1. Diabetes Care Tasks at School: What Key Personnel Need to Know Diabetes Care Tasks at School: What Key Personnel Need to Know DIABETES BASICS

2. 2 Overall Goal: Optimal Student Health and Learning Exercise Legal Rights Glucagon Administration Health & Learning Nutrition Insulin Regimen Ketones Monitoring Blood Glucose Hypoglycemia & Hyperglycemia

3. 3 Learning Objectives Participants will learn: 4 What is diabetes? 4 Why care at school is required 4 Basic components of diabetes care at school 4 Short and long term consequences of diabetes

4. 4 What is Diabetes? 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

5. 5 Type 1 Diabetes  auto immune disorder  insulin-producing cells destroyed  age of onset: usually childhood, young adulthood  daily insulin replacement necessary  most prevalent type of diabetes in children and adolescents

6. 6 SYMPTOMS: Type 1 Diabetes increased urination tiredness weight loss CAUSE : uncertain, likely both genetic and environmental factors increased thirst hunger blurred vision ONSET : relatively quick

7. 7 Type 2 Diabetes  Insulin resistance – first step  Age at onset:  Most common in adults  Increasingly common in children  overweight  inactivity

8. 8 SYMPTOMS: ONSET: Type 2 Diabetes some children show no symptoms at diagnosis in children variable timeframe tired, thirsty, hunger, increased urination

9. 9 Diabetes is Managed, But it Does Not Go Away. GOAL: To maintain target blood glucose

10. 10 Constant Juggling: Insulin/medication with: Exercise Food intake Diabetes Management 24/7 BG BG BG &

11. 11 Diabetes Management Proactive  a response is indicated  corrective actions for highs or low  emergency intervention  keep juggling the balls Reactive

12. 12 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.

13. 13 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

14. 14 Diabetes Medical Management Plan A Diabetes Medical Management Plan (PLAN) should be implemented for every student with diabetes. PLAN 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

15. 15 Elements of a PLAN 4 Date of diagnosis 4 Emergency contact information 4 Student’s ability to perform self-management tasks at school 4 List of diabetes equipment and supplies 4 Specific medical orders for blood glucose monitoring, insulin, glucagon, and other medications to be given at school 4 Meal and snack plan 4 Exercise requirements 4 Actions to be taken in response to hypoglycemia and hyperglycemia

16. 16 Quick Reference Plan  Development based on information from students PLAN  Summarizes how to recognize and treat hypoglycemia and hyperglycemia  Distribute to all personnel who have responsibility for students with diabetes

17. 17 Where to Get More Information American Diabetes Association 1-800- DIABETES www.diabetes.org National Diabetes Education Program/NIH www.ndep.nih.gov

18. Diabetes Care Tasks at School: What Key Personnel Need to Know Diabetes Care Tasks at School: What Key Personnel Need to Know HYPOGLYCEMIA AND HYPERGLYCEMIA

19. 19 Learning Objectives Participants will learn : 4 Symptoms of high and low blood glucose 4 Short- and long-term risks 4 Treatment of high and low blood glucose 4 Prevention of high and low blood glucose

20. 20 Vocabulary Carbohydrate-- source of energy for the body. Glucose --a simple sugar found in the blood. the fuel that all body cells need to function HYPOglycemia--a LOW level of glucose in the blood. Quick-acting glucose --foods containing simple sugar that raise blood glucose levels Glucose tablets or gel-- special products that deliver a pre-measured amount of pure glucose. Glucagon-- a hormone given by injection that raises the level of glucose in the blood.

21. 21 HYPOglycemia = LOW sugar Onset: – sudden, – may progress to unconsciousness if not treated – can result in brain damage or death The PLAN should specify signs and action steps each level of severity: – mild – moderate – severe

22. 22 Hypoglycemia:Risks & Complications Greatest immediate danger Not always preventable Impairs cognitive and motor functioning Early recognition and intervention can prevent an emergency

23. 23 Hypoglycemia: Possible Causes ●Too much insulin ●Too little food ●Extra physical activity

24. 24 SeizuresSudden crying Unconsciousness/comaInability to swallow Dazed appearanceExtreme tiredness/fatigue RestlessnessIrritability/frustration ConfusionYawning Moderate to Severe Symptoms Increased heart rate/palpitations Dilated pupilsBlurry vision AnxietyPaleness SweatingWeakness Changed behaviorShakiness SleepinessHunger Mild Symptoms Hypoglycemia: Signs & Symptoms

25. 25 Mild Hypoglycemia: What to do ●Intervene promptly. Follow PLAN. ●Verify with blood glucose test when available. ●When in doubt, always treat. If no meter is available, treat immediately. Have student eat or drink fast acting carbs (15g) –Test blood glucose 10-15 minutes after treatment –Repeat treatment if blood glucose level remains low or if symptoms persist per PLAN –If symptoms continue, call parents per PLAN

26. 26 QUICK ACTING GLUCOSE Treatment for Lows: 15 g Carbohydrate ●4 oz. fruit juice ●15 gm glucose tablets (2-3 tablets) ●1 tube of glucose gel ●1-2 tablespoons of honey ●6 oz. regular (not diet) soda (about half a can)

27. 27 Severe Hypoglycemia Rare, but life threatening, if not treated promptly: ●Place student on his or her side ●Inject glucagon, per student’s PLAN ●Never attempt to put anything in the student’s mouth ●Call 911, then parent/guardian ●Student should respond in 15 to 20 minutes ●Remain with the student until help arrives

28. 28 Hypoglycemia: Prevention ●Keep a quick-acting sugar source with the student. ALWAYS. ●Treat at onset of symptoms ●Eat, Insulin, Test, Exercise ON TIME. ●Ensure reliable insulin dosing, per PLAN. ●Ensure insulin dosing matches food eaten. Watch picky eaters Provide nutritional information to families

29. 29 Hypoglycemia: Prevention ●Consult with parent/guardian when snack, meal or exercise times must be changed. ●Monitor blood-glucose variations on gym days, an extra snack may be required ½ hour before gym or during prolonged vigorous exercise per PLAN. ●A student should never be unattended when a low blood glucose is suspected.

30. 30 Vocabulary Hyperglycemia too high a level of glucose in the blood. Ketones (ketone bodies) Chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy. Diabetic ketoacidosis (DKA) the build up of ketones in the body that can lead to serious illness and coma. Ketone testing a procedure for measuring the level of ketones in the urine or blood.

31. 31 HYPERglycemia = HIGH Sugar ●Too much sugar in the blood, but cells are starving ●Onset: – Severe hyperglycemia is usually slow to develop – Can be rapid with pumps ●Hyperglycemia due to insufficient insulin may lead to diabetic ketoacidosis (DKA) if not treated (mainly in type 1) ●PLAN should specify signs and action steps at each level of severity: – Mild – Moderate – Severe

32. 32 Hyperglycemia: Risks & Complications ●Hyperglycemia due to inadequate insulin can lead to DKA and/or coma or death (mainly in type 1). ●Interferes with a student’s ability to learn and participate. ●Serious complications develop when glucose levels remain above target range over time or are recurring.

33. 33 ●Too little insulin ●Expired insulin ●Food not covered by insulin ●Decreased physical activity ●Illness, injury ●Stress ●Other hormones ●Menstrual periods ●Any combination of the above Hyperglycemia: Possible Causes

34. 34 Severe Symptoms Labored breathing Confused Very weak Unconscious Moderate Symptoms Hyperglycemia: Possible Signs &Symptoms Frequent urination Blurred vision Flushing of skin Increased hunger Fatigue/sleepiness Stomach pains Sweet, fruity breath Weight loss Dry mouth Vomiting Stomach cramps Nausea Mild Symptoms Lack of concentration Thirst

35. 35 Hyperglycemia: What to do Goal: lower the blood glucose to a target range. Follow PLAN Verify with blood glucose test. Check ketones per PLAN. Allow free use of bathroom and access to water. Administer insulin per Recheck blood glucose per PLAN. Call parents per PLAN.

36. 36 Hyperglycemia: Prevention ●Eat, Insulin, Test, Exercise ON TIME. ●Reliable insulin dosing, per PLAN. ●Ensure that food eaten matches insulin dosing: Monitor food intake per PLAN Report binge eating ●Teachers consult parent/guardian prior to extra snacks. ●Consult with parent/guardian when snack, meal, or exercise times must be changed.

37. 37 Hyperglycemia: Prevention ●Take appropriate action if a missed dose is suspected or if an insulin pump malfunctions. ●Avoid “over treating” low blood sugar reactions. ●Respect the students; realize their limits

38. 38 Practical Implications for Educators ●Students with hyperglycemia or hypoglycemia often do not concentrate well. ●During academic testing: Check blood glucose before and during testing, per educational plan. Access to food/drink and restroom. If a serious high or low blood glucose episode occurs, students should be excused with an opportunity for retake.

39. 39 Practical Implications for Educators ●Students should have adequate time for taking medication, checking blood glucose, and eating. ●“Make the right choice the easy choice” by eliminating barriers to: – snacking – blood glucose testing – access to water and bathrooms ●Avoid making judgments based on individual blood glucose readings.

40. Diabetes Care Tasks at School: What Key Personnel Need to Know Diabetes Care Tasks at School: What Key Personnel Need to Know BLOOD GLUCOSE MONITORING

41. 41 Participants will learn: 4 Why blood glucose is monitored 4 When blood glucose should be monitored 4 How to perform a blood glucose check Learning Objectives

42. 42 Blood Glucose Monitoring maintain blood glucose within target range. GOAL: IMMEDIATE BENEFIT: LONG-TERM BENEFIT: CHALLENGE: maximize learning and participation. prevention of lows and highs. decrease risk of long-term complications maximize health. many variables can impact blood-glucose.

43. 43 Role of the School ●Facilitate blood glucose monitoring per PLAN ●Act on blood glucose check results per PLAN ●Provide monitoring data to parent/guardian

44. 44 Benefits of School Blood Glucose Monitoring ●Enables maintenance of blood glucose levels within target range for safety; promotes long term health and optimal academic performance ●Identifies factors that affect blood glucose

45. 45 Any Time, Any Place Monitoring ●better blood glucose control ●safer for student ●student gains independence ●less stigma ●less time out of class. For students who can self-check:

46. 46 Basic Steps ●Know the target range per PLAN ●Check at times specified in PLAN ●Immediate Action – Treatment to get back within target range

47. 47 When to Check? ●PLAN specifies for an individual student Regularly scheduled checks: Routine monitoring before meals and snacks Before, during and/or after exercise

48. 48 When to Check? Extra checks may be necessary: Periods of stress or illness Hypoglycemia or hyperglycemia symptoms Change in diabetes management – Insulin/medication doses – Meal plan – Activity

49. 49 Lancing Devices Lancets Pen-type Lancing Devices

50. 50 Know the Meter Features vary: – Ease of use – Sample size needed – Wait time – Alternate-site testing capacity – Ability to reapply, if insufficient sample Become familiar with the operation of each student’s meter

51. 51 Preparation 1. Gather blood glucose monitoring supplies: -Lancet -Test strips -Meter 2. Wash hands. 3. If assisting or performing for student, put on disposable gloves.

52. 52 Readying the Meter 4. Turn the meter on 5. Check code # 6. Insert a strip into the meter

53. 53 Lancing the Finger 7. Hold the lancet device to the side of the finger and press the button to stick the finger.

54. 54 Applying Blood to Strip Drop, not smear Cover ALL of test strip window Some strips suck blood onto the strip 8. Follow instructions included with the meter when applying blood to strip

55. 55 250 5 35 3 Results 9. Wait until blood glucose results displayed. 10. Dispose of lancet 11. Record blood glucose results, take action per PLAN.

56. 56 What does the display mean? Check manual Contact manufacturer (1-800; Website)

57. 57 What does the number mean? Reference student’s target range Individualized for student May vary throughout day Take action per PLAN Communicate sensitively

58. INSULIN ADMINISTRATION

59. 59 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

60. 60 Insulin in Schools Today ●Many students need to take insulin in school ●Insulin regimens vary ●Need for assistance will vary. ●GOAL: Maintenance of blood glucose target range

61. 61 Insulin Types ●Rapid-acting – Humalog ®, Novolog ® ●Short-acting - Regular ●Intermediate - Lente, NPH ●Long-acting - Ultralente, Glargine (Lantus) Storage: ●Refrigeration or store at room temperature as specified by PLAN.

62. 62 Delivery Methods ●Insulin Syringe ●Insulin Pen ●Insulin Pump ●Jet Injector

63. 63 When to Give Insulin Administer as specified by PLAN: Generally: ●Before meals ●For blood glucose levels significantly above target range ●For increased ketones

64. 64 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 PLAN.

65. 65 Dosage Specifications PLAN should specify conditions clearly. ●Dosage based upon insulin to carbohydrate ratios for meals and snacks ●Correction dosage to treat hyperglycemia

66. 66 Insulin Syringes ●Sizes – 30, 50, 100 units ●Disposal-

67. 67 Syringe & Vial: Preparation 1. Get Supplies Insulin (Verify) Syringe Alcohol wipe Disposable gloves Sharps container

68. 68 Syringe & Vial: Preparation 2. Wash hands; apply gloves 3. Clean the insulin vial

69. 69 Syringe & Vial: Preparation 4. Have student select injection site. 5. Clean the injection site

70. 70 Syringe & Vial: Preparation 6. Check the insulin dose 7. Remove the cap from syringe.

71. 71 Syringe & Vial: Dosing 8. Pull the plunger down to number of units to be administered. 9. Inject air into bottle.

72. 72 Check Dose 10. Draw out prescribed number of units of insulin as per PLAN. Syringe & Vial: Dosing

73. 73 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.

74. 74 Insulin Pen: Devices ●Prefilled pens ●Reusable (cartridge) pens Techniques for dose preparation and insulin delivery are similar for both types of pen devices.

75. 75 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

76. 76 Insulin Pen: Dosing 6. Prime: Dial “2” units. 7. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows. 8. Dial number of units to be administered as per PLAN.

77. 77 Insulin Pen: Injecting 9. Pinch up the skin. 10. Push the needle into the skin at 90  11. Release pinched skin. 12. Push down on the plunger. 13. Count to “5”. 14. Remove and dispose of pen needle.

78. 78 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

79. 79 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

80. 80 Sampling of Pumps

81. 81 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

82. 82 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

83. 83 After Giving Insulin ●Check site for leakage ●Correction doses: Retest per PLAN ●Meal/snack doses: Timeliness Supervision of food amount per PLAN

84. KETONE MONITORING

85. 85 Participants will learn: 4 What ketones are 4 Why ketones are monitored 4 When ketones should be monitored 4 How to perform a ketone test 4 When to contact parent/guardian or student’s health care provider Learning Objectives

86. 86 Why test for ketones? ●Ketones(acids) can build up and result in diabetic ketoacidosis (DKA). What is DKA? ●Acids that build up in body and cause student to feel ill ●Emergency state, can lead to coma, death. ●Common symptoms include fruity odor to breath, nausea, vomiting, drowsiness ●Number one reason for hospitalizing children with diabetes ●Early detection and treatment of ketones prevents hospitalizations

87. 87 How to test urine ketones 1. Gather supplies 2. Student urinates in clean cup 3. Put on gloves, if performed by someone other than student 4. Dip the ketone test strip in the cup containing urine. 5. Wait 15 - 60 seconds 6. Read results at designated time 7. Record results, take action per PLAN

88. 88 Test Results: Color code  no ketones  trace  small  moderate  large ketones present

89. 89 Treatment of Ketones ●free use of bathroom ●sugar-free liquids ●insulin as per PLAN ●no physical activity ●if vomiting or lethargic, call parents Generally: PLAN specifies for an individual student.

90. GLUCAGON ADMINISTRATION

91. 91 Participants will learn: 4 What glucagon is 4 How glucagon should be stored 4 When glucagon is used 4 How to administer glucagon Learning Objectives

92. 92 What is Glucagon? ●Naturally occurring hormone made in the pancreas ●A life-saving, injectable hormone that raises blood glucose level ●Treatment for severe hypoglycemia ●Can save a life ●Cannot harm a student

93. 93 Glucagon Kit Storage ●Place: As designated in PLAN. ●Store at room temperature ●Expiration date: Monitor ●After mixing, dispose of any unused portion.

94. 94 1 mg of freeze-dried glucagon (Vial) 1 ml of water for reconstitution (Syringe) Emergency Kit Contents: Combine immediately before use

95. 95 When to Give Glucagon If authorized by the student’s PLAN and if student exhibits: Unconsciousness, unresponsiveness Convulsions or seizures Inability to safely eat or drink

96. 96 Procedure: Act Immediately ●Position student safely on side for comfort and protection from injury ●Call 911, parents, school nurse as per PLAN

97. 97 Preparation 1. Flip cap off glass vial containing dry powder 2. Remove cap from syringe

98. 98 Mixing Solution 3. Inject entire fluid in syringe into the bottle containing powder 4. Shake gently or roll to mix until all powder is dissolved and solution is clear.

99. 99 Drawing out 5. Inspect. Solution should be clear and colorless. 6. Draw prescribed amount of glucagon back into syringe.

100. 100 Dosing & Injecting 7. Clean site if possible 8. Inject at 90° into the tissue under cleansed area, using the same technique as an insulin injection (however, needle is much larger than insulin syringe needle) buttocks thigh arm

101. 101 After Injecting 11.May take 15-20 minutes for student to regain consciousness. 12.Check blood sugar. 13.Give sips of fruit juice or regular soda, once student is awake and able to drink. 14. Advance diet as tolerated. 15. Document as per PLAN

102. 102 Don't be surprised if... ●Student does not remember being unconscious, incoherent or has a headache ●Blood sugar becomes very high (over 200) ●Nausea or vomiting occurs

103. NUTRITION AND EXERCISE

104. 104 Learning Objectives Participants will learn: 4 Basic meal plans for students with diabetes 4 Nutrition calculation methods 4 Exercise benefits for students with diabetes 4 Exercise guidelines for students with diabetes

105. 105 Nutrition: Why be concerned?  Good nutrition is important for everyone  Nutrition planning is essential for good diabetes control:  maintain blood-glucose within target range  to prevent or delay complications  to help children and teens grow and develop properly

106. 106 School Nutrition Management Student’s family and health care team determine an individualized meal plan Meals & snacks need to be carefully timed to balance exercise and insulin/medications Encourage healthy eating for all students

107. 107 Basic Meal Plans Key: Balance insulin/medications with carbohydrate intake Most students have flexibility in WHAT to eat. Exchange System Basic Carbohydrate Counting Advanced Carbohydrate Counting Many students have flexibility in WHEN to eat. More precise insulin delivery (pumps, pens) New insulins

108. 108 Basic Carbohydrate Counting Calories from: carbohydrate protein fat Each nutrient type affects blood sugar differently. Carbohydrate has the biggest effect on blood sugar. TOTAL carbohydrate matters more than the source (sugar or starch.)

109. 109 Advanced Carbohydrate Counting The insulin-to-carb ratio: Varies from student to student. Is determined by the student’s health care team Should be included in the PLAN USING THE INSULIN-TO-CARB RATIO

110. 110 School Meals & Snacks Provide school menus and nutrition information to student/family in advance Provide sufficient time for eating Monitor actual food intake per PLAN young, or newly diagnosed picky eaters Respect, encourage independence

111. 111 Beyond the Routine: School Parties  Provide parent/guardian with advance notice of parties/special events.  Follow the student’s PLAN and 504 Plan or IEP  Some students will prefer to bring their own foods.  Provide nutritious party snacks to encourage healthy eating habits for all.

112. 112 What every student with diabetes wants you to remember: Sugar is NOT the Enemy There is no justification for complete restriction of sugar : Sometimes sugar can be a life-saving friend! However, timing matters a lot with diabetes, and sometimes sugar (or any carbohydrate) is not a good choice at all.

113. 113 Beyond the Routine: Field Trips Bring plenty of snacks to treat hypoglycemia. Bring lunch as appropriate. Consult with parent/guardian about food and/or insulin adjustments for extra activity level. Bring diabetes equipment and supplies. Bring list of emergency contacts

114. 114 Exercise & Diabetes Everyone benefits from exercise and physical activity. Students with diabetes should fully participate. In general, exercise lowers blood sugar levels. May need to make adjustments to insulin/medications and food intake. A quick-acting source of glucose, glucose meter, and water should always be available. PE teachers and coaches must be familiar with symptoms of both high and low blood glucose.

115. 115 Exercise & Blood Glucose Monitoring Check before, during, and after exercise per PLAN. Especially when trying a new activity or sport If blood sugar starts to fall, student should stop and have a snack Students with pumps may disconnect or adjust the basal rate downward, in lieu of snacking (per PLAN)

116. 116 Exercise & Insulin/Medication Physical activity can raise blood glucose levels if there is insufficient insulin.  follow PLAN for exercise restrictions when ketones are present Work with parent/guardian to determine the best times for physical activity.

117. LEGAL CONSIDERATIONS

118. 118 Learning Objectives Participants will learn about: 4 Federal laws that protect students with diabetes 4 Impact of state laws upon diabetes care in the school setting 4 Recommendations for 504 Plan or IEP

119. 119 Eliminate Discrimination ●Equal access to educational and school related opportunities. Secure Care ●A medically safe environment for students with diabetes. Needs of children with diabetes in school setting...

120. 120 Federal Laws: Equal Access ●Section 504 - Section 504 of the Rehabilitation Act of 1973 ●ADA - Americans with Disabilities Act ●IDEA - Individuals with Disabilities Education Act

121. 121 Federal Protections ●Prohibits discrimination against people with disabilities by public schools and most private schools that receive federal funds ●Students must be given equal opportunity ●Related aids and services are required to meet the individual needs of a student with disability

122. 122 Written Plans ● Educational needs: 504 Plan IEP ● Health care needs: Diabetes Medical Management Plan (PLAN)

123. 123 Needs Addressed by 504 Plan/IEP Plan ●Location and timing of blood glucose monitoring ●Identity of trained diabetes personnel ●Location of diabetes supplies ●Free access to water and restroom ●Nutritional needs, meals and snacks

124. 124 Needs Addressed by 504 Plan/IEP Plan ●Full participation in all school-sponsored activities ●Alternative times for academic exams if student is experiencing hypoglycemia or hyperglycemia ●Absences without penalty for doctors’ appointments and diabetes-related illness ●Maintenance of confidentiality and student’s right to privacy

125. 125 State Laws & Regulations ●State and local laws and regulations vary regarding who may perform various aspects of diabetes care ●Become familiar with state and local laws that impact school diabetes care ●Regardless of state and local law, the requirements of federal laws must be met