Diabetes Training for School Employees

1. Diabetes Training for School Employees Albemarle County Public Schools

2. Purpose of this Presentation The purpose of this presentation is to provide information for use in the training of school personnel in the management of diabetes including the administration of insulin and glucagon as required by the Code of Virginia.

3. Virginia Senate Bill 889requires public schools with at least one student diagnosed with diabetes to ensure that at least two employees have been trained in the administration of insulin and glucagon. http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+22.1-274 Section 504 of the Rehabilitation Act of 1973 Requires all public schools to afford children with disabilities (including diabetes) an equal opportunity to participate in all academic as well as nonacademic and extracurricular services and activities regardless of disability. Diabetesin Schools: Legislation

4. Diabetes Medical Management Plan A medical management plan must be provided for each student with diabetes (Individualized Health Care Plan – IHCP) completed by the students’ medical management team and signed by both the health care provider and the student’s parent.

5. Components of the Plan • Contact Information – parent and provider • Blood glucose monitoring: when, where, and how independent the student is • Insulin: when, type, amount, how (pen, syringe, pump), by whom (student, nurse) • Diet: Meals and snacks: time, amount • Treatment/management of low blood sugar. • Treatment/management of high blood sugar.

6. BASICS of DIABETES MANAGMENT • Blood glucose testing • Insulin administration • Diet – carb counting • Exercise • Recognizing and treating high blood sugar and low blood sugar • Emergency treatment of severe low blood sugar

7. Blood Glucose Monitoring • Different kinds of meters • Must be calibrated to match test strips

8. Examples of Glucometers • Freestyle One Touch Ascenia

9. When to Check Blood Glucose Students may check their blood glucose: • Before eating snacks or meals • Before physical activity • When they have symptoms of low or high blood glucose • Other times per plan

10. Blood Glucose Monitoring Skills • Wash & dry hands. • Insert test strip in glucose meter • Select appropriate site on the fingertip (top or sides). • Puncture fingertip accurately and obtain optimal amount of blood to perform accurate measurement. • Place drop of blood on test strip. • Obtain accurate reading. • Record blood glucose results.

11. INSULIN All people with Type 1 Diabetes manage their diabetes with insulin. Old method: Long-acting (basal) insulin and 2 doses of intermediate acting insulin. New method: Long acting (Lantus, Levemir, Ultralente) and 3 shorter acting doses (Humalog/Novalog) at mealtimes based on amount of carbohydrates in meal.

12. Carbohydrate Counting • Used in conjunction with a combination of long acting (eg. Lantus) once a day with short acting (Humalog or Novalog) with each meal. • Easier to learn than Exchanges or the Point System. • Food and insulin match better. • Increased variety of food choices. • More flexibility in meal/snack times. • Better blood sugar control. • Carbohydrate information on food labels makes meal planning easier. • Focus is on carbohydrates, but protein and fat are still important. • Count total carbohydrates.

13. Food Label

14. Tools for Carbohydrate Counting Albemarle County Child Nutrition Services: http://schoolcenter.k12albemarle.org/education/sctemp/a93ebbb902ffa8b10a8102e55bd84ddf/1194888543/carb_cts_.xls USDA: http://www.nal.usda.gov/fnic/foodcomp/search/ Fast food: http://www.bddiabetes.com/resource.aspx?IDX=4253

15. Types of Insulin, Dosages & TimesSample Plan

16. Calculating Insulin Dose:Pens and Pumps Determine amount based on plan: • Step 1: Calculate number of carbs in meal then determine the prescribed ratio (eg. 1 unit for each 15 grams carbs). • Step 2: Correction factor for blood glucose reading (add insulin for higher blood sugar reading and subtract for lower reading).

17. Example from Sample Plan Student’s lunch contains 60 grams of carbs and his blood sugar reading is 160mg/dl. Step 1: 1 unit for each 15 grams = 4 units Step 2: Correction factor: add 1 unit for blood sugar reading of 160mg. Insulin dose = 5units

18. More Examples from Sample PlanCalculating Insulin Dose

19. Insulin Chart

20. Types of Insulin Injections Types of Insulin Injections: • Vials and syringes • Insulin pens • Insulin pumps

21. Insulin Vials and Syringes Insulin Vial and Syringes

22. Insulin Pens

23. Insulin Pumps

24. For All Types of Insulin Skills • Determine appropriate storage & security of insulin, syringes, & medical supplies. • State where plan is located. • State “5 rights” of medication administration: student, medication, dose, time and route. • Determine insulin dose per plan. • Document amount of insulin and time of administration.

25. Insulin Types

26. Preparing for Insulin Injection: Steps 1 through 4 Step 1: Remove cap Step 2: Wipe the top with alcohol swab Step 3: Draw air into the syringe equal to the dose Step 4: Put the needle through the rubber top of the vial and push the plunger to inject air into the vial

27. Step 5: Draw up dose Leave syringe in the vial and turn both upside down. Hold the syringe and fial firmly in one hand. Make sure the tip of theneedle is in the insulin Step 6: Check for bubbles Before you take the needle out of the vial, check the syringe for bubbles Step 7: Tap to release If bubbles are in the medicine, hold the syringe straight up and tap the side of the syringe until the bubbles float to the top. Push the bubbles out with the plunger and draw the insulin back in until you have the correct dose. Preparing for Insulin Injection: Steps 5 through 7

28. Gather together the insulin-loaded syringe or pen, an alcohol swab and a dry cotton swab or tissue. Select the injection site (illustration). Swab the site with an alcohol swab. Gently pinch up the skin and fat with the thumb and forefinger. Hold the syringe like a pencil, close to the needle for better control. Push the needle in quickly and all the way, at a 90-degree angle to the pinched-up skin. Push the plunger in to inject the insulin. Slowly let go of the pinched-up skin and then remove the needle. Using a dry swab, apply gentle pressure to the injection site to prevent bruising. Discard the needle and syringe in the sharps container. To avoid possible injury, never leave used needles lying around. Injection Instructions

29. Insulin Pen Injection Skills • Determine amount of insulin to be administered based on plan. • Prepare pen by applying needle appropriately. • Prime the pen with 2 units – dial 2 and push plunger to dispense the two into trashcan. • Dial the correct dose to be administered. • Demonstrate accurate injection technique. • Dispose of used needle correctly. • Document amount of insulin and time administered.

30. Insulin Vials and Syringes Skills • Assemble supplies: vials, syringes, alcohol pads. • Accurately measure insulin dose with syringe. • Locate appropriate sites for injection. • Demonstrate accurate injection technique. • Dispose of syringes in sharps container. • Record amount of insulin and time administered.

31. Insulin Pumps • Pumps vary by manufacturer. • Calculate amount of bolus at meal time per plan. • Enter the amount on pump per instructions. • Record the amount of bolus.

32. Hyperglycemia (High Blood Sugar) Causes of Hyperglycemia: • Too much food • Too little insulin • Decreased activity • Illness • Infection • Stress

33. Symptoms of Hyperglycemia Mild Thirst Fatigue/sleepiness Increased hunger Blurred vision Weight loss Stomach pains Flushing of skin Lack of concentration Sweet fruity breath Moderate Any of the mild symptoms Dry mouth Nausea Stomach cramps Vomiting Severe Any of the mild or moderate symptoms plus: Labored breathing Very weak Confused Unconscious

34. Symptoms of Hyperglycemia

35. Treatment for Hyperglycemia: High Blood Sugar • Allow free use of the bathroom. • Encourage student to drink water. • Check urine for ketones per plan. • Follow instructions in plan. • Students who test positive for ketones should not participate in p.e. or sports until ketones are no longer present. • Call parent for high blood sugar per plan. • Some students’ plan will state that the student needs to go home for blood sugar above a certain number (300 or higher depending on the plan).

36. Hypoglycemia: Low Blood Sugar Causes of low blood sugar • Too much insulin • Missed food • Delayed food • Too much or too intense exercise

37. Mild Hunger Shakiness Weakness Paleness Anxiety Dizziness Sweating Drowsiness Personality change Inability to concentrate Moderate Headache Behavior change Poor coordination Blurry vision Weakness Slurred speech Confusion Severe Loss of consciousness Seizure Inability to swallow Symptoms of Hypoglycemia

38. IMPORTANT!!!! A student who complains of feeling low or who you suspect may be low should never be sent to check blood glucose, to go the nurse’s office or anywhere else alone. The student could lose consciousness or become disoriented.

39. Treatment of Mild Hypoglycemia • Follow plan for parameters for treatment. • Provide quick acting source of carbohydrates such as juice or glucose tablets per plan. • Wait 10 to 15 minutes and recheck blood glucose. • Student may self treat if permitted by plan.

40. Treatment of Moderate Hypoglycemia • Student will need assistance/supervision. • Give quick acting carbohydrate per plan. • Wait 10 to 15 minutes and check again. • Follow parameters of plan for how much carbohydrate to give and when to repeat if needed. • May administer glucose gel or icing if student is low but conscious and able to swallow.

41. Hypoglycemia – Mild to Moderate (Skills) • State signs of hypoglycemia. • State treatment of mild to moderate hypoglycemia. • Describe use of glucose gel or icing for treatment of hypoglycemia.

42. What is GLUCAGON? • A hormone that is made naturally in the pancreas. It releases stores of glucose from the liver causing blood glucose levels to rise. Because it is produced naturally it is a safe drug -- it cannot be overdosed and it has no major side effects. • Glucagon injection is used for severe hypoglycemia when the diabetic is unable to swallow. • When injected it causes blood sugar to rise and the person to regain consciousness. • Glucagon is to be injected into the muscle of the legs, arms or buttocks.

43. Treatment of Severe Hypoglycemia: GLUCAGON Glucagon Kit: Lilly For video on glucagon administration see http://web.diabetes.org/video/glucagon.wmv

44. Remove the flip off seal from the bottle of glucagon. Wipe rubber stopper on bottle with alcohol swab. Remove the needle protector from the syringe and inject the entire contents of the syringe into the bottle of powdered glucagon. Do not remove the plastic clip from the. Swirl bottle gently until the glucagon dissolves completely. Do not shake – shaking may cause bubbles to form. Glucagon should not be used unless the solution is clear and of a water-like consistency. Glucagon Instructions Steps 1 - 3

45. Using the same syringe, hold bottle upside down and making sure the needle tip remains in the solution, gently withdraw all of the solution from the bottle. The plastic clip on the syringe will prevent the rubber stopper from being pulled out of the syringe. Clean the injection site on buttock, arm, or thigh with alcohol. Insert the needle into the loose tissue and inject the amount (half or all per plan). Apply light pressure at the injection site and withdraw the needle. Turn person on side. As soon as patient is able to swallow give fast acting sugar such as juice or soft drink followed by a long acting source of sugar such as crackers and cheese or a meat or peanut butter sandwich. Sprite or ginger ale work well if stomach is upset. Glucagon Instructions Steps 4 through8

46. Severe Hypoglycemia: Glucagon Skills • Accurately state when Glucagon should be administered. • Describe how to mix and withdraw Glucagon from vial. • Determine dose based on plan (0.5mg or 1.0mg). • Locate appropriate injection sites and injection technique (intramuscular). • Precautions: turn child on side, call 9-1-1 & state it is a diabetic emergency, call parents. • Give quick acting carbohydrate such as soft drink (NOT DIET) when student is awake and can swallow. • Document time and amount of Glucagon administered.

47. Sample Log

48. Conclusion As school personnel we want to ensure that all of our students learn and prosper in school. By understanding the basics of diabetes and knowing how to care for a student with diabetes, you will be able to help your student take advantage of all of the learning and growing opportunities your school has to offer. Thank you for interest and willingness to help your student with diabetes succeed and thrive in school.