Checking for Ketones

Pursuant Sec. 5 CSR 20-200.300. Training of School Employees in the Care Needed for Students with Diabetes.–Training of school employees in the care needed for students with diabetes shall take place prior to the commencement of each school year, or as needed when a student with diabetes is newly enrolled at a school or a student is newly diagnosed with diabetes, but in no event more than thirty days following such enrollment or diagnosis. The school nurse or another health care professional with expertise in diabetes shall promptly provide follow-up training and supervision as needed. Coordination, delegation, and supervision of care shall be performed by a school nurse or other qualified health care professional.

Pursuant §167.818 RSMo. A student may perform certain diabetic care for self, when. — Upon written request of the parent or guardian and authorization by the student’s diabetes medical management plan, a student with diabetes shall be permitted to perform blood glucose checks, administer insulin through the insulin delivery system the student uses, treat hypoglycemia and hyperglycemia, and otherwise attend to the care and management of his or her diabetes in the classroom, in any area of the school or school grounds, and at any school-related activity, and to possess on his or her person at all times all necessary supplies and equipment to perform these monitoring and treatment functions. If the parent or student so requests, the student shall have access to a private area for performing diabetes care tasks.

Considerations:
● Provide the student with as much privacy as possible.
● Encourage the student to assist in the procedure as much as they are able to help student learn self-care skills.
● Ensure strips are contained in a tightly sealed container and show no signs of discoloration.
○ Prolonged exposure of test strips to air may lead to inaccurate results.
○ Discolored test strips should be discarded.
● Review manufacturer’s instructions regarding how long to keep an opened bottle of test strips before needing to discard.
● Be sure to inform school staff that a student with diabetes should never be sent anywhere alone if feeling hypoglycemic or hyperglycemic.

Supplies:
● Urine cup, urine hat, or clean container
● Ketone testing strips
● Watch with a second hand or a timer
● Paper towels
● Diabetes Medical Management Plan/Health care provider’s order and student’s Individualized Health Care Plan (IHCP)
● Parent/Guardian authorization form

Procedure for checking for ketones:

1. Review the health care provider’s order/Student Diabetes Medical Management Plan
2. Ensure proper documentation of parent/guardian authorization to perform this procedure
3. Position student to provide as much privacy as possible
4. Explain the procedure to the student at their level of understanding
5. Encourage the student to assist in the procedure as much as they are able to help student learn self-care skills
6. Gather supplies and place on a clean surface
7. Check expiration date on testing strips
   a. If expired, do not use, follow up with parents/guardians
8. Ensure strips are contained in a tightly sealed container and show no signs of discoloration
   a. Discolored test strips should be discarded
9. Wash hands
10. Put on gloves
11. Have the student provide a urine sample in a urine cup, urine hat, or clean container
12. Immerse end of test strip into urine container
13. Remove the strip immediately
14. Gently tap it against the urine container to remove excess urine off the strip
15. Hold the strip in a horizontal position to prevent mixing of chemical reagents
16. Precisely time the number of seconds specified on container
    a. Be sure to follow timing instructions accurately as reading too soon or waiting too long could result in inaccurate results
17. Compare color of the strip with color chart on container
18. Discard the testing strip and urine, per school policy
19. Remove gloves
20. Wash hands
21. Document ketone results in student’s health care record
22. Follow Diabetes Medical Management Plan/health care provider’s orders
23. Update parent’s and health care provider, as needed
    

References:
American Diabetes Association. (n.d.). Training resources for school staff. Tips for school nurses. Retreived June 8, 2023, from https://diabetes.org/tools-support/know-your-rights/safe-at-school-state-laws/training-resources-school-staff/tips-for-school-nurses
Diabetic care may be provided to students, when, trained personnel to be on site. Missouri Revisor of Statutes 167.809. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.809

National Association of School Nurses. (2022, June 15). School nursing evidence-based clinical practice guideline: Students with type 1 diabetes toolkit. Retrieved June 2, 2023, from https://cdn.fs.pathlms.com/HRuI7pAvQWiJPZdzH6i8

National Association of School Nurses. (2021). School nursing evidence-based clinical practice guideline: Students with type 1 diabetes. Silver Spring, MD: Author. Retrieved June 2, 2023, from https://learn.nasn.org/courses/37660

Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Procedural guideline 7.2 Urine screening for glucose, ketones, protein, blood, and pH. In Clinical nursing skills and techniques. (10th ed.). (pp. 186-187). St. Louis, MO: Elsevier.

Plan to be submitted by parent or guardian of student with diabetes — review by school. Revisor of Statutes 167.806. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.806

St. Jude’s Children’s Research Hospital. (2022, September) How to check urine for glucose and ketones. Retrieved June 5, 2023, from https://together.stjude.org/en-us/patient-education-resources/tests-procedures/check-urine-for-glucose-and-ketones.html
Training of school employees, content, requirements. Revisor of Statutes 167.803. (2013). https://revisor.mo.gov/main/OneSection.aspx?section=167.803&bid=8398&hl=.
Training of school employees in the care needed for students with diabetes. Missouri Secretary of State: Code of State Regulations. Division 20–Division of learning services. Chapter 200–Office of college and career readiness. (2022). https://www.sos.mo.gov/cmsimages/adrules/csr/current/5csr/5c20-200.pdf

Acknowledgement of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

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
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Page last updated: February 15, 2024
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures

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