1 Diabetes Care Manager Refresher Training
2 Legal Background NC SB 911 established the legislation which provided guidelines for supporting students with Diabetes in the public school setting. Trained Diabetes Care Managers are required to be on the staff at all public schools.
3 Who is involved? Health Care Management Team: School Nurse ParentStudent Diabetes Care Manager All School Personnel who work with the student
4 Responsibilities of the School Health NurseProvide forms Provide training Act as a resource Continuing education Assist in monitoring and guidance Assist in development of Individual Health Care Plan
5 Responsibilities of the ParentProvide current accurate contact information Provide supplies Provide snacks Provide documentation for school absences Make a care plan request Assist with development of care plan Provide medication forms as required Provide diet information Provide medic alert ID information if needed
6 Responsibilities of the StudentParticipate in self care as much as possible depending upon the child’s Maturity level Responsibility Age Follow the Health Care Plan
7 Responsibilities of the DCMReceive appropriate training Maintain documentation of training Participate in Individual Health Plan conferences Have ready access to the student’s IHP Be readily reached in case of a diabetes emergency
8 Responsibilities of the DCMCommunicate with students/parents/all school personnel as indicated or necessary Assist the student with diabetes care as indicated in the IHP Be available to go with the student on field trips or to school-sponsored extracurricular activities as indicated in the IHP
9 Who are All School Personnel?Administrators Front Office Staff Guidance Counselors Primary Teachers Resource Teachers Cafeteria Staff Bus Drivers First Responders SST Resource Officers
10 Guidelines for Bus DriversIf the student is acting in an unusual manner, contact the school for assistance in contacting parents Students may carry monitor, insulin, glucagon, and snacks on the bus. The student, teacher and parent should communicate with the bus driver. Bus driver may consider carrying extra snacks in case of bus breakdown, traffic jam, etc. (if needed)
11 Liability Protection for DCMThe state of North Carolina requires this program and has directed all schools in the state to adopt the approach. You have received training for the position. You will continue to receive updated training. You have resources to call upon if needed. NC General Statute provides: Immunity for rescuers Immunity for acquirers and enablers
12 What is Diabetes? “Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia (high blood sugar) resulting from defects in insulin secretion, insulin action, or both.” (Diabetes Care, Supplement 1, 26:1, January, 2003, p. S5.)
13 What is Insulin? Insulin is a hormone produced in the beta or islet cells in the pancreas. It is necessary to move the sugar or glucose from the blood stream to the cells. Glucose is necessary to keep the cells in the body.
14 Types of Diabetes Type 1 diabetes Type 2 diabetesThe body makes little or no insulin as the body has destroyed the insulin making cells. Type 2 diabetes The pancreas doesn’t make enough insulin or the body is unable to use the insulin it does make.
15 Management of Type 1 diabetesDaily Insulin An insulin pump An insulin pen An insulin injection Healthy meal plan Keeps blood sugar within a healthy range Physical activity Uses extra sugar in the blood stream Aids in fighting long-term complications of diabetes Regular monitoring of blood sugar Guides the care management plan
16 Management of Type 2 diabetesMost often occurs in adult population but is a rising epidemic in young individuals Often occurs in individuals with other risk factors or characteristics: Family history of diabetes Previous history of gestational diabetes Obesity Certain ethnic groups African-Americans Mexican-Americans Pacific Islanders Pima Indians
17 Management of Type 2 diabetesCan be present for months or years before diagnosis Can be managed with: Diet and exercise alone Healthy diet Physical activity Weight loss Oral medications Insulin injections Regular monitoring of blood sugar
18 Symptoms of Diabetes Frequent urination Excessive thirstExtreme hunger Unusual weight loss Increased fatigue Irritability Blurry vision
19 Normal Blood Sugars Normal blood sugars< 6 years old: before meals and at bedtime 6-12 years old: before meals and at bedtime >12 years old: before meals; <160 2 hours after the start of a meal
20 Complications of DiabetesHypoglycemia Blood sugar drops too low – generally 70 mg/dLor lower Hyperglycemia Blood sugar gets too high – generally greater than 240 mg/dL or higher
21 Causes of HypoglycemiaNot following the meal plan – not eating enough food or delaying meal times Increase in exercise without a snack Too much medication or a change in the time the medication is administered Too much stress Side effects of other medications Drinking alcohol, especially with food
22 Early Symptoms of HypoglycemiaHunger Shakiness Dizziness Sweatiness Fast heart beat Drowsiness Irritable, sad, angry Nervousness Pallor
23 Later Symptoms of HypoglycemiaStubborn attitude Lack of coordination Cold Confusion Weakness Numb lips and tongue Personality change Passing out Seizures
24 Treating HypoglycemiaIf a meter is available, test the blood sugar. If a meter is not available, and the child feels sick – go ahead and treat as if low blood sugar. Test the blood sugar – if it is low follow the “15-15” rule “15-15” Rule Eat 15 grams of carbohydrate (foods that will increase the blood sugar quickly) Wait 15 minutes Test the blood sugar again
25 15 Grams of Fast Acting CarbohydrateGlucose gel or tables (as directed) 4 oz. fruit juice 6 oz. regular soft drink 1 tablespoon of honey 3-4 tablespoons of granulated sugar 2 tablespoons of raisins
26 Follow up If a student is not expected to have a meal within 30 minutes of experiencing low blood sugar, follow up with a snack, such as half a sandwich and a glass of milk or several crackers/cheese (i.e. Nabs)
27 Additional Precautions for HypoglycemiaTry to understand the reason for the low blood sugar by communicating with the student: Did you eat everything on your meal plan? Was your meal or snack delayed? Did you skip a meal? Did you exercise without eating a meal or snack? Did you exert yourself for a long time without eating a snack? Did you exercise when your blood sugar was too low? Did you take more insulin or diabetes pills than the dose prescribed by your doctor? Were you off schedule taking your medication? Were you under more stress than usual?
28 Additional Precautions for HypoglycemiaNotify the School Health Nurse if: The student has three or four low blood sugars within one week. The student has low blood sugar twice or more in 24 hours. The student has low blood sugar the same time for several days in a row. The blood sugar dipped below 50 mg/dL.
29 Treating Unconscious StudentsIF ORDERED AND ON THE CARE PLAN, give an immediate injection of Glucagon to raise the blood sugar level. If Glucagon is not on the care plan, a single tube of cake gel may be given to the student (see slide 38 for directions on administration of cake gel.) Call 911 to transport the student to the hospital. Notify parents. Notify central office of transport.
30 Glucagon Information Should be stored as indicated in student IHP – may be kept with student Should be stored at room temperature Monitor expiration date Should not be used if expired, discolored, or does not dissolve well After mixing, dispose of any unused portion
31 Emergency Kit ContentsCombine immediately before use
32 Administration of GlucagonGlucagon must be injected Review instructions provided within the emergency kit The emergency kit includes: A syringe pre-filled with saline A vial of powdered glucagon Combine the glucagon for injection immediately before use
33 Reminders on when to give GlucagonIf authorized by the student’s care plan and the student exhibits: Unconsciousness or unresponsiveness Convulsions or seizures Inability to safely eat or drink
34 Procedure for administrationFlip cap off glass vial containing dry powder Remove cap from syringe
35 Mixing the Solution
36 Drawing Out the SolutionInspect – solution should be clear and colorless Draw prescribed amount of glucagon into syringe
37 Dosing and Injecting Clean site if possibleInject at 90° into the tissue under cleansed area, using the same technique as an insulin injection (needle is much larger than a syringe needle) Inject Thigh (avoid the inner thigh) Upper arm
38 Administering Cake GelSqueeze the cake gel between the cheek and gum – do not squeeze the entire tube at once. Squeeze 1 to 2 tablespoons and massage the outside of the cheek to help the gel absorb. Repeat the process until the entire tube is used. DO NOT squeeze the gel onto the tongue or the back of the throat. The student will be unable to swallow and could aspirate the gel.
39 Causes of HyperglycemiaToo much food or the wrong foods Too little or no exercise Too little diabetes medication or not taking diabetes medication as instructed Expired insulin or medications Too much stress Infection or illness Diabetes medication not being used properly by the body Menstruation Medications/hormones: i.e. Glucagon, growth hormone, steroids, etc.
40 Symptoms of HyperglycemiaMost common symptoms Tiredness or fatigue Increased appetite Increased thirst Frequent urination Blurred vision Other symptoms Dry, itchy skin Poor healing of wounds Flu-like achiness Headaches
41 Treating HyperglycemiaIf a meter is available, test the blood sugar. If the blood sugar is high, follow the student’s care plan for when to give sliding scale or correction dose insulin. If the student’s blood sugar is over 300 mg/dl – do not have the student exercise in an effort to lower the blood sugar.
42 Prevention of HyperglycemiaTake diabetes medication as instructed Follow the meal plan as developed Follow the exercise plan as developed Learn to manage stress Seek care for illness or injury quickly Test blood sugar often
43 Precautions with HyperglycemiaFor a school age child, a blood sugar greater than 240 mg/dL requires an additional check half an hour later. Two consecutive blood sugars greater than 240 mg/dL requires ketone testing. A single blood sugar greater than 300 mg/dL requires ketone testing. Insulin injections for high blood sugar should be given according to the student’s Individual Health Plan. Maintain contact with the School Health Nurse if a blood sugar is testing more than 240 mg/dL.
44 Testing for Ketones Ketones are waste products produced in the body and excreted in the urine. A buildup of ketones can cause diabetic ketoacidosis (DKA) which can be deadly. The majority of students will not test for ketones at school and those that do should have procedures listed in the Individual Health Plan.
45 Recommendations for Ketone TestingStudents with Type I diabetes Blood sugar level > 240 mg/dL All students with diabetes Times of illness Times of stress Blood sugar level > 300 mg/dL Ketoacidosis suspected
46 Symptoms of KetoacidosisEarly Signs Thirst or very dry mouth Frequent urination High blood sugar High levels of ketone in the uring Later Signs Constantly feeling tired Dry or flushed skin Nausea, vomiting or abdominal pain A hard time breathing Fruity smelling breath Difficulty paying attention or confusion
47 Moderate to High KetonesTreat as an emergency situation according to the student’s Individual Health Plan Do not allow exercise Allow free use of the bathroom Allow sugar free liquids only Give insulin as ordered in the Individual Health Plan Call the School Health Nurse Contact the parent If the student is nauseous and vomiting, contacting 911 may be required.
48 Ketone Testing Gather supplies Student urinates in clean cupPut 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 care plan
49 Blood Sugar Testing Regular self monitoring using a glucometerA1C test – administered by a doctor every few months for long term monitoring (sometimes called a hemoglobin A1C or HgA1c test)
50 Blood Sugar Testing Type 1diabetes – 3 or more times per dayType 2 diabetes – as recommended by doctor Goal <6 years old: before meals & bedtime 6-12 years old: before meals & bedtime >12 years old: before meals; <160 2 hours after the start of a meal
51 Rationale for monitoringAvoidance of blood sugar highs and lows that can affect the student’s overall health and well-being Delay or prevent long-term health problems caused by high blood sugar
52
53 Lancing Devices LANCETS LANCING DEVICE
54 Lancing Devices Requires a lancet – sharp steel blade in a plastic case Lancet is inserted in the lancing device Some lancing devices have an adjustment for depth of puncture Depth of puncture should not cause bruising or pain Lancets should be disposed of in a sharps container according to local policy
55 The Process Gather all supplies: Glucometer Lancing Device LancetsAlcohol Pads Blood Testing Strips Student should wash hands. If assistance is needed, disposable gloves should be utilized.
56 Meter Preparation Turn on the meterCheck code number (should match the code on the vial containing the strips) If the code does not match, adjust the code in the meter Insert a testing strip into the meter (some meters will automatically turn on when a strip is inserted into the meter)
57 Drawing Blood Hold the lancing device to the side of the finger and press the button to puncture the skin Follow directions included with the meter if the meter requires the blood to be dropped onto the test strip. Cover all of the test strip window with a drop of blood – some strips actually pull up the blood
58 Results Wait for results to display on the meter (times to display vary between 15 seconds to 1 minute) Record the results Dispose of lancet according to local procedures Take action based on student’s Individual Health Plan Dispose of testing strips in trash receptacle
59 Interpreting Results May be displayed in numbers – refer to student’s target numbers for blood sugar level May be displayed in words relative to student’s programmed target range – i.e. high, low, moderate May display an “error code” – consult the meter manual for information
60 Response to Results Respond to the results as to whether or not the blood sugar level is within target range for the individual student Consult the Individual Health Plan Consider the student’s feelings when responding Contact the School Health Nurse if there are any questions
61 Effect of Diet on DiabetesFood eaten turns into sugar in the bloodstream Without insulin, the sugar remains in the bloodstream and cannot get to the cells where it is needed Insulin is often needed near mealtimes to help the sugar move from the bloodstream to the cells
62 Types of Food Carbohydrates Protein Fat Fiber Vitamins-MineralsBreads, fruits, starchy vegetables, dairy foods Main source of energy Broken down into glucose (sugar) Protein Meats, poultry, fish, dry beans, eggs, nuts, milk, yogurt, cheese Very little is converted to blood sugar, but should be limited due to amount of cholesterol Fat Small amounts are needed Does not affect blood sugar, but excess fat is stored as excess weight Fiber Whole grains, beans, vegetables Slows the digestion of certain carbohydrates Vitamins-Minerals Fruits and vegetables Strengthens immune system
63 Effect on Blood Sugar Carbohydrate – 100% is converted to blood sugar within minutes Protein – 58% is converted to blood sugar within 3-4 hours Fat – 10%-30% is converted to blood sugar after several hours Important to determine if certain foods cause an unpredictable change in blood sugar for a student
64 Developing a Meal Plan Healthy foods for all individuals are healthy foods for diabetics Meals and snacks need to be balanced with exercise and medications Balancing insulin or medications with carbohydrate intake allows students to have control over food choices and portions
65 Types of Meal Plans Exchange System for Meal PlanningEquivalent food choices can be chosen within a developed plan Basic Carbohydrate Counting Total carbohydrates are counted as eaten Insulin to Carb ratio Rapid insulin is given to cover the amount of carbohydrate consumed at a meal
66 Carbohydrate CountingThe School Health Nurse will write in on the student’s care plan the total allowable amount of carbohydrate for meals and snacks. SCS menu planning information is available on our system website. Parents should send information as to the amount of carbohydrate in foods provided from the home.
67 Example Student OrdersSliding Scale Insulin Call Parent if >400 Type of Insulin: Novalog Pen Carb Coverage Insulin Type of Insulin: Novalog Pen Carbs Eaten Amount of Insulin 15 gm 1 unit 30 gm 2 unit 45 gm 3 unit 60 gm 4 unit 75 gm 5 unit 90 gm 6 unit 105 gm 7 unit Glucometer Reading Amount of Insulin 1 unit 2 unit 3 unit >401 4 unit
68 Example: Meal Choices Chicken nuggets – 11 gm Dinner roll – 14 gmPineapple – 13 gm Frozen fruit bar – 10 gm Chocolate milk – 26 gm Total = 74 gm
69 Results The student’s blood sugar was 135 before lunch – therefore, no sliding scale insulin is necessary as the reading is below 150. The student ate 74 gms of carbohydrate for lunch and will need 4 units of insulin for carb coverage. (Give the lesser amount even though 74 is close to 75 – err on the lower side to avoid hypoglycemia)
70 Insulin Most students with Type 1 Diabetes take 2 insulin injections per day Intermediate acting insulin Long acting or basal insulin Rapid acting insulin Fast acting insulin Some students are on intensive insulin therapy or Wear an insulin pump
71 Insulin administrationAs specified in the student’s IHP Insulin to Carb ratio specifies how much carbohydrate one unit of insulin will match Correction or sliding scale insulin – amount of insulin ordered to correct a blood glucose level above the student’s target range
72 Insulin AdministrationGenerally insulin will be given: Before meals or some snacks, depending on IHP For blood glucose levels significantly above target range as indicated in IHP after contacting parents For increased ketones, call parent immediately
73 Liability Issues Be familiar with the student’s IHPCheck insulin and glucagon dates to be sure they are not expired Check yourself when drawing up a dose of insulin Double check the student if he/she is drawing up a dose of insulin Remember, a vial or pen of insulin is only good for 30 days once opened
74 Types of Incidents Giving too much insulinNotify the child’s health care team Test blood sugar at least every hour for the rest of the day Notify the parent/guardian to let them know of the procedure you have taken Provide extra food/juice for the child Alert the teacher Notify the School Health Nurse
75 Types of Incidents Too little insulin or leakage from the site of injection Blood sugars may run a little higher if insulin leaks from the site. If this is a common problem, take more time with the injection and count 10 seconds before withdrawing the needle. Child refuses insulin injection Document and contact parents immediately.
76 Insulin AdministrationInsulin syringes Different sizes are available Dispose of according to Universal Precautions Pre-filled pens Built in insulin cartridge Reusable pens Insulin cartridge is inserted Disposable needle Insulin pumps
77 Insulin Pumps Delivers small amounts of insulin all the time (basal insulin) – consistent delivery not affected by activity Allows for extra insulin at mealtime (bolus insulin) Contains a reservoir of insulin Requires programming, close monitoring, frequent blood glucose tests
78 Insulin Pumps Supplies involved & provided by parent Infusion setReservoir Insulin Skin prep items Alcohol wipes to clean top of insulin vial Syringe (in case of malfunction) Pump batteries Inserter (if used) Manufacturer’s manual, alarm card
79 Administering Insulin ShotsGet supplies: Insulin - verify Syringe Alcohol Wipes Disposable Gloves Sharps Container Wash hands Apply Gloves Clean the top of the insulin vial with an alcohol wipe Clean the skin area around the injection site with an alcohol wipe.
80 Administering Insulin ShotsCheck the insulin dose and verify the following: Student Insulin Where & how delivered Specific dose for the conditions Remove the cap from the syringe
81 Insulin Administration ShotsPull the plunger down to number of units to be administered Push the needle into the bottle of insuling Push the plunger down to inject air into bottle of insulin
82 Insulin Administration ShotsDraw out prescribed number of units of insulin per student’s Individual Health Plan by turning the bottle upside down and pulling the plunger down to the required number of units. Check the dosage against the student’s Individual Health Plan.
83 Administering Insulin ShotsPinch up the skin at site of injection Push needle in at 90° angle Release the pinch Push the plunger in to administer the dosage Count to “10” Remove the needle and dispose of the syringe properly
84 Administering Insulin from an Insulin PenGather supplies (verify type of insulin) Insulin pen with cartridge Pen needle Alcohol wipes Sharps container Wash hands and apply disposable gloves Choose & Clean the injection site Screw on pen needle
85 Administering Insulin from an Insulin PenPrime the pen by dialing 2 units Remove air by pressing the plunger Repeat the “prime” process if no insulin shows Dial the number of units as prescribed in the student’s Individual Health Plan
86 Administering Insulin from an Insulin PenPinch up the skin at site of injection Push needle in at 90° angle Release the pinch Push down on the plunger to administer the dose Count to “10” Remove and dispose of pen needle
87 Oral Medications Metformin or Glucophage™Enables the body to more effectively utilize the insulin that is produced Prevents the liver from releasing glucose into the blood stream Does not cause low blood sugars Does not cause weight gain May be used in conjunction with insulin Check student’s IHP
88 Priorities Review of student’s Individual Health Plan at the beginning of the school year to determine: Appropriate Care Plan Operation of Equipment Accommodations needed for the student Who should review? School Health Nurse Parents Student Diabetic Care Managers
89 Priorities A copy of the care plan should be given to:Diabetic Care Managers All teachers Bus drivers Coaches After-school supervisors
90 Priorities The student should have immediate access to:Glucometer Emergency Snacks The parent has the responsibility of providing all necessary equipment, supplies, and emergency food or drink for diabetes care during the day.
91 Classroom Testing ImplicationsStudents should test blood glucose levels before and after testing (stress situations) if specified in their care plan or if a situation occurs. Students should have access to food/drink during the testing sessions (does not require a 504 plan.) Students should be excused from testing, with an option for a retest if a serious high or low blood glucose episode occurs.
92 Review with Teachers Students should always be given adequate time for taking medication, checking blood glucose levels, and eating snacks or completing meals. Eliminate barriers to snacking, blood glucose testing, and access to water and bathrooms. Avoid making judgments about blood glucose levels outside of the target range. Focus on actions that will correct the situation by following the Individual Health Plan.
93 Questions or Concerns If you need additional review or have questions or concerns, please contact your School Health Nurse. You may download this presentation to keep for future reference and review. If you have completed the review, please follow the link to complete the quiz and receive credit for the review: Go to Go to Employee Extranet Go to the Resources division of the website Go to Forms and Documents Go to Student Services Forms Click on Returning Diabetes Care Manager Quiz Complete the quiz and submit electronically.