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Diabetes Care Tasks at School:

What Key Personnel

Need to Know <= /div>

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Diabetes in the Schools

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Diabetes Care T= asks at School:

What K= ey Personnel

Need to Know

MANAGING HYPOGLYCEMIA
AND HYPERGLYCEMIA=

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2

Overall goal:
Optimal student health and learning

Managing hypog= lycemia and hyperglycemia are criti= cal to student success. But just one p= iece of a comprehensive manag= ement plan.

Exercise

Legal

Rights

= Health

= &

= Learning

Nutrition <= /div>

Insulin

Administration<= /b>

Hypo= glycemia & Hyperglycemia

Ketones <= /div>

Monitoring

Blood <= /span>= Glucose

Glucagon

Administration

This training component is one of eight components created specifically=

for school nurses and non-medical school personnel who perform

diabetes care tasks at school.

These components include:

•Diabetes Basics

•Hypoglycemia and Hyperglycemia

•Blood Glucose Monitoring

•Insulin Administration

•Glucagon Administration

•Ketone Testing

•Nutrition and Exercise

•Legal Considerations

This unit is Hypoglycemia and Hyperglycemia.

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3

Learning Objectives

4Participants will l= earn:

4Symptoms of high and low blood glucose <= /div>
4Short- and long-term risks

4Treatment of high and low blood glucose =

4Prevention of high and low blood glucose

Our objectives are to learn:<= br>

   Recognition of high and low= blood glucose symptoms

   Treatment of high and low b= lood glucose levels

   Prevention of high and low = blood glucose levels

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4

Vocabulary

lGlucose

l

lHYPOglycemia
l

lQuick-acting glucose.<= span style=3D'font-size:88%'>

l

lGlucose tablets or gel

l

l
lGlucagon

l

l
l Carbohydrate

source of = energy for the body.

a = simple sugar found in the blood. th= e fuel that all body cells need to function.

a L= OW level of glucose in the blood.

foo= ds containing simple sugar that raises blood glucose levels

special products that deliver a pre-measured am= ount of pure glucose.        = ;    They are a fast-acting form of glucose used to counteract hypoglycemia.

a hormone given by injection that = raises the level of glucose in the blood.

There are a few vocabulary terms related to hypoglycemia:

Glucose is a simple sugar found in the blood.&nb= sp; It is the body’s main source of energy. The terms “glucose” and “sugar” are commonly used interchangeably.The same for “blood glucose” and “blood sugar”.

Hypoglycemia. A low level of glucose in the bl= ood..

Quick-acting glucose. Foods containi= ng simple sugar that are used to raise blood glucose levels quickly during hypoglycemia.

Glucose tablets or gel.&= nbsp; Special products that deliver a pre-measured amount of pure glucose. They are a fast-ac= ting form of glucose used to counteract hypoglycemia.

Glucagon. A hormone that raises the le= vel of glucose in the blood. Gluca= gon, given by injection, is used to treat severe hypoglycemia.

Carbohydrate. Carbohydrates are one of three main classes of foods and a source of ener= gy for the body. Foods high in carbohydrates raise blood glucose levels.

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5

lOnset: = 3;

–sudden,

–may progress to unconsciousness if not treated

–can result in bra= in damage or death

lThe DMMP should specify signs and action steps each level of severity:

–mild <= /span>

–moderate

–severe

Hypoglycemia =3D low blood glucose levels. Hypoglycemia is a low level of glucose in t= he blood.

Onset: Sudden, usually mild, but may pr= ogress to unconsciousness if not treated and result in brain damage or death

The Diabetes Medical Management Plan (DMMP) should specify signs and action s= teps for each student at each level of severity of hypoglycemia:

Mild

Moderate

Severe

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6

=

=

<= span style=3D'font-size:133%;layout-flow:horizontal;visibility:hidden'>l

<= span style=3D'font-size:133%;layout-flow:horizontal'>lGreatest immediate danger

<= span style=3D'font-size:133%;layout-flow:horizontal'>lNot always preventable

<= span style=3D'font-size:133%;layout-flow:horizontal'>lImpairs cognitive and motor functioning

lEarly recognition and intervention can prevent an emergency

•Hypoglycemia is the greatest immediate = danger to students with diabetes. Students can quickly get to a state where they cannot reliably help themselves. In this case, they are dependent on others to recognize that they are experiencing a low blood glucose level, and also = to know what to do to treat the low. Left untreated, hypoglycemia can lead t= o: unconsciousness, seizures, and may even be life-threatening.

•Hypoglycemia is one of the most frequent complications of diabetes. It can happen very suddenly and is not always preventable.

•Hypoglycemia impairs cognitive and motor functioning. Even a student= who knows s/he needs to eat might not be able to problem-solve how to get the food, or may not have the fine motor skills to screw off a juice lid or o= pen a cracker package. Some students may become combative and hypoglycemia may be mistaken for misbehavior.

•However, while a hypoglycemia episode i= s an urgency, it need not become an emergency. Most hypoglycemic episodes are quite mild; with students responding to eating a quick acting carbohydrate such as fruit juice, or crackers within 10-15 minutes. Recognizing early symptoms and always having access to appropriate foods are the surest way= to prevent an emergency.

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7

<= span style=3D'font-size:129%'>lToo much insulin

<= span style=3D'font-size:129%;visibility:hidden'>l

<= span style=3D'font-size:129%'>lToo little food

<= span style=3D'font-size:129%;visibility:hidden'>l

<= span style=3D'font-size:129%'>lExtra physical activity

<= span style=3D'font-size:114%;visibility:hidden'>l

Hypoglycemia or “lows” occur= when ever there is too much insu= lin in

the body for the amount of glucose. = This imbalance can happen for

three main reasons:

•Too much insulin has been administered<= /font>

•Too little food has been eaten

•Exercise level has increased

A student may have gotten too little food for a variety of reasons:<= br>

•The student may have not finished a meal or = snack

•The student may have overestimated the amoun= t of carbohydrate in a food or snack

•A meal may have been delayed or skipped altogether.

There are no restrictions on physical activity for students with diabetes.

However, when students are more active than usual at insulin peak times,

they may experience low blood sugar.

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8

Seizures=

Sudden crying

Unconsciousness/coma

Inability to swallow

Dazed appearance

Extreme tiredness/fatigue

Restless= ness

Irritabi= lity/frustration

Confusio= n

Yawning<= /span>

   Moderate to Severe Symptoms =

Increased heart rate/palpitations

Dilated pupils

Blurry vision

Anxiety<= /span>

Paleness=

Sweating=

Weakness=

Changed behavior

Shakines= s

Sleepine= ss

Hunger

                 = ;  Mild Symptoms

Hypoglycemia:
Possible Signs & Symptoms

The symptoms of hypoglycemia vary from one individual to another. Also, they may vary for one individual, from one episode to another.

The symptoms of mild hypoglycemia are the first alert that the body is in a s= tate of sugar deficiency.   Symptoms may include the followin= g:

•Headache    Shakiness

•Tremors=     Dizziness

•Extreme hunger

•Increased heart rate/palpitations

•Pallor&= nbsp;  Clammy skin

•Sweating    Anxiety

•Changed personality

•Diluted pupils

•Lethargic

Mild hypoglycemia can usually be treated easily and effectively. Most episodes= of hypoglycemia that will occur in school setting are of the “mildR= 21; type.

However, if not treated promptly a m= ild hypoglycemic reaction can quickly progress to a severe state or condition which may be characterized by:

•Yawning=     Irritability/frustration

•Behavior/personality changes    Extreme tiredness/fatigue

•Sudden crying

•Confusion    Restlessness

•Dazed Appearance    Inability to swallow

•Unconsciousness/coma    Seizures, convulsions, jerking movemen= ts

Remember, onset and progression can happen very quickly. Each student will have his/her o= wn set of symptoms that characterize hypoglycemia. These should be listed in the DM= MP.

The important thing to remember is that early recognition and intervention is= the best strategy to prevent progression to more severe symptoms.

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9

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .34%; top:.39em;font-family:Wingdings;font-size:70%'>lIntervene promptly.= Follow DMMP.

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .34%; top:.39em;font-family:Wingdings;font-size:70%'>lVerify with blood glucose test when available.

l<= span style=3D'color:#3F0066'>When in doubt, always treat.<= span style=3D'font-size:86%;color:#006638'> If no meter is available, treat immediately.

<= span style=3D'font-family:"Cooper Md BT";font-size:43%;visibility:hidden'>l

lHave student eat or drink fast acting car= bs (15g)

<= span style=3D'font-size:86%'>1.Test blood glucose 10-15 minutes after treatment&#= 13;

2.Repeat treatment if blood glucose level remains lo= w or if symptoms persist p= er DMMP

<= span style=3D'font-size:86%'>3.If symptoms continue, call parents per DMMP=

Intervene promptly when hypoglycemia is mild to prevent the progression to seve= re symptoms. The steps for intervening with each student will be outlined in his/her DMMP.

General steps are as follows:

First, verify with blood glucose test when available. (Some students confuse low &= high symptoms.)

However, if no meter is available, treat = for hypoglycemia.

WHEN IN DOUBT, ALWAYS TREAT FOR LOW BLOOD SUGAR as per DMMP:

Treatment involves the following steps:

1.Have student eat or drink fast acting carbohydrates (15g)

2.Test blood glucose 10-15 minutes after treatment

3.Repeat treatment if blood glucose level= remains low

4.If symptoms continue or blood glucose l= evels do not increase, call parents as specified in DMMP

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0019_image020.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhwwEqAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADB ASgAgAAAAP/yuwKkjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxycUAAAOw== ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0044.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

10

Quick Acting Glucose
for Hypoglycemia

lTr= eatment for Lows: 15 g Carbohydrate

l4 oz. fruit juice

l15 gm glucose tablets (2-3 tablets)

l1 tube of glucose gel

l4-6 small hard candies

l1-2 tablespoons of honey

l6 oz. regular = (not diet) soda (about half a can)

Any quick-acting glucose can be used to treat hypoglycemia. Be careful not to overdose on the treatment or the student will be too high later. Treatment may need to be repeate= d at about 15 minute intervals (based on continued low test results or poor symptom response), but each treatment dose should be 15g unless otherwise stated in the student’s DMMP.   Some quick-acting forms of glucose include:

•4 oz. fruit juice

•3 or 4 glucose tablets

•1 tube of glucose gel

•4-6 small hard candies

•1-2 tablespoons of honey

•6 oz. regular (not diet) soda (about ha= lf a can)

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0044_image021.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh4AEqAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADe ASgAgAAAAP/yuwKqjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxwsPExcbHzsUAAAOw== ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0037.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

11

=

lRare, but life threatening, if not treated promptly: = ;

<= span style=3D'font-size:93%'>lPlace student on his or her side

<= span style=3D'font-size:93%'>lInject glucagon, per student’s DMMP

lNever attempt to give food or put anything in the student’s mouth&#= 13;

<= span style=3D'font-size:93%'>lCall 911, then parent/guardian <= /div>
<= span style=3D'font-size:93%'>lStudent should respond in 15 to 20 minutes

<= span style=3D'font-size:93%'>lRemain with the student until help arrives<= span style=3D'font-size:86%;mso-special-format:lastCR;display:none'>

Procedures for intervening with severe hypoglycemia will be covered in more detail in another unit on glucagon administration.

Remember the steps for intervening with a specific student will be outlined in his or her DMMP.

This slide describes the general steps in intervention.

Severe hypoglycemia is rare, but life threatening, if not treated promptly:<= /b>

•Place student on his or her side=

•Inject glucagon if provided for in the student’s DMMP.

•Never attempt to give food or put anyth= ing in the student’s mouth

•Call 911, and then call parents/guardia= ns

•The student should respond to the gluca= gon in 15 to 20 minutes.

•Remain with the student until help arri= ves.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0037_image022.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh1QEqAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADT ASgAgAAAAP/yuwKnjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxwsPEzMWQAAOw== ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0057.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

12

Hypoglycemia= : <= span style=3D'font-family:Garamond;mso-ascii-font-family:Garamond'>Prevention

lKeep a quick-acting sugar source with the student. ALWAYS.

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .32%; top:.39em;font-family:Wingdings;font-size:70%'>lTreat at onset of symptoms

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .32%; top:.39em;font-family:Wingdings;font-size:70%'>lEat, Insulin, Test, Exercise ON TIME.

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .24%; top:.39em;font-family:Wingdings;font-size:70%'>lEnsure reliable ins= ulin dosing, per DMMP.

<= span style=3D'mso-special-format:bullet;color:#3F0066;position:absolute;left:-3= .32%; top:.39em;font-family:Wingdings;font-size:70%'>lEnsure insulin dosi= ng matches food eaten.

lWatch picky eaters

lProvide nutritional information to families

=

=

n

The onset and progression of hypoglycemia happens quickly. Knowing and following the basics= of prevention is vitally important to a student’s health, learning capacity, safety and feeling of security.

•Keep a quick-acting source of sugar wit= h the student. ALWAYS. During sch= ool hours, extracurricular activities, field trips and exams.

•Treat promptly at the onset of symptoms= .

Preventing high or low blood glucose levels is all about keeping the balance between insulin, food, and activi= ty.

•TIMING is very important in all aspects= of diabetes management. Eat on= time, take insulin on time, test = blood glucose on time and exercise on time.&nb= sp; Eating on time will include snacks for some students.

•Ensure that insulin dosing is accurate,= in accordance with the DMMP. The DMMP should specify what assistance, if any, is needed.

•The same kind of accuracy in “dosing” needs to happen with food as well. With some (especially young) stu= dents this may mean supervision and monitoring what is actually eaten.

•Picky eaters need monitoring.

•Nutritional information should be provi= ded to students/families for all school snacks/meals.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0057_image023.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhgAE3AHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAB/ ATUAgAAAAP/yuwKvjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxwsPExcbHyMnKy8zLxcAAA7 ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0054.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

13

Hypoglycemia= : <= span style=3D'font-family:Garamond;mso-ascii-font-family:Garamond'>Prevention

lConsult with parent/guardian when snack, meal or <= /span>exercise times must be changed.

lMonitor blood-glucose variations on gym days, an <= /span>extra snack may be required ½ hour before g= ym or during prolonged vigorous exercise per DMMP. <= /span>

lA student should never be unattended when a low blood glucose is suspected.

A few more prevention strategies: Changes in the timing of snacks,

meals, or exercise should only be made after consultation with parents

and/or health care provider.

•Monitor blood-glucose variations on gym= days, an extra snack may be required ½ hour before gym or during prolong= ed vigorous exercise per DMMP.

•A student should never be alone when lo= w blood glucose is suspected.

•Don’t over-rely (or under-rely) o= n the student with diabetes for management information. Consult the DMMP. Remem= ber, many kids with diabetes seem like experts, but their expertise has limits, especially when they are low.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0054_image024.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhgAEtAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAB/ ASwAgAAAAP/yuwKejI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7tLUQAA Ow== ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0049.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

14

Vocabulary

lHyperglycemia t= oo high a level of glucose in the blood.

lKetones (ketone bodies) Chemicals that the body makes when there is not enough insulin in the bloo= d and the body must break down fat for its energy.

lDiabetic ketoacidosis (DKA) the build up of ketones in the body that can lead to serious illness and coma= .

lKetone testing a procedure for measuring the level of ketones in the urine or blood.

There are a few key vocabulary terms related to hyperglycemia.

Hyperglycemia is the medical term for “high blood sugar”. It occurs when the body does not= have enough insulin or cannot use the insulin it does have to turn glucose into energy.

Ketones (ketone bodies). Chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy.

Diabetic ketoacidosis (DKA). The= build up of ketones in the body t= hat can lead to serious illness and coma.

Ketone testing. A procedure for measuring the level of ketones in the urine or blood.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0049_image025.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhyAEfAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADG AR4AgAAAAP/yuwKLjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6iupVAAA7 ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0010.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

15

<= span style=3D'font-size:93%'>lToo much sugar in the blood, but cells are starvin= g

<= span style=3D'font-size:93%'>Onset:

–Severe hyperglycemia is usually slow to develop

–Can be rapid with pumps

Hyperglycemia due to insufficient insulin may lead= to diabetic ketoacidosis (DKA) if not treated (mainly= in type 1)

DMMP should specify signs and action steps at each= level of severity:

–Mild <= /span>

–Moderate

–Severe

=

n<= span style=3D'font-family:Arial;layout-flow:horizontal;mso-special-format:lastC= R; display:none'>

Hyperglycemia is a high blood glucose level in the blood. Yet the irony is that with all t= he glucose floating around in the blood the body cells are actually starving because glucose cannot get in.

Generally the onset of hyperglycemia is slow.&= nbsp; An isolated high blood glucose reading is cause for concern, but n= ot alarm. It is especially important to recognize that blood glucose is expe= cted to be higher following a meal or snack.&= nbsp; Hyperglycemia can occur more rapidly in students with insulin pump= s if a pump malfunctions or delivers less insulin.

If there is insufficient insulin due to pump malfunction, failure to take insulin = or insulin not working effectively, there maybe a breakdown in fat, causing ketones to form, ketones may build up in the blood and may result in diab= etic ketoacidosis (DKA).

Hyperglycemia becomes an increasing concern when several consecutive readings have = been high, or when accompanied by vomiting. The student’s DMMP should determine precisely what actions should be taken at each level of severit= y of hyperglycemia.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0010_image026.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh3gEqAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADd ASgAgAAAAP/yuwKpjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxwsPExcbJxaAAA7 ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0021.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

lHyperglycemia due to inadequate insulin can = = lead to DKA and/or coma or death (mainly in type 1).
lInterferes with a student’s ability to learn and participate. <= /div>
lSerious complicatio= ns develop when glucose levels remain above target range over time or are recurring.

l

There are several important reason that to learn the signs, treatment, and prevention strategies for hyperglycemia.

1.If left untreated for an extended perio= d, hyperglycemia due to insufficient insulin can lead to “diabetic ketoacidosis” (DKA) and/or coma and death. The onset is more rapid = for students who wear insulin pumps.

2.High blood sugar can affect a student&#= 8217;s general well-being. Student= s who do not feel well are less able to learn and participate in school activit= ies.

3.When glucose levels remain high over ti= me or are recurring, serious life-limiting complications of diabetes develop. Diabetes is the leading cause of adult blindness, lower limb amputations,= and kidney failure. It can also= cause heart disease and stroke.

4.Many students with diabetes will not ex= perience symptoms from high glucose levels until the level is far above target ran= ge. Therefore, routine glucose testing is needed to identify otherwise undetectable high glucose levels.

The good news is that, treating high glucose levels in accordance with the student’s DMMP,

enables students to participate fully in their education now and enhances their health and

well-being in the future.

------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0021_image027.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh9AEqAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADy ASkAgAAAAP/yuwKwjI+py+0Po5y02ouz3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmMTqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFho eIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp+QkaKjpKWmp6ipqqusra6voKGys7S1tre4ubq7vL2+v7 CxwsPExcbHyMnKy8zNycVwAAOw== ------=_NextPart_01C9D486.BC2669B0 Content-Location: file:///C:/F8644181/glycemia_files/slide0013.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" No Slide Title

17

lToo little insulin

lExpired insulin

lFood not cove= red by insulin

lDecreased phy= sical activity&= #13;

lIllness, injury

lStress <= /span>

lOther hormone= s

lMenstrual periods

lAny combinati= on of the above

l

The first four items in this list - too little insulin, expired insulin, food, activity-are the main players. Keeping these three in balance is generally what keeps blood gluco= se from going too high OR too low.
Adding insulin or exercise generally lowers blood glucose and adding food genera= lly increases blood glucose. So considering these three, hyperglycemia can be caused by too little insulin, too much food, or too little physical activ= ity. Let’s talk about this list= in a little more detail.
•Too little insulin - Forgetting to “cover” a meal or snack with short-acting insulin can happen. Of greater concern = is when students have not taken their long-acting insulin. Students on pumps are especially vulnerable to high blood glucose, if their infusion site pulls out or occludes, preventing insulin delivery.
•Expired or “spoiled” insuli= n: Sometimes insulin that is beyond expiration or has been stored improperly can lose it’s potency and = can cause hyperglycemia.
•Too much food or food that is not cover= ed by insulin. This may be inadve= rtent – not realizing how carbohydrate-rich a particular food is. For example, a student who is us= ed to eating grocery store bagels at home, may not realize that some shop bagels are two time as rich in carbohydrates.
•Decreased exercise or activity.<= br> Other factors may also play a role:
•Illness, injury – an otherwise “unexplained” high glucose reading may be a sign of onset of illness.
•Stress. Other hormones, such as glucago= n, growth hormone, adrenaline, cortisol
•Menstrual periods

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§ <= /span>

Moderate Symptoms

Very weak = ; Unconscious


	This training component is one of eight components created specifically=
	for school nurses and non-medical school personnel who perform
	diabetes care tasks at school.

	These components include:

	•Diabetes Basics
	•Hypoglycemia and Hyperglycemia
	•Blood Glucose Monitoring
	•Insulin Administration
	•Glucagon Administration
	•Ketone Testing
	•Nutrition and Exercise
	•Legal Considerations

	This unit is Hypoglycemia and Hyperglycemia.



	Our objectives are to learn:<= br>
	Recognition of high and low= blood glucose symptoms
	Treatment of high and low b= lood glucose levels
	Prevention of high and low = blood glucose levels


	There are a few vocabulary terms related to hypoglycemia:
	Glucose is a simple sugar found in the blood.&nb= sp; It is the body’s main source of energy. The terms “glucose” and “sugar” are commonly used interchangeably.The same for “blood glucose” and “blood sugar”.
	Hypoglycemia. A low level of glucose in the bl= ood..
	Quick-acting glucose. Foods containi= ng simple sugar that are used to raise blood glucose levels quickly during hypoglycemia.
	Glucose tablets or gel.&= nbsp; Special products that deliver a pre-measured amount of pure glucose. They are a fast-ac= ting form of glucose used to counteract hypoglycemia.
	Glucagon. A hormone that raises the le= vel of glucose in the blood. Gluca= gon, given by injection, is used to treat severe hypoglycemia.
	Carbohydrate. Carbohydrates are one of three main classes of foods and a source of ener= gy for the body. Foods high in carbohydrates raise blood glucose levels.




	Hypoglycemia =3D low blood glucose levels. Hypoglycemia is a low level of glucose in t= he blood.
	Onset: Sudden, usually mild, but may pr= ogress to unconsciousness if not treated and result in brain damage or death
	The Diabetes Medical Management Plan (DMMP) should specify signs and action s= teps for each student at each level of severity of hypoglycemia:
	Mild
	Moderate
	Severe


	•Hypoglycemia is the greatest immediate = danger to students with diabetes. Students can quickly get to a state where they cannot reliably help themselves. In this case, they are dependent on others to recognize that they are experiencing a low blood glucose level, and also = to know what to do to treat the low. Left untreated, hypoglycemia can lead t= o: unconsciousness, seizures, and may even be life-threatening.
	•Hypoglycemia is one of the most frequent complications of diabetes. It can happen very suddenly and is not always preventable.
	•Hypoglycemia impairs cognitive and motor functioning. Even a student= who knows s/he needs to eat might not be able to problem-solve how to get the food, or may not have the fine motor skills to screw off a juice lid or o= pen a cracker package. Some students may become combative and hypoglycemia may be mistaken for misbehavior.
	•However, while a hypoglycemia episode i= s an urgency, it need not become an emergency. Most hypoglycemic episodes are quite mild; with students responding to eating a quick acting carbohydrate such as fruit juice, or crackers within 10-15 minutes. Recognizing early symptoms and always having access to appropriate foods are the surest way= to prevent an emergency.



	Hypoglycemia or “lows” occur= when ever there is too much insu= lin in
	the body for the amount of glucose. = This imbalance can happen for
	three main reasons:
	•Too much insulin has been administered<= /font>
	•Too little food has been eaten
	•Exercise level has increased

	A student may have gotten too little food for a variety of reasons:<= br>
	•The student may have not finished a meal or = snack
	•The student may have overestimated the amoun= t of carbohydrate in a food or snack
	•A meal may have been delayed or skipped altogether.

	There are no restrictions on physical activity for students with diabetes.
	However, when students are more active than usual at insulin peak times,
	they may experience low blood sugar.


	The symptoms of hypoglycemia vary from one individual to another. Also, they may vary for one individual, from one episode to another.

	The symptoms of mild hypoglycemia are the first alert that the body is in a s= tate of sugar deficiency. Symptoms may include the followin= g:
	•Headache  Shakiness
	•Tremors=  Dizziness
	•Extreme hunger
	•Increased heart rate/palpitations
	•Pallor&= nbsp;  Clammy skin
	•Sweating  Anxiety
	•Changed personality
	•Diluted pupils
	•Lethargic

	Mild hypoglycemia can usually be treated easily and effectively. Most episodes= of hypoglycemia that will occur in school setting are of the “mildR= 21; type.

	However, if not treated promptly a m= ild hypoglycemic reaction can quickly progress to a severe state or condition which may be characterized by:
	•Yawning=  Irritability/frustration
	•Behavior/personality changes  Extreme tiredness/fatigue
	•Sudden crying
	•Confusion  Restlessness
	•Dazed Appearance  Inability to swallow
	•Unconsciousness/coma  Seizures, convulsions, jerking movemen= ts

	Remember, onset and progression can happen very quickly. Each student will have his/her o= wn set of symptoms that characterize hypoglycemia. These should be listed in the DM= MP.

	The important thing to remember is that early recognition and intervention is= the best strategy to prevent progression to more severe symptoms.



	Intervene promptly when hypoglycemia is mild to prevent the progression to seve= re symptoms. The steps for intervening with each student will be outlined in his/her DMMP.

	General steps are as follows:
	First, verify with blood glucose test when available. (Some students confuse low &= high symptoms.)
	However, if no meter is available, treat = for hypoglycemia.

	*WHEN IN DOUBT, ALWAYS TREAT FOR LOW BLOOD SUGAR as per DMMP:*

	*Treatment involves the following steps:*
	1.Have student eat or drink fast acting carbohydrates (15g)
	2.Test blood glucose 10-15 minutes after treatment
	3.Repeat treatment if blood glucose level= remains low
	4.If symptoms continue or blood glucose l= evels do not increase, call parents as specified in DMMP


	Any quick-acting glucose can be used to treat hypoglycemia. Be careful not to overdose on the treatment or the student will be too high later. Treatment may need to be repeate= d at about 15 minute intervals (based on continued low test results or poor symptom response), but each treatment dose should be 15g unless otherwise stated in the student’s DMMP. Some quick-acting forms of glucose include:
	•4 oz. fruit juice
	•3 or 4 glucose tablets
	•1 tube of glucose gel
	•4-6 small hard candies
	•1-2 tablespoons of honey
	•6 oz. regular (not diet) soda (about ha= lf a can)


	Procedures for intervening with severe hypoglycemia will be covered in more detail in another unit on glucagon administration.

	Remember the steps for intervening with a specific student will be outlined in his or her DMMP.
	This slide describes the general steps in intervention.

	Severe hypoglycemia is rare, but life threatening, if not treated promptly:<= /b>
	•Place student on his or her side=
	•Inject glucagon if provided for in the student’s DMMP.
	•Never attempt to give food or put anyth= ing in the student’s mouth
	•Call 911, and then call parents/guardia= ns
	•The student should respond to the gluca= gon in 15 to 20 minutes.
	•Remain with the student until help arri= ves.


	The onset and progression of hypoglycemia happens quickly. Knowing and following the basics= of prevention is vitally important to a student’s health, learning capacity, safety and feeling of security.
	•Keep a quick-acting source of sugar wit= h the student. ALWAYS. During sch= ool hours, extracurricular activities, field trips and exams.
	•Treat promptly at the onset of symptoms= .
	Preventing high or low blood glucose levels is all about keeping the balance between insulin, food, and activi= ty.
	•TIMING is very important in all aspects= of diabetes management. Eat on= time, take insulin on time, test = blood glucose on time and exercise on time.&nb= sp; Eating on time will include snacks for some students.
	•Ensure that insulin dosing is accurate,= in accordance with the DMMP. The DMMP should specify what assistance, if any, is needed.
	•The same kind of accuracy in “dosing” needs to happen with food as well. With some (especially young) stu= dents this may mean supervision and monitoring what is actually eaten.
	•Picky eaters need monitoring.
	•Nutritional information should be provi= ded to students/families for all school snacks/meals.


	A few more prevention strategies: Changes in the timing of snacks,
	meals, or exercise should only be made after consultation with parents
	and/or health care provider.
	•Monitor blood-glucose variations on gym= days, an extra snack may be required ½ hour before gym or during prolong= ed vigorous exercise per DMMP.
	•A student should never be alone when lo= w blood glucose is suspected.
	•Don’t over-rely (or under-rely) o= n the student with diabetes for management information. Consult the DMMP. Remem= ber, many kids with diabetes seem like experts, but their expertise has limits, especially when they are low.


	There are a few key vocabulary terms related to hyperglycemia.
	Hyperglycemia is the medical term for “high blood sugar”. It occurs when the body does not= have enough insulin or cannot use the insulin it does have to turn glucose into energy.

	Ketones (ketone bodies). Chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy.

	Diabetic ketoacidosis (DKA). The= build up of ketones in the body t= hat can lead to serious illness and coma.

	Ketone testing. A procedure for measuring the level of ketones in the urine or blood.


	Hyperglycemia is a high blood glucose level in the blood. Yet the irony is that with all t= he glucose floating around in the blood the body cells are actually starving because glucose cannot get in.

	Generally the onset of hyperglycemia is slow.&= nbsp; An isolated high blood glucose reading is cause for concern, but n= ot alarm. It is especially important to recognize that blood glucose is expe= cted to be higher following a meal or snack.&= nbsp; Hyperglycemia can occur more rapidly in students with insulin pump= s if a pump malfunctions or delivers less insulin.
	If there is insufficient insulin due to pump malfunction, failure to take insulin = or insulin not working effectively, there maybe a breakdown in fat, causing ketones to form, ketones may build up in the blood and may result in diab= etic ketoacidosis (DKA).
	Hyperglycemia becomes an increasing concern when several consecutive readings have = been high, or when accompanied by vomiting. The student’s DMMP should determine precisely what actions should be taken at each level of severit= y of hyperglycemia.


	There are several important reason that to learn the signs, treatment, and prevention strategies for hyperglycemia.

	1.If left untreated for an extended perio= d, hyperglycemia due to insufficient insulin can lead to “diabetic ketoacidosis” (DKA) and/or coma and death. The onset is more rapid = for students who wear insulin pumps.

	2.High blood sugar can affect a student&#= 8217;s general well-being. Student= s who do not feel well are less able to learn and participate in school activit= ies.

	3.When glucose levels remain high over ti= me or are recurring, serious life-limiting complications of diabetes develop. Diabetes is the leading cause of adult blindness, lower limb amputations,= and kidney failure. It can also= cause heart disease and stroke.

	4.Many students with diabetes will not ex= perience symptoms from high glucose levels until the level is far above target ran= ge. Therefore, routine glucose testing is needed to identify otherwise undetectable high glucose levels.

	The good news is that, treating high glucose levels in accordance with the student’s DMMP,
	enables students to participate fully in their education now and enhances their health and
	well-being in the future.