Glucagon Glucagon AdministrationAdministration

for for Unlicensed Unlicensed Assistive Assistive Personnel Personnel byby

Donna Canfield, RN, BSN, Donna Canfield, RN, BSN, NCSNNCSN

Objective Objective

To provide Clark County School To provide Clark County School Nurses a tool to train unlicensed Nurses a tool to train unlicensed assistive personnel in Glucagon assistive personnel in Glucagon administration in emergency administration in emergency situations (severe hypoglycemia).situations (severe hypoglycemia).

GoalGoal

The key protocol outcome: The key protocol outcome: unlicensed assistive personnel unlicensed assistive personnel will be trained to recognize signs will be trained to recognize signs and symptoms of severe and symptoms of severe hypoglycemia and administer an hypoglycemia and administer an injection of Glucagon in an injection of Glucagon in an emergency situation.emergency situation.

Nevada School Nurse Nevada School Nurse Regulation and Advisory Regulation and Advisory

Opinion Opinion Delegation Delegation

1.The Registered Nurse determines when it is appropriate 1.The Registered Nurse determines when it is appropriate to delegate or assign any portion of the provision of care. to delegate or assign any portion of the provision of care. This delegation/assignment must occur in accordance This delegation/assignment must occur in accordance with the standards of practice outlined in the Nurse with the standards of practice outlined in the Nurse Practice Act and the guidelines of this Advisory Opinion. Practice Act and the guidelines of this Advisory Opinion.

    2.The Registered Nurse School Nurse is solely responsible 2.The Registered Nurse School Nurse is solely responsible

for the determination of when it is appropriate to for the determination of when it is appropriate to delegate or assign nursing care to a qualified person. A delegate or assign nursing care to a qualified person. A "qualified person" is:   "qualified person" is:   a.a. A person whose license/certification authorizes A person whose license/certification authorizes his/her his/her practice; orpractice; or b. A willing person whom the RN School Nurse has b. A willing person whom the RN School Nurse has determined has acquired and/or maintained knowledge, determined has acquired and/or maintained knowledge, skill and ability to perform the care in a safe and effective skill and ability to perform the care in a safe and effective manner required by the child.manner required by the child.

School Nurse Regulation School Nurse Regulation and Advisory Opinion and Advisory Opinion

(cont.)(cont.) 3.3. This definition precludes the automatic This definition precludes the automatic

utilization of the office manager, secretary or utilization of the office manager, secretary or teacher as a qualified person. Only the School teacher as a qualified person. Only the School Nurse may delegate or assign nursing care. The Nurse may delegate or assign nursing care. The School Administrator cannot legally delegate or School Administrator cannot legally delegate or assign nursing care. A Licensed Practical Nurse assign nursing care. A Licensed Practical Nurse providing nursing care in a school may not delegate providing nursing care in a school may not delegate or assign nursing care procedures to school or assign nursing care procedures to school personnel.   personnel.  

4.    A family member/friend, designated or 4.    A family member/friend, designated or identified by the student's parent or legal guardian, identified by the student's parent or legal guardian, is exempt from the regulations of the Nurse is exempt from the regulations of the Nurse Practice Act and, without delegation, training or Practice Act and, without delegation, training or supervision by the school nurse, may perform supervision by the school nurse, may perform required care for the student unless employed by required care for the student unless employed by the school district.the school district.

Medication Administration Medication Administration under the School Nurse under the School Nurse

RegulationsRegulations To administer medications, the School Nurse must To administer medications, the School Nurse must

have written permission from parent/guardian, and have written permission from parent/guardian, and medication must have been prescribed by licensed medication must have been prescribed by licensed prescribing practitioner, labeled and dispensed by prescribing practitioner, labeled and dispensed by licensed dispensing practitioner/pharmacist. licensed dispensing practitioner/pharmacist. Administration must be accompanied by a reliable Administration must be accompanied by a reliable tracking system. tracking system.

The Nevada State Board of Nursing recognizes the The Nevada State Board of Nursing recognizes the administration/assistance with medication is an administration/assistance with medication is an issue of primary concern in school districts. issue of primary concern in school districts. School Nurses/School Districts are referred to the School Nurses/School Districts are referred to the State Board of Pharmacy to work out a suitable State Board of Pharmacy to work out a suitable mechanism for the accomplishment of this task. mechanism for the accomplishment of this task. Any medication procedure developed must meet Any medication procedure developed must meet the standard requirement for the safe the standard requirement for the safe administration/assistance of medications.administration/assistance of medications.

Medication/Procedure Medication/Procedure Administration Under the School Administration Under the School

Nurse Regulations (cont.)Nurse Regulations (cont.)

……The School Nurse may delegate The School Nurse may delegate the Administration of Glucagon the Administration of Glucagon injection kit in emergent injection kit in emergent situation to a “qualified person”.situation to a “qualified person”.

The Basics of The Good The Basics of The Good Samaritan LawSamaritan Law

“Any person who, in good faith, renders emergency medical care or assistance to an injured person at the scene of an accident or other emergency without the expectation of receiving or intending to receive compensation from such injured person for such service, shall not be liable in civil damages for any act or omission, not constituting gross negligence, in the course of such care or assistance.”

Learning ObjectivesLearning Objectives

Participants will learn: Diabetes basic care Symptoms and treatment of

hypoglycemia (low blood glucose) Procedure for the emergency

administration of Glucagon

Diabetes BasicsDiabetes Basics

Diabetes is a disease where the body does not produce insulin or does not use insulin properly.

Insulin is a hormone normally made by the body. It helps glucose (sugar) enter cells where it can be used for energy.

Without insulin, glucose remains in the blood stream and cannot be used for energy by cells.

Diabetic BasicsDiabetic Basics

Children with diabetes must monitor their blood glucose levels.

Safe blood glucose levels are achieved through a careful balance of food intake, exercise and insulin.

Insulin and exercise –may cause low blood glucose Food –may cause high blood glucose Stress, illness or injury-may cause

low or high blood glucose

Diabetes BasicsDiabetes Basics Sometimes, blood glucose levels are too

high resulting in a condition called hyperglycemia.

If this happens, insulin must be administered to lower blood glucose levels. Insulin administration for children with Type 1 Diabetes is essential for survival. Call RN and/or parent if they are unable to give their own insulin!

Sometimes, blood glucose levels drop below the safe range resulting in a condition called hypoglycemia.

Causes of HypoglycemiaCauses of Hypoglycemia

Too much insulin Too little food or delayed meal or

snack Extra physical activity Illness Medications May occur for no apparent reason

Signs/Symptoms of Signs/Symptoms of HypoglycemiaHypoglycemia

Symptoms of hypoglycemia can range from mild to severe, and include any or all of the following:

•Mild SymptomsHungerSweating

Feeling shaky Feeling nervous•Moderate Symptoms Headache

Behavior changes Blurred, impaired or double vision

Crabbiness or confusionDrowsinessWeaknessDifficulty talking

Signs/Symptoms of Signs/Symptoms of Hypoglycemia (cont.)Hypoglycemia (cont.)

Severe Hypoglycemia Unresponsive (i.e. unable or unwilling

to take oral feeding)

Loss of consciousness Convulsions (seizure activity)

It is important to note that the symptoms of hypoglycemia may vary from person to

person; a given individual may not experience all of these symptoms in the order they are listed.

Seriousness of Seriousness of HypoglycemiaHypoglycemia

Hypoglycemia poses the most immediate risk to a student with diabetes because onset is sudden, it is not always preventable, and may progress to unconsciousness

If person is unresponsive (breathing or pulse are absent) call 9-1-1 and

initiate cardiopulmonary resuscitation (CPR.)

What to do next….What to do next….

1. If breathing and pulse are present, assume the person with diabetes is having severe hypoglycemia. DO NOT give any food or liquid to a person who cannot swallow or is unconscious/unresponsive.

2. Delegate someone to call 9-1-1 or other emergency response system. (If the person is unwilling or unable to take oral feeding, unresponsive or unconscious.)

If possible, also have someone call the affected person’s parent/RN/Health Care Provider.

What to do next (cont.)What to do next (cont.) 3. OBTAIN GLUCAGON EMERGENCY KIT

and check person’s name against kit. Verify any special physician

instructions including correct dosage. NOTE: BRING supplies to the person, do not move the person. Time is critical for administering treatment to ensure recovery.

4. PREPARE AND ADMINISTER Glucagon for injection.

5. If student has Insulin Pump, clamp the tubing so they are not receiving insulin.

What is Glucagon?What is Glucagon?

Glucagon is a hormone produced in Glucagon is a hormone produced in the pancreas. It increases blood sugar the pancreas. It increases blood sugar levels.levels.

Glucagon is used to treat insulin coma Glucagon is used to treat insulin coma or insulin reaction resulting from or insulin reaction resulting from severe hypoglycemia (low blood sugar).severe hypoglycemia (low blood sugar).

For more information about Glucagon, For more information about Glucagon, see see http://www.cigna.com/healthinfo/d0059http://www.cigna.com/healthinfo/d00593a1.html3a1.html

Glucagon Emergency KitGlucagon Emergency Kit

Emergency Kit Contains:

1 mg. of freeze-dried Glucagon 1 mg. of freeze-dried Glucagon (vial)(vial)

1 ml. water for reconstitution 1 ml. water for reconstitution (syringe)(syringe)

PreparationPreparationof Glucagon Injectionof Glucagon Injection

1. Flip cap off glass vial containing dry powder2. Remove cap from syringe

Mixing the Glucagon Mixing the Glucagon SolutionSolution

3. Inject entire fluid in syringe into the bottle containing powder

Mixing Glucagon SolutionMixing Glucagon Solution(cont.)(cont.)

4. Shake gently or roll to 4. Shake gently or roll to mix until all powder is mix until all powder is dissolved and solution dissolved and solution is is

clear.clear.

Drawing Out the Drawing Out the SolutionSolution

5. Inspect. Solution should be 5. Inspect. Solution should be clear and colorless. clear and colorless.

6. Draw prescribed6. Draw prescribed

amount of Glucagonamount of Glucagon

back into the syringe.back into the syringe.

Dosing and InjectingDosing and Injecting

7. Put on gloves.7. Put on gloves.

8. Clean site with alcohol swab if 8. Clean site with alcohol swab if possible. possible.

9. Inject at 909. Inject at 90° into the tissue ° into the tissue under cleansed area under cleansed area buttocks buttocks thighthigh armarm

Injecting Glucagon Injecting Glucagon (cont.)(cont.)

Withdraw needle, then apply light pressure at injection site. Discard needle into a sharps container or, if unavailable, back into its case.

Do not recap needle.

After Injecting GlucagonAfter Injecting Glucagon

It may take 10-15 minutes for the student to regain consciousness.

Vomiting may occur -keep the student positioned on side to prevent choking.

Next StepsNext Steps

• Once the student is awake and able to drink, give sips of fruit juice or regular soda and advance diet as tolerated.

• Remain with the student until emergency medical services assumes control. The student should not resume normal activities.

• Notify appropriate parties of incident details and attend debriefing meeting with school nurse. School nurse will document incident in appropriate health records.

Don’t Be Surprised If…Don’t Be Surprised If…

The student does not remember being unconscious or is incoherent or lethargic.

The student feels nauseated, vomits, or has a headache.

Video reviewVideo review

<I plan to insert the video from <I plan to insert the video from CostalCostal

(Glucagon injection portion only) at (Glucagon injection portion only) at thisthis

time to re-emphasize and re-teach thetime to re-emphasize and re-teach the

actual preparation and injection ofactual preparation and injection of

Glucagon and then have a practice Glucagon and then have a practice session with the UAP’s using the session with the UAP’s using the ‘demos’ from the Lily company>‘demos’ from the Lily company>

Quick ReviewQuick Review

Mild to moderate hypoglycemia can be treated with a quick acting source of carbohydrate (15 grams).

Signs of severe hypoglycemia include:

Unconsciousness Seizures Inability to swallow

Quick Review (cont.)Quick Review (cont.)

Severe hypoglycemia is a medical emergency requiring immediate administration of Glucagon.

Treat, then follow the district policy for medical emergency care.

ReferencesReferences Cigna. (2005). Cigna. (2005). Glucagon Glucagon [Brochure]. Retrieved from [Brochure]. Retrieved from

http://cigna.com/healthinfo/d00593a1.htmlhttp://cigna.com/healthinfo/d00593a1.html Drugsite Trust. (2006). Drugsite Trust. (2006). Glucagon Glucagon [Fact sheet]. Retrieved from [Fact sheet]. Retrieved from

http://www.drugs.com/pro/glucagon.htmlhttp://www.drugs.com/pro/glucagon.html Eli Lilly and Company. (2004). Eli Lilly and Company. (2004). Glucagon for Injection Vials and Glucagon for Injection Vials and

Emergency Kit Emergency Kit [Brochure]. Retrieved from [Brochure]. Retrieved from http://www.theodora.com/drugs/glucagon_for_ http://www.theodora.com/drugs/glucagon_for_ injection_vials_and_emergency_kit_lilly.htmlinjection_vials_and_emergency_kit_lilly.html

Eli Lilly and Company. (2008). Eli Lilly and Company. (2008). Understanding Glucagon Understanding Glucagon [Fact [Fact sheet]. Retrieved sheet]. Retrieved from from http://www.humalog.com/patient/hypoglycemia_treatment.jsphttp://www.humalog.com/patient/hypoglycemia_treatment.jsp

Gursky, B. S., & Ryser, B. J. (2007, April). A Training Program Gursky, B. S., & Ryser, B. J. (2007, April). A Training Program for Unlicensed for Unlicensed Assistive Personnel. Assistive Personnel. Journal of School Journal of School NursingNursing, , 2323, 92-97., 92-97.

McKesson Corporation. (2006). McKesson Corporation. (2006). Diabetes: Glucagon Injections Diabetes: Glucagon Injections [Fact sheet]. [Fact sheet]. Retrieved from Retrieved from http://med.umich.edu/1libr/pa/pa_glucagon_hhg.htmhttp://med.umich.edu/1libr/pa/pa_glucagon_hhg.htm

Nevada School Nurse Regulation and Advisory Opinion, Nevada Nevada School Nurse Regulation and Advisory Opinion, Nevada Administrative Code § 632.226 (2000).Administrative Code § 632.226 (2000).