Abstract
The safety and well-being of children while they are at school or day care is a major concern in our society. It is therefore important that the professionals who are entrusted with the care of young people possess the knowledge and skills necessary to provide a safe and caring environment for all children, including those with chronic disorders such as diabetes. Each day 35 children in the United States are diagnosed with diabetes mellitus. To make their school experiences positive, it is imperative that school employees be aware of the potential challenges associated with diabetes and how to meet these challenges successfully. This article discusses the role of the school nurse in forming an interdisciplinary team to work with a child with diabetes. It addresses the school nurse’s role in diabetes education of food service personnel in the school. Confidentiality issues are also addressed.
Keywords
INTRODUCTION
Laura recently graduated from college, a typical event in the life of many young American women. There is one factor, however, that makes her story slightly different: Laura is diabetic. The diagnosis was made when she was 8 years old, and diabetes has been her constant companion through grade school, high school, and college. After Laura’s parents called the school nurse to inform her of the diagnosis, the nurse formed an interdisciplinary team, which included Laura’s parents, her teachers, and the school’s teaching assistants, counselor, and food service director. The school nurse led the team and made a care plan for Laura; the teachers and staff members attended educational programs about diabetes. Initially after diagnosis, Laura’s diet prescription included skim milk, which, at that time, was not offered in grade school. Upon learning of Laura’s dilemma, the school food service director placed a special order for skim milk to meet Laura’s dietary needs. She also provided a place for Laura to keep snacks. These were small steps, but positive ones nonetheless. The food service director, the teachers, and the staff members were sufficiently concerned to become involved in the care of a child with special needs. Laura graduated from college cum laude with special honors in nutrition. She still remembers her school personnel.
One in every 750 school-age children must face the challenges of diabetes, the complications of which kill 200,000 Americans yearly. Children spend more than a third of their day in school. By understanding the disease and having some practical knowledge, individuals working in the school system can be a valuable resource in the care of students with diabetes (American Diabetes Association [ADA], 2000a).
WHAT IS DIABETES MELLITIS, AND HOW IS IT DETECTED?
Diabetes mellitus is a chronic, noncontagious disease that prevents the body from properly using food. Initial symptoms of diabetes in a child include the following: excessive thirst, frequent urination (often begins as bedwetting), drowsiness (marks fall in school), increased appetite, sudden unexplained weight loss, sudden vision change (noticeable often first in the classroom), fruity odor to breath, mood changes (may cause behavior problems in school), and heavy breathing (Pilliterri, 1999).
It is estimated that approximately 125,000 individuals under the age of 19 in the United States have diabetes; 13,000 more will be diagnosed this year. Many of these young people attend school or some type of day care (ADA, 2000a). Most children have Type 1 diabetes, the focus of this article. Health care providers all over the country, however, are seeing an increase in Type 2 diabetes in children. Type 2 diabetes differs from Type 1 in that children with Type 2 tend to be obese or lack exercise. There are few symptoms associated with it, and insulin, if required, may be taken orally rather than through injection (Rosenbloom, 2001). Two articles, Totka & Stumpf (1995) and Chase (1999) are excellent references for the professional who is learning about diabetes.
Legal Issues
Under federal law (Section 504 of the Individuals with Disability Education Act of 1991 and the Rehabilitation Act of 1973), diabetes is considered a disability, and therefore any school receiving federal funds must reasonably accommodate the special needs of diabetic children (Gelfman & Schwab, 2001). According to the School Bill of Rights for Children With Diabetes (Children With Diabetes, 2001b), each child with diabetes must be allowed to
Do blood sugar checks.
Treat hypoglycemia with emergency sugar.
Inject insulin when necessary.
Eat snacks when necessary.
Eat lunch at an appropriate time and have enough time to finish the meal.
Have free and unrestricted access to water and the bathroom.
Participate fully in physical education (gym class) and other extracurricular activities, including field trips.
An individualized healthcare plan (IHP) should be done for the child with special health care needs. The IHP must be individualized, based on nursing assessments of the student, the identified nursing diagnoses, appropriate nursing interventions, and student outcomes. The Conejo Valley Unified School District (1993) case illustrates the need for IHPs in creating emergency response procedures for students. The parent of a 6-year-old with diabetes filed a complaint with the Office of Civil Rights and the United States Department of Education when the school district failed to provide appropriate support and emergency planning (Hootman, Schwab, Gelfman, Gregory, & Pohlman, 2001). Including an interdisciplinary team in the management of a child with diabetes allows the school nurse to individualize the IHP and create more realistic emergency response procedures (Strawhacker, 2001).
Some schools complete an assessment of every child with diabetes followed by an individualized diabetes care plan developed through a team effort of parents/guardians, medical care givers, and school personnel. The ADA recommends standards that define basic nutritional care for people with diabetes (ADA, 2000b). Additionally, the ADA provides a statement of specific nutritional recommendations for children with diabetes (ADA, 1998).
In the case of a child with diabetes, it is the school nurse’s responsibility to educate school personnel about the disease and the specific emergency care plan, obtain necessary consents for the child, obtain medical supplies from the parent or guardian, and assist the student with blood glucose monitoring as needed. The school nurse must also make decisions regarding any dietary or activity modifications, administer medication per medical orders, assist the student in attainment of self-care skills, provide teaching to peers about the diabetes, maintain communication with the family, and document any change in health status. Periodically, the nurse must convene the IHP team and evaluate the IHP, making adjustments as needed (Schwab & Gelfman, 2001).
Confidentiality
The Family Educational Rights and Privacy Act (FERPA) of 1974 protects school health records, which include both the education and health care record. Specific written consent from the parent is required before the release of any personally identifiable information from education records. If there is no parental consent, some schools have chosen to deal with the issue of confidentiality by not revealing any medical or psychiatric diagnoses to nonhealth professionals within the school. Instead, relevant health information necessary for educational planning and student safety is shared only among school personnel who work with the student. Rather than a diagnosis, functional health terminology is used (National Task Force, 2001).
The increasing numbers of children with special health care needs in the classroom make it more important than ever that school personnel know how to handle confidentiality. The American School Health Association recently published a book addressing confidentiality of student health information. This book is the result of a 5-year effort by a national task force. The book contains valuable information about confidentiality and has samples of parental consent forms. It is a publication with which every school nurse should be familiar or have in his or her library (National Task Force, 2001).
Importance of Control
The maintenance of normal growth and development, the importance of keeping blood sugar levels within a target range as much as possible, and the promotion of emotional well-being are the goals of diabetes management for children. Control of blood sugar levels is of great importance. Not only is it necessary for a child’s sense of well-being and ability to learn, but also it is critical in the prevention or delay of possible complications later in life, such as blindness and kidney failure (Lewis, Heitkemper, & Dirksen, 2000).
Control doesn’t just happen but is a result of balancing three factors: diet, insulin, and exercise. The term diet may be misleading because to many it represents decreased calories or deprivation. However, the diabetic child has the same calorie and nutrient needs as a nondiabetic child; therefore, the term meal planning may be a better fit. The meal plan should be individualized to meet the diabetic child’s needs for sufficient calories to meet daily expenditures of energy and for the requirements of growth and development (Holzmeister, 1997).
One key to the control of blood sugar is consistency in following the meal plan. The old adage “plan the work and work the plan” applies here. Any deviation from the meal plan, such as eating too much food or not eating enough, could result in loss of control over blood sugar and lead to potential problems, such as hyperglycemia and hypoglycemia, discussed in the next section. The meal plan should be carefully designed and then carefully followed. Many schools now have registered dieticians employed in their food service programs. If a child with diabetes attends a school that does not have a registered dietician, the school nurse should ask one to consult with the school and speak with food service personnel about the child’s special diet. As long as the identity of the student and family is protected, consultation about a particular student without parental consent is acceptable (National Task Force, 2001).
Most school-age diabetic children are knowledgeable and comfortable with their meal plans. School food service personnel should also become knowledgeable and comfortable with the meal plan of each diabetic child because food is such an important part of treatment. Herein lies the unique contribution of school food service personnel, keeping food information on each diabetic child such as “meal and snack times, content and amount to be served at each meal and snack, preferred foods, foods to avoid, and foods to have on hand in case of emergencies” (Children with Diabetes, 2001a).
Another aspect of accommodating children with disabilities is the assurance of access to school meal service, even if special meals are needed because of their disabilities. If special meals are needed and requested, certification from a medical doctor must (a) verify that special meals are needed and (b) prescribe the alternate foods and forms of food needed. Table 1 is a sample of a certification for these meals.
The treatment regime for most diabetic children includes taking insulin, either by injections or delivery by insulin pump. According to the School Bill of Rights for Children with Diabetes (Children With Diabetes, 2001b), diabetic children must be allowed to do blood sugar checks. Most parents of diabetic children are eager to provide classroom supplies for blood sugar monitoring, because frequent blood sugar tests enable the student to determine the correct amount of insulin to inject, as well as to identify high or low blood sugars (Strawhacker, 2001). It is not usually the responsibility of food service personnel to test a diabetic child’s blood sugar or give insulin. It is optimal, however, that food service personnel be alert to the signs of potential problems and know whom to contact in case of an emergency. Indeed, all school personnel should have this knowledge.
Exercise also plays a role in the control of diabetes. Running and playing, as well as other normal childhood activities, should be monitored in the diabetic child because exercise works to lower blood sugar. If a diabetic child exercises beyond his or her normal routine, blood sugar levels could fall, resulting in hypoglycemia or low blood sugar. In this respect, the child’s physical education teacher plays a crucial role on the child’s team. It is a wise idea for all school personnel, including food service personnel, to be alert to possible symptoms of hypoglycemia after a diabetic child has been exercising, to know who to contact if a problem is suspected, and to know the location of appropriate snacks and emergency glucose for treatment.
The Juvenile Diabetes Association recommends that an additional snack of about 15 g of carbohydrate be consumed for every 30 minutes of strenuous exercise. Some snack suggestions include one large piece of fruit, half a sandwich, or a small cup of ice cream (Juvenile Diabetes Research Foundation, 1998).
Signs of Problems and Procedures for Emergencies
Problems do occur occasionally, even in the most carefully controlled cases. Two such problems that occur in diabetes are high blood sugar (hyperglycemia), and low blood sugar (hypoglycemia). Both are serious and should be dealt with in a timely manner. All school personnel should be aware of the symptoms of these diabetic problems and should know what actions to take in case they occur.
Hyperglycemia may occur if the child has eaten more food than his or her meal plan allows or if insulin dosage is not appropriate to cover the amount of sugar in the body (Children with Diabetes, 2001a). Table 2 outlines signs and symptoms of high blood sugar and suggests actions to take in case this condition occurs.
If untreated, high blood sugar may lead to ketoacidosis, a condition when the child’s carbohydrate stores are low or when the body cannot use available carbohydrates for fuel. This could occur after a child’s physical education period, oftentimes before lunch; the symptoms occurring at lunch when the food service personnel are present. The school nurse should be contacted immediately if any of the following is observed: labored breathing, vomiting, abdominal pain, fruity odor to breath, or progressive drowsiness possibly leading to coma. Timely treatment is important in the prevention of coma and for the quick recovery from ketoacidosis. Therefore, food service personnel should be alert to any changes in the behavior or appearance of the diabetic child.
Hypoglycemia may occur if the child has not eaten enough food as allowed by the meal plan or has experienced a fall in the blood sugar due to too much insulin or extra exercise (Children with Diabetes, 2001a). Tables 3 and 4 outline signs and symptoms of mild, moderate, and severe hypoglycemia and suggest actions to take (Children with Diabetes, 2001a).
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
Federal mandates bringing greater numbers of children with chronic medical conditions into the regular public classroom has greatly expanded the role of the school nurse (Lundy & Janes, 2001). The importance of interdisciplinary collaboration is paramount. The School Nurse Organization of Minnesota (SNOM) has proposed a model of nursing services that captures the complexity of school nursing. This model includes the interdisciplinary aspects of the school nurse’s role (Lundy & Janes, 2001).
Because school nurses are not always available when a question about the child’s special need or an emergency occurs, it is essential they include other school personnel in the creation and implementation of the IHP. For school personnel to feel comfortable with this plan, they must know about the child with whom they will be dealing and about their special needs. School personnel need and desire greater knowledge of how to manage students’ health needs (Thies, 1999).
Nearly 10,000 children who returned to school in fall of 2001 had diabetes; more and more, school food service personnel will be asked to assist with these children and meet their special needs. Many food service personnel are unfamiliar with diabetes and thus fear it. Simple education from the school nurse can calm this fear (The New Schoolyard Heroes, 2001). Food service personnel are invaluable in assisting the school nurse with decisions regarding dietary modifications. In addition, they may be the ones present when a problem arises. Table 5 is a sample teaching plan for the school nurse to use when talking with food service personnel about diabetes.
Issues of confidentiality should be addressed by the school nurse with the parent or guardian at the beginning of the school year, as should those of medical liability. A standard parent permission form as a component of registration would suffice. This would allow the school nurse to exchange pertinent information with the food service personnel involved in the child’s care (School Health Centers, 2001).
CONCLUSION
Who knows what is next? School food service personnel may be required by law to learn new skills beyond preparing food and keeping records. Research indicates the need for school personnel to know more about diabetes to relieve the fears of parents and the anxiety of the children with diabetes (Waldron, Swift, Raymond, & Botha, 1997).
Laura Langford, the young lady mentioned at the beginning of the article, recently graduated from Jacksonville State University in dietetics. She is currently in the dietetic internship at Moorehead State in Kentucky. The school nurse and food service personnel in Laura’s school made a difference in her life with diabetes.