I wanted to the American Diabetes Association Safe at School program and the Johns Hopkins Division of Pediatric Endocrinology to welcome you this evening to the second part of our seven part series of webinars designed for school nurses. My name is Jackie McManaman and I will be presenting tonight's program. I am a member of the ADA Safe at School working group and I also volunteer as chair of the Virginia Diabetes Council Schools Committee. My day job is a nurse manager with the Fairfax County Health Department in the school health division. I have been a certified diabetes care and education specialist since 2013 and prior to coming to the health department, I worked in a busy pediatric endocrinology practice working primarily with patients with diabetes and their families. The ADA Safe at School program is devoted to protecting the legal rights of students with diabetes so that they may learn and thrive in a safe and healthy school environment and be treated fairly. School nurses play a critical role in making sure the needs of children with diabetes are met in the school setting. Tonight's session, Day-to-Day Management of Diabetes at School, will cover a day in the life of a person with diabetes and will include hypoglycemia and hyperglycemia management in the school setting and managing diabetes related emergencies. Our hope is tonight's program will provide school nurses with increased knowledge, skill and confidence to best support students with diabetes to optimize their education and have the ability to safely participate in all school-sponsored opportunities. The school nurse is the student's advocate and the key provider and coordinator of diabetes care in the school setting. School nurses, parents, providers and students working together can make sure our children with diabetes are indeed safe at school. All right, so please type your questions in the chat box and I'll do my best to answer your questions at the end of my presentation tonight. Soon after this program concludes, attendees will receive an email which will contain a link to an evaluation and a post-test. Pre-continuing education credits will be awarded upon completion of both the evaluation and the post-test. This program is also being recorded and will soon be available on ADA's professional member website. In addition, attendees will be emailed a notification enabling you to register for the remaining programs in this series. Our next webinar will be on January 22nd and it will cover nutrition, so be on the lookout for that email. Finally, the information provided by this program does not constitute legal or medical advice. For medical or legal advice, please seek out a medical provider or attorney. Thank you so much for joining us this evening. Again, please be sure to type any questions you have in the chat box. All right, so let's get started. Again, we are recording this session and we will make it available by the American Diabetes Association on their website for public access. And while the American Diabetes Association attempts to ensure all information is accurate and current, this general information about potential legal protections and medical best practices is not a substitute for individualized legal or other expert advice. The ADA and staff and volunteers do not provide legal or medical advice or represent you. For detailed legal advice or representation, contact and consult an independent attorney And for health care consultation and advice, consult with your professional health care provider. All right, so on the screen here, you'll see our objectives for today. So one of the things I want to spend some time talking about is what a day in the life looks like for a person with type 1 diabetes. And then I really want to drill into understanding hyperglycemia, some of those associated symptoms and common causes and review the management in the school setting. And we'll go through some scenarios that you might see and how to handle them. We're also going to talk about hypoglycemia and again, understanding those associated symptoms and common causes and review that management in the school. We're going to go into ketones and ketone management. So again, talking about diabetes related emergencies like DKA and severe hypoglycemia, as well as discuss the common forms of glucagon. And then as part of a day in a life, I'm going to talk a little bit about exercise as well. So before we dive into what that day in the life looks like, it's very important to understand what normal pancreatic function looks like. So what happens for a person who does not have diabetes? And that will help us understand what's happening in a person who does. This image is taken from the Peter Chase Understanding Diabetes book. So when we eat something, the food that we eat is broken down by our stomach. And if the carbohydrates are broken down into various sugar molecules, those molecules will then enter our bloodstream and start raising blood sugar levels. That rise in our blood sugar levels will signal to the pancreas to secrete from the beta cells insulin. Insulin then comes into the bloodstream and pushes the sugar from that bloodstream over that insulin bridge and into the cell so that it can be used for energy. The presence of insulin also turns off any internal sugar production that is happening from the liver. And that internal sugar production is what happens when we have not eaten for a long time. So when it's been many hours since we've eaten, our pancreas will then secrete glucagon from the alpha cells, which signals to our liver to dump that stored sugar into our bloodstream. So that's how both insulin and glucagon work together to maintain that euglycemia, or those normal blood sugars. So then what happens for a person with diabetes? So the same scenario when you're eating something that contains carbohydrates, you know, again, the food enters your stomach, it's broken down by various sugar molecules, or into various sugar molecules, and then enters your bloodstream. Now in the case of a person with type 1 diabetes, where they're not making insulin, or even in the case of a person with type 2 diabetes, who perhaps isn't making enough insulin, the sugar remains in the bloodstream. And so the presence of that sugar in the bloodstream is raising blood sugar levels. The internal production of sugar by the liver may not be turned off, so you're also getting sugar that way. And so the insulin bridge is not able to be lowered to get the sugar into the cell. So now we have a hungry cell, and we don't have the energy to do the things that we want to do. Now our body does try to get rid of some of that extra sugar, and a way that it does that is by eliminating the sugar through the urine. However, it can't get rid of all of it. And so diabetes, again, is a result of hyperglycemia, or high blood glucose levels. So I know that's a review for many of you, but it sometimes helps put it in the context of what we're talking about. So when we're thinking about how do we take care of a person with diabetes, we have to think about what that typical day looks like for them. What do they have to do to maintain those close to normal blood sugars, or those close to target blood sugars as possible? And so when we're looking at that, you know, frequent blood glucose monitoring is extremely important. And whether that glucose monitoring is via finger stick glucose, or via CGM monitoring, it just depends on the student's preference, but both are something that the student will have to do. They also, with the frequent glucose monitoring, have to be on the lookout for highs and lows. So hypo and hyperglycemia. In addition, the person with type 1 diabetes is going to have to manage their food. So counting carbohydrates is one of the most common food management techniques that we tend to see in the school setting for our students with type 1 diabetes. But you may see other regimens too, like a fixed dosing regimen as well. But now this student with diabetes is having to count all of their carbs, plan their meals, and time their meals accordingly. Another part of a day in the life is taking multiple doses of insulin per day. So whether they're taking their insulin via injection, so are on multi-daily injections or MDI therapy, or using one of the insulin pumps or AID systems, automated insulin delivery systems. It depends on student preference and insurance preference, of course. But they have to take those multiple doses each time they're eating, or each time they need to help their blood sugar come back into target range. And then finally, they have to navigate exercise and managing exercise in school. Whether this is PE class or recess, I know from my experience that kids tend to go crazy during recess running around, and that tends to be where we see more lows in some cases. Or you have to consider your student athletes, those students who are participating in different sports events after school or different sports practices. So all of this is just a kind of a quick way of looking at the different parts of having diabetes in the school setting. So let's take each of these in a little bit more detail. So first, with blood glucose monitoring, we're going to talk about CGMs in the next slide, but when we're thinking about blood glucose monitoring, we should be monitoring glucose levels before meals and anytime we're dosing insulin. So in some cases, it depends on how many meals a student is eating in school. Breakfast is often served, lunch is of course served, there may be snack times that are served. So all of that has to be considered. The student with diabetes is also testing their blood sugar anytime they feel high or low or something just feels off, they're going to be testing their blood sugars. We may want to be testing before or after physical activity, depending on the timing of when those occur during the school day, or any other time that might be requested by the parent guardian. And this may be toward the end of the day before the student gets on the school bus, you know, we want to make sure that they're safe to get on the bus, or before they're going to their after school program. And we also want to advocate for the student to be able to test that blood sugar anytime and anywhere they are. So that we can make sure that they get the treatment that they need. Continuous glucose monitoring has become extremely popular, of course, in the school setting. What a continuous glucose monitor is, is it's a sensor is inserted just under the skin into the interstitial fluid, and it monitors glucose levels continuously. So unlike the finger stick glucose that is just that point in time, the continuous glucose monitors are constantly monitoring and providing not only where they are, but what direction they're going. So these have been tremendously helpful in the school setting, because it limits that interruption from their day, you know, depending on the age of the student and the developmental level of the student, it's as easy as just taking a peek at their CGM before they go run out on the playground for recess or before PE class. CGMs have alarms and alerts that go off for low or high glucose. And pretty much all of the CGMs now available, or the most recent versions of them may be used for treatment decisions and insulin dosing. So this has a really positive impact for the student, because again, it's all about speed, they don't want to be interrupted from their day or from their lunchtime. And so they want to be in and out of there. And then with many of them, it really does require minimal to no finger sticks. One point I'll make with the CGMs is, you know, they they communicate via Bluetooth with the device that the students using whether it's the device that comes with the CGM, or one of the smartphones that, you know, is compatible with the CGM. And then they're also able to communicate via Wi Fi with their parents at home. So it's really important as school nurses to advocate to make sure that the student is given this their device is given access to the school Wi Fi. Some schools may be hesitant on allowing students to get onto the Wi Fi. So you as the nurse need to advocate for them or help advocate for them to why this needs to happen. This is a this is a device that helps them. So it's a medical device, it isn't just a cell phone. We want to make sure that we're supporting our students in getting that. So again, blood glucose monitoring, CGM monitoring, it's extremely important. And we're going to we're going to talk about, you know, insulin administration as well and how using those blood sugars and CGM values become instrumental. Okay, and then the other part was food management that we talked about. So of course, for, you know, every student, it's recommended that they have a balanced diet that that doesn't exclude our students with diabetes either. So they, they should be eating carbohydrates, they should be eating proteins, fruits, vegetables, you know, all the food groups. And the the way we manage food for the most part for our students is through carbohydrate counting. And this is a meal planning technique, where we count the total number of carbs in a meal and divide that by the carb ratio. And the carb ratio is the units of insulin needed to cover the grams of carbs consumed in that meal. And you can find those type of doses on the student's diabetes medical management plan or other health care provider orders. And then comes the tricky part of well, how do we determine how many carbohydrates are in the meal? And what meals is the student eating at school? And how do we get the carb information for that? And so, you know, in our school system, we have all of the school menus are online. And we can see the carb counts based on serving size for for our students with diabetes. Sure, many schools have similar programs to that, or perhaps printed menus that they can use. And then for our students who pack their meals, what we recommend is having an itemized food itemized carb count for each of the items in the lunchbox. That way, if the student decides to eat not the the whole sandwich but half the sandwich and then maybe a couple of the apple slices and half the bag of chips you know we know what each item has in it so that we can accurately you know estimate those carbs that they ate. And one other thing I'll mention too about food in school is also having that conversation with your students families and again depending on the age this I feel like is particularly sometimes a challenge with our younger students and in the elementary school setting but could certainly affect them all when we're thinking about class parties coming up you know when when we think about people have bringing sweet treats to school different upcoming holidays valentine's day is around the corner halloween when that occurs so talking to your students parents and and having a plan for when that happens okay so we don't want to you know deny the student from being able to participate in those events we just want to have a good plan to be able to support them and we want to make sure we have an accurate carb count so that we can dose them with insulin for it as well so it's a good topic of conversation to bring up not only with the student and the student's parents but also with their classroom teachers so they're aware and then another important piece of course of the day in the life for the person with diabetes is insulin insulin is how they are going to use the food that they're eating for energy there that's how they're processing carbohydrates so we want to make sure that the that the student is it has access to their insulin of course throughout the school day and we want to understand the different ways that it may be delivered right or the different delivery devices so certainly all of the insulin delivery devices insulin is injected subcutaneously so that's into the fatty tissue and we want the types of delivery devices that the student may use whether it's syringe and vial insulin pen insulin pump is very patient dependent or student dependent as well as you know what insurance will pay for it too and we also have to make sure we understand the types of insulin our students are on and the types of regiments they're on so for our students who are on you know multiple daily injections or mdi they receive their insulin either via pen or syringe and they likely take a rapid or ultra rapid acting insulin at mealtime and then a long acting insulin either once or twice a day and that long acting insulin is kind of working in the background to help keep blood sugar stable between meals as well as overnight and often in the school setting you know we're not really touching that long acting insulin there might be some situations where perhaps you have a student who there maybe there's some compliance issues at home or or different types of family type situations where perhaps you're giving the long acting but for the most part we won't see that in school we see the rapid acting insulins or the ultra rapid acting insulins but it's important to understand the types of insulins they're on when they start working when they peak and how long they work for so for example your rapid acting insulins which tend to be the ones we most commonly see start working in about 15 minutes peak after about an hour and are gone after about three hours okay so even though we call them rapid acting they're not that fast right it takes about three hours until it's out of the body so that's important to understand our students who are on insulin pumps only receive only have rapid acting insulin infusing into the pump they don't have a long acting insulin on board okay so that's another point that we're going to talk about when we are talking about hyperglycemia a bit too so when we're calculating insulin there's a couple of steps we have to think about not only what their food dose was but also if they need a glucose correction dose so we're looking at two things we will have a future webinar that breaks down the ADA's diabetes medical management plan in a bit more detail but this is a snippet from the diabetes medical management plan that's on ADA's website and it's the dosing table and what we see here is it shows us where the red arrows are pointing we're giving insulin you know before breakfast and before lunch in school and the carb ratio at breakfast is 20 grams per unit of insulin and the carb ratio at lunchtime is 15 grams per unit of insulin so our first step when we're for routine insulin administration at school before meals is to one identify what meal we're in and then to calculate that carb to insulin ratio. The second step is to identify if the student needs an insulin correction dose and an insulin correction dose is the units of insulin needed to correct elevated glucose values so we may not always have to do step two it's only if the student is above their target range so where do we find that information again this is looking at that glucose correction dose on the ADA's DMMP you can see where the red arrows are pointing for both those meals both corrections are the same but the target glucose for both meals is 150 milligrams per deciliter and the correction factor or sometimes called sensitivity factor is 50 milligrams per deciliter per unit. What that tells us is one unit of insulin will reduce the blood sugar by 50 points or 50 milligrams per deciliter so in the example listed and when we're calculating using the formula method which is where you take the current glucose minus the target and divide by the correction factor we did a real easy example if the student's glucose is 200 milligrams per deciliter you would subtract the 200 from 150 which gives you 50 and divide that by 50 which will give you one unit of insulin so this student needs an additional unit along with their food dose to help bring their blood sugar back in a target range. You may in the school setting see a different method a sliding scale method when calculating correction doses and this is where the doctor will put on the DMMP you know a sliding scale so if the blood sugar is between 151 to 200 we get one unit between 201 to 252 between 251 to 300. So in the examples like we did before with the 200 milligrams per deciliter we get the same answer we would give one additional unit for that student using the sliding scale method. It's the gold standard to use the other method the formula method but you may see that some of your students are using sliding scale and it could be that you know perhaps there's some difficulty with calculating using the formula method and so the doctor has chosen to stick with that sliding scale. So then we have to put them both together so step one again was the food step two is correction and then step three is calculating what that total daily dose is so we're taking the food plus the correction and that gives us what our total insulin dose is. So when we're calculating insulin in the school setting you know we we do want to make sure that we're calculating insulin and we're verifying that calculation with a second person okay. It's best practice you know even in hospital settings insulin doses always have to be verified with a second person and so you want to be making sure that that's happening in your school setting whether it's that you know one of the front desk folks who are trained to support you are helping with the calculation but there should be a second person okay and if developmentally appropriate if the doctor feels the student is independent or or close to it in their calculations then they could also be that second person but you should each do separate calculations to ensure you're coming to the right answer. And then finally is exercise management and so sugar gives us energy so exercise burns sugar that's how we're able to sustain those periods of activity so it's really important with the exercise to understand one what is the exercise and and be thinking through when we should be checking their blood sugar. Most commonly we're going to be checking them before the activity but depending on what they're doing it might be a good idea to also take a peek at what it is after the activity okay or during if it's an extended sports practice or even like marching band practice where they're in August just marching in the heat right we want to make sure we're keeping an eye on that and again cgms are great for this because they can really help us keep that close eye and for the most part the blood sugar goals prior to exercise is to have that blood sugar between 120 and 150 milligrams per deciliter you may see it even higher depending on you know what that diabetes medical management plan recommends for that specific student and when we're thinking about exercise and and the type of snacks that we should have you really want to be coupling carbohydrates with protein that way the snack stays with the student for longer versus you know having a juice box right before exercise to boost them up well the juice is not going to stay on board for very long so that the type of snack is really important and oftentimes you know when we're getting supplies from parents we're going to talk a little bit about supplies here toward the end but when we're getting supplies from the parents we want to make sure we have a variety of snacks available so that we can make sure that we can support the student depending on what's happening okay all right so we're going to switch gears a little bit and talk about hyperglycemia and we're going to run through a couple of scenarios you know based on some of the common causes of hyperglycemia and how to handle it there's a lot of nuances in the school setting and and as school nurses you know we're having to deal with a lot of blood sugar variability and supporting the students through that so hyperglycemia is defined as blood sugars greater than 180. now what could cause potentially hyperglycemia is could be a variety of factors you know maybe not enough insulin on board so maybe the student missed a dose or ate some carbs that weren't covered by the mealtime or ate some carbs that you know they had an additional snack so that might be the cause illness can be a cause of hyperglycemia stress so when we're thinking about our our students with diabetes around test taking time it's very stressful some medications cause a rise in blood sugars particularly steroid use so that can cause a real significant rise in blood sugar levels hormones so again with the pediatric population they're always growing and changing and as a result of that growth their insulin needs change too so particularly during the puberty time they're going to need lots more insulin than maybe they will afterwards okay so that's something to bear in mind bad insulin so whether the insulin you know has extended past the 28 day mark depending on the type whether it got frozen by accident or overheated all of those can manipulate those blood sugars and then of course insulin pump malfunction now hyperglycemia is typically not a medical emergency while hyperglycemia is important that we address hyperglycemia if it's happening consistently and we're needing to provide frequent interventions during the school day unless ketones are present it's typically not an emergency but if you are requiring frequent interventions so you're doing ketone check-in you're doing ketone management you're having to provide frequent correction doses all of those type of interventions we would want to definitely encourage the parent to reach out to the endocrinologist or you reaching out to the endocrinologist to share those high glucoses and to see what what can change for that student and it's also really important to keep in mind that it is normal for blood sugars to rise after meals right so when we talked about insulin administration again insulin doesn't start working for 15 minutes so the blood sugar is already rising as the student is eating and that timing some students don't get their insulin until after they eat so as a result you're going to see a rise okay that is normal okay what matters is well then where does it go you know if it continues to rise and stay up and the insulin just doesn't seem to be bringing it down that might signal to us a dosing adjustment might be needed so here are some of the signs and symptoms of hyperglycemia so the common ones we see particularly when you know we're working uh with our students with diabetes is that increased urination and as a result of being very thirsty those are often those first signs other really common symptoms are headache abdominal pain and nausea and feeling hungry right so they're feeling hungry because the sugar they've been eating isn't actually being processed right it's not it's just stuck in their bloodstream and you know in the in the school setting the the teachers and the staff who are working with our students with diabetes really become tuned into what their signs and symptoms might be for that particular student you know they may notice they're having trouble focusing in the classroom or they're withdrawing from the activities that were happening around them and that's not like them so what's going on so your teachers really become instrumental in identifying some of these early symptoms the more severe symptoms that are pointing more toward ketosis would be things like the fruity breath or the nausea and vomiting so all of these are signs and symptoms and again some of the signs for high blood glucose and low blood glucose can look very similar so that's why we always want to be able to identify which we're we're dealing with okay so let's run through some of those common um causes of hyperglycemia of hyperglycemia and and how we can manage them in the school setting so how about a missed insulin dose for a meal okay so you know in this scenario that a student comes to the health room and their glucose is over 300 and they tell you or they just had had lunch let's say for example um and they tell you i forgot to take my insulin at lunchtime or they were went down to the cafeteria and forgot they're supposed to come to you first you know right there's a million a million scenarios like this or they had breakfast at home and forgot to go give themselves insulin because they were in a rush so if the it has been less than 30 minutes between the time where they started eating and now we're coming to you you can cover those carbohydrates. So if they know it, right? So the home scenario might be a harder one, but if they're able to tell you that they, you know, ate lunch, this is what they had for lunch, and it's been, we're within that 30 minute window, then we're going to wanna give them a carbohydrate dose. But we can't give them a correction dose, right? Because what we'd be correcting is they're high from the food that they ate. But on the other hand, if it's been more than 30 minutes, and they, since they've eaten that meal, at this point, all we're gonna do is give a correction dose. Okay? So if they miss their insulin completely, it's been more than 30 minutes since they had that meal, we're not going to go back in time and try to count those carbs and make up those carbohydrates, we're just gonna correct that blood sugar. And then we're gonna encourage the student to drink sugar-free, excuse me, fluids, such as water, to help flush out that hyperglycemia. So it's very important to keep in mind that when we're looking at a missed insulin dose, and if we're able to give that carbohydrate dose, we can give carbohydrate dose only, we can't give correction. If we're not able to give a carbohydrate dose due to the length of time, then we're only going to give a correction dose. So it's kind of one or the other, depending on the scenario. But we see this quite a bit that happens. Another one that we see in the school setting is they come to you, they're just fresh off the bus and their blood sugar is already elevated, right? The CGM is going off, it's over 300, and they haven't taken insulin or eaten anything in at least three hours. So in this scenario, the first thing we're gonna wanna do is, of course, look at our diabetes medical management plan, but we're gonna wanna check ketones, and then we're absolutely gonna wanna give a correction dose for this student, right? We don't wanna allow the student to stay in this hyperglycemic state until their normal scheduled insulin dose time. So for example, if you typically only see this student for lunchtime, we're not going to tell him, go wait for lunch, okay? We're going to give him that insulin right away to help bring that blood sugar back into target range. Now, if this student is on multiple daily injections or MDI, we're also gonna wanna think about when their next scheduled mealtime is. So if, for example, he comes into school, it's nine o'clock, he arrived hyperglycemic, at nine o'clock, we gave him that correction dose, and we know lunch is gonna be at 11 a.m., okay? So lunch is two hours after this correction dose. We can't then give him another correction dose within those two hours. And the reason we can't is because the insulin he took at nine is still in his body at 11 and is still working. So we don't wanna stack our insulin doses. What we can do though is at 11 a.m., we're just going to dose him for the carbohydrates he or she is gonna consume for lunch. So that's unique to our MDIs. You know, if you have a student with an AID or an automated insulin delivery system, the pumps take into account insulin on board and can subtract insulin from the total dose within its own algorithm. So to prevent that insulin stacking that happens. But for MDI students, we don't have that luxury. So that's why we cannot then give another additional correction dose at 11 a.m. And then to the reverse of this, if they arrive hyperglycemic and have already taken insulin. So again, in the same, you know, they arrive at school at 9 a.m. and they tell you, well, I had insulin at eight and I ate, you know, we'll say pancakes with syrup and some Lucky Charms for breakfast. So in that case, we can pretty confidently assume that the blood sugar is elevated related to perhaps what they had for breakfast. And it's only been an hour. So we would encourage that student to drink fluids and then maybe come back and see us in a couple of hours so we can make sure that, or to make sure that glucose is coming back into range. Inadequate insulin doses. So this is when, you know, perhaps this is related to maybe their pubertal and are outgrowing their doses. So if you're seeing repeated patterns of hyperglycemia throughout the school day, you're doing all of the prescribed doses, but it just doesn't seem to be working the way it should. This is a student who needs an insulin dose adjustment. So we would absolutely want to request that the parents contact the diabetes team to review those blood sugars, or again, you contact the diabetes team depending on your consent and, you know, the ability to do that in your school setting. But if you're seeing those repeated patterns, we would absolutely want to make sure that this student gets some more insulin so that we can make sure that they're not in this hyperglycemic state, right? Because this is where, you know, complications can happen and certainly ketone formation can happen. So illness can raise blood sugars. So again, it's a cause of hyperglycemia. And for the most part, we don't want students to be in school while they're sick. But we also know that sometimes that happens and that sometimes illnesses can really drag out, right? We can have those lingering symptoms for a long time, or perhaps the medication the student is taking is affecting their glucose control. So it may be appropriate if they are in the school setting that they need more frequent correction doses. So every three hours throughout the day so that we can maintain those blood sugars as close to target as possible and prevent the development of ketones. But obviously, of course, if a student is not feeling well and if they're not able to participate in school then they should not be in school and they should be at home. And another cause of hyperglycemia again is that bad insulin. So if we're suspicious that something that the insulin is potentially compromised, we would wanna make sure that we start using a new vial or pen, okay? So to ensure that we're using good insulin or insulin that hasn't potentially reached that expiration date. For students who you have, where you store the insulin in your health rooms or in your clinics, you can make sure they're within that 28 day window. But for those students who are independent or perhaps transporting their insulin back and forth, that would be a question of, has this potentially been compromised? Has it been left in the car when it's 20 degrees outside or on the reverse, has it been left in the car when it's 100 degrees outside? So those are very important questions to ask if we're suspecting that maybe it's the insulin causing the hyperglycemia. And then the pump malfunction. So this picture of the CGM tracing really illustrates a pretty clear pump malfunction here. So with our insulin pumpers, remember they only have rapid acting insulin on board. So unlike our MDIs who have that long acting insulin too, our pumpers just have rapid acting. So they can develop ketones within about three to four hours from the malfunction. So very quickly due to the absence of insulin versus our MDI kids that may take a little bit longer, like six to eight hours of not taking any rapid acting and you might see ketones. So our first step for this student, if we're seeing hyperglycemia, we're going to check ketones, according to the diabetes medical management plan. And we're gonna stop using that pump and we're gonna administer a dose via injection. So with your pumpers, you wanna make sure in your school clinics and school health rooms that you have backup insulin available. Now, for the most part, school nurses are not changing diabetes devices in the school, right? They're not reinserting an infusion set or restarting an insulin pump. That's beyond our scope. But perhaps the student can or the parent can. And we wanna have that available to them if they need to. So it's a really good idea to have those backup supplies available in the health room for the parent. If they are gonna be coming straight to the school to help replace the pump, then they're in the school. They don't have to stop at home and delay that treatment. But for your pumpers who you're suspecting a pump malfunction, we wanna stop giving insulin from the pump and we wanna begin administering doses via insulin injection. And then you would follow that dosing table on the diabetes medical management plan for that. So with ketone management, we wanna be checking our ketones if the blood sugar is over 250 to 300 per the diabetes medical management plan. And with ketone testing, for the most part, we're getting the urine keto sticks. So the image on the screen shows you how to be testing the ketones, but we wanna make sure that we're also encouraging hydration when we're seeing hyperglycemia. But in this scenario, if the ketones come back tracer small and the student is over 250 or 300, we wanna make sure that they've gotten an insulin dose. So if they haven't, we could give them a correction dose using our DMMP and then encourage them to drink. And if they're not symptomatic, meaning they feel okay, they can return to class. We can allow a student to stay in school as long as they're feeling okay. If they're not feeling okay, their stomach is starting to hurt, they're feeling very nauseous, then those students need to go home. Now, what happens if the ketones are moderate or large? So in this case, it's the same instructions of give them a correction dose if they haven't received insulin in the last three hours, encourage hydration, but this is where the student's getting into trouble. So what other symptoms is this student having? Are they complaining of a lot of abdominal pain? Are you noticing that they are breathing kind of funny or you're smelling that fruity odor on their breath? That should warn you that this student might be entering into DKA or diabetes ketoacidosis, in which case this student needs to go home and the parent needs to call the endocrinologist immediately. Now, if we're seeing some of these symptoms of, you know, again, the ketones with vomiting, with abdominal pain, not breathing normally, confused, you know, all of this is occurring because the body is using fat for energy instead of sugar. And the reason it's doing that is because the sugar is trapped in the bloodstream, right? Because the insulin isn't there to push it into the cell. So that's why this is happening. This is a medical emergency, okay? This is a 911 call. This is a student who needs help, okay? And it's not appropriate for the student to be managed by you in a school with, you know, 2000 other students. So we definitely need to get support for that student when you're seeing some of those signs and symptoms. All right, we're going to switch gears and talk a little bit about hypoglycemia. And I'm going to review a couple of the glucagon devices that are available too. So with hypoglycemia, again, that's blood sugars that are less than 70 milligrams per deciliter. And this is usually caused from maybe the insulin overdose. So maybe they didn't finish their meal. Maybe the carbs weren't counted accurately. So they got too much insulin. Maybe they got a pre-meal bolus too far in advance, okay? So they got it 30 minutes before they were going to eat and now they're tanking because that insulin has already started kicking in. Exercise that we've talked about. And then again, maybe their insulin doses are too strong. The honeymoon phase or honeymoon period that happens when a person is first diagnosed. Hypoglycemia can very easily result in a medical emergency. So we want to treat hypoglycemia as quickly as we start identifying those signs and identify that it's there. So here's some of the signs and symptoms of hypoglycemia. And it's often easy to remember because we all feel those symptoms sometimes, right? If it's been a while since you've eaten, we think about when you're hangry. Those are the symptoms that start showing. And then for a person with diabetes, they may continue to get worse and worse. And that's when you start seeing the confusion and the not really understanding what's happening. So what do we do? We follow the 15 by 15 rule. That's giving 15 grams of carbs and then rechecking in 15 minutes, okay? There's some examples of those 15 gram options available. Now, not all of your students may need 15 grams. You might find with some of the AID systems that because they're shutting off insulin and because maybe they had done it for a while before the hypoglycemia started, they may only need eight grams or maybe it's a little bit less. So you're going to find that on the diabetes medical management plan. And then if you're using a CGM, it may be important to consider doing a finger stick. Many parents might be hesitant to have that verification at the onset. Rather, they want you to just treat it. But when we're doing that 15 minute recheck, if the CGM is still showing a low blood sugar, it's important to check it by finger stick because we don't want to over-treat, right? We don't want to over-correct. And now we've sent them where now they're 200, right? So it's a balance there that we want to have. And then you also want to encourage, once you kind of get that blood sugar up, we want to encourage that the student eats a little bit of protein so that the sugar doesn't then tank right away again. Okay, again, the protein helps in a slower absorption of carbohydrates. So with severe hypoglycemia, this is a medical emergency. And the treatment is glucagon. And the symptoms for hypoglycemia, a severe hypoglycemia is loss of consciousness, seizures, or inability to eat or drink something. If a student is using an insulin pump and we have administered glucagon, we want to make sure we put the insulin pump into suspend or stop mode so that the student isn't continuing to receive insulin infusion. What glucagon is, again, it's that natural hormone that releases glucose stores from the liver. The symptoms we administer it for is unconsciousness, like we said, seizure, and inability to eat or drink something. We want to make sure we put the student in the recovery position before we administer it, so in the event of vomiting. And we want to make sure we call 911 and, of course, notify the parent and guardian as well. So there's a couple of different types of glucagon now available. The glucagon emergency kit, the traditional lily kit, is no longer manufactured in the United States. It stopped being manufactured in December of 2022. However, you may still see them because of their expiration dates might be through this year. So this one is administered intramuscularly and it is reconstituted. So it has to be mixed and the dose is dependent on the student's weight. So the doctor will prescribe that dose and you will either draw to the whole or half milligram. And we can keep this one at room temp. Baximi is a nasal spray and it's absorbed in the nasal mucosa. And this one is a standard dose of three milligrams and it's FDA approved for over four years old and also stored at room temperature. And the student doesn't have to inhale and it just goes into one nostril. It's very quick and easy to administer. It's becoming quite popular. This is Lily's new product. Givoke has two products, the HypoPen which is a subcutaneous injection. And the HypoPen is similar to an EpiPen in that it's a retractable needle. So you don't see the needle when you inject or after you inject. It is retracted into the pen itself. And again, the dose will be prescribed. So what's dispensed from the pharmacy will be the prescribed dose. And there's the pre-filled syringe which is a syringe product. So exposed needle, but is already reconstituted. So there's no reconstitution needed. And this one is also stored at room temperature. And then the Z-Galog, which is similar to the Givoke HypoPen in that it's an auto-injector and they have a pre-filled syringe option. It has just a standard dose, but for Z-Galog, so it can be stored at room temperature, but storing it, keeping it in the refrigerator will extend the shelf life for up to three years. But once it's been taken out of the fridge, it can't be stored back into the fridge. So this is, so that's something to keep in mind too for the storage of this medication. In the school, it's ideal for all of those supplies that the student will need are provided from home, right? We can't supply the insulin, we can't supply the glucometers. So it's important that we have all of those supplies available to us. If you have a student who's having issues with getting the needed supplies or the family is having trouble providing it, reach out to the endocrinology office. Sometimes, oops, excuse me. Sometimes it's an issue of insurance not approving enough quantity. And so with a phone call from the doctor's office, they can get that quantity increased. So I would recommend reaching out to the endocrinologist to help with that. And we've talked a lot about the diabetes medical management plan. And again, we're gonna have a webinar on the diabetes medical management plan. But the ADA DMMP is a comprehensive medical order that covers that full spectrum of diabetes therapies. And it helps with providing those detailed medical orders for day-to-day care, hypo and hyperglycemia management, handling of the devices, self-care skills. All of that is right in there for you. It also encourages collaboration among not only the healthcare provider and the parent and student, but also with the healthcare team. So I encourage you to download it. If you haven't seen it, find out if your local practices are using it or could use it. It's right on ADA's website, diabetes.org slash DMMP. And then another really important part of diabetes in the school setting and the day-to-day management is the section 504 plan. All students with diabetes should have a 504 plan in place. If a student has an individualized education plan or an IEP already, then these 504 accommodations can be rolled into their IEP. But if they don't have that, they need to have a 504. What this is is it helps to prohibit discrimination against people with disabilities. And under the law, diabetes is a disability. It helps to make sure that the person with diabetes is medically safe, has the same access as other children and is treated fairly. And it really does help minimize those misunderstandings that can happen. And so you as a school nurse can really be the advocate for ensuring that your student with diabetes has a 504 plan. Some parents may not be aware of what a 504 even is. And so it's really important if, you know, where you sit to help them kind of navigate that. Some typical 504 provisions that you may see are, you know, around staff training. It might be around making sure the student's able to self-manage anywhere if that's developmentally appropriate. Ensuring that they're participating, have full participating in field trips and extracurricular activities. Making sure they have alternate arrangements for class time misrelated to medical appointments or because of periods of higher low glucose or illness related to diabetes. This is just a few. There's a full and very comprehensive list on ADA's website, on the Safe at School website. So I included the link here for you as well. So this was a lot of information. I know I'm at the seven o'clock hour, but I think we want to allow 10 minutes to answer questions. And I think, and Crystal has been keeping an eye on the chat for me to take a look at those questions. So how about we dive right in? Thanks. Thanks, Jackie. We have quite a few. We have some great questions, so we'll get through as many as we can. Okay. In New Jersey, parent requesting that student never leaves classroom even when blood sugar is less than 70. Prefers a non-medical personnel manage the student in the classroom. The nurse does not feel comfortable delegating in this case. Is this routine with patients you manage? This is such a good question, Crystal. And this is a hard one. I think when we're looking at our students with diabetes and what can we do for them in the school or in the classroom to limit that interruption, I think hypoglycemia management, we can initiate that hypoglycemia management there in the classroom to get that started. And then the student can, if they're not feeling very well, depending on how low they are and what kind of symptoms they're displaying, we may wanna consider having them come to the health room just so that they have that opportunity to recover. But if they're feeling okay and the teacher could always set a timer or you could set a timer in the clinic and call the classroom back in 15 minutes and say, hey, where are we at? Now with CGMs, I do find in my experience that in 15 minutes, the CGM may still be showing low. And so we need to do that finger stick at that point. And that's often, depending on the student's experience level, they may not be comfortable doing that in the classroom. So often they'll come to the clinic in that situation so that we can assist them with that recheck. But I think it really just depends on what's happening in this scenario, right? And in Virginia, we can train unlicensed staff to support students with diabetes in the administration of insulin and glucagon in our state. So we have the ability to be able to do that and train our teachers to support kids right there in the classroom. Thanks. This has been a struggle for our students with diabetes. Our county has a card menu, but it is never consistent or accurate. There are also a lot of changes in the menus and food substitutions from the card menu. Any suggestions? Oh man, are you from Fairfax? No, I shouldn't say that. That's not fair. I think that this happens probably in so many school districts, right? The student says they're gonna have the baked chicken on a bun. They get down to the cafeteria, it's 43 grams. We dose them for it, off they go. There's no more baked chicken on a bun. And so what we have done when this becomes a problem for our students with diabetes, we ask that they go through the lunch line first and before they dose insulin, so make their selections so that we make sure we're giving as accurate of a carb count as possible for the food that they're eating. Substitutions are hard sometimes to find a food that they have available that equals the same amount of carbs. And so I think work with your cafeteria manager or your food services manager to make sure that we have some other options for our students. But one of the strategies that I think works well or has worked well at least for us here is having the student go through the line first, making sure that they show you then what they're going to eat so that you can then dose them accordingly. So we have parents who wanna have insulin given prior to eating the meal and base insulin dose on what is in the lunchbox. But then when kids don't eat everything, then we have to deal with the lows in the afternoon. My question would be, what is the best practice for dosing based on carbs before or after lunch? I find this to be a bigger problem in the elementary buildings. Yeah, I think it's definitely a bigger problem in the elementary buildings. Best practice is to give the insulin before they eat. And the reason for that is because of the action of insulin. It takes 15 minutes for it to start working, right? And then it doesn't peak for an hour. So when we have students who are pickier eaters, you might wanna talk to the parent about doing it after they eat if it's a consistent problem, right? If they're consistently struggling to finish all of their lunch, because playing catch up or having them just drink tons of juice, like that's not a good option either. So if that student is really having trouble finishing all of their lunch, I would recommend having that conversation with the parent and then making sure that you test their sugar before they eat, send them down and make sure they come back to you for insulin within 30 minutes. We don't want it to extend beyond that, right? But fighting those lows all afternoon is not fun and it's not fun for the student either. So if that's what's happening, you may wanna consider giving an after for that student. How long after a meal bolus are you able to give a correction dose? How long after a meal bolus are you able to give a correction dose? So would this mean in a scenario where you've already eaten and now your blood sugar is elevated? I guess, so if you checked the blood sugar prior to them eating, you can give that correction bolus, I would say within about that 30 minute window. But if you didn't check before and they have already eaten, you should not be giving them a correction dose. You should try to give them a carb dose for the carbs that they consumed if they know how many they consumed. If you don't know how many, then we're kind of back to that original scenario or that first scenario we talked through where you then can just give a correction dose. So let me explain it again. So if we had a person who came in and said that they missed their insulin dose, but they ate their breakfast less than 30 minutes ago, we could dose them for those carbohydrates, okay? If they know them. If they didn't know them, then all we would be giving them is a correction dose, but not both. I hope that that makes sense. Might be getting too late in the evening. I'm not making sense anymore. Do you need orders to give a correction dose when it's not in their diabetes medical management plan? Would you then phone the physician? Correct. And so most of the diabetes medical management plans have that either the dosing table, which says about giving correction doses every three hours if the glucose is above target, or when they're hyperglycemic to give those correction doses if you haven't given insulin within three hours. So the DMMP will indicate it, but yes, you do need orders to give that correction dose. If a student is 300 or greater right off the bus, and the student tells you nothing to eat, no insulin in the last three hours, assume this is a non-pump patient. Are we calling the parent to verify? Yes, absolutely. And I think at that point, you know, if the parent tells you, oh my gosh, we totally forgot to give insulin, this would be the student you wanna make sure you give that correction dose to right away so that we're not waiting until, you know, lunchtime or their next scheduled insulin time. We wanna get that correction dose in them immediately. Good question. Is it the school's responsibility to have the ketone dip strips or is it the parent's responsibility to provide? So this is a good question. You know, certainly ketone testing strips are available over the counter, but you know, in most school districts, parents are responsible for providing the medical equipment. So in our school district, we require that the parent provides those strips to us. So if we have a student who, you know, is hyperglycemic and is symptomatic, but we don't have ketone testing strips available, we're going to send that student home from school because we can't, you know, check on their ketone levels here in school. So Jackie, we're running out of time. This will be the last question. We have so many good questions. Let me just say, we'll create an FAQ. Okay, great. The webinar series has concluded. We'll create an FAQ of all of the chat box questions that live on AED's website. But here's the last one. Regarding the three-hour rule, I have been struggling to understand if I correct someone who was hyper three hours after their last bolus meal, but lunch is less than three hours away, can they have their food bolus and lunch on time? Yes, they can. That's such a good question. With insulin timing, you know, correction doses, you just couldn't give another correction dose. So again, if we corrected a student, let's say at 9 a.m. when they first came in, and then lunch was at 11 a.m. At 11 a.m., we can't give them another correction dose at that point because the 9 a.m. correction is still working, okay? But it's lunchtime, so we wouldn't wanna delay them from eating their meal. So we can just dose them for the carbohydrates they're gonna eat for their lunch. So they just get a food dose at that point. Okay. That concludes our questions. Okay. Well, again, I wanna thank everyone for the time tonight. I'll look forward to taking a look at those questions and putting together, you know, the FAQ document with Crystal. And we just wanna remind everyone too, you should receive an email from the American Diabetes Association directing you to the evaluation and to the post-test so you can receive those continuing education credits. And be on the lookout for the next webinar on January 22nd that covers nutrition. Thanks everyone.

diabetes management

blood glucose levels

hyperglycemia

hypoglycemia

ketones

insulin

15-15 rule

glucagon

medical management plan

504 plan

carb counts