Diabetes Update for School Nurses

1. Arkansas Children’s Hospital Jennifer Sellers, RN,CDE Lisa Still, RN,CDE July 2007 Diabetes Update for School Nurses

2. Diabetes: Type I • Type I diabetes occurs when the pancreas stops producing insulin or is producing very little in sporadic amounts. • People with type I diabetes must take insulin and it is a life long condition. • Type I diabetes generally occurs with in the pediatric population.

3. Type ll • Type II diabetes occurs when the pancreas does not produce enough insulin to keep up with the demands of the body or the cells cannot properly use the insulin that is being produced. • People with type ll diabetes can often be treated with diet, exercise and oral medication. We do however start many on insulin and gradually stop or decrease the dosage. • Type ll diabetes most often occurs when individuals are overweight. In the past, type ll diabetes was limited to adults but we are seeing an increase in the number of children with type ll diabetes. most of the media attention is given to type ll diabetes.

4. Prevalence • In 2005 there were 20.8 Million people with diabetes. (1) • Diabetes is one of the most common chronic diseases among children. (2) • 176,500 people with diabetes are under the age of 20. (2) • 1 in every 400-600 people under age 20 have diabetes. (2) • Each year more than 13,000 young people are diagnosed with Type 1 diabetes. (2)

5. Prevalence at ACH • In 2005 we had 97 newly diagnosed diabetics. • In 2006 we had 135 newly diagnosed diabetics. • As of May 31,2007 we have had 75 newly diagnosed diabetics.

6. Importance of school nurse • The school nurse is vital in the management of children with diabetes. • School nurses are being asked to do more procedures for more students with less staff.

7. Duties • With diabetes they are asked to help children with blood glucose monitoring and recording results, oversee carbohydrate counting and calculate how much insulin is needed, check urine for ketones, treat low blood sugar episodes and on occasion administer glucagon. • Children spend 7 hours a day 5 days a week at school. ( some may spend more with before and after school care) that is an average of 35 hours per week these children need someone to oversee and assist them with their diabetes management. YOU ARE VITAL!

8. Headache irritability confusion sweating Weakness rapid heart rate shakiness personality changes Symptoms of Hypoglycemia

9. Causes of Hypoglycemia • Skipped meals or snacks. • Extra or prolonged exercise without extra food. • Too much insulin. • Mistake in drawing up insulin dose.

10. Treatment of Hypoglycemia • Treat any blood sugar below 70. • For seizure or unconsciousness, use Glucagon Emergency Kit as prescribed.

11. “Rule of 15” • If blood sugar is below 70 • Give 15 gm fast acting carbohydrate. • Wait 15 minutes and recheck blood sugar. • If blood sugar is still <70, retreat with 15 gm fast acting carbohydrate and recheck in 15 minutes. • Once blood sugar is corrected, give small snack or regularly scheduled meal within 30 minutes. • If blood sugar immediately prior to lunch is below 70, follow rule of 15 before sending child to lunch.

12. Examples of 15 gm Fast Acting Carbohydrate • 4 ounces juice or regular soda • 3 glucose tablets • 1 tube glucose gel or cake icing gel • 1 tablespoon honey or corn syrup • 3 sugar packets • 2 rolls smarties candies

13. Symptoms of Hyperglycemia • thirstiness • fatigue • headache • frequent urination • Personality change • Irritability • nausea

14. Causes of Hyperglycemia • overeating • illness • not taking enough insulin or missing a shot • decreased exercise • stress • using insulin that is older then 30 days or that has been exposed to extreme heat or freezing temperatures

15. Remember to Check Ketones When: • Blood sugar is >240 • Illness ( cold, bladder infection etc) • Vomiting Ketones will cause the breath to smell fruity and usually causes nausea.

16. If the child has ketones: • If ketones are moderate to large, call the parents. • If ketones are trace to small, drink 8 oz. of water every hour. Recheck in 2 hours.

17. If Ketones are present • Remove child from physical activity • Encourage fluids (8 ounces of sugar free fluid every hour) no milk, juice or gatorade • Notify parents

18. Points to Remember • If student acting out of character or unable to concentrate, check blood sugar. • Hypo/hyperglycemia can both be seen this way • Always use the buddy system when student is going to the office to check for hypoglycemia. • If in doubt, contact the parents for other questions and concerns.

19. Insulin Short-acting (Regular) onset 30-60 minutes maximum effect 2-3 hours duration up to 12 hours Intermediate-acting (NPH) onset 1.5-4 hours maximum effect 4-12 hours duration up to 24 hours This insulin regimen requires three shots a day and is very limited in flexibility. These shots must be taken about the same time of day (before breakfast, before evening meal and at bedtime). The child using this insulin regimen must eat the prescribed amount of carbohydrates at about the same time every day.

20. Insulin Rapid-acting (Humalog, Novolog) onset 15 minutes maximum effect 30-90 minutes duration 3-5 hours Long-acting (Lantus) onset 1-2 hours maximum effect flat duration 24 hours This insulin regimen is a basal/bolus or meal based regimen also called MDI. Using this regimen requires the use of carbohydrate counting and matching insulin to carbohydrates eaten. This regimen also requires at least four shots per day (before each meal and bedtime). This regimen is more flexible in the amount of food and timing of meals.

21. Pen devices • Many children that use lantus/log regimen use insulin pens to administer their insulin

22. Meals • Children that utilize a NPH/Regular insulin regimen will have a set meal plan that usually consist of 3 meals and 2 or 3 snacks. The snacks must be given regardless of the blood sugar. • Children that are using a lantus/log regimen are not required to eat a set meal pattern, therefore snacks are not required. • Both regimen groups must count carbohydrates to keep their blood sugar readings in check.

23. General School Lunch Guidelines • Most children can eat the regular school lunch. • Some children will require additional snacks, according to their individual meal plan. • Follow the meal/snack times and carbohydrate amounts listed in the individual meal plan. • Children with type 2 diabetes will also require portion limits for fat and protein.

24. Carbohydrate Counting • Calories in food come from carbohydrate, protein, and fat. • Carbohydrates have the biggest effect on blood sugars. Protein and fat have much less of an effect. • Carbohydrates are bread, cereal, rice, pasta, fruit, vegetables, potatoes, chips, crackers, milk, yogurt, desserts, candy, and sugar.

25. How Do You Count Carbs? • The food label will tell you how many grams of carbohydrate are in a serving of that food. • Most kids will count grams of carbohydrate (i.e. 60 gm carbohydrate at a meal)

26. Food Labels • Focus on 2 things: total carbohydrate and serving size. • If counting grams, add up the amount until you get w/in 5 gms of the target.

27. What About Protein? • Protein foods include meat, peanut butter, cheese, cottage cheese, eggs, and nuts. • Unless protein is breaded (i.e. chicken nuggets), do not count carbs for it.

28. What About Fat? • Fats include foods such as oils, butter, margarine, mayo, sour cream, etc. • We do not count carbs for fat foods.

29. What About Sweets? • Sweets are carbohydrates and must be counted as carbs in the meal plan. • Limit sweets to 1 per day.

30. Free Foods • Free foods have less than 20 calories per serving. • Examples are sugar free jello, dill pickles, and sugar free popsicles.

31. Meal Plan for Type 1 Diabetes

32. Meal Plan for Type 2 Diabetes

33. Meal based insulin • People that are using lantus/log insulin regimen must calculate the amount of carbohydrates they are eating then calculate how much insulin to give based on the grams of carbohydrate.

34. Meal Bolus • Ham & cheese sandwich 30gms • Medium orange 15gms • 8 oz. Whole milk 12gms 57 gms If ratio for meal bolus is: 1unit of insulin per 15gms carbohydrate 3.8 unit meal bolus

35. Correction bolus • Children on lantus/log are also instructed to calculate a bolus of insulin to be given with meals only to correct a high blood sugar. • Once the correction bolus is calculated, you add the correction bolus to the meal bolus and give as one injection.

36. High Bolus or Correction Bolus • Formula utilized to bring patient back to target Blood Glucose Actual Blood sugar – target= correction bolus insulin sensitivity 231-target of 120= 1112.2 units of insulin 50 50

37. Calculate bolus • Ham & cheese sandwich 30gms • Medium orange 15gms • 8 oz. Whole milk 12gms 57 gms If ratio for meal bolus is: 1unit of insulin per 15gms carbohydrate 3.8 unit meal bolus • _____________________________________________ • Formula utilized to bring patient back to target Blood Glucose Actual Blood sugar – target=correction bolus insulin sensitivity s231-target of 120= 111 = 2.2 unit 50 50 • 3.8 unit meal bolus +2.2 correction bolus ___________ 6 unit total bolus

38. Pump or CSII (Continuous Sub-cutaneous Insulin Infusion) • Continuous Subcutaneous Insulin Infusion • Subcutaneous delivery of insulin via external electro-mechanical device. Delivery regimen mimics the basal/bolus delivery pattern of a pancreas

39. CSII • Delivery is extremely precise. • Pump accurately delivers doses down to 0.05 unit of insulin • REMEMBER. . .. • The Insulin Pump is a computer. • It can only do what the user tells it to do. • Requires decisions from user. • User requires Blood glucose data and carbohydrate content to make good decisions

40. INSULIN PUMP THERAPY -- PAST

41. Pumps

42. Infusion sets

44. BASAL RATE: • Continuous precision “drip” of insulin given over a 24 hour periods. • Pump can be programmed to change its basal rate to accommodate predictable daily changes in insulin requirements

45. BOLUS • Bolus is not automatic. . .. • Patient determines bolus amount Based on: - Blood sugar - Carbohydrates in Meal or Snack

46. Calculate bolus • Ham & cheese sandwich 30gms • Medium orange 15gms • 8 oz. Whole milk 12gms 57 gms If ratio for meal bolus is: 1unit of insulin per 15gms carbohydrate 3.8 unit meal bolus • _____________________________________________ • Formula utilized to bring patient back to target Blood Glucose Actual Blood sugar – target=correction bolus insulin sensitivity s231-target of 120= 111 = 2.2 unit 50 50 • 3.8 unit meal bolus +2.2 correction bolus ___________ 6 unit total bolus

47. Nurse’s role with a pump • Assist child in counting carbohydrates. • Assist child in calculating bolus for meal and correction. • Verify amount of bolus on pump before delivery. • It may be necessary with very young children for the nurse to actually push the buttons on the pump to set the bolus.

48. Resources • American Diabetes Association, www.diabetes.org • Children with Diabetes, www.childrenwithdiabetes.com • Juvenile Diabetes and Research Foundation, www.jdrf.org • Animas Corporation, www.animascorp.com • Medtronic Minimed www.minimed.com • National Diabetes Education Program www.ndep.nih.gov

49. Bibliography • 1 National Diabetes Information Clearinghouse http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm • 2 National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/diabetes/pubs/factsheets/search.htm • 3 The slides that show the insulin pump were obtained From Tracy Garstka Diabetes Nurse Specialist for Medtronic Minimed. www.minimed.com