1. Diabetes Care Tasks at School: What Key Personnel Need to Know Diabetes Care Tasks at School: What Key Personnel Need to Know INSULIN ADMINISTRATION

2. 2 Overall Goal: Student Health and Learning Following the insulin regimen is critical to student success. But just one piece of a comprehensive management plan. Exercise Legal Rights Health & Learning Nutrition Insulin Administration Hypoglycemia & Hyperglycemia Ketones Monitoring Blood Glucose Glucagon Administration

3. 3 Participants will learn: 4 Types of insulin 4 Insulin delivery basics 4 Vial and syringe administration 4 Pen device administration 4 Pump basics Learning Objectives

4. 4 Insulin in Schools Today Many students need to take insulin in school. Insulin regimens vary with each student and over time. Need for assistance will vary as the student progresses in self-management. GOAL: Maintenance of blood glucose target range.

5. 5 Insulin Types Rapid-acting - Humalog ®, Novolog ® Short-acting - Regular Intermediate - Lente, NPH Long-acting - Ultralente, Glargine (Lantus) Storage: Refrigeration or store at temperature less than 86 degrees as specified by DMMP. Refrigerate unopened vials and insulin pens.

6. 6 Basal Insulin Prandial Boluses Insulin 0hr 24hr BG mg/dl Physiologic Insulin Therapy Jameson: I inserted this to help explain basal/bolus therapy and the goals of insulin replacment.. Jameson: I inserted this to help explain basal/bolus therapy and the goals of insulin replacment..

7. 7 Time Activity of Human Insulins Jameson: Not the best picture but it helps the visual learner. Jameson: Not the best picture but it helps the visual learner.

8. 8 Delivery Methods Insulin Syringe Insulin Pen Insulin Pump Jet Injector

9. 9 When to Give Insulin Administer as specified by DMMP: Generally: Before meals or snacks. For blood glucose levels significantly above target range. For moderate, large, or increasing ketones, as per DMMP.

10. 10 Dosing For many students, insulin dose varies, depending upon: Blood glucose readings Food availability/preference Physical activity level Age/body weight Follow prescribed guideline in DMMP.

11. 11 Dosage Specifications DMMP should specify conditions clearly. Dosage based upon insulin to carbohydrate ratios for meals and snacks. Correction dosage to treat hyperglycemia.

12. 12 Insulin Bolus Dosage Amount to “cover” food eaten - Usually calculated as 1 unit per x number gms of carbohydrate - For example: 6 units needed to cover 60 gms CHO if using 1 unit per 10 gms CHO (60/10 = 6) Amount to lower blood sugar to target range - Usually calculated according to sliding scale or correction factor - Sliding scale: give units of insulin for each range of BG indicated on DMMP - Correction factor: Blood glucose level – target blood glucose/correction factor = units insulin to be given - Ex: BG=150 (actual) minus Target BG (100) = 50 divided by Correction factor (50) = 1 unit insulin needed Add together to get Insulin Bolus Dosage

13. 13 Insulin Syringes Sizes – 30, 50, 100 units Disposal-

14. 14 Syringe & Vial: Preparation 1. Get Supplies Insulin (Verify) Syringe Alcohol wipe Disposable gloves Sharps container

15. 15 Syringe & Vial: Preparation 2. Wash hands; apply gloves 3. Clean the insulin vial

16. 16 Syringe & Vial: Preparation 4. Have student select injection site. 5. Clean the injection site

17. 17 Syringe & Vial: Preparation 6. Check the insulin dose 7. Remove the cap from syringe.

18. 18 Syringe & Vial: Dosing 8. Pull the plunger down to number of units to be administered. 9. Inject air into bottle.

19. 19 Check Dose 10. Draw out prescribed number of units of insulin as per DMMP. Syringe & Vial: Dosing

20. 20 Syringe & Vial: Injecting 11. Pinch up the skin. 12. Push needle into skin at 90 . 13. Release pinch. 14. Push the plunger in. 15. Count to “5”. 16. Remove needle and dispose of syringe. 17. Document time, dosage, site, and blood glucose value.

21. 21 On Target! Jameson: I think the purpose is obvious. Jameson: I think the purpose is obvious.

22. 22 Insulin Pen: Devices Prefilled pens Reusable (cartridge) pens Techniques for dose preparation and insulin delivery are similar for both types of pen devices.

23. 23 Insulin Pen: Preparation 1. Gather supplies. Verify insulin type. pen device (with cartridge) pen needle alcohol wipe sharps container 2. Wash hands. 3. Chose injection site 4. Clean injection site 5. Screw on pen needle

24. 24 Insulin Pen: Dosing 6. Prime: Dial “2” units. 7. Hold upright. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows at end of needle. 8. Dial number of units to be administered as per DMMP.

25. 25 Insulin Pen: Injecting 9. Choose and clean injection site. 10. Pinch up the skin. 11. Push the needle into the skin at 90  12. Release pinched skin. 13. Push down on the plunger. 14. Count to “5”. 15. Remove and dispose of pen needle. 16. Document time, dose, site, and blood glucose value.

26. 26 Insulin Pump Therapy Based on what body does naturally - Small amounts of insulin all the time (basal insulin) - Extra doses to cover each meal or snack (bolus insulin) Rapid or Short-Acting Insulin Precision, micro-drop insulin delivery Flexibility

27. 27 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

28. 28 What Pumps Do Bolus for food intake and to correct high blood glucose levels. Many pumps will calculate bolus dosages. Delivers pre-determined amount of basal insulin throughout the day. Some blood glucose meters communicate with pump.

29. 29 Sampling of Pumps Jameson: Updated pictures. Jameson: Updated pictures.

30. 30 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 event the student becomes unconscious or seizes or if instructed by diabetes care provider. Signs/symptoms that pump site may need to be changed by student, parent, or school nurse. When student might need an injection by pen or syringe. Jameson: HRA stands for Health Room Assistant. I think the purpose is pretty clear. Jameson: HRA stands for Health Room Assistant. I think the purpose is pretty clear.

31. 31 Insulin Pump Manufacturers Animas Corporation 1-877-YES-PUMP (937-7867) www.animascorp.com Medtronic MiniMed, Inc. 1-800-MINIMED (646-4633) www.minimed.com Disetronic Medical Systems, Inc. 1-800-280-7801 www.disetronic-usa.com Deltec Cosmo 1-800-826-9703 www.deltec.com

32. 32 Pump Supplies at School Infusion set Reservoir Insulin Skin prep items Alcohol wipes Syringe (in case of malfunction) Pump batteries Inserter (if used) Manufacturers manual, alarm card

33. 33 After Giving Insulin Check site for leakage Correction doses: - Retest per DMMP to check effectiveness. Meal/snack doses: - Timeliness in relation to eating - Supervision of food amount per DMMP