2015 Safe at School:
Medical
Management for
Children with
Diabetes
Objectives
At the end of this learning session participants will
be able to:
 Describe how the anaphylaxis law affects
treatment students with diabetes will receive
 State the importance of diabetes self-management
 Discuss treatment for hyperglycemia
 Discuss treatment for hypoglycemia
Anaphylaxis Law
 Food
items containing
peanuts
removed
 Supplies needed for school
 Snack
 Treatment
Additional Changes
Diabetes Medical Management Plan

Date

Diagnosis
◦ Type 1 vs Type 2

CGM

Treatment
◦ Hyperglycemia
◦ Hypoglycemia

Insulin orders

Type 2
MANAGEMENT PLAN
(1)
Date of Plan: __________
DIABETES MEDICAL MANAGEMENT PLAN
Expiration date: ______________
(2)
 Insulin Dependent Diabetes
DIAGNOSIS:
 Type 1 Type 2
 Other Diabetes ________________________
(3)
Continuous Glucose Monitor (CGM):  Yes
 No
Brand/Model: _______________________: CGM may be worn for daily or occasionally
Note: Confirm CGM results with blood glucose meter check before taking action on sensor glucose level. No medical treatment should be
rendered based on CGM result only. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM.
TREATMENT AND INTERVENTION FORM
Student’s Name: _______________________________________________________ Date of Birth: _________________
Begin Treatment_____________________________________
Stop Treatment______________________________
Date
Date
DO NOT DISCARD THIS FORM UNTIL THE STOP DATE AS LISTED ABOVE
Diabetes Self-Management
Diabetes Self-Management
Importance:

Gain knowledge

Learn and practice skills

Modify behavior

Successfully self-manage
Diabetes Self-Management
Treatment and Intervention Form
Self-care skills
Blood glucose testing
NA
Ind
supv
total
kept
Ketones testing
NA
Ind
supv
total
kept
Glucose/gel
NA
Ind
supv
total
kept
Count carbohydrates
NA
Ind
supv
total
Calculate insulin dose
NA
Ind
supv
total
Give insulin by injection
NA
Ind
supv
total
kept
Give insulin by pump
NA
Ind
supv
total
kept
Change infusion set
NA
Ind
supv
total
kept
Diabetes Self-Management
Treatment and Intervention Form

Blood glucose monitoring
When to check:


Before meals

Anytime s/s high/low blood glucose
Urine Ketones testing
When to check:


Greater than 300

Student sick and /or vomiting
Glucose tablet/gel
When to use:

Treat hypoglycemia
Diabetes Self-Management

Definition:
 Ind = independent self-management
 Supv= self-management with nurse
supervision
 Total = total care by nurse
 Kept = kept on person
 NA = does not apply to my child; my child is
not doing or using this
Insulin Orders

Review
 Original orders from state
 COA orders
 Pump
 Correction factor + carbohydrate ratio
 Correction factor + fixed
 Sliding scale + fixed
 Sliding scale + carbohydrate ratio
Original Form
Insulin Orders
Pump Therapy
Insulin Orders
Correction + ratio
Insulin Orders
Sliding Scale + Fixed
Insulin Orders
Insulin Orders
Insulin Orders
Treatment:
•Hyperglycemia
•Hypoglycemia
Check blood
glucose:
⁼
(1) as stated in Individualized Care Plan/Treatment-Intervention Form
(2) if student exhibits signs of high blood glucose (extreme thirst, frequent urination, hunger, headache, hyperactivity)
(3) if student has nausea, vomiting, stomach ache or feeling ill
Yes
Blood glucose is greater than
300 mg/dL
No
Follow insulin
orders from
student’s provider
Check
urine for
ketones
Negative
ketones
Administer correction
dose …only if it has
been 3 hours or greater
since student received
a correction.
Student may return
to classroom
activities
Have student
drink 8-24 oz
water or sugarfree/caffeinefree fluids
Recheck blood
glucose & urine
ketones in 2
hours
If student develop
ketones, nausea,
vomiting, or is feeling
ill…follow the correct
pathway for
treatment of
symptoms
Ketones present
Ketones present
no vomiting or nausea
with vomiting or nausea
Administer correction
dose …only if it has been
3 hours or greater since
student received a
correction.
Administer correction
dose …only if it has been
3 hours or greater since
student received a
correction.
Call parent, this
child should go
home, not back
to class.
Have student
drink 8-24 oz
water or sugarfree/caffeinefree fluids
Student may return to classroom activities
.Allow bathroom privileges.
No exercises with ketones
Recheck blood
glucose & urine
ketones in 2
hours
If ketones are still positive
but improving after 2 hours
and student not feeling ill,
with no vomiting or nausea.
Student may stay at school
If ketones are still
positive, not
improving, after 2
hours with vomiting or
nausea..
Call parent/guardian
If you cannot
get in touch
with parents
contact our
diabetes doctor
on-call at 1205-638-9107
or if you do not
get a call back
within 15
minutes call
205-638-9100
and ask for the
diabetes doctor
on-call
Continue to check until
ketones are negative or if
student becomes ill follow
directions from pathway


Student shall be permitted to have access to water by keeping a water bottle in his/her possession and at his/her desk, or by permitting the student to use the
drinking fountain without restriction.
Student should not exercise when ketones are present
Student is not to miss class by sitting in the nurses’ office or be sent home unless vomiting or feeling poorly
Revised 02/02/2015
Injections
Hyperglycemia
If student has extreme thirst, frequent urination, hunger, nausea, vomiting, stomach ache or is feeling ill……
Check blood glucose:
(1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form
(2) if student exhibits signs of high blood glucose (extreme thirst, frequent urination, hunger, headache, hyperactivity)
(3) if student has nausea, vomiting, stomach ache or feeling ill
No
Check
urine for
ketones
Negative
ketones
Small ketones
*Inspect insulin site for
signs of inflammation.
Administer
correction dose
by insulin pump
Administer
correction dose
by insulin pump
Student may
return to
classroom
activities
Have student
drink 8-24 oz
water or sugarfree/caffeinefree fluids
Recheck blood
glucose & urine
ketones in 2
hours
Student may return
to classroom
activities.
No exercises with
ketones
If student develop
ketones, nausea,
vomiting, or is feeling
ill…follow the correct
pathway for
treatment of
symptoms
Recheck blood
glucose & urine
ketones in 2
hours
If ketones are
moderate or
large…. follow the
correct pathway
for treatment of
symptoms
Moderate or Large ketones
no vomiting or nausea
Moderate or Large ketones
with vomiting or nausea
Give correction dose
of insulin by
syringe/pen injection
rather than with the
pump.
The student will need to
change insulin pump
infusion set, site/pod and
refill reservoir/pod with
insulin. If student cannot do
this independently, call the
parent/guardian.
Moderate or Large ketones
no vomiting or nausea
Student may return to
classroom activities
Allow bathroom privileges.
May have water or sugarfree/caffeine-free fluids,
water.
No exercises with ketones
Recheck blood glucose &
urine ketones in 2 hours
If Ketones are still moderate
or large. Call
parent/guardian.
Recommendation to release
to parent/guardian
Moderate or Large ketones
with vomiting or nausea
Call parent, this
child should go
home, not back
to class.
If you cannot get in
touch with parents
contact our diabetes
doctor on-call at 1205-638-9107 or if
you do not get a call
back within 15
minutes call 205-6389100 and ask for the
diabetes doctor oncall
If the student has two consecutive blood glucose readings greater than 240 mg/dL and you nor the student can explain why; for example.. pump is functioning,
reservoir is not empty, and appropriate correction bolus has been given
then check ketones and follow appropriate path listed above.

Student shall be permitted to have access to water by keeping a water bottle in his/her possession and at his/her desk, or by permitting the student to use the
drinking fountain without restriction.

Student should not exercise when ketones are present
Student is not to miss class by sitting in the nurses’ office or be sent home unless vomiting or feeling poorly
Revised 02/19/2015
Pump Therapy
Hyperglycemia
Blood glucose is
greater than 300
mg/dL
Follow insulin
orders from
student’s
If student has extreme thirst, frequent urination, hunger, nausea, vomiting, stomach ache or is feeling
ill…… provider
Yes
Case Studies
Check blood
glucose:
⁼
(1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form
(2) if student exhibit signs of low blood glucose (see below for symptoms)
(3) if student states he/she is feeling low, ill, or student is not acting self
Blood glucose is
less than _*___
mg/dL
Yes
No
Follow insulin
orders from
student’s provider
Remain with student
If student has extreme thirst, frequent urination, hunger, nausea, vomiting, stomach ache or is feeling ill……
Mild
Moderate
Severe
Hypoglycemia
possible symptoms
Hypoglycemia
possible symptoms
Student is alert, trembling,
headache, sweating, pale,
shakiness, dizziness, tired,
falling asleep in class, inability
to concentrate, or has poor
coordination.
Severe confusion,
disorientation, not able or
unwilling to swallow, or may
be combative.
Hypoglycemia
Unresponsive to
commands,
Seizure or loss of
consciousness


Is it meal time?
Yes
No
If it is meal time and blood
glucose is greater than
60mg/dL…

Send student to
lunch.

Student may
receive insulin
immediately after
meal (give insulin
within 30 minutes
of first bite).
DO NOT SKIP INSULIN FOR
LOW BLOOD GLUCOSE

Give 15 grams
fast-acting
carbs.
For example:
simple sugar,
or 3-4 glucose
tablets, or 4 oz
of fruit juice, or
4 oz of regular
soda

Wait 15 minutes and
recheck blood glucose

If blood glucose is still
below _*___mg/dL
retreat with 1 of the
above 15 grams carbs

Recheck blood glucose
again in 15 minutes.
Repeat above steps
until blood glucose is
above __*___mg/dL
If meal time is less than
1 hour away follow box
above
Keep head elevated
Give one of the
following:
(apply between cheek
and gum)
o
Tube of cake
decorating
gel or
o
Instant
Glucose Gel
(15 grams)
Remain with student

Give nothing by mouth

Place student on side

Give prescribed dose of
Glucagon - refer to
prescriber authorization
order: ½ mg or 1 mg
Intramuscular as directed
by his/her diabetes care
provider

Call 911 if student is not
responding to glucagon.
Follow your school
procedure for notifications

Call parent/guardian

Call the physician.

Stay with student until help
arrives
*Use this “age-specific guide” to
insert the appropriate age in the
highlighted boxes:
90 = students less than 6 years
80 = students greater than 6 but less
than 13 years
70 = students 13 years and greater
If meal time is more than 1
hour away …

Give student 15 grams
carbohydrates with a
protein.
For certain patients, a negative correction factor may be used.
Revised 03/06/2015
Injections
Hypoglycemia

(1) as stated in Diabetes Medical Management Plan/Treatment-Intervention Form
(2) if student exhibit signs of low blood glucose (see below for symptoms)
(3) if student states he/she is feeling low, ill, or student is not acting self

Blood glucose is
less than __*__
mg/dL
Yes
No
Follow insulin
orders from
student’s provider
Remain with student
If student has extreme thirst, frequent urination, hunger, nausea, vomiting, stomach ache or is feeling ill……
Mild
Moderate
Severe
Hypoglycemia
possible symptoms
Hypoglycemia
possible symptoms
Hypoglycemia
Unresponsive to
commands,
Seizure or loss of
consciousness
Severe confusion,
disorientation, not able or
unwilling to swallow, or may
be combative.
Student is alert, trembling,
headache, sweating, pale,
shakiness, dizziness, tired,
falling asleep in class, inability
to concentrate, or has poor
coordination.


Is it meal time?
Yes
No
If it is meal time and blood
glucose is greater than
60mg/dL…

Send student to
lunch.

Wait to bolus
immediately after
eating within 30
st
minutes of 1 bite.

Enter the pre meal
low blood glucose
reading into the
insulin pump and
amount of carb eaten.

In this situation the
insulin pump will
adjust the
carbohydrate bolus to
compensate for the
low blood glucose.
DO NOT SKIP INSULIN FOR
LOW BLOOD GLUCOSE

Give 15 grams
fast-acting
carbs
for example:
simple sugar,
or 3-4 glucose
tablets, or 4 oz
of fruit juice, or
4 oz of regular
soda

Wait 15 minutes and
recheck blood glucose

If blood sugar is still below
_*__mg/dL retreat with 1 of the
above 15 grams
carbohydrates and suspend the
insulin pump

Recheck blood glucose again in
15 minutes. Repeat above
steps until blood glucose is
above __*___mg/dL
If meal time is less than
1 hour away follow box
above
Do not forget to
resume
pumping
Keep head elevated
Give one of the following:
(apply between cheek
and gum)
o
Tube of cake
decorating gel
or
o
Instant Glucose
Gel (15
grams)
o
Place insulin
pump in
suspend or
stop
Remain with student

IMMEDIATELY STOP insulin
pump or SUSPEND

Give nothing by mouth

Place student on side

Give prescribed dose of
Glucagon - refer to
prescriber authorization
order: ½ mg or 1 mg
Intramuscular into thigh as
directed by his/her diabetes
care provider

Call 911 if student is not
responding to glucagon.
Follow your school
procedure for notifications
but ..

Call parent/guardian

Call the physician

Stay with student until help
arrives
*Use this “age-specific guide” to
insert the appropriate age in the
highlighted boxes:
90 = students less than 6 years
80 = students greater than 6 but less
than 13 years
70 = students 13 years and greater
If meal time is more than 1 hour away

Give student 15 grams
carbohydrates with a protein.
Resume Pumping
Revised 03/06/2015
Pump Therapy
Hypoglycemia
Check blood glucose:
Case Studies
Type 2
•Student has Type 2 Diabetes
•Able to control their blood sugar levels by managing their weight, eating healthy meals and getting
plenty of exercise. However, if not enough…may have been medications that are taken by mouth
and/or by injections. These medications are not administered during school hours.
•At times this student may have high blood sugars. High blood sugar (hyperglycemia) in people with
diabetes can often cause unusual thirst and the need for frequent urination. If this occurs, he/she will
probably need to go to the restroom more often than usual. Please allow him/her the freedom they
need on these occasions to do so.
• A balanced intake of milk products, fruits, vegetables, breads and meats is the meal plan
Concentrated sweets (candy, sweet rolls, cake, chocolate milk, etc.) should be avoided.
Students with diabetes may eat anything on breakfast or lunch trays except desserts and drinks
containing sugar. We have encouraged him/her to substitute fresh fruit or fruit packed in natural juice
(not syrup) for their dessert.
•Additionally, we have instructed this student to test his/her blood sugar any time he/she is not feeling
well. If the student is required to test his/her blood sugar a treatment intervention form will be sent to
the school.
•This is considered a minimal standard for safety in the school setting and is covered under the
Americans with Disabilities Act.
How Can You Assist Children’s (COA)
 All communication to COA must contain name of
student and date of birth
 Make sure you send glucose readings home.
Caregivers need this information when
communicating with COA.

 It is ok to fax the readings from school; however,
we need all readings
 We have a revised fax sheet for families needing
assisting
Questions
References:

AADE (2011). Diabetes Self-Management. The Art and Science of Disease Self-Management
Education Desk Reference;(2) 22-24.

NDEP (2010). Helping the Student with Diabetes Succeed. A Guide for School Personnel.

Pediatrics (2012). Policy statement- Guidance for the Administration of Medication in School.
Retrieved from http://pediatrics.aappublications.org/content/124/4/1244.full.html