Diabetes

Diabetes, Endocrine

This resource provides current and comprehensive health care information for school health nurses. Related procedures, instructional videos and downloadable skills checklists can be searched by selecting the [More Information] button at the bottom of this web page.

Overview

Diabetes is a metabolic condition characterized by hyperglycemia and insulin resistance. There are two forms of diabetes, type 1 and type 2. Type 1 diabetes is due to autoimmune pancreatic beta cell destruction which usually leads to absolute insulin deficiency. Type 2 diabetes is a non-autoimmune disease that leads to progressive loss of adequate amounts of beta cell insulin secretion in conjunction with insulin resistance and metabolic syndrome. There are other types of diabetes including gestational diabetes and diabetes that is caused by diseases that damage the pancreas, such as cystic fibrosis (ElSayed et al., 2023a). This resource will review the most common forms of diabetes in children, Type 1 and Type 2.

Table: Characteristics of Type 1 and Type 2 Diabetes in Children and Adolescents

Characteristic	Type 1	Type 2
Age of Onset	Can occur at any point in life but usually <20 years of age	Usually occurs at the onset or during puberty
Type of Onset	Abrupt	Gradual
Presenting Symptoms	Polyuria, polydipsia, weight loss, polyphagia, sometimes blurred vision	40% of children are asymptomatic and may be tested for Type 2 due to risk factors or because glycosuria was detected on a urinalysis obtained as part of a routine physical examination 60% of children will present with symptoms associated with hyperglycemia such as polyuria, polydipsia, and nocturia
Ketoacidosis	Children and adolescents may sometimes present with ketoacidosis as the first symptom. Approximately half of children present with ketoacidosis (ElSayed et al., 2023a).	Not common, if present, usually arises in association with the stress of another illness such as infection

Sources: American Diabetes Association, 2014; Laffel & Svoren, 2023; Patterson & Pruett, 2024

Blood Glucose Monitoring: The American Diabetes Association recommends that blood glucose levels should be measured:

Before each meal (and snack, if using an intensive multiple daily injection or pump regimen),
Before (and often after) exercise,
Prior to and hourly while driving (unless using CGM),
Before bed,
When symptoms of hypoglycemia or hyperglycemia are present and,
After treatment for hypoglycemia (ElSayed et al., 2023b).

Self-Monitoring of Blood Glucose (SMBG): Students with diabetes should have their own glucose meter, lancing device, lancets and blood sugar test strips. The school nurse should review the User’s Manual for the student’s blood glucose meter to familiarize themselves with the functions of the meter. The school nurse should develop a plan with the student, parent/guardian, and health care provider on how the student’s blood sugar will be measured if the student forgets or loses their glucometer or if the student’s glucometer malfunctions. Although having a backup glucometer supplied by the parents/guardians would be ideal, it is not always possible. Additionally, the school nurse should review the glucometer manufacturer’s user manual to determine how often quality control checks should be performed. Many meter manufacturers recommend performing a quality control (QC) check when:

A new test strip box is opened.
The test strip container was left open.
There is a concern the test strips are damaged.
There is a need to test the strips and the meter.
The meter is dropped.
The test result does not match the student’s symptoms.
To validate that the test is being performed correctly (Clarity Diagnostics, 2016; Omnis Health, 2019; Roche Diabetes Care, 2021).

Multi-Student-Use Blood Glucose Meters: The Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the U.S. Food and Drug Administration prohibit the reuse of manufacturer-stated single-patient-use blood glucose meters on multiple students due to the risk of transmitting bloodborne pathogens (Joint Commission, 2017). If the school nurse would like to have a back-up blood glucose meter, they need to ensure that they have a meter designated for multiple patient use and individual, disposable single-use lancets. Additionally, it is vital that the school nurse follow the manufacturer’s directions for cleaning, quality control checks, and storage.

A CLIA Waiver is required for schools where the school nurse or UAP is performing a blood glucose test, interpreting the results of the blood glucose test, using the results of the blood glucose test to determine treatment, and/or reporting the results of the blood glucose test results (Centers for Medicare and Medicaid Services (CMS), 2022). For more information on CLIA see the School Environment section.

Continuous Glucose Monitoring (CGM): In the United States, real-time CGM is approved for nonadjunctive use in children aged 2 years and older and intermittently scanned CGM is approved for nonadjunctive use in children aged 4 years and older (ElSayed et al., 2023c, p. S236). “Nonadjunctive use” means that the sensor glucose values may be used directly for diabetes treatment decisions (Berget & Wyckoff, 2020a). The American Diabetes Association recommends that CGM be considered for all students with type 1 diabetes, whether using injections or insulin pump therapy (Chiang et al., 2018, p. 2030). As with other insulin technologies, there are multiple manufacturers and types of CGM devices that have varying levels of glucose monitoring. Some of the CGMs require the student to scan a glucose sensor with a reader to determine their glucose level while other devices can alert the student and others when their glucose is rising or falling rapidly or when their glucose hits a high or low limit. Additionally, some CGMs can be connected through Bluetooth to the student’s insulin pump and allows the insulin pump to adjust the insulin dose based on the blood glucose level (American Diabetes Association, n.d.-a). It is important to note that the CGM sensors estimate the glucose level in the fluid between the cells, which is very similar to the glucose level in the blood but given that the sensor does not measure the amount of glucose in the blood, the blood glucose level obtained by SMBG will most likely not match that obtained by the CGM (National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2023). The two measurements should be close but there may be a greater difference between SMBG and CGM values when the glucose levels are changing rapidly (Berget & Wyckoff, 2020a). The student’s Diabetes Medical Management Plan (DMMP) should indicate whether the CGM can be used for monitoring, treatment, and insulin dosing or if the glucose level needs to be verified by SMGB. Regardless of how the CGM is used, the student should always have a backup blood glucose monitor with their diabetes supplies (ElSayed et al., 2023b). CGMs need to be calibrated with a blood glucose meter every 12 hours. Most times the calibration is completed at home but if a student were on an extended field trip, overnight field trip, or a shelter-in-place situation the calibration may need to be performed. The school nurse should have the knowledge, ability, and skills to perform the calibration and teach a Unlicensed Assistive Personnel (UAP) to perform the procedure, if needed (NASN, 2022a).

It is important to note that acetaminophen may cause inaccurate CGM readings in some CGMs (Dexcom G6 and Medtronic Guardian) (ElSayed et al., 2023b). It is recommended that students who are currently taking acetaminophen, “CGM readings should not be used for treatment decisions for at least 12 hours since the last dose of acetaminophen, and SMBG should be used to monitor glucose values” (Berget & Wyckoff, 2020a, pp. 64-65).

For students using CGM the school nurse should:

Calibrate the CGM per the manufacturer’s instructions.
- Over- or under-calibration can skew glucose readings.
Assess when the sensor was inserted (CGM is less accurate the first day).
Confirm the blood glucose level with a finger stick when tracings are erratic.
Ensure the display shows both the glucose level and the directional arrow.
Consider the rate of change and lag time if glucose levels are changing quickly.
Assess the amount of “insulin on board” (IOB) to avoid overdosing.
Determine if the symptoms match the glucose level; if not, perform a finger stick (Wyckoff, 2019, p. 591).

Insulin Administration: Insulin is administered subcutaneously and can be injected via syringe, pen, or pump.

Insulin Pens: Some students may administer their insulin via an insulin pen. As there are numerous manufacturers of insulin pens, it is important that the school nurse familiarize themselves with the student’s insulin pen since some insulin pens allow for half-unit increments while others only dose in whole units. It is important for the school nurse to determine how long the insulin pen can be used before it needs to be replaced.

Smart Insulin Pens: Smart Insulin Pens have recently been developed and additional smart insulin pens will continue to become available. Smart insulin pens can be used to deliver insulin, help calculate insulin doses, and estimate carbohydrates for meals. The pens use Bluetooth technology to send insulin dose information to the student’s mobile app (Bigfoot Biomedical, 2023; Medtronic, 2023). It will be necessary for the school nurse to obtain the necessary education and training to gain the necessary knowledge, abilities, and skills to use the smart insulin pens along with educating and training others on their use.

Insulin Pumps: Insulin pumps deliver insulin in two ways: basal insulin delivery which is a continuous infusion of insulin and bolus infusion doses which are larger doses of insulin used to manage the rise in blood glucose after meals or reduce an elevated blood glucose level. Basal insulin delivery replaces the use of long-acting insulins and are used to manage glucose levels in between meals and during sleep (Berget & Wyckoff, 2020b). The use of insulin pumps has increased significantly as studies have shown that,

Children treated with continuous subcutaneous insulin infusion have lower A1C levels, lower hypoglycemia rates, improved diabetes related quality of life, higher treatment satisfaction, and less fear of hypoglycemia. Insulin pump studies that incorporate continuous glucose monitoring (CGM) devices used continuously demonstrate significant improvement in both glycemic control and hypoglycemia reduction in pediatric patients with suboptimal blood glucose control at baseline (Chiang et al., 2018, p. 2029).

Given the numerous types and manufacturers of insulin pumps, it is likely that the school nurse and UAPs will require training on how to use the insulin pump, including how to troubleshoot problems that are specific to the make and model the student uses. In addition to the need to be competent to use the student’s insulin pump, the school nurse and UAPs will also have to have the knowledge, abilities, and skills to administer insulin via insulin pen and/or syringe, in the event the insulin pump does not work properly. In addition, the DMMP should include a backup plan in case of device failure (ElSayed et al., 2023b).

The school nurse and the UAP (if the pump management and insulin administration via pump will be delegated to a UAP) should also be trained in the following:

General technical information about the specific insulin pump
Phone number for technical support
Parameters of alarms and how to respond
Safety and handling of the technology
Identification of devices that work together (i.e., diabetes technology and smart devices)
How to unlock the device
How to provide oversight or give a correction bolus
How to give a food bolus
How to give a combined food and correction bolus
How to review the bolus history
How to suspend the pump
How to change a battery
How to charge a pump
When to check for ketones
When to call the parent/guardian, school nurse, and/or health care provider
Plan for pump or site failure
How to use a remote meter, if applicable
How to calibrate with sensor integration, if applicable

(American Diabetes Association, n.d.e; NASN, 2022a).

The American Diabetes Association has developed a School Nurse Pump Training Skills Checklist. It is recommended that instructions for the devices should be outlined in the student’s DMMP.

The list of diabetes products is rapidly evolving and is too exhaustive to be discussed in detail on this site. Please refer to the American Diabetes Association Consumer Guide for more information on pumps, meters, insulin pens, and other devices.

Other Lab Tests:

Ketone Testing: Routine testing of urine ketones is recommended if the student has prolonged hyperglycemia or acute illness such as fever, nausea, vomiting, or abdominal pain (Chiang et al., 2018). The Diabetes Action Plan should indicate when ketone testing should be performed in the school setting. A CLIA Waiver is required for schools where the school nurse or UAP are performing urine ketone testing on students with diabetes (CMS, 2022). For more information on CLIA see the School Environment section.

HbA1c: HbA1c should be measured in all children and adolescents with type 1 diabetes, by their health care provider, at 3-month intervals to assess their overall glycemic control. An A1C target of less than 7% should be considered in children and adolescents with type 1 diabetes but should be individualized based on the needs and situation of the student and family (ElSayed et al., 2023c). With increasing use of CGM devices, outcomes other than A1C, such as time with glucose in target range and frequency of hypoglycemia, should be considered in the overall assessment of glycemic control (Chiang et al., 2018, p. 2029). School nurses should work with the student and their family to help support the attainment of A1C measurement goals since “lower A1C in adolescence and young adulthood is associated with a lower risk and rate of microvascular and macrovascular complications and demonstrates the effects of metabolic memory” (ElSayed et al., 2023c, p. S236).

Time in Range: Through the use of CGMs, students with diabetes and their health care team are now able to track time in range. Time in range is the amount of time the student’s blood glucose level remains in their target range. The ideal blood glucose range for most students with diabetes is 70-180 mg/dL. Time in range is often depicted as a bar graph showing the percentage of time over a specific amount of time when the student’s blood glucose was low, in range, and high. This data is helpful in finding out which types of foods and what activity level causes the student’s blood glucose to rise and fall (American Diabetes Association, n.d.b). Dovc et al., (2023) indicates that for most children with diabetes it is recommended that they aim for a time in range of at least 70% of blood glucose readings while ElSayed et al, (2023c) states “it is still uncertain what the ideal target time in range should be for children, and further studies are needed” (p. S236).

Delegation

Missouri State Statute 167.809. Diabetic care may be provided to students, when, trained personnel to be on site requires the school nurse or a trained diabetes care personnel (also known as a UAP) to perform diabetes care functions including, but not limited to:

Checking and recording blood glucose levels and ketone levels or assisting a student with such checking and recording;
Responding to blood glucose levels that are outside of the student’s target range;
Administering glucagon and other emergency treatments as prescribed;
Administering insulin or assisting a student in administering insulin through the insulin delivery system the student uses;
Providing oral diabetes medications; and
Following instructions regarding meals, snacks, and physical activity.

Statute 167.809 goes on to state that the school nurse or at least one of the trained diabetes care personnel should be on site and available to provide care to each student with diabetes during regular school hours and during all school-sponsored activities, including school-sponsored before-school and after-school care programs, field trips, extended off-site excursions, extracurricular activities, and on buses when the bus driver has not completed the necessary training.

Although Missouri state statute allows the school nurse to delegate diabetes care, there are a number of factors for the school nurse to consider when deciding whether to delegate diabetes care to a UAP. This section will provide a list of questions that the school nurse should answer to assist them in determining whether it is appropriate and safe to delegate the procedures. It is also important to remember that the questions related to delegation need to be answered for every individual student. The decision to delegate is based on circumstances related to the student, the nurse, the UAP, and the situation.

Questions to Ask to Inform Safe Delegation: The delegation questions below are based on the American Nurses Association’s Decision Tree for Delegation by Registered Nurses (ANA, 2012) and the National Association of School Nurses (NASN) Nursing Delegation Considerations for the Student with Type 1 Diabetes (T1D) (NASN, 2022b).

Has the school nurse performed an initial assessment of the student to determine their needs?
The school nurse should not delegate the procedure to a UAP until they have completed the initial assessment.
Does school district policy, the school nurse’s job description, and the UAP’s job description allow procedures related to diabetes medical management to be delegated?
Although the Missouri Nurse Practice Act allows for registered nurses to delegate diabetes medical management, the district may have policies that prohibit or limit the school nurse’s ability to delegate. Additionally, the school nurse’s and UAP’s job descriptions may restrict delegation as well.
Is the school nurse competent to perform this procedure or does the school nurse need to acquire some knowledge or skills to be competent in this procedure?
If the school nurse is not competent or does not feel comfortable performing this procedure they should not delegate this procedure to a UAP. The school nurse must first acquire the necessary knowledge and skill to perform this procedure competently before they can delegate it to someone else. This includes the knowledge, abilities, and skills related to the diabetes technologies such as insulin pump and continuous glucose monitoring device, if applicable.
Is the student’s condition stable? Is this a new procedure for the student? How predictable are the outcomes of the procedure?
A school nurse should not delegate diabetes medical management to a UAP if this is a new diagnosis for the student, if the procedure is new (i.e., a change in the equipment or supplies that the student uses), or if the student’s condition is not stable (i.e., student has been experiencing severe hypoglycemic events, recent hospitalization, consistently elevated HbA1c). The outcomes are not predictable and thus the school nurse should perform the procedures until the student’s condition has stabilized.
Does the procedure require an initial or ongoing assessment to be performed during the procedure?
If an initial or ongoing assessment is required for the procedure to be performed, the procedure should not be delegated.
Does the UAP have the appropriate knowledge, skills, abilities, and willingness to perform the procedure?
All these factors need to be considered. Although a UAP may be competent to perform the procedure they may not be willing to do so and in that situation another UAP should be identified and trained. The registered nurse must retain responsibility for the procedure until training is complete.
Is there a procedure and/or protocol in place for this procedure?
A delegated nursing procedure must have an established sequence of steps that the UAP can follow. These steps should have a predictable outcome. The steps should be outlined in a written procedure or protocol. If the written procedure/protocol has not been developed, the school nurse should retain responsibility for the procedure until the procedure/protocol is in place.
Is the school nurse able to provide supervision to the UAP (direct or indirect depending on the situation)?
If the school nurse is not able to provide supervision, then the procedure should not be delegated. The school nurse will need to assess the situation to determine if direct or indirect supervision is required. The school nurse may also need to reassess the situation if the environment changes, for example, if the procedure is going to be performed during a time that the school nurse is not contracted to provide nursing services (i.e., over the weekend, during the summer, or if the school nurse is part-time).
Is the student ready to assume some responsibility for the procedure?
The school nurse should resume responsibility for the procedure since the school nurse is the only one who can initiate teaching. The school nurse would also want to observe the student performing the procedure to ensure that the student is competent. Once the school nurse has determined that the student is competent and can safely perform the procedure independently, they can delegate the supervision of the student to a UAP. If at a future date the school nurse is needed to teach the student additional skills, the school nurse would again need to resume responsibility for the procedure until the time in which the school nurse determined the student to be competent.

The Decision to Delegate:

There may be times when the school nurse and school administrator have conflicting opinions on the delegation of a procedure to a UAP. The school nurse may feel that delegation is not appropriate or the administrator may want the school nurse to delegate a procedure to an UAP that the school nurse feels is not competent. In these situations the school nurse may need to educate the administrator that the school nurse has a professional and legal responsibility to determine if delegation of a nursing procedure is appropriate and safe (ANA, 2012). A resource developed by the National Association of School Nurses entitled, Fact Sheet for School Administrators, Families, and School Personnel: Nursing Delegation Requires the School Nurse may assist the school nurse in communicating with the school administration. Learn more at Navigating Delegation in the School Setting (PDF)

School Environment

Physical Environment:

Access to Glucagon: A prompt and coordinated response to a hypoglycemic episode is critical. School staff who have regular interactions with a student with diabetes should know where the student’s glucagon is located. If the student self-possesses their glucagon, the student should communicate the location of their glucagon with school staff and the school nurse.

Classroom Management: Teachers and other school staff who have regular interactions with a student with diabetes should be educated and trained to respond to a hypoglycemic episode. They should also know where the student’s glucagon is stored and have easy access to the medication.

Advocating for Least Restrictive Environment: Missouri State Statute 167.818. Student may perform certain diabetic care for self, when– allows the student to have some independence in their diabetes care and if developmentally appropriate, the school nurse should advocate for the student with diabetes to be able to perform their diabetes cares (i.e. checking blood glucose level) “in the classroom or wherever they happen to be” (American Diabetes Association, 2020, p. 25). The American Diabetes Association (2020, p.26) states the advantages of allowing a student to check their blood glucose level any time and any place is:

The student can confirm a low blood glucose level immediately. As a result, the student is less likely to experience a seizure or a coma.
The student is safer when he or she does not have to go to a designated place and does not have to delay treatment for low or high blood glucose levels.
The student spends less time out of class.
The student gains independence in diabetes management when the blood glucose meter is easily accessible and monitoring can be conducted as needed.
The student can achieve better blood glucose control to prevent onset of severe symptoms of high and low blood glucose levels and decrease the risk of long-term complications of diabetes.
When the student can check at any time and in any place, blood glucose monitoring is handled as a normal part of the school day.

Training and Education:

Training of School Staff:

Missouri State Statute 167.803. Training of school employees, content, requirements outlines the education and training that school staff should receive regarding caring for a student with diabetes, it includes:

Recognition and treatment of hypoglycemia and hyperglycemia;
Understanding the appropriate actions to take when blood glucose levels are outside of the target ranges indicated by a student’s diabetes medical management plan;
Understanding physician instructions concerning diabetes medication drug dosage, frequency, and the manner of administration;
Performance of finger-stick blood glucose checking, ketone checking, and recording the results;
The administration of glucagon and insulin and the recording of results;
Understanding how to perform basic insulin pump functions;
Recognizing complications that require emergency assistance; and
Understanding recommended schedules and food intake for meals and snacks, the effect of physical activity upon blood glucose levels, and actions to be implemented in the case of schedule disruption.

Additionally, MO Statute 167.803 also stipulates that a minimum of three school employees at each school attended by a student with diabetes shall receive the education and training outlined above. (One of the three school employees can be the school nurse.)

The American Diabetes Association (2020) recommends that all school staff be educated about diabetes when there is a student with diabetes enrolled in the school. They recommend a tired approach to education and training.

Tier One: Every school staff person should be given general information regarding diabetes which should include:

How to recognize and respond to a student who is exhibiting signs and symptoms of hypoglycemia or hyperglycemia.
Whom to contact in case of an emergency.

Tier Two: Classroom teachers and all school personnel who have a responsibility for students with diabetes throughout the school day should receive Tier One Training and also receive education and training on:

How to carry out their roles and responsibilities.
What to do in case of an emergency.

Tier Three: In addition to the education and training provided in Tier 1 and Tier 2, one or more school staff members should receive:

In-depth training about diabetes and routine and emergency care for each student with diabetes.

The American Diabetes Association has Training Resources for Schools.

Education of Peers:

The school nurse may want to discuss with the student and their family about their desire for the student’s peers and school staff to be made aware and educated about the student’s diabetes diagnosis. Depending on the student and family’s wishes, educating peers may help alleviate endless questions and help teach peers on how to be supportive and inclusive.

Physical Activity and Exercise: Activity and prolonged exercise can impact a student’s blood glucose levels. The school nurse should review the student’s DMMP to determine what precautions or change in treatment are necessary when the student will be engaging in increased physical activity such as physical education class, sporting events, or field trips that have extensive activity or walking. For the safety of the student the school nurse may want to consider setting alerts/alarms; monitoring sensor glucose levels pre-exercise, during exercise, and post-exercise and understanding factors that may affect the CGM readings. It is recommended to set predictive alerts/alarms (decreasing/increasing levels and low/high glucose limits) to avoid hypoglycemia–hyperglycemia during activity. Specifically, to avoid hypoglycemia during exercise, these alerts should be set at a glucose level that indicates treatment needed to maintain stable glucose levels (Wyckoff & Berget, 2020). The student’s DMMP should address whether the student should eat a snack prior to engaging in physical activity. Additionally, while engaged in physical activity, the student should have access to a fast-acting carbohydrate in case of hypoglycemia (ElSayed et al., 2023c).

Prolonged exercise (>60 minutes) can increase insulin sensitivity for several hours after exercise. The student’s DMMP should address whether a change in the basal insulin rate or suspending the basal insulin infusion during exercise is appropriate (ElSayed et al., 2023c). School staff should be made aware of the potential for the student’s blood sugar to decrease hours after exercising and be instructed to monitor the student after prolonged exercise, especially during school sponsored activities, such as a field trip or after school activities, such as participating in a sport (cross country, football, etc.). Staff responsible for the monitoring of the student should also be educated and trained in how to obtain a finger stick glucose reading in case of technology failure or if the student’s symptoms do not match the CGM readings or the glucose levels are rapidly changing (Wyckoff & Berget, 2020).

Carbohydrate Counting: Nutrition management is a key component in the medical management of diabetes. Students with type 1 diabetes will use an insulin to carb ratio to determine how much insulin they should take based on the number of carbohydrates that they plan to consume. The insulin to carb ratio will be included in the students DMMP. The school nurse should communicate with the student’s parents/guardians to determine if the student will be bringing food from home or if the student will be eating a meal provided by the school. If the student is bringing food from home the school nurse will want to determine how the parents/guardians will communicate with the school nurse or UAP the amount of carbohydrates in the student’s lunch. If the student eats a meal prepared by the school or a contracted company, the school nurse will want to collaborate with the nutrition staff and the student’s parent/guardian to ensure that carbohydrate information will be provided so an accurate insulin to carb ratio can be calculated (NASN, 2022c).

In addition to planned meal times, the school nurse should discuss with the student’s teachers and educational team about the need to communicate and coordinate with the student, parents/guardians, and school nurse for times when food will be eaten in the classroom, including snack times and class parties or celebrations (NASN, 2022c).

The National Association of School Nurses has developed a Model Procedure for Carbohydrate Counting.

CLIA Certificate of Waiver: The Clinical Laboratory Improvement Amendments (CLIA) was passed by Congress in 1988 and established federal and quality standards for all laboratory testing in an effort to improve the quality of test results from facilities. All facilities that perform laboratory testing on human specimens for diagnosing, preventing, or treating disease are regulated by CLIA. CLIA would consider schools that perform blood glucose and ketone testing on students who are diabetic to be a facility that performs laboratory testing. Facilities that perform “waived tests” need to apply for a Clinical Laboratory Improvement Amendments (CLIA) Application for Certification. CLIA defines a waived test as simple tests with a low risk for an incorrect result. Both blood glucose and urine ketone are CLIA waived tests (U.S. Food and Drug Administration, 2023). In addition to receiving the CLIA Certificate of Waiver, it is also essential that the school nurse and UAPs engage in safe laboratory practices including, but not limited to:

Cleaning work surfaces before and after testing.
Performing testing in a well-lighted area.
Performing quality control (QC) as recommended in the manufacturer’s instructions.
Ensuring QC results are as expected before performing patient testing.
Identify and correct problems if QC results are not as expected.
Wearing appropriate personal protective equipment (PPE) such as gloves when collecting the sample and testing.
Disposing of biohazardous waste and sharps containers safely.

(Centers for Disease Control and Prevention, n.d.; Moran & Bultas, 2022)

See Missouri Department of Health and Senior Services for more information on applying for a CLIA certificate. The Centers for Medicare and Medicaid have developed an informational sheet on CLIA certificates and over-the-counter tests and a document that provides more information on how to apply for a certificate.

Students

An important first step when caring for a student who has diabetes would be to complete a health history and physical assessment, preferably with the student and their parents present.

Health History Questions: The school nurse may want to ask the student and their parents/guardians the following questions:

Current health conditions
Medications
How is the student’s insulin administered?
What formulation of glucagon is prescribed for the student (i.e., intranasal, injection)?
Allergies
Previous hospitalizations and surgeries
Most recent hospitalization
Most recent HbA1c
Insurance coverage
Health care provider(s) name and contact information
Preferred hospital, if applicable

Additional Assessment Questions:

Does the student have the following plans:
○ DMMP?
○ Hypoglycemic action plan?
○ Hyperglycemic action plan?
How does the student monitor their blood glucose: CGM or finger stick?
Where does the student perform their blood glucose testing?
Is the student able to feel and treat their hypoglycemia?
Is the student able to feel and treat their hyperglycemia?
What is the student’s level of independence in:
○ Measuring blood glucose level
○ Interpreting blood glucose level
○ Counting carbohydrates
○ Determining insulin dose
○ Administering insulin
○ Use of CGM (if applicable)
○ Calibrating the CGM (if applicable)
○ Use of insulin pump (if applicable)
○ Use of insulin pen (if applicable)
○ Performing urine ketone test
○ Self-possession of diabetes equipment (i.e., glucometer)
○ Self-possession of medications
○ Self-possession of emergency medications
What are the student’s symptoms of low blood sugar?
Has the student ever had a severe hypoglycemic episode?
○ If yes, when?
Where are the student’s hypoglycemia medication(s) stored?
Has the student ever been hospitalized due to diabetes ketoacidosis (DKA)?
○ If yes, when?
Does the student have any special dietary needs?
How does this health condition impact the student’s life?
Does the student wear a medical alert bracelet, necklace, or wristband?
Does the student or parents have a concern about the student’s health condition?
What challenges does the student face in managing their health condition?
Do you feel the student has been sufficiently supported by school staff in managing their health condition?
Does the student have a 504 Plan or Individualized Education Program (IEP)?
Would the student benefit from evaluations or assessments in any of the following areas: physical therapy, occupational therapy, speech and language therapy, assistive technology, adapted physical education, functional behavior, psychology, hearing and vision?
Would the student benefit from additional academic support and/or modified education (i.e., copies of notes, extra time, reduced workload, simplified instructions, alternative formats for presentation of material, 504/IEP)?
Does the student have an Individualized Health Care Plan (IHCP)?
Is there a need for a specific plan for this student’s individual needs if there is a crisis in the building?
How is the student transported to and from school?
Does the student attend before or after school care?
Does the student participate in school-sponsored clubs or athletics?

(Missouri Department of Health and Senior Services Bureau of Community Health and Wellness, 2021; NASN, 2022e)

The National Association of School Nurses have developed helpful diabetes resources, including the School Nurse Assessment of Self-Management of Type 1 Diabetes (T1D) and the School Nurse Assessment of Student Self-Management of Type 1 Diabetes (T1D)

Transition Planning:

The school nurse should assess the student’s current and desired level of independence to determine what goals should be established for the student. Additionally, the school nurse should discuss with the student and family what steps have been initiated related to transition planning. The school nurse should consider including goals related to self-management and decision-making skills in the student’s Individualized Health Care Plan (IHCP) (NASN, 2019b) and consider how those goals can be expanded upon each year to support independence, if appropriate. Every student will have varying ability to self-manage their diabetes and the school nurse should refer to the student’s DMMP when developing self-management goals for the student. As the student becomes more independent in their diabetes management the school nurse should discuss with the student and their parent/guardian, and the health care team how often the student should touch base with the school nurse and for what circumstances the student should update the school nurse or seek assistance. This should be documented in the student’s IHP (Jackson & Ablanese-O’Neill, 2016).

Got Transition has developed Transition Readiness Assessment for Youth and a Transition Readiness Assessment for Parents/Caregivers

Transportation:

It is important for the school nurse to determine how the student is transported to and from school. If the student is transported on the school bus the school nurse may be required to educate school bus drivers on diabetes and train them on how to respond to an emergency, including administering glucagon. The school nurse should confer with the school administrator to determine who is responsible to provide the training as school bus drivers who are employed by an outside agency may receive their training through their employer.

Communication

Ongoing communication between the school nurse, student, and teachers, and parents/guardians is crucial. The treatment plan for students with diabetes may be frequently updated and thus the school nurse will want to ensure that they have received the most up to date DMMP. Additionally, with the invention of remote monitoring of CGM, parents/guardians have increased ability to monitor their child’s blood glucose levels. The provision of data sharing should be addressed and approval documented in the Parent/Guardian Authorization Form or the Diabetes Medical Management Plan (DMMP). Additionally, with the access to continuous glucose monitoring, parents/guardians may want to make numerous changes to the insulin dosing or provide supplemental insulin doses. The DMMP should address what changes parents/guardians are able to make to the insulin doses along with how many or how often parents/guardians are allowed to make changes since numerous changes may be difficult for the school nurse or UAP to manage.

The school nurse needs to discuss with the student and their family the best way(s) to communicate with them. Does the parents/guardian have a preference (i.e., email, text, telephone call)? Do the parents prefer to have the communications sent to both parents or is there a parent who manages the communication with the school nurse?

The school nurse may want to consider having the parents/guardians complete a Health Insurance Portability and Accountability Act (HIPAA) compliant medical release form to facilitate communication with the student’s health care team. Although HIPAA does not require parental consent to allow the school nurse to discuss the student’s treatment plan, such as medications and nursing procedures, with the student’s health care provider, having a signed consent form would undoubtedly make the process go smoother for all involved parties (U.S. Department of Health and Human Services & U.S. Department of Education, 2008). FERPA HIPAA Consent Sample

Medication

Type 1 Diabetes: Insulin is the main medication used to manage type 1 diabetes. There are several insulin types as outlined in the table below.

Table: Types of Insulin

Types of Insulin	Begins to Work	Peak	Lasts	Generic (Trade) names
Rapid-acting insulin	15 minutes after injection	1-2 hours after injection	2-4 hours after injection	Insulin aspart (Fiasp, NovoLog) Insulin glulisine (Apidra), and insulin lispro (Admelog, Humalog, Lyumjev)
Regular or short-acting insulin	30 minutes after injection	2-3 hours after injection	3-6 hours after injection	Human Regular (Humulin R, Novolin R, Velosulin R)
Intermediate-acting insulin	2-4 hours after injection	4-12 hours after injection	12-18 hours after injection	NPH (Humulin N, Novolin N, ReliOn)
Long-acting insulin	Several hours after injection		Tends to lower glucose levels up to 24 hours	degludec (Tresiba), detemir (Levemir), and glargine (Basaglar, Lantus)
Ultra-long acting	6 hours after injection		Lasts 36 hours or longer	glargine U-300 (Toujeo)

Source: American Diabetes Association, n.d.e.

Insulin syringes: The standard and most commonly used strength in the United States today is U-100, which means it has 100 units of insulin per milliliter of fluid, though U-500 insulin is available for patients who are extremely insulin resistant (American Diabetes Association, n.d.e.). When administering insulin via syringe it is necessary to make sure the insulin concentration on the vial and syringe match (for example, when using a vial with an insulin concentration of U-100, only use syringes that are for U-100 insulin (American Diabetes Association, 2022).

Type 2 Diabetes: Metformin is the initial pharmacological treatment for children and adolescents diagnosed with type 2 diabetes if their renal function is normal. If the student has an A1C of ≥8.5% and symptoms the initial treatment may also include long-acting insulin in addition to metformin (ElSayed et al., 2023c). “Current pharmacological treatment options for youth-onset type 2 diabetes is limited to three approved drug classes: insulin, metformin, and glucagon-like peptide 1 receptor agonists” (ElSayed et al., 2023c, p. S242).

Health Care Provider’s Order:

Frequently, the health care provider’s order for diabetes management will be included in the student’s DMMP (see the Documentation section for more information on DMMP). If the student does not have a DMMP, at a minimum, the following information should be included in the health care provider’s order for diabetes management:

Name of the student
Date of birth
Name of medication
Dose
Insulin to carb ratio
Route
Time of administration
Reason for administration
Instructions regarding when to check blood glucose
Target blood sugar range
- Important for knowing where the CGM alarms should be set, if applicable
- When action is needed
Blood sugar correction amount
- Sometimes also written as Insulin Sensitivity Factor or Correction Factor
Instructions regarding when to check for ketones

Field Trips

Considerable planning for overall diabetes management and possible emergencies should be undertaken. It is important to note that the Section 504 of the Rehabilitation Act does not allow for a student with a disability to be excluded from a field trip due to their disability.

The school nurse and school personnel should consider the following when planning for a field trip:

Confirm that students on the field trip who have diagnosed diabetes have all the necessary items for the field trip including:
1. Health care provider order/DMMP
2. Emergency Action Plan(s)
3. Diabetes supplies
4. Diabetes medications
5. Emergency Contact Information
Ensure that the Emergency Action Plan is up-to-date and reviewed to determine if any revisions are needed due to the field trip.
Plan to have emergency plans stored with the medication during the field trip. Consider what steps will need to be taken to ensure health plans remain confidential.
Determine where emergency medication will be stored keeping in mind temperature stability, accessibility, and safety.
1. Emergency medication should not be left unattended on the school bus or with a school staff/volunteer who is not with the student.
Determine who will be responsible for carrying extra carbohydrates containing snacks, quick-acting glucose, and water.
Determine if enough supplies have been obtained to cover the duration of the field trip.
Identify which students will be allowed to self-carry their emergency medication. Ensure that proper education, training, competency, and documentation has been completed.
Determine how medications administered on the field trip will be documented.
Develop a plan to obtain additional emergency medication, if needed.
Determine locations of emergency departments and hospitals along the route for the field trip and in the vicinity of the final field trip destination.
Determine if any additional staff are needed on the field trip to meet the health care needs of the students.
Identify whether school staff who will be accompanying students on the field trip have the necessary training, education, and competence to perform the necessary procedures, including emergency procedures such as glucagon administration and insulin pump or CGM procedures including troubleshooting the devices.
Consider that there may be areas where cellphone reception is limited or not available and plan accordingly, especially if needed for diabetes technology and access to emergency medical services.
If the field trip will be occurring out of the state:
- Review the states’ Nurse Practice Acts to confirm that the care of students with diabetes can be delegated to an UAP in that state.
If the field trip will be occurring out of the country the school nurse should discuss with school administration any applicable laws to determine what additional steps may be needed. In addition, the U.S. Embassy can provide information on points of contact for destination countries.
Determine if the states traveled through or visited are a part of the Nurse Licensure Compact.

(Erwin, Clark, & Mercer, 2014; NASN, 2019a; NASN, 2020d; NASN, 2021; Wisconsin Department of Public Instruction, 2019)

The Field Trip planning checklist above was developed based on resources from the National Association of School Nurses–Emergency Medications Toolkit (NASN, 2020a) and School Nursing Evidence-Based Clinical Practice Guideline: Students with Type 1 Diabetes Toolkit (NASN, 2022f)

NASN Resource: Field Trip Preparation Checklist

Documentation

The medical management of student’s diabetes in the school setting will require the school nurse to acquire and complete numerous forms of documentation.

Diabetes Medical Management Plan: Missouri Statute 167.806 states that parents of a student with diabetes should submit to the school a DMMP. The following information should be included in the DMMP:

Date of diagnosis
Contact information (parents/guardians and student’s physician/health care provider)
Specific medical orders for checking blood glucose, administering insulin and other medications, and carbohydrate (carb) counting
Assessment of student’s self-care skills for performing diabetes care tasks
Typical signs, symptoms, and prescribed treatment for hypoglycemia and hyperglycemia
Student’s diabetes equipment and supplies, including blood glucose meter, insulin delivery devices, glucagon, and continuous glucose monitoring systems (CGM)
Use of smartphone and/or other monitoring technology
Additional monitoring and treatment for ketones
Meal and snack plan
Physical activity
72-hour disaster, lockdown, or emergency plan

(American Diabetes Association, 2020).

The American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases have developed Diabetes Medical Management Plans.

Parent/Guardian Authorization: In addition to the health care provider’s order, the school nurse will also need written authorization from the parents/guardians to administer diabetes medications and perform diabetes related procedures (i.e., blood glucose monitoring, urine ketone testing). The DMMP templates developed by the American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases include a section for parent authorization. If the parent authorization is not included on the health care provider orders then the school nurse will want to document the parent/guardian authorization on a separate document.

Procedures and Medication Administration: All medication administration and diabetes-related procedures will need to be documented, whether they are performed by the school nurse or a UAP. Many times the medication administration and procedures are documented in the student’s health record. The school nurse will also want to ensure that medications being administered or procedures being performed during field trips, before or after school, and/or during any school-sponsored activities are being documented.

Emergency Action Plan: A student’s DMMP will include the instructions and orders for the management of hypoglycemia and hyperglycemia. The school nurse should use the information included in the DMMP to create Emergency Action Plans for hypoglycemia and hyperglycemia. The Hypoglycemia Emergency Action Plan and Hyperglycemia Emergency Action Plan should be distributed to all school staff who have responsibility for students with diabetes during the school day and during school-sponsored activities (American Diabetes Association, 2020, p. 67). The emergency plans should contain the following information:

Student name
Date of birth
Blood glucose level that requires treatment for hypoglycemia at rest and during exercise
Blood glucose level that requires treatment for hyperglycemia
Treatment that should be provided if the student is hypoglycemic and is able to eat or drink
Treatment that should be provided if the student is hypoglycemic and is unconscious, having a seizure, or is unable to swallow, including actions to complete related to insulin pump and first aid to be provided
Treatment that should be provided to student who is hyperglycemic
When ketone levels need to be checked
Treatment to be provided if ketones are present
How often blood glucose levels should be checked during the hypoglycemic episode
What level the blood glucose needs to reach before blood glucose levels no longer need to be monitored closely at rest and during exercise
Health care provider name and contact information
Parent/guardian name and contact information
Signature of health care provider
Parent/guardian signature
Date

(American Diabetes Association, n.d.c.).

In addition to the treatment of hypoglycemia and hyperglycemia, the Emergency Action Plan should also include detailed instructions regarding how to handle the insulin site or pump failure, including who to contact, who will replace infusion site, and/or instructions on when to give insulin by injection (Wyckoff & Berget, 2020).

Hyperglycemia Emergency Care Plans and Hypoglycemia Emergency Care Plans that have been developed by the National Institute for Diabetes and Digestive and Kidney Diseases, National Diabetes Education Program, and the Missouri Department of Health and Senior Services.

Self-Possession and Administration: When determining if a student is capable of carrying and self-administering their diabetes medications and performing other diabetes related procedures, the school nurse will want to meet with the student and assess their knowledge, ability, and skills. Upon completing this assessment, the school nurse will want to document their assessment in the student’s health record. The school nurse should also document that the student’s parent/guardian and health care provider agree with the plan of care for the student to self-carry and self-administer their medication and perform diabetes related procedures. The school nurse should review their school district’s policies, procedures, and/or protocols to determine if the student’s self-administration of medication needs to be documented in the student’s health care record.

The National Association of School Nurses has developed a Contract for Student Self-Carry and Self-Administration of Medication that could be used to document the school nurse’s assessment and planning with the student.

Staff Competency Validation: If the diabetes medical management is delegated to a UAP the The school nurse should document that the UAPs knowledge, abilities, and skills have been assessed. Many times these factors are documented on a skills competency checklist (see Skill Competency Checklists [1].There should be a place on the skills competency checklist for the school nurse and UAP to sign to indicate that they feel competent and are willing to perform the procedure. Once the procedure has been delegated the school nurse is responsible for periodic evaluation of the UAP and their competency. The school nurse must determine how often the supervision is needed. After the school nurse has re-evaluated the UAP’s competency, they should document the date of the evaluation (Shannon & Kubelka, 2013; Selekman & Ness, 2019). The school nurse should organize the competency documentation in a way that easily allows them to determine when subsequent evaluation and documentation of competency is needed. For more information on delegation see the Delegation section.

Individualized Health Care Plan: Another document that the school nurse may develop for a student with diabetes is an Individualized Health Care Plan (IHCP). The IHCP outlines the plan of care for the student, including but not limited to:

Daily management needs including:
- Where diabetes supplies will be stored
- Where diabetes procedures will be performed
Self-management abilities
Instructions related to diabetes technologies (CGM, insulin pump, etc.)
Development of an emergency care plan (ECP) for school staff
Documentation of pertinent school staff that will be trained by the school nurse to provide the diabetes care
Plan for diabetes management during physical activity
Promoting independence and self-management of diabetes care
Transition planning

(Wyckoff & Berget, 2020)

Prior to completing the IHCP, the school nurse should complete a health history and physical assessment of the student. For more information on health history see the Student section.

The National Institute for Diabetes and Digestive and Kidney Diseases has developed a sample IHP. (The link directly downloads the document to your computer).

Section 504 Plan: Students with diabetes may qualify for a Section 504 Plan since their health condition may impact a major life activity, which includes the functioning of major bodily systems such as the endocrine system. If the student has been identified as qualifying for a 504 Plan, the school nurse may be involved in identifying appropriate accommodations and writing the plan. Once developed, the school nurse will want to frequently review, update, and document in the 504 Plan (NASN, 2020b). For more information on Section 504 Plans see Legal Issues section.

Emergency Preparedness

There are significant considerations that need to be made when caring for a student with diabetes. The risk of hypoglycemia is always present, and the school nurse must ensure that there are adequate school staff who are educated and trained to respond to a diabetic emergency. This includes during normal school hours but also includes times when the student is participating in before and/or after school activities, field trips, and when the student is being transported by the school (i.e. when on the school bus). See the Field Trip section for more information on planning for field trips.

Shelter-in-Place and Other Emergency Events:

In addition to ensuring that all students with diabetes have Emergency Action Plans (see Documentation section) and that all school staff have been educated on the signs and symptoms of hypoglycemia and hyperglycemia and how to respond to these emergencies (see School Environment); the school nurse should also collaborate with school administration and the student’s education team to plan for other potential emergencies such as lockdown, extreme weather events, evacuations, and shelter-in-place events. It is important that the student has always access to carbohydrate-containing food and water. In addition, it would be ideal if the student were to always have access to their blood glucose meter and medications. The American Diabetes Association (2020) recommends that the student have enough emergency supplies to last for 72 hours. If a shelter-in-place or lockdown situation were to occur and the student did not have access to their medications or glucometer the school nurse must educate the school staff on how to care for the student. This could include reducing the student’s food intake and increasing their intake of water or non-carbohydrate containing liquids (American Diabetes Association, n.d.d.).

It is recommended that the student’s emergency supply kit contain the following supplies:

Blood glucose meter, testing strips, lancets, and batteries for the meter
Urine and/or blood ketone test strips and meter
Insulin, syringes, and/or insulin pens and supplies
Insulin pump supplies
Other medications
Antiseptic wipes or wet wipes
Quick-acting source of glucose, such as juice, regular soda, and glucose tabs/gel.
Water sufficient for 72 hours
Carbohydrate-containing snacks, such as whole grain crackers and dried fruit
Hypoglycemia treatment supplies (enough for three episodes): quick-acting glucose and carbohydrate snacks
Glucagon emergency kit

(American Diabetes Association, 2020, pp. 36-37)

For more information on emergency planning see Missouri School Boards’ Association’s Emergency Planning Guide for Students and Staff with Special and Functional Needs within Schools.

Legal Issues

State Statutes: There are currently six Missouri State Statutes that relate to diabetes care in the school setting. They are:

Section 504 Plan:

Students with diabetes may qualify for a Section 504 Plan. Section 504 of the Rehabilitation Act of 1973 as amended through the Americans with Disabilities Amendment Act (ADAA) in 2008 ensures that students who have disabilities have access to a free and appropriate public education (FAPE) (U.S. Department of Education, 2023). FAPE provides a student with a physical or mental impairment that impacts one or more major life activities (including learning) with related services and accommodations in the general education classroom (U.S. Department of Education, 2023; NASN, 2023). If the student does not have a 504 Plan the school nurse should determine if an evaluation is indicated (see Student section for questions to ask student and family to determine if 504 or IEP evaluation is indicated). If it is determined that the student qualifies for a Section 504 Plan, the school nurse may want to consider the appropriateness of the following accommodations (this list is not all inclusive):

Times/places for blood-glucose monitoring, including accommodations for testing and treating.
Ensuring that staff members are trained in checking blood-glucose levels, recognizing and treating high and low blood-glucose symptoms, and administering both insulin and glucagon.
Allowing the student to eat whenever and wherever necessary, including eating lunch at an appropriate time and allowing enough time to finish eating.
Allowing extra trips to the bathroom or water fountain.
Ensuring the student’s full participation in all sports, extracurricular activities and field trips, with the necessary care and/or supervision.
Permitting extra absences for medical appointments and sick days when necessary, without penalty (JDRF, n.d.).
Having school nutrition services provide a carb count for school meals/
Providing extra time before meals for the student to check blood glucose, calculate carbs, and administer insulin.
Providing extra snacks before activities, physical education, and/or athletics.
Developing a process to notify parents/guardians in advance of parties or events with food at school (NASN, 2022c).
For a student who uses a CGM:
- Allowing the student to have continuous access to the CGM receiver.
- Allowing the student to be allowed to charge the receiver during school hours, as necessary.
- Allowing the student access to the secure school wireless network.
- Students with enabled data sharing with parents/guardians should have the capability of remote communication (NASN, 2022a).

The American Diabetes Association has developed a Sample 504 Plan.

Resources

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Reviewers

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

April 18, 2025

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