Getting Sugar Boy ready to go to school... and getting the school ready for Sugar Boy to be there is one of the hardest tasks Sugar Daddy and I have had to take on as parents. I have copied our 504 plan below. As the school year goes on and as additional school years come and go, I am sure that our 504 plan will be a constant work in progress. I will continue to update this page accordingly. Please feel free to copy the text below and use it for your own 504 plan foundation.
*NOTE - the pump specific operations mentioned below are for a Medtroic insulin pump and CGMS.
1. Overview
"Sugar Boy" has type I (juvenile) diabetes. This is a very serious condition which can quickly lead to life-threatening situations if not managed properly. The basic tasks and procedures to properly manage "Sugar Boy’s" diabetes are outlined below.
As a type I diabetic, "Sugar Boy’s" body does not produce insulin on its own, and he is given insulin throughout the day via an insulin pump. He also wears a Continuous Glucose Monitoring System (CGMS) that is integrated with his pump. Even so, "Sugar Boy" may experience episodes of low blood glucose (hypoglycemia) and high blood glucose (hyperglycemia). Symptoms of each of these states, as well as how to treat them, are also outlined below.
2. General management
Supplies
· "Sugar Boy’s" testing, treatment, and emergency supplies are contained in a blue Thomas the Tank Engine lunchbox, which he knows as his “sugar box.”
§ This primary supply kit will be housed in the Health Office.
§ Additional supply kits for transfer to other locations (e.g. PE specials) will be provided by "Sugar Boy’s" parents upon request.
§ Please alert a parent when supplies are becoming depleted so that we may restock the kit.
Blood glucose testing
· "Sugar Boy’s" blood glucose (BG) level should be checked:
§ at 9:30am each day (after breakfast eaten at home);
§ before lunch (approximately 10:50am);
§ two (2) hours after having received his lunch bolus and/or before snack;
§ before he consumes any food or beverage (excluding water) apart from the events indicated above;
§ two (2) hours after having received an insulin bolus for any food or beverage (excluding water) apart from the events indicated above;
§ whenever an adult suspects high or low BG level (see symptoms list below), or when "Sugar Boy" suggests he doesn’t feel right (e.g. “I feel low” or “my legs feel shaky”);
§ whenever his CGMS alarms a high or low BG level;
§ before, during and/or after physical activity (e.g. PE specials, etc.), as outlined below.
· Please ensure that "Sugar Boy’s" hands are clean before testing his BG level.
Insulin administration
· "Sugar Boy" will need a bolus of insulin (delivered via his insulin pump) whenever he consumes any food or beverage containing carbohydrates.
§ When nutrition information is available, the carbohydrate value entered in the pump should be the total carbohydrate value shown on the label multiplied by the approximate percentage consumed. (For example, if "Sugar Boy" ate 50% of a Twinkie that contains 26 grams of carbohydrates, 13 would be the value entered into the pump.)
§ If nutrition information is not available, the total carbohydrate value should be determined by looking up a comparable food/beverage in the book contained in the “sugar box.”
§ If the approximate number of carbohydrates still cannot be determined, please contact a parent.
· Insulin dosages are to be based only on blood glucose (BG) reading from "Sugar Boy’s" meter; CGMS readings are never to be used for this purpose.
· Insulin dosages are to be handled only by the insulin pump – it is pre-programmed with the appropriate values for dosage calculation (i.e. carbohydrate ratios, sensitivity factors, target BGs, etc.).
In the classroom
· "Sugar Boy" should be permitted to use the bathroom without restriction at all times, as the frequent need to urinate is a side effect of hyperglycemia.
· "Sugar Boy" should be permitted to have immediate and unrestricted access to water at all times, as excessive thirst is also a side effect of hyperglycemia and his body’s attempt to flush excess glucose from his blood.
Equipment issues
· If "Sugar Boy’s" infusion set (the location where tubing from the insulin pump attaches to "Sugar Boy’s" body) becomes detached, contact a parent immediately so we may take appropriate action.
· If "Sugar Boy" is experiencing high BG levels that are not able to be remedied by correction boluses, the pump may have failed – contact a parent immediately so we may take appropriate action.
Other
· If possible, please advise a parent in the event that someone other than the reguar nurse will be staffing the Health Office, so that we may communicate with him/her accordingly.
· We do not mind "Sugar Boy’s" classmates knowing he has diabetes or seeing the treatment of his diabetes. At the same time, we would ask that good judgment be exercised in order to not make a spectacle of his treatment when it is under normal circumstances. We do not want him to be known as “the kid with diabetes,” and hope you would share with us a mindfulness of his emotional needs. In case of danger or emergency, however, his health and safety are more important than his privacy. We realize this may be a difficult balance, and we thank you for working to protect both his health and his feelings while he is in your care.
3. Symptoms of hypo-/hyperglycemia
"Sugar Boy’s" behavior may often be related to his BG level. If he exhibits uncharacteristic behavior (examples are shown below), his BG level should be checked right away. Jacob should only be disciplined for poor behavior if his BG level is in the range of 100-250.
· Symptoms of a low BG level (hypoglycemia) may include:
§ appearing droopy, tired, or “spacey”;
§ excessive whining;
§ hunger;
§ being uncooperative or excessively defiant;
§ saying he doesn’t feel right (e.g. “I feel low” or “my legs feel shaky”)
§ loss of balance and/or coordination.
· After treating a low BG level, "Sugar Boy" may still need time to “come to,” which may simply mean allowing him to sit quietly for a time, after which he will likely resume normal activity.
· Symptoms of a high BG level (hyperglycemia) may include:
§ headache;
§ inability to focus on a task;
§ blurred vision;
§ lethargy;
§ complaint of being thirsty or hungry (especially after having recently eaten);
§ being stubborn or generally uncooperative;
§ frequent urination;
§ identification of some other unspecified abdominal discomfort.
· If "Sugar Boy’s" BG level is high (200 or higher), he will need additional insulin, unless he is going to be engaged in physical activity. Please consult Section 4 below to determine the appropriate action.
4. BG treatment (regular, hypo-/hyperglycemia, and emergency)
· Under normal conditions (regular activity level), if "Sugar Boy’s" BG is:
§ 200 or higher – enter the BG into the pump and let pump issue a correction; re-test in two (2) hours;
§ 100-199 – take no action;
§ 60-99 – administer one (1) glucose tablet (located in his “sugar box”); re-test in fifteen (15) minutes; repeat until BG is in the 100-199 range;
§ 59 or lower – administer one (1) full juice box (located in his “sugar box”); re-test in fifteen (15) minutes; follow instructions for the new BG level.
Physical activity has enormous effects on blood glucose levels. We encourage "Sugar Boy" to engage in as much physical activity as he wants, as we understand the importance of physical activity to keep a child healthy. However, extra diligence is required in monitoring his glucose levels while he is active.
Increased activity will cause "Sugar Boy" to burn glucose at a much higher rate; therefore he will often need additional glucose prior to activity in order to boost his BG level. His BG must be checked prior to any physical activity which contains either running or jumping for more than 15 minutes. He will also need to be tested every half hour while engaged in the activity.
· Prior to and during heightened activity, if "Sugar Boy’s" BG is:
§ 300 or higher – all activity must be restricted (to prevent cardiovascular damage); encourage him to drink water; enter the BG into the pump and let pump issue a correction; re-test in two (2) hours;
§ 200-299 – take no action (allowing him to engage in the physical activity will assist in bringing his blood glucose levels down);
§ 100-199 – administer one (1) glucose tablet (located in his “sugar box”);
§ 60-99 – administer two (2) glucose tablets (located in his “sugar box”); watch him very closely while allowing him to engage in the activity;
§ 59 or lower – restrict activity; administer one (1) full juice box (located in his “sugar box”); re-test in fifteen (15) minutes; follow instructions for the new BG level.
· If "Sugar Boy" were to lose consciousness or have a seizure as a result of a critically low BG level, glucagon must be administered immediately by any available faculty/staff.
§ DOSAGE/ADMINSTRATION >>> .3 mL IM <<<
§ Aseptic precautions are not necessary.
§ The administration steps shown below should be followed precisely:
1. Turn "Sugar Boy" on his side. (He will likely vomit when the glucagon enters his system.)
2. Open the red box.
3. Inject all liquid from syringe into powder vial.
4. Swirl vial to mix well. (DO NOT SHAKE!)
5. Draw above dosage from the vial.
6. Inject mixture into "Sugar Boy’s" thigh, through clothing if necessary.
7. Call 911.
8. Contact Health Office personnel and "Sugar Boy’s" parents.
5. Insulin pump basic operation
· Meal and/or snack bolus administration:
1) Press B button on pump.
2) Leave the BG reading at “---“ – press ACT button.
3) Use up (Ù) and down (Ú) arrows to enter the total number of carbs consumed. Be sure to take into consideration if he ate the ENTIRE snack. (If he didn’t consume the entire snack, you will need to figure out what that number is based on the percentage of snack consumed.)
4) Press ACT button.
5) “Normal Bolus” should be highlighted – press ACT button.
6) Display will show the bolus wizard information – press ACT button.
7) Display will show the final amount of insulin to be delivered.
8) Press ACT button – display will show delivery being made. No further action is required – the pump will finish on its own.
· Correction bolus administration:
1) Press B button on pump.
2) Use up (Ù) and down (Ú) arrows to enter BG number – press ACT button.
3) Pump will ask “Update Sensor” – use up (Ù) and down (Ú) arrows to select “No” – press ACT button.
4) Leave carb count at zero (0) – press ACT button.
5) “Normal Bolus” should be highlighted – press ACT button.
6) Display will show the bolus wizard information – press ACT button.
7) Display will show the final amount of insulin to be delivered.
8) Press ACT button – display will show delivery being made. No further action is required – the pump will finish on its own.
· To clear an alarm, alert, or error:
1) Note the message on the pump screen and respond as indicated in Section 6 below.
2) Press ESC button; screen message will flash.
3) Press ACT button.
· To calibrate the CGMS (only if requested by pump):
1) Press ACT button.
2) Use down (Ú) arrow to highlight “Sensor” -- press ACT button.
3) “Enter meter BG” should be highlighted – press ACT button.
4) Use up (Ù) and down (Ú) arrows to enter BG number – press ACT button.
5) Press ESC button until display is blank.
6)
6. Insulin pump alarms, alerts, and errors
· Alarms
§ LOW BG – check BG with meter; treat as indicated in Section 5 above.
§ HIGH BG – check BG with meter; treat as indicated in Section 5 above.
§ METER BG NOW – calibration is needed for the CGMS to provide monitoring; check BG with meter; calibrate as instructed in Section 5 above.
· Alerts
§ WEAK SIGNAL – the pump is not receiving a signal from the CGMS; warning only; no action necessary.
§ LOW RESERVOIR – the pump is running out of insulin; contact a parent.
§ LOW BATTERY – replace battery with spare from supply kit.
· Errors
§ CALIBRATION ERROR – a previous parent-performed CGMS calibration has failed and a new calibration BG is needed; after clearing the error, the pump will alarm METER BG NOW; calibrate as instructed in Section 5 above.
§ LOST SENSOR – the CGMS has shutdown and will no longer provide monitoring; contact a parent.
7. Contact information
Your contact information can be inserted here.
