Complete diabetes supply kits are also located in his/his/her Core/Homeroom Have tardies and absences excused due to diabetes care. …
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In summary:
NAME wears a MAKE/MODEL OF PUMP insulin pump OR: Insulin delivery
via shot therapy
S/he carries a blood glucose meter, low blood sugar supplies and
emergency Glucagon in his/his/her backpack
Complete diabetes supply kits are also located in his/his/her
Core/Homeroom classroom in RM , the nurses station and in NAMEs
backpack
Blood sugar levels can significantly affect his/her capability to
do school work, take tests, or make decisions about his/her
diabetes care, etc
S/he is allowed to make up tests, homework, classroom work, etc,
s/he has missed due to diabetes care
Substitute teachers are required to review prepared diabetes sub
plan prior to the start of class
NAME is allowed to participate fully in all school activities,
assemblies, field trips, etc
NAME can participate in events/classroom parties with snacks/foods
may need to take insulin to do so
NAME is also allowed to:
Check his/her blood sugar levels at any time and in any location on
campus
Treat a low or high blood sugar as per routine at any time and in
any location on campus
Make phone calls to his/her
parents at any time using a school
phone or cell phone
Use the restroom at any time upon request
Have access to drinking water at any time upon request
Have tardies and absences excused due to diabetes care S/he should
not be penalized for being tardy due to diabetes issues that may
arise, or for frequent diabetes clinic appointments
Daily routines:
Blood Check Schedule:
Create individual sched
Before PE zero period
AM Snack: 10:10-10:20 am
Lunch time: prior to eating
Afternoon Snack: MTThF, 2pm
Min Days/W, @ home
Below 50: Extremely low blood sugar
Symptoms: Says Im low, panicky, shaky, extremely pale, headaches,
nauseas, cranky or belligerent, confused, sometimes with blank or
rolling eyes Watch for signs that s/he might faint or go into
seizure Unclip insulin pump set to detach pump, thereby stopping
insulin delivery Treat for low blood sugar above Possible need for
emergency Glucagon shot
51-80: Low Blood Sugar
Symptoms: Says Im low, panicky, shaky, extremely pale, headaches,
nauseas, confused Treat for low blood sugar
Insert individual symptoms/ set individual ranges and recommendations
for low, normal, high blood
sugar
81-180: Normal Range
NAME can occasionally drop low out of a normal range quite suddenly,
especially if exercising, anxious, or taking a test, etc
180-300 High Blood Sugar AND
Above 300: Extremely High Blood Sugar call parent
Symptoms: Says Im high, shaky, pale, headache, lacks concentration
in doing tasks or schoolwork, spacey, thirsty Check that insulin
pump is still clipped into infusion set and/or that set has not fallen
off NAME is to use pump calculator for dosage recommendation Insert
individual symptoms/shot or pump therapy, etc Follow pump
recommendation Call parent as needed
PARENT CONTACT INFO: Home: XXX-XXX-XXXX
Mom: NAME Cell: XXX-XXX-XXXX
Work: XXX-XXX-XXXX Employer, location
Dad: NAME Cell: XXX-XXX-XXXX
Work: XXX-XXX-XXXX
Employer, location
———————–
Diabetes Care: Blood Glucose Meters determine his/her blood glucose levels
Meters provide data to guide his/her diabetes care After doing a blood
check, NAME will be in a low, normal or high blood sugar range
Low blood sugars should be treated
immediately with juice and/or sugar
cubes Repeat blood sugar check every 15 mins until above 100 Too much
insulin causes low blood sugar levels When s/he has a high blood sugar,
s/he needs more insulin Insulin levels are listed in pump
Extreme lows or highs: CALL PARENT phone numbers below
NAME has type 1 diabetes and is insulin-dependent S/he wears an insulin
pump at all times OR SHOT THERAPY
Date of Birth: XX/XX/XXXX
SAMPLE: S/he is capable of doing her own blood glucose checks and most
insulin pump deliveries if she not compromised by a severe low
hypoglycemia or high hyperglycemia blood sugar episode Please see
NAMEs 504 Plan for detailed instructions for his/her diabetes care at
school
Attach photo here
For clipboards, substitute folders, lunch rooms, etc THIS IS ONLY A SAMPLE
TEMPLATE to be used as a suggestion for students daily diabetes care
Please customize individual students plan as per students 504 Plan and
personal care
Source:closeconcerns.com
