivery. 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 physical activity. Other factors may also play a role: Expired or “spoiled” insulin: Sometimes insulin that is beyond expiration or has been stored improperly can lose it’s potency and can cause hyperglycemia. Illness, injury, infection – an otherwise “unexplained” high glucose reading may be a sign of onset of illness. Stress. Hormone fluctuations, including menstrual periods. Other hormones, such as glucagon, growth hormone, adrenaline, cortisol or medications.

Hyperglycemia: Prevention
Timing is very important – stick to the schedules: Meal time, insulin administration, physical activity Accuracy is very important Insulin dose, monitoring the amount and type of food eaten Changes should only be made after consultation with the parent/guardian and/or school nurse Snack, meal, or insulin or physical activity times or amounts Because severe hyperglycemia is generally slow to develop, school personnel can do a lot to prevent or minimize hyperglycemia by doing the following: First of all, timing is very important in all aspects of diabetes management. Eat on time, check blood glucose level on time, take insulin on time, and physical activity on time. Ensure that insulin dosing is accurate, according to guidelines in the DMMP. The DMMP should specify what assistance, if any, is needed. Take appropriate action according to DMMP if a missed dose of insulin is suspected or if an insulin pump malfunctions. The same kind of accuracy in “dosing” needs to happen with food as well. Many students will be able to choose foods independently if provided with carbohydrate information. However, some students may need assistance or monitoring as indicated in the DMMP. “Extra snacks” can be a problem if not worked into the overall meal plan for the day. On the other hand, many special snacks can be accommodated in consultation with the parent/guardian. Be sure each teacher knows to consult with parent/guardian prior to serving extra snacks. Changes in snack, meal, or physical activity times should only be made after consultation with parent/guardian and/or school nurse.

Information for Teachers
Students with hyperglycemia or hypoglycemia often do not concentrate well Students should have adequate time for taking medication, checking blood glucose, and eating During academic testing, provide accommodations as per 504 plan or IEP Check blood glucose before and during testing, per plan Access to food/drink and restroom If a serious high or low blood glucose episode occurs, students should be excused with an opportunity for retake 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. Students should have adequate time for taking medication, checking blood glucose, and eating. During academic testing: Students should check blood glucose before and during testing, if specified in their 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.

Blood Glucose Monitoring
GOAL: • maintain blood glucose within target range IMMEDIATE BENEFIT: • maximize learning and participation • identification, treatment, and prevention of lows and highs LONG-TERM BENEFIT: • decrease risk of long-term complications • maximize health Blood glucose monitoring is the cornerstone of diabetes care. The Goal: Maintain blood glucose within target range. Immediate benefit: Identification, treatment, and prevention of high and low blood glucose levels. Maximize learning and participation. Long-term benefit: Decrease risk of long-term complications. Maximize health. Challenge: Many variables can impact blood glucose. These variables include insulin, food, activity, stress, injury, and illness. CHALLENGE: • many variables impact blood glucose

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 The Diabetes Medical Management Plan (DMMP) is covered in greater detail in the unit on Diabetes Medical Management Plans. The DMMP is the document that will specify in detail the student’s diabetes needs at school. Educational plans such as a 504 Plan, an Individualized Education Program (IEP) or the Individualized Health Care Plan (IHP) will elaborate on who does what tasks and where these tasks take place. With respect to blood glucose monitoring the school should expect to: Facilitate blood glucose monitoring by: allowing those students who are capable of doing so to check their own blood glucose anywhere and anytime and by performing the check and/or providing direct assistance and supervision to those who need help Act on the results of blood glucose checks in accordance with directives in the DMMP 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 per DMMP

Any Time, Any Place Monitoring
For students who can self-check: Improved blood glucose control Safer for student Student gains independence Less stigma Less time out of class Assists decision making in response to result Who/what determines if the student can self check? A determination regarding individual capacity for self-checking is jointly made by the student, his/her parent/guardian and his/her health care provider – all in collaboration with the school nurse. What are the advantages of checking blood glucose levels any time and any place? The student can achieve improved 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. Self-checking blood glucose levels helps students to learn and understand decision making process in taking the appropriate response to a blood glucose reading result.

Blood Glucose Monitoring Technology
Easy to use Small meters Reliable results (with smaller samples) Options for alternate (to finger poke) site testing Enhanced electronic functions to record, share, and analyze data Limitation – don’t know blood glucose between checks Blood glucose monitoring continues to become simpler and more reliable. The meters have gotten considerably smaller, making it easy for students to carry them from one school setting to another. Additionally, reliability with a very small sample size has improved greatly. Whereas it formerly took a large drop of blood to get a valid blood glucose reading, now the strips actually wick in the blood. The computer technology within the meters allow individuals to track insulin doses and food intake along with blood glucose results. These data can be downloaded to home or clinic computers for further analysis. Yet with all this progress, monitoring still requires repeated “pokes” (5-6 times a day.) Limitation – don’t know blood glucose between checks? Between samplings, students must rely on their body signals to tell them whether their blood glucose level is out of target range.

Continuous Glucose Monitoring (CGM)
How it works: A tiny glucose-sensing device called a "sensor" is inserted just under the skin The sensor measures glucose in the tissue and sends the information to a pager-sized device The system automatically records an average glucose value every 5 minutes for up to 3, 5, or 7 days Finger stick pokes and regular meter needed to calibrate Alarms signal when glucose is out of target range Limited, but increasing use; emerging technology In the past few years considerable progress has been made in the continuous monitoring of glucose levels. The steps on the screen explain the basics of how the continuous monitoring technology works: A tiny glucose-measuring device called a "sensor" is inserted just under the skin. The sensor measures glucose in the tissue fluids several times a minute and sends the information to a pager-sized device. The system automatically displays and records an average glucose value every five minutes for up to 3, 5, or 7 days depending on manufacturer. The state of the continuous monitoring technology is such that finger stick pokes are still required to effectively calibrate the device. Alarms signal when glucose is out of target range. While continuous glucose monitors are becoming more common, they are still not widely used. Some individuals use them for a short period to give the health care providers a picture of what is happening with glucose levels between monitoring times, particularly after meals and at night while sleeping. A student who wears a continuous glucose monitor to school still needs to check blood glucose with a regular meter before treatment.

Basic Steps Know the target range per DMMP
Check at times specified in DMMP Immediate Action – Treatment to get back within target range Basic Steps to using glucose monitoring as a TOOL. Know the target range. Each student’s target range should be clearly identified in the DMMP. Check at times specified in DMMP. Immediate Action – Treatment to get back within target range.

When to Check? DMMP specifies for an individual student
Regularly scheduled checks: Routine monitoring before meals and snacks Before, during and/or after physical activity Blood Glucose Checking Regularly Scheduled checks Routine monitoring before meals and snacks as per DMMP Before, during, and after physical activity

When to Check? Per DMMP, extra checks may be necessary:
Hypoglycemia or hyperglycemia symptoms Change in diabetes management Periods of stress or illness Prior to academic tests Early or delayed release from school CGM alarms There are times when a student needs to check blood glucose more often than usual, including the following When low or high blood glucose is suspected, either because the student feels symptomatic or the adult observes symptoms. During periods of stress or illness Prior to academic tests When there are changes made in the management program - such as a change in medication doses, meal plan, or physical activity. Early or delayed release from school (e.g. inclement weather) When the CGM alarms The conditions for performing non-routine blood glucose checks should be specified in the DMMP. Generally, the student and/or parent/guardian will determine if/when additional blood glucose checks are required based on specific symptoms or concerns. Teachers are encouraged to bring concerns about frequency of blood glucose checks to the attention of the school nurse, student, parent/guardian, and/or health care providers as appropriate.

Lancing Devices MultiClix Lancets Pen-type Lancing Devices
The basic tool for drawing blood for a glucose check is the lancet, a very small, sharp needle in a plastic sleeve. There are many types of lancets and lancet devices. Many students will use a lancing device, a pen-shaped lancet holder that "launches" the needle 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. If possible, allow the student to remove the lancet to avoid accidental contact to an exposed sharp by school staff. Lancets should be disposed of after use in a sharps disposal container as per parent’s/guardian’s agreement with school and local ordinances. Some students may use a multiple fingerstick device that has a self-contained, six-lancet drum, shown in picture at right. NEVER USE ONE STUDENT’S LANCING DEVICE ON ANYONE ELSE.

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 number on back of meter 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 of results. Sample size needed Wait time Alternate-site testing capacity Work with parent/guardian or school nurse to become familiar with the operation of student’s particular meter. Or if not available, blood glucose meters have a number on the back to call for questions about meter and to obtain technical support. Also, manufacturers’ website have videos, demos, and user guides that may be downloaded.

Preparation Gather blood glucose monitoring supplies: - Lancet
- Test strips - Meter 2. Student washes hands and dries thoroughly Instructions: 1. Gather blood glucose monitoring supplies: lancet test strip meter 2. Student washes hands and dries thoroughly. 3. If assisting or performing for student, put on disposable gloves. 3. If assisting or performing for student, put on disposable gloves

Readying the Meter Turn the meter on Check code # (if required)
Insert a strip into the meter Instructions: 4. Turn the meter on if necessary. Some meters turn on automatically when the strip is inserted. 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).

Lancing the Finger 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 Instructions: Hold the lancet device to the side of the finger and press the button to stick the finger. Use the side of the finger, as the tip and pad of the finger have more sensitive nerve endings. Express an adequate drop of blood. If an alterative site is used (per DMMP), the school nurse and/or parent/guardian will give further instructions on the appropriate sites. Note: In the case of suspected hypoglycemia, only the finger should be used for blood glucose sampling.

Applying Blood to Strip
8. Follow instructions included with the meter when applying blood to strip Instructions: 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 wick the blood onto the strip by capillary action upon contact with the drop of blood on the finger (or other alternate site). Cover ALL of test strip window Some strips wick blood onto the strip Drop, not smear

Results 53 250 9. Wait until blood glucose results displayed
10. Dispose of lancet and strip 11. Record blood glucose results, take action per DMMP Instructions: 9. Wait. Blood glucose results will be displayed on the meter. Meter processing times vary. Most will take from 5 to one minute. 10. Dispose of the lancet in as per parent’s/guardian’s agreement with school and local ordinances. Never recap. Test strips may be discarded in a regular trash can. Plan for Disposal of Materials That Come Into Contact with Blood Blood glucose monitoring does not present a danger to other students or staff members when there is a plan for proper disposal of lancets and other materials that come into contact with blood. The school health team should agree on the plan, which should be consistent with standard precautions and local waste-disposal laws. Disposal of sharps may be in a container kept at school or in the student’s personal container—a heavy-duty plastic or metal container with a tight-fitting lid. Used blood glucose test strips and other materials may be discarded in the regular trash. Check with the student’s personal diabetes health care team about health and safety requirements in your area. 11. Record blood glucose result and take action as per DMMP.

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 (1-800; Website) Note: At this point in the training the instructor should demonstrate how to use one or more meters. Have participants practice using meter.

What Does the Number Mean?
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 In responding to and communicating about a specific reading, there are several things to keep in mind. Reaction to blood glucose check 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”. Recognize value may vary according to time since eating, insulin, or physical activity.

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 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 by injection is a life-saving prescription medication (called GlucaGen by one manufacturer). It is given by injection and used to treat serious hypoglycemia. It was created for use by people who are not health care professionals. 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. While it may cause nausea and vomiting when the student regains consciousness, glucagon is a life-saving treatment that 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 When included in the DMMP or physician’s orders, the glucagon kit should be accessible to trained school personnel, and stored in a designated place which may include keeping the kit with the student. Glucagon should be stored at room temperature. The expiration date should be checked before using. Do not administer if expired, discolored, or does not dissolve well. After mixing the contents, dispose of any unused portion within one hour. Expired glucagon emergency kits can be used for future training sessions. Training demonstration kits are also available from kit manufacturers.

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

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 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 having a seizure, is 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.

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 If possible, do a blood glucose check. Don’t delay if a meter is not available and low blood glucose symptoms are being exhibited. If in doubt, always treat. 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 parent/guardian and school nurse as per DMMP.

Preparation 1. Flip cap off glass vial containing dry powder
2. Remove cap from syringe 3. Put on gloves if available 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. 3. Put on gloves if available

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. 147

Dosing and Drawing Out Inspect. Solution should be clear and colorless. Draw prescribed amount of glucagon back into syringe. 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. 148

Injecting Clean site if possible.
Inject at 90° into the tissue under cleansed area (may administer through clothing as necessary thigh arm 7. When possible, the injection site should be exposed and cleaned.However, glucagon can be administered without cleaning and through clothing if necessary. 8. Injection is given at a 90 degree angle into the tissue under the cleansed area in an area such as the buttocks, thigh or arm. Suggested sites include the outer thigh, upper outer buttock, or arm. 149

After Injecting May take minutes for student to regain consciousness Check blood glucose Give sips of fruit juice or regular soda, once student is awake and able to drink Advance diet as tolerated Document as per DMMP Do not recap syringe. Discard sharp in appropriate container It may take minutes for student to regain consciousness. Check blood sugar minutes after administering glucagon. Give sips of regular soda or fruit juice 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 glucose levels elevated to normal levels and to prevent recurrence. Document blood glucose level and glucagon dosage as per DMMP. Do not recap syringe. Discard sharp in appropriate container. 150 150

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 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. The student may be unable to participate in learning or school activities up to several hours after a severe hypoglycemia episode. Continued monitoring is important, but is a challenge in the school setting. The student may need to be transported via EMS or sent home with the 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 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 Note: At this point, the instructor demonstrates administration of glucagon and participants practice.

Vocabulary - Insulin Target Range: A range of numbers that represents an individual’s ideal blood glucose level; determined by health care team with the individual (child with diabetes and parent/guardian) Basal Insulin: Sometimes called "background" insulin, the insulin working steadily throughout the day Bolus Insulin: a single dose of insulin, given for one of two reasons: Carb or Meal/Snack Bolus: Insulin dosed when food is eaten Correction Bolus: Insulin dosed when blood glucose level is too high and needs to be corrected (made lower) Target Range: A range of numbers that represents an individual’s ideal blood glucose level; determined by health care team with the individual (child with diabetes and parent/guardian). Everyone’s blood has some glucose in it. In people who don’t have diabetes, the normal range is about 70 to 120. The American Diabetes Association sets guidelines for normal and abnormal blood glucose levels. However, each person’s target range is determined individually by his/her health care team. Young children with diabetes may have slightly higher target ranges than adults with diabetes. And those starting out on insulin pump therapy or are newly diagnosed with diabetes may initially have higher target ranges to help avoid hypoglycemia. Basal Insulin: Sometimes called "background" insulin, the insulin working steadily throughout the day. Basal insulin may be provided by injection with either long acting or intermediate acting insulin or by continuous infusion of short or rapid acting insulin with an insulin pump. In diabetes treatment the term basal rate refers to the low rate of insulin supply needed to cover the basal metabolic functions of daily living (i.e. breathing, heart rate, and other metabolic processes of the body). That is, the insulin needed to maintain good blood glucose control without taking into account eating any food. Bolus Insulin: a single dose of insulin, given for one of two reasons: Carb or Meal/Snack Bolus: Insulin dosed when food is eaten Correction Bolus: Insulin dosed when blood glucose level is too high and needs to be corrected (made lower)

Insulin in Schools Today
Most students need to take insulin in school Insulin dosing varies from student-to-student and changes over time Student’s need for assistance will vary as the student progresses in self-management Insulin dosing and timing will be specified in the DMMP; physician orders may include provisions for the parent/ guardian and/or capable students to modify dosing Specific school procedures for administration should be documented Not very many years ago, few students with diabetes took insulin injections at school. But now many physicians prescribe intensive insulin therapy for children that requires multiple daily injections to enable students to maintain blood glucose levels within the target range. This is because studies have shown that intensive treatment can prevent or delay long-term complications of diabetes. Today many students will take insulin at lunch or when blood glucose levels are above target range. Regardless of when they need to take insulin, many students will need accommodations to ensure timely, accurate insulin dosing. Most older or more experienced students are capable of self-administration although some may want a private place to inject. Others will need full assistance in drawing out, dosing, and injecting. Insulin dosing and timing will be specified in the DMMP; these physician orders may include provisions for the parent/guardian and/or capable students to modify dosing. How, where, and who may perform or assist with insulin administration is determined jointly by the parent/guardian, student, and school nurse and other school staff and should be documented in an Individualized Health Care Plan (IHP), and the student's 504 Plan, IEP, or other written accommodation plan.

What is Insulin? Insulin is a hormone that is necessary:
Moves glucose from blood into cells for energy Students with type 1 diabetes do not produce insulin Without enough insulin, high blood glucose results: Energy levels are low Dehydration Complications Insulin is a hormone that is needed to convert sugar, starches, and other food into energy by moving glucose from blood into the cells. Students with type 1 diabetes do not produce insulin; their beta cells, the insulin-producing cells of the pancreas have been destroyed. Without enough insulin, students will experience both short and long term complications; they will experience low energy levels, feel listless, become dehydrated, and could become severely ill. Without any insulin, they will become severely ill within hours and if left untreated, could result in death.

Insulin Delivery Methods
Insulin Syringe Insulin Pen Insulin Pump or Pod Jet Injector Many, but not all students take their insulin by using a vial and syringe. An increasing number of students are using other methods, especially pens and pumps. Insulin pens offer the convenience of carrying insulin in a discreet way. An insulin pen looks like a pen with a cartridge. Some pens use replaceable cartridges of insulin; other pen models are totally disposable. A fine needle, similar to the needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin. There are 2 types of insulin pumps: The pump that has been in use for a number of years is about the size of a pager, weighs about 3 ounces, and can be worn on a belt or in a pocket. The pump connects to narrow, flexible plastic tubing that ends with a needle inserted just under the skin in the abdomen, buttocks, or thigh. Users set the pump to give a steady trickle or "basal" amount of insulin continuously throughout the day. Pumps release "bolus" doses of insulin (several units at a time) at meals and at times when blood sugar is too high based on the user’s programming. The newer kind of insulin infusion pump is often referred to as a patch or “pod”. It differs in that it adheres directly to the body, without using additional tubing. It is a disposable unit that is controlled by a separate PDM device. Insulin jet injectors send a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles.

Basal and Bolus Insulin
B’fast Lunch Dinner Snack For people without diabetes, the pancreas automatically releases the right amount of bolus insulin with each meal and snack, and also a basal amount throughout the day and night. Blood glucose rises after meal, but only within a limited range. People who are insulin dependent dose their insulin to mimic the body’s natural pattern. Whether insulin is delivered by a syringe, pen device or pump, the dosing reflects both a relatively constant 24 hour component – (the basal insulin) and a meal or snack component – (the bolus insulin.) If you look at the top graph you can see that basal insulin, represented by the constant green level, acts pretty steadily throughout the day. The bolus insulin is given at each meal or snack (see the black arrows on the upper graph.) As the blue line shows, bolus insulin has a sharp peak of action that coincides with the effects of food on blood glucose. When the pre-meal or bolus insulin is dosed and timed right, it has the effect of moderating the peaks, so that blood glucose stays in within a target range, as you can see in the lower graph.

Insulin Types Rapid-acting - Humalog ®, Novolog ®, Apidra
Short-acting - Regular Intermediate - NPH Long-acting - Glargine (Lantus), Detemir (Levemir) The graph on this slide represents the action patterns of insulin types in use today. Intermediate- and long-acting insulins provide basal insulin concentrations and doses are adjusted based on the student’s pattern of blood glucose. They are not used for acute treatment of high blood glucose levels and are not generally given before meals eaten at school. Intermediate and long-acting insulins are referred to as basal insulin. Basal insulin controls the blood glucose in the fasting state, when you’re not eating. Basal insulin is typically 50% or less of an individual’s total daily insulin dose. Rapid-acting insulins act quickly within minutes and are used primarily to treat a high blood sugar level and to “match” or “cover” a rise in blood glucose levels following food intake. Many students require rapid acting insulin before meals and snacks. Note, hypoglycemia can occur if meal or snack is delayed for than 15 minutes after injection of rapid-acting insulin. Rapid-acting insulin is frequently referred to as bolus insulin. Rapid-acting insulin is also used in insulin pumps. Short-acting insulins are used like rapid-acting insulins, but have a longer duration of action and a delayed peak. Short-acting insulin is also referred to as bolus insulin.

Storing Insulin Review the product storage instructions and check the expiration date Generally store at room temperature less than 86 degrees Refrigerate unopened vials and insulin pens Be careful NOT to freeze The shelf life of insulin after opening varies according to: the type of insulin, the type of container (vial or cartridge), and how insulin is used (in a pen, a cartridge, or a pump). Review the product storage instructions on the manufacturer’s package insert and check the expiration date on the package for specific information. In general, Most opened vials of insulin may be left at room temperature (below 86 degrees Fahrenheit) for 30 days. Most opened disposable pens or pen cartridges may be left at room temperature for less than 30 days, depending on the type of insulin and the type of pen or cartridge. Unopened vials should be stored in a refrigerator and are good until their expiration date.

When to Give Insulin DMMP should specify dosing clearly Generally:
Before meals or snacks For blood glucose levels significantly above target range For moderate or large ketones Insulin must be administered as specified in the student’s DMMP. The DMMP specifies the orders of the student’s health care provider. The DMMP should clearly specify insulin dosing procedures. Generally students will only need to administer their rapid-acting, bolus insulin at school. Their basal insulin will be delivered at home in the morning and/or evening, or throughout the day by insulin pump. Generally bolus insulin, either rapid or short acting insulin, will be given: Before meals or some snacks, depending on DMMP recommendations For blood glucose levels significantly above target range For moderate or large ketones

Where to Give Insulin: On Target!
Insulin works best when it is injected into a layer of fat under the skin, above the muscle tissue. Rotating sites is important to insulin absorption. Common preferred sites are the abdomen, thighs, buttocks, and upper arms. Student should help choose injection site. Inject into fat layer under skin Rotate sites Student should choose site Common sites: abdomen, thigh buttocks, upper arms

Dosing Insulin at School
Generally, students will only take rapid or short acting insulin at meal or snack times: Some students will use a standing insulin dose Others will have a varied dose, depending upon: what food is eaten (carb bolus) and/or whether blood glucose is within the target range (correction bolus) Many students will take rapid or short acting insulin at meal or snack times: Some students will take the same dose, regardless of blood glucose level or food intake. Doses for many students, though, will vary. For those whose doses vary, it is important to understand the 2 concepts of: Carb or meal boluses, to cover what is eaten and Correction boluses, to cover high blood glucose. These two concepts are covered in the next two slides.

Carb Bolus to Cover Meals, Snacks
The insulin to carb ratio varies student to student, is specified in the DMMP: Recorded as 1 unit insulin per X gms of carb Example: 1:10 ratio; 1 unit of insulin for every grams of carb eaten Calculate: Meal of 60 grams CHO 60/10 = 6 6 unite of insulin are needed to cover this meal Most students who vary their dosing at meal time, will do so using an insulin to carbohydrate ratio. The insulin to carb ratio: Varies from student to student, and is specified in the DMMP Specifies how much carbohydrate that each one unit of insulin (rapid or short-acting insulin) will cover or match Calculating the Insulin to Carbohydrate Ratio: For example, a common ratio is 1:10 Usually stated as 1 unit per x number gms of carbohydrate Calculate for a meal that contains 60 grams of carbohydrate. If the ratio is 1:10, then we take the 60 grams divided by 10 to get 6 units of insulin for the correct dose. Most students who vary their dosing at meal time, will do so using an insulin to carbohydrate ratio. The insulin to carb ratio: Varies from student to student, and is specified in the DMMP Specifies how much carbohydrate that each one unit of insulin (rapid or short-acting insulin) will cover or match Calculating the Insulin to Carbohydrate Ratio: For example, a common ratio is 1:10 Usually stated as 1 unit per x number grams (gms) of carbohydrate Calculate for a meal that contains 60 grams of carbohydrate. If the ratio is 1:10, then we take the 60 grams divided by 10 to get 6 units of insulin for the correct dose.

Correction Bolus to Lower Blood Glucose
Amount to lower blood glucose to target, usually calculated by sliding scale or correction factor: Sliding scale: give units of insulin for each interval of BG Example: 1 unit , 2 units , 3 units 250+ Correction factor: Blood glucose level – target blood glucose/correction factor = units insulin to be given Example: BG=150 (actual) minus Target BG (100) = 50 divided by Correction factor (50) = 1 unit insulin needed Correction Bolus: The amount of insulin to correct a blood glucose level above the student’s target range. Once again, this will vary from student to student. It may be stated as a stepwise correction or sliding scale or may need to be calculated by a formula to determine dose. The DMMP will specify if, when and how correction boluses are to be determined and given. Sliding Scale: Correction doses are specified at specific blood glucose intervals: for example a student may need 2 units for blood glucose from , 3 for , 4 for 250+ Correction Factor: Correction doses are calculated by subtracting the target blood glucose from the actual (high) blood glucose. Then the difference is divided by a correction factor to determine how many units of insulin are needed to lower blood glucose to target range. For example, consider a student whose blood glucose level is 150 and the target is If the correction factor is 50, this means 1 unit of insulin would be given as a correction dose to correct for high blood glucose.

Insulin Bolus for Both Carbs and Correction
For some students, dosing at meal time may include both a carbohydrate ratio dose and a correction dose Total dose = Carb ratio dose + Correction dose If student’s blood glucose is below target range, the correction may mean giving less than the usual dose For some students dosing at meal time may include both a and carbohydrate ratio dose and a correction dose for blood glucose that is above or below the target range. In this case, Total dose = Carb ratio dose + Correction dose. If the student’s blood glucose is below target range, the correction may mean giving less than the usual dose. Students whose dosing accounts for both carbohydrates and blood glucose are more likely to need assistance from school staff. Many insulin pumps will automatically calculate the correct dose when blood glucose levels and carbohydrate intake are entered into the pump.

After Giving Insulin Check site for leakage Document on log sheet
Correction doses: - Retest per DMMP to check effectiveness Meal/snack doses: - Timeliness in relation to eating - Supervision of food amount per DMMP A few points to keep in mind after insulin is given, regardless of whether it is by syringe, pen, or pump. Occasionally injection sites or infusion sites will leak when insulin is administered. Document on log sheet. When correction doses are given to lower blood glucose, a retest should be done, if specified in the DMMP, to determine how well the correction dose worked. When insulin has been given prior to a meal or snack, it is important that the food is eaten soon (beginning within 15 minutes) after the insulin has been taken. If necessary, the student should be moved to the front of a long line, or given milk, juice or some other quick-acting carbohydrate. Younger students may need to be supervised at every meal/snack to be sure the amount of food eaten is appropriate for the insulin given.

What Are Ketones? Acids that result when the body does not have enough insulin and uses fats for energy May occur when insulin is not given, during illness or extreme bodily stress, or with dehydration Can cause abdominal pain, nausea, and vomiting Without sufficient insulin ketones continue to build up in the blood and result in diabetic ketoacidosis (DKA) Ketones are acids that result when the body does not have enough insulin and uses fats for energy. Ketones may be observed when insulin is not given, during illness or extreme bodily stress, or with dehydration. Ketones can cause abdominal pain, nausea, and vomiting. Without sufficient insulin ketones continue to build up in the blood and result in diabetic ketoacidosis (DKA).

Why Test for Ketones? DKA is a critical emergency state
Early detection and treatment of ketones prevents diabetic ketoacidosis (DKA) and hospitalizations due to DKA Untreated, progression to DKA may lead to severe dehydration, coma, permanent brain damage, or death DKA is the number one reason for hospitalizing children with diabetes Reasons for testing for ketones It is important to test for ketones 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. 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 continue to 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.

When Should Ketones Be Checked?
The DMMP should specify, generally: When blood glucose remains elevated During acute illness, infection or fever Whenever symptoms of DKA are present Nausea Vomiting or diarrhea Abdominal Pain Fruity breath odor Common symptoms including fruity odor to breath, nausea, vomiting, drowsiness, abdominal pain Rapid breathing Thirst and frequent urination Fatigue or lethargy The individual student’s DMMP should specify when ketones are to be checked. Generally ketones should be checked when : Repeated blood glucose readings are over the target range as specified in the care plan During acute illness, infection or fever If the student has any of the following symptoms of DKA: Nausea Vomiting or diarrhea Abdominal Pain Fruity breath odor Rapid breathing Thirst and frequent urination Fatigue or lethargy

How Quickly Does DKA Progress?
An isolated high blood glucose reading, in the absence of other symptoms is not cause for alarm DKA usually develops over hours, or even days DKA can progress much more quickly for students who use insulin pumps, or those who have an illness or infection Most at risk when symptoms of DKA are mistaken for flu and high blood glucose is unchecked and untreated Unlike low blood glucose, which can progress very quickly, the progression of untreated high blood glucose to DKA is usually a slow process. An isolated high blood glucose reading, in the absence of other symptoms is not cause for alarm. DKA usually develops over hours, or even days. However, DKA can progress much more quickly for students who use insulin pumps, or those who have an illness or infection. Individuals with diabetes are most at risk when symptoms of DKA are mistaken for flu and high blood glucose is unchecked and untreated.

Checking for Ketones Urine testing Blood testing
Most widely used method Blood testing Requires a special meter and strip Procedure similar to blood glucose checks Note: Ketones can be measured in either the blood (using a ketone specific meter) or in the urine. Urine ketone testing continues to be most common in the school setting.

How to Test Urine Ketones
1. Gather supplies 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 cup containing urine. Shake off excess urine 5. Wait seconds 6. Read results at designated time 7. Record results, take action per DMMP 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. Shake off excess 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.

Test Results: Color Code
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. Generally: No ketones = no action needed Trace ketones = encourage drinking water Small ketones = encourage drinking water Moderate ketones = needs insulin Large ketones = insulin critical no ketones trace small moderate large ketones present

Considerations Colors on strips and timing vary according to brand
If using a scale with “urine glucose” and “urine ketones,” be sure to read the correct scale when testing for ketones Follow package instructions regarding expiration dates, time since opening, correct handling, etc., as incorrect results may occur Ketone strips stored in bottles expire six (6) months after opening. Ketone strips stored in individual foil packages expire according to date on box or foil package.

How To Test for Blood Ketones
Prepare lancing device Wash hands using warm soapy water and dry them completely Remove the test strip from its foil packet Insert the three black lines at the end of the test strip into the strip port Push the test strip in until it stops Prepare lancing device. Wash hands using warm soapy water and dry them completely. Remove the test strip from its foil packet. Insert the three black lines at the end of the test strip into the strip port. Push the test strip in until it stops. The monitor turns on automatically.

How To Test for Blood Ketones
Touch the blood drop to the purple area on the top of the test strip. The blood is drawn into the test strip Continue to touch the blood drop to the purple area on the top of the test strip until the monitor begins the test The blood ß-Ketone result shows on the display window with the word KETONE Touch the blood drop to the purple area on the top of the test strip. The blood is drawn into the test strip. Note: If the monitor shuts off before you apply blood to the test strip, remove the test strip from the monitor and try again. Continue to touch the blood drop to the purple area on the top of the test strip until the monitor begins the test. The blood ß-Ketone result shows on the display window with the word KETONE. The result is stored in the monitor’s memory as a blood ß-Ketone result.

Treatment of Ketones DMMP specifies treatment for ketones for the individual student. free use of bathroom sugar-free liquids insulin as per DMMP limit physical activity if vomiting or lethargic, call parent/guardian Generally: If ketones are present, treatment should follow the recommendations specified for the individual student in his/her DMMP, including the notification of parent/guardian and/or student health care providers as appropriate. Generally: Allow free use of bathroom. Students should be encouraged to drink sugar-free, calorie free liquids, like water or diet soda. Students who are nauseous and vomiting may need to take in liquids slowly to avoid more vomiting and dehydration. Extra insulin may need to be given. The student’s DMMP should specify what dose should be given for the blood glucose and ketone test results. Students should not engage in physical activity per DMMP. If vomiting occurs or if student is lethargic with ketones present, parent/guardian should be called or call for medical assistance if parent/guardian cannot be reached.

Nutrition: Why be concerned?
Good nutrition is important for everyone for optimal health Nutrition planning is essential for good diabetes control: maintain blood glucose within target range to prevent or delay complications to help children and teens grow and develop properly to achieve healthy weight promote optimal learning Why be concerned about nutrition? Good nutrition is important for everyone for optimal health. Nutrition is essential for growth and development, health, and well being of all students and staff. Dietary factors are associated with 5 of the 10 leading causes of death including coronary heart disease, some types of cancer, stroke, type 2 diabetes, and osteoporosis. Nationwide, we are facing an epidemic of overweight and obesity, among children and adults. For people with diabetes, following a carefully designed meal plan is necessary to prevent both short and long-term complications by regulating blood glucose levels. Students who follow meal plan guidelines will be less apt to experience hyperglycemia or hypoglycemia and should have better attendance and participation. From a long-term perspective, following meal plan guidelines means that students can help to prevent or delay the onset of serious complications of diabetes, such as kidney disease, high blood pressure, heart disease, and blindness.* *While it is important for school personnel to be aware of the potential for these serious life-limiting or life threatening complications, it is not appropriate for school personnel to discuss risks for complications with individual students. Good nutrition will help children and teens grow and develop properly and help to make them ready to learn.

School Nutrition Management
Student’s parent/guardian and health care team determine an individualized meal plan A diagnosis of diabetes does NOT always limit which foods a student can eat Meals & snacks need to be carefully timed to balance physical activity and insulin/medications Encourage healthy eating for all students The student’s parent/guardian and health care team determine an individualized meal plan. A diagnosis of diabetes does NOT completely limit which foods a student can eat. Foods that were previously thought to be off limits can now be incorporated into a meal plan for kids with diabetes. We now know that the same foods that are healthy for everyone are healthy for the person with diabetes. However, meals and snacks need to be carefully balanced with physical activity and medications (insulin or other diabetes medications). Eating consistent amounts of carbohydrate at scheduled times is important for children using a traditional insulin plan to match the effects of the peaking insulin. Children following a multiple daily insulin injection plan or using a pump have a bit more flexibility in the types of foods and timing than a child following a more traditional insulin plan. Students whose snacks and/or meals are delayed or skipped are at risk for a hypoglycemia if they are using a traditional insulin plan. Children taking multiple daily injections or using an insulin pump do not usually require planned snacks, but would need to give insulin if unplanned snacks are consumed. “Extra” or ill-timed snacks and/or meals can lead to high blood glucose unless the child has a diabetes Medical Management (DMMP) that specifies “coverage” with these extra foods. Timing is everything. One meal plan does not fit all; each student’s plan will vary according to family culture, individual needs and preferences. While establishing optimal blood glucose control is important, allowing students to have control over food choices and portions, within the scope of their meal plans, is important as well. The goal is to avoid creating any food conflicts or control issues and to allow for enjoyable meals and snacks.

School Nutrition Management
Students with type 2 diabetes may need additional accommodations to help manage lipids, blood pressure and weight: May need support at meals and snacks to achieve calorie level targets and consistent carb amounts Assure that healthy foods such as whole grains, low-fat protein and dairy, fruits, and vegetables are available Students with type 2 diabetes may need additional accommodations to help manage lipids, blood pressure and weight. Many children with type 2 diabetes are on a nutrition plan designed to help them achieve a healthy weight. These students may be prescribed a calorie level target for the day as well as consistent carb amounts to aim for at each meal and snack to help control their weight and blood glucose. Assuring that healthy foods such as whole grains, low-fat protein and dairy, fruits, and vegetables are available is critical to their diabetes management.

Basic Meal Plans Key: Balance insulin/medications with carb intake
Most students have flexibility in WHAT to eat Basic Carbohydrate Counting Advanced Carbohydrate Counting Many students have flexibility in WHEN to eat More precise insulin delivery (pumps, pens) Rapid-acting insulins Time dosing of insulin according to DMMP The management of type 1 diabetes has changed dramatically in the last 6-7 years, but the basic idea of balancing insulin or medications with carbohydrate intake has remained the same. More children than ever benefit from the flexibility in meal planning using the exchange or carbohydrate counting methods. These meal planning approaches are used successfully with traditional insulin plans, multiple daily insulin injections, or insulin pumps. The increased use of pen-devices and pumps to deliver insulin has made “on-the-spot” insulin delivery easier and more precise. Additionally, the introduction of newer insulins has cut down on the need to snack just to avoid low blood glucose. Most students will dose their insulin before a meal or substantial snack. However, some, who are picky or unpredictable eaters, may dose after eating, based on the actual amount of carbohydrate eaten. The timing of insulin dosing with respect to meals and snacks should be specified in the DMMP.

Basic Carbohydrate Counting
Calories from: carbohydrate protein fat Each nutrient type affects blood glucose differently Carbohydrate has the biggest effect on blood glucose TOTAL carbohydrate matters more than the source (sugar or starch) Carbohydrate counting is based on the following from nutritional science: Calories in food come from three nutrient types: Carbohydrate Protein Fat Each nutrient type affects blood glucose differently. Carbohydrate, which includes both sugar and starch, has the biggest effect on blood sugar. Approximately % of carbohydrates are converted into glucose in 1-2 hours. Proteins and fats do not effect the blood glucose level much, therefore they are not usually “counted”. Carbohydrates are found in several types of sources: Natural sugar: like fruit, milk Starches with fiber like raw vegetables, legumes, whole grains Starches without fiber like white flour products, refined grain products Concentrated sugar like cake, candy, regular soft drinks TOTAL carbohydrate matters more than the source (sugar or starch). Eating equal amounts of sugar or starch will usually raise blood sugar about the same amount. The TOTAL amount of carbohydrate eaten (whether sugar or starch) will determine how high blood glucose level will be after a meal or snack.

Advanced Carbohydrate Counting
USING THE INSULIN-TO-CARB RATIO The insulin-to-carb ratio: Varies from student to student Is determined by the student’s health care team Should be included in the DMMP Usually stated as a ratio of 1 unit of insulin to x grams carbohydrate May vary from meal to meal for a student The most advanced carbohydrate counting method allows the student to adjust his/her insulin depending on the amount of carbohydrate eaten at each meal or snack. The insulin-to-carb ratio: Insulin-to-carb ratio can be defined as the amount of rapid or short acting insulin that is needed to “cover” the blood glucose raising effect of a carbohydrates that are consumed at the meal or snack. Varies from student to student. Is determined by the student’s health care team Should be included in the DMMP. Usually stated as a ratio of 1 unit of insulin to x grams carbohydrate. The insulin-to carb ratio method is used more often by: Students who are trying to maintain tight control Students who use multiple daily injection insulin plan or insulin pumps Older or more independent students Students who are picky or unpredictable eaters Students who use this method may administer insulin before, during, or after the meal per their DMMP. If students are administering insulin before the meal, it is particularly important that they know the menu and the nutritional value of menu items, whether the lunch is purchased at school or prepared at home.

Using Insulin-to-Carb Ratio
Example: 1:10 Ratio 1 unit of insulin to be given per 10 grams of carbohydrate eaten 60 gm meal / 10 gms = 6 units of insulin needed Here’s an example of how to calculate insulin dose based on a meal with 60 grams of carbohydrate. If a student’s insulin-to-carbohydrate ratio is 1 unit of insulin to 10 grams of carbohydrate, and the total amount of carbohydrate eaten is 60, then we take that carbohydrate amount of 60 and divide it by the number of grams per unit from the carb ratio, or 10. So 60 divided by 10 equals 6 units of insulin.

School Meals & Snacks Provide school menus and nutrition information to student/parent/guardian in advance. Provide sufficient time for eating. Monitor actual food intake per DMMP young or newly diagnosed picky eaters Respect, encourage independence. Some students will need assistance in the school lunchroom. Others will not. All students and their families should be provided with school menus and nutritional information in advance. If a staff member is assisting the student in making food choices she/he also needs to be provided with the menu and nutritional information. Students should be provided with sufficient time for eating. The actual food intake of some students may need direct monitoring per the DMMP. These students may include: younger or newly diagnosed students picky eaters Each student’s level of independence should be respected: Per the DMMP, students should be encouraged to make independent choices to the extent that they can do so responsibly. Students who are independent in making food selections should not be subject to “second-guessing” by staff or other students.

Nutrition Information at School
The approximate carbohydrate content of school meals can be determined in advance by the school nutrition director and can be indicated on the school menu for each item. The approximate carbohydrate content of school meals can be determined in advance by the school nutrition director and can be indicated on the school menu for each item.

Beyond the Routine: School Parties
Provide parent/guardian with advance notice of parties/special events Follow the student’s DMMP, 504 Plan or IEP Some may prefer to bring their own foods, but may eat what is available. Provide nutritious party snacks or non-food treats for all Limit use of food as reward Provide parent/guardian with advance notice of parties/special events. If no advance notice has been given, contact the parent/guardian once the event begins, if there are questions. Don’t restrict unnecessarily. Follow the student’s DMMP. Some students may prefer to bring their own foods, but may eat what is available. Many traditional party foods are high in sugar and fat, so consider providing a selection of healthful foods and snacks to encourage healthy eating habits for all. Limit use of food as reward

Beyond the Routine: Field Trips
Notify school nurse as soon as trip is scheduled to allow for consultation with parent/guardian about food and/or insulin adjustments Bring plenty of quick-acting sugar sources to treat hypoglycemia Bring lunch as appropriate Bring diabetes equipment and supplies, including glucagon, if specified in DMMP Bring list of emergency contacts, copy of emergency care plan Students with diabetes should participate fully in field trips, even including fast food meals and strenuous outdoor adventure activities. Pre-planning is a necessity and should include the following: Notify school nurse as soon as trip is scheduled to allow for consultation with parent/guardian about food and/or insulin adjustments for extra activity level per DMMP. Advance planning will ensure that the student with diabetes can fully participate in all field trip activities. The student’s health care needs must be accommodated by the school district on a school sponsored field trip; the parent/guardian cannot be required to attend a field trip. Bring snacks to treat hypoglycemia in case of unforeseen schedule changes. Keep them with the student at all times. Bring lunch as appropriate. Bring diabetes equipment and supplies including glucagon, if specified in DMMP. Bring a list of emergency phone numbers for parent/guardian, caregivers, and student’s health care provider.

Activity & Diabetes Everyone benefits from physical activity.
Students with diabetes should fully participate. In general, activity lowers blood glucose levels. If there is insufficient insulin, physical activity can raise blood glucose. May need to make adjustments to insulin/medications and food intake, per DMMP A quick-acting source of glucose, glucose meter, and water should always be available PE teachers and coaches must be familiar with symptoms of both high and low blood glucose Physical activity is a critical part of diabetes management. Everyone can benefit from regular activity, but it is especially important for a student with diabetes. Students with diabetes should participate fully in physical education classes and team sports, unless indicated by another health care condition, hypoglycemia, or high ketones as per DMMP. In general, activity lowers blood glucose levels. Students with diabetes may need to make adjustments to insulin/medications and food intake depending upon timing of activity to insulin peaks or meals and snacks. A quick-acting source of glucose, glucose meter, and water should always be available. PE teachers and coaches must be familiar with symptoms of both high and low blood glucose and know what action they should take including how to get help. If there is insufficient insulin, physical activity can raise blood glucose levels. Follow DMMP for activity restrictions when ketones are present.

Activity & Blood Glucose Monitoring
Check before, during, and after physical activity per DMMP: Especially when trying a new activity or sport If blood glucose starts to fall, student should stop and have a snack or quick-acting source of sugar Students with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity Guidelines for activity and blood glucose monitoring: Check before, during, and after physical activity per DMMP. Especially when trying a new activity or sport. If blood sugar starts to fall, student should stop and have a snack. Students with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity (per DMMP). If students disconnect from the pump, they need to have a secure location to store the pump until reconnecting. The effects of activity can last up to 12 hours. Blood glucoses can trend downward for hours after physical activity.

Where to Get More Information
American Diabetes Association DIABETES National Diabetes Education Program/NIH

Medication Administration Sign In

Similar presentations

Presentation on theme: "Medication Administration Sign In"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Medication Administration Sign In

Similar presentations

Presentation on theme: "Medication Administration Sign In"— Presentation transcript:

Similar presentations

About project

Feedback