Diabetes at Diabetes at SchoolSchool

March 2009

Training For School PersonnelInsulin, Blood Checking and

Glucagon

Goals for Today Understand what diabetes

is Recognize a hypoglycemic

reaction and know how to handle a low blood glucose

To be able to perform a blood glucose check

To learn to do carbohydrate counting

Overview of insulin administration

What is Diabetes

Diabetes is a condition in which the body cannot use or does not produce enough insulin

Without insulin, the body cannot get the glucose (sugars), that are the result of food digestion, into the cells for energy.

Insulin

Insulin is a hormone secreted by the pancreas. With diabetes it must be given as an injection

The dose will vary with the blood glucose level, food intake and exercise

Without Insulin

High levels of glucose (sugar) build up in the blood.

The glucose (sugar) cannot get into the cell to provide energy.

Eat

Eat Blood glucose goes up

Eat Blood glucose goes higher

No glucose in cells

This is Called Hyperglycemia

HYPERGLYCEMIASigns and Symptoms

Frequent urination Increased thirst Increased hunger Fatigue/weakness Weight loss Blurry vision Fast, deep breathing Slow or confused

thinking

So… Hyperglycemia

Watch Hyperglycemia Video

Insulin Should…

Lower the blood glucose

Facilitate the glucose getting into the cells to provide energy

Insulin Can Cause Blood Glucose to

Fall Too Low When…

Too much insulin given

Not enough food eaten

Too much exercise done

Illness present

This is Called Hypoglycemia

Hypoglycemia can be life threatening if not treated because

the only energy source for the brain is blood glucose.

HYPOGLYCEMIASigns and Symptoms

• Sweating

• Paleness

• Irritable/Moody

• Crying • Inability to Concentrate

• Poor Coordination • Inappropriate Actions/Responses • Child appears to have unusual drowsiness and fatigue

Objective Signs (can be observed)

HYPOGLYCEMIASigns and Symptoms

Subjective Signs (reported by child) Sudden Hunger • Headache • Nervousness • Shakiness • Confusion • Abdominal Pain • Unusual Drowsiness or Fatigue

Symptoms can progress to: Confusion Blurred Vision

Late stages of Hypoglycemia

include: Coma Seizure Death

Watch Hypoglycemia Video

Exercise

When the student exercises, the body uses the glucose more effectively, which can lead to low blood glucose (hypoglycemia)

The effects of insulin are more efficient with exercise

Treatment

#1 Meal Planning

Deciding what and when to eat Affects the whole family Affects school and school performance Never ending

Meal Plans Good nutrition is important

to everyone, however a student with diabetes must plan their meals carefully

A balanced diet, with moderation of concentrated sweets is the best

Counting the carbohydrates in foods is called Carb Counting

Insulin is given according to the number of carbohydrates eaten

Carbohydrates

Carbohydrate counting is a simple skill that is an important component of figuring the insulin requirement

Carbohydrate amounts are listed on mostly commercially packaged food items

Counting Carbohydrates

First decide what and how much the student will be eating

Know the “Carb to Insulin” ratio ALWAYS ordered by physician such as 1:15 or

1:20

What About Candy, Fast Foods and Sport

Drinks?

#2 Checking Blood Glucose

Check before meals and at bedtime Check whenever there are symptoms of a

HIGH or LOW blood glucose are in question

Why Check Blood Glucose?

Checking blood glucose daily is an important part of diabetes control

Helps maintain blood glucose “target range”

Maximize learning and participation

Prevention of lows and highs. Decrease risk of long-term

complications

Before You Start…

Know the target range: Young Child up to age 7 years is a blood

glucose of 100-200 School Age (7-11 years) 80- 160 Adolescents (12- adult) 70- 150

Consider extra checking: Before, during and/or after exercise Periods of stress or illness With any diabetes management changes

Things You Will Need to Check

a Blood Glucose

Meter Blood strips Lancing Device New Lancet Sharps container

Steps for Checking Blood Glucose

Have the student wash hands Set up meter Prick finger with a lancet Apply blood to the test strip Record results

Reading the Meter

Turn the meter on. Check the code if necessary.

The code number that appears on the meter must match the code number on the bottle of strips.

Insert a strip into the meter.

Blood Glucose Meters

One Touch Ultra 2

One Touch UltraMiniAccu-Chek

Aviva

Freestyle Lite

Accu-Chek Compact

Contour

Lancing the Finger

Using the outside edges of thefingers is less painful.

Doing a Reading

Apply the blood to the strip Wait for the results to be displayed Disposed of the lancet and the strip Record the results

Watch Blood Glucose Monitoring Video

#3 Giving the Insulin

At school we will be givingrapid-acting insulin beforemeals or possibly for a bloodglucose level that is

significantlyabove target range.

Dose of Insulin… Bolus Dose

Insulin dose is a calculation depending on: Blood glucose reading What food will be eaten

Calculating Food Dose

Example: 1 unit of insulin per “X” number of

carbohydrates The ratio is 1 unit of insulin for every 15

carbohydrates The student is going to have 60 carbohydrates

for lunch 60 /15= 4 x1 unit= 4 units of insulin

Calculating for Correction Dose

The doctor will give a scale of how many units of insulin are needed for every number over the target range

The correction dose is the amount of additional insulin to be taken to bring the blood glucose down to the desired target

Calculating the Bolus Dose…

Number of units needed for food eaten+

Correction dose for hyperglycemia if present

= Total Insulin Bolus

Insulin Delivery Systems

Insulin Syringe Insulin Pen Insulin Pump

Insulin By Injection

Preparation of Dose with a Syringe

Get supplies: insulin, syringe Wash hands Clean the insulin vial

Draw Up the Insulin Dose

Remove cap from syringe Pull the plunger down to number of units

needed Inject this air into the insulin bottle Turn the insulin bottle upside down and draw

into the syringe the number of units of insulin needed as calculated for the bolus dose

Giving Insulin with a Syringe

Chose the injection site Recheck the insulin dose Push the needle into the skin at 90° Push the plunger in Count to 5-10 with the needle in Remove the needle and dispose of the syringe

in a sharps container Document time, dose, and site

Watch Insulin by Syringe and Vial Video

Insulin Pens

Gather supplies:Pen device, pen needles

Wash hands Clean the top of the pen device with alcohol Screw on pen needle

Prime needle by dialing up 1-2 units and pushing on the plunger until you see insulin at the end of the needleThis may need to be repeated

Dial in number of units of insulin needed

Insulin Delivery Systems

NovoPen Jr.

NovoLog FlexPen

Humalog Pens

Injection with an Insulin Pen

Chose injection site Push the needle in at 90° Push down the plunger Count to 5-10 Remove the pen needle and dispose of the

pen needle Document time, dose, and site

Watch Insulin by Pen Video

Insulin Pump Therapy

A pump is a device worn externally that delivers a small amount of insulin continuously

A bolus dose is given by the pump at meals or snacks

Insulin Pumps

Deltec Cozmo

Accu-Chek Spirit

MiniMed Paradigm

Animas

OmniPod

Things to Know About the Pump

How to deliver a bolus dose Checking injection site for leakage What to do if the pump is alarming How you would stop the insulin delivery by

using the “suspend” feature

Watch Insulin by Pump Video

Insulin Reaction

This is called… HYPOGLYCEMIA.

Treatment for Hypoglycemia

for a Conscious Person: If you can, check a blood glucose. If it is below

80 treat as a hypoglycemic reaction When in doubt or unable to check a blood

glucose, treat as a hypoglycemic reaction

Treatment for Hypoglycemia

for a Conscious Person: Give a drink high in sugar:

6oz. of regular soda pop (not diet),1/2-2/3 cup fruit juice3-4 glucose tablets

Follow with a milk and protein - or go with them to lunch if they can eat within 10 to 15 minutes

Hypoglycemia with Decreased Awareness

Glucose gels and/or tablets can be used to treat hypoglycemia.

Examples: Insta-glucose, Glucose 15, Glucose

tablets, Dextrose tablets.

Gels are placed in the student’s mouth toward the cheek and back teeth

Stay with the Child!

You should see a response within 15 -20 minutes

You can repeat the treatment in 15 minutes if symptoms are still present or if they become worse

Treatment for an Unconscious Student:

Identify someone to call 9-1-1 Give Glucagon Call the parent

Glucagon

Novo Nordisk® GlucoGen® HypoKit ™

Lilly® Glucagon Emergency Kit

Glucagon Adverse Reactions

The most common side effects are nausea and vomitingThese reactions may also occur with hypoglycemia

Keep the student positioned on his or

her side

Glucagon is Necessary:

Children spend significant hours a day at school.

The goal of diabetes care is to have the blood glucose closer to normal. Despite best efforts hypoglycemia will occur.

Glucagon is the fastest means to raise the blood glucose level.

Steps forGlucagon

Administration

Preparation1. Remove flip top seal

from vial containing dry powder

2. Remove needle protector from syringe

Mixing Solution3. Slowly inject all sterile

water in syringe into the bottle containing the powder

4. Gently swirl vial until all powder is dissolved and solution is clear (don’t shake vial)

Drawing Out & Positioning

5. Withdraw all glucagon solution from vial

6. Turn student on his/her side

Dosing & Injecting7. Insert needle straight in (90 degree

angle) arm (deltoid) muscle or leg (outer thigh) muscleNote: Inject through clothing only if necessary

8. Withdraw needle, apply light pressure at injection site

Completing the Procedure

9. Place used needle back in kit and close the lid (do not recap)

10.Give used kit to EMS personnel

Illness and Stress Affect Diabetes

Let’s Practice!Prepared by: Mary Clark RN, NCSN

JMJ PublisherSalt Lake City, Utah 84105

(801) 467-5083for the

Utah School Nurse Association

Reviewed by:Utah Insulin Delegation Task

Forcethrough the Utah Diabetes

Preventionand Control Program

Videos used with permission from:American Diabetes Association

Utah Insulin Delegation Task ForceJamie Ferdinand, RN, BSN, NCSNPresident Utah School Nurse AssociationGranite School DistrictSalt Lake City, UT Email: jferdinand@graniteschools.org

Shirley Stevens, RN, BSNPresident Elect Utah School Nurse

AssociationRowland Hall St. Mark's SchoolSalt Lake City, UT Email: shirleystevens@xmission.com

Cescilee Rall RN, BSN, NCSNPast President Utah School Nurse

AssociationGranite School DistrictSalt Lake City, UT Email: crrall@graniteschools.org

Kathy Briggs, RN, BSN, NCSNNASN Director, Utah School Nurse

AssociationGranite School DistrictSalt Lake City, UT  Email: kbriggs@graniteschools.org

Betty Sue Hinkson, RN, WebmasterUtah School Nurse AssociationAlpine School DistrictAmerican Fork, UT Email: hink242@alpine.k12.ut.us

Beverly BartelProgram ManagerAmerican Diabetes AssociationSalt Lake City, UT Email: bbartel@diabetes.org

Richard Bullough, Ph.DProgram ManagerUtah Diabetes Prevention & Control

ProgramSalt Lake City, UT  Email: rbullough@utah.gov

Kaylene Ellertson, RNPublic Health Education InternEmail: kaylene.ellertson@imail.org

Lucie Jarrett, MS, APRN, CDEDiabetes Clinical Nurse SpecialistPrimary Children's Medical CenterSalt Lake City, UT Email: lucie.jarrett@imail.org

Catherine A. Hamilton, RN, MS, MBASchool Nurse ConsultantUDOH/Immunization ProgramSalt Lake City, UT Email: chamilto@utah.gov

Dawn Higley, RN, MS, CDEDepartment Manager Diabetes Management ClinicUtah Valley Regional Medical CenterProvo, UTEmail: dawn.higley@imail.org

Laura LandonExecutive DirectorAmerican Diabetes AssociationSalt Lake City, UT Email: llandon@diabetes.org