Risk For Unstable Blood Glucose NANDA 00179

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1 Student Name/Number: Grade/School Year: IHP Completed By & Date: Nursing Assessment Completed By & Date: Scheduled IHP Review Date: Scheduled Nursing Assessment Review Dates: Student Outcome Goal: Student s blood glucose will remain in goal range mg/dl to mg/dl while at school. Documentation (NIC 7020) Establish & document student s routine for maintaining blood glucose within goal range including: BLOOD GLUCOSE MONITORING Where to check blood glucose: Classroom Health room Other When to check blood glucose: Before breakfast Mid morning Before lunch After lunch Before snack Before PE After PE 2 hours after correction dose Before dismissal As needed Other: Student Self Care Skills: Independent Other: Brand/model of BG meter: Brand/model of Continuous Glucose Monitoring: BLOOD GLUCOSE LEVEL (NOC 2300) Blood glucose remains in goal range (23001) Percentage of Time 0% 25% 50% 75% 100% Individualized Healthcare Plan written by: Page 1 of 10

2 KETONE MONITORING Ketones monitored Urine Blood Where to check ketones: Classroom Health room Other When to check ketones: Blood glucose at or above: Other: Student Self Care Skills: Independent Other Brand/model of ketone monitoring equipment: INSULIN ADMINISTRATION Insulin delivery device: Syringe Pump Pen Insulin type: Insulin dose: See medication record Other: When to administer insulin: See medication record Other: Student Self Care Skills: Independent Other: Brand/model of pen: Brand/model of pump: Page 2 of 10

3 SUPPLIES & EQUIPMENT Location of hypoglycemia supplies: Location of other supplies & equipment: HYPO & HYPERGLYCEMIA Hypoglycemia emergency plan Hyperglycemia emergency plan NDEP Level 2 Training* TRAINED SCHOOL PERSONNEL to assist with hypoglycemia & hyperglycemia: NDEP Level 3 Training* UNLICENSED ASSISTIVE PERSONNEL (UAP) (if applicable) to assist with hypoglycemia & hyperglycemia: SPECIFY HOW & WHEN THE SCHOOL NURSE WILL COMMUNICATE WITH: Parent/guardian: Student: HCP: School personnel: SPECIFY HOW & WHEN THE STUDENT WILL COMMUNICATE WITH: Parent/guardian: HCP: School Personnel: School Nurse: Mutual Agreement (Contract) in place Yes No *National Diabetes Education Program s School Guide Helping the student with diabetes succeed: A guide for school personnel (2010 edition) Page 3 of 10

4 Surveillance (NIC 6650) Periodic school nurse assessment and reinforcement of student s ability to perform diabetes care tasks: Blood glucose monitoring Ketone monitoring Insulin administration Hypoglycemia management Hyperglycemia management Following nutritional guidelines (e.g., carbohydrate counting) Routinely monitor hypoglycemia trends r/t class schedule (e.g., time of PE, scheduled lunch, recess) & insulin dosing Routinely monitor hyperglycemia trends r/t class schedule (e.g., time of PE, scheduled lunch, recess), insulin dosing, acute illness, stress, site rotation, & missed meal bolus Page 4 of 10

5 Teaching: Disease Process (NIC 5602) Hypoglycemia & Hyperglycemia Teaching: Individual (NIC 5606) School nurse to reinforce information provided by HCP: Disease process Hypoglycemia & Hyperglycemia Blood glucose monitoring Prescribed medications Insulin administration Nutrition Activity Sick day guidelines Actions to stay safe and healthy Other KNOWLEDGE: DIABETES MANAGEMENT (NOC 1820) Importance of maintaining blood glucose level within target range (182012) Hypoglycemia prevention (182010) Procedures to be followed in treating hypoglycemia (182011) Hyperglycemia prevention (182007) Procedures to be followed in treating hyperglycemia (182008) Onset, peak & duration of prescribed insulin (182019) Page 5 of 10

6 Impact of acute illness on blood glucose level (182013) KNOWLEDGE: HEALTH BEHAVIOR (NOC 1805) Healthy nutritional practices (180501) Benefits of activity and exercise (180502) Page 6 of 10

7 Teaching: Group (NIC 5604) School nurse plan and provide school personnel in service (at least annually) with appropriate documentation NDEP Level 1 Training* All school personnel NDEP Level 2 Training* School personnel who have responsibility for students with diabetes, but who do not perform diabetes care tasks Delegation (NIC 7650) (if applicable) School nurse will plan and provide NDEP Level 3 Training* for Unlicensed Assistive Personnel who have been delegated to treat hypoglycemia: NAME OF UAP DIABETES CARE TASK *National Diabetes Education Program s School Guide Helping the student with diabetes succeed: A guide for school personnel (2010 edition) Page 7 of 10

8 Hypoglycemia Management (NIC 2130) Check blood glucose level when hypoglycemia suspected Treat hypoglycemia (follow student s hypoglycemia emergency plan) Glucagon ordered: Yes No Actions following a hypoglycemia episode: Keep quick acting glucose product to treat on the spot o Type: o Location: Report & consult with parent/guardian, student, HCP, and school personnel as appropriate Evaluate student s ability to recognize s/s of hypoglycemia & ability to inform school personnel Ongoing assessment of student self management skills: o Blood glucose monitoring o Treating hypoglycemia Emphasize to PE teachers & coaches potential for hypoglycemia with activity Emphasize student should never be allowed to walk anywhere alone if symptoms of hypoglycemia Evaluate the ability of school personnel and/or UAP who have responsibility for student to appropriately respond to hypoglycemia as outlined in student s hypoglycemia emergency plan DIABETES SELF MANAGEMENT (NOC 1619) Treats symptoms of hypoglycemia (161913) Identifies & reports symptoms of hypoglycemia Obtains health care if blood glucose levels fluctuate outside of recommended parameters (161941) Monitors (records, reports & correctly responds to results) blood glucose (161911) Demonstrates correct procedure for blood glucose monitoring (161910) Page 8 of 10

9 Hyperglycemia Management (NIC 2120) Check blood glucose level when hyperglycemia suspected Check urine/blood ketones when blood glucose above Treat hyperglycemia (follow student s hyperglycemia emergency plan) Report & consult with parent/guardian, student, HCP, and school personnel as appropriate Check expiration date of insulin Check insulin pump function & infusion site Check insulin pen function Evaluate student s ability to recognize s/s of hyperglycemia & ability to inform school personnel Ongoing assessment of student self management skills: o Blood glucose monitoring o Ketone monitoring o Treating hyperglycemia Evaluate the ability of school personnel and/or UAP who have responsibility for student to appropriately respond to hyperglycemia as outlined in student s hyperglycemia emergency plan Facilitate student unrestricted access to bathroom and hydration DIABETES SELF MANAGEMENT (NOC 1619) Monitors (records, reports & correctly responds to results) blood glucose (161911) Demonstrates correct procedure for ketone monitoring Treats symptoms of hyperglycemia (161912) Identifies & reports symptoms of hyperglycemia Obtains health care if blood glucose levels fluctuate outside of recommended parameters (161941) Page 9 of 10

10 Environmental Management (NIC 6480) Plan for adequate diabetes supplies at school collaborate with parent/guardian to provide student supplies: Plan for school sponsored events (field trips, before & after activities school activities, school parties) Provide advance notification to parent/guardian of these events Collaborate with parent/guardian & teachers to identify & provide training (as appropriate) to who will accompany student on field trip: Collaborate with parent/guardian & teachers to identify who will be available on site for before & after school activities: Collaborate with parent/guardian & teachers to plan for classroom parties Provide student s emergency plans & other instructional materials for these events Ensure diabetes supplies travel with student and are properly stored Promote a supportive learning environment through collaboration with school administrator(s) to enable student to manage his/her diabetes safely & effectively at school Ensure confidentiality Discuss with parent/guardian & student preference about who should know student s health status at school Collaborate with school personnel to create an accepting & understanding environment Excuse absences for diabetes related health appointments Provide supplemental instruction for absences due to diabetes care Allow accommodations during academic testing STUDENT HEALTH STATUS (NOC 2005) School attendance (200503) Severely Not Compromised Compromised Readiness to learn (200504) Severely Not Compromised Compromised Some materials in this toolkit were supported by Cooperative Agreement Number 5U58DP from CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Page 10 of 10

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