1. ATLANTA PUBLIC SCHOOLS
HEALTH SERVICES

2. Diabetes in the School Setting

3. Objectives The learner will: Gain a basic understanding of Diabetes
Learn how to follow a Diabetes Health Management Plan
Demonstrate how to check blood glucose
Understand the difference between insulin correction for high blood glucose and insulin coverage for carbohydrates
Give examples where to find carbohydrate information
Become familiar with the various forms of insulin administration
Learn how to recognize and treat hypo and hyperglycemia
Demonstrate how to give glucagon in case of hypoglycemic emergency
Demonstrate how to perform ketone testing and interpret results

4. CALL YOUR CLUSTER NURSE!!!
Take Home Message
You cannot learn diabetes care in one afternoon. After today’s training you will have a general idea of the basics of caring for a student with diabetes but will need to be checked off 1:1 by an APS RN for each student for whom you will be responsible!
CALL YOUR CLUSTER NURSE!!!
Throughout the next 2 hours you will learn a lot of information about diabetes. Diabetes care is complicated and mistakes can be costly. In order to safely care for students with diabetes you must be checked off one on one with a county nurse before independently caring for a student with diabetes.

5. Video

6. DIABETES – What is it? KEY POINTS
Cells need sugar or glucose for energy.
The main source of glucose is carbohydrates.
Carbohydrates are digested into glucose which goes in the blood stream.
The body needs insulin to move the glucose from the blood stream into the cells where it can be used for energy.
Students with diabetes cannot make insulin so they have to give themselves insulin.
We are going to go over the basics of diabetes for the rest of the day. Care of a student with diabetes is complicated and requires knowledge of a lot of steps. You will get the basics of all of these steps today. Along the way we will talk about important “take home” messages. Whenever I tell you there is an important take home message I want you to pay close attention to these and know that these are key to safely caring for a student with diabetes at your school. There will be a question at the end of this session with a prize for those who guess it correctly. So here is our first take home message of the afternoon:

7. Type 1 Diabetes Autoimmune Disorder
Insulin producing cells are destroyed
Daily Insulin replacement is necessary
Age of onset: usually childhood or adolescence
Type 1 Diabetes is the most prevalent type of Diabetes in children and adolescence

8. Type 2 Diabetes Insulin Resistance is the first sign
Most commonly seen in adults, but prevalence is increasing in children
Obesity and inactivity are contributing to this trend

9. Carbohydrates
BLOOD SUGAR GOES: UP

10. Insulin
BLOOD SUGAR GOES:
DOWN

11. Now what????? Insulin? Carbohydrates?
Goal: to maintain blood glucose within target range (around )
How:
Know how to manage diabetes (follow the Diabetes Management Plan)
Know signs of low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia)
So we know what diabetes is now. We know that in a student with diabetes the pancreas no longer produces insulin so the cells can’t get glucose in the blood to move into the cells where it can be used for energy or stored for later. Our goal for that student is to keep their blood sugars at a normal level like the body would if it had insulin, but how? Well, every student with diabetes will have a diabetes management plan that will tell us what to do and we will learn how to recognize the signs of low blood sugar and high blood sugar and know what to do about it.

12. Diabetes Management Plan
Blood Glucose Monitoring – checking blood sugar level
When, where, how
Insulin Administration – giving insulin to correct or “fix” high blood sugar and to cover or “account for” what student eats
Carbohydrate Counting – determining how many carbohydrates student has eaten

13. Blood Glucose Monitoring (testing/checking blood sugar)
BLOOD GLUCOSE (BG) MONITORING:
(Target range: ____ mg/dl to _____ mg/dl.)
Before meals
PRN (as needed) for suspected low/high BG
Midmorning
2 hours after correction
Mid-afternoon
Before PE
Before boarding afternoon bus
Before tests

14. Blood Glucose Testing Know your target range
Check at times specified in Health Management Plan

15. Blood Glucose Testing
Equipment

16. Insulin Administration
BEFORE MEAL INSULIN: Insulin Type: Humalog Novolog ____________Other  Insulin to Carbohydrate Ratio: ___ unit(s) per ______________ grams carbohydrate  Give ______ units CORRECTION INSULIN for high blood sugar (Check only those which apply) Use the following correction formula: BG - _______ / ______ ( for pre lunch blood sugar over ____) Sliding Scale: BG from _______ to ______ = ______ u Add before meal insulin to correction/ sliding scale insulin for total meal time insulin dose
The diabetes management plan will tell you what kind of insulin the student gets and it will tell you exactly how much the student needs based on two things:
BEFORE MEAL INSULIN – this includes all meals and with some students it may also include snacks. We know that carbohydrates that we eat make blood sugar go…UP! So we need to cover (give) the student with some insulin so that the carbohydrates they eat which will then turn into…glucose… which will then go into the…blood…go into the…cells. This is how we figure that out:

17. Coverage Insulin
 Insulin to Carbohydrate Ratio: ___ unit(s) per ______________ grams carbohydrate  Give ______ units EXAMPLE: 1 unit per 10 grams carbohydrate OR Give __7__ units

18. Coverage Insulin (cont.)
Johnny has diabetes. His plan says:  Insulin to Carbohydrate Ratio: _1__ unit(s) per__10_ grams carbohydrate He tells you that he ate 60 grams of carbohydrate for breakfast. How many units of insulin should Johnny have to “cover” his breakfast?

19. Answer:
60/10=6 units
You always divide by the ratio number. If it is 1:5 you would give 12 units. If it is 1:15 you would give 4 units. It might also just give you a set number of units to give with every meal but this is not very common.

20. Carbohydrate Counting
Meals and snacks need to be carefully timed to balance exercise and insulin.
Remember all of the above work together to help balance the blood glucose
Carbs have the biggest effect on blood glucose, more so than fats and protein

21. Carbohydrate Counting
Foods containing carbohydrates:
Starches – breads, pasta,rice, cereals, legumes (eg. beans/peas) and starchy vegetables (eg. potatoes, corn, squash)
Fruits (fresh, canned, juice)
Milk and yogurt
Vegetables (may have some carbs)
How did we get the number of carbs that the student will eat?

22. Carbohydrate Counting
Carbohydrate values are available on APS website under nutrition
All food labels now list carbohydrate values
If in doubt – contact parent, school cafeteria manager, cluster nurse or Health Services for carbohydrate content

23. Correction Insulin
Use the following correction formula: BG - _______ / ______ ( for pre lunch blood sugar over ____ )
 OR
Sliding Scale:
BG from _______ to ______ = ______ u
Correction insulin is the insulin that a student with diabetes gets to “correct” their blood sugar when it is high. We would never give insulin to correct a blood sugar that is low or in range.

24. Correction Insulin (cont)
Use the following correction formula: BG - __100___ / __60____ ( for pre lunch blood sugar over _150) OR Sliding Scale: BG from __151__ to __199_ = __1___ u BG from __200__ to __299_ = __2___ u BG from __300__ to __399_ = __3___ u BG from __400__ to __499_ = __4___ u BG from __>499 to ______ = __5___ u

25. Correction Insulin (cont.)
Johnny checked his blood sugar before
breakfast. His glucose monitor says his
blood sugar is 210.
Using the correction factor – how much insulin does he need to correct?
Using the sliding scale – how much insulin does he need to correct?
Important take home message. When students are getting ready for a meal they must come in and check their blood sugar BEFORE the meal. Once they have eaten we know their blood sugar is going to go…UP… so now we don’t know if they were low or high or what their blood sugar really was – that number is now meaningless. ALWAYS check before meals.

26. ANSWER: Using formula: 210-100/60 = 1.8 Using sliding scale:
BG from 200 – 299 = 2

27. SO… Add before meal insulin to correction/
sliding scale insulin for total meal time
insulin dose:
 Using the coverage amount and the formula: = 7.8 round up to 8U
Using the coverage amount and the sliding scale: = 8U
See what it says next on the plan:
We always round down if it is and up for anything over We only round after we add both insulins together.

28. TAKE HOME MESSAGE
WHEN STUDENTS WITH DIABETES ARE GOING TO HAVE A MEAL AND SOMETIMES WHEN THEY ARE GOING TO HAVE A SNACK, THEY MUST CHECK THEIR BLOOD SUGAR BEFORE THEY EAT! THEY CAN CORRECT BEFORE OR AFTER BUT MUST CHECK BEFORE!

29. Parties and Special Events
Notify parent in advance
Follow HMP, 504 or IEP
Encourage nutritious snacks
Do not restrict sugar

30. Field trips Bring plenty of snacks
Preferably bring lunch from home with carb counts included from parent
Bring ALL diabetes supplies
Someone trained in diabetes must accompany student. Parents cannot be required to come.

31. Insulin Rapid Acting – Humalog/Novolog
Short Acting – HumulinR, NovolinR
Intermediate – HumulinN, NovolinN
Long Acting – Lantus, Levemir

32. INSULIN DELIVERY METHODS SYRINGES
Now that we have figured out how much insulin to give we are going to talk a bit about how to give it. Insulin is a medication that must be given very cautiously. Never allow anyone to interrupt or disturb you when calculating or giving insulin. Remember – insulin causes blood sugar to …drop. If blood sugar drops too low students can…pass out, have a seizure and die.

33. How to give Insulin Using a Syringe
Gather supplies
Insulin – verify type
Syringe
Alcohol wipe
Gloves
Sharps container

34. How to give insulin using a syringe
Preparation
Wash hands
Apply gloves
Clean the insulin vial
Have student select injection site
Clean injection site with alcohol
Check dose
Remove cap from syringe

35. How to give insulin using a syringe
Dosing
Pull plunger down to number of units to be administered
Inject air into bottle
Draw out prescribed number of units as per plan

36. How to give insulin using a syringe
Injecting
Pinch up skin
Push needle into skin at 90 degree angle
Release pinch
Push plunger in
Count to “5”
Remove needle and dispose of syringe
Document time, dose, and site

37. INSULIN DELIVERY METHODS PENS

38. Insulin Pen devices Prefilled pens Reuseable (cartridge) pens
Techniques for dose preparation and insulin delivery are similar for both types of pen devices

39. Insulin Pen Preparation
Gather supplies. Verify insulin type.
Pen device
Pen needle
Alcohol wipe
Sharps container

40. Insulin Pen Preparation
Wash hands
Allow student to choose injection site
Clean injection site
Screw needle onto pen

41. Insulin Pen Dosing Prime pen by dialing 2 units
Hold upright. Remove air by pressing the plunger. Repeat “prime” if no insulin can be seen at the end of the needle.
Dial number of units to be administered as per plan

42. Insulin Pen Dosing Injecting Pinch up skin
Push needle into skin at 90 degree angle
Release pinch
Push plunger in
Count to “5”
Remove needle and dispose of syringe
Document time, dose, and site

43. INSULIN DELIVERY METHODS PUMPS
We will not be going over pumps today. Most students who have pumps are very familiar with them and know how to use them. If you have a younger student on a pump and you need to help them with it you will receive training on that pump from the parent and the county nurse before you use it independently.

44. Insulin Pump Therapy Based on what the body does naturally
Small amounts of insulin all the time (basal insulin)
Extra doses to cover meals or snacks (bolus insulin)

45. What is an Insulin Pump?
Battery operated device about the size of a pager
Reservoir filled with insulin
Computer chip with user control of insulin delivery
Worn 24 hours per day
Delivers one type of insulin (short acting)

46. What key personnel need to know about an insulin pump
How to deliver routine boluses for carbs and high blood sugars
How to disconnect the pump in the event that the student becomes unconscious or seizes or as instructed by diabetes plan
Signs/symptoms that the pump site may need to be changed
When the student might need an injection by pen or syringe.

47. Blood glucose(sugar) levels
LOW (hypoglycemia)
Shakiness
Fast Heartbeat
Sweating
Dizziness
Anxious
Hungry
Impaired vision Weakness/Fatigue
Headache
Irritability
Because it is not an exact science and we can’t predict exactly how the combination of carbohydrates and insulin may affect blood sugar on any given day – we need to be able to recognize when blood sugars may be running high or low.
This is the most important take home message of the day. High and low blood sugars can be very dangerous. High blood sugars are more dangerous over a longer period of time and at higher levels. Low blood sugars can be very dangerous very quickly. We talked about the range being somewhere in the vicinity of At 70 a student is no longer functioning cognitively where he needs to be. As blood sugars continue to drop students may become more and more confused and unresponsive and, if we don’t do something about it, they will continue to drop leading to unconsciousness, possibly seizures, and eventually death.
TAKE HOME MESSAGE: KNOW WHAT SIGNS OF LOW AND HIGH BLOOD SUGAR LOOK LIKE AND KNOW WHAT TO DO!

48. TAKE HOME MESSAGE
LOW BLOOD SUGAR CAN BE AN EMERGENCY! KNOW THE SIGNS AND WHAT TO DO!! WHEN IN DOUBT, TREAT FOR LOW BLOOD SUGAR!

49. Low Blood Sugar (Hypoglycemia)
MANAGEMENT OF LOW BLOOD GLUCOSE :
MILD: Blood Glucose < 70
 Never leave student alone
 Give 15 gms glucose; recheck in 15 min.
 If BG < 70, retreat and recheck q 15 min x 3
 Notify parent if not resolved
 Provide snack with carbohydrate, fat, protein after
treating and meal not scheduled > 1 hr
*If student is conscious, but unable to swallow, squeeze glucose gel or
cake gel between gum and cheeks. Massage cheek to increase absorption.

50. Treatment of Hypoglycemia
Glucose Tabs Glucose Gel

51. Low Blood Sugar (Hypoglycemia)
SEVERE: Loss of consciousness or seizure Call 911. Open airway. Turn to side. Glucagon injection 0.25 mg  0.50 mg  1.0 mg IM/SQ  Notify parent.

52. Treatment of Hypoglycemia
Glucagon

53. Glucagon
Glucagon is a naturally occurring hormone made in the pancreas that stimulates the liver to quickly release stored glucose into the bloodstream

54. Glucagon preparation Remove gray cap
Inject the entire contents of the syringe into the bottle of glucagon
Remove the syringe from the bottle
Gently shake the bottle until the glucagon dissolves and the solution is clear

55. Glucagon Administration
Withdraw prescribed amount from the bottle
For children weighing less than 44lb, withdraw half the solution from the bottle (0.5mg mark on the syringe)

56. Glucagon Administration
Insert the needle into the loose tissue at the cleansed site on buttock, arm or thigh
Turn student on his/her side. When an unconscious person awakens, he or she may vomit

57. TAKE HOME MESSAGE
LOW BLOOD SUGAR CAN BE AN EMERGENCY! KNOW THE SIGNS AND WHAT TO DO!! WHEN IN DOUBT, TREAT FOR LOW BLOOD SUGAR!

58. Blood glucose(sugar) levels
HIGH (hyperglycemia)
Extreme Thirst
Increased Hunger
Frequent Urination
Irritability Dry Skin
Blurred Vision
Drowsiness
Nausea
Because it is not an exact science and we can’t predict exactly how the combination of carbohydrates and insulin may affect blood sugar on any given day – we need to be able to recognize when blood sugars may be running high or low.
This is the most important take home message of the day. High and low blood sugars can be very dangerous. High blood sugars are more dangerous over a longer period of time and at higher levels. Low blood sugars can be very dangerous very quickly. We talked about the range being somewhere in the vicinity of At 70 a student is no longer functioning cognitively where he needs to be. As blood sugars continue to drop students may become more and more confused and unresponsive and, if we don’t do something about it, they will continue to drop leading to unconsciousness, possibly seizures, and eventually death.
TAKE HOME MESSAGE: KNOW WHAT SIGNS OF LOW AND HIGH BLOOD SUGAR LOOK LIKE AND KNOW WHAT TO DO!

59. High Blood Sugar (Hyperglycemia)
MANAGEMENT OF HIGH BLOOD GLUCOSE (Above 300 mg/dl)
 Sugar-free fluids/frequent bathroom privileges.
 If BG is greater than 300, and it’s been 2 hours since last dose, give  HALF of FULL correction formula noted above.
 If BG is greater than 300, and it’s been 4 hours since last dose, give FULL correction formula noted above.
 If BG is greater than 300 check for ketones. Notify parent if ketones are present.
 Note and document changes in status.
 Child should be allowed to stay in school unless vomiting and moderate or large ketones are present.

60. Testing for Ketones
When the body does not have enough insulin, fats are used for fuel instead of glucose. A by-product of burning fats is the production of ketones. Ketones are passed in the urine and can be detected with a urine test.
Test for ketones
when blood sugars
are high
Follow the Plan

61. Resources www.diabetes.org www.wikipedia.com www.medlineplus.gov
The First Book For Understanding Diabetes, Children’s Diabetes Foundation at Denver, Colorado