coach of student’s diabetes. w Inform transportation of diabetes if student rides Fast- acting carbohydrate foods for lows Oral medications for diabetes …
|STUDENT INFORMATION |
|Name |
|Birth Date School Grade |
|Emerge|Parents Name |Emergen|Parents Name |
|ncy | |cy | |
|Contac| |Contact| |
|t | | 2 | |
| 1 | | | |
| |Relationship | |Relationship |
| |Home phone | |Home phone |
| |Work phone | |Work phone |
| |Cell/pager | |Cell/pager |
|Emerge|Name |Emergen|Name |
|ncy | |cy | |
|Contac|
|Contact| |
|t | |4 | |
|3 | | | |
| |Relationship | |Relationship |
| |Home phone | |Home phone |
| |Work phone | |Work phone |
| |Cell/pager | |Cell/pager |
|Address |
|Email address |
|Health Care Provider |
|Office Contact Person |
|Office phone |
|Office FAX |
|Type of diabetes |
|Age at diagnosis
|
|Preferred hospital |
|Allergies? |
|Conditions/medications other than diabetes? |
|BLOOD SUGAR MONITORING AT SCHOOL? Yes No Type of meter: |
|Target blood sugar range: ______ - _______mg/dl Location of |
|meter/supplies: |
|Can student perform own blood sugar checks? Yes Needs |
|assistance Needs supervision |
|Times to be performed: Before breakfast As needed for |
|signs of highs or lows |
| Before lunch Other______________________________ |
| Dismissal |
|Place to be performed: Classroom Clinic |
| Other
|
|Check ketones if blood sugar is ___________mg/dl |
|Notify parent/guardian if blood sugar is _______ or ______ mg/dl, or if |
|ketones are moderate or large |
|Notify physician if ketones are moderate or large |
|Comments: |
|HOME INSULIN REGIMEN Update orders PRN |
|Type of |Dose |Time Given |Change/Date |Change/Date |Change/Date |
|Insulin | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|INSULIN TO BE TAKEN AT SCHOOL? Yes No |
|Update orders PRN
|
| |
|Can student: Determine correct dose? Yes No With |
|assistance Needs supervision |
|Draw up correct dose? Yes No With assistance |
| Needs supervision |
|Give own injection? Yes No With assistance |
| Needs supervision |
| Insulin to be given by: Syringe Pen Pump If by |
|pump, see Insulin Pump Supplement |
| Injection sites to be used: Abdomen Legs Arms|
| Hips |
| Type of |Time |Dose |Change/Da|Change/Date|Change/Da|Change/Da|Change/Da|
|Insulin | | |te | |te |te |te |
| | | | | | | | |
|
| | | | | | | |
| Calculate insulin dose for carbohydrate intake? Yes |
| No |
|Insulin to carbohydrate ratio: 1 unit of ___________insulin per__________ |
|grams of carbohydrate |
|Correction supplement for high blood sugar? Yes No |
|When?______________________ |
| | |Correction supplement per sliding |
|C Correction supplement per | |scale: |
|formula: |OR |using______________ insulin |
| | | |
|B Blood Sugar - _______ | |Blood sugar:____________ |
|_______ | |Units:_________ |
| | |Blood sugar:____________ |
| units of _________insulin |
|Units:_________ |
|needed | |Blood sugar:____________ |
| | |Units:_________ |
| | |Blood sugar:____________ |
| | |Units:_________ |
| | |Blood sugar:____________ |
| | |Units:_________ |
|Location of insulin/supplies: |
|Comments: |
|OTHER DIABETES MEDICATIONS AT SCHOOL? Yes No |
|Medication |Dose |Time |Route |Change / Date |
| | | | | |
|Comments: |
|MEALS/SNACKS 1 CARBOHYDRATE SERVING 1 CARB CHOICE 15 GRAMS CARBOHYDRATE |
| 1 starch 1 fruit 1 milk
|
|Can student calculate the carbohydrate grams/choices accurately? Yes No |
| With assistance |
|FOOD |TIME |CARB GRAMS/CHOICES |CHANGE / DATE |
|Breakfast | | | |
|Mid AM snack? | | | |
|Lunch | | | |
|Mid PM snack? | | | |
|Before gym / activity?| | | |
|Class/school party instructions: |
|Comments: |
|EXERCISE, SPORTS, AND FIELD TRIPS |
|Regularly scheduled activities gym, sports, band, etc: |
| |
| Blood sugar monitoring and snacks as above generally 15 grams per every
_____ |
|minutes of exercise |
| Provide access to carb-free liquids, fast-acting carbs, snacks, and monitoring|
|equipment |
| Student should not have exercise: - if blood sugar is _____ and has |
|moderate to large ketones |
|- if blood sugar is ________ Treat for hypoglycemia No exercise until |
|blood sugar is ______mg/dl |
| Inform gym teacher/coach of students diabetes |
| Inform transportation of diabetes if student rides bus |
|Comments: |
|OUT-OF-RANGE BLOOD GLUCOSE MANAGEMENT: General guidelines for treating |
|hyperglycemia and hypoglycemia will be followed according to the attached |
|decision trees unless other instructions are specifically detailed by the health |
|care provider |
|HIGH BLOOD SUGAR HYPERGLYCEMIA
OVER_____________mg/dl |
| | |
|Students usual signs/symptoms |Treatment |
| Increased thirst |Check for ketones |
| Increased urination |Have student drink 4-6 oz of a non-carb |
|Sleepiness |liquid every hour |
| Blurred vision |Follow instructions on Hyperglycemia |
|Rapid breathing |Decision Tree |
| Increased appetite Warm, |If student is over 10 yrs old, and it is |
|dry skin |more than 2 hrs since a meal/insulin, may |
| Fruity breath |correct blood sugar if ill |
| Nausea/vomiting, abdominal pain | |
|LOW BLOOD SUGAR HYPOGLYCEMIA UNDER______________mg/dl |
|Students usual | |
|signs/symptoms |TREAT if blood sugar is ________ with symptoms, or
|
| |_______ without symptoms, if the student is alert and able|
| Weak/shaky |to swallow |
| Hunger |If blood sugar is ____, DOUBLE the amount of |
| |carbohydrates given to 30 grams |
| Rapid heartbeat | |
| |Give 15 grams of fast-acting carbohydrates like one of the|
| Cool/clammy |following: |
| Tired/pale | 4 oz juice or regular soda |
| Personality change | 3-4 glucose tablets |
| Slurred speech | tube of gel or cake frosting |
| | 8 oz milk |
|Inattention/confusion | Other___________________________ |
| Dizzy/staggering |Retest blood sugar 15 minutes after treating |
| |Repeat treatment if needed till blood sugar is _____ |
| Seizure |If more than 1 hour
until next meal/snack, or if going to|
| Loss of |activity, follow treatment with protein-containing snack |
|consciousness |of ______________________ |
| | |
| MEDICAL EMERGENCY |
| |
|If student is unconscious or is having a seizure, assume it is a low blood sugar |
|reaction |
|Call 911 immediately and notify parents |
| |
| Glucagon injection mg or 1 mg circle |
|desired dose should be given by trained personnel |
| Following injection, turn student on side until fully awake When alert |
|enough to swallow, give food as above |
| Glucose gel 1 tube can be administered slowly inside cheek and massaged
from|
|outside if unable to give Glucagon and student is able to swallow |
|Location of Glucagon injection / glucose gel: |
|School personnel trained to give Glucagon injection: |
|SUPPLIES TO BE FURNISHED BY PARENTS IMMEDIATELY UPON REQUEST |
| Blood glucose meter/strips/lancets/lancing device Insulin |
|vial/syringes |
| Ketone testing strips |
|Insulin pen/pen needles/cartridges |
| Fast- acting carbohydrate foods for lows Oral |
|medications for diabetes |
| Carbohydrate free beverages/water bottles for highs Glucagon Emergency Kit|
| |
| Routine snacks if needed per meal plan Glucose |
|gel/cake frosting |
|STATEMENT OF RESPONSIBILITY
|
| |
|Parents/Guardians are responsible to: |
|Notify school personnel of all changes in their childs medical management plan |
| |
|Give permission for the school nurse to consult with students health care |
|provider regarding their care when necessary |
|Keep an adequate supply of all appropriate supplies listed above which are needed|
|for student |
|Provide current information on how to be contacted if necessary due to students |
|medical needs |
|Have a designated, knowledgeable person who shall be able to be contacted, and |
|who will be responsible for the student if parents/guardians are unavailable |
|Give permission for all pertinent health information to be provided to |
|appropriate school staff
|
|See that the medical management plan is updated at least yearly and that the |
|school has a copy of it |
| |
|School Personnel are responsible to: |
|Follow the medical management plan as outlined above while the student is at |
|school |
|Notify the parents/guardians of any required treatment for low and/or high blood |
|sugars on the date of the occurrence |
|Notify parents/guardians when supplies need replenished The method of |
|notification will be discussed and agreed upon by school personnel and |
|parents/guardians at the beginning of the school year |
|If a medical management plan for the current school year is not provided to the |
|school, the most recent plan available to the school will be followed |
|SIGNATURES: The following have read and agree to adhere to the above plan and |
|pump
supplement if using pump |
|Health Care Provider |Date |
|Parent/Guardian |Date |
|Student |Date |
|School Nurse |Date |
Source:nephcure.org
