CLINIC. NATIONAL MINORITY HEALTH MONTH “DIABETES AWARENESS WALK” After the Diabetes Walk, join us at Broussard-Harris Recreation Center for the Health Fair. …
INFORMATION FOR SCHOOL MANAGEMENT OF DIABETES MELLITUS
School Year: _______________
Students Name: _________________________ Date of Birth: _______________
Effective Date: ____________
School Name: __________________________________ Grade: ________ Homeroom:
___________________
CONTACT INFORMATION:
Parent/Guardian 1: ____________________Phone : Home: ____________Work:
_________ Cell/Pager: __________
Parent/Guardian 1: ____________________Phone : Home: ____________Work:
_________ Cell/Pager: __________
Diabetes Care Provider: _______________________________________ Phone :
_____________________________
Other emergency contact: _____________________________________
Relationship: _________________________
Phone Numbers: Home: _______________________________ Cellular/Pager:
_______________________________
Insurance Carrier: _____________________________________ Preferred
Hospital: ____________________________
EMERGENCY NOTIFICATION: Notify parents of the following conditions:
a Loss of consciousness or seizure convulsion immediately after
calling 911 and administering Glucagon
b Blood sugars in excess of _______________ mg/dl
c
Positive urine ketones
d Abdominal pain, nausea/vomiting, fever, diarrhea, altered breathing,
altered level of consciousness
STUDENTS COMPETENCE WITH PROCEDURES: Must be verified by parent and
school nurse
? Blood glucose monitoring ? Carry supplies for BG
monitoring
? Determining insulin dose ? Carry supplies for insulin
administration
? Measuring insulin ? Monitor BG in classroom
? Injecting insulin ? Self treatment for mild low
blood sugar
? Independently operates insulin pump ? Determine own snack/meal
content
MEAL PLAN: Time Location CHO Content Time
Location CHO Content
? Bkft ________ ___________ ___________ ? Mid-PM
______ ___________ ___________
? Mid-AM ________ ___________ __________ ? Before PE
______ ___________ ___________
? Lunch ________ ___________ ___________ ? After PE: ______
___________ ___________
Meal/snack will be considered mandatory Times of meals/snacks will be at
routine school times unless alteration is indicated School nurse will
contact diabetes care provider
for adjustment in meal times Content of
meal/snack will be determined by:
? Student ? Parent ? School nurse ? Diabetes
provider
Please provide school cafeteria with a copy of this meal plan order to
fulfill USDA requirements
Parent to provide and restock snacks and low blood sugar supplies box
LOCATION OF SUPPLIES/EQUIPMENT: To be completed by school personnel
Blood glucose equipment: ? Clinic/health room ? With student
Insulin administration supplies: ? Clinic/health room ? With
student
Glucagon emergency kit: ______________ Glucose gel: _______________
Ketone testing supplies: _____________
Fast acting carbohydrate: ? Clinic/health room ? With
student Snacks: ? Clinic/health room ? With student
SIGNATURES: I understand that all treatments and procedures may be
performed by the student and/or unlicensed personnel within the school or
by EMS in the event of loss of consciousness or seizure I also understand
that the school is not responsible for damage, loss of equipment, or
expenses utilized in these treatments and procedures I give permission
for school personnel
to contact my childs diabetes provider for guidance
and recommendations I have reviewed this information form and agree with
the indicated information This form will assist the school in developing
a health plan and in providing appropriate care for my child
PARENT SIGNATURE: ______________________________________________ DATE:
________________________
SCHOOL NURSE SIGNATURE: _______________________________________ DATE:
________________________
HEALTH CARE PROVIDER AUTHORIZATION FOR SCHOOL MANAGEMENT OF DIAB ETES
STUDENT: ______________________________________ DOB: ________________
DATE: ____________________
BLOOD GLUCOSE BG MONITORING: Target range: ________ mg/dl to
____________ mg/dl
None required at this time ? 2 hrs after correction
? Before meals ? PRN for suspected low/high BG
? Midmorning ? Mid-afternoon
INSULIN ADMINISTRATION: Dose determined by: ? Student ?
Parent ? School nurse
Insulin delivery system: ? Syringe ? Pen ? Pump Use
supplemental form for Student Wearing Insulin Pump
BEFORE MEAL INSULIN:
Insulin Type:
_____________________
o Insulin to Carbohydrate Ratio: ________ units per ______________ grams
carbohydrate
o Give ______ units
CORRECTION INSULIN for high blood sugar Check only those which apply
? Use the following correction formula: BG - ________ / _________
for pre lunch blood sugar over _______
? Sliding Scale:
BG from _______ to ______ ______ u
BG from _______ to ______ ______ u
BG from _______ to ______ ______ u
BG from _______ to ______ ______ u
BG from _______ to ______ ______ u
Add before meal insulin to correction/ sliding scale insulin for total
meal time insulin dose
MANAGEMENT OF LOW BLOOD GLUCOSE :
MILD: Blood Glucose ___________ SEVERE: Loss of consciousness
or seizure
o Never leave student alone Call 911 Open
airway Turn to side
o Give 15 gms glucose; recheck in 15 min Glucagon injection
025 mg 050 mg 10 mg IM/SQ
o If BG 70, retreat and recheck q 15 min x 3 Notify parent
o Notify parent if not resolved
? Provide snack with carbohydrate, fat, protein after
treating and meal not
scheduled 1 hr
MANAGEMENT OF HIGH BLOOD GLUCOSE Above _____ mg/dl
o Sugar-free fluids/frequent bathroom privileges
o If BG is greater than 300, and its been 2 hours since last dose, give
HALF FULL correction formula noted above
o IfBG is greater than 300, and its been 4 hours since last dose, give
FULL correction formula noted above
o If BG is greater than 300 check for ketones Notify parent if ketones
are present
o Note and document changes in status
o Child should be allowed to stay in school unless vomiting and/or
moderate or large ketones are present
EXERCISE:
Faculty/staff must be informed and educated regarding management Staff
should provide easy access to sugar-free liquids, fast-acting
carbohydrates, snacks, and BG monitoring equipment during activities
Child should NOT exercise if blood glucose levels are below ____________
mg/dl or above _____________ mg/dl and urine contains moderate or large
ketones
o Check blood sugar right before PE to determine need for additional
snack
o If BG is less than target range, eat 15-45 grams carbohydrate before,
depending on intensity and length of exercise
o Student may disconnect insulin pump for ______ hours or decrease basal
rate by _______
My signature provides authorization for the above orders I understand
that all procedures must be implemented within state laws and regulations
This authorization is valid for one year
? If changes are indicated, I will provide new written authorized
orders may be faxed
? Dose/treatment changes may be relayed through parent
Healthcare Provider Signature: ___________________________________________
Date: ________________________
Address:
____________________________________________________________________________
__
|SUPPLEMENTAL INFORMATION FOR STUDENT WEARING AN INSULIN PUMP AT SCHOOL |
|School Year __________________________ |
| |
|Students Name: ___________________________________ Date of Birth: _________ Pump |
|Brand/Model: |
|Pump Resource Person: _______________
Phone/ Beeper _______ See diabetes |
|care plan for parent phone Blood Glucose Target Range: _______ |
|Pump Insulin: Humalog Novolog |
|Insulin Correction Factor for Blood Glucose Over Target: _______________________ |
| |
|Insulin Carbohydrate Ratios: _ _________________ __ _ |
|Student to receive insulin bolus for carbohydrate intake immediately before |
|______ minutes before eating after _____ minutes after eating |
|Location of Extra Pump Supplies |
| INDEPENDENT MANAGEMENT |
|This student has been trained to independently perform routine pump management and to |
|troubleshoot problems including but not limited to: |
| |
|Giving boluses of insulin for both correction of blood glucose above target range and |
|for food
consumption |
|Changing of insulin infusion sets using universal precautions |
|Switching to injections should there be a pump malfunction |
|Parents will provide extra supplies to include infusion sets, reservoirs, batteries, |
|pump insulin and syringes |
| |
| NON-INDEPENDENT MANAGEMENT Child Lock On? Yes No |
|Because of young age or other factors, this student cannot independently evaluate pump|
|function nor independently change infusion sets |
| Pump calculates insulin dose |
| Insulin for meals and snacks will be given and verified as follows: |
|_______________________ |
|_____________________________________________________________________________________ |
|
|
| Insulin for correction of blood glucose over _ _ will be give and verified as |
|follows: |
|______________________________________________________________________________________|
|___ __ _ |
|PARENT NOTIFICATION: Refer to basic diabetes care plan and check all others that |
|apply Contact the Parent in event of: |
|Pump alarms / malfunctions Corrective measures do not return |
|blood glucose to target range within ___ hrs |
|Soreness or redness at site Student has to change site |
|Detachment of dressing / infusion set our of place |
|Leakage of insulin |
|Student must give insulin injection |
|Other: __________
|
|______________________________________________________________________________________|
|_____________ |
|MANAGEMENT OF HIGH / VERY HIGH BLOOD GLUCOSE: Refer to previous sections and to basic |
|Diabetes Care Plan |
|MANAGEMENT OF LOW BLOOD GLUCOSE Follow instructions in basic Diabetes Care Plan, but |
|in addition: |
|If low blood glucose recurs without explanation, notify parent / diabetes provider for|
|potential instructions to suspend pump |
|If seizure or unresponsiveness occurs: |
|Give Glucagon and / or glucose gel See basic Diabetes Health Plan |
|CALL 911 |
|Notify Parent |
|Stop insulin pump by: |
|Placing in Suspend or stop mode
|
|Disconnecting at pigtail or clip |
|If pump was removed, send with EMS to hospital |
|COMMENTS: |
|______________________________________________________________________________________|
|______________________________________________________________________________________|
|______________________________________________________________________________________|
|_____ |
Effective Dates: From: ______________________________ To:
____________________________________
Parents Signature: ___________________________________ Date:
_________________________________
School Nurses Signature: _____________________________ Date:
__________________________________
Diabetes Care Provider Signature: ________________________ Date:
__________________________________
