TOPICS:

Chapter 23

The School/
Work and
Diabetes

Monitoring
(checking blood
sugars/ketones,
giving insulin)
Prevent, Detect
and Treat Acute
Complications
Psychosocial
Adjustment

Susie Owen, RN, CDE

H. Peter Chase, MD

TEACHING OBJECTIVES:

INTRODUCTION

2. Identify supplies needed to

prevent acute complications at
school/work.

The first and main job of parents in relation to school is

to educate those who will be working with the child at
school about diabetes. Parents want to feel that their child is
in safe hands while at school (often the place where the
majority of the childs waking hours are spent). Parents also
want to make sure their child is not treated differently because
of having diabetes. The next few pages are meant to be cut out
or copied (permission is granted to copy as often as wished) for
the school. It is wise for the parent to phone the school nurse,
teacher or principal to discuss the best way to inform all of the
necessary people. The week before classes start is usually the
best time. A checklist is provided in Table 1 to remind parents
of their responsibilities. The school may want a School Intake
Interview (Table 2). There is also a letter at the back of this
chapter that may be helpful.

1. Assess who will educate

school/work personnel about
diabetes.

3. Develop a health action plan for

school/work.

LEARNING OBJECTIVES:
Learner (parents, child, relative or
self) will be able to:
1. Define who will educate
school/work personnel about
diabetes.
2. List all supplies needed at
school/work to prevent acute
complications.
3. Design a health action plan for
school/work with healthcare
provider(s).

Some parents in our area will buy or borrow a copy of one

of the videos (see Resources at the end of this chapter) on
diabetes and the school or on hypoglycemia and take it to show
the nurse, health aide, teachers and others likely to be involved
with their child. It can be a good starting place for a discussion
about hypoglycemia, the most likely emergency to occur at
school.

251

It is essential for the family to educate the:

teacher(s); including gym, art and music
school nurse
health aid

There is often a special anxiety about a

young child starting preschool.
This anxiety is due to a young child who:
may not yet be able to recognize low blood
sugars

bus driver
lunchroom workers
playground aides

may not be mature enough to help

remember snacks. The teacher will need to
remind the child or the child may wear a
watch with a preset alarm.

others involved with their child at school

Sometimes the school nurse or the teacher
will help educate other staff. It is also important
that when a substitute teacher is at school, the
substitute knows that a child in the classroom has
diabetes. A copy of your childs school care plan
should be placed in the substitute folder and in
the teachers attendance book. Attach a recent
photo of your child to the plan. It is important
NOT to leave it up to the child to inform and
educate the school. They may be self conscious
or embarrassed and not get the job done.
A second job of parents is to keep an
adequate supply of items at school for the
treatment of low blood sugars.
These might include:
instant glucose or cake decorating gel
glucose tablets
small cans of juice or juice boxes
Gatorade or a can of sugar pop (soda)
peanut butter or cheese and crackers and/or
graham crackers
quarters so the school staff can purchase
these items
These should be kept in a container in the
teachers, principals or nurses office. The
container should be clearly labeled with the
childs name and a set of instructions (with
contact phone numbers). They should be
readily available to the child at all times. They
shouldnt be locked in the young persons
locker. The child may not remember their own
locker combination if hypoglycemic.

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Chapter 23 The School/Work and Diabetes

might not have been away from the care of

the parents for any significant period of time
prior to starting preschool
Separation may be difficult for the parents
and the child. And yet, preschool may be
important for the child in learning social and
other skills. It is important to allow
participation just as one would if the child did
not have diabetes. The information at the end
of this chapter may be given to the preschool
teacher just as it is to regular schoolteachers.

SCHOOL HEALTH PLAN

Schools in most states now require a School
Health Plan. We have included a possible plan
in this chapter (Table 3). It would be
appropriate for all children and schools. You
have our permission to copy this form as often
as you wish. There is also a generic school
letter at the end of this chapter that may be of
help in introducing your childs diabetes to the
school. Also note that there is a letter for sports
coaches at the end of Chapter 13. Either of
these letters may be copied as often as desired.
Finally, directions for accessing a 504 health
care plan online are included in the legal
portion of this chapter.

BLOOD SUGAR TESTING IN

THE SCHOOL
All children must have at school:
a blood sugar (glucose) meter; it should
NOT be kept in the childs locker

 strips for the meter

a lancing device (finger poker)
At a minimum, a test must be done
whenever the child is feeling low. Some
physicians and parents ask that a test be done
routinely prior to lunch. Often children carry
their own meter in their backpack. This should
then be noted in the School Health Plan.
We prefer that the child be allowed to test
in the classroom. Less school is missed when
this is allowed. If the child is testing in the
classroom, an adult may need to look at the
result. The adult can determine if a low blood
sugar has occurred. The biggest disadvantage
of testing in the classroom is that the hands
cannot be washed first if there isnt a sink. A
trace of sugar on the finger can cause a high
reading. If alcohol is used to clean the finger,
be sure to let it dry completely before lancing.
It should be noted, if the child feels low and
no blood sugar equipment is available, TREAT
the low with a source of carbohydrate.

INSULIN IN THE SCHOOL

If insulin is to be given at school, the parent
and the childs physician must sign a school
medication form (see example). It must specify
when the insulin is to be given and the dose.
This physician order is usually mandatory in
order for the nurse to deliver a dose of insulin at
school. Some parents have difficulty when the
school nurse cant just accept a dose from them,
but it would be illegal for the nurse to do so.
Individual state laws often dictate how this dose
can be delivered. In some states, only a school
nurse, the child or the childs guardian may
administer the insulin. In others, the nurse or
principal may delegate this task to a layperson(s)
in the school setting. If a child is drawing up
the insulin and giving their own dose, it is a
good idea to have an adult check the amount.
On other occasions the parent may need to
come in and give the injection. If a layperson
will be responsible for the job, its important
that there be at least two people trained (in the

event one is absent). These delegates should be

recertified routinely and their names should be
recorded in the childs care plan. Insulin pens
are often a great tool for injections at school.
They are very convenient, more accurate and
leave less room for error when drawing up the
dose at school. Unfortunately insurance may
not cover their cost.

GLUCAGON IN THE
SCHOOL
As discussed in Chapter 6, glucagon is a
hormone with the opposite effect of insulin. It
raises the blood sugar, but it is not sugar.
Glucagon is used for emergencies when a
person becomes unconscious, has a seizure or is
unable to safely drink a liquid carbohydrate due
to a low blood sugar. The use of glucagon in
the school can be found in the Emergency
Response Plan (Table 4). Unfortunately, it
must be mixed with a liquid and it is then
injected just like insulin. It can be injected
under the skin into the subcutaneous fat (like
insulin) or deeper into muscle. It works just as
well either way. Some physicians, schools and
families work out a way that the glucagon can
be given at the school in case of an emergency.
(The physician must give orders for dose and
when to give it.) If the family lives in a rural
area, where emergency personnel are not
immediately available (we have heard of
responses taking as long as 40 minutes),
glucagon should be kept in the school. It may
have to be administered by a lay person, but
most parents are lay people, and they administer
glucagon. At least two people should be
trained. The school nurse must arrange for
routine recertification of these skills for the
school staff members assigned to do this task.
The instructions from Chapter 6 should be
taped to the box. Our 2001 video on
hypoglycemia (see Resources at the end of
this chapter) also teaches how to give
glucagon. You can also access a video and
written directions for training online at the
American Diabetes Associations website
(www.diabetes.org).
Chapter 23 The School/Work and Diabetes

253

LOW BLOOD SUGAR

(Insulin Reaction or
Hypoglycemia)
See the Emergency Response Plan (Table 4)
for the specific care for a given child.
This is the only emergency likely to occur at
school. The severity of the low blood sugar is
not determined by the glucose value but rather
by symptoms.
A. Onset: SUDDEN and, if not treated
promptly, can be an emergency.
B. Signs: Variable, but may be any of the
following:

hungry

sweating, shaking

pale or flushed face

headaches

weak, irritable or confused

speech and coordination changes

eyes appear glassy, dilated or big pupils

personality changes such as crying or

stubbornness

inattention, drowsiness or sleepiness at

unusual times

if not treated, loss of consciousness and/or

seizure

C. Most likely times to occur: Before lunch or

after gym class.
D. Causes: Too much insulin, extra exercise, a
missed snack or less food at a meal than is
usually eaten. Field days or field 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 can be
provided.
E. IF YOUR CHILD IS SENT TO THE
OFFICE, THEY MUST ALWAYS HAVE
SOMEONE ACCOMPANY HIM/HER.
The child may become confused and not
make it to the office if he/she is alone.

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Chapter 23 The School/Work and Diabetes

F. Treatment: This depends on the severity of

the reaction:
1. Mild Reaction (also see Table 4:
Emergency Response Plan)
Symptoms: Hunger, shaking, personality
changes, drowsiness, headache, paleness,
confusion or sweating.
Blood sugar: If equipment is available to
do a blood sugar test, this is ideal to do
even if treatment has been taken. We prefer
this to be done by the student (if old
enough) in the classroom so that extra
energy is not spent going elsewhere.
However, we realize that for some schools
this is not possible. It takes up to 20
minutes for the blood sugar to rise after the
carbs have been given. Doing the blood
sugar tests will help to tell if the blood sugar
was truly low and how low. A rapid fall in
blood sugar, even though the blood sugar is
in a normal range, may cause symptoms of
being low and require a solid food snack to
stop the symptoms.
Treatment: Give three or four glucose
tablets, or 4-6 oz or 1/2 cup of juice, or any
sugar-containing food or drink. Liquids are
absorbed in the stomach more rapidly than
are solid foods. Avoid use of high fat foods
as a first line of treatment. The higher the fat
content the slower the treatment will be
absorbed. INSULIN REACTIONS
TREATED WITH LIQUIDS
INITIALLY SHOULD BE FOLLOWED
IN 10-15 MINUTES WITH MORE
SUBSTANTIAL FOOD (e.g., cheese and
crackers or 1/2 sandwich, etc.).
2. Moderate Reaction
Symptoms: Combative behavior,
disorientation, lethargy.
Blood sugar: Do the same as in a Mild
Reaction (see above).
Treatment: Always check for the risk of
choking before treating. Elevate the childs
head. Give instant glucose or cake

decorating gel immediately, and then give

sugar or juice when the person is more alert.
After the person is feeling better (10-15
minutes), give solid food as above.
3. Severe Reaction
Symptoms: Seizure or unconsciousness
Treatment: CALL 911 IMMEDIATELY
Give glucagon subcutaneously or
intramuscularly. Check the School
Health Plan for the dose.
A checklist for the school nurse to follow
in developing the Individualized Health
Care Plan is shown in Table 5.

HIGH BLOOD
SUGAR/KETONES
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 300 mg/dl
(16.7 mmol/L), urine or blood ketones also
need to be checked. 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, a parent should be notified. The diabetes
care provider can then adjust the insulin dose.
The student may also occasionally need to
check ketones at school. This may be because
ketones were present earlier at home, because
the blood sugar is above 300 mg/dl (16.7
mmol/L) or because the child is not feeling
well. The parents should be notified if
moderate or large urine ketones (or a blood
ketone test shows > 0.6 mmol/L) are present,
as extra insulin will be needed. When a child
has moderate or large ketones, we recommend
that the child be treated by adults who can
provide constant supervision, usually at home.

CLASS PARTIES
If the class is having a special snack, the
child with diabetes should also be given a snack.
Parents should be notified 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.
If an alternate snack is not available, the
student should be given the same snack as the
other children.

BUS TRAVEL
It is important for the child with diabetes to
take some food with him/her on the bus. If
the child feels low, he/she must be allowed to
eat the food. At times, bus rides take longer
than usual due to bad weather or delays, and
the child needs to have a snack available and
permission from the bus driver to eat it if
necessary.
Chapter 23 The School/Work and Diabetes

255

SUBSTITUTE TEACHERS
Ask to have a copy of the School Health
Plan (Table 3) placed in the substitute teachers
folder and the attendance register so that a
substitute would know:
1. which child in the class has diabetes (attach a
photo)
2. when he/she usually eats a snack
3. symptoms and treatment of an insulin
reaction
4. where the treatment supplies are kept

GYM (PHYSICAL
EDUCATION) TEACHERS
AND COACHES
It is particularly important for the gym
teacher or coach to also have a copy of the
School Health Plan. Low blood sugars may
occur during exercise and a source of instant
sugar should be close. Often a snack is
recommended before gym. The child should
get the snack early enough to help them be on
time. Exercise is even more important for
children with diabetes than for other children.
They should not be excluded from gym or
sports activities. If the child is wearing an
insulin pump and disconnects during PE,
provision must be made for the pump to be
stored in a safe place.

afternoon insulins to be peaking. If a snack is

not taken, an insulin reaction is likely to occur.

SPECIAL DAYS (FIELD

TRIPS, FIELD DAYS)
Field trips or field days usually involve extra
excitement and exercise. Both of these can
result in an increased chance of low blood
sugars. The parents should ask to be notified
beforehand so that they can reduce the dose of
insulin. They may also wish to send extra
snacks (granola bars, fruit roll ups, etc). It is
important for parents to be aware that in the
public school system, the childs diabetes
should never be a cause for the school to
exclude him or her from any school sanctioned
activity, whether during or after regular school
hours. This includes overnight field trips and
band or sporting activities away from the
school. If the child would be allowed to
participate without diabetes the school must
accommodate the childs needs with diabetes.

INSULIN PUMPS IN THE

SCHOOL
More and more children are now using
insulin pumps. The pumps allow sugar control
to be more like that of a person who does not
have diabetes. Table 6 lists some of the special
issues of insulin pump use in the school. If
more information is desired, Chapter 26 deals
with insulin pumps.

AFTER SCHOOL
DETENTION

MEDICAL RELEASE

Children with diabetes should not be

singled out or treated differently from the rest
of the class. However, if required to remain
after school (at noon or in the afternoon) for a
longer time than usual, the teacher should be
asked to give an extra snack. Most parents will
have packets of cheese and crackers, peanut
butter and crackers or some such snack for the
teacher to keep in the drawer. This is a
common time of the day for the morning or

It is important for the parent or legal

guardian to give the school written
permission to contact the childs health care
provider. This may be necessary in the event
of an emergency. Without this medical
release in place, the doctor or care provider
may not discuss or give advice pertaining to
the childs care. An example of a medical
release may be found in the School Care
Plan (Table 2) later in this chapter.

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Chapter 23 The School/Work and Diabetes

LEGAL RIGHTS
Section 504 of the Rehabilitation Act of
1973 prohibits recipients of federal funds from
discriminating against people on the basis of a
disability (including diabetes). A formal
contractual health care plan outlining all
accommodations necessary to care for the child
with diabetes during school is known as a
504 plan. Putting this plan together usually
involves meetings between the parents, child,
school staff (nurse, teachers, principal, special
education facilitator) and diabetes health care
providers. The child is not only protected from
discrimination by this law during the school day
but on any school sanctioned activity as well.
In our experience, the parents and school staff
are usually able to agree on a School Health
Care Plan (Table 3). Formalizing the care
through a 504 plan is then not necessary.
However, in the rare case where it is necessary,
additional resources are provided below. A
child with diabetes has the right to a free and
appropriate public education including
accommodations to manage their diabetes at
school. The child may also need special
accommodations under the Individuals with
Disabilities Act (IDEA). This law protects
children who may be experiencing learning
difficulties due to their disability. In the case of
diabetes this may arise as a result of reoccurring
hypo or hyperglycemia impacting the ability to
learn or think clearly on exams. If the child
must leave the classroom frequently to test,
snack or inject and misses lesson time this may
also impact their ability to learn.
Accommodations in either of these cases must
be made to assist the child to learn. This may,
for example, mean making provision for the
child to test in the classroom so as not to miss
teaching time. It may also provide for the child
to test blood sugar before exams in order to
bring sugar levels to the appropriate target prior
to sitting for an exam. The plan outlining what
provisions must be made to assist the child to
learn is called an IEP (individualized education
plan). It will be put together through the
schools special education program in
conjunction with the parents, child and health

care providers. You can review these rights on

the ADA website, www.diabetes.org. The ADA
also has a brochure called Your School and
Your Rights.
Additional resources for parents who wish
to formalize the health care plan through a
Section 504 are listed here:
1. The Law, Schools and Your Child with
Diabetes at:
www.childrenwithdiabetes.com/
d_0q_000.htm (please note the underscore)
This website allows access to:
Your School and Your Rights, from the
American Diabetes Association, discusses
the legal obligations of school systems
under Section 504 of the Rehabilitation Act
of 1973 and the Education for All
Handicapped Children Act of 1975,
amended in 1991.
The National Information Center for
Children and Youth with Disabilities
(NICHCY) is a U.S. Governmentsponsored clearinghouse that provides
information about disabilities, including
information about obtaining assistance at
school.
2. The US Department of Education website
(www.ed.gov) includes:
The Individuals with Disabilities Education
Act, with detailed information about IDEA.
IDEA: The Law contains links to
downloadable versions of the law.
3. Helping the Student With Diabetes Succeed
(A Guide for School Personnel). This is a 76
page primer that can be downloaded from:
www.ndep.nih.gov.
4. How to Write an IEP, a book designed to
help parents who have children with
disabilities succeed in school.
5. www.childrenwithdiabetes.com/504
6. www.niddk.nih.gov and search for schools.
Chapter 23 The School/Work and Diabetes

257

QUESTIONS AND ANSWERS

FROM NEWSNOTES
My son recently had a cold and
small urine ketones when he woke
up. He felt good enough to go to
school and wanted to go. Was I wrong in
letting him do this?

As long as he felt well enough and

wanted to go, I think it was good that
you let him do so. At least he wanted
to go and must like school! You might have
sent one of the large plastic drinking cups with
a straw so that he would remember to drink
fluids to help wash away the ketones. Probably
a special note to the teacher explaining the
situation and the possible need for extra
bathroom privileges would be wise.
Finally, it would be important for a parent
(or the child, if old enough) or the
school nurse to make sure the urine
ketones were checked again at lunchtime
to make sure they went away and did not
increase to the moderate or large level.
Children with moderate or large urine ketones
or blood ketones > 0.6 mmol/L need to stay
home with adult supervision until the ketones
have gone down.

We have had difficulty

with our child getting
the care we request at
school of late. What are our
legal options?

The Individual
Disabilities Education Act
(IDEA) provides an opportunity for
the school to obtain extra funds for an aide to
help with an individualized education program
(IEP). Diabetes is listed as one of the covered
health conditions, but in order to obtain the
assistance the students diabetes must
adversely affect educational
performance so that the student
requires special education and/or
related services. An example is a
student who has trouble

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Chapter 23 The School/Work and Diabetes

concentrating because of recurring high or low

blood sugars that adversely affect the students
educational performance. Examples of
supplementary aides that might be requested
could be: help with administering insulin or
glucagon, providing assistance in doing blood
sugar checks and help in choosing snacks. The
school must apply for the grant through the
Office of Special Education Programs (OSEP)
in the Office of Special Education and
Rehabilitation Services (OSERS) in the U.S.
Department of Education.

Table 1

School Diabetes Management Checklist for Parents

_____

Discuss specific care of your child with the teachers, school nurse, bus driver, coaches and
other staff who will be involved.

_____

Complete the individualized school health care plan with the help of school staff and your
diabetes care staff (see Table 3 and Table 5 in this chapter).

_____

Make sure your child understands the details of who will help him/her with testing, shots
and treatment of high or low blood sugars at school and where supplies will be kept.
Supplies should be kept in a place where they are always available if needed.

_____

Make arrangements for the school to send home blood sugar records weekly.

_____

Keep current phone numbers where you can be reached. Collect equipment for school:
meter, strips and finger-poker, lancets, insulin, insulin
syringes or pen, biohazard container, log book or a
copy of testing record form, extra insulin
pump supplies, ketone testing strips, photo
for substitute teachers folder.

_____

Food and drinks; parents need to

check intermittently to make sure
supplies are not used up:
juice cans or boxes (approximately 15g
of carb each)
glucose tablets
instant glucose or cake decorating gel
crackers ( peanut butter and/or cheese)
quarters to buy sugar pop (soda) if needed
Fruit-Roll Ups
dried fruit
raisins or other snacks

_____

box with the childs name to store these food

and drink items

Chapter 23 The School/Work and Diabetes

259

Table 2

School Intake Interview/Careplan Diabetes

Student ______________________________________________________ Date of Birth ____________________
School _______________________________ Grade _____ Homeroom Teacher __________________________
Parent(s)/Guardian(s) __________________________________________________________________________
Phone (H) ____________________ (W) _______________________ (Other) _____________________________
Emergency contact (other than parent/guardian) ___________________________Phone __________________
Physician name______________________Office Phone _____________________ Fax ______________________
Diabetes Nurse Educators name _______________________________ Office Phone ______________________
Medical release of information signed? Yes ___ No ___
Mode of transportation to and from school?__________________ Bus driver notified of diabetes? Yes __ No __
Does child participate in after school activities? Yes __ No ___
Before ___ or after ___ care?
Explain _______________________________________________________________________________________
Adult leader notified of diabetes? Yes ___ No ___
Field trip recommendations: _____________________________________________________________________
Blood Sugar Monitoring:
Test will be performed in ____________________________ (location).
Needs assistance with testing? Yes ___No ___ Explain ________________________________________
Required test times ______________________________________________________________________
Call parent if blood sugar below _______ or above _______
Staff to record values and report to parents daily ____ weekly ____
Comments: ___________________________________________________________________________________
Meds: Insulin:
Can child give own injections/operate pump independently? Yes ___ No ___
Explain ________________________________________________________________________________
Order for insulin on file? Yes ___ No___
Time(s) insulin is to be administered at school: ______________________________________________
Type/Dosages: _________________________________________________________________________
Form of administration: _________________________________________________________________
(Injection, Pen, Pump)
Oral medications: Type _______________________Times _______________ Dose _______________
Comments: ___________________________________________________________________________________
Assigned student lunch time(s)? _____________________________
Is child following a prescribed meal plan? Yes___ No___ Assistance required? Yes ___ No___
Explain ________________________________________________________________________________
_______________________________________________________________________________________
Snack time(s)? __________________________________________ Assistance required? Yes ___ No ___
Explain ________________________________________________________________________________
Snack will be eaten in __________________________ (location)
Snacks will be stored in _________________________ (location)
Recommended snacks ___________________________________________________________________
Parent wishes to be notified in advance of class parties? Yes ___ No ___
Child may partake in class treats? Yes___ No ___ Explain _____________________________________
Comments: ___________________________________________________________________________________
Diet:

Physical Education:
Scheduled at: ________________
Is snack necessary before physical education?
Yes ___ No ___
Yes ___ No ___
Does child participate in after school sports?
P.E. Teacher/Coach aware of childs diabetes? Yes ___ No ___
Location pump to be stored when disconnected ___________________________
Comments: ___________________________________________________________________________________

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Chapter 23 The School/Work and Diabetes

Table 2 (continued)

Interventions For Emergency Situations

INTERVENTIONS FOR LOW BLOOD SUGAR
Hypoglycemia (Low blood sugar) Insulin Reaction (Must be accompanied to Health Office):
(Any blood sugar level below _____ constitutes a low blood sugar.)
If blood sugar cannot be obtained, treat based on symptoms? Yes ____ No ____
Mild reaction signs person might exhibit are:
hunger
irritability
shakiness
sleepiness
sweating
pallor
other ___________________________________________________________________________________
Person usually recognizes the symptoms? Yes _____ No _____
Time reactions most frequently occur? _______________________________________________________
Treat mild low blood sugar as follows:
____ glucose tabs
____ cup juice
____ cup regular pop (soda)
other: __________________________________________________________________________________
Person should_____ should not_____follow initial treatment with a snack of _______________________ in
________ minutes or once symptoms subside.
Moderate reaction signs person might exhibit are:
confusion
slurred speech
disoriented
sleepiness
change in personality
other ___________________________________________________________________________________
Treat moderate low blood sugars as follows:
___ tube glucose gel
___ tube cake decorating gel
___ cup juice
other: __________________________________________________________________________________
Person should _____ should not _____ follow with a snack of _________________________in_____ minutes
or once symptoms subside.
Severe reaction signs person might exhibit are:
unconscious episode
seizure
unable/unwilling to take gel or juice
For severe low blood sugar, treat as follows:
___ cc glucagon injection ( ____ units)
Call 911
Notify parents
Order for glucagon on file? Yes____ No____
Call parent in the event _______________________________________________________________________
Personnel trained to administer glucagon: 1) ________________________________________________________
2) ________________________________________________________

INTERVENTIONS FOR HIGH BLOOD SUGAR

Hyperglycemia:
A blood sugar above ______ will___may ___ require an insulin administration (see insulin dosages).
If blood sugar is greater than_______, test blood ketones ___ urine ketones___.
Child will____ will not ____ need supervision in testing ketones.
Notify parent if blood glucose is above _______ or when ketones are _________________
Comments: ____________________________________________________________________________________
____________________________________________________________________________________
Permission signatures:
As parent/guardian of the above named student, I give permission for use of this health plan in my students
school and for the school staff to contact the below providers regarding the above condition. Orders are valid
through the end of the current school year.
Parent Signature _______________________________________________________Date ____________________
Nurse Signature ________________________________________________________Date ____________________
Physician Signature _____________________________________________________Date ____________________
Chapter 23 The School/Work and Diabetes

261

Table 3

Individualized School Health Care Plan: Diabetes

Date: ___________ (Also see Emergency Response Plan)
Student __________________________________________________________Date of Birth _______________________
School ____________________________________________________ Grade ________ Teacher ___________________
Parent(s)/Guardian(s) ________________________________________________________________________________
Phone (H) ___________________________________ (W) _____________________ (Other) ______________________
Additional emergency contact information _______________________________________________________________
Diabetes Care Provider _____________________________ Phone ____________________ Fax ____________________
Diabetes Nurse Educator ___________________________ Phone ____________________ Fax ____________________
Hospital of choice ____________________________________________________________________________________
ROUTINE MANAGEMENT Target Blood Sugar Range ___________ to _____________
Required blood sugar testing at school:
Trained personnel must perform blood sugar test
Trained personnel must supervise blood sugar test
Student can perform testing independently

Times to do blood sugar:

Before lunch
After lunch
Before P.E.
After P.E.
As needed for signs/symptoms of low or high blood sugar
Call parent if values are below _______________ or above _______________

Medications to be given during school hours:

Oral diabetes medication(s)/dose _____________________ Time to be administered:_____________
To be administered immediately:
Sliding scale:
After lunch
Insulin (subcutaneous injection) using Humalog/NovoLog/Regular (circle type) Before lunch
____ Unit(s) if lunch blood sugar is between _____ and _____

____ Unit(s) if lunch blood sugar is between _____ and _____

____ Unit(s) if lunch blood sugar is between _____ and _____

____ Unit(s) if lunch blood sugar is between _____ and _____

Insulin/Carb Ratio ____ Unit for every ____ grams of carbohydrate eaten,
plus ____ unit(s) for every _____ mg/dl points above _____ mg/dl
Student can draw up and inject own insulin
Student cannot draw up own insulin but can give own injection
Trained adult will draw up and administer injection Student can draw up but needs adult to inject insulin
Student is on pump (attach Table 6 to these instructions) Student needs assistance checking insulin dosage
Glucagon (subcutaneous injection) dosage (see Table 2 in this chapter); dosage = __ cc
Diet:
Lunch time __________________ Scheduled P.E. time __________________ Recess time __________________
Snack time(s) __ a.m. ___p.m. Location that snacks are kept ______________Location eaten _____________________
Child needs assistance with prescribed meal plan (see attached). Parents/Guardian and student are responsible for
maintaining necessary supplies, snacks, testing kit, medications and equipment.
Field trip information:
1. Notify parent and school nurse in advance so proper training can be accomplished.
2. Adult staff must be trained and responsible for students needs on field trip.
3. Extra snacks, glucose monitoring kit, copy of health plan, glucose gel or other emergency supplies must
accompany student on field trip.
4. Adults accompanying student on a field trip will be notified on a need to know basis.
People trained for blood testing and response:
Name _______________________________________________________________________ Date __________________
Name _______________________________________________________________________ Date __________________
Permission signatures:
As parent/guardian of the above named student, I give permission for use of this health plan in my students school
and for the school staff to contact the below providers regarding the above condition. Orders are valid through the
end of the current school year.
Parent Signature _____________________________________________________________ Date ___________________
School Nurse Signature _______________________________________________________ Date ___________________
Physician Signature ___________________________________________________________ Date ___________________

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Table 4

Emergency Response Plan

Student Name ________________________________________ Grade/Teacher ___________________ Date ___________
Mild Low Blood Sugar:
(Student to be treated when blood sugar is below _______.)
Symptoms could include (please circle all that apply): hunger, irritability, shakiness, sleepiness, sweating, pallor,
uncooperative, crying or other behavioral changes. Additional student symptoms: ___________________________________
Treatment of Mild Low Blood Sugar: With any level of low blood sugar never leave the student unattended. If treated
outside the classroom, a responsible person should accompany to the health clinic or office for further assistance.
Test blood sugar. If kit is not available, treat child immediately for low blood sugar.
If blood sugar is between _____ and _____ and lunch is available, escort to lunch and have child eat immediately! If
lunch is unavailable, treat immediately as listed below.
If blood sugar is below _____, give 4 oz of juice or 6 oz (1/2 can) of regular sugar pop (soda) or 2-3 glucose tablets.
Wait 10-15 minutes. Re-check blood sugar. Re-treat as above if still below _________.
Follow with snack or lunch when blood sugar rises above _______ or when symptoms improve.
Notify _____ school nurse _____ and parent.
Comments: ______________________________________________________________________________________________
Moderate Low Blood Sugar:
Symptoms: In addition to those listed above for a mild low blood sugar, student may be combative, disoriented or incoherent.
Treatment of Moderate Low Blood Sugar:
If student is conscious yet unable to effectively drink the fluids offered:

Administer 3/4 to 1 tube (3 tsp) of glucose gel, or 3/4 to 1 tube of cake decorating gel.
Place between cheek and gum with head elevated. Encourage student to swallow. May be uncooperative.
Call _____ parent and ______school nurse.
Re-test in 10-15 minutes. If still below ______, re-treat as above.
Give regular snack after 10-15 minutes, when blood sugar rises above_____ or when symptoms improve.
Comments: ______________________________________________________________________________________________
Severe Low Blood Sugar:
Student symptoms include: seizures or loss of consciousness, unable/unwilling to take gel or juice

Stay with student

Appoint someone to call 911

Roll student on side

Protect from injury

Do not put anything in mouth

Give glucagon subcutaneously; dose = _______ cc (can use an insulin syringe to administer if needed: number of units of
glucagon = _______ units)
Comments: ______________________________________________________________________________________________
High Blood Sugar: This student needs to be treated when blood sugar is above ______. Call parent or guardian when
blood sugar is greater than ________.
Symptoms could include: extreme thirst, headache, abdominal pain, nausea, increased urination
Additional student symptoms: _______________________________________________________________________________
Treatment of High Blood Sugar:
Drink 8-16 oz of water or sugar-free fluids every hour
Use restroom as often as needed

Be allowed to carry water bottle with them

Check urine ketones ____or blood ketones ____if sugar is greater than _______ or when ill. If urine ketones are moderate
to large, or if blood ketones are greater than 0.6 mmol/L, call parent immediately! Do not allow exercise.
Administer insulin if ordered. If student is on an insulin pump, see pump addendum.
If student exhibits nausea, vomiting, stomachache or is lethargic, notify ___ school staff and ___ parent contact ASAP. Send
student back to class if none of the above physical symptoms are present.
Signatures:
Parent: _______________________________________________Physician: __________________________________________
Nurse: _______________________________________________School Principal: ____________________________________
Phone: _______________________________________________Fax: _______________________________________________

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Table 5

Individualized Health Care Plan Check List for the School Nurse
STUDENT: __________________________________________________________ D.O.B.: _____________________
STUDENT #: ________________ SCHOOL: _________________________________ DATE: __________________
1. Enter completion date and initial each step listed below.
2. File completed checklist in the students health file.
Date and Initial
___________1. Health Care Plan developed with _______________________ and ___________________________
parent or guardian
area nurse consultant
___________2. Physician signature needed: _____ is not needed: _____
___________3. Send home original Health Care Plan and memo from nurse consultant:
with student: ______ by mail: ______ by email: ______ for parent signature
___________4. School staff information and copy of Health Care Plan to the following:
Clinic aide

_______

Secretaries

_______

Classroom teacher(s) _______

Admin.

_______

P.E.

_______

Art

_______

Music

_______

Cafeteria

_______

Transportation

_______

Others: _____________________________________________________________________________
List Names
___________5. Copies of signed plan in

________ Clinic Health Care Plan Book

________ Substitute Folder
________ With student information/emergency page

___________6. Original plan with signatures in health file

___________7. Classroom presentation requested: __ No __ Yes __ Who requested: ________________________
___________8. Inservice: ___ No ___ Yes Who requested: ______________________________________________
___________9. Training/delegation needed: ___ No ___ Yes ___
Procedure: #1________________________________________________________________________
Staff: Name: _______________________________Position: ________________ Date: ___________
Staff: Name: _______________________________Position: ________________ Date: ___________
Staff: Name: _______________________________Position: ________________ Date: ___________
Procedure: #2________________________________________________________________________
Staff: Name: _______________________________Position: ________________ Date: ___________
Staff: Name: _______________________________Position: ________________ Date: ___________
Staff: Name: _______________________________Position: ________________ Date: ___________

ALL HEALTH CARE PLANS ARE CONFIDENTIAL

(Information to be shared on a need to know basis only!)

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Table 6

Insulin Pumps in the School Setting

__________________________________ is a
student in your school who has diabetes and is
wearing an insulin pump. An insulin pump is a
device that provides small amounts of fast-acting
insulin (basal) every few minutes through a
small catheter under the skin. The student then
takes an additional amount of insulin doses
(boluses) through the pump for meals and
snacks. We would like to emphasize that
problems and complications with insulin pumps
are seldom seen. For the most part, you will not
be aware that the student is using the pump,
although you may hear an occasional quiet beep
when insulin is taken for a meal or a snack. The
following information may assist you in helping
the student wearing an insulin pump.

Low and High Blood Sugars

These occur with the students receiving
insulin pump therapy just as they do with
children receiving insulin shots. They are
handled similarly, and this should be outlined in
the specific students Emergency Response Plan
(Table 4). If a severe low did occur in a person
using a pump, it is important for the school
personnel to know how to disconnect the plastic
tube from the pump to the persons insertion
under the skin.
High blood sugars with moderate to large
urine or blood ketones (levels > 0.6) will
necessitate administration of an injection of
rapid-acting insulin with a syringe immediately.
The student may need to perform a change of
infusion set at school. Provision must be made
for this in the childs school care plan.

Basal and Bolus Insulin Pump

Dosages
Insulin pumps give a constant basal dose of
insulin that is set by the doctor and family. The
school personnel will not be involved with the
basal settings. A bolus insulin dose is given
before or after food intake. It may require
assistance from the school staff to help to
calculate the bolus dose. Some children need
help from the school staff in remembering to
administer their bolus dose, particularly at

lunch. Missing bolus dosages of insulin is the

main reason for poor diabetes control (high
blood sugars) in people who use pumps.

Calculating the Bolus Dose

This is usually done by counting grams of
carbohydrate and giving a unit of insulin for a
certain number of grams of carbohydrate (carb).
The latest smart pumps allow the entry of this
carb value into the pump which then calculates the
appropriate dose based on pre-programmed ratios.
In addition, a correction bolus to bring the
blood sugar into the desired range is often added
to the above dose. This is based on sensitivity
(how much one unit of insulin lowers blood
sugar) and the desired target glucose level. Both
of these parameters are pre-programmed into the
pump. An entry of a current blood glucose value
into the pump will trigger the pump to
automatically calculate the appropriate
recommended dose of insulin based on what
parameters were programmed. The wearer must
activate the pump to deliver these dosages.

Exercise
During times of vigorous exercise, the
student may need to disconnect the pump. For
this, the student needs to place the pump in a
safe place where it will not be damaged. During
prolonged exercise, many students reconnect the
pump periodically and take insulin. Some
students wear their pump during exercise and use
a special case to protect it.

Alarms
Pumps are programmed to alarm under
various circumstances, e.g., low battery, no
insulin delivery, out of insulin, etc. This is
discussed in detail in Chapter 26. There is also a
1-800 number on the back of all pumps to call
for assistance.
There is an entire chapter (Chapter 26) in
this book about insulin pumps. This may be
helpful for school personnel wanting more
information.
Chapter 23 The School/Work and Diabetes

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RESOURCES
Three videos parents often take to show the
school personnel are:
1. Managing and Preventing Diabetic
Hypoglycemia. This video, made in 2001, is
available from the Childrens Diabetes
Foundation. Call for prices at 303-863-1200
or 1-800-695-2873. Credit cards may be
taken by phone. Their address is: Childrens
Diabetes Foundation at Denver, 777 Grant
Street, Suite 302, Denver, CO 80203.
2. The Care of Children With Diabetes in Child
Care and School Settings. (This comes as two
tapes with the skills part sold separately for
approximately $198.00 or both tapes for
$279.00.) The address is: Managed Designs,
Inc., P.O. Box 3067, Lawrence, KS 66046,
Phone: 785-842-9088, Fax: 785-842-6881.

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Chapter 23 The School/Work and Diabetes

3. Living With Diabetes: Tips for Teachers is a

19-minute video tape available from
Maxishare. Call for prices. Their address is:
Maxishare, P.O. Box 2041, Milwaukee, WI
53201. Phone: 1-800-444-7747, Fax:
414-266-3443. A customer service
representative for Maxishare can be
contacted at 414-266-3428. Hospitals can
pay for this video with purchase orders and
individuals can pre-pay with a check or
credit card. Some clinics have copies of
these videos that can be loaned to parents to
take to their school.
4. Diabetes in the School; Students at Risk.
South Florida Association of Diabetes
Educators, P.O. Box 770236, Coral Springs,
FL, 33077-0236.

Attention: Principal

Date: _______________________

Attention: School Nurse

Dear Principal and School Nurse,

___________________________ is a _________ year old with type 1/type 2 diabetes who will be attending
school at ____________________________________________ this year.

Children with diabetes need to test their blood sugars by poking a finger and placing the blood on a strip in
a meter that then gives a number. The blood sugar tests are often done at school prior to lunch and must be
done if the child is having a possible low blood sugar. These children may take insulin by injection, by an
insulin pump or may take oral diabetes medication (type 2 diabetes) to control their blood sugar.

Children with diabetes can participate in all activities without restrictions, but they may need extra snacks
to prevent low blood sugars before or during P.E. or other activities.

Children with diabetes may not feel well if they have low or high blood sugar. A child with a high blood
sugar may require increased water intake and access to restroom facilities without embarrassing
restrictions. Please refer to the School Health Care Plan for details.

If you or your staff have any questions, you may contact one of our nursing staff at
________________________________.

Sincerely,

_______________________________________

_______________________________________

Physician

Nursing Case Manager

_______________________________________
Parent

Chapter 23 The School/Work and Diabetes

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12:43

Off to school!

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