Hands on Guidance for Diabetic Care The following is designed for competency in providing care for Diabetics. McDowell County School System Reviewed July 6, 2009 Revised July 6, 2009
Diabetes in America
It is estimated that approximately 125,000 people under the age of 19 are diabetic.
It is a rising health concern in the US possibly due to our decrease in activity as well as the increase of food comsumption, increased weight levels and high intake of processed sugars.
Years ago, school systems rarely had to deal with students that were diabetic. Today in almost every school there is a student with this need.
Because of this, it is important that all staff be informed on how to handle diabetic needs if they should arise during the day.
The following presentation will discuss:
Laws governing diabetes in schools
What diabetes is
What can be seen with both high and low
How to handle these situations as they arise.
Federal laws that protect children with diabetes include the Rehabilitation Act of 1973, Section 504, the Individuals with Disabilities Education Act of 1991, and the Americans with Disabilities Act of 1992. Under these laws, diabetes has been determined to be a disability, and it is illegal for schools and/or day care centers to discriminate against children with diabetes.
Any school that receives federal funding or any facility considered open to the public must reasonably accommodate the special needs of children with diabetes. The required accommodations should be provided within the child's usual school setting with as little disruptions to the school's and the child's routine as possible and allowing the child full participation in all school activities. Federal law requires an individualized assessment of any child with diabetes
It is important to remember that all diabetic concerns need to be treated as a potentially life threatening situation.
If a student asks to leave because of their concerns related to diabetes, this must always be granted.
They may need to check their sugar levels at any time. Snacks may be needed in class to increase their sugar levels. They may need to go to the bathroom often or need to get water or keep water at their desk. All these should be allowed on an as need basis.
But if these occur on a regular basis, then it is important you make your school nurse aware of this. They will then need to set up a meeting with the student and parent to see what if any changes may need to be made in maintence care.
What is Diabetes?
In Diabetes the body does not make or properly use insulin.
Insulin is needed to move glucose from the blood to the cells for them to use as energy.
If Insulin isn’t working, high blood glucose can result in:
Energy levels being low.
People with diabetes have increased blood glucose (sugar) levels for one or more of the following three reasons: Either
Little or no insulin is being produced,
Insulin production is insufficient, and/or
The body is resistant to the effects of insulin
As a result, high levels of glucose build up in the blood, and spill into the urine and out of the body. The body loses its main source of fuel and cells are deprived of glucose, a needed source of energy.
High blood glucose levels may result in short and long term complications over time.
There are 2 Types of Diabetes
Type 1 Diabetes
Type 1 diabetes is an auto-immune disorder. In type 1 diabetes, the immune system attacks the beta cells, the insulin-producing cells of the pancreas, and destroys them.
The pancreas can no longer produce insulin, so people with type 1 diabetes need multiple daily administrations of insulin to live.
Type 1 diabetes can occur at any age, but the disease develops most often in children and young adults.
Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States.
Type 2 Diabetes
Type 2 diabetes is the most common form of diabetes. In type 2 diabetes, either the body does not produce enough insulin or the cells ignore the insulin, a condition called insulin resistance.
With insulin resistance the body needs increasing amounts of insulin to control blood glucose, but sometimes cannot make enough.
Type 2 diabetes use to be found mainly in adults who were overweight and over age 40. Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people.
Diabetes is Managed but Does Not Go Away
Diabetes is managed with medication, nutrition, physical activity and glucose monitoring, but there is NO cure
Care needed at School will vary with each student.
Many students will be able to handle all or almost all of their routine diabetes care by themselves – they can check their own blood glucose, and they can dose and give their own insulin or medication, keeping it in balance with physical activity and food intake.
Some students, because of age, developmental level, or inexperience, will need help from school staff, including performing tasks like insulin administration, blood glucose monitoring, or carbohydrate counting.
ALL students with diabetes will need help in the event of an emergency situation.
The level of care and assistance will be outlined in the Diabetes Medical Management Plan (DMMP) agreed upon by the health care provider, parent/guardian, school nurse and student.
Hypoglycemia or “lows” occur whenever there is too much insulin in the body for the amount of glucose.
This imbalance can happen for these possible reasons:
Too much insulin has been administered
Too little food has been eaten
Extra/unanticipated physical activity
The following will give you examples of things to look for with the students throughout the day. These will not all be seen with each student.
Mild “Low” Symptoms May Include:
Increased heart rate/palpitations
Medium “Low” may exhibit:
Inability to swallow
Unconsciousness/coma jerking movements
Severe “Low” May show:
Loss of Consciousness
Inability to Swallow
Intervene promptly when hypoglycemia is mild/moderate to prevent the progression to severe symptoms
LOW BLOOD SUGAR
To treat low blood sugar the 15/15 rule is usually applied. Eat or drink 15 grams of carbohydrate and wait 15 minutes. The following foods will provide about 15 grams of carbohydrate:
Half cup (4 ounces) of fruit juice or regular soda
3 glucose tablets
1 small tube prepared cake icing
1 tablespoon of sugar
6 or 7 hard candies
After the carbohydrate is eaten, the person should wait about 15 minutes for the sugar to get into their blood. If the person does not feel better within 15 minutes more carbohydrate can be consumed. Their blood sugar should be checked to make sure it has come within a safe range.
When student is able, Long Acting Sugars should be given after short acting sugars to maintain blood glucose levels. Items such as a Ham (meat) or Cheese Sandwich or Peanut Butter or Cheese Crackers need to be given when student can tolerate them. This will help to maintain their sugar level.
Hyperglycemia or “highs” occur whenever there is too much blood glucose in the blood and for some reason is not being totally used by the body.
This imbalance can happen for these possible reasons:
Not enough insulin has been administered (late, missed or too little)
Too much food has been eaten
Less physical activity
Hormone Changes (puberty)
The following will give you examples of things to look for with the students throughout the day. These will not all be seen with each student
Mild “high” may exhibit
Lack of concentration
Sweet, fruity breath
Flushing of skin
Medium “high” may show
Sweet, fruity breath
Severe “high” may show
How to prevent “highs”
Timing is very important. Stick to schedules for meals, blood sugar monitoring, insulin dosages and amounts of physical activity.
Accuracy in the amounts of insulin given versus food intake.
Any changes made to these can only happen after consultation with parent/guardian or nurse.
Why do I need to know anything else?
Many of our students go with staff on off campus activities or are in classrooms or other areas on campus far from the office.
Because of the need for immediate care , all staff should be able to check glucose levels, give fast acting sugars and give insulin if needed.
The following slides will provide the imformation needed to be able to provide this care.
Checking Blood Sugar Levels
Checking blood sugar levels is fairly easy to understand if you follow these basic steps.
Gather supplies and prepare your equipment.
Get a good drop of blood for the sample.
Make sure to follow instructions for placement of blood droplet.
Know the machine and what the reading means.
Know the Care Plan for each student and follow as directed.
Preparing the Glucometer
Using a typical glucometer and lancing device, the sampling and measurement process is generally as follows.
First, the user prepares the meter for use by removing a test strip from a protective wrapper (fig 1) or vial and inserting it in to the meter (fig 2). Be sure to insert as directed. The area for the blood droplet must be outside the meter.
Ready or Not?
The glucometer may confirm the proper placement of the test strip and indicate that it is prepared for a sample.
Most glucometers will be blank until the strip is inserted. It will then have some type of reading if inserted correctly. Many times it may read OK or blink letting you know to proceed.
Preparing the Lancet (or needle)
The user prepares the needle or lancing device by removing a cap from the device (fig 1), placing a disposable needle in the lancing device (fig 2), removing the needle safety cover, replacing the cap, and setting a spring-like mechanism that provides the force to drive the needle or lancet into the skin.
These steps may happen simultaneously (e.g., typical lancing devices set their spring mechanisms when one installs the lancet).
Sticking the Finger.
The user then uses an alcohol swab to cleanse the site for the needle. Place the lancing device on the finger. After positioning the device on the finger, press a button or switch on the device to release the lancet. The spring drives the lancet forward, creating a small wound.
After lancing, a small droplet of blood appears at the lancing site
Applying the blood to the strip
If an adequate drop of blood is available, place the sample of blood on a test strip according to manufacturer's instructions. Different strips will apply blood differently. You will either let the drop of blood fall onto the center of the strip or hold the drop of blood at the end of the strip where it will be drawn into the strip for reading (see figure). Ask the nurse if you have any questions.
The meter then measures the blood glucose concentration
The Read Out What Do I Do Now?
Depending on the reading from the glucometer you will do one of four things.
Readings of high, low or error will need to be checked again.
If the reading is within normal limits for the student and it is not meal time, no action will be taken. If this is before lunch insulin still may be needed with normal limits to compensate for the carbohydrates the student will be consuming.
If the reading is high then insulin will need to be given according to their care plan.
If the reading is low some type of fast-acting sugar will need to be given (this will be discussed later on). A slow-acting sugar/protein will need to be given afterwards to maintain the level.
Always recheck the sugar level within 15 to 30 minutes after treating a high or low, to make sure the sugar levels are returning to normal.
Devices for insulin injections
INSULIN has to be given by injection into the fat layer under the skin (subcutaneous injection). Injections can be given by:
These are available in various sizes (25 30 50 and 100 unit) depending on the dose required and available with two different length needles (12.7 mm and 8 mm).
Your nurse will advise which syringe is best for each student but in general the smallest syringe that will hold the required dose is best for accuracy and 8 mm needles are generally more suitable for children and small infants.
Insulin syringes are disposable and made for single use only. Syringes pens or insulin vials must never be shared with another person because of the risk of spreading serious diseases such as hepatitis or HIV.
How to Give an Insulin Injection Using an Insulin Syringe
Checking the insulin before drawing it up.
The vial or cartridge of insulin should be checked before each use for:
The expiration date.
The date you opened the insulin cartridge or bottle (write this on the bottle when you open it).
The name of student on bottle with directions.
Are you giving the correct amount of the right insulin ? If the insulin’s look similar mark them clearly so you can easily tell the one with the long—acting insulin from the short—acting insulin.
Short—acting insulin must look clear like water (discard if it looks cloudy).
Long—acting insulin must look milky or cloudy after gentle mixing.
If the insulin contains lumps or flakes or sticks to the glass it should not be used.
Drawing Up Insulin
You will need 3 things to draw up the insulin, alcohol pad(s), the insulin itself and a disposable needle.
Using an alcohol pad wipe down the rubber top of the bottle and let dry.
Pull back the plunger of the syringe to the number amount to be given.
Push the needle into the bottle and insert the air into the bottle.
Hold the bottle up so the needle is in the fluids and pull out the correct amount of insulin to be given. You can pull out a little bit more so to be able to level off before giving.
The abdomen (tummy) is the preferred site of injection because insulin is absorbed more quickly and uniformly from the abdomen and the abdomen is less affected by exercise than other sites.
In general, insulin absorption is quickest from the abdomen, followed by the arms, buttocks and thighs.
Injections in the arms are generally not recommended in small children who have only a thin layer of fatty tissue beneath the skin here. It is easy for the insulin injection to go too deep and end up in the muscle and be absorbed too fast.
Injection sites will vary, discuss with your nurse sites for each student.
To give an injection:
Draw up insulin as described above.
Take a pinch of skin with the index finger and thumb, the pinch needs to be at least to the depth of the needle.
Insert the needle straight into the pinched up skin (i.e. at 90 degrees) to its full length and push the plunger slowly all the way down to push in the insulin. In very lean individuals, injecting at a 45 degree angle to the skin may be necessary to avoid the injection going too deep.
Let go of the skin and leave the needle in for 5 to 10 seconds, then gradually pull out the needle.
Insulin pens can be helpful if you want the convenience of carrying insulin with you in a discreet way. An insulin pen looks like a pen with a cartridge (fig.1). Some of these devices use replaceable cartridges of insulin; other pen models are totally disposable. A short, fine needle, similar to the needle on an insulin syringe, is on the tip of the pen (fig. 2). Users turn a dial to select the desired dose of insulin, inserts needle as described before and press a plunger on the end to deliver the insulin just under the skin.
One significant advantage of pens is their ease of use.
How to Use an Insulin Pen
Screw on a new needle.
If necessary, prime the pen to remove any air from the pen by setting on 1 unit and pushing button.
Reset pen by turning the knob on the end of the pen (or "dial") to the number of units needed.
Alcohol skin and inject the needle under the skin as directed above.
Press the button on the end of the pen and hold till completed. Count to five.
Remove and dispose of needle.
External insulin pumps are devices that deliver insulin through narrow, flexible plastic tubing that ends with a needle inserted just under the skin near the abdomen. The insulin pump is about the size of a deck of cards, weighs about 3 ounces, and can be worn on a belt or carried in a pocket. Users set the pump to give a steady trickle or "basal" amount of insulin continuously throughout the day. Pumps release "bolus" doses of insulin (several units at a time) at meals and at times when blood glucose is too high based on the programming set entered by the user. They also can be programmed to release smaller amounts of insulin throughout the day. Frequent blood glucose monitoring is essential to determine insulin dosages and to ensure that insulin is delivered.
Disposal of syringes and pen needles
USED syringes and pen needles should be placed in an approved sharps container which needs to be kept out of reach of children. These can be obtained from your school nurse. When full these sharps containers need to be properly disposed of. Do not place syringes or pen needles in anything other than an approved sharps container.
Needles syringes pens insulin cartridges and insulin bottles should never be shared with others because of the possible risk of contamination and spread of infection.
Mistakes with insulin doses
It is important to be concentrating and unhurried at insulin injection times but occasionally a mistake will occur with an insulin dose. Provided the mistake is recognized appropriate adjustments are usually easily made. If you are not sure how to compensate or it is a major mistake contact your nurse or diabetes specialist or parent/doctor for advice without delay.
Errors in insulin doses can be dealt with by thinking about has the insulin been given in too large or too small a dose and how long the insulin will act.
If the mistake has been to give too much insulin test the blood glucose more frequently and give extra carbohydrate.
If the mistake has been to give too little insulin test the blood glucose more frequently and compensate with extra small doses of short—acting insulin.
Mistakes can happen to anyone. It is very important though that you report them to the proper authority.
My student wants to give their injection through their clothes when they are out in the class so as not to be embarrassed by lifting up their clothing. Will this cause problems?
Although this is not the best practice and cannot be generally recommended, it is better to have the injection through the clothes than to avoid it because of embarrassment. A number of studies have shown no harm from injecting insulin through clean clothing.
Should I move to a completely different injection site every day?
Insulin is absorbed differently from different areas of the body. The abdomen (tummy) is the best injection site and many use this for all injections, but some students prefer to use other areas. It is best to give the injection at different sites to keep the area healthy
Are insulin pens better than syringes?
Both pens and syringes give a dose of insulin just as well. Some people prefer pens for convenience, especially when on three or four injections a day. Students may like the convenience and cleanliness of carrying the pen in school.
What to do when a diabetic person is unconscious
REMAIN CALM. You can do this!
Act Quickly/ Prolonged unconsciousness may be harmful and blood glucose can continue to drop quickly even over a matter of minutes.
YELL specifically for someone by name (or point and say ‘You”) to call 911, don’t just randomly say “someone” call 911
As stated before, milder cases of hypoglycemia can be treated by giving sugars by mouth, don’t wait because the person can lose consciousness in a matter of minutes.
Give Glucagon if:
The person is unconscious or
The person is unable to eat sugar or a sugar-sweetened product or
The person is having a seizure or convulsion or
Repeated administration of sugar or sugar-sweetened product does not improve the patient’s condition.
Remember that Glucagons will only work when injected under the skin into muscle or into fatty tissue.
**Students or staff MUST have a doctors order on file to give glucagon.
How to prepare Glucagons for Injection
The contents of the syringe are inactive. You must mix the contents of the syringe with the glucagons in the accompanying bottle before giving injection.
Do not prepare Glucagons for injection until you are ready to use it.
Turn the patient on his/her side to prevent patient from choking while preparing.
How to Mix Glucagon
1. Remove the flip-off seal from the bottle of glucagon. Wipe rubber stopper on bottle with alcohol swab.
2. Remove the needle protector from the syringe. Do not remove the plastic clip from the syringe.
3. Inject the entire contents of the syringe into the bottle of glucagon.
4. Remove syringe from the bottle.
5. Swirl bottle gently until glucagon dissolves completely
How to Draw up Glucagon
USING THE SAME SYRINGE, HOLD BOTTLE UPSIDE DOWN AND MAKING SURE THE NEEDLE TIP REMAINS IN SOLUTION.
Gently withdraw all of the solution (1mg mark on syringe) from bottle
The plastic clip on the syringe will prevent the rubber stopper from being pulled out of the syringe; however, if the plastic plunger rod separates from the rubber stopper, simply reinsert the rod by turning clockwise.
The usual adult dose is 1 mg (1 unit). For children weighing less that 44 lb (20 kg), give ½ adult dose (0.5mg).
For children, withdraw ½ of the solution from the bottle to the 0.5 mg mark on the syringe or as directed.
How to Give Glucagon
Inject glucagon the same way the you inject insulin. You can inject into the fat or muscle (fat is preferred, but don’t worry-just get it under the skin), THERE IS NO DANGER OF OVERDOSE.
Using the following directions, inject glucagon IMMEDIATELY after mixing:
Cleanse injection site on buttock, arm or thigh with alcohol swab.
Insert the needle into the loose tissue under the cleanses injection site, and inject all of the solution. Inject just as you would insulin.
Apply light pressure at the injection site, and withdraw the needle. Press an alcohol swab against the injection site.
Turn the patient on his/her side. When an unconscious person awakens, he /she may vomit. Turning the patient on their side will prevent them from choking.
Call 911 and parent or guardian, but don’t leave the person alone if at all possible.
Feed the person as soon as they awaken and is able to swallow. Give them a fast-acting source of sugar (such as a regular soft drink or fruit juice) and a long-acting source of sugar (such as crackers and cheese/peanut butter or a meat sandwich).
If the person does not awaken within 15 minutes, give another dose of glucagon if available and if the paramedics have not arrived yet.
A doctor should always be notified whenever severe hypoglycemic reactions occur.
Some students will need to have ketones checked if their sugar levels a very high.
This is a simple technique.
Along with their supplies will be a bottle of testing strips.
The student will take the strip to the bathroom and will urinate on the strip.
Glove up your hands because the student not be able to read the strip and bring it to you the strip to read.
Follow the directions on the bottle to read level of ketones by matching the color from the strip to the colors on the bottle.
Return to the students Care plan to see what actions need to be taken at that time.
If Ketones are checked during the day, be sure to let the parent know.
Where Do I Go For Questions?
Your school has several people that can answer any questions you may have.
The school nurse or your diabetic specialist is always available.
Your students parents or physician can also answer questions and be a guidance in any situation.
Key points for diabetes management are:
Insulin therapy: This is required to replace the insulin that the body cannot make. Insulin has to be given by injection into the fat layer under the skin (subcutaneous). It cannot be given by tablets, since digestion destroys the insulin.
A food plan: A healthy food plan and a regular intake of carbohydrates is required to balance the insulin that is given by injection.
Exercise: Exercise and being active are part of a healthy lifestyle. It is important to understand how exercise affects diabetes.
Education and knowledge: There is a lot to learn about diabetes to keep it in good control. This learning is an ongoing process.
In Service Competency
Please take time to answer questions related to Diabetes Care In-service. This is required for your yearly training. Return test to School Nurse when completed. Be sure to sign and date.
In-service and testing must be within the first two (2) weeks of school starting.
Staff responsible for diabetic care, will also have to demostrate to the nurse competencies in administration of the information given.
Thanks for your cooperation.
American Diabetes Association: www.diabetes.org/advocacy-and-legalresources/discrimination/schools.jsp