2015 Safe at School: Medical Management for Children with Diabetes.

2015 Safe at School:2015 Safe at School:

Medical Management for

Children with Diabetes

ObjectivesObjectivesAt the end of this learning session participants will

be able to:

Describe how the anaphylaxis law affects

treatment students with diabetes will receive

State the importance of diabetes self-management

Discuss treatment for hyperglycemia

Discuss treatment for hypoglycemia

Anaphylaxis LawAnaphylaxis Law

Food items containing peanuts removed

Supplies needed for schoolSnack Treatment

Additional ChangesAdditional ChangesDiabetes Medical Management PlanDateDiagnosis

◦ Type 1 vs Type 2

CGM

Treatment◦ Hyperglycemia◦ Hypoglycemia

Insulin ordersType 2

MANAGEMENT PLAN(1)

Date of Plan: __________DIABETES MEDICAL MANAGEMENT PLAN Expiration date: ______________

TREATMENT AND INTERVENTION FORM

Student’s Name: _______________________________________________________ Date of Birth: _________________Begin Treatment_____________________________________ Stop Treatment______________________________

Date DateDO NOT DISCARD THIS FORM UNTIL THE STOP DATE AS LISTED ABOVE

(2) Insulin Dependent Diabetes DIAGNOSIS: Type 1 Type 2 Other Diabetes ________________________

(3)Continuous Glucose Monitor (CGM): Yes NoBrand/Model: _______________________: CGM may be worn for daily or occasionallyNote: Confirm CGM results with blood glucose meter check before taking action on sensor glucose level. No medical treatment should be rendered based on CGM result only. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM.

Diabetes Self-ManagementDiabetes Self-Management

Importance:

Gain knowledge

Learn and practice skills

Modify behavior

Successfully self-manage

Diabetes Self-ManagementDiabetes Self-Management

Diabetes Self-ManagementDiabetes Self-ManagementTreatment and Intervention Form

Self-care skills

Blood glucose testing NA Ind supv total kept

Ketones testing NA Ind supv total kept

Glucose/gel NA Ind supv total kept

Count carbohydrates NA Ind supv total

Calculate insulin dose NA Ind supv total

Give insulin by injection NA Ind supv total kept

Give insulin by pump NA Ind supv total kept

Change infusion set NA Ind supv total kept

Diabetes Self-ManagementDiabetes Self-ManagementTreatment and Intervention Form

Blood glucose monitoring

When to check: Before meals

Anytime s/s high/low blood glucose

Urine Ketones testing

When to check: Greater than 300

Student sick and /or vomiting

Glucose tablet/gel

When to use: Treat hypoglycemia

Diabetes Self-ManagementDiabetes Self-ManagementDefinition:

Ind = independent self-management

Supv= self-management with nurse

supervision

Total = total care by nurse

Kept = kept on person

NA = does not apply to my child; my child is

not doing or using this

Insulin OrdersInsulin OrdersReview

Original orders from state COA orders

Pump

Correction factor + carbohydrate ratio

Correction factor + fixed

Sliding scale + fixed

Sliding scale + carbohydrate ratio

Ori

gin

al Form

Ori

gin

al Form

Insulin OrdersInsulin Orders


Pu

mp

Th

era

py

Pu

mp

Th

era

py


Corr

ecti

on

+ r

ati

oC

orr

ecti

on

+ r

ati

o


Slid

ing

Scale

+ F

ixed

S

lid

ing

Scale

+ F

ixed

Insu

lin

Ord

ers

Insu

lin

Ord

ers


Hyp

erg

lycem

iaH

yp

erg

lycem

ia

Inje

cti

on

sIn

jecti

on

s

⁼

Check blood glucose: (1) as stated in Individualized Care Plan/Treatment-Intervention Form (2) if student exhibits signs of high blood glucose (extreme thirst, frequent urination, hunger, headache, hyperactivity)

(3) if student has nausea, vomiting, stomach ache or feeling ill

If student has extreme thirst, frequent urination, hunger, nausea, vomiting, stomach ache or is feeling ill……

Blood glucose is greater than 300 mg/dL

No Yes

Check urine for ketones

Call parent, this child should go home, not back

to class.

Negative ketones

Administer correction dose …only if it has

been 3 hours or greater since student received

a correction.

If student develop ketones, nausea,

vomiting, or is feeling ill…follow the correct

pathway for treatment of

symptoms

Ketones present no vomiting or nausea

Administer correction dose …only if it has been 3 hours or greater since

student received a correction.

Recheck blood glucose & urine

ketones in 2 hours

If ketones are still positive, not

improving, after 2 hours with vomiting or

nausea.. Call parent/guardian

Have student drink 8-24 oz

water or sugar-free/caffeine-

free fluids

Student may return to classroom activities .Allow bathroom privileges. No exercises with ketones

If ketones are still positive but improving after 2 hours and student not feeling ill,

with no vomiting or nausea. Student may stay at school

Administer correction dose …only if it has been 3 hours or greater since

student received a correction.

If you cannot get in touch with parents contact our

diabetes doctor on-call at 1-

205-638-9107 or if you do not get a call back

within 15 minutes call

205-638-9100 and ask for the diabetes doctor

on-call

Student shall be permitted to have access to water by keeping a water bottle in his/her possession and at his/her desk, or by permitting the student to use the drinking fountain without restriction.

Student should not exercise when ketones are present Student is not to miss class by sitting in the nurses’ office or be sent home unless vomiting or feeling poorly Revised 02/02/2015


ketones in 2 hours

Student may return to classroom

activities

Ketones present with vomiting or nausea



free fluids

Continue to check until ketones are negative or if student becomes ill follow directions from pathway

Follow insulin orders from student’s provider

Hyp

erg

lycem

iaH

yp

erg

lycem

ia

Pu

mp

Th

era

py

Pu

mp

Th

era

py

Blood glucose is greater than 300

mg/dL No Yes

Check urine for ketones

Call parent, this child should go home, not back

to class.

Negative ketones

Administer correction dose by insulin pump

If student develop ketones, nausea,

vomiting, or is feeling ill…follow the correct

pathway for treatment of

symptoms

Small ketones *Inspect insulin site for signs of inflammation.

Moderate or Large ketones no vomiting or nausea


ketones in 2 hours

If ketones are moderate or

large…. follow the correct pathway for treatment of

symptoms



free fluids

Student may return to classroom

activities. No exercises with

ketones

Recheck blood glucose & urine ketones in 2 hours

Student may return to classroom activities

Moderate or Large ketones with vomiting or nausea

If you cannot get in touch with parents

contact our diabetes doctor on-call at 1-205-638-9107 or if

you do not get a call back within 15

minutes call 205-638-9100 and ask for the diabetes doctor on-

call

Allow bathroom privileges. May have water or sugar-free/caffeine-free fluids,

water. No exercises with ketones

Student may return to

classroom activities


ketones in 2 hours

Give correction dose of insulin by

syringe/pen injection rather than with the

pump.

Administer correction dose by insulin pump

If the student has two consecutive blood glucose readings greater than 240 mg/dL and you nor the student can explain why; for example.. pump is functioning, reservoir is not empty, and appropriate correction bolus has been given then check ketones and follow appropriate path listed above.

Student shall be permitted to have access to water by keeping a water bottle in his/her possession and at his/her desk, or by permitting the student to use the drinking fountain without restriction.

Student should not exercise when ketones are present Student is not to miss class by sitting in the nurses’ office or be sent home unless vomiting or feeling poorly Revised 02/19/2015

The student will need to change insulin pump

infusion set, site/pod and refill reservoir/pod with

insulin. If student cannot do this independently, call the

parent/guardian.

Moderate or Large ketones no vomiting or nausea

Moderate or Large ketones with vomiting or nausea

If Ketones are still moderate or large. Call

parent/guardian. Recommendation to release

to parent/guardian

Check blood glucose: (1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form (2) if student exhibits signs of high blood glucose (extreme thirst, frequent urination, hunger, headache, hyperactivity)

(3) if student has nausea, vomiting, stomach ache or feeling ill



Case StudiesCase Studies

Hyp

og

lycem

iaH

yp

og

lycem

ia

Inje

cti

on

sIn

jecti

on

s

⁼

Check blood glucose: (1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form (2) if student exhibit signs of low blood glucose (see below for symptoms) (3) if student states he/she is feeling low, ill, or student is not acting self


Blood glucose is less than _*___

mg/dL No Yes

Mild Hypoglycemia

possible symptoms Student is alert, trembling, headache, sweating, pale, shakiness, dizziness, tired,

falling asleep in class, inability to concentrate, or has poor

coordination.

Give 15 grams fast-acting carbs. For example: simple sugar, or 3-4 glucose tablets, or 4 oz of fruit juice, or 4 oz of regular soda

Moderate Hypoglycemia

possible symptoms Severe confusion,

disorientation, not able or unwilling to swallow, or may

be combative.

Severe Hypoglycemia

Unresponsive to commands,

Seizure or loss of consciousness

Wait 15 minutes and recheck blood glucose

If blood glucose is still below _*___mg/dL retreat with 1 of the above 15 grams carbs

Recheck blood glucose again in 15 minutes. Repeat above steps until blood glucose is above __*___mg/dL

Keep head elevated Give one of the

following: (apply between cheek and gum)

o Tube of cake decorating gel or

o Instant Glucose Gel (15 grams)

If it is meal time and blood glucose is greater than 60mg/dL…

Send student to lunch.

Student may receive insulin immediately after meal (give insulin within 30 minutes of first bite).

DO NOT SKIP INSULIN FOR LOW BLOOD GLUCOSE

If meal time is more than 1 hour away …

Give student 15 grams carbohydrates with a protein.

Remain with student Give nothing by mouth Place student on side Give prescribed dose of

Glucagon - refer to prescriber authorization order: ½ mg or 1 mg Intramuscular as directed by his/her diabetes care provider

Call 911 if student is not responding to glucagon. Follow your school procedure for notifications

Call parent/guardian Call the physician. Stay with student until help

arrives

For certain patients, a negative correction factor may be used.

If meal time is less than 1 hour away follow box

above

Remain with student

Revised 03/06/2015

Is it meal time?

Yes No


*Use this “age-specific guide” to insert the appropriate age in the highlighted boxes: 90 = students less than 6 years 80 = students greater than 6 but less than 13 years 70 = students 13 years and greater

Hyp

og

lycem

iaH

yp

og

lycem

ia

Pu

mp

Th

era

py

Pu

mp

Th

era

py

Check blood glucose: (1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form (2) if student exhibit signs of low blood glucose (see below for symptoms) (3) if student states he/she is feeling low, ill, or student is not acting self


Blood glucose is less than __*__

mg/dL No Yes

Mild Hypoglycemia

possible symptoms Student is alert, trembling, headache, sweating, pale, shakiness, dizziness, tired,

falling asleep in class, inability to concentrate, or has poor

coordination.

Give 15 grams fast-acting carbs for example: simple sugar, or 3-4 glucose tablets, or 4 oz of fruit juice, or 4 oz of regular soda

Moderate Hypoglycemia

possible symptoms Severe confusion,

disorientation, not able or unwilling to swallow, or may

be combative.

Severe Hypoglycemia

Unresponsive to commands,

Seizure or loss of consciousness

Wait 15 minutes and recheck blood glucose

If blood sugar is still below _*__mg/dL retreat with 1 of the above 15 grams

carbohydrates and suspend the insulin pump

Recheck blood glucose again in 15 minutes. Repeat above steps until blood glucose is above __*___mg/dL

Keep head elevated Give one of the following:

(apply between cheek and gum)

o Tube of cake decorating gel or

o Instant Glucose Gel (15 grams)

o Place insulin pump in suspend or stop

If it is meal time and blood glucose is greater than 60mg/dL…

Send student to lunch.

Wait to bolus immediately after eating within 30 minutes of 1st bite.

Enter the pre meal low blood glucose reading into the insulin pump and amount of carb eaten.

In this situation the insulin pump will adjust the carbohydrate bolus to compensate for the low blood glucose.

DO NOT SKIP INSULIN FOR LOW BLOOD GLUCOSE

If meal time is more than 1 hour away Give student 15 grams

carbohydrates with a protein. Resume Pumping

If meal time is less than 1 hour away follow box

above

Remain with student

Revised 03/06/2015

Is it meal time?

Yes No

Remain with student IMMEDIATELY STOP insulin

pump or SUSPEND Give nothing by mouth Place student on side Give prescribed dose of

Glucagon - refer to prescriber authorization order: ½ mg or 1 mg Intramuscular into thigh as directed by his/her diabetes care provider

Call 911 if student is not responding to glucagon. Follow your school procedure for notifications but ..

Call parent/guardian Call the physician Stay with student until help

arrives


Do not forget to resume

pumping

*Use this “age-specific guide” to insert the appropriate age in the highlighted boxes: 90 = students less than 6 years 80 = students greater than 6 but less than 13 years 70 = students 13 years and greater

Case StudiesCase Studies

Type 2Type 2•Student has Type 2 Diabetes •Able to control their blood sugar levels by managing their weight, eating healthy meals and getting plenty of exercise. However, if not enough…may have been medications that are taken by mouth and/or by injections. These medications are not administered during school hours.

•At times this student may have high blood sugars. High blood sugar (hyperglycemia) in people with diabetes can often cause unusual thirst and the need for frequent urination. If this occurs, he/she will probably need to go to the restroom more often than usual. Please allow him/her the freedom they need on these occasions to do so.

• A balanced intake of milk products, fruits, vegetables, breads and meats is the meal plan Concentrated sweets (candy, sweet rolls, cake, chocolate milk, etc.) should be avoided. Students with diabetes may eat anything on breakfast or lunch trays except desserts and drinks containing sugar. We have encouraged him/her to substitute fresh fruit or fruit packed in natural juice (not syrup) for their dessert.

•Additionally, we have instructed this student to test his/her blood sugar any time he/she is not feeling well. If the student is required to test his/her blood sugar a treatment intervention form will be sent to the school.

•This is considered a minimal standard for safety in the school setting and is covered under the Americans with Disabilities Act.

How Can You Assist Children’s (COA)How Can You Assist Children’s (COA)

All communication to COA must contain name of student and date of birth

Make sure you send glucose readings home. Caregivers need this information when communicating with COA.

It is ok to fax the readings from school; however,

we need all readings

We have a revised fax sheet for families needing assisting

Questions

References:References:

AADE (2011). Diabetes Self-Management. The Art and Science of Disease Self-Management Education Desk Reference;(2) 22-24.

NDEP (2010). Helping the Student with Diabetes Succeed. A Guide for School Personnel.

Pediatrics (2012). Policy statement- Guidance for the Administration of Medication in School. Retrieved from http://pediatrics.aappublications.org/content/124/4/1244.full.html

2015 Safe at School: Medical Management for Children with Diabetes.

Documents

Transcript of 2015 Safe at School: Medical Management for Children with Diabetes.