Type I Diabetes: When the pancreas fails to produce insulin. This diabetes is more common in children and adolescents (formerly referred to as Juvenile Diabetes).
Type II Diabetes: Defined by the American Diabetic Association as, “a type of diabetes that occurs primarily as a result of insulin resistance, characterized by diminished liver, muscle, and adipose tissue sensitivity to insulin...”
Diabetic Medical Management Plan (DMMP): Provider orders outlining daily care of diabetic students. DMMP should address blood glucose monitoring, insulin orders (for blood sugar correction and carb coverage) and treatment for high and low blood sugar (see appendix for MT DMMP).
Hypoglycemia: Low blood glucose, typically less than 300 70mg/dl.
Hyperglycemia: High blood glucose, typically over 300 70mg/dl.
Continuous Glucose Monitor (CGM): A way to measure glucose levels in real-time throughout the day and night. A tiny electrode called a glucose sensor is inserted under the skin to measure glucose levels in tissue fluid. It is connected to a transmitter that sends the information via wireless radio frequency to a monitoring and display device. (www.medtronicdiabetes.com/treatment-and-products/continuous-glucose-monitoring).
Students with Type I Diabetes
Considerations in Planning Care
- The school nurse should work with student’s family and provider to obtain a DMMP for each Diabetic student.
- All diabetic students should have an Emergency Care Plan that addresses actions to take if the student is hyperglycemic or hypoglycemic.
- Diabetic students should have an IHP and be considered for a 504 plan.
- The school nurse needs to assist in establishing meetings for all staff involved with student to review care plans and emergency procedures. School nurse oversees training and possible delegation of diabetes care tasks.
Elements of Care Plan for Diabetes
- Where will supplies be kept? Can they keep extra supplies in the classroom or office?
- Blood glucose testing: When/where will student test? Do they need supervision or assistance? If so, who will that person be and who will train them?
- Blood glucose monitoring: What blood sugar range is acceptable? When and how do parents want to be notified.
- What are the student’s typical symptoms of hypo/hyperglycemia? Can they identify when they have high or low blood sugar? Can they communicate this to an adult?
- If the student cannot self-administer insulin, who will be assisting?
- Snacks for the students: who will provide the snacks and where will they be kept?
- Dietary concerns: Type I Diabetics may also have celiac considerations. If the student is eating school lunch will you be able to provide carb counts?
- Recess accommodations: Does the student need to test their blood glucose prior to recess. What training will the recess aids need?
- Fieldtrip accommodations: What supplies will the student need? Do they need a UAP, licensed person, or parent to accompany them?
- Who will be trained to assist student with daily needs and/or administer glucagon.
- Accommodations during classroom parties: Does the student provide their own snack? Can they participate in the party as long as they cover carbs eaten with insulin?
- Physical activity: discuss with family the effects that exercise has on the student’s blood glucose levels. Consider if BG testing should be done prior to or after PE if necessary.
- After school and extracurricular activities: Identify if the student needs support during extracurricular activity time and discuss your role in supporting this process.
Training School Staff
- Review ECP with at least all staff that have daily contact with student. You may want all staff to be familiar with a student if they are a young child in elementary school.
- Some staff may need an overview of Diabetes if they will be assisting with care in any way. See example training record under “Forms”.
- Glucagon: Please refer to MCA 20-5-412, otherwise known as “the Glucagon law.” The nurse may facilitate the teaching of staff to use glucagon after they have been designated by the diabetic student’s parents. Under this law the nurse is not delegating injection of Glucagon, but is identified as teaching the skill. See “Forms” for glucagon related resources.
Students with Type II Diabetes
Students with Type II Diabetes may not require as much daily assistance as students with Type I Diabetes, but it is still recommended that the school nurse have these students identified as students with a chronic condition. It is advisable to discuss their potential needs with the child’s parents and develop an emergency care plan and any other plans deemed appropriate by the school nurse.
Considerations in Planning Care
- Dietary concerns: Does this student have any prescribed dietary plan that requires accommodations in the school day?
- Treatment plan support: If the child’s medical provider has them on a treatment plan discuss with the family if there are ways that you can support this plan at school.
Diabetes Medication Administration
MCA 20-5-412 Definition -- parent-designated adult -- administration of glucagon -- training
It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) is the school staff member who has the knowledge, skills, and statutory authority to fully meet the healthcare needs of students with diabetes in the school setting. Diabetes management in children and adolescents requires complex daily management skills (American Association of Diabetes Educators [AADE], 2016). Health services must be provided to students with diabetes to ensure their healthcare needs are met; requirements of relevant federal and state laws are met; and they can fully participate in school and school-sponsored events (AADE, 2016).
Diabetes is the third most common chronic health disease affecting an estimated 2.22/1,000 children and adolescents according to The Search for Diabetes in Youth (SEARCH) Study (Pettitt et al., 2014). Children and adolescents are defined as youth under the age of 20 years. In 2009, approximately 191,986 or one in 433 youth with diabetes lived in the U.S. From these, 87% have type 1 diabetes and 11% have type 2 diabetes (Pettitt et al., 2014). In the year 2008 to 2009, 18,436 youth were newly diagnosed with type 1 diabetes and 5,089 youth were newly diagnosed with type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2014).
Advances in diabetes technology continue to enhance the students' ability to manage diabetes at school, thus improving their quality of life. Children and adolescents monitor blood glucose levels several times a day via blood glucose meters and continuous glucose monitors, conduct carbohydrate calculations, and inject insulin via syringe, pen and pump to attain blood glucose control (Brown, 2016). Intensive resources and consistent evidenced-based interventions will achieve the long-term health benefits of optimal diabetes control, according to the landmark study from the Diabetes Control and Complications Trial Research Group (DCCT, 1993).
Each student with diabetes is unique in his or her disease process, developmental and intellectual abilities, and levels of assistance required for disease management. An individualized Diabetes Medical Management Plan (DMMP) is completed by the healthcare provider and includes the medical orders to manage the student's diabetes needs during the school day and at school-sponsored activities (Jackson et al., 2015). The school nurse develops an individualized healthcare plan (IHP) in partnership with the student and his or her family, based on the medical orders in the DMMP and the nurse's assessment. (American Nurses Association/National Association of School Nurses [ANA/NASN], 2011). The IHP outlines the student's diabetes management strategies and personnel needed to meet the student's health goals in school (National Diabetes Education Program [NDEP], 2016). The school nurse also prepares an emergency care plan (ECP), based on the DMMP medical orders, that summarizes how to recognize and treat hypoglycemia and hyperglycemia and directs action to take in an emergency. Copies of the ECP should be distributed to all school personnel who have responsibilities for the student during the school day and during school-sponsored activities (NDEP, 2016).
Throughout childhood and adolescence, the student who has diabetes continuously moves through transitions toward increasing levels of independence and self-management (American Diabetes Association [ADA], 2016), requiring various levels of supervision or assistance to perform diabetes care tasks in school. Students who lack diabetes management experience or cognitive and developmental skills must have assistance with their diabetes management during the school day, as determined by nursing assessment and as outlined in the IHP (Wyckoff, Hanchon, & Gregg, 2015).
Hypoglycemia (low blood glucose) is the greatest immediate danger to the student with diabetes. During hypoglycemic incidents, the student may not be able to self-manage due to impaired cognitive and motor function. A student experiencing hypoglycemia should never be left alone, sent anywhere alone, or escorted by another student. Communication systems and trained school staff should be in place to assist the student. Hypoglycemia can occur suddenly and requires immediate treatment (NDEP, 2016).
Another complication of diabetes, hyperglycemia (high blood glucose), can develop over several hours or days (NDEP, 2016). If untreated, hyperglycemia can lead to the life-threatening condition, diabetic ketoacidosis (DKA) (Wyckoff et al., 2015). For students using insulin infusion pumps, lack of rapid-acting insulin increases their risks of developing DKA more rapidly (Brown, 2016). School nurses may utilize one or more of the model NDEP three levels of staff training to facilitate prompt, safe, and appropriate care for students with diabetes (NDEP, 2016).
Students with disabilities, which include students who have special healthcare needs such as diabetes, must be given an equal opportunity to participate in academic, nonacademic, and extracurricular activities. Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act prohibit recipients of federal financial assistance from discriminating against people on the basis of disability (NDEP, 2016). These laws are enforced by the Office for Civil Rights (OCR) in the U.S. Department of Education. Schools are required to identify all students with disabilities and to provide them with a free appropriate public education (FAPE) (NDEP, 2016).
Advances in science, technology, and evidence-based practices related to diabetes management require school nurses to attain and maintain current knowledge and competence in the delivery and coordination of the care for the student with diabetes (NDEP, 2016, Pansier & Schultz, 2015).
Children and adolescents with diabetes are confronted with many challenges and potential educational barriers in school. Some of the main barriers include lack of informed and trained staff, absence of a school nurse who is on site daily, and lack of diabetes management policies (Pansier & Schultz, 2015). School-based diabetes interventions led by school nurses are essential to improve health and academic outcomes and ensure a safe school environment for children and adolescents with diabetes.
The increasing prevalence of health-related disabilities, including type 1 and type 2 diabetes, has compounded the need for coordination of care between the school, the student's healthcare team, the family, and service providing agencies (McClanahan & Weismuller, 2015). Recent studies show that care coordination in the school setting improves quality of life, diabetes glucose control, ability to self-manage, readiness to learn, classroom participation, and academic performance (Pansier & Schultz, 2015). Care coordination, a core professional school nursing principle, and its related practice components involve developing and maintaining competence in creating, updating, and implementing care plans that comprehensively create an environment where students will maintain optimal health in the school setting so that they can succeed academically (NASN, 2016).
School nurses implement the DMMP, develop IHPs and ECPs, and train school personnel (McClanahan & Weismuller, 2015). When nursing delegation of diabetes care tasks is deemed appropriate, the school nurse provides ongoing supervision and evaluation of student health outcomes (Wyckoff et al., 2015). School nurses are accountable for addressing the students’ ongoing healthcare needs, encourage independence and self-care within the student’s ability, and promote a healthy, safe school environment that is conducive to learning (NDEP, 2016).
Ineffective management of diabetes in school may lead to absenteeism, depression, stress, poor academic performance, and poor quality of life (Pansier & Schulz, 2015). Managing diabetes at school is most effective when there is a partnership among students, parents/guardians, school nurses, healthcare providers, and other school personnel (e.g., teachers, counselors, coaches, transportation, food service employees, and administrators). The school nurse provides the health expertise and coordination needed to ensure cooperation from all partners in assisting the student toward self-management of diabetes. Poorly controlled diabetes not only affects academic performance but can lead to long-term complications such as retinopathy, cardiovascular disease, and nephropathy. Maintaining blood glucose levels within a target range can prevent, reduce, and reverse long-term complications of diabetes (DCCT, 1993).
Diabetes is listed as the third most common chronic health condition that impacts approximately one in 433 children and adolescents in the United States (Pettitt et al., 2014). The school nurse is the most appropriate staff member in the school to fully meet the healthcare needs of students and should be the key coordinator and care provider for the student who has diabetes (ADA, 2016). The school nurse’s competence in the practice components of the principle of Care Coordination (e.g., case management, collaborative communication, providing and/or coordinating the provision of direct care, training of non-medical personnel) is essential to promoting the health, safety, and academic success of students who have diabetes within the school setting (AADE, 2016; McClanahan, 2015; NASN, 2016).
Life Threatening Allergies and Anaphylaxis
Anaphylaxis: An acute and potentially lethal multi system reaction. Unlike common allergy, anaphylaxis onset may be sudden and requires instant action to prevent fatality. Anaphylaxis can be presented as severe symptoms in at least one body system OR it can be presented as a combination of symptoms in two or more body systems.
Epinephrine is the first line choice for treatment of anaphylaxis. ALL student that receive epinephrine should be sent to the emergency department for further evaluation. “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand. Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013). A second dose is recommended if symptoms are not resolved within 5-20 minutes (consult student’s provider order).
Dosing Guidelines of Epinephrine
<66 pounds (second grade and lower)
Use junior dose: 0.15mg
>66 pounds (3rd grade and older)
Use adult dose: 0.3mg
“Antihistamines may be administered with epinephrine, but never instead of epinephrine…” (Selekman 2013). Consult student’s physician and guardian to develop protocol for the use of antihistamines, and document in student Emergency Care Plan.
Consider anaphylaxis treatment if any of these signs and symptoms are present and severe:
OR if there are a COMBINATION of symptoms from different body areas:
Lungs: Short of breath, wheeze, repetitive cough
Heart: Pale, blue, faint, weak pulse, dizzy, confused.
THROAT: Tightness, hoarse, trouble breathing/swallowing.
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN: hives over body
SKIN: hives, itchy rashes, swelling (eyes, lips)
GUT: Vomiting, cramping pain, diarrhea
HEENT: Runny nose, sneezing, swollen eyes, phlegmy throat
OTHER: Confusion, agitation, feeling of impending doom.
Guidelines for administering Epinephrine (taken from the sample protocol developed by the Epinephrine Policies and Protocols Workgroup of the National Association of School Nurses, 12/2014)
Planning Care for Students with Life Threatening Allergies
- Identify students diagnosed with allergies
- Obtain history from parents on their history of anaphylaxis.
- Establish Emergency Care Plan. Consider IHP or 504 for accommodations.
- Obtain orders for student’s medications (epinephrine autoinjector, Benadryl). Students may self-carry emergency medication with MT Self Carry Authorization form filed. (See MT Authorization to Self-Carry)
- Medication: Where will medication be stored? “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand. Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013)
- Accommodations: does this student need special diet order? Do they need a “nut free” table? Are their airborne issues with their allergen? What will the child do when there is a class party? Can they have classroom snacks? Are their items in art class or other classrooms that may cause an allergic reaction.
- If your school is going to have a “nut free classroom” or “nut free policy” make sure that all parents are aware. Letters should be sent home. Administrators may choose to have parents sign and return letters.
- Make sure teachers and other team members are familiar with child, their allergies, and their ECP.
- Plan appropriately for field trips and extracurricular activities.
- Train staff in use of epinephrine auto injector.
- Communicate with transportation department if child rides the bus.
- Consider sending letter home to parents. (Sample letter)
Laws and Regulations
20-5-420, MCA Self-administration or possession of asthma, severe allergy, or anaphylaxis medication
27-1-714, MCA Limits on liability for emergency care rendered at scene of accident or emergency
20 USC 1232 Family Education Rights and Privacy Act
According to MCA 20-5-420 Section 2 it is legal for Montana schools to possess a stock supply of epinephrine auto injectors . “Approximately 20-25% of epinephrine administration in schools involve individuals who allergy was unknown at the time of the reaction,” (NASN SCHOOL NURSE. “The Case for stock Epinephrine in Schools. Vol. 27. No 4. July 2012). Stock epinephrine is to be used in the event that an individual (student, staff, visitor, etc) is having an allergic reaction. Many of these incidents will be first time exposures.
Sample MT Stock Epinephrine Policy: See attachment
Free epinephrine auto-injectors are currently available at www.epipen4schools.com.
- Montana Authorization to possess or Self-Administer Asthma, Severe Allergy, or Anaphylaxis Medication
- Sample Stock Epinephrine Policy
- Sample Anaphylaxis Emergency Plan