Diabetes Management in School. Signs and Symptoms of Hypo and Hyper glycemia Blood Glucose Testing Glucagon Injections

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1 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 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.

2 When a new diabetic student comes to your site... Contact t 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.

3 Diabetes Management at School

4 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.

5 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.

6 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. 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 e or delayed with healthy lifestyle diet, weight control & exercise. *Cited from US Centers for Disease Control and Prevention. National Diabetes Fact Sheet, Atlanta: US Dept. of Health and Human Services

7 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 Any glucose levels outside this range indicate the need for treatment.

8 HYPOglycemia

9 Learning Objectives Participants i t will learn: Symptoms of low blood glucose Short and long term risks Treatment of low blood glucose Prevention of low blood glucose

10 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 gform of fglucose used to counteract hypoglycemia. gy Glucagon a hormone given by injection that raises the level of glucose in the blood. Carbohydrate source of energy for the body.

11 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.

12 Hypoglycemia: yce 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

13 Hypoglycemia: y Risks & Complications Greatest immediate danger Impairs cognitive and motor functioning Early recognition and intervention can prevent an emergency Not always preventable

14 Mild Hypoglycemia: What to do Goal: To raise blood glucose level Intervene promptly. If a meter is available, test blood glucose immediately and d minutes after treatment. t t 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.

15 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)

16 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 s mouth if they are unconscious or having a seizure. Remain with the student until help arrives.

17 AN Note About tglucose 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.

18 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.

19 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.

20 HYPERglycemia

21 Learning Objectives Participants will learn: Symptoms of high blood glucose Short and long term risks Treatment of high blood glucose Prevention of Hyperglycemia

22 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.

23 HYPERglycemia l i = 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.

24 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

25 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.)

26 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

27 Hyperglycemia: What to do Goal: lower the blood glucose to target t 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). sufficient) Recheck blood glucose per care plan.

28 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 self- administered insulin dose is missed or pump malfunctions. Consult with parents if meal or exercise times need to be changed. Discourage binge eating

29 BLOOD GLUCOSE MONITORING

30 LEARNING OBJECTIVES Participants i t will learn: Why blood glucose is monitored When blood glucose should be monitored How to perform a blood glucose check

31 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.

32 Blood Glucose Monitoring GOAL: Maintain blood Role of the School glucose within target range Immediate Benefit: Facilitate blood Maximize learning & glucose monitoring participation in school Know target blood Prevent lows and highs glucose results and Long-Term Benefit: Decrease risk of long-term how to act on them complications Provide monitoring Maximize health data to parent or Challenge: Many variables can impact blood-glucose guardian to give to levels the MD

33 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 H l i or hyperglycemia symptoms Change in diabetes management

34 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.

35 Equipment and Procedure

36 Lancing Devices Lancets Pen-type Lancing Devices

37 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!

38 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.

39 Readying the Meter Insert strip to activate meter. Check code # on vial of strips. Code # on meter should match.

40 Lancing the Finger Hold the lancet device to the side of the finger and press the button to stick the finger.

41 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 Meter will indicate if amount of blood is sufficient.

42 Results Wait until blood glucose results are displayed. Dispose of lancet. Record blood glucose results on log & take action per plan

43 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 t t are found on the Algorithms for Blood Glucose Results form. (next slide)

44 Student s Name: School: School Nurse: Nurse Contact Number: Parent s Phone Number: Home: Work: Cell: ALGORITHMS FOR BLOOD GLUCOSE RESULTS Check Blood Glucose Target Range From: 70 To: 300 STUDENT S PHOTO Above: 300 Below: Give fast acting sugar source.* 2. Observe for 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 twoormoreepisodesinoneweek or episodes in one week. If Student Becomes Unconscious, Seizures, or is Unable to Swallow: 1. Call 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 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. Student Feels Ok Ketones Neg. Small 1. Give 1-2 glasses of water every hour. 2. Insulin/exercise per MD orders & IHCP 3. Notify parents if small ketones are present. 4. Notify School nurse if two or more episodes occur in one week. Check ketones (if ordered) 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 *FAST ACTING SUGAR SOURCES: 15 gm. Glucose Tabs (3 4 Tabs) 4 oz. Apple Juice 15 gm. Glucose Gel 4 oz. Grape Juice 1/3 c. Regular Soda (Not Diet) Tube of Cake Mate Gel 4 oz. Orange Juice 3 tsp. sugar in water 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 Revised 8/13/07 JM (N Drive: Forms-Diabetes)

45 Documentation Document the results on the Diabetes Monitoring Log. After each entry on the Monitoring Log, place your initials in the appropriate a box. Whenever new Monitoring Log is started, remember to sign/initial in one of the designated areas on bottom of sheet. (Sample documentation following).

46 Vista Unified School District Vista, CA DIABETES MONITORING LOG Student s Name: Johnnie Jones Birthdate: 1/22/99 Teacher: Grade: Parent: Doctor: Phone: Phone: School Nurse: Cell: Date Time Blood Glucos e Level Time/Re- check of Glucose Level Ketones Insulin Dose 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). 5/20/09 11: Within target range. Ate 45 carbs for lunch TT 5/21/09 11:30 55 Gave 4 oz. apple juice. 11:45 Rechecked glucose level TT 11:45 70 Up to target range ate 47 carbs for lunch TT Initials Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials Terry Tech TT

47 What does the display mean? Check manual Contact manufacturer by yphone or website

48 Practical Implications for Educators Students with hyperglycemia or hypoglycemia often do not concentrate well. During academic testing: Check blood glucose before and during testingti 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.

49 Glucagon Administration

50 Learning Objectives Participants will learn: What glucagon is How glucagon should be stored When glucagon g is used How to administer glucagon

51 What is Glucagon? Naturally occurring hormone made in the pancreas. A life-saving, injectable hormone that raises blood glucose level. Treatment t for severe hypoglycemia. Can save a life. Cannot harm a student.

52 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 s trained by a licensed RN or physician.

53 Glucagon Kit Storage Store at room temperature Expiration date: Monitor After mixing, dispose of any unused portion.

54 Emergency Kit Contents: t 1 mg of freeze-dried glucagon (Vial) 1 ml of water for reconstitution (Syringe) Combine immediately before use

55 When to Give Glucagon If authorized by the student s Health Care Plan and if student exhibits: Unconsciousness, unresponsiveness Convulsions C l i or seizures Inability to safely eat or drink

56 Procedure: Act Immediately Position student safely on side for comfort and protection from injury Call 911, parents, school nurse

57 Preparation Flip cap off glass vial containing dry powder Remove cap from syringe

58 Mixing Solution Inject entire fluid in syringe into the bottle containing gpowder Shake gently or roll to mix until all powder is dissolved and solution is clear.

59 Drawing out Inspect. Solution should be clear and colorless. Draw prescribed amount of glucagon back into syringe. Check the doctor s orders.

60 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.

61 After Injecting Turn student on side as he/she may vomit prepare for this to happen. May take 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.

62 Vista Unified School District Vista, CA DIABETES MONITORING LOG Student s Name: Johnnie Jones Birthdate: Teacher: Grade: Parent: Doctor: Phone: Phone: School Nurse: Cell: Date Time Blood Glucose Level Time/Recheck of Glucose Level Ketones Insulin Dose 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). 4/30/09 10:30 30 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 Tri- City Hospital Initials FA Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials Fantastic Annie FA

63 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

64 Ketone Monitoring

65 Learning Objectives Participants will learn: What ketones are Why ketones are monitored When ketones should be monitored How to perform a ketone test

66 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 es results s in early detection ec and treatment e of DKA and prevents hospitalizations

67 When to test t 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.

68 Student s Name: School: School Nurse: Nurse Contact Number: Parent s Phone Number: Home: Work: Cell: ALGORITHMS FOR BLOOD GLUCOSE RESULTS Check Blood Glucose From: To: STUDENT S PHOTO Above: Below: 1. Give fast acting sugar source.* 2. Observe for 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 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 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. Student Feels Ok Ketones Neg. Small 1. Give 1-2 glasses of water every hour. 2. Insulin/exercise per MD orders & IHCP 3. Notify parents if small ketones are present. 4. Notify School nurse if two or more episodes occur in one week. Check ketones (if ordered) 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 *FAST ACTING SUGAR SOURCES: 15 gm. Glucose Tabs (3 4 Tabs) 4 oz. Apple Juice 15 gm. Glucose Gel 4 oz. Grape Juice 1/3 c. Regular Soda (Not Diet) Tube of Cake Mate Gel 4 oz. Orange Juice 3 tsp. sugar in water 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 Revised 8/13/07 JM (N Drive: Forms-Diabetes)

69 How to test urine for ketones Gather supplies Student urinates in clean cup Put on gloves, if performed by someone other than student t Quickly dip the ketone test strip in the cup containing urine Wait seconds Read results at designated time Record results, take action per Health Care Plan

70 Test Results: Color code no ketones trace small moderate large ketones present

71 Documentation ti 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.

72 Vista Unified School District Vista, CA DIABETES MONITORING LOG Student s Name: Johnnie Jones Birthdate: Teacher: Grade: 4 th Parent: Doctor: Phone: Phone: School Nurse: Cell: Blood Date Time Glucose Level Time/Re- check of Insulin Comments: (Note any signs and symptoms of hypo or hyperglycemia, document action Ketones Glucose Dose taken, document the response of the student, and document any phone calls made). Level 5/6/09 11: Trace 3u Novalin Assisted Johnnie in testing urine for ketones, gave him 8 oz. water per care plan & verified insulin dosage per sliding scale before he self- administered insulin in right upper arm. Initials AG Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials Alice Good AG

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