Glucagon Administration for Unlicensed Assistive Personnel Glucagon Administration for Unlicensed Assistive Personnel by Donna Canfield, RN, BSN, NCSN Donna Canfield, RN, BSN, NCSN

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

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

Nevada School Nurse Regulation and Advisory Opinion Delegation 1.The Registered Nurse determines when it is appropriate to delegate or assign any portion of the provision of care. This delegation/assignment must occur in accordance with the standards of practice outlined in the Nurse Practice Act and the guidelines of this Advisory Opinion. 1.The Registered Nurse determines when it is appropriate to delegate or assign any portion of the provision of care. This delegation/assignment must occur in accordance with the standards of practice outlined in the Nurse Practice Act and the guidelines of this Advisory Opinion. 2.The Registered Nurse School Nurse is solely responsible for the determination of when it is appropriate to delegate or assign nursing care to a qualified person. A "qualified person" is: 2.The Registered Nurse School Nurse is solely responsible for the determination of when it is appropriate to delegate or assign nursing care to a qualified person. A "qualified person" is: a.A person whose license/certification authorizes his/her a.A person whose license/certification authorizes his/her practice; or b. A willing person whom the RN School Nurse has determined has acquired and/or maintained knowledge, skill and ability to perform the care in a safe and effective manner required by the child. b. A willing person whom the RN School Nurse has determined has acquired and/or maintained knowledge, skill and ability to perform the care in a safe and effective manner required by the child.

School Nurse Regulation and Advisory Opinion (cont.) 3.This definition precludes the automatic utilization of the office manager, secretary or teacher as a qualified person. Only the School Nurse may delegate or assign nursing care. The School Administrator cannot legally delegate or assign nursing care. A Licensed Practical Nurse providing nursing care in a school may not delegate or assign nursing care procedures to school personnel. 3.This definition precludes the automatic utilization of the office manager, secretary or teacher as a qualified person. Only the School Nurse may delegate or assign nursing care. The School Administrator cannot legally delegate or assign nursing care. A Licensed Practical Nurse providing nursing care in a school may not delegate or assign nursing care procedures to school personnel. 4. A family member/friend, designated or identified by the student's parent or legal guardian, is exempt from the regulations of the Nurse Practice Act and, without delegation, training or supervision by the school nurse, may perform required care for the student unless employed by the school district. 4. A family member/friend, designated or identified by the student's parent or legal guardian, is exempt from the regulations of the Nurse Practice Act and, without delegation, training or supervision by the school nurse, may perform required care for the student unless employed by the school district.

Medication Administration under the School Nurse Regulations To administer medications, the School Nurse must have written permission from parent/guardian, and medication must have been prescribed by licensed prescribing practitioner, labeled and dispensed by licensed dispensing practitioner/pharmacist. Administration must be accompanied by a reliable tracking system. To administer medications, the School Nurse must have written permission from parent/guardian, and medication must have been prescribed by licensed prescribing practitioner, labeled and dispensed by licensed dispensing practitioner/pharmacist. Administration must be accompanied by a reliable tracking system. The Nevada State Board of Nursing recognizes the administration/assistance with medication is an issue of primary concern in school districts. School Nurses/School Districts are referred to the State Board of Pharmacy to work out a suitable mechanism for the accomplishment of this task. Any medication procedure developed must meet the standard requirement for the safe administration/assistance of medications. The Nevada State Board of Nursing recognizes the administration/assistance with medication is an issue of primary concern in school districts. School Nurses/School Districts are referred to the State Board of Pharmacy to work out a suitable mechanism for the accomplishment of this task. Any medication procedure developed must meet the standard requirement for the safe administration/assistance of medications.

Medication/Procedure Administration Under the School Nurse Regulations (cont.) …The School Nurse may delegate the Administration of Glucagon injection kit in emergent situation to a “qualified person”. …The School Nurse may delegate the Administration of Glucagon injection kit in emergent situation to a “qualified person”.

The Basics of The Good Samaritan 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 Objectives Participants will learn: Diabetes basic care Symptoms and treatment of hypoglycemia (low blood glucose) Procedure for the emergency administration of Glucagon

Diabetes 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 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 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 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 Hypoglycemia Symptoms of hypoglycemia can range from mild to severe, and include any or all of the following: Mild Symptoms Hunger Sweating Feeling shaky Feeling nervous Moderate Symptoms Headache Behavior changes Blurred, impaired or double vision Crabbiness or confusion Drowsiness Weakness Difficulty talking

Signs/Symptoms of 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 Hypoglycemia 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 and initiate cardiopulmonary resuscitation (CPR.)

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 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.) 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? Glucagon is a hormone produced in the pancreas. It increases blood sugar levels. Glucagon is a hormone produced in the pancreas. It increases blood sugar levels. Glucagon is used to treat insulin coma or insulin reaction resulting from severe hypoglycemia (low blood sugar). Glucagon is used to treat insulin coma or insulin reaction resulting from severe hypoglycemia (low blood sugar).

Glucagon Emergency Kit

Emergency Kit Contains: 1 mg. of freeze-dried Glucagon (vial) 1 ml. water for reconstitution (syringe)

Preparation of Glucagon Injection 1. Flip cap off glass vial containing dry powder 2. Remove cap from syringe

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

Mixing Glucagon Solution (cont.) 4. Shake gently or roll to mix until all powder is dissolved and solution is clear. clear.

Drawing Out the Solution 5. Inspect. Solution should be clear and colorless. 6. Draw prescribed amount of Glucagon back into the syringe.

Dosing and Injecting 7. Put on gloves. 8. Clean site with alcohol swab if possible. 9. Inject at 90° into the tissue under cleansed area buttocks buttocks thigh thigh arm arm

Injecting Glucagon (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 Glucgaon It may take minutes for the student to regain consciousness. Vomiting may occur -keep the student positioned on side to prevent choking.

Next 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… The student does not remember being unconscious or is incoherent or lethargic. The student feels nauseated, vomits, or has a headache.

Video review <I plan to insert the video from Costal <I plan to insert the video from Costal (Glucagon injection portion only) at this time to re-emphasize and re-teach the actual preparation and injection of Glucagon and then have a practice session with the UAP’s using the ‘demos’ from the Lily company>

Quick 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.) Severe hypoglycemia is a medical emergency requiring immediate administration of Glucagon. Treat, then follow the district policy for medical emergency care.

References Gursky, Beverly S. & Ryser, Barbara J., (2007). A Training Program for Unlicensed Assistive Personnel. The Journal of School Nursing. Volume 23, Number 2 Gursky, Beverly S. & Ryser, Barbara J., (2007). A Training Program for Unlicensed Assistive Personnel. The Journal of School Nursing. Volume 23, Number 2 Online: Online: Drugs Drugs Healthwise Healthwise Lily Company Lily Company Medline Plus Medline Plus Nevada Nursing Board Nevada Nursing Board Oregon Oregon Theodora Theodora