Diabetes care in school: prepare for the unexpected.

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Diabetes
November 2008
www.schoolnursenews.org School Nurse News 39
Diabetes Care in School:
Prepare for the Unexpected
By Catherine Marschilok, MSN, CDE, BC-ADM
C
of time since diagnosis, and self-care
knowledge and abilities, diabetes in
school can create unpredictable dif-
ficulties, sometimes at inconvenient
times. It is not easy to predict how well
a student and family will cope with
diabetes and it can be difficult to an-
ticipate the school nurse’s workload
and stress level associated with caring
for the student with diabetes. Some
“real life” scenarios are presented here
to help school nurses understand the
complexities of diabetes management
and provide families appropriate and
timely support and guidance.
aring for students with diabetes
is challenging. Regardless of the
student’s type of diabetes, length
The new school year is about to begin
You are the nurse at School #1 and twin
brothers with diabetes have just moved
to your school. The twins are 12 years
old and live with their single mother
and two sisters. They developed type 1
diabetes at ages 4 and 7. Both use insu-
lin pumps. The family has little money.
Your school nurse colleague at School
#2 has a 12-year-old student who devel-
oped type 1 diabetes 2 years ago and be-
gan pump therapy 9 months ago. She is
an only child, living with two well edu-
cated and employed parents, in a subur-
ban neighborhood. After her diagnosis
of diabetes she independently learned
all her diabetes care tasks.
Most readers would assume that the
nurse caring for the twin boys would
have more diabetes management diffi-
culties during the school year, but just
the opposite occurred. At School #1, the
boys arrived in September with their
glucagon kits, low-blood-glucose sup-
plies for every class, back-up insulin in
the form of pens, and extra blood glu-
cose meter test strips. Each day they ar-
rived at school with functional infusion
set sites and enough insulin and battery
power to get through the school day.
Their mother was responsive to requests
from the school nurse to deliver sup-
plies as needed. Good communication
about the boys’ needs was established on
a regular basis between the mother and
the school nurse.
In contrast, at School #2, the appro-
priate supplies were delivered on the
first day of school, but once they were
used up, the parents did not respond to
requests to replenish them. The student
often arrived with an infusion set that
was not functioning or that had been
in situ for more than three days. She
also often did not have enough insulin
in her pump cartridge to last through
the school day. When her parents were
called they were concerned, but failed
to become more attentive. This com-
munication pattern with the parents,
and the student’s apparent inability to
manage her diabetes, proved to be very
frustrating for the school nurse. Two
episodes of diabetic ketoacidosis (DKA)
occurred. During one of the girl’s acute
care hospitals stays, her pump and
blood glucose meter memory features
revealed that there were days that she
did not inject the prescribed bolus
doses of insulin and that she tested her
blood glucose infrequently.
The twin boys at School #1 have had
A1Cs less than 7 percent for the last
few years, and neither one has had an
episode of DKA. The twins’ mother ac-
cepted their diabetes diagnosis as a chal-
lenge in life that required her to channel
her energies into doing the best job pos-
sible to manage their diabetes. While
the mother is “in charge” of their dia-
betes care, she clearly expects her twins
to be responsible for their diabetes self
care. To meet her expectations, the boys
do all they need to do to take care of
their diabetes during the school day,
after school program hours, and during
summer programs.
At School #2, the student’s A1C
climbed into double digits during the
year. The parents were ineffectual in
taking responsibility for their daugh-
ter’s diabetes management and in pro-
viding her appropriate guidance and
support, and in clarifying expectations
for self care. Even during her two en-
tirely preventable DKA episodes the
parents failed to recognize that their
lack of supervision of some crucial ele-
ments of their daughter’s diabetes care
put her life at risk. Unlike the twins’
mother, the girl’s parents had become
immobilized by grief. The school nurse
and other members of the healthcare
team recommended that the family be
referred for counseling to help them ad-
just to and cope with the demands of
diabetes care.
Type 2 diabetes in school-aged children
requires a variety of diligent efforts by
the school nurse
Student A is a 14-year-old girl diagnosed
with type 2 diabetes a year ago. Her
treatment plan began with nutrition
therapy and metformin. Three months
ago insulin therapy was initiated. Her
weight has climbed to over 250 pounds
and her A1C is 11.5 percent, which in-
dicates that her average blood glucose is
above 310 mg/dl. A is an only child and

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Diabetes
40 School Nurse News
www.schoolnursenews.org November 2008
lives with her mother in a subsidized
apartment. Her father lives out of town
and A sees him irregularly. Her mother
cries during every visit to the healthcare
team. During a recent visit, A’s mother
admitted she did not always supervise
her daughter’s insulin administration,
and A stated that she omits doses when
she “does not feel like taking it.” The
school nurse was allowing A to step be-
hind a curtain for privacy when inject-
ing her lunch-time insulin and A also
admitted to regularly omitting that
dose as well.
A strategy to increase the level of
supervision was implemented. The
mother and the school nurse agreed
that they would observe all A’s insulin
injections, and be willing to give the in-
jection when A requested. This simple
action and ongoing encouragement of
A’s efforts resulted in improved blood
glucose values.
Student B is a 14-year-old boy re-
cently diagnosed with type 2 diabetes
who lives with his single mother and
three brothers. He is enrolled in special
education setting because of his autism
and limited verbal abilities. Upon di-
agnosis, B’s A1C was 12, indicating his
average blood glucose was above 345
mg/dl. Metformin was prescribed and
his mother and older brother received
nutrition therapy counseling. They
seized upon what they learned and im-
proved the nutrition of the entire fam-
ily, despite their limited means. At his
3-month visit to the healthcare team,
B’s A1C had decreased several
percentage points and 6 months
following his diagnosis his A1C
was 7 percent. The school nurse
was instrumental in supporting
the boy’s diabetes care plan and
in facilitating the prescribed
regimen of blood glucose test-
ing during the school day. The
nurse also advocated for incor-
poration of physical activity
into his educational plan and commu-
nicated regularly with the family about
his management.
Student C is a 13-year-old boy who
was told by his teacher to go to the
bathroom to wash his neck. The stu-
dent complied with the request and re-
turned to class. When the dark marks
on the back of his neck looked the same,
the teacher repeated the request. C re-
turned from the bathroom unchanged a
second time. The next day, C brought a
note in from his parents informing the
teacher that he had pre-diabetes and
that his healthcare team was working
with his family to take steps to prevent
him from developing type 2 diabetes.
The boy had very noticeable acanthosis
nigricans on his neck. The school nurse
had not been informed of C’s pre-dia-
betes and so had no opportunity to in-
form school personnel about acanthosis
nigricans and its association with insu-
lin resistance and pre-diabetes.
There are many issues related to man-
agement of type 2 diabetes in school.
Treatment regimens can be labor in-
tensive if they involve blood glucose
monitoring and insulin administra-
tion. Carbohydrate counting and help-
ing students achieve adequate physical
activity are further challenges. In ad-
dition, there may be social and behav-
ioral issues that affect families as they
attempt to provide consistent, quality
diabetes care.
What are the similarities between the
management of type 1 and type 2
diabetes in school?
Both types of diabetes can present dif-
ficulties and challenges. Both require
lifestyle change and adaptation for the
child and the family. Emotional
responses and family dynamics
often “make or break” successful
diabetes management. The ex-
pertise and ability of the school
nurse is a vital treatment com-
ponent as the nurse guides the
student’s and family’s success
during the school day and com-
municates issues to the larger
health care team.
AbouT The AuThor
Catherine Marschilok, MSN, CDe, bC-ADM is a
diabetes educator in New York and a member of the
National Diabetes Educations Program’s Diabetes in
Children and Adolescents Work Group.