information for school management of diabetes … · 2019. 2. 1. · will contact diabetes care...

Forsyth County Schools does not discriminate on the basis of race, color, religion, national origin, age, disability, or gender in

employment decisions or educational programs and activities .1

Student’s Name: Date of Birth: Effective Date:

School Name: Grade: Homeroom:

CONTACT INFORMATION:

Parent/Guardian #1: Home Phone: Work: Cell:

Parent/Guardian #2: Home Phone: Work: Cell:

Diabetes Care Provider: Phone:

Other emergency contact: Relationship:

Phone Numbers: Home: Work: Cell/Pager:

Insurance Carrier: Preferred Hospital:

EMERGENCY NOTIFICATION: Notify parents of the following conditions:

a. Loss of consciousness or seizure (convulsion) immediately after calling 911 and administering Glucagon. b. Blood sugars in excess of 300 mg/dl with ketones present. c. Positive urine ketones. d. Abdominal pain, nausea/vomiting, fever, diarrhea, altered breathing, altered level of consciousness.

STUDENT’S COMPETENCE WITH PROCEDURES: (Must be verified by parent and school nurse)

□ Blood glucose monitoring □ Carry supplies for BG monitoring

□ Determining insulin dose □ Carry supplies for insulin administration

□ Measuring insulin □ Monitor BG in classroom

□ Injecting insulin □ Self treatment for mild low blood sugar

□ Independently operates insulin pump □ Determine own snack/meal content

MEAL PLAN Time Location CHO Content Time Location CHO Content

□ Bkft. □ Mid-PM

□ Mid-AM □ Before PE

□ Lunch □ After PE

Meal/Snack will be considered mandatory. Times of meals/snacks will be at routine school times unless alteration is indicated. School nurse will contact diabetes care provider for adjustment in meal times. Content of meal/snack will be determined by:

□ student □ parent □ school nurse □ diabetes provider

Please provide school cafeteria with a copy of this meal plan in order to fulfill ESDA requirements. Parent to provide and restock snacks and low blood sugar supplies box.

Location of supplies/equipment: (To be completed by school personnel)

Blood glucose equipment □ Clinic/health room □ With Student

Insulin Administration supplies □ Clinic/health room □ With Student

Glucagon emergency kit: Glucose gel: Ketone testing supplies

Fast Acting carbohydrate: □ Clinic/health room □ With Student Snacks: □ Clinic/health room □ With Student

Signatures: I understand that all treatments and procedures may be performed by the student and/or the student and/or unlicensed personnel within the school or by EMS in the event of loss of consciousness or seizure. I also understand that the school is not responsible for damage, loss of equipment, or expenses utilized in these treatments and procedures. I give permission for school personnel to contact my child’s diabetes provider for guidance and recommendations. I have reviewed this information form and agree with the indicated information. This form will assist the school in developing a health

plan and in providing appropriate care for my child.

Parent Signature: Date:

School Nurse Signatures: Date: *Refer to 504 coordinator if appropriate Updated 7/11

INFORMATION FOR SCHOOL MANAGEMENT OF DIABETES MELLITUS School Year:



Name of Student

1. Don’t panic 2. Has 911 been called? 3. Have the parents been called? 4. If convulsions, protect head! DO NOT PUT ANYTHING IN MOUTH!!!!! 5. Prepare Glucagon (Only persons designated by parents)

A. Remove flip-off seal from bottle of glucagon. B. Remove needle protector from syringe, and inject the entire contents of the syringe into the bottle of

glucagon. (Do not remove plastic clip from syringe.) C. Remove syringe from bottle D. Swirl bottle gently until glucagon dissolves completely. (GLUCAGON SHOULD NOT BE USED UNLESS

THE SOLUTION IS CLEAR AND OF A WATER-LIKE CONSISTENCY.) 6. Inject Glucagon (Only persons designated by parents)

A. Using the same syringe, hold bottle upside down and gently withdraw the amount prescribed by the physician. (See page 57 “Health Care Provider Authorization for School Management of Diabetes)

B. Cleanse upper outer thigh with alcohol swab. C. Insert needle into the muscle and completely inject all of the solution. (THERE IS NO DANGER OF

OVERDOSE!) D. Apply light pressure at the injection site and withdraw the needle. E. Turn the patient to his/her side. When an unconscious person awakens, he/she may vomit. Turning the

patient to his/her side prevents choking. 7. HE/SHE SHOULD AWAKEN WITHIN 15 MINUTES OF INJECTING GLUCAGON. If not, he/she could be

unconscious due to severe high blood sugar, which requires medical attention immediately! 8. Feed the patient as soon as he/she awakens and IS ABLE TO SWALLOW. Foods to give:

Other instructions:

Parent/Guardian Signature Date

Contact Numbers

Physician Signature Date

Printed Physician Name Phone

List of Persons trained to give Glucagon:

1.

2.

3.

I give permission for the above persons to administer glucagon to my child, who is diabetic, in the even that he/she has a seizure or becomes unconscious.

Parent Signature Date

Physician’s Signature Date

Printed Physician’s Name Phone Updated 4/10

DIABETES EMERGENCY: Seizure or Unconscious

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Student Name

Parent:

Phone # home cell

Physician:

Physician’s Signature:

Algorithm For Blood Glucose Results

Check Blood Glucose (Refer to appropriate procedures for further details)

Below 70

70 - If Student Feels OK

Above

Student’s Photo

If Student Does Not Feel OK

1. Give fast acting sugar source.* 2. Observe for 10 minutes 3. Retest blood glucose, if less than 70

repeat sugar source according to procedure. If ordered, give carbohydrate and protein snack (e.g. crackers and cheese) or within one hour to next meal feed early.

4. Notify school nurse if two or more episodes in one week. If student becomes unconscious, seizures, or is unable to swallow:

a. Call 911 b. Turn student on side to ensure

open airway. c. Give glucose gel and

glucagons if ordered.

d. Notify school nurse & parents.

1. If 70 or above and student feels OK, may resume school activities. Provide treatment according to orders.

2. If 70 or above and student is feeling “low,” retest immediately. Treat for hypoglycemia and notify school nurse if results are contradictory for further advice.

3. If student is hyperglycemic and feels ill, consult parent (in the meantime provide treatment according to orders).

1. Provide water if student is thirsty and/or has dry mucous membranes.

2. Provide additional treatment per ISHP. (This may include insulin administration, ketone check and/or activity restriction).

3. May resume classroom activities.

4. Document action and provide

copy to school nurse.

1. Call parents to pick up student.

2. Provide water if student is thirsty and/or has dry mucous membranes.

3. Provide additional treatment per ISHP (this may include insulin administration, ketone check and/or activity restriction).

4. Notify school nurse if there are further immediate concerns or questions. Document action and provide copy to school nurse.

5. For vomiting with confusion, labored

breathing and/or coma Call 911 Notify Parents Contact School Nurse

Fast Acting Sugar Sources

15 gm Glucose tablets

15 gm Glucose gel

1/3 c. sugared soda

½ c. orange juice

½ c. apple juice

1 tube Cakemate™ gel (19 gm)

3 tsp. sugar (in water)

Communicate with school nurse via telephone

or written documentation depending on

urgency of situation. School nurse will notify

parent and health care provider per ISHP.

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Student Name: Teacher: School: Grade: Date School Nurse:

Symptoms

Action Needed Notify School Nurse

If possible, check blood glucose per plan But always, when in doubt,

TREAT

Never send a child with suspected low blood sugar anywhere alone. Adapted from Washington State Task Force for Students with Diabetes Manual, 1999

Low Blood Glucose (Hypoglycemia) Management Algorithm

Student Photo

Causes Too much insulin

Missed food Delayed food

Too much exercise Unscheduled exercise

Onset

Sudden

Mild Hunger Dizziness Irritable Pallor Shakiness Sweating Weak Drowsy Sweaty Crying Anxious Headache Unable to concentrate Numbness of lip & tongue Other:

Moderate Sleepiness

Erratic behavior Poor coordination

Confusion Slurred speech

Severe Unable to swallow

Combative Unconscious

Seizure

Mild □ Provide sugar source:

2-3 glucose tablets or 4-8 oz. juice or 4-8 oz. regular soda or Glucose gel product

□ Wait 10 minutes

□ Provide sugar source if

symptoms persist or blood glucose less than 70.

□ Provide a snack of carbohydrate

& protein, i.e., crackers and cheese.

□ Communicate with parents.

Moderate □ Provide Glucose source:

3 glucose tablets or 15 gm glucose gel

□ Wait 10 minutes. Repeat glucose if

symptoms persist or blood glucose less than 70.

□ Follow with a snack of carbohydrate &

protein, i.e., crackers and cheese.

□ Notify Parents

Severe □ Call 911 □ Give Glucagon, if ordered □ Position on side □ Contact parents & School Nurse

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Student: Birth Date: School: Grade:

Equipment and Supplies

1. Blood glucose meter kit 2. Fast acting carbohydrates, i.e., apple juice, orange

juice 3. Glucose tablets 4. Glucose gel such as Insta-Glucose, Monogel and

Glucose

5. Carbohydrate and protein snack, (i.e., prepackaged crackers/cheese or peanut butter, ½ sandwich, 2 graham crackers with ½ cup milk, Nite Bite™)

Essential Steps Key Points and Precautions 1. Observe/recognize signs/symptoms of low blood glucose; ask student to describe

how he/she feels. (Student’s known signs/symptoms are checked below).

Mild Symptoms Moderate Symptoms

□ Headache □ Weakness, fatigue □ Droopy eyelids, sleepy

Unable to swallow Combative Uncooperative – Unconscious Seizure. Proceed immediately to Procedure for Severe Low Glucose.

□ Moist skin, sweating □ Numbness of lips/tongue

□ Erratic behavior

□ Shakiness □ Irritability □ Slurred speech

□ Pale skin □ Blurred vision □ Loss of coordination

□ Sudden hunger □ Crying □ Confusion

□ Stomach ache

1. Test blood (if testing equipment is available), (a) If below 70, proceed to #3 (b) If 70 or

above and student is feeling “low,” retest immediately. Proceed to #3.

3. Treatment for Hypoglycemia

(a) Treat with one (1) of the following fast acting carbohydrates;

4 oz. (1/2 cup) apple juice or orange juice (or regular soda pop).

15 gm glucose tablets (chewed thoroughly before swallowing)

Glucose gel (i.e., gm tube Insta-Glucose, or 15 gm Monogel or Glutose).

1 tube gel Cakemate™ (19 gm, mini-purse size) (b) Observe for 10 minutes, then check for improvement:

Student states symptoms are gone and appears OK.

Blood sugar over 70 per student retest. (c) If no improvement, repeat Step 2a and 2b (second attempt) except use the 15-30 gm glucose tablets or glucose gel product, if available. AND If still no improvement, repeat again (3rd attempt and if needed, 4th attempt). If no improvement after third attempt, call parent and school nurse. If no improvement after fourth attempt, call parent and paramedics. (d) When student is feeling better:

If ordered, provide extra carb and protein snack if over 1 hours until lunch or snack time, or provide lunch or snack, whichever is due within the hour.

Resume classroom activities if fully recovered or have health office call for assistance if not fully recovered.

If moderate symptoms, provide immediate adult supervision. Treat “on the spot;” do not send elsewhere, and, if none of the listed fast acting carbohydrates are available, use 2 tsps. Of sugar or honey or 4 ounces of milk or fruit punch, etc. Notify school nurse if results are contradictory with student symptoms for further advice. If in classroom and retest is needed, request health office assistance.

AND

If student becomes unable to participate in care, proceed immediately to Emergency Procedure for Severe Blood Glucose. School nurse will advise regarding further care.

4. Document – Blood glucose results and care provided on appropriate forms and/or logs. Notify parent.

Procedure for Mild or Moderate Low Blood Glucose (Hypoglycemia / Insulin Reaction)

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EMERGENCY PROCEDURE FOR SEVERE LOW BLOOD GLUCOSE (HYPOGLYCEMIA/INSULIN REACTION)

Glucose Gel Followed by Glucagon Injection

Student:

DOB: School: Grade:

Equipment and Supplies: 1. Glucose gel 3. Regular (not diet) soda pop 2. Glucagon kit 4. Blood glucose meter kit

Essential Steps

Key Points & Precautions

1. Verify signs of severe low blood glucose: unable to swallow, unconsciousness, combative, uncooperative, seizures

Signs are so severe that student cannot participate in care.

2. Place student on side, or in upright position if restless/uncooperative, and have someone call paramedics, school nurse, and parent

If seizure occurs, follow standard seizure procedure.

3. Place one of the following in cheek pouch closest to ground and massage: 15 gm of glucose gel: 15 gm tube Insta-Glucose OR 15 gm pkt. Monogel or Glutose

Maintain head position to one side for preventing aspiration.

4. Give glucagon injection (use procedure below)

5. When student is able to swallow, repeat Step 3 and give sips of regular soda pop (not diet) as tolerated until paramedics arrive.

Avoid orange juice. Glucagon can cause nausea/vomiting.

6. When paramedics arrive, student will be transported for medical care. When transported, notify physician.

7. Document on Procedure Log.

9

EMERGENCY PROCEDURE FOR SEVERE LOW BLOOD GLUCOSE (HYPOGLYCEMIA/INSULIN REACTION)

Glucagon Injection Followed by Glucose Gel (when able to swallow)

Student:

DOB: School: Grade:

Equipment and Supplies: 1. Glucose gel 3. Regular (not diet) soda pop 2. Glucagon kit 4. Blood glucose meter kit

Essential Steps

Key Points & Precautions

1. Verify signs of severe low blood glucose: unable to swallow, unconsciousness, combative, uncooperative, seizures

Signs are so severe that student cannot participate in care.

2. Place student on side, or in upright position if restless/uncooperative, and have someone call paramedics, school nurse, and parent


3. Give glucagon injection (use procedure below)

4. Place one of the following in cheek pouch closest to ground and massage: 15 gm of glucose gel: 15 gm tube Insta-Glucose OR 15 gm pkt. Monogel or Glutose and Give sips of regular soda pop (not diet) as tolerated until paramedics, arrive.

Avoid orange juice. Glucagon may cause nausea/vomiting.

If able to swallow but not fully alert, position head to one side for preventing aspiration.

5. When paramedics arrive, student will be transported for medical care. When transported, notify physician


10

Updated July 2011

PROCEDURE FOR INTRAMUSCULAR GLUCAGON INJECTION


1. Glucagon kit (dilutent in syringe and vial of glucagons powder) 2. Alcohol wipes and cotton ball 3. Bandage 4. Sharps container 5. Gloves (if indicated)

Essential Steps Key Points & Precautions

Prepare Glucagon Syringe

1. Remove vial cap, clean vial top with alcohol (if time allows). Remove needle cover.

2. Inject contents of syringe into vial (held upright).

3. Swirl vial gently until dissolved / clear.

4. Hold vial upside down, and withdraw the amount prescribed by the physician.

See page 57 “Health Care Provider Authorization for School Management of Diabetes

5. Withdraw needle from vial, hold syringe upright, and remove air/bubbles from syringe, then create dribble at needle tip.

Administer Glucagon

1. Expose injection site (upper, outer area of thigh, arm or buttock).

2. Hold syringe safely; use other hand to clean injection site with alcohol (if time allows).

District policy may require gloves for injections.

3. Insert needle straight into muscle of buttock, arm or thigh and inject glucagon.

4. Withdraw needle while pressing gently with alcohol wipe or cotton ball at injection site.

5. Massage injection site for 10 seconds; apply bandage if needed

6. Put use syringe and vial in Sharps container.

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PROCEDURE FOR SUBCUTANEOUS GLUCAGON INJECTION


1. Glucagon kit (dilutent in syringe and vial of glucagons powder) 2. Alcohol wipes and cotton ball 3. Insulin Syringe (for glucaton sq) 4. Bandage 5. Sharps Box


Prepare Glucagon Syringe

1. Remove vial cap, clean vial top with alcohol (if time allows). Remove needle cover.

2. Inject contents of syringe into vial (held upright).

3. Swirl vial gently until dissolved / clear.

4. Hold vial upside down, and withdraw all solution.

5. Withdraw needle from vial, hold syringe upright, and remove air/bubbles from syringe, then create dribble at needle tip.

Administer Glucagon

1. Expose injection site (upper, outer area of thigh, arm).

2. Hold syringe safely; use other hand to clean injection site with alcohol (if time allows).

3. Pinch up skin/muscle (still holding alcohol wipe).

4. Insert needle straight into muscle of buttock, arm or thigh and inject glucagons.

5. Withdraw needle while pressing gently with alcohol wipe or cotton ball at injection site.

6. Massage injection site for 10 seconds; apply bandage if needed.

7. Put used syringe and vial in Sharps container.

12

EMERGENCY PROCEDURE FOR SEVERE LOW BLOOD GLUCOSE (Hypoglycemia/Insulin Reaction)

Glucose Gel Only

Student:

DOB: School: Grade:

Equipment and Supplies 1. Glucose gel 2. Regular (not diet) soda pop 3. Blood glucose meter kit 4. Glove (if indicated)

Essential Steps Key Points & Precautions 1. Verify signs of severe low blood glucose: unable to swallow,

unconsciousness, combative, uncooperative, seizures Signs are so severe that student is unable to participate in care.

2. Place pupil on side or in upright position if restless/uncooperative, AND have someone call paramedics, school nurse, and parent.


3. Place one of the following in cheek pouch closest to ground and massage: Glucose gel: 15 gm tube Insta-Glucose OR 15 gm Monogel or Glucose

Maintain head position to one side to prevent aspiration.

4. When student is able to swallow, repeat Step 3, Give sips of regular soda pop (not diet) as tolerated until paramedics arrive.

5. When paramedics arrive, student will be transported for medical care. When transported, notify physician.

Avoid orange juice. Glucagon can cause nausea/vomiting.


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Name: Teacher: Grade: Date:

School: School Nurse:

SYMPTOMS

Action Needed

High Blood Glucose

(Hyperglycemia) Management

Causes Too much food Too little insulin

Decreased Activity Illness, Infection

Stress

Onset Over time

Several hours or days

Student

Photo

Early Symptoms: Symptoms progressively become worse: Thirst / dry mouth Sweet breath Frequent urination Weight loss Fatigue / sleepiness Facial flushing Increased hunger Dry, warm skin Blurred vision Nausea / stomach pains Lack of concentration Vomiting Weakness Confusion Labored breathing Unconsciousness / coma

Check blood glucose (per ISHP)

If Student is Not Feeling Well □ Call parents to pick up student □ Provide water if student is thirsty □ Provide additional treatment per ISHP (ketone check, insulin) □ Notify school nurse if there are

further immediate concerns or questions. Document action and provide copy to school nurse.

For vomiting with Confusion, labored

breathing and/or coma

□ Call 911 □ Contact School Nurse □ Notify parents

If Student is Feeling OK □ Provide water if student is

thirsty □ Allow liberal bathroom privileges □ Provide additional treatment per ISHP □ May resume classroom activities □ Document action and provide copy to school nurse

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High Blood Glucose Management General Procedures

The procedure for inserting an infusion set and operating a pump will be independently performed by the student in accordance with the actions delineated under “General Information.” The school nurse can assist with trouble shooting the following situations:

Student: DOB: School: Grade:

Equipment and Supplies: 1. Blood glucose meter kit 2. Water bottle 3. Insulin supplies (if indicated)


1. Test blood glucose per procedure.

2. Initiate care per health care provider authorization consent. This may include insulin administration and checking for ketones and possibly activity restriction.

Exercising when ketones are present may elevate blood glucose levels even further.

3. If student is thirsty or has dry mucous membranes, provide fluids as tolerated.

If student resumes classroom activities, he/she may use a water bottle in class for symptoms of thirst and/or dehydration.

4. If student is feeling OK, resume classroom activities. If student does not feel well (nausea, lethargy, headache) then the parents should be called to take the child home.

Notify the school nurse so follow-up care can be ensured.

5. If student develops severe stomach pains, vomiting and/or rapid breathing, call paramedics, school nurse and parent immediately.

6. Document care on procedure log. School nurse or parent will notify the health care provider.

information for school management of diabetes … · 2019. 2. 1. · will contact diabetes care...

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