Recognition and Treatment of
Hypo/Hyperglycemia (low and high blood
sugars)
Hypoglycemia
Signs/symptoms of hypoglycemia (see additional info sheet):
Shaking/trembling (especially look at their hands)
Irritable/inexplicable crying
Suddenly very hungry
Lethargy/blank stares/inability to focus
Pale
Blurred vision
Sweaty/clammy
Hypoglycemia treatment:
Ages = 5-10
Blood Sugar
Check blood sugar if above symptoms are reported or observed. A blood sugar
less than 80 is a low blood sugar.
If the blood sugar is between 50 and 80, the standard is to give 15 grams of fastacting carbohydrates (carbs). If below 50, the standard is to give 30 grams fastacting carbs. This is a rule of thumb for average-age, average-sized kids. Many
of your students will have specific school orders from their endocrinologists that
list much more exact treatments for low blood sugars based on age and blood
sugar range. If your student has these orders, refer to them for treatment and do
not go by the above “rule of thumb.” The following is a commonly used
treatment plan:
Amount of Carbohydrate
60-80
50-60
40-50
30-40
10
20
30
40
Ages = 11-18
Blood Sugar
Amount of Carbohydrate
60-81
50-61
40-51
30-41
15
30
45
60
Fast-acting carbs are any source of carb that is a “quick sugar.” These are items
which are absorbed quickly through the stomach lining. Anything that contains
fat or fiber is NOT a fast-acting carb (ie. chocolate, apples, peanut butter, etc).
Examples of fast-acting carbs are: juice, regular soda, Smarties, Sweet Tarts,
sugar packets or cubes, raisins, glucose tablets – anything that is all sugar, easily
chewed and swallowed, and does NOT contain fat.
Recheck blood sugar 15 minutes after student is treated with fast-acting carb.
Repeat this treatment cycle until student’s blood sugar is >80.
If child is not eating within the next hour, then they need eat a fat/fibercontaining snack to prevent the low blood sugar from recurring. Examples of
these include cheese and crackers, peanut butter and crackers, milk (not skim),
ice cream, lunch meat, etc. Follow the directions on the school orders or
instructions from the family to determine whether or not you should give the
student insulin for these snacks.
If child is very low and unable to swallow, use glucose gel or cake gel and
massage into cheek/gums while massaging throat to encourage swallowing.
If unconscious or combative, use glucagon. This is an intramuscular shot to the
child’s thigh, and can be given through their clothes (subcutaneous shots work
more slowly).
o Under age 6: 0.3 mL
o Ages 6-18: 0.5 mL
o Age 18 and above or for large teens: 1 mL
Roll child on side after delivery and expect vomiting. Give carb-containing
fluids after awake, and then at least a 30 gram protein/fiber containing snack
when able to tolerate fluids. If no response, repeat dose if there is any left, and
call 911.
Hyperglycemia
Signs/symptoms of hyperglycemia (see additional info sheet):
Nausea/loss of appetite/vomiting
Headache
Blurred vision
Irritable/inexplicable crying
Fatigue/inability to concentrate
You may notice that many of the signs of low blood sugars are similar to those of high blood
sugar. If your student does not appear well or states that he/she “doesn’t feel right,” do a blood
sugar check.
Hyperglycemia treatment:
Check blood sugar if above signs and symptoms are reported or observed. If
blood sugar is over 300 for those students on insulin injections or over 250 for
those students on insulin pumps, check urine ketones. If ketones are not present,
have child drink lots of water and exercise if possible. If ketones are present in
any amount, have child drink lots of water and rest (no exercise). Call the parent
if ketones are present as insulin is the only way to eliminate ketones. If child is
severely ill, call 911.
May correct a pre-meal blood sugar if child has school orders to do so – follow
the directions given on the school orders using the child’s correction factor.
Child will need to have unlimited bathroom privileges and ability to drink water
at desk if blood sugar is high.
Child will feel sick with high blood sugar, especially if ketones are present, and
will have difficulty concentrating – expect them not to perform well. As the
school health care provider, you may have to educate teachers on this (ie the
student may need to take a test on a different day, etc).
Step-by-Step Guide to Checking Blood Glucose
1. Gather supplies.
2. Instruct student to wash hands with warm water.
3. Load lancet device with new lancet. NEVER reuse lancets – each
use dulls the metal, and can leave metal shards in the skin.
4. Load test strip – most monitors turn themselves on when you do
this.
5. Hold lancet device to side of fingertip.
6. Activate lancet by pressing button.
7. Turn finger down to get full drop of blood, may milk finger if
necessary. Do not add blood to test strip-obtain result from one
blood drop only.
8. Hold strip to drop of blood – the strip will absorb the blood by
capillary action.
9. Record results (results help the student’s MD obtain patterns of
blood sugars and see where changes may be needed with insulin).
10. Remove lancet from lancet device and dispose of properly.
TIPS:
 Controls are done: Each time you open a new bottle of test
strips, drop monitor, do not believe results, or if strips are left
out in the heat.
 Different types of batteries are used depending on the meter.
Some are AAA, others are watch batteries. The family can
provide backups of these.
 Never share monitor with another student.
 Alternative sites are a great alternative to finger sticks and are
reported to be less painful. However, do not use an alternative
site if you think the student’s blood sugar is low. If you get a low
blood glucose result, you need to retest on a fingertip.
Disposable Pen Instructions:
1. Get Prepared:
a. Wash hands.
b. Check to see that Humalog/Novolog is clear. If cloudy, do not use.
c. Check to see where the rubber stopper is located on the side of the
pen (ie. is there enough insulin left to inject?)
d. Wipe off rubber seal on the end of the Pen with alcohol.
e. Remove the paper tab from the outer Pen needle shield.
f. Screw the capped needle clockwise onto the end of the Pen until tight.
Remove the inner Pen needle shield and discard into trash.
2. Prime the Pen:
a. Lilly Prefilled Pen for Humalog: Turn the dose knob clockwise until the
arrow appears in the magnifying dose window. Pull out the dose knob.
A “0” will appear in the window. Turn the dose knob clockwise until a
“2” appears.
a. Novolog FlexPen, Humalog Kwikpen: Turn the dose knob clockwise
until you reach the line next to the “2”.
b. Remove the cover from the needle and point the Pen up.
c. Tap the clear plastic barrel lightly then press the injection button in all
the way until you see a drop or small stream of insulin. If no insulin
comes out, repeat the priming steps until you do.
3. Dial the dose:
a. Lilly Prefilled for Humalog: Turn the dose knob clockwise until the
arrow appears in the magnifying dose window. Pull out the dose
knob. A “0” will appear.
Dial the number of units for the insulin dose. If the dose is dialed too
high, turn the knob backward until the correct dose appears
b. Novolog FlexPen, Humalog Kwikpen: Set the dose indicator to the
appropriate number of units you want to inject.
4. Double check dose with student, if age appropriate, by checking dose
window together and checking MD orders.
5. Deliver the dose:
a. Place the needle into the subcutaneous tissue at a 90 degree angle
(injection sites are: back of arms, abdomen, hips, thighs), and press
the injection button down completely. Then, count slowly to 6 (One,
one thousand, Two, one thousand, Three, one thousand etc). If all
the insulin was given, a diamond or arrow should appear in the Lilly
Prefilled Pen window. In the Novolog Flexpen and the Humalog
Kwikpen, the dose indicator window should reset to zero. Remember
to rotate sites.
6. Store the Pen/Document the Injection:
a. Replace the outer needle shield.
b. Unscrew the capped needle and dispose per school district sharps
policy.
c. Place the cap back on the Pen for storage and keep at room
temperature (no higher than 86 degrees, and not in fridge). The
pen can be used for 1 month at room temperature, provided the
insulin doesn’t run out.
d. Document injection: dose, time, site, BG reading and whether pre- or
post meal. Injections should be done pre-meal in most children,
though they are sometimes done post-meal in very young children
(preschool, kindergarten) who are unsure what they will eat.
NovoPen Jr. Instructions:
1. Introduction – these have a removable cartridge that is replaced and a better
mechanism than disposable pens. The NovoPen Jr. is the only available
insulin pen that can dose ½ units. Though there is between 0.1-0.2 units of
error with the NovoPen Jr., this is far more accurate that even a well-trained
nurse can do with a syringe and is therefore much safer for small children
and much more accurate for teenagers.
2. If you have dialed too large a dose, follow the following instructions for
turning the dose back to zero – this is a different procedure than with the
disposable pens!
3. To remove an empty cartridge, you must unscrew the pen halves. After the
halves are taken apart, the old cartridge will slide right out of the lower half
of the pen. You only take apart a pen when a cartridge is empty, and NEVER
replace an empty cartridge with a partially used cartridge, or refill from a vial.
4. To refill pen with a new cartridge, you must first wind the plunger back into
the top half of the pen – this is done by manually twisting the plunger
counter-clockwise backwards into the top part of the pen device. Once
plunger is all the way back into pen device, you may now refill the pen with
the new insulin cartridge.
5. After a new cartridge is placed in pen, it must now be primed. The initial
priming of a brand new cartridge may take 2-8 units of insulin in 2 unit
increments in order to get all the air out. First, you must place a needle onto
the pen following the same instructions above used for disposable pens.
Then, you turn the pen with the needle pointing up, and begin priming with 2
units of insulin. Repeat until several drops of insulin are seen coming out of
the needle. Proceed to injection.
6. A function check of the pen should be performed whenever the pen is
dropped or exposed to extreme temperatures, as well as once a month to
ensure proper functioning. Please refer to following instructions.
Tips
 Use a new needle with each dose.
 Prime before each injection or the dose may be inaccurate.
 Push the injection button all the way in. If the full dose wasn’t given, the
magnifying/dose window will reveal the number of units left.
 Never leave the needle on after using an insulin pen. ALWAYS remove and
replace with cap, otherwise insulin will leak out and air bubbles will enter
the cartridge.
 Do not refrigerate insulin pens which are in use.
 Once a month, perform a function check on the NovoPen Jr. If the
function check fails, repeat and if it fails again, do not use the Pen.
 When giving medications, you must have the drug in its original container
and have followed the policies and procedures of the district that governs
medication administration by having a written request/authorization from
the parent and/or physician.