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NASN School Nurse

http://nas.sagepub.com Insulin Pump Therapy

Catherine Marschilok NASN School Nurse 2009; 24; 25 DOI: 10.1177/1942602X08328275 The online version of this article can be found at: http://nas.sagepub.com

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National Association of School Nurses

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Diabetes

Insulin Pump Therapy

Catherine Marschilok, MSN, CDE, BC-ADM, New York

Brought to you by the National Diabetes Education Program Keywords: diabetes; children; school issues; psychological adjustment; insulin pump

M

ore children with diabetes are using pump therapy than ever before. All adults responsible for a student with diabetes during the school day need to have a basic understanding of how the pump works and when they may have to intervene to troubleshoot or help the student who uses a pump. School Nurses, in particular, need a higher level of understanding and competence than other school personnel do. This article provides an overview of pump therapy and how to help students manage their use of the pump in the school setting.

Advantages of Insulin Pump Therapy

To live with diabetes, children with type 1 diabetes must control their blood glucose by balancing food, insulin, and exercise. Insulin can be given by traditional injection, pen, or pump. Pump therapy more closely mimics normal physiology by delivering insulin continuously. The insulin pump has several advantages, as shown in Table 1.

Insulin Pump

Source: Medtronic MiniMed Paradigm® REAL-Time System, Courtesy Medtronic, Inc.

How the Insulin Pump Works

Insulin pumps are computerized devices that may look similar to pagers, beepers, or handheld electronic devices. Pumps attach with a small needle that stays in place or a guide needle drives a small catheter through skin and is then removed, leaving a small, flexible cannula under the skin. The pump might be tethered to the student with tubing that connects the pump to the site. Another style pump holds insulin in a pod that adheres to skin and communicates with separate handheld device. Sites used for all types of pumps most often include

DOI: 10.1177/1942602X08328275

the fatty tissue areas of the abdomen, buttocks, thighs, or arms. The pump site needs to be changed every 48 to 72 hours. Pumps deliver insulin in basal or bolus doses. Basal Doses Basal insulin is the steady dose of short-acting insulin delivered throughout the day (approximately half of the total insulin for the day). In most cases, the nurse will not need to make any changes in the basal dosage. Bolus Doses Bolus doses are given at meal or snack time or to lower blood glucose when it is too high. When the student checks blood glucose and inputs carbohydrate count, the pump suggests insulin bolus dose needed to correct the blood

glucose to the target range and accommodate carbohydrate intake. The student or caregiver then pushes a button to deliver the bolus dose of insulin. Students should come to school with a functioning site and enough insulin in the pump reservoir to last through the school day. Parents should provide the following back-up supplies to be available in the School Nurse's office: batteries, two infusion sets, infusion set inserter device if needed, two insulin reservoirs, insulin bottle, traditional syringe or insulin pen and pen needle, skin prep supplies (disposable pad that cleanses skin), alcohol wipes, a user manual for the pump the student uses, a quick programming card, ketone strips, blood glucose testing supplies, glucagon emergency kit, and glucose tablets.

January 2009 | NASN School Nurse

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Table 1

Advantages of Pump Therapy

Precise Predictable Convenient Continuous delivery Individualized therapy Smart Delivers insulin in precise units--as little as one tenth of a unit-- to closely match the student's needs. Absorption of rapid-acting insulin is more predictable than that of long-acting insulin. Holds a supply of insulin for several days. Delivers background or basal insulin 24 hours per day. Programmed to meet the student's needs; easily adjusted. Most calculate insulin doses based on carbohydrate intake, student's personal insulin to carbohydrate ratio needs and insulin sensitivity factor, and previous dose. Lifesaving for children who have widely fluctuating blood glucose levels. Freedom to vary when, what, and how much to eat. Children who wear pumps can participate in all school activities. They can leave the pump in place during most athletic activities.

· Deliver a bolus dose of insulin. · Check the pump memory. · Troubleshoot problems (if a problem with insulin delivery occurs, insert new pump site or give alternative form of insulin via injection with syringe or pen). · Replace batteries. School Nurses have several options for obtaining training in insulin pump therapy. Diabetes educators and insulin pump company staff members often provide training for School Nurses and staff. Contact your local chapter of the American Association of Diabetes Educators to discuss training needs (www .diabeteseducator.org). The back of most pumps lists a toll-free telephone number for technical assistance (see below). Also, most children who use insulin pumps live with adults who are very involved in their diabetes care and many of these care givers are capable of providing School Nurses with necessary training.

Improved control Flexibility

How to Handle Common Problems

Even with diligent self-care, the following may occur and require the involvement of the School Nurse. The needle, cannula, or pod can accidentally fall out or get pulled out. The cannula can become occluded fully or partially under the skin and prevent or interfere with insulin absorption. The pump or pod can run out of insulin. The pump can break. If steady delivery of insulin is compromised because of these or other problems, the blood glucose rises fast, high blood glucose symptoms escalate, and within a few hours the student can progress into diabetic ketoacidosis (DKA), an acute complication of high blood glucose. School Nurses and staff members must understand that students who use an insulin pump have no long-acting insulin to help prevent the progression to DKA. Therefore, students must be able to respond quickly to any situation that interferes with steady delivery of insulin: · Change the site in school, with help from the School Nurse or a trained school staff member, or · Take an injection of insulin to make up for missed basal doses.

Care Plans for the Student With a Pump

All children who use pumps should have a school healthcare plan that spells out the following: · The responsibilities of the School Nurse and the level of self-direction of the student. · Basal dose, bolus dose for high blood glucose, and bolus dose for meals and snacks. · Emergency contact numbers. · A protocol for handling pump problems including an alternative form of insulin delivery. To be safe with insulin pump therapy in school, students must · Check their blood glucose multiple times throughout the day. · Respond to low or high blood glucose readings. · Receive help when blood glucose levels are low or high. · Never go anywhere alone when they are experiencing high or low blood glucose.

Resources: Insulin Pump Companies

Animas: www.animascorp.com; 1-877-937-7867 Medtronic Minimed: www.minimed.com; 1-800-933-3322 Nipro: www.niprodiabetes.com; 1-888-651-7867 Omnipod: www.myomnipod.com; 1-800-591-3455 Roche: www.disetronic-usa.com; 1-800-280-7801 Smith Medical: www.DeltecCozmo.com; 1-800-826-9703 Catherine Marschilok, MSN, CDE, BC-ADM

Grant Manager Center of Excellence, Albany Medical Center Albany, NY

Pump Information and Training Resources

To assist students with diabetes who use pumps, School Nurses should be technically competent to

Catherine serves on the Juvenile Diabetes Research International Public Affairs Committee and on the National Diabetes Education Program's Diabetes in Children and Adolescents Work Group.

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