Emergency Intervention, Endocrine
Discussion: Just in Time Learning
Pursuant to 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.
Considerations:
- Low blood sugar in children with diabetes can have varied symptoms. These can include but are not limited to:
- nervousness,
- shakiness,
- weakness,
- extreme hunger,
- slight nausea,
- dizziness,
- headache,
- blurred vision,
- fast heartbeat and/or
- feeling tired.
- Based on the student’s diabetes medical management plan/health care provider’s order, low blood sugar is treated with some type of quick-acting oral sugar, such as candy, icing/cake frosting tubes, and/or juice.
- Severe low blood sugar symptoms include disorientation, unconsciousness, and seizures. If not treated promptly it could lead to death.
- Glucagon is a medication used in emergency situations when the student is unresponsive or unable to swallow because of very low blood sugar.
- Given that when a student is having symptoms of severe low blood sugar, it can be a stressful situation, it is highly recommended that you familiarize yourself with the student’s emergency plan beforehand.
- The school nurse or other qualified health care professional must review the glucagon procedure with staff to ensure that they have the skills to perform this emergency medication administration.
- Store the diabetes medical management plan/health care provider’s order and glucagon in a location that is easily accessible during a severe blood sugar event.
- Be sure that staff members who have regular contact with the student know where the medication is stored.
- If the student self-carries their glucagon be sure to communicate with the student to know where they store their medication.
- The school nurse should develop a plan to systematically check the expiration date on medication to ensure medication is not expired.
- Remember to keep the student’s health care information confidential.
Supplies:
- Glucagon kit
- Alcohol wipe
- Gauze or cotton ball
- Gloves
- Diabetes Medical Management Plan/health care provider’s order and student’s Individualized Health Care Plan (IHCP)
- Parent/Guardian authorization form
Procedure for administering injectable glucagon:
- Identify that symptoms of a severe low blood sugar reaction are present and that based on the student’s Diabetes Medical Management Plan/health care provider’s order, emergency medication needs to be given
- Call for assistance
- Ask that another school staff person call 911 or emergency medical services
- If able, move the student to a lying position
- Explain the procedure to the student at their level of understanding
- Review the six rights of medication administration to be sure it is:
- The right student
- The right medication
- The right dose
- Being given at the right time
- Being given by the right route
- Being given for the right reason
- Check the medication expiration date
- Ensure proper documentation of parent/guardian authorization to administer medication
- Review the student’s allergy status
- Wash your hands, if possible
- Assemble supplies and place on a clean surface
- Review the six rights again to ensure that it is:
- For the right student
- The right medication
- The right dose
- Being given at the right time
- Being given by the right route
- Being given for the right reason
- Put on gloves; if gloves are not available, continue with procedure
- Remove the glucagon vial and syringe containing the liquid or diluent from the case
- Remove the cap from the glucagon vial
- Remove the cap from the syringe containing the liquid
- Do not remove the plastic clip from the syringe, as this may allow the push rod to come out of the syringe
- Insert the needle tip in the center top of the rubber stopper on the vial and slowly push the liquid from the syringe into the vial
- Gently swirl the vial with the syringe still in the vial until the solution is clear (this takes about 10-15 seconds). Do not take the syringe out of the vial
- Do not use if the solution is cloudy or if you see particles in the solution
- Turn the vial upside down, being sure that the needle does not fall out of the vial
- Pull the solution into the syringe, by pulling back on the plunger, as you withdraw the ordered amount of glucagon solution
- Do not pull the plunger out of the syringe
- Keep the needle inside the vial
- Check the syringe for air bubbles
- If you see bubbles, tap the syringe until the bubbles rise to the top of the syringe
- Gently push on the plunger to move only the air bubbles back into the vial
- If this method does not work to remove all the air bubbles, push the dose back into the vial and pull back on the plunger again to withdraw the ordered amount of glucagon
- Once all the air bubbles have been removed, take the syringe and needle out of the vial
- Identify the location (buttock, thigh, or arm) for the injection
- If you have an alcohol wipe, cleanse the injection site
- Insert the needle into the skin at a 90 degree angle
- Slowly inject the solution
- Once all the solution has been injected, remove the needle
- Put the used syringe in the carrying case
- Close the carrying case to avoid a possible needle stick injury
- Apply pressure using the gauze pad or cotton ball
- If the student is not lying on their side, move the student to a side-lying position because vomiting often follows the injection of glucagon
- If needed, ask another person for assistance
- If alone with student, and you have not already called 911 or emergency medical service, do so now
- Monitor the student’s arousal, pulse and respirations, and for potential seizure
- If the student begins to seize, clear the area of anything hard or sharp, to prevent injury
- Place something soft under the student’s head and time the seizure
- If breathing stops, move the student onto their back
- Begin rescue breaths
- If breathing and heartbeat stop, begin CPR
- Stay with the student until rescue squad arrives
- As soon as the individual is awake and able to swallow, give the individual a fast-acting source of sugar (such as fruit juice)
- Once rescue squad arrives, inform them of medication administered, including type of medication, dose and time
- Send along glucagon kit with used dose
- Dispose of all used materials in proper receptacles
- Remove gloves and wash hands
- Follow up with the parent or guardian and health care provider, as needed
- Document medication administration in the student’s medication administration log
References
American Diabetes Association. (n.d.). Hypoglycemia (low blood sugar). Retrieved June 2, 2023, from https://diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia
American Diabetes Association. (n.d.). Medications and treatments. Glucagon and other emergency glucose products. Retrieved June 2, 2023, from https://diabetes.org/healthy-living/medication-treatments/glucagon-other-emergency-glucose-products#:~:text=Glucagon%E2%80%94a%20hormone%20that%20raises,you%20in%20case%20of%20emergencies
Centers for Disease Control and Prevention. (2022, January 2). Seizure first aid. Retrieved June 6, 2023, from https://www.cdc.gov/epilepsy/about/first-aid.htm
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
Fresenius Kabi. (2019, November). Summary of instructions for use. Glucagon emergency kit for injection, 1mg/ml. Retrieved June 2, 2023, from https://glucagonemergencykit.com/wp-content/uploads/2019/12/Glucagon_IFU_191122.pdf
Levitsky, L.L., & Misra, M. (2022). Hypoglycemia in children and adolescents with type 1 diabetes mellitus. In a J. I. Wolfsdorf (Ed.), UpToDate. Retrieved: June 2, 2023, from https://www.uptodate.com/contents/hypoglycemia-in-children-and-adolescents-with-type-1-diabetes-mellitus
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
National Diabetes Education Program. (2016). Helping the student with diabetes succeed: a guide for school personnel. Retrieved June 2, 2023 from https://diabetes.org/sites/default/files/2020-02/NDEP-School-Guide-Full-508.pdf
National Library of Medicine. (2019). Glucagon injection. Retrieved June 2, 2023, from https://medlineplus.gov/druginfo/meds/a682480.html#:~:text=Glucagon%20can%20be%20injected%20with,and%20how%20to%20administer%20glucagon
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
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
Wyckoff, L. (2019). Students with diabetes. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 575-602). Philadelphia PA.: F.A. Davis Co.
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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 21, 2024
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