Diabetes Care Tasks at School: What Key Personnel Need to Know DIABETES BASICS This training is based on and should be used in conjunction with “Helping the Student with Diabetes Succeed: A Guide for School Personnel”, a guide developed by the National Diabetes Education Program (NDEP), which is a federally sponsored partnership of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention and over 200 partner organizations. Training participants should read the NDEP guide prior to this training in order to gain a full understanding of the requirements of appropriate school diabetes care. Participants should have a copy of the guide during this training and for future reference. Some Key points about the overall training: Overall objective: The overall goal is to optimize both health and learning for students with diabetes by providing diabetes care training to school nurses and to other school personnel about how and when to perform routine and emergency diabetes care tasks for students. Completion of training will help prepare school personnel to perform diabetes care tasks. Rationale: The school nurse, when available, is the most appropriate person in the school setting to provide care for a student with diabetes. However, many schools do not have full-time nurses. Even for schools that do, the nurse may not always be available during the school day, during extracurricular activities, or field trips, etc., to assist with routine care and emergency care, so trained non-medical school staff members must be available to provide coverage.

Overall Goal: Optimal Student Health and Learning Monitoring Blood Glucose Hypoglycemia & Hyperglycemia Ketones Health & Learning Glucagon Administration Legal Rights This training component is one of eight components created specifically for school nurses and non-medical school personnel who perform diabetes care tasks at school. These components are: Diabetes Basics Hypoglycemia and Hyperglycemia Blood-Glucose Monitoring Insulin Administration Glucagon Administration Ketone Testing Nutrition and Exercise Legal Considerations This unit is Diabetes Basics. Insulin Regimen Exercise Nutrition

Learning Objectives Participants will learn: What is diabetes? Why care at school is required Basic components of diabetes care at school Short and long term consequences of diabetes Our objectives are to learn the following: What is diabetes? Why care at school is required. Basic components of diabetes care at school Short and long term consequences of diabetes

What is Diabetes? no insulin production Body does not make or properly use insulin: no insulin production insufficient insulin production resistance to insulin’s effects No insulin to move glucose from blood into cells: high blood glucose means: fuel loss. cells starve short and long-term complications Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy by moving glucose from blood into the cells. People with diabetes have increased blood glucose (sugar) levels for one or more of the following three reasons: Either 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.

Type 1 Diabetes auto immune disorder insulin-producing cells destroyed daily insulin replacement necessary age of onset: usually childhood, young adulthood Type 1 Diabetes Type 1 diabetes is a disease of the immune system, which is the body’s system for fighting infection. In people with 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 to take insulin daily 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. most prevalent type of diabetes in children and adolescents

Type 1 Diabetes ONSET: relatively quick increased urination tiredness weight loss increased thirst hunger blurred vision SYMPTOMS: Symptoms. The symptoms of type 1 diabetes usually develop over a short period of time. They include increased thirst and urination, constant hunger, weight loss, and blurred vision. Children may also feel very tired all the time. If not diagnosed and treated with insulin, the person with type 1 diabetes will eventually lapse into a life-threatening condition known as diabetic ketoacidosis (KEY-toe-asi-DOE-sis) or DKA. Risk factors. Though scientists have made much progress in predicting who is at risk for developing type 1 diabetes, they do not know exactly what triggers the immune system’s attack on beta cells. They believe that type 1 diabetes is due to a combination of genetic and environmental factors. uncertain, likely both genetic and environmental factors CAUSE:

Type 2 Diabetes Insulin resistance – first step Age at onset: Most common in adults Increasingly common in children overweight inactivity Type 2 Diabetes The first step in the development of type 2 diabetes is often a problem with the body’s response to insulin, called insulin resistance. This means that the body needs increasing amounts of insulin to control blood glucose. The pancreas tries to make more insulin, but after several years, insulin production may drop off. Type 2 diabetes used 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. Many people with type 2 diabetes are overweight.

Type 2 Diabetes in children ONSET: variable timeframe tired, thirsty, hunger, increased urination SYMPTOMS: Onset in children: variable timeframe. Some children develop type 2 diabetes rather quickly, other more slowly. Some symptoms similar to type 1: Tired, thirsty, hunger, increased urination Some children show no symptoms at diagnosis. some children show no symptoms at diagnosis

Diabetes is Managed, But it Does Not Go Away. GOAL: To maintain target blood glucose Whether we consider type 1 or type 2 diabetes, the goal of effective diabetes management is to control blood glucose levels by keeping them within a target range that is individually determined for each child. Optimal blood glucose control helps to promote normal growth and development and allows for optimal learning. It is also needed to prevent the immediate dangers of blood glucose levels that are either too high or too low. Research has shown that maintaining blood glucose levels within the target range can prevent or delay the long-term complications of diabetes such as heart attack, stroke, blindness, kidney failure, nerve disease, and amputations of the foot or leg. When insulin is no longer made, it must be obtained from another source--insulin shots or an insulin pump. All people with type 1 diabetes must take insulin. People with type 2 diabetes use diet and exercise, and oral medications, and/or insulin to manage their disease. Neither insulin nor other medications, however, are cures for diabetes: they only help control the disease.

Constant Juggling: Diabetes Management 24/7 Insulin/medication with: Exercise Food intake BG BG Maintaining good blood glucose control is a constant juggling act, 24 hours a day, 7 days a week. The key to optimal diabetes control is a careful balance or juggling of food, exercise, and insulin and/or oral medication. As a general rule, insulin/oral medication and exercise/activity makes blood glucose levels go down. Food makes blood glucose levels go up. Several other factors, such as stress, illness or injury, also can affect blood glucose levels. & BG

Diabetes Management Proactive Reactive keep juggling the balls a response is indicated corrective actions for highs or low emergency intervention The juggling act of managing the BIG 3 – insulin and/or medication, food, and activity level is the proactive part of diabetes management. Keeping those balls in the air by following the diabetes regimen prescribed by the student’s health care team will go a long way in preventing health problems that might disrupt learning and participation in school. Knowing how to react when the juggling isn’t going very well is also an important part of the diabetes management plan. If blood glucose levels are too low (hypoglycemia) or too high (hyperglycemia), immediate corrective action must be taken such as administering insulin, eating, or modifying activity level.

Assistance in Diabetes Management Routine Care: Many students will be able to handle all or almost all routine diabetes care by themselves Some students, because of age, developmental level, or inexperience, will need help from school staff. Urgent Care: Any student with diabetes may need help with emergency medical care. The need for assistance with diabetes care tasks will vary from student to student. Routine Care: Many students will be able to handle all or almost all of their routine diabetes care by themselves. Some students, because of age, developmental level, or inexperience, will need help from school staff. Urgent Care: Any student with diabetes may need help with emergency medical care.

Care in the Schools: School Nurses and Others Nurse most appropriate to: Supervise diabetes care Provide direct care (when available) However, a nurse is not always available. Non-medical school staff can be trained to assist students For both routine and emergency care Including insulin and glucagon injections The school nurse is the most appropriate person in the school setting to provide care for a student with diabetes. Many schools in this country, however, do not have a full-time nurse and sometimes a single nurse must cover a large number of schools. Moreover, even when a nurse is assigned to a school full time, he or she will not always be available during the school day, during extracurricular activities, or on field trips. Yet, because diabetes management is needed 24 hours, 7 days a week -- and diabetes emergencies can happen at any time -- a student will always need access to diabetes care at school and at all school-related activities. Because school nurses are not always available to provide direct care, non- medical school staff can and should be trained to assist students in both routine and emergency care, including insulin and glucagon injections.

Diabetes Medical Management Plan A Diabetes Medical Management Plan (DMMP) should be implemented for every student with diabetes. DMMP is developed by the student’s personal health care team and family and signed by a member of student’s personal health care team implemented collaboratively by the school diabetes team, including: school nurse the student parents/guardians other school personnel A Diabetes Medical Management Plan (DMMP) should be implemented for every student with diabetes. A DMMP is written with the specific needs of an individual student in mind and should detail all the elements of care and assistance for that student. This type of plan could go by a different name in some school districts. The DMMP is developed and signed by the student’s personal health care team and family and implemented collaboratively by the school diabetes team, which includes the school nurse, student, parents, and other school personnel. In addition to a DMMP, a Section 504 Plan, Individualized Education Program (IEP) or other education plan is usually developed to specify how the student’s medical and academic needs will be implemented at school, and school nurses also often develop an individual nursing care plan.

Elements of a DMMP Date of diagnosis Emergency contact information Student’s ability to perform self-management tasks at school List of diabetes equipment and supplies Specific medical orders for blood glucose monitoring, insulin, glucagon, and other medications to be given at school Meal and snack plan Exercise requirements Actions to be taken in response to hypoglycemia and hyperglycemia Turn to page 49 of “Helping the Student with Diabetes Succeed: A Guide for School Personnel” for a sample DMMP. A good school diabetes medical management plan includes the following elements: Date of diagnosis Emergency contact information Student’s willingness and ability to perform self-management tasks at school List of diabetes equipment and supplies Specific medical orders for blood glucose monitoring, insulin, glucagon, and other medications to be given at school Meal and snack plan Exercise requirements Actions to be taken in response to hypoglycemia and hyperglycemia

Quick Reference Plan Development based on information from students DMMP Summarizes how to recognize and treat hypoglycemia and hyperglycemia Distribute to all personnel who have responsibility for students with diabetes Turn to page 53 of “Helping the Students with Diabetes Succeed: A Guide for School Personnel” for a sample quick reference plan. Development based on information from student’s DMMP Summarizes how to recognize and treat hypoglycemia and hyperglycemia. Distribute to all personnel who have responsibility for a student with diabetes.

Where to Get More Information American Diabetes Association 1-800- DIABETES www.diabetes.org National Diabetes Education Program/NIH www.ndep.nih.gov