Diabetes Type 1 or Type 2. Routine Management Target Blood Student is on oral diabetes medication(s) Dose: Times to be given . Student is on insulin. …
Falcon High School
INDIVIDUALIZED HEALTH
PLAN: DIABETES
IHP for SCHOOLS
|Student | |DOB | |
|School | |Phone| |
|Nurse | | | |
|School | |Grade | |
|Health |Diabetes Type 1 or Type 2 |
|Concern | |
|Routine Management Target | |to| |
|Blood Glucose Range | | | |
Required blood glucose testing at school: Times to test
blood glucose:
Trained personnel must perform blood glucose test Before lunch
Before PE
Trained personnel must supervise blood glucose test After lunch
After PE
Student can perform testing independently Before snack
Before getting on bus/going home
Student can carry supplies and test where needed As needed for
signs/symptoms of low/high blood glucose
Call parent if blood glucose values are below or above
Medications to be given during school hours:
Student is on oral diabetes medications Dose: Times
to be given
Student is on insulin Type: Dose: Times to
be given
Sliding Scale: Blood Glucose Correction and Insulin Dosage using Rapid
Acting Insulin:
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
and check ketones
Blood Glucose Range mg/dl Administer units
and check ketones
Blood Glucose Range mg/dl Administer units
and check ketones
Blood Glucose Range mg/dl Administer units
and check ketones
Insulin to Carbohydrate Ratio units for
every
grams of carbohydrate or to be eaten
Student independently administers insulin Student self injects with
supervision by trained school personnel
Student self injects with verification of dosage by trained school
personnel
Injections should be done by trained school personnel
Parent/guardian authorized to increase or decrease sliding scale /- 2
units of insulin
Parent/guardian authorized to increase or decrease insulin to
carbohydrate count within the following range: 1 unit per prescribed grams
of carbohydrates /- 5 grams of carbohydrates
Diet: Lunch time: Scheduled PE Time: Recess
Time:
Snack times: am pm Location where snacks are kept:
Location eaten:
STUDENT NAME: DOB:
Emergency Response Plan
LOW BLOOD GLUCOSE: Hypoglycemia - Below 70 mg/dl
With any level of low blood glucose never leave the student
unattended
If treated outside the classroom, a responsible person should
accompany student to the health clinic or office for further
assistance
Student to be treated when blood glucose is below:
mg/dl
Symptoms could include: hunger, irritability, shakiness, sleepiness,
sweating, pallor, uncooperative, or other behavior changes
Additional student symptoms:
MILD LOW BLOOD GLUCOSE STUDENT IS ALERT:
Treatment Mild Low Blood Glucose:
Check blood glucose If blood glucose meter is not available, treat child
immediately for low blood glucose
If blood glucose is between mg/dl and mg/dl and lunch is
available, escort to lunch and have student eat immediately
If lunch is unavailable, treat immediately as listed below
If blood glucose is below mg/dl, give 2-4 oz of 100 juice or
1/3 can regular sugar pop or 2-4 glucose tablets
Re-check in 10 minutes If still below mg/dl re-treat as above
Follow with snack or lunch when blood glucose rises above mg/dl
or when symptoms improve
Notify parent and school nurse
Comments:
MODERATE LOW BLOOD GLUCOSE STUDENT IS NOT ALERT:
Symptoms: In addition to those listed above for mild low blood glucose,
student may be combative, disoriented, incoherent, or have slurred speech
Treatment Moderate Low Blood Glucose:
If student is conscious yet unable to
effectively drink the fluids offered:
V Administer to 1 tube 3 tsp of glucose gel, or tube to 1 tube of
cake decorative gel
V Place between cheek and gum then massage into gums, elevate head and
encourage student to swallow Student may be uncooperative
V Notify parent and school nurse
V Retest in 10 minutes If still below mg/dl retreat as above
V Give regular snack after retest and when blood glucose rises above
mg/dl or when symptoms improve
Comments:
SEVERE LOW BLOOD GLUCOSE:
Student symptoms include: Seizures or loss of consciousness,
unable/unwilling to take gel or juice
Treatment Severe Low Blood Glucose:
|Stay with student |Roll student on side |Do not put anything in |
| | |mouth |
|Appoint someone to call 911|Protect from injury |Contact Parent |
Give Glucagon if ordered and if a nurse or other delegated person is
available:
Dose mgs or units on insulin syringe
Intramuscular
Subcutaneous
Comments:
STUDENT NAME: DOB:
HIGH BLOOD
GLUCOSE:
o Student needs to be treated when blood glucose is above mg/dl
o Call parent or guardian when blood glucose is greater than
mg/dl
o Symptoms could include circle all that apply: extreme thirst,
headache, abdominal pain, nausea, increased urination
Treatment of High Blood Glucose:
|Drink 6-16 oz water or DIET |Be allowed to carry |Use rest room as often |
|pop |water bottle |as needed |
|caffeine free every hour | | |
Use sliding scale insulin orders when blood glucose is over mg/dl
and recheck blood glucose in two hours
Check urine ketones or blood ketones, if glucose is greater than 300 mg/dl
2x or when ill/and or vomiting
If urine ketones are moderate to large or if blood ketones are greater
than 06 mmol, call parent immediately
Recommend child be released from school when ketones are large in
order to be treated and monitored more closely by parent/guardian
? If student exhibits nausea, vomiting, stomachache or is lethargic;
contact parent, student should be released
from school
? Student can return to
class if none of the above physical symptoms are
present
Field trip information:
1 Notify parent and school nurse in advance so proper training can be
accomplished
2 Adult staff must be trained and responsible for students needs on field
trip
3 Extra snacks, blood glucose monitor, copy of health plan, glucose gel or
other emergency supplies must accompany student on field trip
4 Adults accompanying student on a field trip will be notified of
students health accommodations on a need to know basis
|SUPPLIES |NEEDED |NOT NEEDED |
|Blood glucose meter and blood glucose strips | | |
|Lancets with lancing device | | |
|Blood ketone strips if using the Precision | | |
|meter | | |
|Urine ketone strips | | |
|Insulin syringes | | |
|Antibacterial skin cleanser or alcohol wipes | | |
|Bottle of refrigerated rapid acting insulin |
| |
|-Type: | | |
|Glucose tabs, Cake Mate gel, juice, or other | | |
|source of glucose | | |
|Carbohydrate snack | | |
|Glucagon Emergency Kit if delegated by RN | | |
|Sharps container | | |
As parent/guardian of the above name student, I give my permission to the
school nurse and other designated staff to perform and carry out the
diabetes tasks as outlined in this Individualized Health Plan IHP and for
my childs healthcare provider to share information with the school nurse
for the completion of this plan I understand that the information
contained in this plan will be shared with school staff on a need-to-know
basis It is the responsibility of the parent/guardian to notify the
school nurse whenever there is any change in the students health status or
care Parents/Guardian and student are responsible for maintaining
necessary supplies, snack, blood glucose monitor, medications
and
equipment
Parent/Guardian: Date:
School Nurse: Date:
———————–
Picture
of
Student
