MICHIGAN STATE BOARD OF EDUCATION MODEL POLICY ON THE MANAGEMENT OF DIABETES IN THE SCHOOL SETTING Diabetes is a cmmn chrnic disease f childhd. There are an increasing number f children with diabetes wh require accmmdatins during the schl day t d bld glucse testing, have between meal snacks, and take insulin injectins r make insulin pump adjustments. The need fr careful cntrl and self-management f diabetes by the child/family is an essential cmpnent f care in rder t prevent shrt and lng term cmplicatins frm diabetes. Cmmunicatin between parent/guardian, schl persnnel, the student s health care prviders, and the schl nurse (if available) is imprtant t successfully manage diabetes. This mdel plicy cntains infrmatin and sample frms that can be used by schl persnnel t facilitate the cmmunicatin needed t enable the student with diabetes t successfully manage his/her diabetes and cntinue t achieve academically. Clear guidelines and prcedures shuld be established by schl administratrs as t the rles and respnsibilities f designated staff wh will assist the student with diabetes with bld glucse mnitring, insulin and glucagn administratin r ther needed health services in the schl setting. Emergency plans need t be written and be accessible t designated staff in case f hypglycemia (lw bld glucse reactin) r suspected nset f hyperglycemia (high bld glucse). This mdel plicy includes: Diabetes Fact Sheet Actins fr Schl Persnnel Actins fr the Parent/Guardian and Student with Diabetes Quick Tip Sheets fr Hyperglycemia and Hypglycemia Diabetes Resurce List The Natinal Diabetes Educatin Prgram (NDEP) Medical Management Plan, Individualized Health Plan, and Emergency Care Sheets fr Hyperglycemia and Hypglycemia Glssary
DIABETES FACT SHEET Diabetes is ne f the mst cmmn chrnic diseases f schl-age children. In the United States, apprximately 215,000 children and yuth under the age f 20 have diabetes 1. The number f children with diabetes wh require accmmdatin during the schl day t d bld glucse mnitring (by finger stick r a cntinuus glucse mnitring system), have between meal snacks, and administer insulin (by injectin with a syringe, injectin pen, r an insulin pump) has dramatically increased as medical science recgnizes the need fr careful cntrl f this disease. Self-management by the child f his/her disease is an imprtant cmpnent f that cntrl. Diabetes is NOT a cmmunicable r cntagius disease. Diabetes is a chrnic disrder that can result in lng-term cmplicatins such as damage t the eyes, kidneys, and vascular and nervus systems if nt managed prperly. There are tw types f diabetes: Type 1 diabetes usually has a rapid nset and is caused by an autimmune disrder in which the insulin-prducing cells f the pancreas are destryed. Insulin is a hrmne that is essential in allwing sugar t mve int the cells and be used fr energy by the bdy. Peple with Type 1 diabetes must take insulin injectins (via syringe, injectin pen, r pump) every day. Type 2 diabetes usually has a gradual nset and is caused by an insufficient prductin f insulin by the bdy r an inefficient usage f insulin by the bdy s cells. Peple with Type 2 diabetes may take insulin injectins, take ral medicatin, fllw a meal plan, and engage in physical activity t cntrl his/her bld glucse levels, r any cmbinatin f these methds. Type 2 diabetes in yuth is a rapidly grwing health prblem. Risk factrs fr this type f diabetes include besity, inactivity, and a family histry f diabetes. Children with diabetes are taught it is a self-managed disease. This means that the child r adlescent (depending upn the child s age and abilities) may be giving themselves insulin with a syringe, injectin pen, r insulin pump, taking ral diabetes medicatins, mnitring his/her bld glucse levels with a meter, testing urine, keeping written recrds, and taking snacks as needed between meals in the schl setting and at schl functins. Treatment is individualized based n the student s needs. Schls shuld refer t the student s diabetes medical management plan (DMMP). It is critically imprtant t knw the management f diabetes n a day-t-day basis is maintaining a balance between insulin intake r prductin, fd intake, and physical activity. All three (insulin, fd, and activity) have a majr effect n diabetes cntrl and the preventin f acute cmplicatins such as hypglycemia (lw bld glucse) and hyperglycemia (high bld glucse). Bth f these cmplicatins can ccur during 1 Centers fr Disease Cntrl and Preventin. Natinal diabetes fact sheet: natinal estimates and general infrmatin n diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department f Health and Human Services, Centers fr Disease Cntrl and Preventin, 2011. 2
schl hurs, but a hypglycemic (lw bld glucse) reactin is the mst cmmn, can happen very quickly, and requires immediate attentin. Hypglycemia (lw bld glucse) ccurs when the student with diabetes has taken insulin r a medicatin t increase insulin prductin, and either fd is nt eaten in the amunt needed r extra exercise r physical activity has increased the bdy s need fr energy. The student may r may nt recgnize the early warning symptms f lw bld glucse, but the student needs immediate attentin: a quick-acting surce f glucse (sugar), fllwed by a less rapidly absrbed surce f carbhydrates and prteins (see student s DMMP). Mild t mderate hypglycemia has a number f symptms such as shakiness, hunger, and sleepiness and can usually be treated with 15 grams f carbhydrate such as 3-4 glucse tabs r 4 unces f fruit juice. Hypglycemia (lw bld glucse) can prgress quickly and the student may lse cnsciusness and exhibit seizures. This is a medical emergency and calls fr an injectin f glucagn (a hrmne that naturally releases sugar frm the liver) and an immediate call fr emergency medical care. Never give an uncnscius student anything by muth fds r liquids. Never leave a child alne wh is experiencing hypglycemia symptms. (See Hypglycemia Quick Tip Sheet in Appendix A) Hyperglycemia means bld glucse levels are abve target range and ccurs mre slwly than hypglycemia, but schl persnnel need t be alert t the early signs and symptms f this cnditin. Almst all children with diabetes will experience bld glucse levels abve their target range at times thrughut the day, but these episdes are usually shrt in duratin. Other children will experience daily spikes f their bld glucse levels which are f lnger duratin requiring extra insulin. In children, a minr illness such as a cld r the flu can upset the balance f insulin, fd, and activity and result in a build-up f extra sugar in the bld stream. If a student tests his/her bld and it shws a high bld glucse reading, the student may need t d a test fr ketnes. Ketnes are an acid prduced when the bdy is using fat fr energy because the available insulin cannt prperly feed the cells glucse. Ketne tests are dne via a urine sample r a meter with special strips fr ketne testing. Hyperglycemia is treated with the intake f water r anther sugar-free beverage and smetimes insulin. (See Hyperglycemia Quick Tip Sheet in Appendix A) 3
1. LEGAL REQUIREMENTS ACTIONS FOR SCHOOL PERSONNEL The fur federal laws gverning schls respnsibilities fr students with diabetes are Sectin 504 f the Rehabilitatin Act f 1973 (Sectin 504), the Americans with Disabilities Act f 1990 (ADA), the Individuals with Disabilities Educatin Act (IDEA), and the Family Educatinal Rights and Privacy Act (FERPA). Sectin 504 states that students with disabilities must be given an equal pprtunity t participate in academic, nnacademic, and extracurricular activities. A student nt receiving special educatin services can still be entitled t related aids and services under Sectin 504. Administering insulin r glucagn, prviding assistance in checking bld glucse levels, and allwing the student t eat snacks in schl, having a buddy walk dwn t the ffice with a student that has lw bld glucse, are a few examples f related aids and services that schls may have t prvide t a student with diabetes. These related aids and services as well as any needed special educatin services are cmmnly written up in a dcument called a Sectin 504 Plan. A child with diabetes may als be cvered by IDEA. T qualify, the student s diabetes must adversely affect a student s educatinal perfrmance as defined by the Michigan Administrative Rules fr Special Educatin. An example f this wuld be a student wh has high r lw glucse t the pint that it negatively affects his/her educatinal perfrmance r if the student has anther disability that adversely impacts his/her academic perfrmance. IDEA specifies that schl persnnel and parent/guardian wrk tgether t develp and implement an Individualized Educatin Prgram (IEP). Generally, if a student can manage his/her diabetes effectively and maintain academic success, the child is nt eligible under IDEA. Hwever, that child is still eligible fr services under Sectin 504. FERPA states that infrmatin abut a child with diabetes shuld nt be released r disclsed as part f an educatin recrd withut prir cnsent frm the parent/guardian r eligible student. The exceptin t this law is if a schl fficial has a legitimate educatinal interest in the infrmatin. The infrmatin may als be disclsed t apprpriate parties in cnnectin with an emergency if knwledge f the infrmatin is necessary t prtect the health r safety f the student r ther individuals. Fr example, it is necessary fr a paramedic attending t a student in an emergency t knw that the student has diabetes. Links t cpies f these laws can be fund in Appendix B. 2. TRAINING OF SCHOOL PERSONNEL All schl persnnel shuld be given training abut diabetes and hw t manage it. Hwever, that training shuld be brken dwn int different levels depending n the respnsibility f each staff member twards the student with diabetes. The training 4
shuld be administered by a schl nurse r certified diabetes educatr (r a qualified persn designated by the lcal schl administratr if neither are available). Training shuld take place at the beginning f each schl year and shuld be repeated when a current student is newly diagnsed with diabetes r when a student with diabetes enrlls in the schl. Refresher training is t be dne as needed. Level 1 training Administered t all schl persnnel at the beginning f the year. Level 1 training cntent: An verview f diabetes Hw t recgnize and respnd t hypglycemia (lw bld glucse) and hyperglycemia (high bld glucse). Useful charts are fund in Appendix A. Wh t cntact fr help in an emergency Level 2 training Designed fr schl persnnel wh have respnsibility fr the student with diabetes thrughut the schl day, including but nt limited t: classrm, physical educatin, music, and art teachers, as well as ther persnnel such as lunchrm staff, caches, and bus drivers. Level 2 training cntent: Cntent frm Level 1 with specific instructins fr what t d in case f an emergency Rles and respnsibilities f individual staff members Expanded verview f diabetes Prcedures and brief verview f the peratin f devices (r equipment) cmmnly used by students with diabetes Impact f hypglycemia (lw bld glucse) r hyperglycemia (high bld glucse) n behavir, learning, and ther activities The student s Individualized Health Care Plan (IHP), 504 Plan, IEP, r ther educatin plan The student s Emergency Care Plans and hw t activate Emergency Medical Services in case f a diabetes emergency Tips and planning needed fr the classrm and fr special events Overview f the legal rights f students with diabetes in the schl setting Level 3 training Fr ne r mre schl staff members designated as trained diabetes persnnel wh will perfrm r assist the student with diabetes care tasks. Level 3 training cntent: Cntent frm Level 1 and Level 2 General training n diabetes care tasks: Bld glucse mnitring Ketne testing (urine and bld) Insulin administratin 5
Glucagn administratin Basic carbhydrate cunting Student-specific training, when addressing each diabetes care task, including: Clear identificatin and understanding f the task as utlined in the student s DMMP Each student s symptms and treatment fr hypglycemia (lw bld glucse) and hyperglycemia (high bld glucse) Step-by-step instructin n hw t perfrm the task using the student s equipment and supplies Clear parameters n when t perfrm the task, when nt t d s, and when t ask fr help frm a health care prfessinal Hw t dcument all care tasks prvided Plan fr nging evaluatin Ideally, at least three adults shuld be trained as a Level 3. Mnitring all emplyees wh assist students with diabetes is the respnsibility f each schl. 3. COORDINATION OF CARE FOR BEST RESULTS Cllabratin and cperatin are key elements in planning and implementing successful diabetes management at schl. Like ther chrnic diseases, students with diabetes are mre likely t succeed in schl when the student s schl health team and the student s persnal health care team wrk tgether. Persnnel may include: Schl Health Team Student with diabetes Parent/guardian Schl nurse r ther qualified persnnel Other schl health care persnnel Trained diabetes persnnel Principal and ther administratrs 504/IEP Crdinatr Office Staff Teacher(s) Guidance cunselr, cach(es), and ther schl staff members respnsible fr the student Persnal Health Care Team Student with diabetes Parent/guardian Dctr Nurse Registered Dietician (if available) Diabetes Educatr (if available) Cllabratin between these tw teams shuld result in each student with diabetes having a DMMP, an IHP, Emergency Care Plans fr Hypglycemia (lw bld glucse) and Hyperglycemia (high bld glucse), and the apprpriate educatin plan (if needed). 6
Diabetes Medical Management Plan (DMMP) Cntains all aspects f rutine and emergency diabetes care Develped by the student s persnal diabetes health care team Individualized Healthcare Plan (IHP) Written plan develped t implement the student s DMMP Develped by the schl nurse (r ther qualified persnnel) in cllabratin with the student s persnal diabetes health care team and family Incrprates assessment f schl envirnment Student-specific infrmatin Reviewed by nurse (r ther qualified persnnel) and parents at beginning f the year and peridically afterwards Emergency Care Plans Based n medical rders in the DMMP Summary f hw t recgnize and treat hypglycemia (lw bld glucse) Shuld be given t all persnnel respnsible fr the student with diabetes (teachers, caches, bus drivers, lunchrm staff, etc.) Educatin plan 504 plan r IEP Develped as needed, nt all students with diabetes will have ne r bth Written by team f schl persnnel, parents, and apprpriate crdinatr fr the schl district Sample plans can be fund in Appendix C. 4. SOCIAL AND EMOTIONAL IMPACT Schl persnnel shuld recgnize that diabetes care tasks set children apart frm their peers. Since there is such a large imprtance placed n fitting in fr children, rutine diabetes care can make the child feel singled ut r that they d nt fit in. Effrts shuld be made by schl persnnel t minimize the time away frm his/her peers fr diabetes care, and t accept it as part f the student s everyday rutine. Children with diabetes als react differently t having the disease. They may be accepting, resentful, pen t discussing it, r attempt t hide it. Often, the same child will experience all f these feelings ver time. Children and adlescents wh have a chrnic disease such as diabetes are als knwn t have higher rates f depressin and anxiety. It is imprtant t recgnize the signs and symptms and knw where t get help. (Refer t resurces in Appendix B.) With permissin f the student and his/her parent/guardian, schls may arrange fr a teachable mment fr ther students in the classrm. This can serve t nt nly educate students abut the disease, but als prvide anther level f hypglycemia (lw 7
bld glucse) and hyperglycemia (high bld glucse) awareness in the student with diabetes peers. ACTIONS FOR THE PARENT/GUARDIAN AND STUDENT WITH DIABETES 1. DIABETES MEDICAL MANAGEMENT PLAN The DMMP shuld be prvided by the parent/guardian f the student with diabetes, develped in crdinatin with the student s persnal health team. The DMMP shuld: Be signed by the parent/guardian and the licensed physician wh is a part f the student s health care team Outline the parental respnsibility f carbhydrate cunting and crdinating the calculating insulin adjustments with student s health care team Detail the health care services needed by the student at schl Evaluate the student s ability t self-manage and level f understanding f his/her diabetes A sample DMMP can be fund in Appendix C. 2. EMERGENCY SUPPLY KIT Parent/guardian shuld prvide an emergency supply kit fr use in the event f natural disasters r emergencies when students need t stay in schl. This kit shuld cntain enugh supplies fr at least 72 hurs t carry ut the medical rders in the DMMP. Parents shuld be respnsible fr restcking any used items and ensuring items with expiratin dates are up t date. The kit shuld include: Bld glucse meter, testing strips, lancets, and batteries fr the meter Urine and/r bld ketne test strips and meter Insulin, syringes, and/r insulin pens and supplies Insulin pump and supplies, including syringes, pens, and insulin in case f pump failure (depending if the student uses a pump) Other medicatins Antiseptic wipes r wet wipes Quick-acting surce f glucse Water Carbhydrate-cntaining snacks with prtein Hypglycemia treatment supplies (enugh fr three episdes): quick-acting glucse and carbhydrate snacks with prtein Glucagn emergency kit 8
3. STUDENT SELF-MANAGEMENT Diabetes care depends upn self-management. Students shuld have the right t selfmanage, when apprpriate. The age at which a child can self-manage his/her disease varies frm student t student and frm task t task because children develp and mature at different rates. A student s ability t participate in self-care als depends upn his/her willingness t d s. It is preferable that students be permitted t perfrm diabetes care tasks in the classrm, at every campus lcatin, r at any schl activity (e.g., testing bld glucse). If the steps are perfrmed crrectly and materials are dispsed f prperly, there is n risk f bld r any ther unsanitary material cntact t ther students. General guidelines fr the degrees f self-management expected frm students: Elementary schl-aged children ften are able t perfrm their wn bld glucse mnitring, but usually will require supervisin. Older elementary schl-aged children are beginning t self-administer insulin with supervisin and understand the factrs that influence bld glucse levels. Unless children have hypglycemic unawareness (inability t tell when their bld glucse level is lw), mst shuld be able t let an adult knw when they are experiencing hypglycemia (lw bld glucse). Middle- and high schl-aged children shuld be able t prvide self-care depending upn the length f time since diagnsis and level f maturity, but they always will need help when experiencing hypglycemia (lw bld glucse). 4. TEAM EFFORTS Since diabetes is a disease that requires an effrt n all frnts t cntrl, there is a large respnsibility n the parent/guardian f the child with diabetes. Parental respnsibility is a 24 hur cmmitment and des nt end when a child with diabetes is at schl. Any persn will benefit frm a healthy diet, but fr a child with diabetes the imprtance is magnified. A healthy and nutritius meal during schl hurs, with an accurate carbhydrate cunt, is paramunt t cntrlling and managing diabetes prperly. The schl health team can wrk with the parent/guardian n prviding a carbhydrate cunt n lunches brught frm hme and the fd service persnnel f the schl shuld prvide carbhydrate cunts n schl meals and individual items t any parent that requests this infrmatin. 5. FOOD AND SPECIAL EVENTS It is imprtant that the schl wrk clsely with the family t plan fr special events such as classrm parties, field trips and ther schl-spnsred activities. There are n frbidden fds in a meal plan fr students with diabetes. Hwever, serving mre nutritius fds will be healthier fr all students and will encurage gd eating habits. 9
Healthy and nutritius meals and snacks at schl with an accurate carbhydrate cunt and nutritinal infrmatin will enable the student t incrprate special fds int his/her meal/snack plan and accrdingly adjust the insulin dsage. Every student lks frward t field trips. Even thugh many parents chse t chaperne their child and class n field trips, parental attendance shuld never be a prerequisite fr participatin by students with diabetes. These materials and resurces will prve useful t schl persnnel as they wrk t meet the needs f students with diabetes. The schl health team can use this dcument as a guide t minimize the effects f diabetes n the student s academic life and prvide an envirnment where all students can excel. Prtins f this mdel plicy are adpted frm 2010 Helping the Student with Diabetes Succeed A Guide fr Schl Persnnel, by NDEP and the U.S. Department f HHS. Adpted Nvember 8, 2011 10
Appendix A Quick Tip Sheets fr Hyperglycemia and Hypglycemia (adapted with permissin frm Students with Diabetes: A Resurce Guide fr Wiscnsin Students and Families) http://www.dhs.wiscnsin.gv/health/diabetes/pdfs/srg02.pdf
Appendix B Diabetes Resurce List
American Diabetes Assciatin (ADA)* www.diabetes.rg www.diabetes.rg/schltraining 1-800-DIABETES ADA-Bingham Farms, MI 888-342-2383 ADA-Grand Rapids, MI 616-458-9341 Juvenile Diabetes Research Fundatin (JDRF) www.jdrf.rg JDRF-Grand Rapids, MI* 616-942-5487 www.jdrfwestmichigan.rg JDRF Metr Detrit Area, Suthfield, MI* 248-355-1133 www.jdrfdetrit.rg Michigan Assciatin f Schl Nurses (MASN) http://www.michiganschlnurses.rg/ DIABETES RESOURCE LIST Michigan Assciatin f Schl Psychlgists (MASP) Traverse City, MI http://www.maspweb.cm/ Michigan Department f Cmmunity Health Diabetes, Kidney and Other Chrnic Diseases Sectin www.michigan.gv/diabetes Michigan Department f Educatin Crdinated Schl Health and Safety Prgrams Unit www.michigan.gv/cshsp Michigan Crdinating Bdy f the American Assciatin f Diabetes Educatrs (AADE) www.diabeteseducatr.rg Cntact: Carlyn Jennings, cjennings@nkfm.rg 313-259-1574 ext. 27 Natinal Assciatin f Schl Psychlgists (NASP) Bethesda, MD 20814 866-331-NASP http://www.naspnline.rg
Natinal Diabetes Educatin Prgram (NDEP) www.ndep.nih.gv 888-693-NDEP (6337) Helping the Student with Diabetes Succeed: A Guide fr Schl Persnnel ndep.nih.gv/media/yuth_ndepschlguide.pdf Natinal Kidney Fundatin f Michigan Ann Arbr, MI 1-800-482-1455 www.nkfm.rg Upper Peninsula Diabetes Outreach Netwrk (UPDON)* Marquette, MI 906-228-9203 updn@diabetesinmichigan.rg *Prvides staff in-service training Federal laws - Sectin 504 f the Rehabilitatin Act f 1973, as amended, 29 U.S.C. 794, implementing regulatins at 34 CFR Part 104. http://www2.ed.gv/plicy/rights/reg/cr/edlite-34cfr104.html Title II f the Americans with Disabilities Act f 1990, as amended, 42 U.S.C. 12134 et seq., implementing regulatins at 28 CFR Part 25. http://www2.ed.gv/plicy/rights/reg/cr/edlite- 28cfr35.html The Americans with Disabilities Act Amendments Act f 2008. http://frwebgate.access.gp.gv/cgibin/getdc.cgi?dbname=110_cng_bills&dcid=f:s3406enr.txt.pdf Individuals with Disabilities Educatin Act, 20 U.S.C. 1400 et seq., implementing regulatins at 34 CFR Part 300 http://www2.ed.gv/abut/ffices/list/sers/sep/index.html Family Educatinal Rights and Privacy Act, 20 U.S.C.1232g, implementing regulatins at 34 CFR Part 99. http://www2.ed.gv/plicy/gen/guid/fpc/index.html Michigan Administrative Rules fr Special Educatin Supplemented with IDEA Federal Regulatins. http://www.michigan.gv/dcuments/mde/marse-april09_274156_7.pdf
Appendix C The Natinal Diabetes Educatin Prgram (NDEP) Medical Management Plan, Individualized Health Plan, and Emergency Care Sheets fr Hyp- and Hyperglycemia http://ndep.nih.gv/media/schl-guide-tls.pdf
Diabetes Medical Management Plan (DMMP) This plan shuld be cmpleted by the student s persnal diabetes health care team, including the parents/guardian. It shuld be reviewed with relevant schl staff and cpies shuld be kept in a place that can be accessed easily by the schl nurse, trained diabetes persnnel, and ther authrized persnnel. Date f Plan: This plan is valid fr the current schl year: - Student s Name: Date f Birth: Date f Diabetes Diagnsis: type 1 type 2 Other Schl: Schl Phne Number: Grade: Hmerm Teacher: Schl Nurse: Phne: Tls CONTACT INFORMATION Mther/Guardian: Address: Telephne: Hme Wrk Cell: Email Address: Father/Guardian: Address: Telephne: Hme Wrk Cell: Email Address: Student s Physician/Health Care Prvider: Address: Telephne: Email Address: Emergency Number: Other Emergency Cntacts: Name: Relatinship: Telephne: Hme Wrk Cell: Helping the Student with Diabetes Succeed 99
Diabetes Medical Management Plan (DMMP) Page 2 Checking Bld Glucse Target range f bld glucse: 70 130 mg/dl 70 180 mg/dl Other: Check bld glucse level: Befre lunch Hurs after lunch 2 hurs after a crrectin dse Mid-mrning Befre PE After PE As needed fr signs/symptms f lw r high bld glucse As needed fr signs/symptms f illness Befre dismissal Other: Preferred site f testing: Fingertip Frearm Thigh Other: Brand/Mdel f bld glucse meter: Nte: The fingertip shuld always be used t check bld glucse level if hypglycemia is suspected. Student s self-care bld glucse checking skills: Independently checks wn bld glucse May check bld glucse with supervisin Requires schl nurse r trained diabetes persnnel t check bld glucse Cntinuus Glucse Mnitr (CGM): Yes N Brand/Mdel: Alarms set fr: (lw) and (high) Nte: Cnfirm CGM results with bld glucse meter check befre taking actin n sensr bld glucse level. If student has symptms r signs f hypglycemia, check fingertip bld glucse level regardless f CGM. HYPOGLYCEMIA TREATMENT Student s usual symptms f hypglycemia (list belw): If exhibiting symptms f hypglycemia, OR if bld glucse level is less than mg/dl, give a quick-acting glucse prduct equal t grams f carbhydrate. Recheck bld glucse in 10 15 minutes and repeat treatment if bld glucse level is less than mg/dl. Additinal treatment: 100 www.yurdiabetesinf.rg
Diabetes Medical Management Plan (DMMP) Page 3 HYPOglYCEMIA TREATMENT (Cntinued) Fllw physical activity and sprts rders (see page 7). If the student is unable t eat r drink, is uncnscius r unrespnsive, r is having seizure activity r cnvulsins (jerking mvements), give: Glucagn: 1 mg 1/2 mg Rute: SC IM Call 911 (Emergency Medical Services) and the student s parents/guardian. Cntact student s health care prvider. Site fr glucagn injectin: arm thigh Other: HYPERGLYCEMIA TREATMENT Student s usual symptms f hyperglycemia (list belw): Tls Check Urine Bld fr ketnes every hurs when bld glucse levels are abve mg/dl. Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse, give crrectin dse f insulin (see rders belw). Fr insulin pump users: see additinal infrmatin fr student with insulin pump. Give extra water and/r nn-sugar-cntaining drinks (nt fruit juices): unces per hur. Additinal treatment fr ketnes: Fllw physical activity and sprts rders (see page 7). Ntify parents/guardian f nset f hyperglycemia. If the student has symptms f a hyperglycemia emergency, including dry muth, extreme thirst, nausea and vmiting, severe abdminal pain, heavy breathing r shrtness f breath, chest pain, increasing sleepiness r lethargy, r depressed level f cnsciusness: Call 911 (Emergency Medical Services) and the student s parents/ guardian. Cntact student s health care prvider. Helping the Student with Diabetes Succeed 101
Diabetes Medical Management Plan (DMMP) page 4 INSULIN THERAPY Insulin delivery device: syringe insulin pen insulin pump Type f insulin therapy at schl: Adjustable Insulin Therapy Fixed Insulin Therapy N insulin Adjustable Insulin Therapy Carbhydrate Cverage/Crrectin Dse: Name f insulin: Carbhydrate Cverage: Insulin-t-Carbhydrate Rati: Lunch: 1 unit f insulin per grams f carbhydrate Snack: 1 unit f insulin per grams f carbhydrate Carbhydrate Dse Calculatin Example Grams f carbhydrate in meal Insulin-t-carbhydrate rati = units f insulin Crrectin Dse: Bld Glucse Crrectin Factr/Insulin Sensitivity Factr = Target bld glucse = mg/dl Crrectin Dse Calculatin Example Actual Bld Glucse Target Bld Glucse = units f insulin Bld Glucse Crrectin Factr/Insulin Sensitivity Factr Crrectin dse scale (use instead f calculatin abve t determine insulin crrectin dse): Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units 102 www.yurdiabetesinf.rg
Diabetes Medical Management Plan (DMMP) page 5 INSUlIN THERAPY (Cntinued) When t give insulin: Lunch Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Snack N cverage fr snack Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Crrectin dse nly: Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse. Other: Tls Fixed Insulin Therapy Name f insulin: Units f insulin given pre-lunch daily Units f insulin given pre-snack daily Other: Parental Authrizatin t Adjust Insulin Dse: Yes N Parents/guardian authrizatin shuld be btained befre administering a crrectin dse. Yes N Parents/guardian are authrized t increase r decrease crrectin dse scale within the fllwing range: +/- units f insulin. Yes N Parents/guardian are authrized t increase r decrease insulin-tcarbhydrate rati within the fllwing range: units per prescribed grams f carbhydrate, +/- grams f carbhydrate. Yes N Parents/guardian are authrized t increase r decrease fixed insulin dse within the fllwing range: +/- units f insulin. Helping the Student with Diabetes Succeed 103
Diabetes Medical Management Plan (DMMP) page 6 INSUlIN THERAPY (Cntinued) Student s self-care insulin administratin skills: Yes Yes Yes N N N 104 www.yurdiabetesinf.rg Independently calculates and gives wn injectins May calculate/give wn injectins with supervisin Requires schl nurse r trained diabetes persnnel t calculate/give injectins ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP Brand/Mdel f pump: Type f insulin in pump: Basal rates during schl: Type f infusin set: Fr bld glucse greater than mg/dl that has nt decreased within hurs after crrectin, cnsider pump failure r infusin site failure. Ntify parents/guardian. Fr infusin site failure: Insert new infusin set and/r replace reservir. Fr suspected pump failure: suspend r remve pump and give insulin by syringe r pen. Physical Activity May discnnect frm pump fr sprts activities Yes N Set a temprary basal rate Yes N % temprary basal fr hurs Suspend pump use Yes N Student s self-care pump skills: Independent? Cunt carbhydrates Yes N Blus crrect amunt fr carbhydrates cnsumed Yes N Calculate and administer crrectin blus Calculate and set basal prfiles Calculate and set temprary basal rate Change batteries Discnnect pump Recnnect pump t infusin set Prepare reservir and tubing Insert infusin set Yes Yes Yes Yes Yes Yes Yes Yes N N N N N N N N Trublesht alarms and malfunctins Yes N
Diabetes Medical Management Plan (DMMP) page 7 OTHER DIABETES MEDICATIONS Name: Dse: Rute: Times given: Name: Dse: Rute: Times given: MEAL PLAN Meal/Snack Time Carbhydrate Cntent (grams) Breakfast t Mid-mrning snack t Lunch t Mid-afternn snack t Other times t give snacks and cntent/amunt: Instructins fr when fd is prvided t the class (e.g., as part f a class party r fd sampling event): Special event/party fd permitted: Parents/guardian discretin Student discretin Student s self-care nutritin skills: Yes N Independently cunts carbhydrates Yes N May cunt carbhydrates with supervisin Yes N Requires schl nurse/trained diabetes persnnel t cunt carbhydrates Tls PHYSICAL ACTIVITY AND SPORTS A quick-acting surce f glucse such as glucse tabs and/r sugar-cntaining juice must be available at the site f physical educatin activities and sprts. Student shuld eat 15 grams 30 grams f carbhydrate ther befre every 30 minutes during after vigrus physical activity ther If mst recent bld glucse is less than mg/dl, student can participate in physical activity when bld glucse is crrected and abve mg/dl. Avid physical activity when bld glucse is greater than mg/dl r if urine/ bld ketnes are mderate t large. (Additinal infrmatin fr student n insulin pump is in the insulin sectin n page 6.) Helping the Student with Diabetes Succeed 105
Diabetes Medical Management Plan (DMMP) page 8 DISASTER PLAN T prepare fr an unplanned disaster r emergency (72 HOURS), btain emergency supply kit frm parent/guardian. Cntinue t fllw rders cntained in this DMMP. Additinal insulin rders as fllws: Other: SIGNATURES This Diabetes Medical Management Plan has been apprved by: Student s Physician/Health Care Prvider Date I, (parent/guardian:) give permissin t the schl nurse r anther qualified health care prfessinal r trained diabetes persnnel f (schl:) t perfrm and carry ut the diabetes care tasks as utlined in (student:) s Diabetes Medical Management Plan. I als cnsent t the release f the infrmatin cntained in this Diabetes Medical Management Plan t all schl staff members and ther adults wh have respnsibility fr my child and wh may need t knw this infrmatin t maintain my child s health and safety. I als give permissin t the schl nurse r anther qualified health care prfessinal t cntact my child s physician/health care prvider. Acknwledged and received by: Student s Parent/Guardian Date Student s Parent/Guardian Date Schl Nurse/Other Qualified Health Care Persnnel Date 106 www.yurdiabetesinf.rg
Sample Template Individualized Health Care Plan (IHP) Student: Grade: Dates: Schl Year: IHP Cmpleted by and Date: IHP Review Dates: Nursing Assessment Review: Nursing Assessment Cmpleted by and Date: Nursing Diagnsis Managing Ptential Diabetes Emergencies (risk fr unstable bld glucse) Sample Interventins and Activities Establish and dcument student s rutine fr maintaining bld glucse within gal range including while at schl: Bld Glucse Mnitring Where t check bld glucse: Classrm Health rm Other When t check bld glucse: Befre breakfast Mid-mrning Befre lunch After lunch Befre snack Befre PE After PE 2 hurs after crrectin dse Befre dismissal As needed Other: Student Self-Care Skills: Independent Supervisin Full assistance Brand/mdel f BG meter: Date Implemented Sample Outcme Indicatr Bld glucse remains in gal range Percentage f Time 0% 25% 50% 75% 100% 1 2 3 4 5 Date Evaluated Tls Brand/mdel f CGM: Helping the Student with Diabetes Succeed 107
Sample Template Individualized Health Care Plan (IHP) (Cntinued) Nursing Diagnsis Sample Interventins and Activities Date Implemented Sample Outcme Indicatr Date Evaluated Supprting the Independent Student (effective therapeutic regimen management) Hypglycemia Management STUDENT WILL: Check bld glucse when hypglycemia suspected Treat hypglycemia (fllw Diabetes Emergency Care Plan) Take actin fllwing a hypglycemia episde: Mnitrs Bld glucse (recrds, reprts, and crrectly respnds t results) Never Demnstrated Cnsistently Demnstrated 1 2 3 4 5 Keep quick-acting glucse prduct t treat n the spt Type: Lcatin: Rutinely mnitr hypglycemia trends r/t class schedule (e.g., time f PE, scheduled lunch, recess) and insulin dsing Reprt and cnsult with parents/ guardian, schl nurse, HCP, and schl persnnel as apprpriate Supprting Psitive Cping Skills (readiness fr enhanced cping) Envirnmental Management Ensure cnfidentiality Discuss with parents/guardian and student preference abut wh shuld knw student s cping status at schl Cllabrate with parents/guardian and schl persnnel t meet student s cping needs Cllabrate with schl persnnel t create an accepting and understanding envirnment Readiness t learn Severely Cmprmised Nt Cmprmised 1 2 3 4 5 108 www.yurdiabetesinf.rg
Hypglycemia Emergency Care Plan (Fr lw Bld glucse) Student s Name: Grade/Teacher: Date f Plan: Emergency Cntact Infrmatin Mther/Guardian: Email address: Hme phne: Wrk phne: Cell: Father/Guardian: Email address: Hme phne: Wrk phne: Cell: Tls Health Care Prvider: Phne number: Schl Nurse: Cntact number(s): Trained Diabetes Persnnel: Cntact number(s): The student shuld never be left alne, r sent anywhere alne, r with anther student, when experiencing hypglycemia. Causes f Hypglycemia T much insulin Missing r delaying meals r snacks Nt eating enugh fd (carbhydrates) Getting extra, intense, r unplanned physical activity Being ill, particularly with gastrintestinal illness Onset f Hypglycemia Sudden symptms may prgress rapidly Helping the Student with Diabetes Succeed 109
Hypglycemia Symptms Circle student s usual symptms. Mild t Mderate Shaky r jittery Uncrdinated Sweaty Irritable r nervus Hungry Argumentative Pale Cmbative Headache Changed persnality Blurry visin Changed behavir Sleepy Inability t cncentrate Dizzy Weak Cnfused Lethargic Disriented Other: Severe Inability t eat r drink Uncnscius Unrespnsive Seizure activity r cnvulsins (jerking mvements) Actins fr Treating Hypglycemia Ntify Schl Nurse r Trained Diabetes Persnnel as sn as yu bserve symptms. If pssible, check bld glucse (sugar) at fingertip. Treat fr hypglycemia if bld glucse level is less than mg/dl. WHEN IN DOUBT, ALWAYS TREAT FOR HYPOGLYCEMIA AS SPECIFIED BELOW. Treatment fr Mild t Mderate Hypglycemia Prvide quick-acting glucse (sugar) prduct equal t grams f carbhydrates. Examples f 15 grams f carbhydrates include: N 3 r 4 glucse tablets N 1 tube f glucse gel N 4 unces f fruit juice (nt lw-calrie r reduced sugar) N 6 unces f sda (½ can) (nt lwcalrie r reduced sugar) Wait 10 t 15 minutes. Recheck bld glucse level. Repeat quick-acting glucse prduct if bld glucse level is less than mg/dl. Cntact the student s parents/guardian. Treatment fr Severe Hypglycemia Psitin the student n his r her side. D nt attempt t give anything by muth. Administer glucagn: mg at site. While treating, have anther persn call 911 (Emergency Medical Services). Cntact the student s parents/guardian. Stay with the student until Emergency Medical Services arrive. Ntify student s health care prvider. 110 www.yurdiabetesinf.rg
Hyperglycemia Emergency Care Plan (Fr High Bld glucse) Student s Name: Grade/Teacher: Date f Plan: Emergency Cntact Infrmatin Mther/Guardian: Email address: Hme phne: Wrk phne: Cell: Father/Guardian: Email address: Hme phne: Wrk phne: Cell: Tls Health Care Prvider: Phne number: Schl Nurse: Cntact number(s): Trained Diabetes Persnnel: Cntact number(s): Causes f Hyperglycemia T little insulin r ther glucselwering medicatin Fd intake that has nt been cvered adequately by insulin Decreased physical activity Illness Infectin Injury Severe physical r emtinal stress Pump malfunctin Onset f Hyperglycemia Over several hurs r days Helping the Student with Diabetes Succeed 111
Hyperglycemia Signs Hyperglycemia Emergency Symptms Circle student s usual signs and symptms. (Diabetic Ketacidsis, DKA, which is assciated with hyperglycemia, ketsis, and dehydratin) Increased thirst and/r dry muth Frequent r increased urinatin Change in appetite and nausea Blurry visin Fatigue Other: Dry muth, extreme thirst, and dehydratin Nausea and vmiting Severe abdminal pain Fruity breath Heavy breathing r shrtness f breath Chest pain Increasing sleepiness r lethargy Depressed level f cnsciusness Actins fr Treating Hyperglycemia Ntify Schl Nurse r Trained Diabetes Persnnel as sn as yu bserve symptms. Treatment fr Hyperglycemia Check the bld glucse level: mg/dl. Check urine r bld fr ketnes if bld glucse levels are greater than: mg/dl. If student uses a pump, check t see if pump is cnnected prperly and functining. Administer supplemental insulin dse:. Give extra water r nn-sugar-cntaining drinks (nt fruit juices): unces per hur. Allw free and unrestricted access t the restrm. Recheck bld glucse every 2 hurs t determine if decreasing t target range f mg/dl. Restrict participatin in physical activity if bld glucse is greater than mg/dl and if ketnes are mderate t large. Ntify parents/guardian if ketnes are present. Treatment fr Hyperglycemia Emergency Call parents/guardian, student s health care prvider, and 911 (Emergency Medical Services) right away. Stay with the student until Emergency Medical Services arrive. 112 www.yurdiabetesinf.rg
Appendix D Glssary
Glssary American with Disabilities Act - A federal law enacted in 1990, and amended in 2008, t prtect peple with disabilities frm discriminatin. Under this law, diabetes can be cnsidered a disability. Basal Insulin Lng-acting r immediate-acting insulin delivered nce r twice a day. Basal insulin is used t cntrl bld glucse levels vernight and between meals. Bld Glucse Level - The amunt f glucse (sugar) in the bld. Bld Glucse Meter A small, prtable machine that measures hw much glucse is in the bld. After pricking the skin with a lancet, ne places a drp f bld n a special test strip, which is inserted in the machine. The meter (r mnitr) then gives the bld glucse level as a number n the meter s digital display. Bld Glucse Mnitring - The act f checking the amunt f glucse in the bld. Als called self-mnitring f bld glucse. Carbhydrates r Carbs - One f the three surces f energy in fd fr the bdy. Carbhydrates are mainly sugars and starches that the bdy breaks dwn int glucse. Fds that cntain carbhydrates raise bld glucse levels. Carbhydrate fds include: breads, crackers, and cereals; pasta, rice, and grains; vegetables; milk and ygurt; fruit, juice, and sweetened sdas; and table sugar, hney, syrup, and mlasses, cakes, pies, and ckies. Cntinuus Glucse Mnitr (CGM) A device that recrds glucse levels thrughut the day. The CGM wrks thrugh a sensr inserted under the skin that measures interstitial glucse levels (the glucse fund in the fluid between cells) at regular intervals. The CGM sends the current glucse level wirelessly t a pump r a separate mnitr that the student carries r wears in a pcket, a backpack, r a purse. When glucse levels are t high r t lw, the CGM sets ff an alarm. Diabetes Medical Management Plan - Describes the medical rders r diabetes care plan develped by the student's persnal diabetes health care team. Educatin Plan A plan that addresses the student s needs fr services t manage their diabetes safely and effectively in schl, where required under Sectin 504 f the Rehabilitatin Act r the Individuals with Disabilities Act (IDEA). These include the 504 Plan, ther educatin plan, r individualized educatin prgram (IEP). Emergency Care Plans Plans that prvide schl persnnel with essential infrmatin n hw t recgnize and respnd t symptms f hypglycemia and hyperglycemia, wh t cntact fr help, and what t d in an emergency.
Family Educatinal Rights and Privacy Act (FERPA) - A federal law that prtects the privacy f student educatin recrds. The law applies t all schls that receive funds under an applicable prgram f the U.S. Department f Educatin. Glucagn - A hrmne that raises the level f glucse in the bld. Glucagn, given by injectin, is used t treat severe hypglycemia. Glucse - A simple sugar fund in the bld. It is the bdy's main surce f energy. Glucse Crrectin Factr The amunt f insulin the student needs t lwer bld glucse t the target level. Hrmne - A chemical prduced by an rgan that travels in the bld t affect ther rgans. An example f a hrmne is insulin. Hyperglycemia -A high level f glucse in the bld. High bld glucse can be due t a mismatch in insulin, fd, exercise r illness r pump malfunctin. Hypglycemia - A lw level f glucse in the bld. Lw bld glucse is mst likely t ccur during r after exercise, if t much insulin is present, r nt enugh fd is cnsumed. Individualized Educatin Prgram (IEP) - A prgram designed fr a student with a disability cvered by the Individuals with Disabilities Educatin Act (IDEA). Each child s IEP must include the supplementary aids and services t be prvided fr, r n behalf f, the child, and a statement f the prgram mdificatins r supprts fr schl persnnel that will be prvided fr the child t make prgress and t be invlved in the general educatin curriculum. Individuals with Disabilities Educatin Act (IDEA) - A Federal law that prvides funds t states t supprt special educatin and related services fr children with disabilities, administered by the Office f Special Educatin Prgrams in the U.S. Department f Educatin. T be eligible fr services under IDEA, a student's diabetes must impair his r her educatinal perfrmance s that he r she requires special educatin and related services. IDEA als cntains specific cnfidentiality prtectins fr student recrds. Insulin - A hrmne made in the pancreas that allws glucse t enter the cells f the bdy where it is used fr energy. Several types f insulin are used in cmbinatin t treat peple with diabetes. These different types f insulin have been manufactured either t have immediate (rapid-acting r shrt-acting insulin), intermediate, r lng (basal insulin) nset f actin and duratin f actin in the bdy. A crdinated cmbinatin f different types f insulin is used t achieve target bld glucse levels at meals, snacks, during perids f physical activity, and thrugh the night. Insulin Injectins - The prcess f putting insulin int the bdy with a needle and a syringe r with an insulin pen. Insulin Pen A pen-like device used t put insulin int the bdy.
Insulin Pump - A cmputerized device that is prgrammed t deliver small, steady dses f insulin thrughut the day. Additinal dses are given when needed t cver fd intake and t lwer high bld glucse levels. The insulin is delivered thrugh a system f plastic tubing (infusin set). Ketnes (Ketne Bdies) - Chemicals made by the bdy when there is nt enugh insulin in the bld and the bdy must break dwn fat fr energy. Ketnes are usually assciated with high bld glucse, but als may ccur when a student is ill and bld glucse levels fall belw the student s target range. Lancet A small needle, inserted in a spring-laded device, used t prick the skin and btain a drp f bld fr checking bld glucse levels. mg/dl (Milligrams per deciliter) - This term is used in bld glucse mnitring t describe hw much glucse is in a specific amunt f bld. Pancreas - The rgan behind the lwer part f the stmach that makes insulin. Persnal Diabetes Health Care Team Includes the student with diabetes, the parents/guardian, the student s dctr, nurse, registered dietitian, diabetes educatr, and ther health care prviders invlved in the student s care. Sectin 504 f the Rehabilitatin Act - A Federal law, amended in 2008, that prhibits recipients f Federal financial assistance frm discriminating against peple n the basis f disability. Schl Nurse The schl staff member wh prmtes the health and safety f students, intervening t manage actual and ptential health prblems. The schl nurse prvides case management services and actively cllabrates with thers t build the student s and family s capacity t manage health issues. Schl nurse services are prvided t the entire schl ppulatin infants, tddlers, pre-schlers, children with special needs, traditinal schl ppulatins, and schl persnnel. Schl nurses hld current licenses as registered nurses in the states in which they practice. Syringe A devise used t inject medicatins such as insulin int bdy tissue.
MDE Diabetes Memrandum Revisin Partner Listing Rsanne Bursn, University f Detrit Mercy Shawn Cannarile, Michigan Public Health Institute (MPHI) Martha Funnell, University f Michigan Sharn Gdsell, Garden City Hspital Stephen Habbe, American Diabetes Assciatin (ADA) Mary Jean Klebba, DPAC Bard (parent f child with type 1 diabetes) Crystal Jacksn, American Diabetes Assciatin (ADA) Evilia Jankwski, Michigan Assciatin f Schl Nurses (MASN) Carlyn Jennings, Natinal Kidney Fundatin f Michigan (NKFM), Michigan Member f the American Assciatin f Diabetes Educatrs (AADE) Sally Jy, Natinal Kidney Fundatin f Michigan (NKFM) (has type 1 diabetes) Jim McGwan, American Diabetes Assciatin (ADA) (parent f child with type 1 diabetes) Kathy J. Mran, University f Detrit Mercy (parent f child with type 1 diabetes) Denise Pentescu, Juvenile Diabetes Research Fundatin (JDRF) (parent f child with type 1 diabetes) Tnya Sessins, Juvenile Diabetes Research Fundatin (JDRF) (parent f tw children with type 1 diabetes) Nicle Tickner, Juvenile Diabetes Research Fundatin (JDRF) (parent f child with type 1 diabetes) Wiscnsin Diabetes Preventin and Cntrl Prgram Diabetes Partners in Actin Calitin (DPAC) Advcacy and Plicy Wrkgrup Michael Wd, MD, Helen DeVs Children s Hspital Michigan Department f Cmmunity Health Shannn Carney Oleksyk, Cardivascular Health, Nutritin and Physical Activity Sectin Jean Chickering, Diabetes and Other Chrnic Diseases Sectin Dawn Crane, Diabetes and Other Chrnic Diseases Sectin Jennifer Edsall, Diabetes and Other Chrnic Diseases Sectin Richard Wimberley, Diabetes and Other Chrnic Diseases Sectin Michigan Department f Educatin Kim Kvalchick, Crdinated Schl Health and Safety Prgrams Patty Lawless, Crdinated Schl Health and Safety Prgrams