Update on Insulin Pump Therapy
By Catherine Marschilok, MSN, CDE, BC-ADM
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Children with diabetes are using
pump therapy in greater numbers
than ever before. When students
with diabetes make the leap from injection
therapy to insulin pump therapy,
everyone involved in their care, including
school nurses and staff members, must
be prepared to make the leap with them.
School nurses, in particular, need a higher
level of understanding and competence
than other school personnel.
This article provides an overview
about pump therapy and how to help
students manage their use of the pump
in the school setting.
Advantages of Insulin Pump Therapy
All children with type 1 diabetes require insulin from an outside source.
To live with diabetes, they must control
their blood glucose by balancing food, insulin, and exercise. Insulin can
be given by traditional injection, pen, or pump. The pump acts somewhat
like the pancreas by delivering insulin continuously. The insulin pump has
several advantages over other forms of insulin delivery:
Precise — The pump delivers insulin
in precise units – as little as one tenth
of a unit – that can be closely matched
to needs.
Predictable — Absorption of short-acting insulin, which is used in the pump, is more
predictable than that of long-acting insulin. Continuous delivery — The pump delivers
background or basal insulin 24 hours a day and also allows the user to change
the amount delivered on an hourly basis, if necessary.
Convenient — The pump holds a supply of insulin for several days and it eliminates
the need for scheduled injections since it delivers insulin continuously.
Individualized therapy — The pump can be programmed to meet each person’s
needs and is easily adjusted to keep blood glucose levels in the target range during
illness or physical activity.
Smart — Most current pumps calculate insulin doses needed based on carbohydrate
intake, user’s personal insulin-to-carbohydrate ratio and insulin sensitivity
factor, and insulin still active in the body from the previous dose.
Improved control — The pump can be lifesaving for children who have a history
of widely fluctuating blood glucose levels. People who use the pump are better
able to keep their blood glucose in the target range.
Flexibility — The pump gives children more freedom to vary when, what and
how much they eat, through the continuous infusion of short-acting insulin
and the ability to “cover” with additional doses as needed.
How the Insulin Pump Works
Insulin pumps are computerized devices that look similar to a pager or beeper.
The pump is attached to its user through a cannula that is inserted through the
skin and taped into place. A needle is used to insert the cannula and then removed.
The sites used most often include the fatty tissue areas of the abdomen,
buttocks, thigh or arm. The pump site needs to be changed every 48 to 72 hours.
Pumps deliver insulin in two ways.
Basal insulin refers to the steady dose of short-acting insulin that the pump
delivers throughout the day. Approximately
half of the total insulin for the
day might be received in the basal insulin
that is pre-programmed. In most
cases, the nurse will not have to make
any changes in the dosage.
Pumps also deliver bolus doses of insulin.
When the student checks blood
glucose and inputs carbohydrate count,
the pump suggests the insulin bolus
dose needed to correct the blood glucose
to the target range and accommodate
carbohydrate intake. The student
or care giver then pushes a button to
deliver the bolus dose of insulin. The
bolus is given at meal or snack time or to
lower blood glucose when it is too high.
Students should come to school with a
functioning site and enough insulin in
the pump reservoir to last through the
school day. The following back-up supplies
should be available in the school
nurse’s office: batteries, 2 infusion sets,
infusion set inserter device if needed, 2
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, a quick programming
card, ketone strips, blood
glucose testing supplies, glucagon kit,
and glucose tablets.
How to Handle Common Problems
Even with diligent self-care, a student’s
pump site can become nonfunctional
during the school day and may require
the involvement of the school nurse.
The cannula 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. When a student has
used more insulin than usual since the
last site change, the pump can run out
of insulin. Pumps can break.
If steady delivery of insulin is compromised
due to these or other problems, the
blood glucose rises quickly, hyperglycemia
symptoms escalate, and within a few hours,the student can progress into DKA (diabetic
ketoacidosis). 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.
They either may change the site in school,
with help from the school nurse or a trained
school staff member, or they may take an
injection of insulin to make up for missed
basal and bolus doses.
Care Plans for the Student with a Pump
All children who use pumps should
have a school healthcare plan that carefully
spells out the responsibilities of the
school nurse, the level of self-direction of
the student, emergency contact numbers,
and a plan for an alternative form of insulin
delivery. The student’s healthcare provider
should include current basal dose,
bolus dose for high blood glucoses, and
bolus dose for meals/snacks. Boluses for
meals are given according to the amount
of carbohydrates eaten. The student’s
healthcare plan also should include a
protocol for handling pump problems.
This protocol should be individualized
to the student’s abilities and to the school
nurse’s comfort level. Children who wear
pumps can participate in all school activities.
They can leave the pump in
place during most athletic activities and
they have flexibility in food choices and
meal timing. As noted above, when students
suspect problems with their pumps,
they may need to go to the nurse’s office
quickly and may not be able to wait until
the end of class.
To be safe with insulin pump therapy in
school, students must:
- check their blood glucose multiple
times throughout the day, preferably
in the location where they are at the
time they need to test;
- respond to low or high blood glucose
readings;
- receive help when blood glucose levels
are low or high; and
- never go to the nurse’s office or anywhere
alone when they are experiencing
high or low blood glucose episodes.
Pump Information and
Training Resources
To be prepared to assist students with
diabetes who use pumps, school nurses
should achieve technical competence with
the following pump therapy tasks:
- inserting the pump cannula (if the
student’s healthcare plan specifies
this task);
- delivering a dose of insulin through
the pump (bolus);
- checking pump memory (time of the
last bolus dose);
- troubleshooting steps (how to determine
if there is a problem with the
pump); and
- replacing 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 the local chapter of the
American Association of Diabetes Educators
to discuss your training needs.
The back cover of most pumps lists a
toll-free telephone number that can be
called for technical assistance or for
obtaining copies of user manuals from
manufacturers (see the list below). In
addition, most children who use insulin
pumps live with adults who are very
involved in their diabetes care and are
trained in use of the pump. Many of
these people are capable of providing
school nurses with necessary training.
Conclusion
We all have a role in helping the student
with diabetes succeed. School nurses
are encouraged to obtain a copy of the
National Diabetes Education Program’s
publication “Helping the Student with
Diabetes Succeed: A Guide for School
Personnel,” to put an effective management
approach in place in their schools.
The school guide can be obtained by
calling (800) 438-5383 or by visiting the
program’s website at www.ndep.nih.gov
and downloading a copy. Furthermore,
the American Diabetes Association
(ADA) offers a set of companion instructional
modules, based on the school
guide, for healthcare professionals to
train school personnel on diabetes care
tasks. The modules can be downloaded
free of charge from the ADA’s website at
www.diabetes.org/schooltraining.
On a personal note, having raised two
children with diabetes who are pump
users, my hope for every school-aged
child with diabetes is to receive the support
of a school nurse who has the time
and interest to learn all that is needed
to grow into the role of a well-informed
care giver and advocate.
SOURCES FOR SUPPORT
Insulin Pump Companies
Diabetes Organizations
ABOUT THE AUTHOR
Catherine Marschilok, MSN, CDE is Board Certified in Advanced Diabetes Management and has certification in Animas, Deltec, Medtronic Minimed and Omnipod Insulin Pumps. She currently serves on JDRF’s Clinical Affairs Advisory Committee and International Public Affairs Committee and on the National Diabetes Education Program’s Diabetes in Children and Adolescents Work Group.
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