diabetes care plan requires the signatu Contact trained school diabetes care provider or school nurse as soon as possible. …
Students Name _________________________ Date of Birth __________ School _________________________________ Bus /Transportation ____________________ Effective Dates for Plan: __/__/__ to __/__/__
Student ID ____________________ Date of Diabetes Diagnosis ________ Grade __________ Homeroom Teacher ______________ Type _____ Diabetes
Photo of Student Pasted Here When Available
DIABETES CARE PLAN
Parent/Guardian: Complete this plan with the assistance of your childs health care provider and the school nurse The diabetes care plan requires the signature of the students parent/guardian and health care provider Return the completed, signed plan to the school Attach other instructions/forms if needed This information will be shared with appropriate school staff unless you state otherwise Health Care Provider: Review and authorize this diabetes care plan and make any necessary changes or additions Sign and return the plan to parent/guardian or school nurse Parent/Guardian 1:_______________________________ Address________________________________________ Telephone Home ________________ Work ______________________ Cell ____________________ Parent/Guardian 2:_______________________________
Address________________________________________ Telephone Home ________________ Work ______________________ Cell ____________________ Physician Treating Student for Diabetes: _____________________________ Telephone ______________________ Other Physician: __________________________________________________ Telephone ______________________ Nurse or Diabetes Educator: ________________________________________ Telephone ______________________ Other Emergency Contact: _________________________________________ Relationship ____________________
Telephone Home ________________ Work ______________________ Cell ____________________ There will be trained school personnel to assist with diabetic care Where are students daily diabetes supplies kept? _______________________________________________________ Does the student wear a medic alert? Yes No
Notify parents in the following situations: _______________________________________________________________
504 Accommodations are in place Yes Date Received ____________________ Reasonable accommodations for this student include but are not limited to: Bathroom privileges: Access to water: Testing concerns:
Allow free and unlimited use of bathroom
facility If this is being abused please contact school nurse Student should be allowed to carry water bottle if desired Academic performance may be adversely affected due to fluctuations in blood sugar levels Therefore, additional accommodations may be necessary
No
EMERGENCY ACTION PLAN
LOW BLOOD SUGAR Hypoglycemia
SYMPTOMS Hunger, sweating, trembling, pale appearance, inability to concentrate, confusion, irritability, sleepiness, headache, dizziness, crying, slurred speech, poor coordination, personality change, complains of feeling low, blood sugar below ___________________mg/dl Call parent/guardian and health care provider if blood sugar below ____________________mg/dl Symptoms of low blood sugar for this student: _____________________________________________________ Times student is most likely to experience a low blood sugar: _________________________________________ Where are glucose tablets and snacks kept?______________________________________________________ Has health care provider authorized use of glucagon? YES NO Where is glucagons kept? ____________________________________________________________________
BLOOD SUGAR MONITORING
TREATMENT FOR LOW BLOOD SUGAR
Hypoglycemia If student is conscious, cooperative, and able to swallow:
o o o o o o o o Give fast sugar immediately, such as glucose tablets, fruit juice, regular soda, glucose gel, or ____________________ Amount of fast sugar to be given: ____________________________________________________________________ If symptoms do not improve in __________ minutes, give fast sugar again When symptoms improve, provide an additional snack of __________________________________________________ Check blood sugar level every __________ minutes until it is above __________ Do not leave student alone or allow him/her to leave the classroom alone Remain with student until fully recovered Contact trained school diabetes care provider or school nurse as soon as possible Notify parents of low blood sugar episode If symptoms worsen, call 911, parent/guardian, and health care provider Glucagon, if authorized by students health care provider, may be needed if student becomes unconscious, has a seizure, or is unable to swallow
If student is unconscious, experiencing a seizure, or unable to swallow:
o o o o o Contact trained school diabetes care provider or school nurse immediately to inject emergency
glucagon, if authorized for student Call 911, parent/guardian, and health care provider Glucagon dosage if authorized: _________________________ Turn student on side and keep airway clear Do not insert objects into students mouth or between teeth Student may vomit Keep student on side to prevent choking on vomit Keep airway clear Other instructions for treating low blood sugar: _____________________________________________________________
HIGH BLOOD SUGAR Hyperglycemia SYMPTOMS
Frequent urination, excessive thirst, nausea, vomiting, dehydration, sleepiness, confusion, confusion, blurred vision, inability to concentrate, irritability, or blood sugar above _______________________mg/dl Symptoms of high blood sugar for this student: __________________________________________________________________ Call parent/guardian and health care provider if blood sugar is over ______________________________________mg/dl Where are insulin and ketone testing supplies kept? Daily _____________________ Back-up _____________________________
TREATMENTS FOR HIGH BLOOD SUGAR Hyperglycemia LUNCH TIME INSULIN
o o Contact trained school diabetes care manager who will provide insulin administration,
insulin pump care, and ketone testing To correct high blood sugar, give insulin: _____________ units for every __________ mg/dl over _________________ Sliding Scale _____ to _____ _____ units _____ to _____ _____ units _____ to _____ _____ units _____ to _____ _____ units o o o o o o
INSULIN INJECTIONS Does student know how to: Give own injection? Determine correct insulin dose? Draw up correct insulin dose? Handle and dispose of needles safely?
YES NO YES NO YES NO YES NO
Insulin correction for hyperglycemia should be given every _____ hours until the target range of _____ is reached Check for ketones if blood sugar is above _____ Check blood sugar again in _____ and at _____ intervals Allow free and unlimited use of bathroom Encourage student to drink water or other sugar-free liquid If moderate of higher ketones are present, call health care provider and parent/guardian immediately If symptoms worsen or the student begins vomiting, call health care provider and parent/guardian immediately Other instructions for treating high blood sugar ___________________________________________________________ Type of Meter: ______________ Logbook kept at school? Yes No
Target range of
blood sugar: _____ to _____
What help will student need with blood sugar testing?______________________________________________________ Usual times for student to test blood sugar: ______________________________________________________________ Will student need insulin at school? YES NO Where is insulin kept at school? __________________________________ What help will student need with insulin injections? _________________________________________________________ Insulin/carbohydrate ratio for meals/snacks: ________________________ units for every ___________________________
FOR STUDENTS ON INSULIN PUMPS
Type of pump: ________________________ Type of insulin used in pump: ______________________________________ Insulin/carbohydrate ratio for meals/snacks: _________________ units for every ___________________________________ High blood sugar correction ratio: __________ units for every _______________ mg/dl over ______________ Back-up means of insulin administration? __________________________________________________________________ What help will student need with pump? ___________________________________________________________________ ORAL
MEDICATIONS:_________________________________________________________________________________ ____________________________________________________________________________________________________
FOOD AND EXERCISE
MEAL/SNACK Breakfast Mid-Morning Lunch Mid-Afternoon TIME _____ _____ _____ _____ FOOD CONTENT / AMOUNT ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________
FOODS TO AVOID: PREFERRED SNACKS:
Before Exercise _____ After Exercise Other _____ _____
Student should not exercise if blood sugar is below _____mg/dl OR above _____ mg/dl Other Exercise/activity instructions: _____________________________________________________________________________
Parent/Guardian Signed Date Health Care Provider Reviewed and signed Telephone Date School Nurse Date Received
