Transcript Diabetes Update for School Nurses

Diabetes Update for School
Nurses
Arkansas Children’s Hospital
Jennifer Sellers, RN,CDE
Lisa Still, RN,CDE
July 2007
Diabetes: Type I
• Type I diabetes occurs when the pancreas stops
producing insulin or is producing very little in
sporadic amounts.
• People with type I diabetes must take insulin and
it is a life long condition.
• Type I diabetes generally occurs with in the
pediatric population.
Type ll
• Type II diabetes occurs when the pancreas does
not produce enough insulin to keep up with the
demands of the body or the cells cannot properly
use the insulin that is being produced.
• People with type ll diabetes can often be treated
with diet, exercise and oral medication. We do
however start many on insulin and gradually stop
or decrease the dosage.
• Type ll diabetes most often occurs when
individuals are overweight. In the past, type ll
diabetes was limited to adults but we are seeing
an increase in the number of children with type ll
diabetes.
most of the media attention is given to type ll diabetes.
Prevalence
• In 2005 there were 20.8 Million people
with diabetes. (1)
• Diabetes is one of the most common
chronic diseases among children. (2)
• 176,500 people with diabetes are
under the age of 20. (2)
• 1 in every 400-600 people under age
20 have diabetes. (2)
• Each year more than 13,000 young
people are diagnosed with Type 1
diabetes. (2)
Prevalence at ACH
• In 2005 we had 97 newly diagnosed
diabetics.
• In 2006 we had 135 newly diagnosed
diabetics.
• As of May 31,2007 we have had 75
newly diagnosed diabetics.
Importance of school nurse
• The school nurse is vital in the
management of children with
diabetes.
• School nurses are being asked to do
more procedures for more students
with less staff.
Duties
• With diabetes they are asked to help
children with blood glucose monitoring
and recording results, oversee
carbohydrate counting and calculate how
much insulin is needed, check urine for
ketones, treat low blood sugar episodes
and on occasion administer glucagon.
• Children spend 7 hours a day 5 days a
week at school. ( some may spend more
with before and after school care) that is
an average of 35 hours per week these
children need someone to oversee and
assist them with their diabetes
management. YOU ARE VITAL!
Symptoms of Hypoglycemia
•Headache
•irritability
•confusion
•sweating
•Weakness
•rapid heart rate
•shakiness
•personality
changes
Causes of Hypoglycemia
• Skipped meals or snacks.
• Extra or prolonged exercise without
extra food.
• Too much insulin.
• Mistake in drawing up insulin dose.
Treatment of Hypoglycemia
•Treat any blood sugar below 70.
•For seizure or unconsciousness, use
Glucagon Emergency Kit as prescribed.
“Rule of 15”
•
•
•
•
If blood sugar is below 70
Give 15 gm fast acting carbohydrate.
Wait 15 minutes and recheck blood sugar.
If blood sugar is still <70, retreat with 15
gm fast acting carbohydrate and recheck
in 15 minutes.
• Once blood sugar is corrected, give small
snack or regularly scheduled meal within
30 minutes.
• If blood sugar immediately prior to lunch is
below 70, follow rule of 15 before sending
child to lunch.
Examples of 15 gm Fast Acting Carbohydrate
•4 ounces juice or
regular soda
•3 glucose tablets
•1 tube glucose gel or
cake icing gel
•1 tablespoon honey or
corn syrup
•3 sugar packets
•2 rolls smarties
candies
Symptoms of Hyperglycemia
•thirstiness
•fatigue
•headache
•frequent urination
•Personality
change
•Irritability
•nausea
Causes of Hyperglycemia
• overeating
• illness
• not taking enough insulin or missing a
shot
• decreased exercise
• stress
• using insulin that is older then 30 days or
that has been exposed to extreme heat or
freezing temperatures
Remember to Check Ketones
When:
•Blood sugar is >240
• Illness ( cold,
bladder infection etc)
•Vomiting
Ketones will cause the breath
to smell fruity and usually
causes nausea.
If the child has ketones:
•If ketones are moderate to large, call the
parents.
•If ketones are trace to small, drink 8 oz. of
water every hour. Recheck in 2 hours.
If Ketones are present
• Remove child from physical
activity
• Encourage fluids (8 ounces
of sugar free fluid every hour)
no milk, juice or gatorade
• Notify parents
Points to Remember
• If student acting out of character or unable to
concentrate, check blood sugar.
• Hypo/hyperglycemia can both be seen this
way
• Always use the buddy system when student is
going to the office to check for hypoglycemia.
• If in doubt, contact the parents for other
questions and concerns.
Insulin
Short-acting (Regular)
onset 30-60 minutes
maximum effect 2-3 hours
duration up to 12 hours
Intermediate-acting (NPH)
onset 1.5-4 hours
maximum effect 4-12 hours
duration up to 24 hours
This insulin regimen requires three shots a day and is very
limited in flexibility. These shots must be taken about the
same time of day (before breakfast, before evening meal and
at bedtime). The child using this insulin regimen must eat
the prescribed amount of carbohydrates at about the same
time every day.
Insulin
Rapid-acting (Humalog, Novolog)
onset 15 minutes
maximum effect 30-90 minutes
duration 3-5 hours
Long-acting (Lantus)
onset 1-2 hours
maximum effect flat
duration 24 hours
This insulin regimen is a basal/bolus or meal based
regimen also called MDI. Using this regimen
requires the use of carbohydrate counting and
matching insulin to carbohydrates eaten. This
regimen also requires at least four shots per day
(before each meal and bedtime). This regimen is
more flexible in the amount of food and timing of
meals.
Pen devices
• Many children that use lantus/log
regimen use insulin pens to
administer their insulin
Meals
• Children that utilize a NPH/Regular insulin
regimen will have a set meal plan that
usually consist of 3 meals and 2 or 3
snacks. The snacks must be given
regardless of the blood sugar.
• Children that are using a lantus/log
regimen are not required to eat a set meal
pattern, therefore snacks are not required.
• Both regimen groups must count
carbohydrates to keep their blood sugar
readings in check.
General School Lunch
Guidelines
• Most children can eat the regular school
lunch.
• Some children will require additional
snacks, according to their individual meal
plan.
• Follow the meal/snack times and
carbohydrate amounts listed in the
individual meal plan.
• Children with type 2 diabetes will also
require portion limits for fat and protein.
Carbohydrate Counting
•Calories in food come from
carbohydrate, protein, and
fat.
•Carbohydrates have the
biggest effect on blood
sugars. Protein and fat have
much less of an effect.
•Carbohydrates are bread,
cereal, rice, pasta, fruit,
vegetables, potatoes, chips,
crackers, milk, yogurt,
desserts, candy, and sugar.
How Do You Count Carbs?
•The food label will tell you how
many grams of carbohydrate are in
a serving of that food.
•Most kids will count grams of
carbohydrate (i.e. 60 gm
carbohydrate at a meal)
Food Labels
•Focus on 2 things: total
carbohydrate and serving
size.
•If counting grams, add up
the amount until you get
w/in 5 gms of the target.
What About Protein?
•Protein foods include
meat, peanut butter,
cheese, cottage
cheese, eggs, and
nuts.
•Unless protein is
breaded (i.e. chicken
nuggets), do not count
carbs for it.
What About Fat?
•Fats include foods
such as oils, butter,
margarine, mayo,
sour cream, etc.
•We do not count
carbs for fat foods.
What About Sweets?
•Sweets are carbohydrates and must be
counted as carbs in the meal plan.
•Limit sweets to 1 per day.
Free Foods
•Free foods have less
than 20 calories per
serving.
•Examples are sugar
free jello, dill pickles,
and sugar free
popsicles.
Meal Plan for Type 1 Diabetes
Bks Snac
k
Lunch Snack Dinne Snack
r
Carb
Choices
4
1
4
2
4
2
Grams
of
carbohydrate
60
15
60
30
60
30
Meal Plan for Type 2 Diabetes
Bkst
Snack
Lunch Snack
Dinner
Snack
Carb
Choices
3
1
3
1
3
2
Grams of
Carbohydrate
45
15
45
15
45
30
Ounces
of protein
1
XX
3
XX
3
XX
Fat
Servings
1
XX
1
XX
1
XX
Meal based insulin
• People that are using lantus/log
insulin regimen must calculate the
amount of carbohydrates they are
eating then calculate how much
insulin to give based on the grams of
carbohydrate.
Meal Bolus
•Ham & cheese sandwich
•Medium orange
•8 oz. Whole milk
57 gms
If ratio for meal bolus is:
1unit of insulin per 15gms
carbohydrate
3.8 unit meal bolus
30gms
15gms
12gms
Correction bolus
• Children on lantus/log are also
instructed to calculate a bolus of
insulin to be given with meals only to
correct a high blood sugar.
• Once the correction bolus is
calculated, you add the correction
bolus to the meal bolus and give as
one injection.
High Bolus or Correction Bolus
• Formula utilized to bring patient back
to target Blood Glucose
Actual Blood sugar – target = correction bolus
insulin sensitivity
231-target of 120= 111 2.2 units of insulin
50
50
Calculate bolus
•Ham & cheese sandwich
•Medium orange
•8 oz. Whole milk
30gms
15gms
12gms
57 gms
If ratio for meal bolus is:
1unit of insulin per 15gms carbohydrate
3.8 unit meal bolus
•_____________________________________________
•Formula utilized to bring patient back to
target Blood Glucose
Actual Blood sugar – target=correction bolus
insulin sensitivity
s231-target of 120= 111 = 2.2 unit
50
50
•3.8 unit
meal bolus
+2.2
correction
bolus
___________
6 unit total
bolus
Pump or CSII (Continuous Subcutaneous Insulin Infusion)
• Continuous Subcutaneous
Insulin Infusion
• Subcutaneous delivery of
insulin via external electromechanical device. Delivery
regimen mimics the basal/bolus
delivery pattern of a pancreas
CSII
• Delivery is extremely precise.
• Pump accurately delivers doses
down to 0.05 unit of insulin
• REMEMBER. . ..
•
•
•
•
The Insulin Pump is a computer.
It can only do what the user tells it to do.
Requires decisions from user.
User requires Blood glucose data and
carbohydrate content to make good
decisions
INSULIN PUMP THERAPY -PAST
Pumps
Infusion sets
BASAL RATE:
• Continuous precision “drip” of
insulin given over a 24 hour
periods.
• Pump can be programmed to
change its basal rate to
accommodate predictable daily
changes in insulin requirements
BOLUS
• Bolus is not automatic. . ..
• Patient determines bolus
amount Based on:
- Blood sugar
- Carbohydrates in Meal or
Snack
Calculate bolus
•Ham & cheese sandwich
•Medium orange
•8 oz. Whole milk
30gms
15gms
12gms
57 gms
If ratio for meal bolus is:
1unit of insulin per 15gms carbohydrate
3.8 unit meal bolus
•_____________________________________________
•Formula utilized to bring patient back to
target Blood Glucose
Actual Blood sugar – target=correction bolus
insulin sensitivity
s231-target of 120= 111 = 2.2 unit
50
50
•3.8 unit
meal bolus
+2.2
correction
bolus
___________
6 unit total
bolus
Nurse’s role with a pump
• Assist child in counting
carbohydrates.
• Assist child in calculating bolus for
meal and correction.
• Verify amount of bolus on pump
before delivery.
• It may be necessary with very young
children for the nurse to actually
push the buttons on the pump to set
the bolus.
Resources
• American Diabetes Association,
www.diabetes.org
• Children with Diabetes,
www.childrenwithdiabetes.com
• Juvenile Diabetes and Research Foundation,
www.jdrf.org
• Animas Corporation, www.animascorp.com
• Medtronic Minimed www.minimed.com
• National Diabetes Education Program
www.ndep.nih.gov
Bibliography
• 1 National Diabetes Information Clearinghouse
http://diabetes.niddk.nih.gov/dm/pubs/statistics/in
dex.htm
• 2 National Center for Chronic Disease Prevention
and Health Promotion
http://www.cdc.gov/diabetes/pubs/factsheets/sear
ch.htm
• 3 The slides that show the insulin pump were
obtained From Tracy Garstka Diabetes Nurse
Specialist for Medtronic Minimed.
www.minimed.com