1 Diabetes Basics Helping Belton ISD Students Stay Safe & HealthyWhat Every BISD Staff Needs to Know About: Diabetes Basics Belton ISD Health Services Diabetes

2 What Every BISD Staff Needs to Know About DiabetesWhat is diabetes? How to recognize and respond to the signs & symptoms of low blood glucose (hypoglycemia) & high blood glucose (hyperglycemia) Who to contact immediately in case of an emergency

3 What is Diabetes? Diabetes is a serious, chronic disease that impairs the body’s ability to use food. Body does not make or properly use insulin: no insulin production insufficient insulin production resistance to insulin’s effects 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 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.

4 What Happens When We Eat?KEY MESSAGE: To understand diabetes, it is helpful to know some basic facts about metabolism and the role of blood glucose in providing cells with energy. Supporting Points In diabetes, too much glucose (a type of sugar) builds up in the blood. To understand normal blood glucose control, people need to know what happens to food after eating. Explain that: In the digestive tract, food is broken down into protein, carbohydrates, and fat. These nutrients then are absorbed into the blood. Carbohydrates in food are converted into blood glucose. Glucose is transported from the blood into the body’s cells. Inside the cells, glucose is used as fuel to supply most of the body’s energy. Extra glucose is stored as fat, an energy source that is used when glucose is not available.

5 Insulin’s job is to get glucose into cells

6 Diabetes occurs when there is not enough insulin for what the body needs. Without insulin, the body’s main energy source, glucose, cannot be used as fuel and builds up in the blood.

7 Before this diabetic child received insulin he was starving because he was not receiving glucose for energy

8 Insulin Saved His Life

9 Two Main Types of DiabetesKEY MESSAGE: The two most common types of diabetes are type 1 and type 2. Supporting Points Type 1 and type 2 diabetes are the most common forms of the disease. In type 1 diabetes, the beta cells of the pancreas stop producing insulin. Type 2 diabetes is a metabolic disorder in which the body does not properly use insulin or produce insulin in the right amounts or at the right times. Other types of diabetes can occur. Gestational diabetes develops in 2% to 5% of all pregnancies. Women with gestational diabetes are at increased risk for developing type 2 diabetes after pregnancy or later in life. Other specific types of diabetes may result from surgery, use of certain medications, various illnesses, and other specific causes.

10 Type 1 Diabetes People with Type 1 Diabetes must receive insulin through either injections or an insulin pump. Insulin taken in this manner does not cure diabetes and may cause their blood glucose to become dangerously low. They must carefully balance food, medications, and activity to keep blood glucose levels as close to normal as possible. Glucose CANNOT enter cell without…..insulin

11 Type 2 Diabetes: The Obesity CycleType 2 Diabetes is the most common form typically afflicting obese adults and youth. The larger you are, the more insulin your body has to make. High insulin levels cause an increase in appetite Increase food intake cause the body to make more insulin. Insulin does not work well in fatty tissue. Type 2 diabetics can control their disease through diet and exercise alone or may require oral medications or insulin injections.

12 Diabetes is Managed, But it Does Not Go AwayGOAL: To maintain target blood glucose Whether we consider 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 helps to promote normal growth and development and allows for optimal learning. It is also needed to prevent the immediate dangers of blood glucose levels that are either too high or too low. 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. When insulin is no longer made, it must be obtained from another source--insulin shots or an insulin pump. All people with type 1 diabetes must take insulin. People with type 2 diabetes use diet and exercise, and oral medications, and/or insulin to manage their disease. Neither insulin nor other medications, however, are cures for diabetes: they only help control the disease.

13 Diabetes Management 24/7 Constant Juggling: with: Exercise Food intakeInsulin/medication with: Exercise Food intake BG BG Maintaining good blood glucose control is a constant juggling act, 24 hours a day, 7 days a week. The key to optimal diabetes control is a careful balance or juggling of food, exercise, and insulin and/or oral medication. As a general rule, insulin/oral medication and exercise/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. & BG

14 Know How to Recognize and Respond to the Signs & Symptoms of High Blood Glucose Allow student to check their blood glucose Stop testing/ class work/exercise. The student’s diabetic plan specifies when they may resume these activities Do not send a symptomatic student to the clinic unescorted. Send with a responsible buddy/adult. Provide/encourage access to water and bathroom Seek help from the student’s unlicensed diabetic care assistant (UDCA) or school nurse Maintain confidentiality

15 Know How to Recognize and Respond to the Signs & Symptoms of Low Blood Glucose Allow student to check their blood glucose and eat a snack Stop testing/ class work/exercise. The student’s diabetic plan specifies when they may resume these activities Do not send a symptomatic student to the clinic unescorted. Send with a responsible buddy/adult. Seek help from the student’s unlicensed diabetic care assistant (UDCA) or school nurse Maintain confidentiality

16 Assistance in Diabetes ManagementRoutine Care: Many students will be able to handle all or almost all routine diabetes care by themselves Some students, because of age, developmental level, or inexperience, will need help from school staff. Urgent Care: Any student with diabetes may need help with emergency medical care. The need for 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. Some students, because of age, developmental level, or inexperience, will need help from school staff. Urgent Care: Any student with diabetes may need help with emergency medical care.

17 Care in the Schools: School Nurses and OthersNurse will: Coordinate diabetes care Supervise diabetes care Provide direct care (when available) However, a nurse is not always available. Non-medical school staff can be trained to assist students For both routine and emergency care Including checking blood glucose, administering insulin and glucagon injections The school nurse is the most appropriate person in the school setting to provide care for a student with diabetes. Many schools in this country, however, do not have a full-time nurse and sometimes a single nurse must cover a large number of schools. Moreover, even when a nurse is assigned to a school full time, he or she will not always be available during the school day, during extracurricular activities, or on field trips. Yet, because diabetes management is needed 24 hours, 7 days a week -- and diabetes emergencies can happen at any time -- a student will always need access to diabetes care at school and at all school-related activities. Because school nurses are not always available to provide direct care, non- medical school staff can and should be trained to assist students in both routine and emergency care, including insulin and glucagon injections.

18 Every Diabetic Should Have a Diabetes CarePlan that gives Instructions on : Daily schedule/Routine Care Student’s Participation in their Care Location of Equipment & Supplies Emergency Contact Info Physician Contact Info Names and contact info of Trained Staff (nurse & UDCAs)

19 The Diabetes Plan should include a Quick Reference Plan or an Emergency Care PlanSummarizes how to recognize and treat hypoglycemia and hyperglycemia Distribute to all personnel who have responsibility for students with diabetes Turn to page 53 of “Helping the Students with Diabetes Succeed: A Guide for School Personnel” for a sample quick reference plan. Development based on information from student’s DMMP Summarizes how to recognize and treat hypoglycemia and hyperglycemia. Distribute to all personnel who have responsibility for a student with diabetes.

20 Helping the Diabetic Student SucceedAll BISD staff need to have a basic understanding of diabetes and to recognize and respond to the signs & symptoms of low and high blood glucose Some may need to learn the knowledge and skills to assist the student in an emergency situation Others may be assigned to be an unlicensed diabetic assistant(UDCA). They will be taught the knowledge and be allowed to practice and demonstrate the skills so that they can be responsible for all aspects of the diabetic care. Legal Considerations Nutrition & Physical Activity Considerations How to Check Blood Sugar How to Give Glucagon How to Intervene when Blood Sugar is Low How to Intervene When Blood Sugar is High How to Check Ketones How TO Give Insulin (Syringe, pen, or pump)

21 Helping the Diabetic Student Succeed Legal Considerations III

22 Laws protect diabetic studentsEliminate Discrimination Provide equal access to educational and school related opportunities. Provide a medically safe environment Law: Chapter 168 Passed in 2005

23 Law Requires a Plan that Addresses:Level of ability of student to participate in care Location/timing of blood glucose monitoring Identity of trained diabetes personnel Location of diabetes supplies Free access to water & restroom Ensure meals and snacks allowed at necessary times Full participation in all school-sponsored activities Alternative times for academic exams if student is experiencing hypo- or hyperglycemia Absences without penalty for diabetes-related appointments/illness Confidentiality & student’s right to privacy

24 Unlicensed Diabetes Care AssistantUDCA Parent/guardian must authorize & state that they understand that an unlicensed diabetes care assistant is not liable for civil damages as provided by Section UDCAs will have access to the student’s plan and to a person with expertise in diabetes (physician, RN, CDE, dietician) Principal must have access to MD if RN is not available

25 UDCA has Immunity from Disciplinary Action or LiabilityNot considered practicing nursing Exempt from applicable laws restricting activities Exercise reasonable judgment in emergencies Section (b), Education Code School nurse not responsible for actions of unlicensed diabetes care assistant (UDCA) Unlicensed diabetes care assistant…

26 Helping the Diabetic Student Succeed Nutrition & Exercise III

27 School Nutrition ManagementMeals & snacks may need to be carefully timed to balance exercise and insulin/medications Most students have flexibility in WHAT to eat due to Basic Carbohydrate Counting Many students have flexibility in WHEN to eat due to insulin pumps and improved insulin. The student’s family and health care team determine an individualized meal plan. A diagnosis of diabetes does NOT always limit which foods a student can eat. Foods that were once 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 with exercise and medications (insulin or oral diabetes pills). Eating consistent amounts of carbohydrate at scheduled times is important for children using a traditional insulin plans 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 hypoglycemic reaction 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 sugar unless the child has a diabetes Medical Management (DMMP) that specifies “coverage” of these extra foods. Timing is everything. One meal plan does not fit all; each student’s plan will vary according to family culture, individual medical 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.

28 Our Job: School Meals & SnacksProvide school menus and nutrition information to student/family in advance. Belton ISD website provides this information Provide sufficient time for eating Only monitor actual food intake if its part of their plan. May need to do for: 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.

29 Beyond the Routine: School PartiesProvide parent/guardian with advance notice of parties and special events. Some students will prefer to bring their own foods. Beyond the Routine: Field Trips Train and send at least 2 UDCAs if nurse is not going Send appropriate lunch & plenty of snacks to treat hypoglycemia Send diabetes equipment and supplies Send plan including list of emergency contacts Consult with parent/guardian about food and/ or insulin adjustments for extra activity level. Provide parent/guardian with advance notice of parties/special events. If no advance notice has been given, contact the parents once the event begins. Don’t restrict unnecessarily. Follow the student’s DMMP. Some students may prefer to bring their own foods. 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.

30 Sugar is NOT the Enemy There is no justification for complete restriction of sugar: Sometimes sugar can be a life-saving friend! Timing does matter! and sometimes sugar (or any carbohydrate) is not a good choice. Sugary foods used to be seen as a danger for people with diabetes. Doctors and Registered Dietitians thought that simple sugars were more quickly digested and absorbed into the blood than complex carbohydrates, like the starch in potatoes and breads. They thought that simple sugar would cause a larger rise in blood glucose. They were wrong. Recent studies have shown that simple sugars don't spike blood glucose any higher or faster than other carbohydrates. The American Diabetes Association changed its nutritional recommendations in 1994. Nevertheless, some myths are take a long time to die out. Students with diabetes get a lot of mixed messages and misinformed free advice about sugary foods. You can help by knowing the facts, and by letting students know that you know that diabetes nutrition is not just “All about the sugar”.

31 Exercise & Diabetes Everyone benefits from exercise and physical activity. Students with diabetes should fully participate.

32 Exercise & Diabetes Since exercise can lower blood sugar levels…. May need to make adjustments to insulin/ medications and food intake. 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. Exercise and physical activity are critical parts of diabetes management. Everyone can benefit from regular exercise, 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, exercise lowers blood sugar levels. Students with diabetes may need to make adjustments to insulin/medications and food intake. 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.

33 Exercise & Blood Glucose MonitoringMay need to check before, during, and after exercise 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, in lieu of snack Guidelines for exercise and blood-glucose monitoring: Check before, during, and after exercise 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, in lieu of snacking (per DMMP).

34 Blood Glucose MonitoringHelping the Diabetic Student Succeed Blood Glucose Monitoring III

35 School Blood Glucose (sugar) CheckKnow the target blood glucose range in PLAN Check at times specified in PLAN Provide Immediate Action – Treatment to get back within target Provide monitoring data to parent/guardian/Dr. when requested 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.

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

37 Regularly scheduled checks may be done: Extra checks may be necessary:When to Check? Regularly scheduled checks may be done: Before meals and snacks Before, during and/or after exercise Extra checks may be necessary: Periods of stress or illness Hypoglycemia or hyperglycemia symptoms Change in diabetes management Insulin/medication doses Meal plan Activity Blood Glucose Checking Regularly Scheduled checks Routine monitoring before meals and snacks Before, during, and after exercise

38 Supplies to Check Blood Glucose (Sugar)Blood Glucose Meter Blood Glucose Strips Lancets Lancing Device There are many reliable meters on the market. Each has a unique set of features and operating procedures. A number of features vary from meter to meter. Some of the features are convenience-based. Others can be critical to accuracy in test results. Ease of use Sample size needed Ability to reapply, if insufficient sample Wait time Alternate-site testing capacity Become familiar with the operation of each student’s meter

39 Preparation Gather blood glucose monitoring supplies:- Lancets and lancing device - Test strips and meter Wash hands Have student wash hands If assisting or performing for student, put on disposable gloves. Instructions: 1. Gather blood glucose monitoring supplies: lancet, test strip, meter, 2. Wash hands. 3. If assisting or performing for student, put on disposable gloves.

40 Readying the Lancet & the Meter4. Insert a lancet into the device 5. Check the setting for the depth of the stick 6. Insert a strip into the meter Lancing the Finger 7. Hold the lancet device to the side of the finger and press the button to stick the finger. Instructions: 4. Turn the meter on 5. Check code number that appears on meter with the code number found on the container of the test strips. Correct meter code if codes do not match. 6. Insert a strip into the meter (some meters turn on automatically when the strip is inserted).

41 Applying Blood to Strip8. Follow instructions included with the meter when applying blood to strip Results Wait until blood glucose results displayed. Dispose of lancet Record blood glucose results, take action per PLAN Instructions: 8. How blood is applied to the strip is a little different from meter to meter. Follow instructions included with the meter in how to apply the blood sample. This slide shows three different kinds of strips to illustrate some things to keep in mind. With the first type of meter & strip, on the left: Be sure to drop, do not smear the blood onto the strip. With all meters and strips, be sure to completely cover the test strip window. The picture on the right illustrates that some strips actually suck the blood onto the strip by capillary action upon contact with the drop of blood on the finger (or other alternate site).

42 What does the number mean?September 11, 2009 Know the student’s target range If they are not in their target range, assist the student to take the appropriate action…Follow the PLAN Communicate sensitively La Feria ISD In responding to and communicating about a specific reading, there are several things to keep in mind. Reaction to blood glucose testing results should always consider the student’s target range as it has been specified in the DMMP. Not all children will have the same target range. Even for an individual child, the target range may be somewhat different at different times of the day. Take action for blood glucose levels that fall outside of students target range as per DMMP. Avoid referring to the numbers as “good” or “bad,” both to the student and to others. The fact that the blood sugar is being checked is good, no matter what the results are. Refer to numbers as "in target", or "out of target“ or “below target” or “above target”.

43 Managing Hypoglycemia:Helping the Diabetic Student Succeed Managing Hypoglycemia: Low Blood Sugar III

44 Vocabulary Glucose a simple sugar found in the blood. the fuel that all body cells need to function. HYPOglycemia a LOW level of glucose in the blood Quick-acting glucose foods containing simple sugar that raises blood glucose levels Glucose tablets or gel special products that deliver a pre-measured amount of pure glucose … a fast-acting form of glucose used to counteract hypoglycemia

45 Hypoglycemia: Possible CausesToo much insulin Too little food Extra physical activity

46 Hypoglycemia: Possible Signs & SymptomsMild Symptoms Seizures Sudden crying Unconsciousness/coma Inability to swallow Dazed appearance Extreme tiredness/fatigue Restlessness Irritability/frustration Confusion Yawning Moderate to Severe Symptoms Increased heart rate/palpitations Dilated pupils Blurry vision Anxiety Paleness Sweating Weakness Changed behavior Shakiness Sleepiness Hunger

47 Mild Hypoglycemia: What to doIntervene promptly. Follow PLAN. Verify with blood glucose test when available. When in doubt, always treat. If no meter is available, treat immediately. Have student eat or drink fast acting carbs (15g) Test blood glucose minutes after treatment Repeat treatment if blood glucose level remains low or if symptoms persist If symptoms continue, call parents

48 Quick Acting Glucose for HypoglycemiaTreatment for Lows: 15 g Carbohydrate 4 oz. fruit juice 15 gm glucose tablets (2-3 tablets) 1 tube of glucose gel 4-6 small hard candies 1-2 tablespoons of honey 6 oz. regular (not diet) soda (about half a can)

49 Hypoglycemia: PreventionKeep a quick-acting sugar source with the student. ALWAYS. Treat at onset of symptoms Eat, Insulin, Test, Exercise ON TIME. Ensure reliable insulin dosing. Ensure insulin dosing matches food eaten. Watch picky eaters Consult with parent/guardian when snack, meal or exercise 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 exercise A student should never be unattended when a low blood glucose is suspected.

50 Severe Hypoglycemia: What to doRare, but life threatening, if not treated promptly: Place student on his or her side Inject glucagon, per student’s IHP Never attempt to give food or put anything in the student’s mouth Call 911, then parent/guardian Student should respond in 15 to 20 minutes Remain with the student until help arrives

51 Glucagon AdministrationHelping the Diabetic Student Succeed Glucagon Administration Glucagon a hormone given by injection that raises the level of glucose in the blood. III

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

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

54 Preparation 1. Flip cap off glass vial containing dry powder2. Remove cap from syringe 1. Flip the plastic cap off the glass vial of powdered glucagon. 2. Remove the plastic cap off the syringe needle. Do not remove plastic clip from syringe as it prevents the rubber stopper from being pulled out.

55 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.

56 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.

57 Dosing & Injecting buttocks thigh arm 7. Clean site if possible8. Inject at 90° into the tissue under cleansed area, using the same technique as an insulin injection (however, needle is much larger than insulin syringe needle) buttocks 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, using the same technique as an insulin injection, in an area such as the buttocks, thigh or arm. (The needle on the syringe is usually larger than those on insulin syringes.) Suggested sites include the outer thigh, upper outer buttock, or arm.

58 After Injecting Don’t be surprised if:May take minutes for student to regain consciousness. Check blood sugar. Give sips of fruit juice or regular soda, once student is awake and able to drink. Advance diet as tolerated. Document as per PLAN Don’t be surprised if: Student does not remember being unconscious, incoherent or has a headache Blood sugar becomes very high (over 200) Nausea or vomiting occurs It may take minutes for student to regain consciousness. Check blood sugar minutes after administering glucagon. Give sips of fruit juice or regular soda once student is awake and able to drink. Follow with concentrated sugar with snack containing proteins and carbohydrates such as peanut butter sandwich or cheese crackers to keep blood sugar levels elevated to normal levels and to prevent recurrence. Document blood glucose level and glucagon dosage as per DMMP.

59 Managing Hyperglycemia:Helping the Diabetic Student Succeed Managing Hyperglycemia: High Blood Sugar III

60 HYPERglycemia = HIGH SugarToo much sugar in the blood, but cells are “starving” Hyperglycemia due to insufficient insulin may lead to diabetic ketoacidosis (DKA) if not treated (the build up of ketones in the body that can lead to serious illness and coma) PLAN should specify signs and action steps that might include: Ketone testing a procedure for measuring the level of ketones in the urine or 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. Hyperglycemia is a high blood glucose level in the blood. Yet the irony is that with all the glucose floating around in the blood the body cells are actually starving because glucose cannot get in. Generally the onset of hyperglycemia is slow. An isolated high blood glucose reading is cause for concern, but not alarm. It is especially important to recognize that blood glucose is expected to be higher following a meal or snack. Hyperglycemia can occur more rapidly in students with insulin pumps if a pump malfunctions or delivers less insulin. If there is insufficient insulin due to pump malfunction, failure to take insulin or insulin not working effectively, there maybe a breakdown in fat, causing ketones to form, ketones may build up in the blood and may result in diabetic ketoacidosis (DKA). Hyperglycemia becomes an increasing concern when several consecutive readings have been high, or when accompanied by vomiting. The student’s DMMP should determine precisely what actions should be taken at each level of severity of hyperglycemia.

61 Hyperglycemia: Risks & ComplicationsHyperglycemia due to inadequate insulin can lead to coma or death (mainly in type 1). Interferes with a student’s ability to learn and participate. Serious complications (heart, healing, kidneys, eyesight)develop when glucose levels remain above target range over time or are recurring. There are several important reason that to learn the signs, treatment, and prevention strategies for hyperglycemia. If left untreated for an extended period, hyperglycemia due to insufficient insulin can lead to “diabetic ketoacidosis” (DKA) and/or coma and death. The onset is more rapid for students who wear insulin pumps. High blood sugar can affect a student’s general well-being. Students who do not feel well are less able to learn and participate in school activities. When glucose levels remain high over time or are recurring, serious life-limiting complications of diabetes develop. Diabetes is the leading cause of adult blindness, lower limb amputations, and kidney failure. It can also cause heart disease and stroke. Many students with diabetes will not experience symptoms from high glucose levels until the level is far above target range. Therefore, routine glucose testing is needed to identify otherwise undetectable high glucose levels. The good news is that, treating high glucose levels in accordance with the student’s DMMP, enables students to participate fully in their education now and enhances their health and well-being in the future.

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

63 Hyperglycemia: Possible Signs & SymptomsSevere Symptoms Labored breathing Confused Very weak Unconscious Moderate Symptoms Stomach cramps Nausea Dry Mouth Vomiting Mild Symptoms Lack of concentration Thirst Frequent urination Blurred vision Flushing of skin Increased hunger Sweet, fruity breath Weight loss Fatigue/sleepiness Stomach pains Action needs to be taken at the first signs of hyperglycemia; These signs 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 signs indicate that hyperglycemia has escalated. Mild symptoms plus: Dry mouth Nausea Vomiting Stomach cramps This last group of symptoms indicate severe hyperglycemia, and probable ketoacidosis. Mild and moderate symptoms plus: Labored breathing Very weak Confused Unconscious The important thing to remember is that intervention at any of these levels will prevent progression to more severe symptoms.

64 Hyperglycemia: What to doGoal: lower the blood glucose to a target range. Follow IHP Verify with blood glucose test. Check ketones . Allow free use of bathroom & access to water. Administer insulin if PLAN indicates (pen, syringe, pump). Recheck blood glucose in 1-2 hours. Call parents . The goal in the treatment of hyperglycemia is to lower the blood glucose level to within a student’s target range. Always follow the individual child’s DMMP. Generally, the action steps for hyperglycemia are: First of all, verify status with a blood-glucose test as specified in the DMMP. Secondly, check ketones as specified in the DMMP. Allow free use of bathroom and access to water Administer insulin as specified in the DMMP. Recheck blood glucose per DMMP. The parents should be notified immediately when the conditions for contact are present as specified in the DMMP.

65 Hyperglycemia: PreventionStay on schedule for blood glucose checks, insulin doses, meals, snacks, & exercise Ensure that food eaten matches insulin dosing: Monitor food : count carbs of all food eaten if plan indicates Consult with parent/guardian when snack, meal, or exercise times must be changed. Take appropriate action if a missed dose is suspected or if an insulin pump malfunctions. Avoid “over treating” low blood sugar reactions. Respect the students; realize their limits 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, take insulin on time, and check blood glucose on time. Ensure that insulin dosing is accurate, according to guidelines in 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 students this may mean supervision and guidance about food choices, including monitoring what is actually eaten. Any suspected binge eating should be reported to parent/guardian. “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 parents/guardians. Be sure each teacher knows to consult with parents/guardians prior to serving extra snacks. Changes in snack, meal, or exercise times should only be made after consultation with parents.

66 Practical Implications for EducatorsStudents with hyperglycemia often do not concentrate well. During academic testing: Check blood glucose before and during testing, per educational plan. Provide 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. Students should have adequate time for taking medication, checking blood glucose, and eating. Eliminate barriers to: snacking blood glucose testing access to water and bathrooms Avoid making judgments based on individual blood glucose readings. A few practical implications for educators related to the prevention and/or intervention of hyper- and hypoglycemia: Students with hyperglycemia or hypoglycemia often do not concentrate very well; students may need to have information repeated. During academic testing: Students should test blood glucose before and during testing, if specified in their educational plan. Students should have access to food/drink and restroom during the testing period Students should be excused from testing with an opportunity for retake later, should a serious high or low blood glucose episode occur. Students should be given adequate time for taking medication, checking blood glucose levels, and eating snacks or completing meals.

67 Helping the Diabetic Student Succeed Ketone Testing III

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

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

70 Test Results: Color codeno ketones trace small moderate large ketones present When recording results record the descriptor from color coding on the packaging. Record both the word and numerical result labels. Note: At this point in the training the instructor of training demonstrates checking of urine ketones and how to read results when compared to color coding on packaging.

71 Treatment of Ketones Generally:PLAN specific for an individual student Generally: free use of bathroom sugar-free liquids insulin as per DMMP no physical activity if vomiting or lethargic, call parents If ketones are present, treatment should follow the recommendations specified for the individual student in his/her DMMP, including the notification of parents 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, parents should be called or call for medical assistance if parents cannot be reached.

72 Insulin AdministrationHelping the Diabetic Student Succeed Insulin Administration III

73 Insulin in Schools TodayMany students need to take insulin in school Insulin regimens vary Need for assistance will vary. GOAL: Maintenance of blood glucose target range 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 in target range. This is because studies have shown that this intensive treatment prevents or delays 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. 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. The student’s Diabetes Medical Management Plan (DMMP) will state what accommodations are needed.

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75 Delivery Methods Insulin Syringe Insulin Pen Insulin PumpNo longer do all students take their insulin by using a vial and syringe. Many do. But 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. The insulin pump 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. Insulin jet injectors send a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles. This training contains a review of the basics of insulin delivery for students who use syringes, pens, or pumps. Since each pump or pen is somewhat different than the others, further training will be needed on specific technology that is used by students in your school. Training videos are generally available from the manufacturers. Additionally, most of the companies now post their product manuals online as PDF files, so that you can print a copy of a pump or pen device manual to keep in the health office for training and troubleshooting.

76 When to Give Insulin Administer as specified by Physician Orders:Generally: Before meals For blood glucose levels significantly above target range For increased ketones Insulin must be administered as specified in the student’s DMMP. The DMMP specifies the orders of the student’s health care provider. Generally insulin will be given: Before meals or some snacks, depending on DMMP recommendations For blood glucose levels significantly above target range For increased ketones

77 Dosing For many students, insulin dose varies, depending upon:Blood glucose readings Food availability/preference Physical activity level Age/body weight Follow prescribed guideline by PLAN. Many students do not take the same amount of insulin every day. Insulin dose will vary, depending upon: blood glucose readings food availability/preference activity level age and body weight See student’s DMMP for specific instructions.

78 Insulin Injection with SyringeGet supplies and explain procedure to student Wash hands and place gloves Inspect insulin. Check expiration date. Roll bottle to mix if bottle instructions indicate Pull syringe down to ____units Push needle into bottle and push plunger up Pull plunger down to ___units Locate injection site and wipe with alcohol swab Pinch up skin and push needle into skin and push plunger in Pull needle out Dispose of needle properly Document

79 Insulin Injection with PenGet supplies and explain procedure to student Wash hands and place gloves Inspect insulin pen. Check expiration date and amount of insulin Attach needle using sterile technique Dial pen to correct amount: ____units Locate injection site and wipe with alcohol swab Pinch up skin and push needle into skin and push pen plunger in Pull needle out Dispose of needle properly Document

80 Insulin with an Insulin PumpBattery operated device about the size of a pager that delivers insulin into the body via a thin plastic tube: an infusion set (reservoir filled with insulin) Computer chip helps control insulin delivery by punching a keypad. An insulin pump is an external, battery-powered device that continuously delivers insulin in small doses to the body. It looks very much like a pager and can be attached to a belt or waistband, carried in a pocket, or held with a strap around the arm or thigh. The pump contains a cartridge, or reservoir, of insulin. While the pump contains computer technology, it is not completely automatic. The user still has to decide how much insulin will be given. An insulin pump requires programming, close monitoring, and frequent blood glucose tests. Pump settings are determined by the student, family, and health care provider.

81 Components Pump Insulin Reservoir Tubing/Need le/catheter

82 Worn 24 hours a Day Site changes every 2-3 days

83 Insulin Pump Therapy Based on what body does naturallyGives small amounts of insulin all the time . That is called the basal rate (basal insulin) Gives extra doses to cover each meal or snack (bolus insulin) Pump therapy is based on what the human body does naturally - deliver small amounts of insulin all the time (basal insulin) - and then when at meals or snacks, a little extra insulin is delivered to cover that amount of food (bolus insulin). The Pump Uses Rapid or Short-Acting Insulin Students who are on injections use both long and short acting insulin. Generally their long-acting insulin will be taken either once or twice daily. Absorption of injected long-acting insulin can be extremely unpredictable. This is a big reason that blood sugar can vary so much from one day to the next. Pumps uses rapid or short-acting insulin which is much more predictable than long-acting insulin. The Pump Delivers Insulin in micro-drops that are continuous and accurate. With injections, the insulin is injected in larger doses. The level of activity directly affects when that insulin goes into the bloodstream. Just sitting at a desk, it will go into a student’s system more slowly. But the student goes for a walk or a run, it will go into her system much more quickly. Pumps continuously send a little bit of insulin every few minutes (like a pancreas) so you don't have this inconsistency problem.

84 Basal Rate Basal rate is set. It is the amount of insulin that is being continually given automatically.

85 Meal Bolus Meal Bolus changes. The amount of insulin given depends upon how many carbohyrdrates are going to be eaten. Buttons on the pump must be pushed.

86 Determine # of Carbs TOTAL= 72 grams 12 grams 15 grams 30 grams

87 How to Give an Insulin BolusPress B. ENTER BG screen: Use arrow to enter blood glucose value and then press ACT. If blood glucose is high, screen will read “check for occlusion.” Press ACT. Screen will read “BG to update sensor”, No will be highlighted. Press ACT. ENTER FOOD screen: Use arrows to enter # of carbs being consumed. Press ACT. ESTIMATE DETAILS screen: Confirm bolus (insulin amount__.___) and press ACT SET BOLUS screen: Confirm bolus (insulin amount__.___) and press ACT BOLUS DELIVERY screen: Insulin bolus starts counting up & beeps when completed

88 Correction Bolus Here is an example of when you might need to give insulin with a pump because the student’s blood glucose is high. This is called giving a correction bolus of insulin. Student has a headache and checks her blood sugar. Blood sugar is 323. You want the blood sugar to return to the target range. Follow the directions for high blood sugar. (Check ketones, drink water) Enter the blood sugar into the pump and follow the directions it gives for the units of insulin to give as a bolus.

89 How to Suspend and Remove the Insulin PumpSuspend and remove pump if student’s becomes unconscious and a severe blood blood sugar is suspected. Do this after glucagon is given and 911 is called.

90 Pump Management at SchoolSupplies Where is the PLAN? What is the student’s schedule? When will they have PE? Wil they have a snack? When do they eat? Where is the list of carbs for the school menu?(school website) Where is the meter, quick acting sugar, glucagon, ketone strips, and extra pump supplies?

91 Example of Pump Management at School: Routine ScheduleResponsibility Time Location of student Person responsible Taking off pump before PE 10:30 10:00 210 Teacher & UDCA Assist student to replace pump, check blood sugar, & document in log. 11:10 Gym or playground UDCA On some days (WED) student will have PE early and return to class to replace pump with teacher Accompany student to cafeteria, count carbs, enter blood sugar, carbs, & insulin bolus in pump. Document. 11:20 cafeteria Enter carbs of snack & insulin bolus in pump. Document. 3:00 311