Diabetes Mellitus

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Introduction

Diabetes mellitus (diabetes) is a chronic condition in which the bodys capacity to deliver or react to the hormone insulin is inhibited. This results in the irregular breakdown of carbohydrates, and elevated or decreased glucose in the body. The side effects of high and low glucose can cause many serious, even life threatening conditions (Selekman, 2002). The prevalence of diabetes in school age children continues to rise and that means there are more diabetic students in schools.

The increased population requires an increase in the amount of people who must care for these students. The role of the school nurse is of utmost importance for the diabetic student. The nurse not only cares for the child but must educate the staff in regard to the child's condition. In addition to educating the staff it is the nurses responsibility to put into place an Individual Health Plan (IHP), an Emergency Care Plan (ECP) and a 504 if warranted. All children are entitled to an education regardless of health status and it is the duty of the school nurse to ensure the diabetic student is in an environment in which they are able to learn and have their health needs met.

Literature Review

The care of diabetic children in the school setting is widely discussed topic. This review discusses the benefits of having a nurse in school for diabetic students. The literary review was done using the terms diabetic children, school, nurse and school age child to utilize articles from 2012 through present. The articles focus on the child and parents experience for the diabetic student in school.

The benefits of having a nurse to care for the child while in school and the laws that are associated with diabetes in the school setting. Background information on diabetes was obtained from the Centers For Disease Control and the American Diabetes Foundation for Children. The laws that pertain to the diabetic school age child were acquired form the Pennsylvania code and from the Department of Health.

Discussion of the Findings

History While the incidents of adult onset diabetes has been declining in recent years, juvenile diabetes, Type 1 and 2, has been on the rise (CDC, 2017). Diabetes dates back thousands of years. The diagnosis of diabetes consisted of doctors observing the amount of urinating a person did, and if copious amounts of sweet smelling urine were produced the doctor would diagnose diabetes. There was no understanding of the disease process or how to treat the condition.

Fast forward to the 17th century when Dr. Thomas Willis would taste his patients urine to diagnosis diabetes. He found that if their urine was sweet tasting they has diabetes (Roberts, 2015). This diagnostic technique remained the same until the twentieth century. It was not until researchers experimented by removing a dogs pancreas in 1889, was the role of the pancreas understood (WJD, 2016). In 1921, Frederick Banting and Charles Best,using what was already known about the pancreas were able to extract the pancreatic islets and administer to patients suffering from type 1 diabetes (WJD, 2016).

This discovery of insulin was the turning point for the treatment of diabetes. It was not until the 1950s that the first oral diabetes medication was introduced and in the decade after many different treatments for diabetes including metformin, glucosidase inhibitors and insulin sensitisers(Lakhtakia, 2013) were used to treat diabetes in different ways. The first human insulin (Lakhtakia, 2013) was made with synthetic insulin following shortly after in 1982. In the late 1970s, the first needle-free insulin delivery system was developed(Lakhtakia, 2013. The advances have continued in recent years with pumps that monitors insulin levels and are able to not only stop the insulin dose but can send an alert via phone to inform of the low blood sugar level (Ahern, 2017).

Symptoms/Diagnosing

The symptoms of diabetes include but are not limited to polyuria, polydipsia, fatigue, vision disturbances, and unexplained weight loss. Type 1 diabetes is usually a sudden unset and needs immediate treatment or it can be fatal (JDRF). Undiagnosed type 1 diabetes can result in Diabetic Ketoacidosis (DKA). DKA is the leading cause of death in children with diabetes. When the body does not make insulin it breaks down fat to use for energy. The using of the fat creates ketones, which at high levels can be fatal due to creating a state of ketoacidosis. The diagnosis of diabetes is done by checking the blood sugar level and the Glycated hemoglobin (A1C) level, which is the average blood sugar level over a three month period. Blood work which checks for common antibodies in diabetics, and urine dip test to check for ketones will also be done. Once a diagnosis of diabetes is confirmed treatment and education will begin immediately .

Treatment School age children spend a major part of their day in a school setting and it is crucial for the school to work in conjunction with the families with the treatment plan put forth by the doctors. (Pansier, 2015). Working with the family and the care team, the school must ensure the child is receiving the treatment in an environment which ensures the childs health. The data shows this is best done with a nurse in the school to ensure the safety of the child and to educate the staff on the warning signs and treatment which is needed (Peery et al, 2012). When a child with diabetes starts school it is of the utmost importance for the family and the school staff to work together. All necessary forms, in which each school district differs, must be filled out by the doctors to enable the school and the school nurse to administer the treatment.

The Individual Health Care Plan (IHCP) would be developed with input from the family and the Diabetes Medical Management Plan (DMMP) from the childs medical care team. The IHCP and if needed the Section 504 Accommodation Plan are imperative to the safety of a diabetic student. The individual treatment plan of the child would dictate what would be in the IHCP and 504. The treatment of the child must be done in an environment which ensures the childs dignity and privacy (Stefanowicz et al, 2018).

They IHCP should include the plans to ensure the students blood glucose within the range dictated in the DMMP and what actions needed to be done if the levels are not in the range (PA.DOH,2017). Also included in the IHCP would be designated trained diabetes personnel, these would be staff members who would be designated to care for the child if no nurse was available. An Emergency Care Plan (ECP) would also be drawn up for episodes of hyperglycemia and hypoglycemia. This plan would then be given to all staff members who have responsibility for the student. This may include but is not limited to teachers, lunch room personnel, and bus drivers.

Current Legislation

One of the federal laws which would affect a student with diabetes is the Rehabilitation Act of 1973, Section 504. A 504 plan is a federal law which ensures that all students, regardless of disability are ensured an education. With this education they are guaranteed to be treated fairly and modifications to their education are made if needed. The 504 can be used for a student with diabetes to outline what happens if a student is having episodes of high or low blood sugars and misses class work. The 504 gives the student reasonable services needed(ADA). A state law in Pennsylvania which pertains to diabetic students is House Bill 1606. This law states that a staff member, which is not a nurse, can administer insulin if a nurse is not available.

The staff member must receive training, and they can not be forced to take on the responsibility. The staff member must complete educational training either through the state or from a licensed health care provider( H.B. 1606). The law also states the parent and doctor need to give written permission for the staff member to provide treatment for the student.

House Bill 1606 also ensure that a diabetic student can self administer and can carry their supplies if the student has written permission from their doctor and parent and shows competency. The school nurse must have the student demonstrate competency and then both the nurse and the student would sign a document in which the student acknowledges he was informed of the school policies and will abide by all rules. The school has the authority to remove the students right to carry said supplies if any rules were not abided to by the student.

Implications for school nurse practice

With children being in school for six to eight hours a day, sometimes more with extra curricular activities or after care programs, the school nurse is a crucial part of a diabetic students care (Kise et al, 2017) According to the American Association of Diabetes Educators, the care of diabetic students requires complex daily management skills. Maintaining optimal blood glucose levels helps the student with learning and also establishes long term health benefits (Kise et al, 2017). Having a school nurse to assist the student on a daily basis certifies the child is being followed by a health care professional, and the nurse can ensure the childs wellbeing. Poor management of diabetes in school can lead to poor academic performance, increased absences and increased health risks.

With the nurse as the primary health care professional in the building in most cases it falls on them to educate not only the child but the staff on health conditions. Diabetes is a chronic condition which can have life threatening ramifications if not treated properly. A child with diabetes, especially newly diagnosed, needs a great deal of education on the condition and the school nurse is able to assist the childs doctor with this education. The nurse sees the child five days a week, in some cases multipole times a day.

The education which the child receives can help to ensure the child is checking blood sugars as directed, not skipping doses of insulin and eating well balanced meals. The school nurse office gives the student a safe, private space to check blood sugars and administer insulin. According to the review done by Stefanowicz, parents of children with type 1 diabetes believe having a school nurse in the building are consistently effective and should have an impact on the condition, improvement of metabolic control, school activity and safety at school.

Conclusion

The school nurse is an integral player in a diabetic students education. The nurse ensures the childs health needs are being met at all times during the school day and educating the child on the chronic condition which will shape the students life. The role of the school nurse is vastly underrated by many in the medical field but without school nurses student health would be at risk. The school nurse maintains a connection with the diabetic student, teachers and family members to make sure the child is being educated in a safe and healthy environment.

With the population of diabetic students increasing it is more important than ever for the school nurse to be available. The National Association of School Nurses states that diabetes is the number three health condition affecting children in the school setting. With both federal and state laws requiring students health needs be met while in school, the literature maintains that a school nurse is the best possible resource for the student.  

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