Individualized Healthcare Plan For Management of Diabetes at School School will include a copy of the ISHP for Diabetes Management with the Disaster Supplies. …
Diabetes Individualized Healthcare Plan
|Pupil: |
|Grade: |DOB |Educational Placement: |
|School: |
|District: |
|School Nurse: |Pager |Cell |
|Parent/Guardian Consent Date: Physician Authorization Date: |
|Parent Signature: |
|Mother |Home |Work |Pager/Cell |
|Father |Home |Work |Pager/Cell |
|Guardian |Home |Work |Pager/Cell |
|Home Address |City |Zip |
|Other Contact Relationship: |Home |Work |
|Physician |Phone |Fax
|
|Physician Address |City |Zip |
|Healthcare Service |Management of Diabetes at School and School Sponsored Events: |
|Needed at School | |
| | |
|Purpose of an ISHP |The purpose of an Individualized School Healthcare Plan ISHP is |
| |to provide safe management of healthcare needs and services for |
| |pupils at school and during school-related activities |
| | |
| |The school nurse, in collaboration with the student and the |
| |students parent/guardian, healthcare providers, and school team, |
| |is responsible for: |
| |Development, implementation, and revisions of the ISHP |
| |The training and supervision of all designated personnel who will |
|
|provide healthcare according to the ISHP and standard procedures |
| | |
| |The ISHP may be attached as a document for a 504 Plan and/or IEP |
| | |
| |ISHP revisions must be directed to the school nurse prior to |
| |implementation All physician changes must have a written |
| |physician authorization and written parent consent Revisions, not|
| |requiring physician authorization, may be made with written parent |
| |consent |
| | |
| |ISHP review must occur annually and whenever necessary to ensure |
| |provision of safe care |
Individualized Healthcare Plan For Management of Diabetes at School
Completed With Parent and Pupil
|Pupil
DOB School Grade |
|Diabetic Routines|Daily Snacks: Times _________________________________________ |
|At School Per |Place specified____________________________________ |
|Parent | Done independently |
|Request/Consent | Needs reminder |
| | Needs daily compliance verification |
| |Extra Snacks: Before exercise |
| | After exercise |
| | 10 gms CHO every 30 minutes during vigorous exercise |
| | Needs daily compliance verification |
| |Daily Blood Test: Before Meals Prior to Exercise As |
| |Needed |
| |Location for testing Classroom Health Office |
| |Student is to be tested where they
are at if Hypoglycemic |
| | By pupil independently |
| | Adult verifies results |
| | Needs assistance specify___________________ |
| | Refer to Algorithms for Blood Glucose Results, attach sheet |
| | |
| |Exercise: None if blood glucose test results are below |
| |_____________ mg/dl |
| | |
| |Lunch Eaten At time ________ Regardless of schedule changes, field |
| |trips, disaster, etc |
| | Needs daily verification of meal eaten |
| | Written consent with schedule changes with snack and meal times |
| |In Event of Field Trips, all diabetic supplies are taken and care is |
|
|provided according to this ISHP a copy is taken on trip |
| | |
| |The School Nurse Must Be Notified Two Weeks Before The Field Trip To |
| |Plan For Qualified Personal To Provide Procedures |
| | |
| |In Event of Classroom/School Parties, food treats will be handled as |
| |follows: |
| | Pupil will eat the treat |
| | Replace with parent supplied alternative |
| | Put in baggie and take home with teacher note |
| | Modify the treat as follows: |
| | Do not eat snack |
| |In Event of Bus Transportation: |
| | Blood test given 10 to 20
minutes before boarding If 70 or |
| |less, provide care per Procedure For Mild to Moderate Low Blood |
| |Glucose and call parent to provide transportation home |
| | Blood test not required |
| |Scheduled After-School Activities: |
| |____________________________________ |
| | |
|Training and |The following personnel will be notified of my childs medical |
|Notification of |condition and participate in Diabetes Basic Training Program: |
|School Employees |All School Personnel School Personnel that have contact with my|
|of Diabetes Basic|child Cafeteria Staff Other _______ |
|Training Program | |
|Other | |
| |Specify:______________________________________________________
|
| |Student has unrestricted use of the bathroom and water |
Individualized Healthcare Plan
For Management of Diabetes at School Continued
Completed With Parent and Pupil
|Pupil DOB School Grade |
| | | |
|Equipment |Provided By Parent |Provided By Parent Continued |
|and supplies| | |
| |Daily Snacks for AM/PM snack |Insulin Supplies |
| |times Specify: | Insulin pen |
| | | Pre-filled syringes labeled per |
| |________________________________ |dose |
| | | Insulin and syringes |
| | | Extra pump supplies such as: |
| |Extra Snacks for before, after, |
Vial of insulin, syringes |
| |and/or during exercise Specify: | Pump syringe |
| | | Pump tubing/needle |
| |________________________________ | Batteries |
| | | Tape |
| |Blood Glucose Meter Kit | Sof-Serter |
| |Includes meter, testing strips, |Insulin supplies stored: |
| |lancing device with lancet, cotton|______________________________ |
| |balls, spot Band-Aids | |
| |Brand/Model:____________________ | |
| | |Emergency Supplies |
| |Low Blood Glucose Supplies, 5 day| |
| |supply | Glucagon kit stored: |
| | |_______________________________ |
|
| Fast Acting Carbohydrate Drinks:| |
| | | 3 day disaster food supply stored: |
| |Apple juice and/or orange juice, |_______________________________ |
| |sugared | |
| |soda pop-NOT diet, at least 6 |3 Day Disaster Diabetes Supplies |
| |containers | Vial of insulin; 6 syringes |
| | | Insulin pen with cartridge and |
| | Glucose Tablets, 1 package or |needles |
| |more | Blood glucose testing kit testing |
| | |strips lancing device |
| | Glucose Gel Products |with lancets |
| |Insta-Glucose, | Glucose gel product and glucose |
| |Monogel or Glutose/25–31 Gms, 2|tablets |
| |or |
Glucagon kit |
| |more | Food supply include daily meal plan|
| | |stored as |
| | Gel Cakemate not frosting, |follows:_______________________________|
| |19 Gm, | |
| |mini-purse size, 2 or more | Ketone strips/plastic cup |
| |Note: Not used in Emergency | |
| |Procedure For Severe Low Blood |School will include a copy of the ISHP |
| |Sugar |for Diabetes Management with the |
| | |Disaster Supplies Stored as follows: |
| | Prepackaged Snacks such as |_______________________________________|
| |crackers |_______________________________________|
| |with cheese or peanut butter, nite|__________________ |
| |bite, | |
|
|etc, 5 - 6 servings or more |Other Supplies, Specify: |
| | | |
| |High Blood Glucose Supplies | |
| | | |
| | Ketone Test Strips/Bottle | |
| | Urine cup | |
| | Water bottle | |
| |Note: Timing device may be wall | |
| |clock or watch worn by pupil or | |
| |personnel | |
Algorithms for Blood Glucose Results
———————–
1 Give fast acting carbohydrate If meal or snack is within 30 minutes,
no additional carbs are needed If student is not going to eat within 30
minutes additional carb and protein snack is to be given
If
students blood sugar result is immediately following strenuous
activity, give an additional fast acting sugar
Students Name:
School:
Nurse Contact number/pager:
Parents Phone Numbers:
Physicians number:
Student is fine
If exercise is planned before a snack or a meal, including recess, the
student must have a snack before participating
1 Give fast Acting sugar source and carbohydrate
2 Observe for 15 minutes
3 Retest Blood Glucose, if less than 70 repeat sugar source If over 70
give carbohydrate and protein snack eg Crackers and cheese if not
eating within 15 minutes
4 Notify School nurse
5 Notify Parent/PMD if less then 50
If Student Becomes Unconscious, Seizures, or is Unable to Swallow:
1 Call 911
2 Turn student on side to ensure open airway
3 Give glucose gel and glucagons if ordered
4 Notify school nurse, parents/PMD
Ketones Present - Notify School Nurse Immediately Notify Parents/PMD
Provide 1-2 glasses of water every hour
Do not exercise
If at any time student vomits, becomes lethargic, and/or has labored
breathing CALL 911
15 gm Glucose tablets
15 gm Glucose gel
1/3 c sugared soda
c orange juice
c apple juice
c grape juice
tube
cake mate gel
3tsp Sugar in water
Fast Acting Sugar Sources Do not give chocolate
Check Ketones If ordered
can not exercise unless urine is negative for Ketones
Provide extra water
Parents Phone Numbers:
126-240
91-125
Below 70
70-90
Above 240
Check Blood Glucose
Signs of Low Blood Sugar:
Fatigue, excessive sweating, trembling, clammy, dizziness, headache, hunger
pangs, visual impairment, accelerated heart beat, anxiety, difficulty
concentration, blackouts, confusion, crying, irritability, poor
coordination, nausea, inappropriate behavior
Never send a child with suspected low blood glucose anywhere alone
Signs of high Blood sugar:
Early Symptoms:
Thirsty /dry mouth, frequent urination, fatigue/sleepiness, increased
hunger, blurred vision, lack of concentration
Symptoms progressively become worse:
Sweet breath, nausea/stomach pains, vomiting, weakness, confusion, labored
breathing,
unconsciousness/coma
Source:schoolhealthservicesny.com
