Transcript Diabetes Management at School Powerpoint

ONLINE TRAINING FOR
Diabetes Management in School
This training will cover the following Diabetic Care
Tasks:
Signs and Symptoms of Hypo and Hyper
glycemia
Blood Glucose Testing
Glucagon Injections
Ketone Monitoring
Documentation
Please read through each section. There is a
post-test at the end. Print the test and answer the
questions. Contact your school nurse for an
appointment to go over the test and perform
return demonstrations on glucose testing and
glucagon administration.
When a new diabetic student
comes to your site . . .
Contact your School Nurse if she is not
already aware of it.
 Your School Nurse will . . .

 have
specific paperwork that must be
completed before Diabetic Care Procedures
can be available for the new student.
 develop an Individualized Health Care Plan for
the student.
Diabetes Management at
School
Much of the information in this
training was taken from:

Diabetic Care Tasks at School: What Key Personnel
Need to know. Powerpoint presentation from The
American Diabetic Association.

Mary Zombec, RN, MS, CPNP. P.E.D.S., Pediatric
Education for Diabetes in Schools. Copyright June
2001 PADRE Foundation in Partnership with the
California State Dept. of Education.
Diabetes is a Complex Disease and . . .
occurs when special cells in the pancreas
produce inadequate or no insulin.
 is influenced by diet, exercise, general
health, emotions and other factors.
 often managed by oral or injectable
medications, depending on the type and
severity of the diabetes.
 can be one of two types.

Type 1 and Type 2 Diabetes






Type 1*
Develops when person’s own
immune system destroys
pancreatic cells that make
insulin.
Usually occurs in childhood or
young adulthood.
Medical help sought because
people are seriously ill from
sudden symptoms of high blood
sugar.
Usually treated with insulin
replacement.
Episodes of low blood sugar are
common
Cannot be prevented.
*Cited
from US Centers for Disease Control and Prevention.
National Diabetes Fact Sheet, 2007. Atlanta: US Dept.
of Health and Human Services






Type 2*
Develops when cells do not
properly use insulin.
Body does not make an
adequate amount of insulin.
May not have symptoms before
diagnosis.
Usually discovered in
adulthood, but is being found in
increasing number of children.
Associated with obesity and
inactive lifestyle.
Can be prevented or delayed
with healthy lifestyle – diet,
weight control & exercise.
Goal of Diabetic Management

To keep blood glucose levels within an
individual’s TARGET RANGE.

This range is determined by the physician,
based on each individual’s condition and lab
results.
 Any
glucose levels outside this range indicate
the need for treatment.
HYPOglycemia
Learning Objectives
Participants will learn:

Symptoms of low blood
glucose

Short and long term risks

Treatment of low blood
glucose

Prevention of low blood
glucose
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 raise blood glucose levels.
Glucose tablets or gel
special products that deliver a pre-measured amount of pure glucose.
they are a fast-acting form of glucose used to counteract hypoglycemia.
Glucagon
a hormone given by injection that raises the level of glucose in the blood.
Carbohydrate
source of energy for the body.
HYPOglycemia = LOW sugar
Onset:
Sudden.
May
be caused by too little food, too much
insulin or extra physical exercise.
May
quickly progress to unconsciousness if
not treated.
Can
result in brain damage or death if not
treated.
Hypoglycemia:
Possible Signs and Symptoms











Mild Symptoms
Hunger
Sleepiness
Shakiness
Changed Behavior
Weakness
Increased Heart
Rate/Palpitations
Sweating
Pale Color
Anxiety
Blurry Vision
Dilated Pupils











Moderate Symptoms
Yawning
Irritability/Frustration
Extreme tiredness/fatigue
Confusion
Restless
Dazed Appearance
Sudden Crying
Severe Symptoms
Unable to Swallow
Seizures
Combative
Unconsciousness
Hypoglycemia: Risks &
Complications

Greatest immediate danger

Impairs cognitive and motor functioning

Early recognition and intervention can
prevent an emergency

Not always preventable
Mild Hypoglycemia: What to do
Goal: To raise blood glucose level







Intervene promptly.
If a meter is available, test blood glucose immediately
and 10-15 minutes after treatment.
When in doubt, always treat!
Treat by having student eat or drink 15 gm. fast acting
carbs.
Repeat treatment if blood glucose level remains low or if
symptoms persist.
If symptoms continue, call parents per plan.
Never leave a student with suspected low blood glucose
unattended.
Quick Acting Glucose for HYPOglycemia
Treatment for Lows: One of the following
choices provides 15 gm. of carbohydrates

4 oz. fruit juice

15 gm glucose tablets (2-3 tablets)

1 tube of glucose gel

4-6 small hard candies

1-2 tablespoons of honey

6 oz. regular (not diet) soda (about half a can)
Severe Hypoglycemia: What to do
Rare, but life threatening, if not treated
promptly:

Inject Glucagon, if ordered by M.D. and you have
been trained by your School Nurse.

Call 911, then parent/guardian.

If Glucagon is not ordered, call 911 immediately.

Never attempt to give food or put anything in the
student’s mouth if they are unconscious or having
a seizure.

Remain with the student until help arrives.
A Note About Glucose Gel

It is the only fast-acting oral carbohydrate
source you might use for an unconscious
person if Glucagon is not available or no
one is trained to give the injection.

It can only be done if it is ordered by the
doctor on the Physician’s Authorization
form under “Emergency Care of Severe
hypoglycemia.”
Procedure for Using Glucose Gel

What to do:
 Perform
procedure with extreme caution/use gloves.
 Turn the unconscious person on their side.
 Place the tip of the tube in the cheek that is down.
 Squirt the gel between the cheek & teeth.
 Massage outside of cheek to help glucose penetrate
into the gums.
 Allow the saliva/gel to drain out on a towel.
 To avoid aspiration, keep person on their side until
they regain consciousness.
Prevention of Hypoglycemia






Follow individualized diabetic management plan
regarding eating, glucose testing, insulin
coverage and exercise.
ALWAYS keep a quick acting sugar source on
hand.
Treat at first sign of symptoms.
Ensure that carbs in food match insulin dose.
Watch for picky eaters.
Consult with parent before class parties.
HYPERglycemia
Learning Objectives
Participants will learn:

Symptoms of high blood glucose

Short and long term risks

Treatment of high blood glucose

Prevention of Hyperglycemia
Vocabulary
Hyperglycemia: too high a level of glucose in the
blood.
Ketones (ketone bodies) Acidic chemicals that the
body makes when there is not enough insulin in
the blood and the body must break down fat for
its energy.
Diabetic ketoacidosis (DKA) the build up of
ketones in the body that can lead to serious
illness and coma.
Ketone testing a procedure for measuring the
level of ketones in the urine or blood.
HYPERglycemia = HIGH Sugar
Onset: Severe hyperglycemia is usually
slow to develop
 Too much glucose in the blood
 Too little insulin to transfer glucose into
cells


If left untreated, may lead to diabetic
ketoacidosis, a serious illness.
Hyperglycemia:
Possible Signs and Symptoms
Mild Symptoms







Thirst
Frequent Urination
Flushed Skin
Lack of Concentration
Fatigue/Sleepiness
Blurred Vision
Increased Hunger












Moderate Symptoms
Dry Mouth
Stomach Cramps
Vomiting
Nausea, Stomach Pain
Weakness
Dry, warm skin
Weight Loss
Sweet, Fruity Breath
Severe Symptoms
Labored Breathing
Very Weak
Confused
Unconsciousness
HYPERglycemia:
Risks & Complications



Interferes with a student’s ability to learn
and participate, they chronically feel lousy.
Hyperglycemia due to inadequate insulin
can lead to coma or death .
Serious long term complications develop
when glucose levels remain above target
range over time or are recurring.
(Blindness, lost limbs, stroke, heart attack,
shorter life span.)
Hyperglycemia: Possible Causes








Too little insulin
Expired insulin
Too many carbs for insulin dose
Decreased physical activity
Illness, infection, injury
Stress
Other hormones
Menstrual periods
Hyperglycemia: What to do
Goal: lower the blood glucose to target range.
• Check urine for ketones if ordered.
• Depending on the amount of ketones, give 8 oz. of
water per instructions on Algorithms form.
• Licensed nurse to administer insulin per established
care plan (student may self-administer if determined to
be self-sufficient).
• Recheck blood glucose per care plan.
Prevention of Hyperglycemia




Avoid “over treating” low blood sugar reactions.
Give only 15 gms. of quick acting glucose at a
time.
Contact School Nurse or parent if a selfadministered insulin dose is missed or pump
malfunctions.
Consult with parents if meal or exercise times
need to be changed.
Discourage binge eating
BLOOD GLUCOSE
MONITORING
LEARNING OBJECTIVES
Participants will learn:
Why blood glucose is monitored
 When blood glucose should be
monitored
 How to perform a blood glucose check

What is blood glucose monitoring?

It is a procedure that is done to obtain a
small amount of blood to test a person’s
blood glucose level.
Blood Glucose Monitoring


GOAL: Maintain blood
glucose within target range
Immediate Benefit:



Maximize learning &
participation in school
 Prevent lows and highs


Long-Term Benefit:

Decrease risk of long-term
complications
 Maximize health

Challenge: Many variables
can impact blood-glucose
levels

Role of the School
Facilitate blood
glucose monitoring
Know target blood
glucose results and
how to act on them
Provide monitoring
data to parent or
guardian to give to
the MD
When to Check
Regularly scheduled checks on individual basis:
 Routine
monitoring before meals and snacks
 Before,
during and/or after exercise
Extra checks may be necessary:
 Periods
of stress or illness
 Hypoglycemia
 Change
or hyperglycemia symptoms
in diabetes management
Any Time, Any Place Monitoring

Blood Glucose Testing may be done at
any time or any place the student is
having any symptoms of hypo or hyper
gycemia and a Glucose Monitoring Kit
is available.
Equipment and Procedure
Lancing Devices
Lancets
Pen-type Lancing Devices
Know the Meter

Features vary:
–
–
–
–
–

250
Ease of use
Sample size needed
Wait time
Alternate-site testing capacity
Ability to reapply, if insufficient sample
53
Become familiar with the operation of
each student’s meter. Read the manual!
Preparation

Gather blood glucose monitoring
supplies:
-Lancing Device and Lancet
-Meter
-Test strips

Wash hands (if student performs
test, have them thoroughly wash
and dry their hands).

If assisting or performing for
student, put on disposable gloves
and observe Universal
Precautions.
Readying the Meter

Insert strip to activate meter.

Check code # on vial of strips.

Code # on meter should match.
Lancing the Finger

Hold the lancet device to
the side of the finger and
press the button to stick the
finger.
Applying Blood to Strip
 Follow instructions included with the
meter if different from instructions below.
•Place tip of strip in
drop of blood on finger.
•Blood is automatically
sucked up into strip.
•Meter will indicate if
amount of blood is
sufficient.
Results

Wait until blood
glucose results
are displayed.

Dispose of lancet.

Record blood
glucose results on
log & take action
per plan.
250
53
What does the number mean?
Refers to the glucose level in the blood

May vary throughout day.

When compared to the Target Range, it
is an indicator of which treatment, if any,
is needed.

Guidelines for treatment are found on the
Algorithms for Blood Glucose Results
form. (next slide)
ALGORITHMS FOR BLOOD GLUCOSE RESULTS
Student’s Name: __________________________
School: _________________________________
School Nurse: ____________________________
Nurse Contact Number: ____________________
Parent’s Phone Number: Home: _____________
Work: _____________ Cell: ________________
STUDENT’S
PHOTO
Check Blood Glucose
Target Range
From: 70 To: 300
Above: 300
Below: ___70__
1. Give fast acting sugar source.*
2. Observe for 10 - 15 minutes.
3. Retest blood glucose, if less than 70
repeat sugar source.*
4. If over 70 give carbohydrate and
protein snack (ie. crackers and
cheese) or if within one hour to next
meal, feed early.
5. Notify school nurse if student has
two or more episodes in one week.
If Student Becomes Unconscious,
Seizures, or is Unable to Swallow:
1. Call 911.
2. Maintain open airway
3. Turn student on side to prevent
aspiration
4. Give Glucose Gel and/or Glucagon
per MD orders
5. Notify parents and school nurse
*FAST ACTING SUGAR SOURCES:
15 gm. Glucose Tabs (3 – 4 Tabs)
15 gm. Glucose Gel
1/3 c. Regular Soda (Not Diet)
4 oz. Orange Juice
Revised 8/13/07 JM (N Drive: Forms-Diabetes)
4 oz. Apple Juice
4 oz. Grape Juice
Tube of Cake Mate Gel
3 tsp. sugar in water
1. If student feels OK,
may resume school
activities.
2. If student does not
feel OK, retest blood
glucose.
3. If glucose < 70
then follow
directions on the
left.
 If glucose > 300 &
Ketone check is
ordered, follow
instructions on the
right. If no orders,
contact school nurse.
Check ketones (if ordered)
1.
2.
3.
4.
Student Feels Ok –
Ketones Neg. –Small
Give 1-2 glasses of
water every hour.
Insulin/exercise per MD
orders & IHCP
Notify parents if small
ketones are present.
Notify School nurse if
two or more episodes
occur in one week.
Student Does Not Feel
OK - Ketones Mod.Large
1. Consult with
school nurse.
Notify parents.
2. Provide 1-2 glasses
of water every
hour.
If at any time student
vomits, becomes
lethargic, and/or has
labored breathing CALL 911
To Physician
Please make desired modifications to the standard procedure above and
insert number for personal algorithms for this child in the boxes provided.
Please list any additional needs for special considerations for this child.
____________________________________________________________
____________________________________________________________
____________________________________________________________
Physician’s Signature __________________________________________
Documentation
Document the results on the
Diabetes Monitoring Log.
After each entry on the Monitoring
Log, place your initials in the
appropriate box.
Whenever new Monitoring Log is
started, remember to sign/initial in
one of the designated areas on
bottom of sheet. (Sample
documentation following).
Vista Unified School District
Vista, CA 92084
DIABETES MONITORING LOG
Student’s Name: Johnnie Jones
Parent:
Phone:
Date
Time
Blood
Glucos
e Level
5/20/09 11:30 110
5/21/09 11:30 55
11:45
Signature of staff providing care
Terry Tech
Birthdate: 1/22/99
Time/Recheck of
Glucose
Level
Ketones
Insulin
Dose
Teacher:
Doctor:
School Nurse:
Grade:
Phone:
Cell:
Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action taken,
document the response of the student, and document any phone calls made).
Within target range. Ate 45 carbs for lunch
Gave 4 oz. apple juice. 11:45 Rechecked glucose level
Up to target range – ate 47 carbs for lunch
70
Initials
TT
Signature of staff providing care
Initials
Signature of staff providing care
Initials
TT
TT
TT
Initials
What does the display mean?
 Check
manual
 Contact
manufacturer by phone or website
Practical Implications for Educators

Students with hyperglycemia or hypoglycemia often
do not concentrate well.

During academic testing:
 Check
blood glucose before and during testing
 Allow access to food/drink and restroom.
 If a serious high or low blood glucose episode occurs,
students should be excused with an opportunity for
retaking tests.

Eliminate barriers and provide adequate time for taking
medication, checking blood glucose, and eating.
Glucagon
Administration
Learning Objectives
Participants will learn:
What glucagon is
 How glucagon should be stored
 When glucagon is used
 How to administer glucagon

What is Glucagon?

Naturally occurring hormone made in the
pancreas.

A life-saving, injectable hormone that raises
blood glucose level .

Treatment for severe hypoglycemia.

Can save a life.

Cannot harm a student.
Comparison of
Insulin and Glucagon





Insulin
Hormone normally secreted by
the pancreas.
Essential for the metabolism of
blood glucose.
In certain diabetics, it is an
injectable med given daily at
specified times & doses to
lower blood glucose levels.
Doses are determined and
regulated by patient’s doctor
according to each individual.
Given only by licensed health
care providers.




Glucagon
Hormone normally secreted by
the pancreas.
Functions to raise blood
glucose levels when needed.
Used as an emergency
injectable med for diabetics to
raise extremely low blood
glucose levels.
May be given in an emergency
by non-licensed persons
trained by a licensed RN or
physician.
Glucagon Kit Storage



Store at room temperature
Expiration date: Monitor
After mixing, dispose of any unused portion.
Emergency Kit Contents:
1 mg of freeze-dried glucagon (Vial)
1 ml of water for reconstitution (Syringe)
Combine immediately before use
When to Give Glucagon
If authorized by the student’s Health Care Plan
and if student exhibits:
 Unconsciousness,
 Convulsions
 Inability
unresponsiveness
or seizures
to safely eat or drink
Procedure: Act Immediately

Position student safely on side for comfort
and protection from injury

Call 911, parents, school nurse
Preparation

Flip cap off glass vial
containing dry powder
 Remove
cap from syringe
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.
Drawing out

Inspect. Solution should
be clear and colorless.

Draw prescribed amount
of glucagon back into
syringe. Check the
doctor’s orders.
Dosing and Injecting


Clean site if possible
Inject needle at 90° angle into the muscle of one of the
following sites:
•
Largest part of thigh is preferred site
• Middle of deltoid muscle in upper arm




Very slightly pull back on plunger to check for blood.
If no blood, inject solution
Remove needle and massage site w/ cotton ball
Dispose of needle in puncture-proof container.
After Injecting

Turn student on side as he/she may vomit –
prepare for this to happen.

May take 15 – 20 minutes for student to
regain consciousness.

Check blood sugar level.

Give sips of fruit juice or regular soda – only
if student is awake and able to drink.

Document under “comments” on the
Diabetes Monitoring Log.
Vista Unified School District
Vista, CA 92084
DIABETES MONITORING LOG
Student’s Name: Johnnie Jones
Parent:
Phone:
Date
Time
Blood
Glucose
Level
4/30/09
10:30
30
Birthdate:
Time/Recheck of
Glucose
Level
Ketones
Insulin
Dose
Teacher:
Doctor:
School Nurse:
Grade:
Phone:
Cell:
Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action taken,
document the response of the student, and document any phone calls made).
Initials
Johnnie was carried in by custodian – collapsed outside classroom.
Unconscious. 911/parents called.. Administered Glucagon 1 mg IM in right
Thigh. As he was turned on his side, vomited small amount. As paramedics
arrived, Johnnie started to revive. Parents arrived – Johnnie transported to TriCity Hospital
Signature of staff providing care
Initials
Signature of staff providing care
FA
Initials
Signature of staff providing care
Fantastic Annie
Initials
FA
Don't be surprised if. . .

Student does not remember being
unconscious, is incoherent or has a
headache

Blood sugar becomes very high (over 200)

Nausea or vomiting occurs
Ketone Monitoring
Learning Objectives
Participants will learn:
What ketones are
 Why ketones are monitored
 When ketones should be monitored
 How to perform a ketone test

Why test for ketones?

Ketones(acids) are produced when the body burns fat for
energy. Ketones can build up and result in diabetic
ketoacidosis (DKA)
What is DKA?
 Acids that build up in body and cause student to feel ill
 Emergency state, can lead to coma, death
 Common symptoms include fruity odor to breath, nausea,
vomiting, drowsiness
 Number one reason for hospitalizing children with diabetes
 Testing for ketones results in early detection and treatment of
DKA and prevents hospitalizations
When to test for ketones?
Ketones are usually checked when the
blood sugar is high – how high is
determined on an individual basis.
 Check the doctor’s orders to determine if
ketones are to be checked and at what
glucose level.
 Follow the instructions on the Algorithms
for Blood Glucose Results Form.

ALGORITHMS FOR BLOOD GLUCOSE RESULTS
Student’s Name: __________________________
School: _________________________________
School Nurse: ____________________________
Nurse Contact Number: ____________________
Parent’s Phone Number: Home: _____________
Work: _____________ Cell: ________________
STUDENT’S
PHOTO
Check Blood Glucose
From: ________ To: _________
Above: ________
Below: _____
1. Give fast acting sugar source.*
2. Observe for 10 - 15 minutes.
3. Retest blood glucose, if less than
______ repeat sugar source.*
4. If over ______, give carbohydrate
and protein snack (ie. crackers and
cheese) or if within one hour to next
meal, feed early.
5. Notify school nurse if student has two
or more episodes in one week.
If Student Becomes Unconscious,
Seizures, or is Unable to Swallow:
1. Call 911.
2. Maintain open airway
3. Turn student on side to prevent
aspiration
4. Give Glucose Gel and/or Glucagon
per MD orders
5. Notify parents and school nurse
*FAST ACTING SUGAR SOURCES:
15 gm. Glucose Tabs (3 – 4 Tabs)
15 gm. Glucose Gel
1/3 c. Regular Soda (Not Diet)
4 oz. Orange Juice
Revised 8/13/07 JM (N Drive: Forms-Diabetes)
4 oz. Apple Juice
4 oz. Grape Juice
Tube of Cake Mate Gel
3 tsp. sugar in water
1. If student feels OK,
may resume school
activities.
2. If student does not
feel OK, retest blood
glucose.
3. If glucose < ______,
then follow
directions on the
left.
 If glucose > ______
& Ketone check is
ordered, follow
instructions on the
right. If no orders,
contact school nurse.
Check ketones (if ordered)
1.
2.
3.
4.
Student Feels Ok –
Ketones Neg. –Small
Give 1-2 glasses of
water every hour.
Insulin/exercise per MD
orders & IHCP
Notify parents if small
ketones are present.
Notify School nurse if
two or more episodes
occur in one week.
Student Does Not Feel
OK - Ketones Mod.Large
1. Consult with
school nurse.
Notify parents.
2. Provide 1-2 glasses
of water every
hour.
If at any time student
vomits, becomes
lethargic, and/or has
labored breathing CALL 911
To Physician
Please make desired modifications to the standard procedure above and
insert number for personal algorithms for this child in the boxes provided.
Please list any additional needs for special considerations for this child.
____________________________________________________________
____________________________________________________________
____________________________________________________________
Physician’s Signature __________________________________________
How to test urine for ketones







Gather supplies
Student urinates in clean cup
Put on gloves, if performed by
someone other than student
Quickly dip the ketone test strip in
the cup containing urine
Wait 15 - 60 seconds
Read results at designated time
Record results, take action per
Health Care Plan
Test Results: Color code





no ketones
trace
small
moderate
large ketones present
Documentation
Record your findings on the Diabetes
Monitoring Log under the column
“Ketones.”
 Under “comments” record what actions
you took.
 Your actions should correspond to the
instructions on the Algorithms for Blood
Glucose Results form.

Vista Unified School District
Vista, CA 92084
DIABETES MONITORING LOG
Student’s Name: Johnnie Jones
Parent:
Phone:
Date
Time
Blood
Glucose
Level
5/6/09
11:30
350
Birthdate:
Time/Recheck of
Glucose
Level
Ketones
Insulin
Dose
Trace
3u Novalin
Teacher:
Doctor:
School Nurse:
Grade: 4th
Phone:
Cell:
Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action
taken, document the response of the student, and document any phone calls made).
Initials
Assisted Johnnie in testing urine for ketones, gave him 8 oz. water
per care plan & verified insulin dosage per sliding scale before he selfadministered insulin in right upper arm.
Signature of staff providing care
Initials
Signature of staff providing care
Initials
AG
Signature of staff providing care
Alice Good
Initials
AG