HEALTHCARE FOR DAILY MANAGEMENT OF DIABETES. Section I - Parent (Please Print) 1. Diet prescribed by physician: grams of DIABETES …
INDIVIDUALIZED HEALTHCARE FOR DAILY MANAGEMENT OF DIABETES | |
| |
|Section I - Parent Please Print: |
|optional |
|Student Name:| |Date of | |Grade: | |Weight:| |
| | |Birth: | | | | | |
| ? | |
|Allergies: | |
|Parent/Guardian |Name: | |Home Phone:| |
|1: | | | | |
| |Work Phone 
|Cell/Pager | |
| | | |: | |
|Parent/Guardian |Name: | |Home Phone | |
|2: | | |: | |
| |Work Phone |Cell/Pager |
|
| | | |: | |
| |
|Physician:| |Phone | |
| | |: | |
|Preferred hospital in case of | |
|emergency: | |
|Insurance | |Policy/Group| |
|Provider: | |: | |
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Section II - Physician:
|SNACK |Times snacks are to be| |Snacks | |gm carbs|
| |eaten: | | | | |
| | |
|MEAL PLAN |1 Diet prescribed by | |grams of carbohydrates per |
| |physician: |
|meal |
| |2 Copy of diet orders to | |NO | | Check one |
| |cafeteria? YES | | | | |
| | |
|BLOOD GLUCOSE |1 Blood glucose | |mg/dl to| |mg/dl |
|TESTING |target range: | | | | |
| |2 Check blood glucose: Check all that apply |
| | | |before lunch | |1-2 hours after lunch |
| | | |before snacks | |when he/she feels low or |
| | | | | |ill |
| | | |before getting on | |before PE |
| | | |bus | | |
| | | | | | |
| | | | | |Other |
| |3 Student will complete blood glucose testing: Check one |
| | | |independently
|
| | | |independently with adult supervision |
| | | |with assistance from an adult |
| |4 Glucometer will | |location |
| |be kept: | | |
| | |
|INSULIN |1 Student receives insulin | |Insulin pump| |Check one |
| |by: Injection | | | | |
| |2 Insulin | |
| |type: | |
| |3 Insulin dose based on carb | |NO | |Ck one |
| |counting? YES | | | | |
| |4 If so, | |units insulin| |grams carbs |
| |give | |per | |eaten |
| |5 If not, insulin order| |
| |is as
follows: | |
| |6 Insulin administration: |
| | | |Student administers insulin independently |
| | | |Student administers insulin independently with adult |
| | | |supervision |
| | | |Insulin administered with assistance of or by an adult |
| |7 Student has| |brand insulin pump |
| |an | | |
| |8 Insulin bolus dosage calculation: |
| | | |Student calculates dose independently |
| | | |Student calculates dose independently with adult |
| | | |supervision |
| | | |Dose calculated with assistance of or by an adult |
| |9 Insulin taken at home: Type:|Dose: / |
| | |Time: / |
|KETONES
|1 When should student check | |
| |ketones? | |
| |2 Limitations when ketones | |NO | |Check |
| |present? YES | | | |one |
| |3 If limitations, | |
| |please list: | |
| | | |
| | |
|DIABETES - EMERGENCY PLAN |
| |
|Note: In cases of any health concern regarding diabetic students, please |
|observe the following precautions: 1 Notify nurse to come to classroom, |
|2 Have adult accompany student to clinic or nurses office, |
|3 Notify nurse that student is being sent to clinic/office |
|IF YOU SEE THIS |DO THIS
|
|Student exhibiting signs of low |1 Check blood glucose BG |
|blood sugar; | |
|shaky, |2 If blood | |mg/dl, |
| |glucose | |student |
|irritable, | will | |gram carb snack |
| |eat a | | |
|sweating, |3 Observe student for 15 minutes |
|Other: |4 If 30 minutes to mealtime and/or |
| |there is no |
| | improvement, repeat above and call |
| |parent |
|Student confused and/or unable to |1 Check blood glucose if not checked |
|respond |previously |
|appropriately to questions |2 Administer glucose paste or cake icing|
| |to inside of cheeks
|
| | |
|Student becomes unconscious |1 Check blood glucose if not previously |
| |checked |
| |2 Glucagon | |No | |Ck |
| |ordered? YES | | | |one |
| |3 If ordered, administer glucagon IM |
| |Dose - 5mg or 1mg |
| |4 If glucagon not ordered, place student|
| |in side - lying |
| | position and call 9-1-1 |
| |5 Call parent / guardian |
| |6 Report to EMS personnel |
| | |
|Student exhibiting signs of high |1 Check blood glucose |
|blood sugar; |
|
|thirsty, |2 Administer insulin if ordered by |
| |physician |
|drowsy, |3 Have student drink at least 16 ounces |
| |of water |
|nauseated, |4 If blood | |ml/dl, student|
| |glucose is | | |
|urinating frequently, | will check urine for ketones |
|Other: |5 Recheck blood | |minutes |
| |glucose in | | |
|Blood glucose remains elevated at |1 Call parent / guardian |
|time of | |
|re-check and urine ketones are NOT |2 Encourage student to continue to drink|
|present |water |
| |3 Encourage student to do mild exercise |
|
|such as |
| | hall-walking with supervision |
|If blood | |and ketones |1 Restrict student from PE and Recess |
|glucose | |ARE | |
|present: |2 Encourage fluid intake water |
| |3 Call parent / guardian /emergency |
| |contact |
|If blood glucose |4 Student needs to be picked up from |
|and ketones |school |
|Student begins to vomit or have |1 Call parents / guardian / emergency |
|diarrhea |contact to pick up student |
|with or without ketones present | |
A copy of this form will be released to EMS personnel
|I authorize school personnel to implement the IHP described above |
| | | |
|Physicians Signature
|Printed Name |Date |
| |
| | |
|Parent/Guardians Signature |Printed Name |Date |
HCS280-17B Revised: 5/1/08
