Diabetes Care Tasks at School:

1
Diabetes Care Tasks at School What Key
Personnel Need to Know
DIABETES BASICS
2
Overall Goal Optimal Student Health and Learning
Hypoglycemia Hyperglycemia
Monitoring Blood Glucose
Ketones
Health Learning
Legal Rights
Glucagon Administration
Exercise
Insulin Regimen
Nutrition
3
Learning Objectives

• Participants will learn
• What is diabetes?
• Why care at school is required
• Basic components of diabetes care at school
• Short and long term consequences of diabetes

4
What is Diabetes?

• Body does not make or properly use insulin
• no insulin production
• insufficient insulin production
• resistance to insulins effects
• No insulin to move glucose from blood into cells
  
• high blood glucose means
• fuel loss cells starve
• short and long-term complications

5
Type 1 Diabetes

• auto immune disorder
• insulin-producing cells destroyed

• daily insulin replacement necessary

• age of onset usually childhood, young adulthood

• most prevalent type of diabetes in children and
  adolescents

6
Type 1 Diabetes
ONSET
relatively quick
increased thirst hunger blurred vision

• increased urination
• tiredness
• weight loss

• SYMPTOMS

uncertain, likely both genetic and environmental
factors
CAUSE
7
Type 2 Diabetes

• Insulin resistance first step
• Age at onset

• Most common in adults
• Increasingly common in children

• overweight
• inactivity

8
Type 2 Diabetes
in children variable timeframe
ONSET
tired, thirsty, hunger, increased urination
SYMPTOMS

• some children show no symptoms at diagnosis

9
Diabetes is Managed,But it Does Not Go Away.

• GOAL

To maintain target blood glucose
10
Diabetes Management 24/7

• Constant Juggling
• Insulin/medication
• with
• Exercise
• Food intake

BG
BG

BG
11
Diabetes Management

• Proactive

• keep juggling the balls

Reactive

• a response is indicated
• corrective actions for highs or low
• emergency intervention

12
Assistance in Diabetes Management

• Routine Care
• Many students will be able to handle all or
  almost all routine diabetes care by themselves
• Some students, because of age, developmental
  level, or inexperience, will need help from
  school staff.
• Urgent Care
• Any student with diabetes may need help with
  emergency medical care.

13
Care in the Schools School Nurses and Others

• Nurse most appropriate to
• Supervise diabetes care
• Provide direct care (when available)
• However, a nurse is not always available.
• Non-medical school staff can be trained to assist
  students
• For both routine and emergency care
• Including insulin and glucagon injections

14
Diabetes Medical Management Plan

• A Diabetes Medical Management Plan (PLAN) should
  be implemented for every student with diabetes.
• PLAN is
• developed by the students personal health care
  team and family and signed by a member of
  students personal health care team
• implemented collaboratively by the school
  diabetes team, including
• school nurse
• the student
• parents/guardians
• other school personnel

15
Elements of a PLAN

• Date of diagnosis
• Emergency contact information
• Students ability to perform self-management
  tasks at school
• List of diabetes equipment and supplies
• Specific medical orders for blood glucose
  monitoring, insulin, glucagon, and other
  medications to be given at school
• Meal and snack plan
• Exercise requirements
• Actions to be taken in response to hypoglycemia
  and
  hyperglycemia

16
Quick Reference Plan

• Development based on information from students
  PLAN
• Summarizes how to recognize and treat
  hypoglycemia and hyperglycemia
• Distribute to all personnel who have
  responsibility for students with diabetes

17
Where to Get More Information

• American Diabetes Association
• 1-800- DIABETES
• www.diabetes.org
• National Diabetes Education Program/NIH
• www.ndep.nih.gov

18
Diabetes Care Tasks at School What Key
Personnel Need to Know
HYPOGLYCEMIA AND HYPERGLYCEMIA
19
Learning Objectives

• Participants will learn
• Symptoms of high and low blood glucose
• Short- and long-term risks
• Treatment of high and low blood glucose
• Prevention of high and low blood glucose

20
Vocabulary
Glucose--a simple sugar found in the blood. the
fuel that all body cells need
to function
HYPOglycemia--a LOW level of glucose in the blood.
Quick-acting glucose--foods containing simple
sugar that raise
blood glucose levels
Glucose tablets or gel--special products that
deliver a pre-measured amount of pure glucose.
Glucagon--a hormone given by injection that
raises the level of glucose
in the blood.
Carbohydrate--source of energy for the body.
21
HYPOglycemia LOW sugar

• Onset
• sudden,
• may progress to unconsciousness if not treated
• can result in brain damage or death
• The PLAN should specify signs and action steps
  each level of severity
• mild
• moderate
• severe

22
HypoglycemiaRisks Complications

• Greatest immediate danger
• Not always preventable
• Impairs cognitive and motor functioning
• Early recognition and intervention can prevent an
  emergency

23
Hypoglycemia Possible Causes

• Too much insulin
• Too little food
• Extra physical activity

24
Hypoglycemia Signs Symptoms
25
Mild Hypoglycemia What to do

• Intervene promptly. Follow PLAN.
• Verify with blood glucose test when available.
• When in doubt, always treat. If no meter is
  available, treat immediately.
• Have student eat or drink fast acting carbs (15g)
• Test blood glucose 10-15 minutes after treatment
• Repeat treatment if blood glucose level remains
  low or if symptoms persist per PLAN
• If symptoms continue, call parents per PLAN

26
QUICK ACTING GLUCOSE

• Treatment for Lows 15 g Carbohydrate
• 4 oz. fruit juice
• 15 gm glucose tablets (2-3 tablets)
• 1 tube of glucose gel
• 1-2 tablespoons of honey
• 6 oz. regular (not diet) soda (about half a can)

27
Severe Hypoglycemia

• Rare, but life threatening, if not treated
  promptly
• Place student on his or her side
• Inject glucagon, per students PLAN
• Never attempt to put anything in the students
  mouth
• Call 911, then parent/guardian
• Student should respond in 15 to 20 minutes
• Remain with the student until help arrives

28
Hypoglycemia Prevention

• Keep a quick-acting sugar source with the
  student. ALWAYS.
• Treat at onset of symptoms
• Eat, Insulin, Test, Exercise ON TIME.
• Ensure reliable insulin dosing, per PLAN.
• Ensure insulin dosing matches food eaten.
• Watch picky eaters
• Provide nutritional information to families

29
Hypoglycemia Prevention

• Consult with parent/guardian when snack, meal or
  exercise times must be changed.
• Monitor blood-glucose variations on gym days, an
  extra snack may be required ½ hour before gym or
  during prolonged vigorous exercise per PLAN.
• A student should never be unattended when a low
  blood glucose is suspected.

30
Vocabulary

• Hyperglycemia too high a level of glucose in the
  blood.
• 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 that can lead to serious
  illness and coma.
• Ketone testing a procedure for measuring the
  level of ketones in the urine or blood.

31
HYPERglycemia HIGH Sugar

• Too much sugar in the blood, but cells are
  starving
• 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)
• PLAN should specify signs and action steps at
  each level of severity
• Mild
• Moderate
• Severe

32
Hyperglycemia Risks Complications

• Hyperglycemia due to inadequate insulin can lead
  to DKA and/or coma or death (mainly in type 1).
• Interferes with a students ability to learn and
  participate.
• Serious complications develop when glucose levels
  remain above target range over time or are
  recurring.

33
Hyperglycemia Possible Causes

• Too little insulin
• Expired insulin
• Food not covered by insulin
• Decreased physical activity
• Illness, injury
• Stress
• Other hormones
• Menstrual periods
• Any combination of the above

34
Hyperglycemia Possible Signs Symptoms
Severe Symptoms Severe Symptoms
Labored breathing Confused Labored breathing Confused
Very weak Unconscious Very weak Unconscious

Moderate Symptoms Moderate Symptoms











Dry mouth Vomiting
Stomach cramps Nausea
Mild Symptoms
Lack of concentration Thirst
Frequent urination Blurred vision
Flushing of skin Increased hunger
Sweet, fruity breath Weight loss
Fatigue/sleepiness Stomach pains
35
Hyperglycemia What to do

• Goal lower the blood glucose to a target range.
  
• Follow PLAN

• Verify with blood glucose test.
• Check ketones per PLAN.
• Allow free use of bathroom and access to water.
• Administer insulin per Recheck blood glucose per
  PLAN.
• Call parents per PLAN.

36
Hyperglycemia Prevention

• Eat, Insulin, Test, Exercise ON TIME.
• Reliable insulin dosing, per PLAN.
• Ensure that food eaten matches insulin dosing
• Monitor food intake per PLAN
• Report binge eating
• Teachers consult parent/guardian prior to extra
  snacks.
• Consult with parent/guardian when snack, meal, or
  exercise times must be changed.

37
Hyperglycemia Prevention

• Take appropriate action if a missed dose is
  suspected or if an insulin pump malfunctions.
• Avoid over treating low blood sugar reactions.
• Respect the students realize their limits

38
Practical Implications for Educators

• Students with hyperglycemia or hypoglycemia often
  do not concentrate well.
• During academic testing
• Check blood glucose before and during testing,
  per educational plan.
• Access to food/drink and restroom.
• If a serious high or low blood glucose episode
  occurs, students should be excused with an
  opportunity for retake.

39
Practical Implications for Educators

• Students should have adequate time for taking
  medication, checking blood glucose, and eating.
• Make the right choice the easy choice by
  eliminating barriers to
• snacking
• blood glucose testing
• access to water and bathrooms
• Avoid making judgments based on individual blood
  glucose readings.

40
Diabetes Care Tasks at School What Key
Personnel Need to Know
BLOOD GLUCOSE MONITORING
41
Learning Objectives

• Participants will learn

• Why blood glucose is monitored
• When blood glucose should be monitored
• How to perform a blood glucose check

42
Blood Glucose Monitoring
GOAL

• maintain blood glucose within target range.

IMMEDIATE BENEFIT
maximize learning and participation. prevention
of lows and highs.
LONG-TERM BENEFIT
decrease risk of long-term complications
maximize health.
CHALLENGE
many variables can impact blood-glucose.
43
Role of the School

• Facilitate blood glucose monitoring per PLAN
• Act on blood glucose check results per PLAN
• Provide monitoring data to parent/guardian

44
Benefits of School Blood Glucose Monitoring

• Enables maintenance of blood glucose levels
  within target range for safety promotes long
  term health and optimal academic performance
• Identifies factors that affect blood glucose

45
Any Time, Any Place Monitoring
For students who can self-check

• better blood glucose control
• safer for student
• student gains independence
• less stigma
• less time out of class.

46
Basic Steps

• Know the target range per PLAN
• Check at times specified in PLAN
• Immediate Action Treatment to get back within
  target range

47
When to Check?

• PLAN specifies for an individual student
• Regularly scheduled checks
• Routine monitoring before meals and snacks
• Before, during and/or after exercise

48
When to Check?

• Extra checks may be necessary
• Periods of stress or illness
• Hypoglycemia or hyperglycemia symptoms
• Change in diabetes management
• Insulin/medication doses
• Meal plan
• Activity

49
Lancing Devices
Lancets
Pen-type Lancing Devices
50
Know the Meter

• Features vary
• Ease of use
• Sample size needed
• Wait time
• Alternate-site testing capacity
• Ability to reapply, if insufficient sample
• Become familiar with the operation of each
  students meter

51
Preparation

• 1. Gather blood glucose monitoring supplies
  -Lancet
• -Test strips
• -Meter
• 2. Wash hands.

3. If assisting or performing for student, put
on disposable gloves.
52
Readying the Meter

• 4. Turn the meter on
• 5. Check code
• 6. Insert a strip into the meter

53
Lancing the Finger

• 7. Hold the lancet device to the side of the
  finger and press the button to stick the finger.

54
Applying Blood to Strip
8. Follow instructions included with the meter
when applying blood to strip
Cover ALL of test strip window
Some strips suck blood onto the strip
Drop, not smear
55
Results
9. Wait until blood glucose results
displayed. 10. Dispose of lancet 11. Record
blood glucose results, take action per PLAN.
56
What does the display mean?

• Check manual
• Contact manufacturer (1-800 Website)

57
What does the number mean?

• Reference students target range
• Individualized for student
• May vary throughout day
• Take action per PLAN
• Communicate sensitively

58
INSULIN ADMINISTRATION
59

Learning Objectives

• Participants will learn
• Types of insulin
• Insulin delivery basics
• Vial and syringe administration
• Pen device administration
• Pump basics

60
Insulin in Schools Today

• Many students need to take insulin in school
• Insulin regimens vary
• Need for assistance will vary.
• GOAL Maintenance of blood glucose target range

61
Insulin Types

• Rapid-acting Humalog , Novolog
• Short-acting - Regular
• Intermediate - Lente, NPH
• Long-acting - Ultralente,
• Glargine
  (Lantus)
• Storage
• Refrigeration or store at room temperature as
  specified by PLAN.

62
Delivery Methods

• Insulin Syringe
• Insulin Pen
• Insulin Pump
• Jet Injector

63
When to Give Insulin

• Administer as specified by PLAN
• Generally
• Before meals
• For blood glucose levels significantly above
  target range
• For increased ketones

64
Dosing

• For many students, insulin dose varies, depending
  upon
• Blood glucose readings
• Food availability/preference
• Physical activity level
• Age/body weight
• Follow prescribed guideline in PLAN.

65
Dosage Specifications

• PLAN should specify conditions clearly.
• Dosage based upon insulin to carbohydrate ratios
  for meals and snacks
• Correction dosage to treat hyperglycemia

66
Insulin Syringes

• Sizes 30, 50, 100 units
• Disposal-

67
Syringe Vial Preparation

• 1. Get Supplies
• Insulin (Verify)
• Syringe
• Alcohol wipe
• Disposable gloves
• Sharps container

68
Syringe Vial Preparation

• 2. Wash hands apply gloves
• 3. Clean the insulin vial

69
Syringe Vial Preparation

• 4. Have student select injection site.
• 5. Clean the injection site

70
Syringe Vial Preparation

• 6. Check the insulin dose
• 7. Remove the cap from syringe.

71
Syringe Vial Dosing

• 8. Pull the plunger down to number of units to be
  administered.
• 9. Inject air into bottle.

72
Syringe Vial Dosing

• 10. Draw out prescribed number of units of
  insulin as per PLAN.

73
Syringe Vial Injecting

• 11. Pinch up the skin.
• 12. Push needle into skin at 90?.
• 13. Release pinch.
• 14. Push the plunger in.
• 15. Count to 5.
• 16. Remove needle and dispose of syringe.

74
Insulin Pen Devices

• Prefilled pens
• Reusable (cartridge) pens
• Techniques for dose preparation and insulin
  delivery are similar for both types of pen
  devices.

75
Insulin Pen Preparation

• 1. Gather supplies. Verify insulin type.
• pen device (with cartridge)
• pen needle
• alcohol wipe
• sharps container
• 2. Wash hands.
• 3. Chose injection site
• 4. Clean injection site
• 5. Screw on pen needle

76
Insulin Pen Dosing

• 6. Prime Dial 2 units.
• 7. Remove air by pressing the plunger. Repeat
  Prime if no insulin shows.
• 8. Dial number of units to be administered as per
  PLAN.

77
Insulin Pen Injecting
9. Pinch up the skin. 10. Push the needle into
the skin at 90? 11. Release pinched skin. 12.
Push down on the plunger. 13. Count to 5. 14.
Remove and dispose of pen needle.
78
Insulin Pump Therapy

• Based on what body does naturally
• Small amounts of insulin all the time
• (basal insulin)
• Extra doses to cover each meal or snack
• (bolus insulin)
• Rapid or Short-Acting Insulin
• Precision, micro-drop insulin delivery
• Flexibility

79
What is an Insulin Pump?

• Battery operated device about the size of a pager
• Reservoir filled with insulin
• Computer chip with user control of insulin
  delivery
• Worn 24 hours per day
• Delivers one type of insulin

80
Sampling of Pumps
81
Insulin Pump Manufacturers

• Disetronic Medical Systems, Inc.
  1-800-280-7801 www.disetronic-usa.com
• Deltec Cosmo
• 1-800-826-9703
• www.deltec.com

• Animas Corporation
• 1-877-YES-PUMP (937-7867)
• www.animascorp.com
• Medtronic MiniMed, Inc.1-800-MINIMED
  (646-4633)www.minimed.com

82
Pump Supplies at School

• Infusion set
• Reservoir
• Insulin
• Skin prep items
• Alcohol wipes
• Syringe (in case of malfunction)
• Pump batteries
• Inserter (if used)
• Manufacturers manual, alarm card

83
After Giving Insulin

• Check site for leakage
• Correction doses
• Retest per PLAN
• Meal/snack doses
• Timeliness
• Supervision of food amount per PLAN

84
KETONE MONITORING
85
Learning Objectives

• Participants will learn
• What ketones are
• Why ketones are monitored
• When ketones should be monitored
• How to perform a ketone test
• When to contact parent/guardian or students
  health care provider

86
Why test for ketones?

• Ketones(acids) can build up and result in
  diabetic ketoacidosis (DKA).
• What is DKA?
• Acids that build up in body and cause student to
  feel ill
• Emergency state, can lead to coma, death.
• Common symptoms include fruity odor to breath,
  nausea, vomiting, drowsiness
• Number one reason for hospitalizing children with
  diabetes
• Early detection and treatment of ketones prevents
  hospitalizations

87
How to test urine ketones

• 1. Gather supplies
• 2. Student urinates in clean cup
• 3. Put on gloves, if performed by someone other
  than student
• 4. Dip the ketone test strip in the cup
  containing urine.
• 5. Wait 15 - 60 seconds
• 6. Read results at designated time
• 7. Record results, take action per PLAN

88
Test Results Color code

• no ketones
• trace
• small
• moderate
• large ketones present

89
Treatment of Ketones
PLAN specifies for an individual student.
Generally

• free use of bathroom
• sugar-free liquids
• insulin as per PLAN
• no physical activity
• if vomiting or lethargic, call parents

90

• GLUCAGON ADMINISTRATION

91

Learning Objectives

• Participants will learn
• What glucagon is
• How glucagon should be stored
• When glucagon is used
• How to administer glucagon

92
What is Glucagon?

• Naturally occurring hormone made in the pancreas
• A life-saving, injectable hormone that raises
  blood glucose level
• Treatment for severe hypoglycemia
• Can save a life
• Cannot harm a student

93
Glucagon Kit Storage

• Place As designated in PLAN.
• Store at room temperature
• Expiration date Monitor
• After mixing, dispose of any unused portion.

94
Emergency Kit Contents

• 1 mg of freeze-dried glucagon (Vial)
• 1 ml of water for reconstitution (Syringe)

Combine immediately before use
95
When to Give Glucagon

• If authorized by the students PLAN and if
  student exhibits
• Unconsciousness, unresponsiveness
• Convulsions or seizures
• Inability to safely eat or drink

96
Procedure Act Immediately

• Position student safely on side for comfort and
  protection from injury
• Call 911, parents, school nurse as per PLAN

97
Preparation

• 1. Flip cap off glass vial containing dry powder
• 2. Remove cap from syringe

98
Mixing Solution

• 3. Inject entire fluid in syringe into the bottle
  containing powder
• 4. Shake gently or roll to mix until all powder
  is dissolved and solution is clear.

99
Drawing out

• 5. Inspect. Solution should be clear and
  colorless.
• 6. Draw prescribed amount of glucagon back into
  syringe.

100
Dosing Injecting

• 7. Clean site if possible
• 8. Inject at 90 into the tissue under cleansed
  area, using the same technique as an insulin
  injection (however, needle is much larger than
  insulin syringe needle)
• buttocks
• thigh
• arm

101
After Injecting

1. May take 15-20 minutes for student to regain
   consciousness.
2. Check blood sugar.
3. Give sips of fruit juice or regular soda, once
   student is awake and able to drink.
4. Advance diet as tolerated.
5. Document as per PLAN

102
Don't be surprised if. . .

• Student does not remember being unconscious,
  incoherent or has a headache
• Blood sugar becomes very high (over 200)
• Nausea or vomiting occurs

103
NUTRITION AND EXERCISE
104
Learning Objectives

• Participants will learn
• Basic meal plans for students with diabetes
• Nutrition calculation methods
• Exercise benefits for students with diabetes
• Exercise guidelines for students with diabetes

105
Nutrition Why be concerned?

• Good nutrition is important for everyone
• Nutrition planning is essential for good diabetes
  control
• maintain blood-glucose within target range
• to prevent or delay complications
• to help children and teens grow and develop
  properly

106
School Nutrition Management

• Students family and health care team determine
  an individualized meal plan
• Meals snacks need to be carefully timed to
  balance exercise and insulin/medications
• Encourage healthy eating for all students

107
Basic Meal Plans

• Key Balance insulin/medications
• with carbohydrate intake
• Most students have flexibility in WHAT to eat.
• Exchange System
• Basic Carbohydrate Counting
• Advanced Carbohydrate Counting
• Many students have flexibility in WHEN to eat.
• More precise insulin delivery (pumps, pens)
• New insulins

108
Basic Carbohydrate Counting

• Calories from
• carbohydrate
• protein
• fat
• Each nutrient type affects blood sugar
  differently.
• Carbohydrate has the biggest effect on blood
  sugar.
• TOTAL carbohydrate matters more than the source
  (sugar or starch.)

109
Advanced Carbohydrate Counting
USING THE INSULIN-TO-CARB RATIO

• The insulin-to-carb ratio
• Varies from student to student.
• Is determined by the students health care team
• Should be included in the PLAN

110
School Meals Snacks

• Provide school menus and nutrition information to
  student/family in advance
• Provide sufficient time for eating
• Monitor actual food intake per PLAN
• young, or newly diagnosed
• picky eaters
• Respect, encourage independence

111
Beyond the Routine School Parties

• Provide parent/guardian with advance notice of
  parties/special events.
• Follow the students PLAN and 504 Plan or IEP
• Some students will prefer to bring their own
  foods.
• Provide nutritious party snacks to encourage
  healthy eating habits for all.

112
What every student with diabetes wants you to
remember

• Sugar is NOT the Enemy
• There is no justification for complete
  restriction of sugar
• Sometimes sugar can be a life-saving friend!
• However, timing matters a lot with diabetes, and
  sometimes sugar (or any carbohydrate) is not a
  good choice at all.

113
Beyond the Routine Field Trips

• Bring plenty of snacks to treat hypoglycemia.
• Bring lunch as appropriate.
• Consult with parent/guardian about food and/or
  insulin adjustments for extra activity level.
• Bring diabetes equipment and supplies.
• Bring list of emergency contacts

114
Exercise Diabetes

• Everyone benefits from exercise and physical
  activity.
• Students with diabetes should fully participate.
• In general, exercise lowers blood sugar levels.
• May need to make adjustments to
  insulin/medications and food intake.
• A quick-acting source of glucose, glucose meter,
  and water should always be available.
• PE teachers and coaches must be familiar with
  symptoms of both high and low blood glucose.

115
Exercise Blood Glucose Monitoring

• Check before, during, and after exercise per
  PLAN.
• Especially when trying a new activity or sport
• If blood sugar starts to fall, student should
  stop and have a snack
• Students with pumps may disconnect or adjust the
  basal rate downward, in lieu of snacking (per
  PLAN)

116
Exercise Insulin/Medication

• Physical activity can raise blood glucose levels
  if there is insufficient insulin.
• follow PLAN for exercise restrictions when
  ketones are present
• Work with parent/guardian to determine the best
  times for physical activity.

117

• LEGAL CONSIDERATIONS

118
Learning Objectives

• Participants will learn about
• Federal laws that protect students with diabetes
• Impact of state laws upon diabetes care in the
  school setting
• Recommendations for 504 Plan or IEP

119
Eliminate Discrimination
Needs of children with diabetes in school
setting...

• Equal access to educational and school related
  opportunities.
• Secure Care
• A medically safe environment for students with
  diabetes.

120
Federal Laws Equal Access

• Section 504 - Section 504 of the Rehabilitation
  Act of 1973
• ADA - Americans with Disabilities Act
• IDEA - Individuals with Disabilities Education
  Act

121
Federal Protections

• Prohibits discrimination against people with
  disabilities by public schools and most private
  schools that receive federal funds
• Students must be given equal opportunity
• Related aids and services are required to meet
  the individual needs of a student with disability

122
Written Plans

• Educational needs
• 504 Plan
• IEP
• Health care needs
• Diabetes Medical Management Plan (PLAN)

123
Needs Addressed by 504 Plan/IEP Plan

• Location and timing of blood glucose monitoring
• Identity of trained diabetes personnel
• Location of diabetes supplies
• Free access to water and restroom
• Nutritional needs, meals and snacks

124
Needs Addressed by 504 Plan/IEP Plan

• Full participation in all school-sponsored
  activities
• Alternative times for academic exams if student
  is experiencing hypoglycemia or hyperglycemia
• Absences without penalty for doctors
  appointments and diabetes-related illness
• Maintenance of confidentiality and students
  right to privacy

125
State Laws Regulations

• State and local laws and regulations vary
  regarding who may perform various aspects of
  diabetes care
• Become familiar with state and local laws that
  impact school diabetes care
• Regardless of state and local law, the
  requirements of federal laws must be met