1. Diabetic Care Provider Training © A Level III Course

2. Diabetes is Here to Stay! n Seventeen million Americans have diabetes, and over 200,000 people die each year of related complications. n 41 million Americans have pre-diabetes [blood glucose higher than normal, but not high enough to be diagnosed as diabetes yet] n Diabetes can cause heart disease, stroke, blindness, kidney failure, leg and foot amputations, pregnancy complications, and deaths related to flu and pneumonia n Among U.S. adults, diagnosed diabetes increased 49% from 1990 to 2000

3. What is Diabetes? n Diabetes is a serious, chronic disease that impairs the way the body uses food n Insulin, a hormone produced by the pancreas, helps the body convert food into energy n In diabetes, the pancreas does not make insulin or the body cannot use the insulin properly n This can cause the blood sugar level to be too high or too low to be too high or too low

4. Diabetes and Today’s Youth! n Type 1 diabetes in youth: There is a higher incidence in Caucasians The peak incidence occurs during puberty (10-12 years in females; 12-14 years in males) The peak incidence occurs during puberty (10-12 years in females; 12-14 years in males) n Type 2 diabetes in youth: -There is a higher incidence in African- Americans, Hispanics, and Native Americans -There is a higher incidence in African- Americans, Hispanics, and Native Americans -80% of youth may be overweight at time of diagnosis

5. The Cost of Diabetes n In 2002, one dollar out of every 10 healthcare dollars was spent on the treatment of diabetes totaling $132 billion dollars n Direct cost: $92 billion n Indirect cost: $40 billion (disability, work loss and premature death)

6. Diabetes Facts n Diabetes cannot be cured, only managed n Diabetics must carefully balance food, medications and activity levels to keep the blood sugar level as close to normal as possible n Increased exercise, illness and a change in the meal schedule can alter the blood sugar level sugar level

7. 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  Meals and snacks should be carefully timed to balance exercise and insulin/medications

8. 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]

9. Carbohydrate Counting Using the Insulin-to-Carb Ratio The insulin-to-carb ratio:  Varies from student to student  Is determined by the student’s health care team  Should be included in the IHP

10. 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

11. 2 Types of Diabetes Type I n Pancreas does not produce insulin n Must receive insulin through injections or a pump n Most common type afflicting school- age children Type II n Insulin is not used properly in the body n May be able to control the disease with diet and exercise n May require oral medications and/or injections n Obesity is a high risk factor

12. Blood Sugar Levels

13. Hyperglycemia-Possible Causes n too little insulin n decreased physical activity n illness or injury n stress n insulin not utilized efficiently by the body

14. Early Symptoms of HYPERglycemia (High Blood Sugar) n Thirst/dry mouth n Frequent urination n Fatigue/Sleepy n Increased Hunger n Blurred Vision n Lack of concentration

15. Hyperglycemia Symptoms gradually become worse: n Sweet breath n Nausea/stomach pains n Vomiting n Weakness n Confusion n Labored breathing n Unconsciousness/coma

16. Treatment for Hyperglycemia n Test Blood Sugar... If above 250: n If within 30 minutes of lunch, nurse or unlicensed diabetes care assistant to administer correct dose of insulin per IHP n Check urine ketones n If Ketones are negative or small: –Give 1-2 glasses of water every hour n If Ketones are moderate or large: –Student should remain in clinic for monitoring –Notify parent for pick up

17. Treatment for Hyperglycemia (Continued) n If Ketones are moderate or large: –Give 1-2 glasses of water every hour –If student remains at school, retest blood sugar and ketones every 2-3 hours or until ketones are negative n Do not allow student to participate in PE or other forms of exercise if blood sugar is above 250, or if ketones are present n If student develops nausea/vomiting, rapid breathing, and/or fruity odor to the breath, call 911, the nurse and the parents

18. Hypoglycemia-Possible Causes n too much insulin n too little food n extra physical activity

19. Mild Symptoms of HYPOglycemia (Low Blood Sugar) n Headache n Sweating n Shakiness n Pale Skin n Sudden hunger n Stomach ache n Crying n Weakness, fatigue n Numbness of lips/tongue n Yawning n Irritability n Blurred Vision

20. Moderate Symptoms of Hypoglycemia n Droopy eyelids, sleepy n Erratic behavior n Slurred speech n Loss of coordination n Confusion

21. Treatment of Mild - Moderate Hypoglycemia n Test blood sugar, if below 70: n Treat with one of the following carbohydrates: –4 oz. apple or orange juice -- 6 oz. Regular soda –3-4 glucose tablets -- 6 lifesavers (thoroughly chewed) n Observe for 10 minutes then retest and retreat if necessary. After the 2nd treatment, call parent and nurse for further instructions n Can administer Glucose Gel if needed n NEVER leave student unattended

22. An Unlikely Case... n There are many things to do before a person’s blood sugar gets so low that they become unconscious n However, it could be the case that a student does not realize their own symptoms of low blood sugar and are found in a bathroom or on the playground unconscious or seizing

23. Severe Symptoms of Hypoglycemia There are 2 Severe symptoms of Hypoglycemia: Seizuresand/orUnconsciousness

24. Procedure to Follow If you find a Diabetic Student that is unconscious and/or seizing you need to: n Open the airway - mouth open, head tilt, chin lift n Call 911 n Test the student’s blood sugar... If below 70: n Turn the student on his/her side n Administer Glucose Gel & Glucagon n Call the Parent and School Nurse n Provide support and monitor until EMS arrives

25. How to Test Blood Sugar (Only if the student is unable to do so him/herself.)

26. Blood Glucose Testing: Supplies n Gloves n Alcohol prep pad n Finger lancing device (Lancet, Autolet, Penlet, etc.) n Blood Glucose testing meter such as Advantage, Elite One Touch, etc.

27. Clean Hands n Wash your hands n Put on gloves n Clean the area to be tested –Student should wash hands if able –Or if unable, use alcohol pad to wipe tip of finger. Make sure finger is dry before testing

28. Test Strip n Place glucose testing strip into the electronic meter according to manufacturer’s instructions

29. Lancing Device n Prepare lancing device according to manufacturer’s instructions

30. Prepare the Site n Use the side of a finger tip for your site n Hang the arm below the level of the heart for 30 seconds to increase blood flow, then gently squeeze the fingertip in a “milking” fashion to further increase the blood supply to the site

31. Puncture the Site n Hold the lancing device firmly onto the side of the fingertip n Puncture the site with the lancing device Gently squeeze the finger in a downward motion to obtain a large enough drop of blood to cover the test strip

32. Blood onto Strip n Place blood onto testing strip and compete instructions according to manufacturer n Clean off site, use Band Aid if necessary n Record results on the student’s Diabetic Log n Treat according to student’s IHP

33. How to Test for Ketones

34. What are Ketones? n Ketones are acids produced from the breakdown of body fat n Insulin normally controls the production of ketones n People with Diabetes may produce extra ketones if they become unwell (i.e. infection), or stop their insulin injections n Excess ketones cause the blood to become too acidic (ketoacidosis)

35. Testing for Ketones n Saturate the test strip with urine by one of the following: –Student to hold test strip in urine flow –Student to urinate in cup/jar, then strip is dipped into urine n If assisting the pupil, wear gloves during this procedure n Wait for test strip to develop per direction on test strip bottle

36. Testing for Ketones (Continued) n Compare color of strip to chart on bottle. Results will be read as negative, small, moderate, or large n Record results in student’s Diabetes Log and treat according to IHP

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

38. How to Administer Insulin

39. 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

40. Insulin Types  Rapid-acting - Humalog ®, Novolog ®  Short-acting - Regular  Intermediate - NPH  Long-acting - Glargine (Lantus) Storage:  Refrigeration or store at room temperature as specified by the manufacturer

41. Delivery Methods  Insulin Syringe  Insulin Pen  Insulin Pump  Jet Injector

42. When to Give Insulin Administer as specified by IHP, based on the doctor’s orders  Generally:  Before meals  For blood glucose levels significantly above target range  For increased ketones

43. Dosing Specifications For many students, insulin dose varies, depending upon:  Blood glucose readings  Food availability/preference  Physical activity level  Age/body weight The IHP should specify conditions clearly.  Dosage based upon insulin-to-carbohydrate ratios for meals and snacks  Correction dosage of insulin to treat hyperglycemia *Follow the prescribed orders in the IHP*

44. Insulin Syringes  Sizes – 30, 50, 100 units  Disposable

45. The 5 Rights of Medication Administration Right student Right student Right medicine Right medicine Right dosage Right dosage Right time Right time Right method of administering (by mouth, by injection, etc) Right method of administering (by mouth, by injection, etc)

46. Syringe & Vial: Preparation Get Supplies Insulin [Verify with doctor’s orders] Insulin [Verify with doctor’s orders] Syringe Syringe Alcohol wipe Alcohol wipe Disposable gloves Disposable gloves Sharps container Sharps container

47. Syringe & Vial: Preparation Wash hands Wash hands Apply gloves Apply gloves Clean the insulin vial Clean the insulin vial

48. Syringe & Vial: Preparation Have student select injection site [examples of injection sites are abdomen, upper arms and thighs] Have student select injection site [examples of injection sites are abdomen, upper arms and thighs] Clean the injection site Clean the injection site

49. Syringe & Vial: Preparation Check the insulin dose [verify with the doctor’s orders] Check the insulin dose [verify with the doctor’s orders] Remove the cap from syringe Remove the cap from syringe

50. Syringe & Vial: Dosing Pull the plunger down to number of units to be administered Pull the plunger down to number of units to be administered Inject air into bottle Inject air into bottle Draw out prescribed number of units of insulin as per the IHP Draw out prescribed number of units of insulin as per the IHP

51. Remove the Bubbles Hold syringe upright and remove air bubbles by tapping syringe and expelling air Hold syringe upright and remove air bubbles by tapping syringe and expelling air

52. Syringe & Vial: Dosing Verify the correct dose with another RISD employee Verify the correct dose with another RISD employee Check Dose

53. Syringe & Vial: Injecting Pinch up the skin Pinch up the skin Push needle into skin at 90  Push needle into skin at 90  Release pinch Release pinch Push the plunger in Push the plunger in Count to 5 Count to 5 Remove needle and dispose of syringe Remove needle and dispose of syringe DO NOT RECAP NEEDLE! DO NOT RECAP NEEDLE!

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

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

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

57. What is an Insulin Pump? Delivers a steady, preprogrammed dosage of insulin all day Delivers a steady, preprogrammed dosage of insulin all day Adjustments can be made with a bolus dose to accommodate changes in carbohydrate intake Adjustments can be made with a bolus dose to accommodate changes in carbohydrate intake

58. Sampling of Pumps

59. How to Use Glucose Gel

60. What is Glucose Gel, and Why Use It? n Glucose gel is a small tube that looks like cake icing n The gel is readily absorbed in the mucous membranes without the students having to be able to swallow, or if the student is uncooperative/confused n This will help to raise the blood sugar

61. How to use Glucose Gel n Put on Gloves n Turn person on his/her side n Squeeze two inches of gel into the mouth, between the cheek and gums n Rub the outside of the cheek to help the gel absorb quickly n Repeat until the entire tube is empty n Retest the blood sugar in 10 minutes and follow the student’s IHP

62. How to Administer Glucagon

63. n Glucagon is an emergency diabetes medication used during an episode of severe hypoglycemia [low blood sugar] n Glucagon is prescribed by the physician as a part of an extensive diabetes healthcare plan n Glucagon only comes in an injectable form What is Glucagon?

64. Indications to Administer Glucagon Glucagon should ONLY be administered to a Diabetic Student who exhibits the following symptoms of severe hypoglycemia: Glucagon should ONLY be administered to a Diabetic Student who exhibits the following symptoms of severe hypoglycemia: n Seizures and/or Unconsciousness n Get Help—tell someone to call 911!

65. Glucagon n Comes in a individual case for each diabetic student n The medication is pre-measured n The directions for giving the shot are right there for you to review! n It comes in a vial containing powder that must be mixed with the pre-filled syringe

66. Two Makers of Glucagon n The Glucagon Emergency Kit from Novo Nordisk n The Glucagon Emergency Kit from Eli Lilly

67. Prepare the Glucagon n Remove vial cap n Remove needle cover n Inject contents of syringe into vial [held upright] n Remove needle from vial. Handle safely n Swirl vial gently until powder is dissolved and liquid is clear

68. Fill the Syringe Once solution is clear: n Hold vial upside down and withdraw all solution into syringe. If the student weighs less than 44 pounds (about 5 years old), only 1/2 of the solution is withdrawn into the syringe n Remove needle from vial

69. Remove the Bubbles n Hold syringe upright and remove air bubbles by tapping syringe and expelling air

70. Clean the Skin n Expose injection site [upper, outer area of arm or thigh] n Hold syringe safely, use other hand to clean injection site with alcohol Wipe Chosen Site

71. Inject the Glucagon n “Pinch up” skin/ muscle n Insert needle straight into skin/muscle of arm or thigh n Push plunger in to inject Glucagon n Count to 5 Pinch up skin. Push needle straight in! Push plunger in.

72. Remove the Needle n Remove needle while pressing gently with alcohol wipe or cotton ball at injection site n DO NOT RECAP THE NEEDLE! n Massage site for 10 seconds, apply Band-Aid if necessary n Carefully put used syringe back into the Glucagon case Withdraw the needle and wipe the site.

73. After Administration n Keep the student on his/her side - this is the “Recovery Position” that keeps them safe n It may take the student 10-20 minutes to wake up n Maintain an open airway n Wait for EMS - hopefully they’ve already arrived! The Recovery Position

74. Don’t be surprised… n if student doesn’t remember being unconscious, incoherent or has a headache n if blood sugar becomes very high (over 200) n if student has nausea and/or vomiting Remember: Document the event afterwards

75. Thank You! You will have an opportunity to practice these procedures with your school nurse