Q. What is best practice for treating hypoglycemia (low blood sugar)?
A: To treat hypoglycemia, follow the student’s healthcare provider orders. The blood glucose (BG) range at which a student experiences symptoms of hypoglycemia may vary individually. BG below 70 milligrams/deciliter (mg/dl) is generally considered low. Students should be monitored constantly until hypoglycemia has resolved. Symptoms of hypoglycemia may vary individually as well.

Symptoms of mild hypoglycemia commonly include:

• Hunger or nausea
• Shakiness, weakness
• Sleepiness
• Sweating
• Pale colored skin
• Behavior changes
• Blurry vision, dilated pupils
• Anxiety, nervousness
• Irritability
• Increased heart rate, palpitations

Healthcare provider orders commonly include the following for managing hypoglycemia:

1. Check BG
2. Give quick-acting glucose (sugar) replacement*
3. Recheck BG after 15 minutes.
4. Repeat glucose replacement if BG is still low or student remains symptomatic.
5. If symptoms worsen follow steps for treating severe hypoglycemia (below)

*Quick-acting glucose sources are generally given in 15gm carbohydrate amounts, and include:

• 4 oz. fruit juice
• 3-4 glucose tablets
• 1 tube of glucose gel
• 6-8 oz. of sports drink (not sugar-free types)
• 1 tablespoon of honey, jelly, syrup, or cake frosting
• 6 oz. regular (not diet) soda (about half a can)
• 3 teaspoons table sugar (3 packets)
• One-half tube of cake gel
• Certain candies such as Skittles, Starburst, Smarties, gummy bears, jellybeans, or gum drops.

Note: Glucose sources, such as chocolate, ice cream, cookies, granola bars, or similar complex carbohydrates, contain fat which slow the release of glucose into the bloodstream and, therefore, will not raise the BG of a person with hypoglycemia fast enough.

Symptoms of severe hypoglycemia commonly include:

• Inability to swallow
• Visual disturbances
• Pallor
• Rapid or irregular heart rate
• Seizures (convulsions)
• Unconsciousness

Severe hypoglycemia is an emergency. School personnel should:

• Administer glucagon immediately if the student has orders for glucagon;
• As soon as possible (ask another staff member if available), call for emergency medical services per district policy (protocol). It is important to inform the emergency responders that there is a student with diabetes experiencing severe hypoglycemia; and
• Obtain a BG if able.

Q: What is best practice for treating hyperglycemia (high blood sugar)?
A: To treat hyperglycemia, follow the student’s healthcare provider orders. BG above 300 mg/dl is generally considered high. The BG range at which a student experiences symptoms of hyperglycemia may vary individually, and the symptoms may also vary.

Symptoms of hyperglycemia commonly include:

• Thirst
• Fatigue
• Frequent urination
• Blurry vision
• Headache
• Flushed skin
• Fruity breath
• Abdominal discomfort
• Nausea, vomiting.

Healthcare provider orders commonly include the following for managing hyperglycemia:

• Encourage consumption of water (or sugar-free fluids) 4 – 8 oz every 30 minutes.
• Allow frequent trips to the bathroom.
• The student may consume fluids in the classroom.
• Check for ketones (see questions below)

Q: What are ketones?
A: Ketones are a type of acid made in the liver and are produced when there is not enough of the hormone insulin in the body to turn glucose into energy. The body needs another source of energy, so the body uses fat instead. The liver turns this fat into ketones and sends them into the bloodstream. The body cannot tolerate large amounts of ketones and will excrete excess ketones through urine.

Q: How are ketones tested?
A: Ketones can be checked using urine or blood. Checking for urine ketones is the most common.  A trained staff member can assist the student if necessary.

To check for urine ketones, obtain ketone strips and a clean cup. If performed by someone other than the student, put gloves on. After the student urinates in the clean cup, the ketone test strip is dipped in the cup, and excess urine is shaken off. Follow the instructions on the test strip bottle, as the timing varies by manufacturer. The wait time is typically 15– 60 seconds. Read and record the results. Follow the healthcare provider orders, or DMMP, to determine the next step.

To check for blood ketones a special meter is used, like blood glucose checks. Begin with hand washing and then prepare the lancet. Next, remove the test strip from the packet and insert the three black lines at the end of the test strip into the strip port. The test strip must be pushed in until it stops. Touch the drop of blood to the purple area of the test strip, and the blood will be drawn into the strip. The result will be shown in the display window with the word ketone. Follow the healthcare provider orders, or DMMP, to determine the next step.

Q: When should ketones be tested?
A: In persons with diabetes, ketones upset the chemical balance in the blood and can lead to diabetic ketoacidosis (DKA). DKA is a life-threatening emergency. Students with diabetes will usually have healthcare provider orders for when ketones should be tested. Ketones should be tested according to those orders.

The acceptable range for ketones is negative/trace.  Always check the expiration date on the container to ensure test strips are not expired. Do not use discolored ketone test strips.

Healthcare provider orders commonly advise to test for ketones when:

• BG is at 300 or greater
• The student is nauseated, vomiting, or having abdominal pain
• The student is fatigued
• The student is thirsty or has a dry mouth
• The student is having difficulty breathing
• The student’s breath smells fruity
• The student is confused or “in a fog”

Q: Who should check ketones?
A: If a student requires assistance to check for ketones, a trained staff member may assist the student. However, the school nurse will determine what to do based on the test results and the healthcare provider orders.

Q: Should a student with a BG>300 who is negative for ketones and asymptomatic be sent home?
A: No, the student can be safely managed at school. Many students with diabetes will experience blood glucose levels above their target range at times throughout the day. Follow the healthcare provider orders to lower the student’s BG and inform the parent/guardian of actions taken.

Q: When should insulin be administered?
A: Insulin is administered according to the healthcare provider orders. Typically, there are routine times for checking blood glucose via fingerstick or continuous glucose monitor (CGM) and, if appropriate, correction insulin may be given at those times.

Q: Can a student refuse insulin administration?
A: A student can refuse medication administration, and therefore can refuse insulin. When a student refuses their insulin, this is an opportunity to provide education to the student about the importance of taking insulin, why insulin is necessary, and the consequences of not taking their insulin.

If the student still refuses to take their insulin, then the parent/guardian must be notified immediately. The school should continue to follow the healthcare provider orders.

Q: Can a school mandate that a student have a cell phone (or other device) so the school nurse can remotely monitor BG?
A: No, the school cannot mandate that a student have a cell phone. Districts should provide the nurse with a district device for monitoring student CGM data. As the information from the CGM is part of the student’s cumulative health record (CHR) maintained by a nurse, and the CHR is part of the education record, the information on the device is subject to Family Educational Rights and Privacy Act (FERPA) and Education Law 2-d.

Q: If the parent/guardian asks the school nurse to monitor a student’s BG or CGM beyond what is required in the healthcare provider orders, how should a school handle this request?
A: As indicated in the NYS Education Department’s Medication Management Guidelines, School personnel should not follow trending data but should respond to CGM alarms. When the CGM alarms, school staff generally check a fingerstick blood glucose (BG) and follow the individual student’s healthcare provider orders. BG checks should be conducted as required in the healthcare provider orders or as needed based on the professional judgment of the nurse.

The nurse should meet with the parent/guardian and address their concerns. Building a relationship and ongoing communication with the parent/guardian is important to ensure the needs of the student are met. The school nurse can also provide reassurance by explaining that healthcare provider orders are followed. A communication plan with the parent/guardian can be established. For example, a communication book or daily email between home and school providing information about the student’s BG/CGM, insulin administered etc. Often, parents/guardians benefit from the reassurance that their child with diabetes will be safely cared for in school.

Q: Can a nurse request an order from the healthcare provider to feed a student who has not eaten all their food/carbohydrates after insulin coverage has been administered?
A: If the student has not eaten all their food/carbohydrates, and insulin has already been administered, a nurse should not and does not need to ask a provider for orders to feed the student. The nurse should provide the student with food, or a beverage, which is comparable to the number of carbohydrates that were not consumed. Take the opportunity to provide education and help the student understand the relationship between carbohydrates and insulin and the importance of eating the number of carbohydrates that were covered by the units of insulin administered.

Q: Is it normal for a student to have a postprandial (after eating) BG rise even though the correct insulin dose was given?
A: Yes. Students with diabetes can have an elevated BG after they eat, even though the correct insulin dose was given. This may be due to many factors, such as the type of insulin used, the food that was eaten, and eating additional carbohydrates that were not counted when calculating the dose of insulin to cover the meal.

It is important for the school nurse to know the type of insulin that is being administered when it peaks and the acceptable BG range for the student. The school nurse should be following the student’s DMMP and healthcare provider orders.  

Q: What can a school nurse do if the insulin pump stops working?
A: The school nurse can check to see if the tubing is kinked and unkink the tubing, or if the pump battery is low or dead, replace it. The nurse can also check to make sure there is insulin present in the reservoir. See Clarification on Insulin Pumps regarding pump reservoirs. If the pump cannot be used, follow health care provider orders and notify the parent/guardian.

Q: If a student who has been diagnosed with type 1 diabetes does not have healthcare provider orders for school, should they be excluded from school?
A: No, a student should not be excluded from school if they do not have healthcare provider orders. The school nurse should contact the parent/guardian and request that the parent/guardian contact the healthcare provider for orders. The nurse may also contact the student’s healthcare provider directly to request school orders in which case the nurse must ensure that the parent/guardian provides written consent. If the student is present at school and does not have healthcare provider orders, the school administration must inform the parent/guardian that the nurse may not provide any care that requires a healthcare provider order, such as administering insulin, and if urgent care is required for the student, emergency medical services will be called. 

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