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In this Chapter

• School Health Room Aide - When a New Diabetic Student Enters School

• Diabetes Description

• Hypoglycemia (Low Blood Sugar)

• Hyperglycemia (High Blood Sugar)

• What is Diabetes?

• Management of the Student with Diabetes

• Responsibilities of the Core Team

  • Healthcare Provider

  • Parent/Guardian

  • Student with Diabetes

  • Student Self-Management Request Procedure

  • School Registered Nurse

  • Health Room Aide

  • Food and Nutrition Services (FNS)

  • Educational Personnel

  • School Counselor / Social Worker

  • School Administrator

  • Transportation Director and Bus Drivers

• Field Trip Procedure for Diabetic Students

  • Parent/Guardian responsibility

  • School’s Responsibility

  • Field Trip - Blood Glucose Monitoring Procedure

• Disaster Preparedness

• Nutritional Requirements and Snacks

  • Principles of Healthy Eating

  • Medical Nutrition for Students with Diabetes

    • Type 1 Diabetes

    • Type 2 Diabetes

  • Carbohydrate Counting

  • Meal Planning Approaches

    • Consistent Carbohydrate Approach

    • Carbohydrate-to-Insulin Ratios

    • Exchange Meal Plan

  • General Guidelines for Daily Carbohydrate Intake

  • Carbohydrate Counting Tables

• Exercise and Sports

  • General Physical Activity Guidelines

  • General Guidelines to Increase Food Intake for Activity

• Blood Glucose Monitoring

  • Blood Glucose Meter

  • Continuous Glucose Monitor (CGM)

• Ketone Monitoring

• Ketoacidosis

• Insulin

  • General Information

  • Types of Insulin and Duration

• Insulin Delivery System

  • Syringes

  • Insulin Pens

  • Pumps

  • Responsibilities of Pump Wearer

• Resources

• Glossary of Diabetic Terms

SCHOOL HEALTH ROOM AIDE - WHEN A NEW DIABETIC STUDENT ENTERS SCHOOL

New diabetic student procedures: 

• Obtain parent telephone number/s.

• Inform parent that the school registered nurse will contact them to discuss the student's condition, set up a plan of care, and provide relevant forms.

• Let the parent know that until the registered nurse meets with them, they are responsible for their student's diabetes care while in school.

• Immediately notify the school registered nurse of the student's presence and give the nurse the parent's phone number.   The nurse will follow-up with the parents and provide them with the required documents.

Description:   

Diabetes is a chronic disease that impairs the body's ability to use food for energy, causing a need to achieve a balance between insulin therapy, diet, and activity.

HYPOGLYCEMIA  (LOW BLOOD SUGAR)

Hypoglycemia First Aid Pictorial - See forms to download

Description:   

Hypoglycemia (low blood glucose) is defined as a blood glucose level less than 70 mg/dl (or as specified in the student’s Diabetes Medical Management Plan). The student may feel “low” and show any of the symptoms below.  A low blood glucose episode does not feel good and may be frightening for the student.  Low blood glucose can develop within minutes and requires immediate attention.  Never send a child with suspected low blood glucose anywhere alone. 

Causes: 

• Too much insulin

• Late food or too little food

• Too much or too intense exercise

• A planned or unplanned activity without additional food

Onset:

• Sudden

Signs and Symptoms:  

Symptoms can vary with each student as well as each hypoglycemic event.  Some children will not have an awareness of low blood sugar symptoms.

Mild:

• Hunger

• Shakiness

• Weakness

• Paleness

• Anxiety

• Irritability

• Dizziness

• Sweating

• Drowsiness

• Personality Change

• Inability to concentrate

Moderate:

• A headache

• Behavior change

• Poor coordination

• Blurry vision

• Weakness

• Slurred speech

• Confusion

Severe:

• Loss of consciousness

• Seizure

• Inability to swallow

NOTE:  Refer to the Diabetic Medical Management Plan - MD orders.

If symptoms occur and the student is CONSCIOUS:

1.   Notify health room.  Health room aide will notify the school nurse.
2.   Give 15 grams of fast-acting sugar like glucose tabs, candy, juice, or soft drink or as directed by the Diabetes Management Plan.
3.   Test blood glucose - ask the student if a meal/snack was missed.
4.   Wait 15 minutes then re-test blood glucose.
5.   In target? Stop treating.
6.   Below target?  Repeat glucose (Step 2.)
7.   If no improvement, call the parent and advise medical assessment.

If a student is or becomes UNCONSCIOUS:

1.   Notify health room.  Health room aide will notify school RN.
2.   Check Airway, Breathing, and Circulation and initiate CPR as needed.
3.   Call 911.
4.   If CPR is not needed, position student on side.
5.   Follow physician’s orders for management of low blood sugar - administer glucagon per MD's orders, if available
6.   Place a small amount of table sugar/cake frosting inside the cheek below gum line and massage over the outer cheek. (DO NOT give liquids.)
7.   Test blood sugar.
8.   School RN/Health room aide will notify parent /principal.

HYPERGLYCEMIA  (HIGH BLOOD SUGAR)

Hyperglycemia First Aid Pictorial - See forms to download

Description:   

Hyperglycemia (high blood sugar) is defined as a blood sugar level greater than 240 mg/dl. It occurs over time, hours and days, and indicates the need for evaluation of management. 

Causes:

• Too much food

• Too little insulin

• Illness

• Infection          

• Decreased activity      

• Stress                        

• Increased growth                      

• Puberty  

Onset:

• Over time – several hours or days 

Signs and Symptoms:

Mild:

• Thirst

• Frequent urination

• Fatigue/sleepiness

• Increased Hunger 

• Blurred vision

• Weight Loss

• Stomach pains

• Flushing of skin

• Lack of concentration

• Sweet, fruity breath

Moderate:

• Mild symptoms plus:

• Dry mouth

• Nausea 

• Stomach cramps

• Vomiting 

Severe:

• Mild and moderate symptoms plus:

• Labored breathing

• Very weak 

• Confused

• Unconscious

NOTE:  Refer to Diabetic Medical Management Plan - MD orders

If symptoms occur and the student is CONSCIOUS:

1.   Notify health room.  Health room aide will notify school RN.
2.   Test blood sugar.
3.   Test for ketones and take appropriate action per physician’s orders.
4.   Administer insulin per physician’s orders.
5.   Follow physician’s orders for management of high blood sugar.
6.   Encourage the student to drink water or sugar-free drinks.
7.   Allow student free use of the bathroom.
8.   School RN/Health room aide will notify the parent.

If a student is or becomes UNCONSCIOUS: 

1.   Notify health room.  Health room aide will notify school RN. 
2.   Check Airway, Breathing, and Circulation and initiate CPR as needed.
3.   Call 911.
4.   School RN/Health room aide will notify parent /principal.

WHAT IS DIABETES?

Type 1 diabetes is more commonly diagnosed in children than in adults.  In this form, the body has no ability to produce insulin, and the blood glucose is controlled with the administration of insulin, along with blood glucose monitoring, exercise, and healthy eating.  Failure to maintain control of blood glucose levels may result in a coma if levels are too high, or unconsciousness and even death if levels are extremely low.

Type 2 diabetes was generally thought of as adult diabetes, however, it is becoming increasingly prevalent in school children, most likely due to increases in childhood obesity.  In this form, the pancreas makes some insulin, but either it cannot make enough or the insulin it does make does not work very well.  Blood glucose may be controlled with blood glucose monitoring, exercise and healthy eating, and/or oral medications/insulin injections.  Children with type 2 diabetes are not as prone to dramatic swings between high and low blood sugars as children with type 1 diabetes.

There is no cure for diabetes but good health care and self-management can greatly improve the health outcome for children with diabetes.  Achieving good blood glucose control usually requires frequent blood glucose monitoring, regular physical activity, and nutrition therapy and may require multiple doses of insulin per day or insulin administered with an infusion pump. 

The medical treatment plan is directed at managing diabetes by balancing exercise, nutrition, and insulin and/or oral diabetic medications.  Students who can control their diabetes by maintaining normal or close to normal blood sugar levels lower their risk of complications and enjoy a better quality of life.  The individualized health care plan, written by the school nurse, should outline student-specific signs and symptoms of hypo- and hyperglycemia (low and high blood glucose levels) and guidelines for carrying out the medical treatment plan in the school setting.

According to the American Diabetes Association, appropriate diabetes care in the school is necessary for the student’s long-term well-being and optimal academic performance.  Even mild low blood glucose levels can lead to immediate consequences in the classroom such as a decrease in cognition, lack of attention to detail and difficulty with decision making.  Extremely low blood glucose levels can cause unconsciousness or even death.  High blood glucose levels can contribute to long-term complications such as damage to the eyes, kidneys, nerves and blood vessels.

MANAGEMENT OF THE STUDENT WITH DIABETES

The safety of the diabetic student is the primary consideration in the delivery of all health-related services provided in the school.  Diabetes management is best done using a core team approach. Upon identification of a student with diabetes, members of the core team implement these guidelines and take responsibility for their role as outlined. 

RESPONSIBILITIES OF THE CORE TEAM

Healthcare Provider

The physician/healthcare provider should provide information and guidance to the school RN to use in developing the Individual Health Care Plan (IHP).  Physicians should take into consideration the resources available in the school to assist students with their care. 

To safeguard student health, the physician should:

• Provide the school RN with all medical documentation as requested, including written orders on the Diabetic Medical Management Plan.

• Be accessible by phone or fax to review or contribute to the IHP and for emergency orders.

• Educate the student and the parent/guardian regarding management of diabetes.

• Determine the level of self-care allowed based on the student’s knowledge, developmental level, and abilities. 

Parent/Guardian  

According to the School Health Services Act (s. 381.0056 F.S.), school health services supplement rather than replace parental responsibility.  

In order for children to receive the services they need in the safest possible manner while in school, it is important for parents and guardians to:  

• Inform the school as soon as possible when a student is newly diagnosed as having diabetes or when a previously diagnosed student enrolls in a new school so that planning and training of personnel can be arranged quickly. Ideally, parents should work with the school staff prior to their child’s admittance to ease the student‘s transition into the school environment.  

• Provide the school with accurate and current emergency contact information. 

• Provide the school with the health care provider’s written medical orders related to the student’s diabetes management. 

• Participate in a care planning conference as soon as possible after diagnosis and at the start of each school year. 

• Provide the school nurse with any new written medical orders when there are changes in the medical management that must be implemented in school. 

• Provide and transport to the school all medications, equipment, supplies, and carbohydrate snacks associated with the medical management of the student’s diabetes. 

• Assume responsibility for the maintenance and calibration of all medical equipment.

• Accept financial responsibility for 911 calls and transportation to the hospital if needed. 

• Sign appropriate written permission for authorization of treatment and sharing of three health related information.

• Provide the student with a medical identification tag or jewelry and encourage the student to wear it in school. 

• Work with health care providers, their staff, and the child to promote self-sufficiency in diabetic management.  

It is recommended that the parent/guardian work with the health care provider to complete the Diabetes Medical Management Plan recommended by the Governor’s Diabetes Advisory Council and, if appropriate, the Diabetes Medical Management Plan Supplement for Student Wearing an Insulin Pump. 

Student with Diabetes  

To remain active and healthy, the student with diabetes should learn to maintain blood glucose levels within a target range.  School health policy and staff will promote and support the student toward self-sufficiency and independence in following the medical management plan designed by their health care provider.  The student, however, must also assume some of the responsibility.

The following responsible actions are recommended:

• Cooperate with school personnel in implementing the diabetes plan of care. 

• Wear medical identification tag or jewelry while in school. 

• Observe all local policies and procedures related to blood and body fluid precautions and sharps disposals. 

• Seek adult help immediately when low blood glucose levels are suspected or verified by blood glucose monitoring. 

• Record and report all blood glucose monitoring according to the medical plan of care. 

• Conform to all nutritional guidelines according to the medical plan of care. 

• Complete the initial and ongoing diabetes education provided by the primary health care provider. 

• Seek authorization from the primary health care provider, parent and school nurse to function independently. 

• Demonstrate competence in blood glucose monitoring and insulin administration in the school setting. 

• Agree to follow the local policies and safety procedures and Student Handbook regulations.  

Diabetes Student Self-Management Procedure

Requests for Blood Glucose Monitoring and Diabetes Self-Management in the Educational setting are initiated by parent/guardian(s) of the student.

1.   The following forms are to be given to the parent:

• The Blood Glucose Testing and Diabetes Self-Management in the Educational Setting Physician’s Report is to be completed by the child’s Primary Diabetes Physician initially and if a student fails to demonstrate appropriate diabetes management skills at annual evaluation by the school nurse.

• The Affidavit – Medical Release Form for Student Blood Glucose Monitoring and Diabetes Self-Management in the Educational Setting is to be completed by the parent each school year.

• The Diabetes Medical Management Plan is to be completed by the child’s Primary Diabetes Physician in conjunction with the parent/guardian each school year.

2.   Upon completion of the above, the Registered Nurse will observe the student performing blood glucose monitoring and other skills necessary for diabetes self-management, then document the student’s competency in these skills on the Skills Checklist(s) initially and annually for renewal.

3.   The school RN will develop and initiate the Individual Health Care Plan with input from a parent, student and appropriate school personnel.  The plan needs to include provisions for an appropriate private space to facilitate student diabetes management in the educational setting.

4.   The school RN will provide training for the classroom teachers and other appropriate school personnel on an Action Care Plan, including the signs and symptoms of hyper/hypoglycemia.  The school RN will also review the student self-testing process as documented in the student’s individual health care plan.

5.   If there are any concerns regarding the student diabetes self-management, the school RN will be notified and convene the school’s CARE Team.

6.   The following information will be shared with school staff as determined by the school RN:

• Folder with a picture of the student (supplied by a parent)

• Individual Health Care Plan including the Emergency Action Plan for diabetes

• Copy of the signed Affidavit – Medical Release Form  

School Registered Nurse 

The school nurse should function under the scope of practice defined by Florida’s Nurse Practice Act.  The school nurse may be the only full or part-time licensed health care professional in the school setting.  When the school nurse is assigned to multiple schools, the nurse should recognize the need to set students with diabetes as a high priority whenever part or all of their care is delegated to an unlicensed assistive person. 

To ensure the safety of the students, the school nurse should:

• Obtain and maintain a current knowledge base and update skills and abilities related to the medical management of diabetes in the school-age population.  Included in this is knowledge relating to the current standard of care prevalent in the community. 

• Organize and facilitate planning meetings with the student’s parent/guardian and other key school staff to discuss the planning and implementation of the student’s individualized health care plan.  

• Perform a nursing assessment on the student based on a home or school health room visit to obtain health and psycho-social information.  

• Develop an individualized health care plan in cooperation with the student, the parents/guardians, the health care provider, and other school-based staff.   

• Regularly review and update the individualized health care plan whenever there is a change in medical management or the student’s response to care. 

• If necessary, request the health care provider to re-evaluate the student’s competency level to further enhance the student’s independence or, if necessary, to require closer supervision until the student’s knowledge and skills improve. 

• Collaborate with the principal to select and delegate the most appropriate unlicensed assistive personnel for each student. 

• Train and supervise the unlicensed assistive person designated to provide procedures for the student with diabetes. It is recommended that two or more backup persons be trained in each school to assure adequate coverage in an emergency. 

• Communicate pertinent health-related information to teachers and staff.

• Practice universal precautions and infection control procedures at all student encounters and include information in the training for all unlicensed assistive personnel. 

• Train and supervise unlicensed assistive personnel who can serve as a second adult to verify any dose of insulin administered by the student in school. 

• Provide or arrange for child-specific training to all school-based personnel who will have direct contact with the student on how to respond in an emergency. 

• Maintain appropriate documentation of the training and care provided and monitor the documentation of services provided by unlicensed assistive personnel.

• Act as a resource to the principal and other school-based personnel, providing or arranging for in-service education appropriate to their level of involvement with the student with diabetes.

• Establish a diabetes resource file of pamphlets, brochures, and other publications for use by school personnel. 

• Establish and maintain a working relationship with the student’s parent/guardians and health care provider and act as a liaison between the student‘s authorized health care provider and the school.

• Participate in Individualized Education Planning or Section 504 planning meetings and provide relevant health information. 

• Serve as the student’s advocate. Respect the student’s confidentiality and right to privacy.

• Establish a process for on-going and emergency communication with the parent/guardian (this should include a parental notification procedure to address repairing or replacing equipment, and replenishing supplies and medications), the authorized health care provider, the unlicensed assistive personnel, and the school staff that come into direct contact with the student.

School Health Room Aide 

When a new diabetic student enters your school:

• Obtain parent telephone number/s.

• Inform parent that the school registered nurse will contact them to discuss the student’s condition, set up a plan of care, and provide relevant forms.

• Let the parent know that until the registered nurse meets with them, they are responsible for the student’s diabetes care while in school. 

• Immediately notify the school registered nurse of the student’s presence and give RN the parent’s phone number.  The RN will follow-up with the parents and provide them with the required documents. 

Health room aides (HRA) perform under the administrative supervision of the School Principal and have the guidance and direction of the school RN for health-related issues.  The HRA performs services within the school health services program according to the written policies and procedures in the School Health Services Manual. 

The health room aide should: 

• Develop (in collaboration with the school RN) a current high-risk list of students with diabetes.

• Be familiar with the IHP of the student with diabetes.

• Assist parents and school staff in assuring the student has supplies that are up to date at all times.

• Be trained (by the school RN) about the signs and symptoms of hypoglycemia and hyperglycemia and ketone monitoring.

• Demonstrate competency in the use of child-specific glucose monitoring device, blood glucose testing, and monitoring the student's use of insulin pens and/or other equipment used.

• Have sharps disposal container in the health room.

• Always have snacks and fast-acting sugar source (supplied by parent/guardian) available in the health room as designated on the IHP.

• Arrange for the child to be accompanied by an adult (preferred) or classmate to the health room to check blood sugar.

• Encourage the student to test blood sugar: 

  • If the child “feels low” or demonstrates signs of low blood sugar

  • If the child feels sick

  • According to orders from physician

• Assist with arrangements to make sure that ALL INSULIN INJECTIONS AND BLOOD GLUCOSE MONITORING/TESTING IS DONE IN THE HEALTH ROOM according to Sarasota County School Board Exposure Control Plan and school board procedure unless specified otherwise in the IHP.

• Record blood sugar results in SIS and Procedure/Treatment Log for diabetes with date, time, result and treatment.

• Provide emergency treatment and supportive care, in accordance with the established emergency care plan, for students having an insulin reaction.

• Maintain student confidentiality.

• Be knowledgeable about activation of emergency services (call 911 first, then notify principal, parent/guardian, and school RN).

NOTE: Insulin shall only be given by licensed medical personnel as designated in their job description. 

Food and Nutrition Services (FNS)

Food and Nutrition service staff members play an important role in providing nutritional and balanced meal for all students, including diabetic students. FNS has published carbohydrate counts for each week’s menu, via the Nutrislice website (sarasotacountyschools.nutrislice.com). 

The Food and Nutrition Services should:

• Keep information about diabetic students readily available.

• FNS manager and lunchroom aide should be knowledgeable about activation of emergency services.

• If a student appears distressed, the FNS manager or lunchroom aide will facilitate the student’s safe transport to the clinic for monitoring and/or assessment by the assigned school RN.

Educational Personnel (teachers, aids, coaches, before-and after-school program staff)  

To the extent possible, teachers and coaches should provide a supportive learning environment and treat the student with diabetes the same as any other student while at the same time making the required accommodations.  Not all teachers or coaches in a school will have direct contact with the student who has diabetes. 

If the teachers or coaches are scheduled to have direct contact with the student, the teachers/coaches and before- and after-school program staff should:  

• Be aware of which students have diabetes and cooperate with the accommodations listed in the individualized health care plan or Section 504 Plan. 

• Recognize the signs and symptoms associated with hypo- and hyperglycemia. 

• Be aware of any student-specific emergency actions that might be necessary. 

• Provide the student with a safe location (if possible) to monitor blood glucose or administer insulin in accordance with the student’s individualized health care plan. 

• Monitor before exercise or strenuous activity and allow for snacks before and after the physical activity if indicated in the student’s individualized health care plan. 

• Communicate with health room aide or school nurse when a field trip or class party might require an adjustment in their meal plan or insulin administration. (See Field Trip Procedure for Diabetic Students below) 

• Leave a clear message for any substitute regarding the special needs of the student. 

• Respect the student‘s right to confidentiality and privacy.

NOTE: With the parents/guardians and the student‘s permission, the teacher or the school nurse may educate the class about the special needs of an individual with diabetes and use this as an opportunity to educate students regarding nutrition, exercise, and health.

School Counselor/Social Worker 

While the school counselor and/or social worker may not always have direct contact with the student, they should be aware of the students in their schools who have diabetes and the potential impact of diabetes and its treatment on the student‘s behavior and performance.  The school counselor or social worker may be called upon to assist the student with any expressed concerns regarding diabetes and to identify and respond to ineffective coping mechanisms demonstrated by the student or the family as they relate to school performance and attendance.  The school counselor/social worker should be familiar with community resources and services available to assist the student and family. 

School Administrator

The principal should set the example for the rest of the school-based staff to create a safe environment for the student with diabetes. 

The principal should:

• Provide leadership for all school-based personnel to ensure that all health policies related to diabetes management at school are current and implemented. 

• Be aware of the federal and state laws governing the educational requirements for students with diabetes. 

• Collaborate with the school nurse in selecting and designating unlicensed assistive personnel to provide the student-specific services required for each student with diabetes in their school.

• Require that each designated unlicensed assistive person complete the necessary general and student-specific training and meet the locally designed competency requirements. 

• Facilitate problem solving and negotiations among members of the school team and the student’s family. 

• Provide physical resources on campus to safely execute all accommodations and activities noted in the individualized health care plan. 

• Respect the student’s confidentiality and right to privacy.

Transportation Director and Bus Drivers 

The bus drivers should: 

• The designated school bus driver should receive notification from the Bus Transportation Director of a student who has diabetes and should know how to implement the emergency response plan.

• Understand that diabetic student may carry snacks or equipment for emergency response and may need to eat and/or drink during the bus ride. 

• Consider encouraging the diabetic student to sit near the front of the bus to allow for closer observation. 

• Communicate to the school nurse any concerns regarding the student’s actions or behavior regarding diabetes management. 

• Respect the student’s right to confidentiality and privacy.

FIELD TRIP PROCEDURES FOR DIABETIC STUDENTS

Parent/Guardian Responsibility

The preference is for the parent/guardian of the diabetic student to accompany their child on the field trip as a volunteer chaperone and supervise or perform the procedure(s) with the child. Parents/guardians must be cleared as a school district volunteer and can perform glucose checking on their own child only. 

Parent/guardian must supply glucometer, appropriate snack(s,) and a suitable high glucose source (such as glucose tablets, a tube of cake frosting, or other oral solution) for their child’s emergency use while on the field trip.

Parent/guardian may want to include a current picture of their child to assist in easy visual identification with the child’s name and emergency phone number on the back.

School’s Responsibility

Teachers will be notified by the School RN when a diabetic student is in their classroom.  The teacher requesting/organizing the field trip will coordinate with the principal, School RN, Health room aide, or designee to meet the diabetic student's health care needs.

An accompanying school board employee must have received child specific training in the blood glucose monitoring procedure as documented on the skills checklist by the school RN. The school board employee must also be trained in the signs/symptoms of high and low blood sugar and follow the student specific emergency care plan.  This employee will supervise the carrying of the glucometer, snack/s, glucose source, a copy of the diabetic orders, and emergency information card.

The teacher in charge of the field trip will have immediate access to communication (i.e. cell phone).

Field Trip - Blood Glucose Monitoring Procedure

• If the student ordinarily performs his own finger stick and testing, he will do this while on the field trip if necessary.  If the student’s parent is present, he/she will supervise/perform the procedure.  If there is a first aid station, trained fire department or EMS personnel may perform the procedure, otherwise, trained school board personnel may perform the procedure. 

• The trained school board employee and another adult will take the student to a quiet area away from everyone to perform the procedure(s).

• The physician orders will be followed if high or low blood sugar is found.  If student appears disoriented or level of consciousness deteriorates after doctor’s orders are followed, call 911.

• No finger sticks or insulin injection will be permitted while on a moving object (i.e. bus).  In an emergency, the bus will pull over to the side of the road. 

• Volunteers cannot perform medical procedures, as per School Board Rule 7.416.

DISASTER PREPAREDNESS

It is most likely that in the face of a natural disaster or emergency all students would be sent home from school.  In the event that environmental hazards exist that would prevent the students from leaving the school, preparations should be made to secure enough emergency food and supplies for 72 hours.  

Each school district and county health department should have disaster plans in place to accommodate the general population.  School administrators or their designees should review those plans to ensure that any food or equipment unique to the needs of students with diabetes is covered by those plans.  If a school nurse is not available during a disaster, the unlicensed assistive person who has been trained to follow the student‘s individualized health care plan should administer care.  Every effort should be made to remove the student with diabetes safely and/or get insulin to the student as quickly as possible.

NUTRITIONAL REQUIREMENTS AND SNACKS

Principles of Healthy Eating  

It is critical to encourage and enable all children, not only those with diabetes, to incorporate more healthy foods and more exercise into their lifestyles. 

For all students, a healthy eating plan provides for: 

• Appropriate calories for normal growth, weight, and development. 

• Improvement or maintenance of overall health through optimal nutrition.

These goals are more easily achieved when there are a variety of healthy foods from which to choose, positive nutritional role models, and a pleasant, un-hurried eating environment. 

Balanced intake, ideally foods from all five food groups, helps to ensure adequate nutrient intake. 

Groups and recommended number of servings for children include:

• Grains, beans, and starchy vegetables (6 or more servings/day) 

• Vegetables (3-5 servings/day) 

• Fruits (2-4 servings/day)

• Meats (2-3 servings/day of 2-3 oz. each) 

• Milk/Dairy (2-3 servings daily) 

• Fats and sweets used sparingly

Nutrients are substances contributed by foods/beverages that are essential to growth and health. 

They include:

• Carbohydrates are the body’s major energy source.  This energy is used as fuel for playing, learning, and growth. Carbohydrates should provide 50-55% of calorie intake.

• Protein builds muscle and bone.  Proteins should provide 10-20% of calories. 

• Fats provide for stored energy and growth, adds flavor to foods, and slows the emptying time after a meal.  Fat calories should provide less than 30% of total calorie intake.  Less than 10% of calories should come from saturated fats. 

• Vitamins/minerals promote growth, formation of blood cells, healthy skin, good vision, strong teeth and bones. 

• Water is the most important nutrient for human survival.  Normal need is at least six 8-oz glasses liquid/day. 

• Fiber provides bulk, which helps satisfy appetite and promote digestion.

It is now widely recognized that many American children take in far more calories at school, at home, or in fast food restaurants than they need.  Dietary fat is a very dense source of calories and is found in large amounts in fast foods.  Sugared sodas and other sugared beverages are being consumed in greater amounts by children, contributing unneeded calories.  Many children have become inactive.  Being overweight/obese has become much more common and as a result the incidence of Type 2 Diabetes has increased.  In addition, excessive dietary fat intake can also lead to problems with blood lipids (cholesterol and triglycerides) and lead to heart disease.

Medical Nutrition Therapy for Students with Diabetes 

The principles of healthy eating and general nutrition-related goals discussed in the previous section also apply to students with diabetes. 

In addition, food management in diabetes should help:

• Keep blood glucose level as close to normal as possible. 

• Normalize lipid levels.

• Avoid long-term complications. 

• Minimize severe hypoglycemia.

Students with diabetes should be allowed to eat the same foods as their peers, but it may be necessary to control some portions and timing of meals and snacks.  The student with diabetes should be able to participate in class parties and food tastings.  Parents and the school personnel can discuss how to best accommodate each child.  While occasional sweets are permitted, it should be remembered that they are often high in fat as well and are not healthy for any students when used to excess.

Type 1 Diabetes  
In type 1 diabetes, the main objective in meal planning is to coordinate the rise in blood glucose from food eaten with the action of insulin taken. The total carbohydrate in the meal (rather than just the carbohydrate from sugars) will have the greatest impact on blood glucose levels.  Carbohydrate foods include milks, grains, fruits, starchy vegetables, juice, and sweets. 

Type 2 Diabetes  
Type 2 diabetes in children can be managed by weight control and exercise but treatment may also require oral medications, insulin, or both.  Most children with type 2 diabetes are overweight or obese.  Making lifestyle changes can be difficult for everyone, especially children.  They need the support of family, friends, and school personnel to be successful.  Community programs that encourage healthy habits have been found most effective.  Putting children on rigorous diets or severely restricting their food choices does not work!  For children that are still growing, often preventing further weight gain will help them reach a healthier weight for height.  

To make type 2 diabetes medications work optimally, carbohydrate intake should be balanced with medication, just as in type 1 diabetes.  Attention should also be paid to fat intake and sodium intake (if the student has developed high blood pressure).

Carbohydrate Counting

Because carbohydrates affect blood glucose levels more than any other nutrient, they are the major focus of most meal planning approaches.  Research has shown that avoiding sweets or foods with sugar is not necessary as long as the carbohydrate content of the particular food is counted.

• Many sugar-free products such as cookies, candies, and ice cream contain similar amounts of carbohydrate as their regular counterparts.  Use of regular products in appropriate portions is preferable.

• Counting carbohydrate by grams involves using food labels and tables to find the amount of carbohydrate in foods. 

• A “carbohydrate choice” is the amount of food that contains 15 grams of carbohydrate.  For most starches and fruits this is a 2 cup serving.

Many excellent references are available to help count carbohydrates.  School food service personnel, parents, and your school RN can help locate resources. 

Meal Planning Approaches

Consistent Carbohydrate Approach 

• This is a meal plan that calls for a child to eat about the same amount of carbohydrate at a certain meal or snack from day to day.  Generally the insulin dose is the same each day. The intermediate-acting insulin given in the AM is expected to balance the carbohydrate eaten at lunch.  This plan can be simple to follow and understand but does not readily allow for changes in a student’s preferences or appetite or unexpected foods. 

Carbohydrate-to-Insulin Ratios 

• This can be thought of as a variable carbohydrate counting approach.  That is, the amount of rapid- or short-acting insulin that is given just before eating is calculated based on the amount of carbohydrate by a pre-determined formula.  While this approach requires a bit more effort, it affords the student the most flexibility in eating amounts and times, and can lower the risk of low blood glucose.

Exchange Meal Plan 

• This is a diet prescription providing for a set amount of servings at each meal and snacks from six food lists.  These food lists group foods together that are similar in calorie, protein, carbohydrate, and fat content.  Foods within a list can be exchanged for one another. This approach provides the most structure but for many can be rather restrictive.  It does assure adequate intake of all nutrients when followed.

General Guidelines for Daily Carbohydrate Intake

Table 1. Snack Examples

15-20 gm carb snacks:

• 1 small apple or orange

• 8 animal crackers

• 4-5 vanilla wafers

• ½ cup applesauce

20-30 gm carb snacks:

• 1 granola bar

• 1 packet of sandwich crackers

• 1 pudding cup

• 1 large banana

Table 2. Meal Carbohydrate Amounts by Age

5-12 years old:   

• Boys/Girls - 45 to 60 grams of carbs at each meal 

Teens:

• Boys - 60 to 75+ grams of carbs at each meal 

• Girls -  45 to 75 grams of carb at each meal    

The student’s registered dietitian or healthcare provider will help determine the amount of carb that is right for each child at each meal. 

Adapted from American Diabetes Association (ADA) (2006) Diabetes Meal Planning Made Easy. (3rd ed.). Alexandria, VA: Warshaw, Hope S.

Carbohydrate Counting 

Knowing the carbohydrate content of given foods allows the student more flexibility in meal planning.  
The following chart illustrates examples of foods that contain approximately 15 grams of carbohydrates.  

One Choice = 15 Gram Carbohydrate

Breads: 

• Bread, white or whole wheat  - 1 slice 

• Bagel, small ≈ 2 oz.  - 1/2

• Biscuit, small ≈ 2 1/2 inch  - 1 

• Bread sticks - 4 inches long  - 2 

• Cereal, cooked with water  -  1/3 - 1/2 cup 

• Cereal, dry - 3/4 cup 

• Crackers, graham -1 1/2 inch sq  - 3

• Crackers, saltines  - 4 

• French toast  - 1 slice

• Grits, cooked  - 1/2 cup 

• Hot dog or hamburger bun 2 oz.  - 1/2 

• Noodles, cooked  - 1/3 cup 

• Pancake - 4 inches  - 1 

• Pasta, cooked  - 1/2 cup 

• Pita bread - 6 inch  - 1/2

• Rice, cooked white or brown  - 1/3 cup 

• Sub roll - 6 inch  - 1/3

• Tortilla, corn (taco shell) - 6 inch  - 1 

• Tortilla, flour - 6 inch   - 1 

• Waffle - 4 inch  - 1

Starchy Vegetables: 

• Corn - 1/2 cup 

• Corn on cob, small  - 1 

• Beans, cooked dried  - 1/2 cup

• Peas, green  - 1/2 cup 

• Potato, baked (after cooking) 
  -  Small (1 ¾ - 2 ½ diameter) - 1/2 potato 
  -  Large (3 - 4¼“ diameter)  - 1/4 potato 

• Potato, mashed  - 1/2 cup 

• Potatoes, French fried ≈10  - 1/2 cup 

• Potatoes, rounds  - 1/2 cup 

• Potato wedges, frozen  - 3/8 cup 

• Sweet potatoes 
  -  Heated, drained  - 1/3 cup 
  -  Mashed  - 1/4 cup

Fruit: 

• Apple, medium - 1 

• Applesauce, unsweetened  - 1/2 cup 

• Apricots, medium  - 4 

• Banana, small (5 inch)  - 1  

• Blackberries  - 3/4 cup

• Blueberries  - 3/4 cup

• Cherries, fresh  - 12

• Fruit cocktail, light syrup  - 1/2 cup

• Grapefruit, large  - 1/2

• Grapes  - 15-17

• Honeydew, diced  - 1 cup    

• Juice - apple, orange, grape  -  6 oz.

• Peach, fresh (2 ½ inch ≈ 6 oz.)  - 1 

• Pears, fresh (2 x 3 inch ≈ 5 oz.)  - 3/4

• Pears, canned, light syrup  - 1/2 cup 

• Pineapple, canned, light syrup  - 1/2 cup 

• Plums, fresh -2 inch ≈ 2 oz.  -  2 

• Orange, fresh (2² inch ≈ 5 oz.)  - 1 

• Strawberries 
  -  Fresh, 1 ¼ inch  - 18 
  -  Frozen, sliced, sweetened   - 1/4 cup 

• Watermelon  - 1 ¼ cups

Milk:

• Hot chocolate mix  - 1/2 cup 

• Ice Cream, low fat  - 1/2 cup 

• Milk, chocolate  - 1/2 cup 

• Milk, skim, 2%, Whole  - 1 cup 

• Pudding, regular  - 1/4 cup 

• Pudding, sugar-free  - 1/2 cup 

• Sherbet  - 1/4 cup

• Yogurt, low fat – plain  - 3/4 cup

Vegetables: 
1/2 cup cooked or 1 cup raw = approximately 5 Gram Carbohydrate   

• Asparagus 

• Beans, green or wax

• Bean sprouts 

• Beets 

• Broccoli 

• Brussel sprouts

• Cabbage

• Carrots

• Cauliflower 

• Celery

• Cucumber

• Eggplant 

• Green onions, scallions 

• Greens 

• Mushrooms 

• Okra 

• Pea pods 

• Peppers 

• Radishes 

• Spinach 

• Summer squash 

• Tomato 

• Turnips 

•  Zucchini

Other Carbohydrates: 
These carbohydrate values represent averages of many brands.  More accurate information can be obtained from food labels or brand-specific nutrition references.
Food – Portion = Grams of Carbs  

• Brownie, without frosting  - 2″ square  = 15 carbs 

• Cake, without frosting  - 2″ square  = 15 carbs 

• Cake, with frosting  - 2″ square  = 30 carbs 

• Cereal breakfast bar - 1 = 20-29 carbs  (see label)

• Chicken noodle soup  - 1 cup  = 15 carbs

• Chicken nuggets  - 6  = 15 carbs 

• Chips, potato or tortilla  - 12 (1 oz.)  = 15 carbs 

• Cinnamon roll  - 2 oz (2 ¾") = 30 carbs 

• Cookies, chocolate chip  - 2  = 15 carbs

• Cookies, sandwich cremes  - 2  = 15 carbs

• Cookie, medium (homemade)  - 1  = 15 carbs

• Corn dog  - 1  = 15 carbs

• Cupcake, with frosting  - 1 small  = 30 carbs

• Doughnut, glazed  - 2 oz. (¾")  = 30 carbs 

• Doughnut, plain cake  - 1 ½ oz.  = 20 carbs

• Ice cream bar  - 1  = 30 carbs 

• Jam or jelly, regular  - 1 Tbsp   = 15 carbs

• Jello, sugared  - ½ cup  = 19 carbs

• Jello, sugar-free  - ½ cup =  0 carbs

• Juice- grape, orange, apple  - 6 oz. can   =  13-16 carbs 

• Macaroni and cheese  - 1 cup  = 30 carbs

• Nachos, with cheese sauce  - 12 chips  = 22 carbs 

• Peanut butter & jelly sandwich 
  -  2 slices bread = 30 carbs
  -  2 oz. Peanut Butter =  13 carbs
  -  1 Table jelly  = 15 carbs 

• Pizza, pan-style  - 1 slice of medium pie  = 30 carbs

• Pizza, thin crust  - 1 slice of medium pie  = 30 carbs 

• Popcorn  - 3 cups  = 15 carbs

• Raisins, seedless  - ¼ cup (75 raisins)  = 30 carbs 

• Salad dressing, reduced calorie  - 1 oz.  = 6 carbs 

• Sodas, cola or lemon-lime  - 12 oz.  = 45 carbs

• Sports drink
  -  Regular  -  1 cup  = 15 carbs
  -  Lo-Carb (Propel, etc.)  - 1 cup  = 5 carbs

• Syrup, light  - 2 Tbsp.  = 15 carbs 

• Syrup, regular  - 1 Tbsp.  = 15 carbs 

• Toaster pastry (unfrosted)  - 1  = 30 carbs 

• Trail mix, commodity  - 1/3 cup  = 22 carbs 

Tables approved by Karla Pignotti Dumas, RD, LD/N 2009.  

EXERCISE AND SPORTS

General Physical Activity Guidelines

• Drink lots of sugar-free fluids, especially water. 

• Have rapid-acting carbohydrate sources available. 

• Test blood sugar according to Individualized Health Care Plan or Physician’s Orders. 

• Wear medical alert identification. 

• To avoid low blood sugar, eat more carbohydrates or talk with your health care provider about reducing the amount of insulin before physical activity. 

• Examples of moderate exercise include walking, leisurely bicycling, playing basketball. 

• Examples of high-intensity exercise include jogging, bicycle racing, and a basketball game.   

General Guidelines to Increase Food Intake for Activity*

Blood Glucose Level  - Intensity of Activity  = Snack (Grams of Carbohydrate)

Before the activity:

• Less than 80  -  No activity until above 80  = 0 grams

• 80-180  - Light  = 15 grams

• 80-180  - Moderate to high  =  15 – 30 grams

• 180-300  = No snack necessary

• 250 or greater - Check for urine ketones, if present – no activity = No snack necessary 

During activity – at 30-minute intervals:

• Less than 120  - Light to moderate  =  15 grams

• Less than 120  - High  = 30 grams

After activity – within 15 minutes:

• Less than 120  = 15 grams

After activity – up to 24 hours:

• Less than 120  = 15 grams

* Discuss the guidelines with your diabetes care team.

American Dietetic Association (2003).Eating Right When You Have Diabetes. Hoboken, NJ: Powers, Maggie.

Blood Glucose Monitoring

Diabetes- Continuous Glucose Monitor (CGM) Trend Arrows Pictorial- Pictorial 

The goal of effective diabetes management is to keep blood glucose levels within a target range determined by the student’s personal diabetes health care team.

Many students with diabetes check their blood glucose levels throughout the day using a blood glucose meter. Some students also wear a continuous glucose monitor (CGM). Students who use a CGM also use a blood glucose meter to verify CGM readings when blood glucose levels are too low (hypoglycemia) or too high (hyperglycemia), corrective actions need to be taken.

Blood Glucose Meter

A blood glucose meter is a small portable machine used to check blood glucose levels. Before using the blood glucose meter, wash and dry hands and the test site. Insert the test strip into the meter. Using a lancet (a small needle inserted in a spring-loaded device), perform a finger stick by pricking the side of the fingertip. Apply a drop of blood to the test strip. The meter then gives the blood glucose level as a number on its digital display.

Heat and humidity may affect blood glucose meters and test strips and may reduce the accuracy of blood glucose readings. This is especially important when blood glucose is checked outside (e.g., on the practice field). Consult the manufacturer’s instructions regarding the operation and storage environment for the student’s blood glucose meter.

Continuous Glucose Monitor (CGM)

Some students use a continuous glucose monitor (CGM), a device that measures glucose levels and trends throughout the school day. THE CGM works through a sensor inserted under the skin that measures interstitial glucose levels (the glucose found in the fluid between cells) at regular intervals and sends the current equivalent blood glucose level wirelessly to a monitor. There are different brands and models of CGMs; the monitor may be part of the insulin pump or it may be a separate device, like a smartphone.

The CGM provides a display of the current glucose level along with various alerts triggered by high, low or rapidly changing glucose measurements. The CGM may not always be in perfect correlation between measuring the blood glucose level and the CGM value because the CGM can lag 10-15 minutes behind during episodes of rapid change. Use of a CGM for treatment of glucose levels requires a written order from the health care provider. Never ignore a CGM alarm. Appropriate action should be taken in accordance with the student’s Diabetes Medical Management Plan (DMMP).

CGM technology allows the device to communicate wirelessly to the student’s receiver, student’s cell phone and /or parent’s cellphone. It is not appropriate for the school nurse and/or school staff to use school-issued or personal electronic devices to monitor student CGM data. The school nurse and school staff are not responsible for the continuous receipt of CGM results throughout the school day.  Diabetes care at school will be provided in accordance with the regimen prescribed in the student’s DMP/Orders. Remote monitoring of the CGM in school is not required as the child is usually adult-supervised by school nurse or trained school staff and alarms are used to identify urgent blood glucose levels requiring action. However, the parent can monitor remotely and communicate via phone with school nurse or trained school staff if needed. 

However, school staff is responsible for responding and providing appropriate interventions to CGM data based on the DMMP.

Helping the Student with Diabetes Succeed: A Guide for School Personnel

NASN-Wearable Medical Technology in the Schools- The Role of the School Nurse

KETONE MONITORING 

Positive results of the presence of ketones in the urine may indicate that the body is starved for glucose (sugars).  Without enough insulin, the body is unable to process the sugar.  The body starts burning fat causing the build-up of acids in the blood. The product of this process is ketones, excreted in the urine.

The ketone level will be checked according to the student’s Individualized Health Plan (IHP) following the physician's order.  Ketone testing is a reliable method of measuring ketone levels when a consistent and accurate technique is used.  Instructions that come with the strips must be followed.  Ketone testing will only be done in the school health room per the Sarasota County School Board Exposure Control Plan.  The physician’s order must be renewed each school year.

Be supportive and sensitive to the student’s attitude toward ketone testing. 

Considerations and Accommodations:

• The student or health room aide may do ketone testing after successful demonstration per skills checklist.

• The student’s Diabetes Medical Management Plan and, if self-managing, the Physician’s Report, as well as emergency parent notification numbers, should be readily available for reference.

• Watch for individual signs of ketosis or ketoacidosis such as extreme thirst, abdominal pain, labored breathing, fruity, sweet, or wine-like odor on breath, nausea, vomiting, weakness, dizziness and fatigue/drowsiness. NOTIFY school RN if ketones are positive.

• Contact the parent/guardian immediately for any of these symptoms and have parent/guardian come to get the child and seek immediate medical attention.   If left untreated the student can lapse into a coma. 

KETOACIDOSIS

Hyperglycemic episodes may result in a serious condition called diabetic ketoacidosis.   Ketoacidosis may happen to students with type 1 diabetes but rarely occurs in type 2 diabetes.  This condition happens when insulin levels are far less than the body’s need.  This may occur because of illness or taking too little insulin.  The body starts using stored fat for energy.  Ketones are acids that build up in the blood.  They appear in the urine when the body doesn't have enough insulin.  If uncorrected, in just a few hours, acid levels can rise in the blood causing ketoacidosis.  Fluids and insulin must be given quickly since ketoacidosis can lead to coma and even death.

Onset:

• Can be rapid and lead to severe illness or even death. 

Signs and Symptoms:  

• Abdominal pain

• Dehydration

• Dizziness

• Drowsiness

• Fruity breath

• A headache

• Labored breathing

• Vomiting

Treatment:

1. Check blood glucose levels

2. Check for ketones and for high blood glucose level as specified in the Diabetes Medical Management Plan and/or symptoms of stress or illness are present or as specified in the Diabetes Medical Management Plan. 

3. If ketones are not present, have student drink extra water and administer a correction dose of insulin per the Diabetes Medical Management Plan.

4. If ketones are present, call school RN and parents. Administer extra insulin per the Diabetes Medical Management Plan.  Encourage water/sugar-free liquids and walking.

5. If ketones are moderate to large, if child unable to retain fluids, or if no extra insulin available, have parent/guardian come to get the child and seek medical attention.

6. Follow exercise precautions in the Diabetes Medical Management Plan. Increased physical activity can cause blood glucose to become more elevated and result in further ketone development.

7. If unable to reach a parent/guardian when ketones are present, the school RN will contact the health care provider promptly for further direction. If unable to reach the school RN, Landings School Health office may be able to assist.

To Check for Ketones:  

1. Dip ketone test strips in a paper cup filled with enough urine to wet color pad.

2. Wait several seconds.

3. Read results by visual comparison to a color chart per manufacturer‘s instructions.

4. Record results. 

5. Discard the test strips if the information on the bottle indicates they are out-of-date.

Adapted from the American Diabetes Association website - www.diabetes.org/ketoacidosis 2009

INSULIN

Insulin General Information

Children with type 1 diabetes must inject insulin daily.  The health care provider will determine the insulin types, dosages and times needed. The insulin needs vary with each child. There are many different types of insulin, for different situations and lifestyles. 

Characteristics:

• Onset - length of time before insulin reaches the bloodstream and begins lowering the blood sugar.

• Peak Time - The time during which insulin is at its maximum strength in terms of lowering blood sugar levels.

• Duration - How long the insulin continues to lower the blood sugar.

• Storage - Opened vials may be left at room temperature for 28-30 days after opening, or as indicated on the package.  Avoid exposure to extreme temperatures.  Unopened vials should be stored in the refrigerator and are good until the expiration date on the package.

• Expiration Date - Monitor insulin and supplies regularly to be sure the date for use has not expired.

Types and Duration of Insulin Action 

Type of Insulin & Brand Names

Rapid-Acting Insulin: 

• Humalog or Lispro 
  Onset: 15-30 min
  Peak:  30-90 min
  Duration:  3-5 hours

• Novolog or Aspart
  Onset:  10-20 min
  Peak:  40-50 min
  Duration:  3-5 hours  

• Apidra or Glulisine
  Onset:  20-30 min
  Peak:  30-90 min
  Duration:  1-2½ hours

Role in Blood Sugar Management for Rapid-Acting Insulin:

• Rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection. This type of insulin is used with longer-acting insulin.

Short-Acting Insulin: 

• Regular (R) Humulin or Novolin
  Onset:  30 min - 1 hour
  Peak:  2-5 hours
  Duration:  5-8 hours

• Velosulin (for use in the insulin pump) 
  Onset:  30 min - 1 hour
  Peak:  2-3 hours
  Duration:  2-3 hours

Role in Blood Sugar Management for Short-Acting Insulin:

• Short-acting insulin covers insulin needs for meals eaten within 30-60 minutes 

Intermediate-Acting Insulin:

• NPH (N)
  Onset:  1-2 hours
  Peak:  4-12 hours
  Duration:  18-24 hours

• Lente (L)
  Onset:  1-2½ hours 
  Peak:  3-10 hours
  Duration:  18-24 hours

Role in Blood Sugar Management for Intermediate-Acting Insulin:

• Intermediate-acting insulin covers insulin needs for about half the day or overnight. This type of insulin is often combined with rapid- or short-acting insulin. 

Long-Acting Insulin: 

• Ultralente (U) 
  Onset:  30 min - 3 hours
  Peak:  10-20 hours
  Duration:  20-36 hours

• Lantus
  Onset:  1-1½ hours
  Peak:  No peak time; insulin is delivered at a steady level
  Duration:  20-24 hours

• Levemir or Detemir (FDA approved June 2005)
  Onset:  1-2 hours
  Peak:  6-8 hours
  Duration:  Up to 24 hours

Role in Blood Sugar Management for Long-Acting Insulin:

• Long-acting insulin covers insulin needs for about one full day. This type of insulin is often combined, when needed, with rapid- or short-acting insulin. 

Pre-Mixed* Insulin: 

• Humulin 70/30
  Onset:  30 min
  Peak:  2-4 hours
  Duration:  14-24 hours

• Novolin 70/30 
  Onset:  30 min
  Peak:  2-12 hours
  Duration:  Up to 24 hours

• Novolog 70/30
  Onset:  10-20 min
  Peak:  1-4 hours
  Duration:  Up to 24 hours

• Humulin 50/50
  Onset:  30 min
  Peak:  2-5 hours
  Duration:  18-24 hours

• Humalog mix 75/25
  Onset:  15 min
  Peak:  30 min.-2½ hours
  Duration:  16-20 hours

Role in Blood Sugar Management for Pre-Mixed Insulin:

• These products are generally taken twice a day before mealtime. 

*Pre-mixed insulins are a combination of specific proportions of intermediate-acting and short-acting insulin in one bottle or insulin pen (the numbers following the brand name indicate the percentage of each type of insulin).

*Adapted from WebMD Medical Reference provided in collaboration with the Cleveland Clinic 2009

INSULIN DELIVERY SYSTEMS

Syringes, pumps, and pens all do the same thing -- deliver insulin.  These items deliver insulin into the tissue so it can be used by the body.  This category also includes injection aids -- products designed to make giving an injection easier.

Syringes

Today's syringes are smaller, have finer needles and have special coatings that work to make injecting as easy and painless as possible.  When insulin injections are done properly, most people discover they are relatively painless.   

Points to Consider for Optimal Insulin Delivery by Syringe: 

• The syringe being used should be the right size for the insulin dose.  It should be easy to draw up and visualize the dosage (devices are available to make this task less complicated). Shorter, smaller needles are available which allow for ease of administration. 

Insulin Pens  

There is a wide range of insulin pen options available.  Pens are preloaded with insulin and can make taking insulin much more convenient.  Some students find the pens make the injection more comfortable.  Before injecting insulin with the insulin pen, you must waste approximately three units of insulin (you should see it drip out of the end of the needle).  This is called priming the needle. 

Pumps 

Insulin pumps are computerized devices, about the size of a beeper or pager, which are worn on the belt or in a pocket. Pumps deliver a steady, measured dose of insulin through a cannula (a flexible plastic tube) with a small needle that is inserted through the skin into the fatty tissue. The cannula is taped in place -- not the needle.  Insulin pumps may be worn during most athletic activities as recommended by the health care provider. The pump may be placed on one of several sites on the body including the abdomen, buttocks, thigh or arm.    

Advantages: 

• Pumps most closely mimic the body's normal release of insulin. 

• Pumps deliver insulin in two ways: 
  − Basal dose: small, continuous dose that is pre-programmed. 
  − Bolus dose: supplemental dose given to cover food or high blood sugar.

• Wearing a pump does not prohibit a student from participating in any school activities.

Responsibilities of Pump Wearer 

• Be willing to test blood sugar a minimum of four times per day. 

• Learn how to make adjustments in insulin, food and exercise in response to test results. 

• Check to assure the pump is functioning properly if high or low blood sugar readings occur. 

• Keep back-up insulin, syringe or pen, and pump supplies available at school.

Resources 

Professional Organizations

• American Association of Clinical Endocrinologists, 1000 Riverside Ave. Suite 205 Jacksonville, FL 32304, 904-353-7878 http://www.aace.com 

• American Diabetes Association, 1701 N. Beauregard St. Alexandria, VA 22311, 800-342-2382 http://www.diabetes.org 

• American Association of Diabetes Educators, 100 W. Monroe, 4th FL Chicago, IL 60603, 800-832-6874 http://aadenet.org 

• American Dietetic Association, 216 W. Jackson Blvd. Suite 800 Chicago, IL 60606, 800-877-1600 http://www.eatright.org 

• American School Health Association, P.O. Box 708 Kent, OH 44240, 330-678-1601 www.ashaweb.org 

• Center for Disease Control and Prevention Division of Diabetes Translation, 4770 Buford Highway NE Atlanta, GA 30341, 800-232-3422 http://www.cdc.gov/diabetes 

• Diabetes Action Research and Education Foundation, 426 C, St. NE Washington, DC 20002, 202-333-4520 http://www.daref.org 

• Florida Department of Health, Bureau of Chronic Disease, Diabetes Control Program,4052 Bald Cypress Way Bin A-18 Tallahassee, FL 323994330, 850-245-4330 http://www.doh.state.fl.us/family /dcp/index.html  

• Florida Department of Health, Family & Community Health, School Health Services Program, 4052 Bald Cypress Way Bin A-13 Tallahassee, FL 323991723, 850-245-4445 www.doh.state.fl.us/Family/sch ool/index.html  

• Juvenile Diabetes Research Foundation International, 120 Wall St. New York, NY 10005, 800-533-2873 http://www.jdrf.org 

• Joslin Diabetes Center, One Joslin Place Boston. MA 02215, 617 731-2400 http://www.joslin.harvard.edu 

• National Diabetes Education Program, One Diabetes Way Bethesda, MD 20892, 800-438-3600 www.ndep.nih.gov 

• National Association of School Nurses, Inc., 1416 Park Street, Suite A Castle Rock, CO 80104, 303-6633-2329 www.nasn.org 

• USDA USDA, Agricultural Research Service, USDA, Team Nutrition 3101 Park Center Drive Rm 632 Alexandria, VA 22302 Nutrient Data Laboratory Beltsville Human Nutrition Research Center 10300 Baltimore Avenue Building 005, Room 107, BARC-West Beltsville, MD 20705-2350, http://schoolmeals.nal.usda.gov Phone: 301-504-0630; Fax: 301504-0632 http://www.nal.usda.gov/fnic/foo dcomp

Food & Activity Pyramids

U.S. Food and Drug Administration, Food Guide Pyramid, 2005., http://www.mypyramid.gov/

GLOSSARY

Blood Glucose Level: The amount of glucose or sugar in the blood.  For monitoring/testing the student independently or with assistance use a drop of their blood and a specially calibrated device to determine the current blood glucose level.

Bolus: A dose of insulin delivered when a child eats or to lower high blood glucose levels in response to a high blood glucose reading.

Delegation: The transference to a competent individual the authority to perform a selected task or activity in a selected situation by a nurse qualified by licensure and experience to perform the task or activity. (Chapter 64B9-14, F.A.C.)  

Diabetic Ketoacidosis (DKA): Severe, out-of-control high blood glucose levels that need emergency treatment. DKA happens when blood glucose levels get too high or insulin levels are far less than the body needs.  This may happen because of illness or taking too little insulin. The body starts using stored fat for energy and ketone bodies and acids build up in the blood. The signs include nausea and vomiting, stomach pain, deep, rapid breathing, flushed face, rapid weak pulse, dry skin, and a fruity breath odor.  Fluids and insulin must be given quickly since ketoacidosis can lead to coma and even death.

Carbohydrate Counting: The method of calculating the number of grams of carbohydrate in the food the child eats.  In conventional insulin therapy when used in its simplest form, this is a method of maintaining consistency in carbohydrate intake from day to day. When this is used in intensive therapy it serves as the basis for determining the amount of insulin to administer for any given meal.   

Glucagon: A hormone produced in the pancreas that raises the level of glucose in the blood. A glucagon injection may be given to a diabetic child in an emergency to raise extremely low blood glucose levels.   

Hyperglycemia: A condition in which blood glucose levels are elevated, generally 240 mg/dl or higher.  

Hypoglycemia: A condition in which blood glucose levels are low, generally 60 mg/dl or lower.  

Individualized Health Care Plan (IHP): A nursing care plan developed by the school nurse describing the way health-related services will be provided to specific students in the school setting. It can be a stand-alone care plan that contains the items listed on page 18 or an attachment to the Diabetes Medical Management Plan, which is provided by the physician and parent/guardian. The attachment should specify the unlicensed assistive person who will be delegated and trained to provide selected tasks, where, in the school setting, blood glucose monitoring and insulin administration will take place.  It should also include any other information that the school nurse identified during the care planning process with parents and school personnel.   

Insulin: A hormone secreted by the islet cells in the pancreas that allows the body‘s cells to absorb glucose for energy.  It is used as a medication when the body does not make enough insulin to maintain proper blood glucose levels.   

Mg/dl- Milligrams per Deciliter:  A unit of measurement used in blood glucose monitoring to describe how much glucose is in a specific amount of blood.  

Nonmedical Assistive Personnel: Any individual who has been trained and delegated (as required under s.1006.062. F.S.) to perform health-related services for students while they are in school. May also be referred to as unlicensed assistive personnel (UAP), as listed in Chapter 64B9-14 F.A.C.  

Nursing Care Plan: See  Individualized Health Care Plan (IHP).  

School Nurse:  A professional nurse registered and licensed to practice in Florida who is employed by the county health department, local school district or contracted by the county health department or local school district from a community-based agency. The school nurse may be assigned to one or more schools and provides leadership and services consistent with the Nurse Practice Act (Chapter 464 F.S.) and the School Health Services Program (s. 381.0056. F.S.)  Ideally, the school nurse should have a minimum of a Bachelor of Science degree, National School Nurse Certification and experience and additional education in pediatric assessment and intervention of the school-age child.

Sliding Scale: A medical order for adjusting the insulin dose on the basis of blood glucose monitoring. It is sometimes referred to as supplemental insulin or a correction dose. In some cases, the amount of insulin to be given is calculated with a simple mathematical formula specific to the student.

Supervision: The provision of guidance by a qualified nurse and periodic inspection by the nurse for the accomplishment of a nursing task or activity provided by unlicensed assistive personnel. The nurse must be qualified and legally entitled to perform such a task or activity.   

Direct supervision: means the supervisor is on the premises but not necessarily immediately physically present where the tasks and activities are being performed. 

Indirect supervision: means the supervisor is not on the premises but is accessible by two-way communication, is able to respond to an inquiry when made, and is readily available for consultation. (Chapter 64B9-14, F.A.C.) 

Universal Blood & Body Fluid Precautions:  Measures intended to prevent transmission of hepatitis B, human immunodeficiency virus (HIV) and other infections, as well as decrease the risk of infection for care providers and students.  It is not currently possible to identify all infected persons so blood and body fluid precautions must be used with every student, regardless of medical diagnosis. All schools should have a current policy in place regarding universal blood and body fluid precautions.    

Unlicensed Assistive Personnel (UAP): Unlicensed persons who have been assigned and trained to function in an assistive role to registered nurses or licensed practical nurses in the provision of patient care services through regular assignments or delegated tasks or activities and under the supervision of a nurse (Chapter 64B9-14 F.A.C.).  May also be referred to as non-medical assistive personnel (s. 1006.062 F.S.).