Diabetes Medical Management Plan by the school nurse, trained diabetes personnel, and other authorized personnel. This Diabetes Medical Management Plan …
Royse City Independent School District
School Health Services
Date of Plan: _______________
Diabetes Medical Management Plan
This plan should be completed by the students personal health care team
and parents/guardian It should be reviewed with relevant school staff and
copies should be kept in a place that is easily accessed by the school
nurse, trained diabetes personnel, and other authorized personnel
Effective Dates:
_______________________________________________________________
Students Name:
_______________________________________________________________
Date of Birth: _______________________ Date of Diabetes Diagnosis:
__________________
Grade: _____________________________ Homeroom Teacher:
________________________
Physical Condition: Diabetes type 1 Diabetes type 2
Contact Information
Mother/Guardian:
_____________________________________________________________
Address:
_____________________________________________________________________
____________________________________________________________________________
Telephone: Home __________________ Work
_________________
Cell_________________
Father/Guardian:
______________________________________________________________
Address:
_____________________________________________________________________
____________________________________________________________________________
_
Telephone: Home _________________ Work __________________ Cell
_________________
Students Doctor/Health Care Provider:
Name:
_______________________________________________________________________
Address:
_____________________________________________________________________
Telephone: ________________________ Emergency Number:
__________________________
Other Emergency Contacts:
Name:
_______________________________________________________________________
Relationship:
__________________________________________________________________
Telephone: Home _________________ Work _________________ Cell
__________________
Notify parents/guardian or emergency contact in the following situations:
__________________
____________________________________________________________________________
_
____________________________________________________________________________
_
Blood Glucose
Monitoring
Target range for blood glucose is 70-150 70-180 Other
__________________
Usual times to check blood glucose
________________________________________________
Times to do extra blood glucose checks check all that apply
before exercise
after exercise
when student exhibits symptoms of hyperglycemia
when student exhibits symptoms of hypoglycemia
other explain:
____________________________________________________________
Can student perform own blood glucose checks? Yes No
Exceptions:
__________________________________________________________________
____________________________________________________________________________
Type of blood glucose meter student uses:
__________________________________________
____________________________________________________________________________
Insulin
Usual Lunchtime Dose
Base dose of Humalog/Novolog /Regular insulin at lunch circle type of
rapid-/short-acting insulin used is _____ units or does flexible dosing
using _____ units/ _____ grams carbohydrate
Use of other insulin at lunch: circle type of insulin used:
intermediate/NPH/lente _____ units or basal/Lantus/Ultralente _____
units
Insulin Correction Doses
Parental authorization should be obtained before administering a correction
dose for high blood
glucose levels Yes No
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
Can student give own injections? Yes No
Can student determine correct amount of insulin? Yes No
Can student draw correct dose of insulin? Yes No
_______ Parents are authorized to adjust the insulin dosage under the
following circumstances:
____________________________________________________________________________
_
____________________________________________________________________________
_
For Students with Insulin Pumps
Type of pump: _______________________ Basal rates: _____ 12 am to _____
_____ _____ to _____
_____ _____ to _____
Type of insulin in
pump:
________________________________________________________
Type of infusion set:
____________________________________________________________
Insulin/carbohydrate ratio: ________________________ Correction factor:
________________
Student Pump Abilities/Skills: Needs Assistance
Count carbohydrates Yes No
Bolus correct amount for carbohydrates consumed Yes No
Calculate and administer corrective bolus Yes No
Calculate and set basal profiles Yes No
Calculate and set temporary basal rate Yes No
Disconnect pump Yes No
Reconnect pump at infusion set Yes No
Prepare reservoir and tubing Yes No
Insert infusion set Yes No
Troubleshoot alarms and malfunctions Yes No
For Students Taking Oral Diabetes Medications
Type of medication: ____________________________________ Timing:
________________
Other medications: ___________________________________
Timing:
________________
Meals and Snacks Eaten at School
Is student independent in carbohydrate calculations and management? Yes
No
Meal/Snack Time Food content/amount
Breakfast ______________________ __________________________________
Mid-morning snack ______________________
___________________________________
Lunch ______________________
___________________________________
Mid-afternoon snack ______________________
___________________________________
Dinner ______________________
___________________________________
Snack before exercise? Yes No
Snack after exercise? Yes No
Other times to give snacks and content/amount:
____________________________________________________________________________
_
Preferred snack foods:
____________________________________________________________________________
_
Foods to avoid, if any:
____________________________________________________________________________
_
Instructions for when food is provided to the class eg, as part of a
class party or food sampling
event:
_______________________________________________________________________
____________________________________________________________________________
_
Exercise and Sports
A fast-acting carbohydrate such as
_________________________________________________ should be available at
the site of exercise or sports
Restrictions on activity, if any: _______________________________________
student should not exercise if blood glucose level is below
____________________ mg/dl or above ____________________ mg/dl or if
moderate to large urine ketones are present
Hypoglycemia Low Blood Sugar
Usual symptoms of hypoglycemia:
________________________________________________
____________________________________________________________________________
_
Treatment of
hypoglycemia:______________________________________________________
____________________________________________________________________________
_
Glucagon should be given if the student is unconscious, having a seizure
convulsion, or unable to swallow
Route _______, Dosage _______, site for glucagon injection: _______arm,
_______thigh, _______other
If glucagon is required, administer it promptly Then, call 911 or
other
emergency assistance and the parents/guardian
Hyperglycemia High Blood Sugar
Usual symptoms of hyperglycemia:
________________________________________________
____________________________________________________________________________
_
Treatment of hyperglycemia:
_____________________________________________________
____________________________________________________________________________
_
Urine should be checked for ketones when blood glucose levels are above
_________ mg/dl
Treatment for ketones:
__________________________________________________________
____________________________________________________________________________
_
Supplies to be Kept at School
_______Blood glucose meter, blood glucose test strips, batteries for meter
_______ Lancet device, lancets, gloves, etc
_______Urine ketone strips
_______Insulin pump and supplies
_______Insulin pen, pen needles, insulin cartridges
_______Fast-acting source of glucose
_______Carbohydrate containing snack
_______Glucagon emergency kit
Signatures
This Diabetes Medical Management Plan has been approved by:
_________________________________________________
_______________________
Students
Physician/Health Care Provider Date
I give permission to the school nurse, trained diabetes personnel, and
other designated staff members of ______________________________ school to
perform and carry out the diabetes care tasks as outlined by
__________________________s Diabetes Medical Management Plan I also
consent to the release of the information contained in this Diabetes
Medical Management Plan to all staff members and other adults who have
custodial care of my child and who may need to know this information to
maintain my childs health and safety
Acknowledged and received by:
_________________________________________________
______________________
Students Parent/Guardian Date
_________________________________________________
______________________
Students Parent/Guardian Date
Source:utexas.edu
