Diabetes Care Guide Book - Hackensack University Medical Center
Contents
1. Incomplete meals and or snacks e Not enough food in particular not enough carbohydrate Taking too much insulin 25 Increased physical activity without extra food or reducing insulin Alcohol consumption especially on an empty stomach Prevention of hypoglycemia Fongwimg these steps can help to prevent hypoglycemia Take correct amount of insulin Check blood sugar at least four times per day Check blood sugar before exercising and if necessary eat additional snack Know the warning signs of low blood sugar All caretakers teachers and coaches should be aware of early symptoms and treatment of hypoglycemia Always carry a rapid acting sugar so that you can treat a low blood sugar reaction right away Treatment of mild to moderate hypoglycemia You should treat a hypoglycemic episode as soon as the symptoms are recognized If mild or moderate hypoglycemia is not treated in time they can lead to severe hypoglycemia which then affects the brain That is why it is so important to treat hypoglycemia right away If you are ever in doubt about whether or not the blood sugar is low test it 26 THE RULE OF 15 TO TREAT MILD HYPOGLYCEMIA 15 grams of fast acting carbohydrate every 15 minutes STEP 1 TEST BLOOD SUGAR STEP 2 If LOW Treat With 15 Grams Of Fast Acting Carbohydrate Treat for low blood sugar if Blood glucose level is below 80 mg dL during the day Blood glucose level is below 100 mg dL at2. bedtime snack If you are 6 12 years old your target is 80 180 mg dL before meals and 100 180 mg dL before bedtime snack less than 200 mg dL 2 hours after start of meal If you are over 12 years old your target is 80 150 mg dL before meals and 100 150 before mg dL bedtime snack less than 200 mg dL 2 hours after start of meal You may need a different target range so you should talk to your diabetes healthcare team about it You may always have occasional blood sugars that are not in range The important thing is to look for patterns of high or low blood sugars that happen at the same time of day You should then speak with your healthcare team about adjusting the insulin to correct the problem until you are comfortable doing so yourself If More Than Half of Your Blood Sugars Are In Your Target Range CONGRATULATIONS You Are In Good Control Of Your Diabetes When Should You Check Blood Sugars At least four times day before each meal and before evening snack Before during and after periods of exercise lasting more than 1 hour Before driving and periodically while driving long distances Additional Times To Check Blood Sugar e You feel signs of low or high blood sugar e You feel ill or stressed Two hours after meals to check blood sugar control between meals If your schedule changes increased physical activity vacation travel job school Between 12 2 a m if BG is less than 100 mg dL befor
3. clear Lantus Levemir The table below represents typical action times It is important to note that duration of action can vary substantially from child to child and from one injection to the next Variations of action times also occur with different manufacturing companies Name Letter Onset Peak Duration Humalog H 5 15 min 1 hour 2 4hrs Novolog 5 15 min 1 hour 2 4hrs Regular R 30 min 1hr 2 D5Dhrs 6 16 hrs NPH N 1 2hrs 4 12 hrs 24 hrs Lente L 1 3 hrs 6 15 hrs 22 hrs Ultralente U 4 6hrs 8 30 hrs 36 hrs Lantus 45 min 2 hrs Does not peak up to 24 hrs Levemir 3 6 hrs Does not peak up to 23 hrs Novolog and Humalog should be given right before the meal However for toddlers or when unsure of amount to be eaten give within 15 30 minutes of when a child starts eating this helps to prevent hypoglycemia if the entire meal is not eaten You and your doctor will decide which insulin s are best for you You should not change the type or brand of insulin without first consulting your doctor You should not mix two different brands of insulin The amount of insulin taken daily is based on several factors including a person s weight activity level food intake and blood sugar reading The dose of long acting insulin is usually kept constant from day to day The dose of short acting insulin is usually given depending on what the blood sugar reading is before that injection and depending on how many grams of carboh
4. completely 2 Assemble supplies needed before testing Automatic lancing device lancet needle to prick finger test strip glucose meter alcohol wipe if necessary and cotton ball or tissue 3 Massage or milk the finger to be pricked to bring blood to the fingertip Point the hand down towards the floor 4 Puncture the finger using the automatic pricking device It is best to puncture the side of the fingertip as there is more blood and fewer nerve endings in these areas If a large drop of blood does not form gently milk the finger to push blood into the tip 5 Place the blood on the test strip according to the manufacturer instructions 6 Continue the test as indicated to obtain results 7 Record results and time of test in the blood glucose logbook It is also possible to obtain blood samples from other parts of your body using a special type of lancet device or meter Ask your diabetes educator to demonstrate these to you if you are interested Blood Glucose Targets It is acceptable for children with newly diagnosed diabetes to have blood sugars that are above the target range for their age for the first days after diagnosis as long as they do not have positive ketones in their urine or blood Once the child returns to his her normal routine of food and activity the goal is to keep blood sugars in the target range If you are 6 years old or younger your target is 100 200 mg dL before meals and before
5. if more than 1 hour after last meat Other 6 Check ketones Ui when blood sugar is more than 240mgid O on sick deys 7 Do not exercise if ketones are moderate or large 8 Call parents if ketones are moderate or large or vomiting is present 9 Give Glucagon sm IM for emergency loss of consciousnesa selzures or low BG that can not be treated by mouth end call 911 10 if symptomatic student should NOT be sent to the nurse s office by him herself Other Recommendations 1 6 2 7 3 8 4 9 5 10 Signature s MD NP Date Parents Phone numbers H wW Cell Beep Molly Center Phone numbers 1 201 996 5329 Fax 201 525 0115 Monday to Friday 8 30am 4 30pm Signature Parent Guardian Date Total Daily Lantus dose 50 Basal Rate using Insulin to Correction Factor of TDD 50 at basal rate Carbohydrate 1800 TDD or mg Dose TDD TDD 2 24 ratio 500 TDD or dl drop in blood 0 5 TO 1 UNIT KG hours grams of carbs glucose for every covered by 1 unit of unit of Humalog or Humalog or Novolog Novolog 10 units 5 units 0 2 u h lu 50 grams lu 180mg d1 drop 12 units 6 units 0 25 u h lu 40grams lu 150mg d1 drop 14 units 7 units 0 3 u h lu 35grams lu 130mg d1 drop 16 units 8 units 0 33 u h lu 30grams lu 110mg dl drop 18 units 9 units 0 38 u h lu 30grams lu 100mg d1 drop 20 units 10 units 0 42 u h lu 25grams lu 90me dl drop 22 units 11 units 0 4
6. if normally cloudy should be without clumps and should look like skim milk after mixing Insulin pens should be kept at room temperature once you start using them INSULIN PUMPS Another way to get insulin into the body is with an insulin pump An insulin pump is asmall computer about the size of a beeper that is programmed according to how much insulin is needed by a person s body The pump gives a steady flow of insulin except for when it is told by the pumper to give more such as at mealtimes and when blood glucose is too high Insulin doses can be easily adjusted to match what a person does and to what he she eats each day When an insulin pump is used a small needle is inserted under the skin The needle is connected to tubing which leads to the pump The needle delivering the insulin needs to be changed every two days Pumps have to be worn at all times except for bathing and swimming and brief periods when the pump might be damaged if worn Insulin pumps do not check blood sugars In fact most pumpers check their blood glucose more often than they did when they used syringes It takes time and practice to learn how to use a pump well but many people feel the advantages are worth the extra work Speak with your healthcare provider for more information about insulin pumps You should also check with your insurance carrier to find out if an insulin pump would be covered by your plan ORAL DIABETES MEDICATION Children with type 1 d
7. of metformin for a child is 2500 mg per day The upset stomach that some children may experience when they start taking metformin usually goes away after a week or so BLOOD GLUCOSE MONITORING Self monitored blood glucose SMBG is a very important part of controlling blood sugar Monitoring and recording the results will help you and your healthcare team to discuss and manage your diabetes in the best possible way Proper diabetes control may help to prevent some of the complications associated with diabetes There are many products available to help you test blood glucose Regardless of which meter you use the basic principles for using each one are similar In order to check your blood glucose level you first prick a finger to obtain a drop of blood You then place the drop of blood ona test strip which is placed in the meter The meter then reads the test strip and gives you a result It is important to carefully read and follow the instructions for your meter before using it You should also receive instruction on the proper technique from your healthcare provider before using the meter independently so that accurate results can be obtained Tips For Monitoring Blood Glucose 1 Wash your hands and your child s hands with warm water and soap Dry thoroughly This cleanses the skin and increases circulation to the fingertips If you are unable to wash your hands clean the fingertip to be pricked with an alcohol swab and let air dry
8. plunger back on syringe to the prescribed dose Units 8 Check for air bubbles If air bubbles are present tap the syringe with your finger or a pen to make the bubbles float to the top Inject bubble into the bottle Pull plunger back again to desired dose You may also choose to inject all the insulin back into the vial Repeat steps 7 and 8 until all large bubbles are gone If you have difficulty seeing the numbers on the syringe there are numerous products available to magnify them for you This will enlarge the numbers on the syringe so that you can better draw up the correct dose Injection Sites Possible injection sites are shown on the diagram below Each area of the body absorbs insulin into the blood at a slightly different rate Insulin is absorbed fastest from the abdomen slower from the arms and legs and slowest from the buttocks For this reason it is recommended that injection sites be rotated and injected within a single area at the same time of day It is a good idea to work out a schedule for rotating injections For example morning shot in the arm suppertime shot in the leg and bedtime shot in the buttocks or morning shot in the abdomen suppertime shot in the arm or leg and bedtime shot in the buttocks Rotation of sites is also recommended to prevent thickening of skin area and to prevent excessive fat deposits hypertrophy or dimpling atrophy due to repeated use of the same site Your goal in rotating injectio
9. to those your child may have experienced Sevena days to weeks before diagnosis Increased urination The kidneys try to get rid of excess sugar Increased thirst The body needs more fluids because of increased urination Fatigue Vision changes blurring fuzziness The shape of the eye changes because of prolonged high blood sugar and changes in fluid level Irritability or behavioral changes Flushing of skin Weight loss The body breaks down fat for energy when it cannot use glucose There may also be significant fluid loss from increased urination Causes of hyperglycemia Not enough insulin oral medication Too much food or incorrect balance of carbohydrates fats and proteins Illness or infection Stress i e surgery accident severe emotional upset Less physical activity Some other types of medications may interfere with the effectiveness of insulin causing an increase in blood glucose Sometimes high blood sugars can happen and you may not be able to figure out the reason why they occur Prevention of hyperglycemia Following these steps can help to prevent hyperglycemia Take the correct amount of insulin medication on time and with an adult who knows about its administration Monitor blood glucose levels as prescribed by your healthcare provider Usually at least 4 times per day and more often when you do not feel well Take part in physical activity on a regular basis Notify your physic
10. too large for you to download you can request a free copy of the document by printing the order form and faxing or mailing it to the NDEP American Diabetes Association ADA o Guide to Diabetes in Children for Parents and Children 40 http www diabetes org for parents and kids jsp Juvenile Diabetes Research Foundation o Diabetes In School General information articles and related resources for parents of children with diabetes in school http www jdrf org index cfm page_id 103439 Washington State Task Force o Guidelines for Care of Students with Diabetes A comprehensive tool for families school personnel and healthcare providers that provides diabetes care guidelines in the school setting www k12 wa us HealthServices pubdocs diabetes GuidelinesStudentswithDiabetes pdf Children With Diabetes o Diabetes Management at School This guide provides an outline for school districts to use in designing a diabetes management program http www childrenwithdiabetes com d_Oq_500 htm Camp Nejeda o Camp for children with diabetes http www campnejeda org camp html P O Box 156 910 Saddleback Rd Stillwater NJ 07875 973 383 2611 41 REFERENCES USED FOR THIS BOOKLET American Association of Diabetes Educators 2003 Basic skills for Self Care Library of Patient Handouts for Diabetes Education Timonium MD Milner Fenwick Inc American Diabetes Association 1997 Life with Diabetes Alexandria VA Am
11. uses fat for energy Since ketones are acids a person can become very ill if the levels become too high If left untreated a condition called diabetic ketoacidosis may occur Therefore it is very important for you to know if there are ketones in the body Diabetic Ketoacidosis is discussed in the Special Topics Section When to check for ketones 1 Every morning 2 When there is unexplained blood glucose greater than 240 mg dl on two consecutive occasions greater than 240 on one occasion for pump users 3 When your child is ill has nausea or vomiting or has an infection even if blood sugars are normal Ketones should not be present in the body under normal conditions Trace ketones in the early morning may be normal but should disappear by midmorning If urine tests trace or small for ketones give the normal dose of insulin and drink extra water at least 8 oz an hour to try and flush the ketones from the body If urine ketones test moderate or large or blood ketones test greater than or equal to 0 8 mmol L call your healthcare provider immediately for advice day or night You will probably need to give more short acting insulin your healthcare provider will tell you how much to give and drink extra water at least 8 oz an hour Whenever ketones are positive you should continue to check them every two to four hours until they return to negative You should record results of ketone tes
12. 6 u h lu 25grams lu 80meg dl drop 24 units 12 units 0 5 u h lu 20grams lu 75meg dl drop 26 units 13 units 0 54 u h lu 20grams lu 70meg dl drop 28 units 14 units 0 58 u h lu 15grams lu 65meg dl drop 30 units 15 units 0 62 u h lu 15grams lu 60me dl drop 32 units 16 units 0 67 u h lu 15grams lu 50meg dl drop 36 units 18 units 0 75 u h lu 15grams lu 50meg dl drop 40 units 20 units 0 83 u h lu 10grams lu 45meg dl drop 44 units 22 units 0 92 u h lu 10grams lu 40meg dl drop 48 units 24 units lu h lu 10grams lu 40meg dl drop 52 units 26 units 1 08 u h lu 10grams lu 35meg dl drop 56 units 28 units 1 16 u h lu 10grams lu 30meg dl drop 60 units 30 units 1 25 u h lu 10grams lu 30mg dl drop 65 units 32 units 1 35 u h lu 8grams lu 30mg dl drop 70 units 35 units 1 46 u h lu 8grams lu 25meg dl drop 75 units 38 units 1 56 u h lu 8 grams lu 25mg dl drop 80 units 40 units 1 67 u h lu Sgrams lu 20mg dl drop 90 units 45 units 1 88 u h lu 5grams lu 20mg dl drop Addressograph Diabetes Care Guide Questionnaire Parent We would like to know how helpful this booklet was for you and your family Please complete this form with the nurse during your hospital stay while receiving diabetes education Thank you for your cooperation 1 I understand the type of diabetes my child has 2 I understand how insulin works when to give it and where to inject Please circle one response only Ye
13. DIABETES X RESOURCES FOR DIABETES MANAGEMENT APPENDIX A Food and Activity Records B Blood Glucose Medication Log Sheets C School Letter and Guidelines D School Nurse Order Form E Insulin Dosing Guidelines F Diabetes Care Guide Questionnaire 10 16 17 18 24 25 29 31 33 36 36 38 39 40 DIABETES CARE GUIDE FOR CHILDREN WITH DIABETES GENERAL INFORMATION Introduction When you first find out that you or your child has diabetes it is natural to have many different feelings You may be shocked afraid and a bit confused You may also feel overwhelmed by the thought of having to learn so many new things This booklet is designed to give you basic information about how to care for yourself or a child with diabetes Your healthcare team will review this information with you so that you can feel comfortable as an active participant in your care This booklet is only a beginning to your learning process We encourage you to continue to learn more about diabetes Your diabetes healthcare team can provide you with the resources and ongoing education in order to do so Although there is no cure for diabetes yet the good news is that diabetes can be treated and controlled With the help of supportive families and good healthcare children and adults with diabetes can lead healthy fun filled lives What Is Diabetes Diabetes is a life long disorder in which the body cannot use food properly because of a
14. Hackensack University Medical Center Patient and Family Education THE JOSEPH M SANZARI CHILDREN S HOSPITAL The MOLLY Center for Children with Diabetes and Endocrine Disorders DON IMUS WFAN Pediatric Center PC 251 Hackensack NJ 07601 201 996 5329 Office 201 525 0115 Fax 201 996 3436 Nutrition Office 201 996 5342 Child Life Office Pedsmolly humed com The MOLLY Diabetes Education Management Center at Hackensack University Medical Center 211 Essex Street Suite 101 Hackensack NJ 07601 201 968 0585 Office 201 968 0586 Fax Hackensack University Medical Center is pleased to provide access to the resource material contained herein This material is provided for informational use only and is not intended to be medical advice It is important that you discuss any questions you may have with your physician or healthcare provider 30 PROSPECT AVENUE HACKENSACK NJ 07601 201 996 2000 WWW HUMC COM TABLE OF CONTENTS I GENERAL INFORMATION II FOOD AND NUTRITION III INSULIN A Types of Insulin B Insulin Preparation and Injection C Insulin Pumps IV ORAL DIABETES MEDICATIONS V BLOOD GLUCOSE MONITORING VI KETONE TESTING VII SPECIAL TOPICS A Balancing Your Blood Sugar 1 Hypoglycemia low blood sugar 2 Hyperglycemia high blood sugar 3 Diabetic Ketoacidosis B Physical Activity and Exercise C Emergency Identification D Sick Day Guidelines VIII EMOTIONAL ADJUSTMENT TO DIABETES IX SCHOOL AND
15. Regular Insulin peaks in 2 5 hours NPH or Lente peaks in 4 15 hours Lantus or Levemir no peak The best time to exercise is after a meal If you do exercise when insulin is peaking be sure to plan for either more carbohydrates or less insulin before and after exercise vV You May Need To Eat Extra Food For Exercise You may need to eat a snack before and after exercise depending on your blood glucose level and on how close to your regular meal snack you are exercising For example if you start to exercise less than an hour after eating a meal snack and your blood sugar is greater than 120 mg dL you may not need extra food On the other hand if it has been more than an hour after eating a meal snack and your blood sugar is less than 120 mg dL you may need extra food You should come up with your own set of guidelines with the help of your healthcare team In general if your blood glucose is less than 120mg dL eat a snack 34 before exercising 15 grams of carbohydrate should be eaten for every hour of moderate exercise For example swimming bike riding tennis Jogging Remember to drink extra fluid before during and after exercising especially when the weather is warm Cool water sports drinks or fruit juice mixed water are good choices v Your Blood Glucose Can Continue To Drop For Up To 48 Hours After Exercise Blood glucose often drops 4 10 hours after exercise By checking your blood suga
16. Total 60 gm of carbohydrates 37 EMOTIONAL ADJUSTMENT TO DIABETES Children with diabetes can lead full and normal emotional lives but they will need the help and support of their families as they learn to adapt to the life changes that diabetes creates While diabetes may present a challenge to the whole family it need not control your lives All children and families react differently when they find out that they or a loved one has diabetes Young children may feel they are being punished for something they did They may even fear they are going to die because diabetes starts with the sound die Teenagers who are already struggling with normal teenage concerns may become angry or distant when they realize the demands of diabetes self care Parents and siblings may also struggle with the emotional challenges and additional care taking responsibilities of diabetes It is important to know that you are not alone in your struggle There are support groups and diabetes organizations for parents and children Children benefit by being around other children with diabetes and parents benefit from sharing experiences and feelings about life with diabetes You and your family will have the opportunity to meet with a licensed clinical social worker and child life specialist and or creative arts therapist during your inpatient stay You can ask your nurse to contact any of these clinicians for you They are also available to mee
17. at you are learning to solve problems with the help of your healthcare team Hemoglobin Alc A1C The Big Picture Measures the amount of sugar that attaches to protein in the red blood cell The greater the amount of sugar in your blood the higher your A1C results will be e This is the most valuable way to monitor blood sugar levels over time Tells you about your blood sugar control for the past three months The Diabetes Control and Complications Trial OCCT proved the risk of eye kidney and nerve problems in people with type 1 diabetes was lowered by intensive treatment plans in patients with average A1C of 7 2 percent normal 4 6 percent Target A1C Less than 6 years of age within 2 percent of upper limit of normal 22 6 years of age and older within 1 5 percent of upper limit of normal The A1C should be as close to normal as possible as long as the child is not experiencing frequent low blood sugars It is important to note that while frequent low blood sugars can lead to a lower A1C it may not indicate good blood sugar control Monitor A1C 3 4 times per year Know Your Number My A1C Test Record Normal range for my lab is___ percent ___percent __ Test Date Goal Results Next Test Date o o H o o Yo 23 KETONE TESTING When there is not enough effective insulin in the body to allow glucose to be used for energy fats are used instead Ketones are formed when the body
18. atigue Vision changes blurring fuzziness The shape of the eye changes because of prolonged high blood sugar and changes in fluid level Irritability or behavioral changes Flushing of skin 9 Recurring vaginal infections skin rashes or slow healing wounds Types Of Diabetes The two main types of diabetes are type 1 or immune mediated formerly called insulin dependent diabetes type 2 formerly called non insulin dependent diabetes Children and young adults usually have type 1 diabetes in which the pancreas makes little or no insulin Without insulin the body cannot control blood levels of sugar so people with type 1 diabetes need to take insulin injections every day Type 2 diabetes is the most common type of diabetes People with type 2 diabetes usually produce some insulin but the body cannot use it efficiently While this type of diabetes usually develops in adults over the age of 40 it accounts for at least 10 percent of diabetes diagnosed in children in this country What Causes Diabetes We do not know exactly what causes diabetes We know that people inherit a tendency to get diabetes but not all people who have this tendency will get the disease We also know that you cannot catch diabetes like a cold Eating too much sugar does not cause it either Methods Of Control That Help Manage Diabetes The goals of treatment for diabetes in children include maintaining normal growth and development
19. bedtime or overnight STEP 3 REST and Wait 15 Minutes RETEST Blood Sugar Repeat STEPS 2 AND 3 if blood sugar is still less than 100 mg dL You should check with your doctor as to how often you may repeat the treatment before notifying him or her STEP 4 Once blood sugar is above 100 mg dL eat the regular meal snack if scheduled If it is not time for your regular meal snack eat an extra snack Example cheese and crackers or 4 sandwich The amount of quick acting carbohydrate needed will depend on the severity of the low blood sugar and the child s size For example if the child s blood sugar is less than 50 mg dL 30 gm of a quick carbohydrate may be needed instead of 15 gm That is why it is necessary to recheck the blood sugar and make a note of how the child s blood sugar reacted so the next time a low occurs you will have a better idea of how to treat it Liquids are absorbed in the stomach more quickly than solid food so they will raise blood sugar faster Never use foods with protein or fat as your first choice to treat a low blood sugar Foods with protein or fat will take longer to raise your blood sugar 27 SAMPLE LIST OF LIQUIDS FOODS WITH 15 GRAMS OF FAST ACTING CARBOHYDRATE 4 6 oz juice or non diet soda 2 small rolls Sweet Tarts 3 4 glucose tabs 15gm 6 7 regular size Life Savers Concentrated glucose gel 15 gm 8 10 jellybeans Cake gel small tube 12gm 3 4 tsp sugar syru
20. ck is recommended before gym and the child may be delayed in getting started Exercise is even more important for children with diabetes than for other children They should not be excluded from gym or sports activities unless they have moderate or large ketones in their urine HACKENSACK UNIVERSITY MEDICAL CENTER THE MOLLY CENTER FOR CHILDREN WITH DIABETES AND ENDOCRINE DISORDERS SCHOOL NURSE ORDER FORM F MED Student name 1 insulin dose is insulin to Carbohydrate Ratios grams of carbohydrates covered by 1 unit of rapid acting insulin Novolog Humatog Breakfast 1 unit covers grams of carbohydrates Lunch tumit covers ss gvrams of carbohydrates Dinner Tunit covers___ grams of carbohydrates Try to keep ali snacks less than 15 grams of carbohydrates for the first wook M snack gt 15g use funit covers____ grams of carbohydrates for entire snack Correction Factor Use ONLY at meals not at snacks mgd drop in blood glucose for each unit of rapid acting insulin 1 unit lowers BG by__ mg dl down to your target of ___emg ail Lantus dose units at AMPM Other 2 Check BG C Lunch C 2 hours after meals C Before Gym C When symptomatic or requested by student IA Student can check Blood Glucose independently 4 Treat any BG fess than 80mg dl with 15 grams of rapid acting Carbohydrate every 15 minutes unti BG Is gt 100mg di and follow treatment immediately with lunch or snack 5 Eat Snacks at AM PM Before Gym
21. crements ask your doctor to specify this on your syringe prescription In most states including New Jersey you need a prescription from your physician to purchase insulin syringes Syringes should be stored ina safe place out of reach of children and should only be taken out for injections Before discarding the syringe the needle can be clipped off with a special needle cutter designed for this purpose Syringes unclipped needles and lancets should be discarded after each use ina sharps container A sharps container can be any puncture proof non recyclable container such as a thick plastic detergent container This will prevent any accidental puncture injury Ask your local health department how to dispose of the full containers because there may be local regulations Pens Components Pen with and without cartridge pen needles Parts of the pen Barrel dial pen needle cover Insulin Pen Types There are 2 major categories of insulin pens reusable pens and disposable pens e Reusable insulin pens must be loaded with a cartridge of insulin before using sold separately in boxes of five cartridges Cartridges typically hold 150 or 300 units of insulin Depending on the size of your doses a cartridge may give you enough insulin to last for several days of injections When the cartridge is empty you throw it away and load a new cartridge With good care a reusable pen can often be used for several years Disposable
22. dren with diabetes can become ill with colds flu and viruses just like any other child However having diabetes means you will need to follow some special guidelines when you feel too sick to eat usual meals These guidelines are only used when a child is vomiting has a fever diarrhea or dental work and is unable to eat his her usual diet When a child has a minor illness cold fever sore throat flu but can still eat it is important to Continue to give insulin as prescribed by the doctor Encourage the child to drink plenty of fluids to avoid dehydration at least 6 8 oz 3 4 1 cup of carbohydrate free liquid every hour If there are ketones in the child s body he should drink at least 8 0z hour if the child s stomach is upset encourage her to take small sips every 15 minutes to keep from vomiting Test blood glucose at least every four hours Check urine or blood ketones every 2 4 hours Check the child s temperature at least every four hours Look for signs that may indicate that the child is becoming dehydrated such as dry mouth thirst lack of tears dry skin decreased or more darkly colored urine e Follow the sick day meal plan if the child cannot eat his her usual diet The child s doctor should be called if always check ketones before calling 1 The child feels too sick to eat normally or vomits more than once 2 There is persistent diarrhea stomach pain or other unusual symptom
23. e bedtime snack At3a m at least weekly or as directed by your doctor As directed by diabetes healthcare team when beginning pump initiation or more intensive management 8 10x day REMEMBER TO WAIT AT LEAST TWO HOURS AFTER FOOD IS EATEN TO CHECK BLOOD SUGAR otherwise reading may be high because of meal or snack HEM HEHEHE HEHEHE HAH HH HAHAH AHHH AKHKKKKAKKKKKKAKKKAKKKAKEAAKKAHKKKAKKKAKIAA 20 Reasons Why You May Not Get A True Blood Glucose Reading Site used for testing is not clean and dry sugar on site will raise result water or alcohol will interfere with result Using an alternate site for testing not fingertip when blood sugar is on its way up or down Only use alternate sites when it has been at least two hours since you have last eaten Also do not use an alternate test site if you are feeling like your blood sugar is low use your fingertips for more accurate results Not enough blood on the strip or adding more blood after time limit for doing so is past Meter parts are dirty Codes on strips and meters are not matched Strips are old or have been damaged by exposure to heat light or moisture Once test strip vial box is opened discard unused test strips after three months Taking Care Of Your Meter Match meter code number with test strips If your meter has a check strip use it as recommended after cleaning your meter once a week if you question results Check your meter wi
24. erate or large blood ketones greater than or equal to 0 8 mmol L You should also let your team know if ketones remain positive for several hours Notify your doctor when your child is vomiting or unable to eat but check ketones first 32 PHYSICAL ACTIVITY AND EXERCISE Children with diabetes can and should be encouraged to participate in games and athletic activities Exercise helps to lower blood glucose levels It also helps to make our hearts and muscles stronger and helps us feel better too It is important for people with diabetes to get regular exercise because of the need to balance the effect of exercise with food and insulin It is a good idea to check the blood sugar before exercising In this way you can see if an extra snack is needed so that a low blood sugar episode may be avoided Your healthcare providers can give you additional guidelines for blood glucose monitoring and adjustments for food and insulin related to exercise Because children s lives involve a lot of unplanned activity it is a good idea to always carry snack foods like pretzels or crackers with cheese or peanut butter Children with diabetes should also carry glucose tablets or another form of quick acting sugar to treat low blood glucose The timing of exercise meals and insulin will affect blood glucose It is a good idea to ask your school for meal snack and gym times kkkkkkkkxkxkkkxkkkkkkkkkkkkkkkkkkkkkkkkkkkkxkxkkkkxkkkkkkkkkkkkkkkkk
25. erican Diabetes Association Becton Dickinson amp Company 2007 BD Diabetes com Retrieved March 1st 2007 from http www bddiabetes com Chase H 2002 Understanding Insulin Dependent Diabetes 10th ed Denver CO University of Colorado Health Sciences Center Franz M J amp American Association of Diabetes Educators 2003 Core Curriculum for Diabetes Educators 5 ed Chicago American Association of Diabetes Educators Illustrations used in this booklet were obtained from the following sites Becton Dickinson amp Company 2006 BD ultra fine pen needles Retrieved March 1st 2007 from http www bddiabetes com us pdf PenNeedle_PenDetSheet_WEB2 pdf Diabetes Services Inc 2005 Diabetes mall health through information Retrieved March 1st 2007 from http www diabetesnet com diabetes_technology insulinpumps_animas php Insulet Corporation 2007 OmniPod insulin management system Retrieved March 1st 2007 from http www myomnipod com products Medtronic MinMed Inc 2007 Medtronic Retrieved March 1st 2007 from http www minimed com Smiths Medical MD Inc User manual Deltex Cozmo Insulin Pump Retrieved March 1st 2007 from http www cozmore com fileupload manual_5291 51A pdf Originated January 2004 Revised March 2007 42 Directors 1 Beceni the ime of the meal or Food amp Activity Record RS sack and your blood glucose L Witte down everything you eat and drink inctadi
26. extra exercise a missed snack or less food at a meal than is usually eaten Field days or trips with extra exercise and excitement may result in reactions The parents should be aware of all field days or trips so that the insulin dose can be reduced and or extra snacks provided D Treatment Treat for low blood glucose if BG is below 80mg d1 with or without symptoms OR for BG below target range with symptoms of low BG Follow the Rule of 15 Student and family are advised to follow this same guideline THE RULE OF 15 TO TREAT HYPOGLYCEMIA STEP 1 TEST BLOOD SUGAR STEP 2 If LOW BS lt 80 Treat With 15 Grams Of Fast Acting Carbohydrate See sample list STEP 3 REST and RETEST Blood Sugar After Waiting 15 Minutes Repeat STEPS 2 AND 3 if blood sugar is still less than 70mg aL STEP 4 Once blood sugar is gt 100 eat the regular meal snack if scheduled If it is not time for your regular meal snack eat an extra snack Example cheese and crackers or 2 sandwich The amount of food eaten for this extra snack should not be subtracted from the next regular meal snack Liquids are absorbed in the stomach more quickly than solid food so they will raise blood sugar faster Never use foods with protein or fat as your first choice to treat a low blood sugar Foods with protein or fat will take longer to raise your blood sugar SAMPLE LIST OF LIQUIDS FOODS WITH 15 GRAMS OF FAST ACTING CARBOHYDRATE 4 6 oz
27. he next day so that hopefully further reactions can be prevented Children often forget to tell their parents that they had an insulin reaction V HIGH BLOOD SUGAR People with diabetes may have high blood sugars and spill extra sugar into the urine on some occasions These occasions include periods of stress illness overeating and or lack of exercise High sugars are generally NOT an emergency unless accompanied by vomiting When the blood sugar is above 240mg dl on two consecutive occasions above 250 mg on one occasion for pump wearers the urine ketones also need to be checked a urine dipstick The student may occasionally need to check the urine ketones at school This may be because ketones were present earlier at home because the blood sugar is above 240 mg dl or because the child is not feeling well Parents should supply individually wrapped ketone strips The parents should be notified if moderate or large urine ketones are present as extra insulin will be needed The student should not participate in physical activity if ketones are moderate or large When the sugar is high the child will have to drink more and urinate more frequently It is essential to make bathroom privileges readily available If the teacher notes that the child is going to the bathroom frequently over a period of several days the parent should be notified The diabetes care provider can then adjust the insulin dose VI CLASS PARTIES If the class is havi
28. here is no specific age when children are ready to give their own insulin injections However regardless of when a child begins giving their own injections they should always have an adult s supervision Purchasing Insulin When purchasing insulin here are a few things to remember Check the name type brand color concentration and expiration date on the bottle Do not accept any insulin that is stringy in appearance or has lumps that float or stick to the sides of the bottle Buy an extra bottle of each type of insulin in case a bottle is broken or lost so that you will have another bottle available In many states insulin is a nonprescription drug However a prescription may be necessary for reimbursement from a pharmaceutical plan Storing Insulin Insulin in vials should be kept under refrigerated conditions whenever possible Do not freeze Insulin should be kept at room temperature for approximately 30 minutes before use to ensure better absorption Most insulins can be kept up to 28 days at room temperature However it may lose its strength if exposed to direct sunlight or extreme temperatures less than 32 or greater than 86 F Discard any insulin that has been exposed to extreme heat cold or direct sunlight For travel it is best to keep insulin in an insulated bag for protection Keep an extra bottle of insulin in the refrigerator Unopened insulin can be kept up until the expiration date Other types of insulin
29. hool a snack is usually needed before gym If the child is required to remain after school for longer than usual an extra snack may be needed TIME SNACK USUALLY EATEN A M P M To be completed by parent HI BLOOD SUGAR TESTING There may be times that blood sugar testing needs to be done at school This may be at a set time e g before lunch or it may be when a low blood sugar is suspected Children have their own testing equipment This should be kept in their backpack or an extra set should be in their desk the nurse s or the principal s office When possible we prefer that the student be allowed to test their blood sugar at their desk School personnel may need to be taught how to do blood sugar testing to help younger children V LOW BLOOD SUGAR Insulin Reaction or Hypoglycemia This is the only emergency likely to occur at school A Onset SUDDEN and if not treated promptly may lead to LOSS OF CONSCIOUSNESS AND OR SEIZURE Most likely time to occur is before lunch or after gym class B Signs May be any of the following Hungry Eyes appear glassy dilated or big pupils Personality changes such as crying or stubbornness Inattention drowsiness or sleepiness at unusual times Pale sweating shaking Pale or flushed face Headaches Weak irritable or confused Speech and coordination changes s usual symptoms are To be completed by parent and school nurse C Causes Too much insulin
30. iabetes are not treated with oral medications Children with type 2 diabetes may need to take oral diabetes medications if they cannot meet their target blood glucose levels with a meal plan and physical activity They may take an oral medicine alone or in combination with insulin There are several types of oral medications and they each work differently The most commonly used oral medications for children are Glucophage and Glucophage XR metformin Metformin works by keeping the liver from releasing too much glucose It helps to keep blood glucose from going too high throughout the day and night Metformin may also help with weight loss The main side effect of metformin is upset stomach diarrhea vomiting and bloating It is important to know that lactic acidosis is a rare side effect that can occur if metformin is not stopped when a person has the stomach flu or a severe illness It can also happen during an X ray when dyes are used and during episodes of vomiting diarrhea and pneumonia or with lung diseases Metformin needs to be stopped during times of surgery severe illness or with vomiting or diarrhea Insulin will be substituted during these times until metformin can be restarted Consult with your doctor or nurse if you have any questions regarding metformin use The dose of metformin is usually started with 500 mg once daily and gradually increased over the next few weeks as needed and as tolerated by the child The maximum dose
31. ian when you are ill or have an infection until you learn how to adjust the insulin medication dose on your own 29 Treatment of hyperglycemia Check ketones if blood sugar is higher than 240mg dL two times in a row higher than 240 mg dL one time for pump users and anytime you are not feeling well Call Your Diabetes Healthcare Team if You Test Positive for Ketones Do not exercise if urine ketones are moderate or large blood ketones greater than or equal to 0 8 mmol L Check blood sugar at least every four hours Take the right amount of insulin Drink lots of extra water and or sugar free liquids You do not need to make changes in your diet with high blood sugars 30 Diabetic Ketoacidosis DKA If hyperglycemia is not treated it can develop into a very serious condition known as Diabetic Ketoacidosis Ketoacidosis happens when the body does not have enough insulin to allow glucose to be used for energy The 3 Main Jobs Done By Insulin 1 Lets sugar pass into cells where it can be used for energy 2 Turns off excess production of sugar in the liver and muscle 3 Turns off fat breakdown If the body does not have enough insulin to use glucose for energy the body will use fat instead When fats are used for energy acid like waste products called ketones are produced The ketones build up in the blood and eventually spill into the urine The combination of hyperglycemia and ketones in the body can make a person very i
32. in if needed You will also need to provide emergency telephone numbers where you can be reached during school hours There are many resources available to both you and school personnel Some of the resources you may find most helpful are listed in the resource section of this booklet 39 RESOURCES FOR DIABETES MANAGEMENT American Association of Diabetes Educators 1 800 338 3633 http www aadenet org American Diabetes Association 1 800 232 3472 request Wizdom Kit for Kids with Diabetes http www diabetes org Juvenile Diabetes Research Foundation 1 800 JDF CURE http www jdrf org general information about diabetes and the JDRF Diabetes Exercise and Sports Association DESA 1 800 898 4322 8001 Montcastle Drive Nashville TN 37221 http www diabetes exercise org ADDITIONAL INTERNET RESOURCES Children with Diabetes A comprehensive web site regarding children with diabetes Includes extensive information on children with diabetes at school www childrenwithdiabetes com ADDITIONAL SCHOOL RESOURCES National Diabetes Education Program NDEP o Helping the Student with Diabetes Succeed A Guide for School Personnel The NDEP developed this guide to educate and inform school personnel about diabetes how it is managed and how each member of the school staff can help meet the needs of students with the disease http ndep nih gov diabetes pubs Youth_NDEPSchoolGuide pdf o If the 88 page PDF file is
33. insulin pens come filled with insulin and are thrown away when they are empty Most disposable pens used in the U S today hold 300 units of insulin and are sold in boxes of five Pen needles must be changed after each time you inject NovoPen Junior 11 ane a or J Humalog Pen t The BD Ultra Fine Ill Short Pen Needle 8 mm 5 16 x 31G Insulin Preparation Most of the time you will use only one type of insulin per dose When using Lantus or Levemir insulin no other insulin can be mixed in the same syringe Your healthcare provider will provide you with instructions on how to draw up and inject your insulin correctly See handouts on Drawing Up Insulin for diagrams How to Draw Up One Type of Insulin 1 Wash your hands with soap and water 2 Gather supplies Insulin insulin syringe and alcohol swab 3 If using cloudy insulin gently roll or turn the vial up and down rotate 20 times to mix making sure that there are no insulin crystals at the bottom Do this step immediately before drawing up this insulin Do not shake the vial which might cause damage to the insulin or introduce air bubbles into the solution 4 Clean top of insulin vial with alcohol swab 5 Remove the needle cover and draw air into the syringe until the end of the plunger is in line with the desired dose Units 6 Insert the needle through the stopper and inject air into the vial 7 Turn vial of insulin upside down and pull
34. juice or non diet soda 2 rolls Sweet Tarts 3 4 glucose tabs 15gm 6 7 Life Savers Concentrated glucose gel 15 gm 8 10 jelly beans Cake gel small tube 12gm 2 tablespoons raisins 1 cup of skim milk 3 4 tsp sugar may dissolve in water 1 Mild Reaction usually less than 60 mg dl Symptoms Hunger shaking personality changes drowsiness headache paleness confusion or sweating 2 Moderate Reaction less than 60 mg dl Symptoms Combative behavior disorientation lethargy Treatment Give glucose gel immediately then give sugar or juice After the person is feeling better follow Rule of 15 3 Severe Reaction usually less than 40 mg dl Symptoms Seizure or unconsciousness Treatment CALL 911 IMMEDIATELY GIVE NOTHING BY MOUTH Give glucagon intramuscularly if nurse is available to administer IF YOU SEND THE CHILD TO THE OFFICE HAVE SOMEONE ACCOMPANY HIM HER The child may become confused and not make it to the office if he she is alone If you suspect that the child is having a low blood sugar reaction and it is not possible to do a blood sugar do not hesitate to give the child something sweet to drink such as juice or soda NEVER LEAVE A CHILD ALONE WHEN YOU SUSPECT HE OR SHE IS HAVING A LOW BLOOD SUGAR REACTION In general it is helpful if the school will notify the parents whenever a low blood sugar reaction occurs at school This will allow for adjustment of the insulin dose t
35. ke one injection of long acting insulin a day Lantus plus additional injections of rapid acting insulin with each meal snack However some children take two to three injections a day at the same time each day Other children may use an insulin pump for a continuous infusion of insulin throughout the day Using Lantus plus rapid acting insulin or an insulin pump allows for greater flexibility in both the timing and amounts of food eaten Regardless of which insulin schedule you use the goal is to keep blood sugars as balanced as possible throughout the day not too high and not too low TYPES OF INSULIN Children with diabetes will usually be using different types of insulin Each type of insulin has a different action time When insulin is injected beneath the skin it takes time for it to be absorbed into the bloodstream and to reach the cells where it acts The type of insulin will determine how soon it will start to work and how long its effects will last There are four major types of insulin each differing in 1 Onset the time the medication begins working 2 Peak the time the medication is working the most 3 Duration how long the medication lasts after it is injected The four types of insulin are categorized according to their action times 1 Rapid Acting clear Humalog Novolog Aphidra 2 Short Acting clear Regular 3 Intermediate Acting cloudy NPH Lente 4 Basal Insulin
36. keeping blood glucose levels within a target range as much as possible and promoting healthy emotional well being Blood sugar levels can be maintained within a target range by balancing insulin food and physical activity Food raises blood glucose levels insulin and physical activity lower them A diabetes treatment plan includes eating a balanced diet on a consistent schedule monitoring blood glucose levels throughout the day adjusting medication as blood glucose levels and physical activity warrant in consultation with your diabetes healthcare team and taking part in physical activity regularly Diabetes treatment plans have changed in recent years and are now more flexible than they had been in the past Current treatment now places more emphasis on individual lifestyle differences and attempts to meet the needs of each person and his or her family Honeymoon Period Within a few weeks of beginning treatment for type 1 diabetes many people may experience what is called the honeymoon period It usually starts within two to eight weeks although not all people will have this honeymoon period During the honeymoon period the pancreas is still making some insulin The body may not need much extra insulin during this time although the person still has diabetes This period usually lasts one to three months After the honeymoon period is over the body will need more insulin again We advise our patients to continue taking insulin du
37. kkkkkkkk Safe Exercise Checklist vV Be Sure You Are In Good Control Of Your Diabetes If blood sugar is greater than 240 check ketones before exercise Tf urine ketones are trace small or blood ketones are less than 0 8 mmol L make sure you drink extra water before and during exercise Tf urine ketones are moderate or large or blood ketones are greater than or equal to 0 8 mmol L do not exercise Wait to exercise until diabetes is in better control v Always Carry Fast Acting Sugar and an Extra Snack Examples of fast acting sugars would be fruit juice glucose tablets sugar packets Extra snacks could be a granola bar or peanut butter crackers 33 v Check Your Blood Sugar Before And After Exercise If you exercise for a long time more than 1 hour check your blood sugar before starting and then every hour while you are exercising Checking and recording what happens to your blood sugar when you exercise will help you to do it safely YOU WANT TO PREVENT A LOW BLOOD SUGAR If you do not feel well while exercising STOP EXERCISING RIGHT AWAY check your blood sugar and treat if necessary If you needed to treat a low blood sugar recheck it in 10 15 minutes before starting to exercise again V Know When Your Injected Insulin is Working The Hardest Exercising when insulin action is peaking can make your blood sugar too low unless you plan ahead Humalog peaks in 1 hour Novolog peaks in 1 3 hours
38. lack of effective insulin Normally when food is eaten it is digested and turned into a sugar called glucose Glucose is then carried in the blood to our body cells to be used as energy Glucose needs insulin to help it travel from our blood into our cells Insulin s job is to regulate how the body uses glucose Insulin is made ina part of our body called the pancreas NORMAL DIGESTION Food is eaten Food is digested in the stomach and intestines and is turned into glucose v Blood glucose level increases v Pancreas releases insulin v Insulin helps glucose enter the cells of the body N Glucose is used for energy Some glucose is stored Blood glucose level decreases v Pancreas releases less insulin When a person has diabetes the body does not have insulin to carry glucose to the cells If glucose cannot enter the cells where it is needed for energy it b uilds up in the blood instead causing a high blood glucose level This is called hyperglycemia Hyperglycemia may cause a person to experience some of the following symptoms CO Signs and Symptoms of Hyperglycemia 1 Excessive hunger 2 3 Excessive urination The kidneys are trying to get rid of excess sugar Excessive thirst The body needs more fluids because of increased urination Weight loss The body breaks down fat for energy when glucose cannot be used There may also be significant fluid loss from increased urination F
39. ll KETOACIDOSIS IS A SERIOUS PROBLEM THAT REQUIRES IMMEDIATE MEDICAL ATTENTION For Pump Users DKA can happen rapidly if there is a problem with insulin delivery Pump users need to remember you do not have any long acting insulin circulating in your body Signs And Symptoms Of DKA Blood sugar is usually high greater than 240mg dL Moderate or large ketones in urine blood ketones greater than or equal to 0 8 mmol L Sweet fruity odor to the breath e Nausea abdominal cramps vomiting e Dry mouth thirst and frequent urination if blood sugar is high GO TO THE EMERGENCY ROOM IMMEDIATELY IF ANY OF THE FOLLOWING SYMPTOMS OCCUR Drowsiness confusion extreme weakness Deep labored breathing If these symptoms are not taken care of eventually loss of consciousness coma may occur The 3 Main Causes Of DKA 31 Not enough insulin Forgetting to take an insulin shot Illnesses For pump users Some Causes of Hyperglycemia DKA Related to Pump Use Infusion set occlusion or leak e Loss of insulin potency Empty insulin syringe Prevention Of DKA Never skip an insulin dose Monitor blood glucose levels regularly Test for ketones when there is an unexplained blood glucose greater than 240 mg dL on two consecutive occasions greater than 240 mg dL on one occasion for pump users or if illness or infection is present Call your diabetes team immediately day or night if urine ketones are mod
40. n weight lost before diagnosis After a few weeks these children usually regain the weight and return to previous eating habits You will meet with a Registered Dietitian RD who will help you learn to count carbohydrates and give specific recommendations for your child and his her lifestyle It is helpful to use a Food and Activity Record to keep track of food and activity and their effects on blood glucose levels A sample and blank Food and Activity Records are provided in the back of this booklet Please copy and use these records These records will also be helpful to you when you speak with the dietitian about your meal plan INSULIN Insulin is a hormone that attaches to the cells in our bodies and allows glucose to move from the blood into our cells to be used for energy Children with type 1 diabetes do not make insulin which is why they always require insulin injections to control their diabetes Children with type 2 diabetes still make insulin but it does not work very well If ketones are present at the time of diagnosis these children will also require insulin Some children with type 2 diabetes may be able to take oral diabetes medication instead of insulin It is important to realize that these children with type 2 diabetes may need to take insulin again especially during times of illness or inadequate blood glucose control Insulin must by injected into the body it cannot be taken orally Most children who take insulin ta
41. n sites is consistent and reliable absorption of insulin Insulin Injection 1 Select site for injection 2 Make sure the site is clean 3 Carefully remove the needle cap 4 With one hand gently pinch up a fold of skin between your thumb and index finger 5 Using the other hand hold the syringe like a dart and gently push the needle straight into the skin with one steady motion The angle at which you insert the needle will depend on the length of the needle and the amount of fat at the site Generally when using the 5 16 short needle you will inject at a 90 degree angle If you are using a gt long needle you may need to use a 45 degree angle Your doctor or nurse will show you how to best inject your insulin at different sites 6 Push the plunger down to inject all the insulin into the site Wait 5 10 seconds 7 Release the skin withdraw the needle and immediately place the alcohol swab over the injection site You may press lightly but do not rub area 8 Safely dispose of the needle and syringe as discussed earlier 9 Record the dosage of insulin and site of injection in your record book Insulin may be injected with a needle and syringe an insulin pen an insulin pump or with a needle free injector There are also devices that you can place a needle and syringe inside of so that the needle is hidden and the needle insertion is done automatically Ask your nurse about these devices if you are interested T
42. ng a special snack the child with diabetes should also be given a snack Please notify the parents ahead of time so that they can decide whether the child may eat the same snack as the other students or they may want to provide an alternate food Preferred types of snacks are fruit fresh or dried trail mix pretzels diet soda etc If an alternate snack is not available the student should be given the same snack as the other children VII BUS TRAVEL Please allow the child with diabetes to take some food with him her on the bus It would also be helpful if the teacher checks with the bus driver to see what arrangements parents can make for allowing snacks on the way to or from school At times bus rides take longer than usual due to bad weather or stalls and the child needs to have a snack available and permission from the bus driver to eat it if necessary VIII SUBSTITUTE TEACHERS Place a copy of this information sheet in either the substitute teacher s folder or mark the attendance register so that a substitute would know 1 there is a child with diabetes in the class 2 when s he usually eats a snack and 3 symptoms and treatment of an insulin reaction IX GYM PHYSICAL EDUCATION TEACHERS AND COACHES It is particularly important for the gym teacher or coach to also have a copy of this information For children taking insulin low blood sugars may occur during exercise and a source of instant sugar should be nearby Often a sna
43. ng portion stres Name ee example THE MOLLY CENTER FOR CHILDREN WITH DIABETES AND ENDOCRINE DISORDERS FAX TO 1 201 525 0115 FOR ROUTINE NON URGENT INSULIN ADJUSTMENTS DATE PATIENT NAME REASON FOR THIS FAX PATIENT MR BEST NUMBERS TO REACH YOU IF NEEDED HOME OFFICE MOBILE For Pump Lantus Users Humalog Novolog Insulin rbohydrate Rati Breakfast 1 u covers CHO Lunch 1u covers CHO Dinner 1u covers CHO Snack 1u covers CHO rrection F ri 1 u lowers BG by mg dl down to target mg dl Basal Rate ___units hour at AM PM ___units hour at AM PM ___units hour at AM PM ___units hour at AM PM BLOOD GLUCOSE URINE KETONES INSULIN DOSES GIVEN BT Breakf Comments exercise illness etc Please describe the problem you see with the blood glucoses The change in dose you would make is Staff recommendations MD RN Signature gNote If you have not heard from us in 72 hours and you still need assistance please call 1 201 996 5329 Date Attention Principal Attention School Nurse isa year old child with diabetes who will be attending your school this year In order to maximize this student s learning potential in the classroom it is important that staff be aware of ways that they can help this student keep his her blood sugars as stable as possible Low blood sugars are an emergency and must be t
44. oglycemia seizure loss of consciousness 2 Insulin before lunch units Humalog Regular insulin for blood sugar Insulin to be given by __ Child with school RN supervision Parent School RN OTHER SPECIFIC INSTRUCTIONS Physician s signature Date Address I GENERAL INFORMATION FOR SCHOOL PERSONNEL Diabetes is not contagious Diabetes occurs when the pancreas does not produce enough effective insulin The result is too much sugar in the blood Treatment consists of daily medication shots of insulin blood sugar tests food management and exercise The priority for a child with diabetes is to lead a normal life Children with diabetes can participate in all school activities including sports Although performance may be impaired during and after low blood sugars schoolwork and grades should not be affected by diabetes II FOODS AND SNACKS In general large amounts of high sugar foods are avoided When a child with diabetes is taking insulin s he may need snacks in the morning and or afternoon as these are often the times when insulin has its greatest effect and blood sugars are lowest In general the morning afternoon snacks should be midway between meals If not too disruptive to the class most children do best just eating their snack at their desk By doing this they will not miss as much school time If gym class is more than one hour after a meal or snack the parents should find out before the first day of sc
45. p Treatment for Moderate Hypoglycemia Conscious but combative or uncooperative Follow Rule of 15 as for mild hypoglycemia EXCEPT treat initially with glucose or cake gel until child is cooperative Continue to follow the above steps until blood sugar goes up appropriately Treatment for Severe Hypoglycemia Seizure Loss of Consciousness If the child cannot swallow or if he she passes out do not attempt to put food or liquid in his her mouth Doing so may cause choking In this instance glucagon must be given by injection The child should then be rolled onto his her side in case of vomiting and the caretaker should call 911 Glucagon will make the liver release sugar into the bloodstream Once the child is awake carbohydrates in the form of liquid and or food should be given to avoid another episode of hypoglycemia You should let the child s diabetes healthcare provider know whenever your child has a severe hypoglycemic episode Your healthcare provider will show you how to use glucagon before your child is discharged from the hospital They will also provide you with an instructional handout for glucagon administration Hyperglycemia High Blood Sugar Hyperglycemia happens when blood glucose levels become too high It does not 28 usually develop suddenly When your blood sugar stays high this is telling you that your diabetes is out of control Signs and symptoms of hyperglycemia These signs and symptoms are similar
46. r every two hours after strenuous exercise you can check how your body reacts to exercise Be sure to include protein fat with your bedtime snack on days that you exercise v Don t Inject Insulin Into A Part Of Your Body You Will Be Using Heavily During Exercise Your body may absorb the insulin too rapidly For example do not inject short acting insulin into your arm if you are going to play tennis right away use an area like your stomach instead And Remember These Tips Don t Keep Your Diabetes A Secret Try To Exercise With A Friend Who Knows About Low Blood Sugar Reactions Make Sure Coaches and Teachers Know About Low Blood Sugar Reactions Always Wear And Carry Identification Know When To Check Your Blood Sugar Keep Snacks Handy Watch for Hypoglycemia and Treat It Right Away Drink Lots of Water SPEAK WITH YOUR DIABETES HEALTHCARE PROVIDER BEFORE STARTING A NEW EXERCISE PROGRAM EMERGENCY IDENTIFICATION 35 A person who has diabetes should always wear and carry some form of emergency identification so that others can quickly identify him as having diabetes and provide him with proper care Children should carry an identification card and wear a medical alert bracelet necklace or tag Some parents place identification inside articles of clothing or on the shoelaces of younger children Your healthcare provider can provide you with sources for purchasing medical ID SICK DAY GUIDELINES Chil
47. reated by the school staff promptly and correctly Children with diabetes usually test their blood sugar 3 4 times per day by poking their skin and placing the blood on a strip in a meter that then gives a number The blood sugar tests are done before meals often before exercise and must be done if the child is possibly having a low blood sugar episode These children also take injections of insulin each day usually before breakfast and dinner and possibly before lunch Many children with diabetes use an insulin pump to deliver insulin continuously throughout the day Children with diabetes are able to participate in all activities without restrictions but may require extra snacks with exercise to prevent low blood sugars Students with diabetes attending public schools should have an Individualized Health Plan IHP which would include an emergency healthcare plan The development of the IHP should be coordinated by the school nurse in collaboration with the parent and in consultation with healthcare team The New Jersey Department of Education NJDE has developed a document entitled Guidelines for the Care of Students with Diabetes in the School Setting to assist in the development of the IHP You may obtain a copy of this document by calling the NJDE at 609 292 4469 Included with this letter are suggestions for information to be incorporated into the IHP and a prescription for medications to be given at school Please develop an IHP
48. ring the honeymoon period although they may only take a very small amount In this way a person who has diabetes will know that they must always remember to take their insulin everyday You will need to be in contact with your diabetes healthcare team frequently when the honeymoon period starts Insulin doses will need to be lowered immediately to prevent very low blood sugars due to too much insulin FOOD AND NUTRITION Children with diabetes have the same nutritional needs as children who do not have diabetes The goals of healthy eating are to promote growth maintain a desirable body weight and to feel well There is a need to balance your insulin with your food intake and physical activity Carbohydrate counting is a method used by many people with diabetes It is effective because carbohydrates are the main nutrient in food that affects blood glucose levels Children with diabetes will learn to cover or match the carbohydrates eaten at a meal or snack Using Lantus or Levemir and Novolog or Humalog allows for flexibility with meals and snacks For example children can skip breakfast and eat brunch with their family on weekends if they choose There is no need to eat at certain times of the day We want children with diabetes to follow the same schedule as the rest of the family Sometimes children who have been recently diagnosed with type 1 diabetes are very hungry They should be allowed to eat to satisfy their hunger and regai
49. s 3 Urine ketone test is moderate or high or blood ketones are greater than or equal to 0 8 mmol L 36 4 The child has signs of dehydration no urine for more than 6 hours dry lips or mouth decreased activity no tears 5 Blood glucose is less than 70 mg dL or remains greater than 300mg dL with moderate or large ketones 6 The child is having trouble breathing 7 The child is very sleepy or confused 8 The illness lasts more than 24 hours Sick Day Meal Plan When the child cannot eat his usual meal plan you must encourage him her to drink fluids that contain carbohydrates to prevent dehydration and low blood sugar The child should drink fluids containing approximately 15 grams of carbohydrates per hour while awake or enough to replace every 15 grams of carbohydrates in his her normal meal These are examples of foods containing approximately 15 grams of carbohydrates per serving All foods listed contain sugar DO NOT substitute with sugar free foods 1 2 cup Jell O 1 2 cup vanilla ice cream 1 2 cup applesauce 1 2 twin popsicle bar 4 oz fruit juice 1 slice toast 4 oz regular soda 6 saltine crackers 1 cup Gatorade 1 cup chicken noodle soup 1 4 cup sherbet When the child feels well enough he she can consume 60 grams of carbohydrates every four hours For example he she could have 1 2 cup fruit juice 15 gm 1 cup soup 15 gm 6 saltine crackers 15 gm 1 slice toast 15 gm
50. s Yes 3 I understand the purpose of carbohydrate counting Yes in diabetes management 4 I understand how and when to check blood sugars Yes 5 I understand what to do if my child s blood sugar goes too low 6 I understand how to use Glucagon Yes Yes No No 7 I understand what to do if my child s blood Yes No sugar goes too high 8 I understand why and how to check urine Yes No ketones Parent signature Date Nurse signature Date STAFF NURSE PLEASE FAX A COPY OF THIS COMPLETED FORM TO THE MOLLY CENTER 201 525 0115 ATTENTION NURSE EDUCATOR THANK YOU
51. t with you and your family individually or during support groups after hospital discharge SCHOOL AND DIABETES 38 Children spend the majority of their waking hours at school In order for your child to be safely cared for at school you will need to help educate those who will be working with your child about diabetes Those people will include teachers school nurse health aid bus driver gym teacher lunchroom and playground aides and any others who might be responsible for your child at school The school nurse and teacher may help to educate other staff and classmates if you and your child ask them to You and your child will feel more confident about the return to school when you meet with the school nurse to develop an Individualized Healthcare Plan IHP The IHP will outline your child s health needs while at school including school sponsored after school activities and field trips You should plan to meet with the school nurse to update this plan at the beginning of each year There is a sample letter to school staff about diabetes and guidelines for creating an Individualized Healthcare Plan at the end of this booklet You will also find a sample of the School Nurse Order Form like the one that you and your doctor will complete As a parent you will be responsible to keep an adequate supply of items at school for your child s treatment including blood sugar and ketone testing supplies treatment for low blood sugars and insul
52. th control solutions when you open a new vial of strips if you suspect a problem with the meter or strips discard control solutions three months after opening Clean your meter weekly according to instruction guidelines Check your meter at least once a year with a laboratory blood glucose test Doa finger stick test using your meter within five minutes of the lab 21 draw When you get the result compare the two readings It is not uncommon for the result to be 10 20 percent higher Accuracy of the meter is very important Blood Glucose values are used to make treatment decisions concerning insulin adjustments food intake or timing and exercise timing Record Keeping It is very important to record all blood glucose results medications and important comments so that you can discuss them with your healthcare provider Decisions regarding insulin adjustments will be based largely on this information Please make copies of and use the Blood Glucose Medication Log forms provided in the back of this booklet Use these logs to fax non urgent information and communicate regularly with your diabetes healthcare team The more detailed your comments are the more useful they will be to you and your diabetes team in adjusting your plan of care You should always include your impression of any problems and possible solutions It is not important that you always be correct with your impression or solution The important thing is th
53. ting in the blood glucose logbook You can purchase products for ketone testing You should follow the manufacturer s instructions in order to obtain accurate results Consult with your healthcare provider on the proper use of the product SPECIAL TOPICS 24 BALANCING YOUR BLOOD SUGARS The best way to keep diabetes in good control is by keeping blood sugars in balance If you know the signs and symptoms when the blood sugar is out of balance you can take immediate action to treat it If blood sugars are above or below the target range you should talk to your diabetes healthcare team about what you can do to get them into better control Hypoglycemia Low Blood Sugar Hypoglycemia happens when blood glucose levels become too low Hypoglycemia is the most common problem for a person taking insulin and some other types of diabetes medications It is usually mild but you need to treat it as soon as possible to avoid further problems Signs and symptoms of hypoglycemia Symp rama of mild to moderate hypoglycemia may include Trembling shaking weakness Sweating Irritable sad or angry for no reason Dizziness Hunger Headache e Pale skin Blurred vision e Pounding heart fast pulse If left untreated symptoms may lead to Slurred speech Fatigue sleepiness Inability to think clearly confusion Seizures e Unconsciousness Causes of hypoglycemia The most common reasons for hypoglycemia are
54. with this student s family and then send fax a completed copy to us for our review We will contact you if we have any suggestions for changes to the IHP and we will the return a signed copy to your school Children with diabetes may require frequent changes to their treatment regimes Parents should keep you abreast of these changes We will continue to update you regarding medication changes required at school If you or your staff have any questions you may contact one of our nurses at 201 996 5329 Sincerely The MOLLY Center Staff THE MOLLY CENTER FOR CHILDREN WITH DIABETES AND ENDOCRINE DISORDERS DIABETES HEALTHCARE PLAN To be completed by parent and school nurse DATE SCHOOL GRADE STUDENT BIRTHDATE HOME ADDRESS PARENT GUARDIAN PARENT S PHONE Home Mom s work Dad s work EMERGENCY CONTACT NAME NUMBER AND RELATIONSHIP ALLERGIES HEIGHT WEIGHT EMERGENCY MEDICAL INFORMATION PRIMARY PHYSICIAN AND PHONE PEDIATRIC ENDOCRINOLOGIST AND PHONE kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk kkkkkkkkkkkkkkkkk To be completed by physician DIAGNOSIS Type 1 diabetes Type 2 diabetes Type 2 diabetes insulin requiring BLOOD GLUCOSE TESTING AT SCHOOL Before Lunch Before Gym Before Snack Time Other Target range of blood sugar is 80 180 mg dl Other MEDICATIONS WHICH MAY BE REQUIRED AT SCHOOL 1 Glucagon mg Intramuscularly for severe hyp
55. ydrate are to be eaten The dose of insulin may need to be decreased if a person will be physically active at the time the insulin is peaking Your doctor will give you an insulin dose schedule to follow He she will also give guidelines as to when to call for an insulin dose change Eventually you will learn to make insulin adjustments on your own INSULIN PREPARATION AND INJECTION Syringes Syringes come in various sizes with varying needle widths and lengths Be sure to discuss this with your healthcare provider so that you can help choose the best syringe and needle for your needs It will be easier to draw up the insulin correctly if you use the smallest syringe that will hold the dose of insulin The injection will be more comfortable and effective when the needle length is right for you The most common sizes are e icc holds up to 100 units e 1 2 cc holds up to 50 units 1 3 cc holds up to 30 units ME Oe aeasesss en eea a ee 8 8 The syringe concentration is marked on each syringe Remember to use a syringe and insulin with the same concentration You will most likely be using U 100 insulin so that you will need to use U 100 syringes There are three parts to an insulin syringe 1 Needle 2 Barrel 3 Plunger The unit measurements are located on the barrel of the syringe Most syringes are marked in one unit increments Syringes marked in 3 unit increments are also available If your insulin dose is in unit in
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