Usual times to test blood glucose: _Times to do extra tests (check Diabetes Where are the diabetes care supplies kept? _Where are the supplies of …
Diabetes Care Plan for ____________________________ Date ___________ Blood Glucose Target range for blood glucose: ______________mg/dl to ___________mg/dl Usual times to test blood glucose: ________________ ________________ ________________ ________________ Times to do extra tests check all that apply: ______________Before exercise ______________After exercise ______________Other explain _______________________________ Can child perform own blood glucose tests? _______yes _________no Type of blood glucose meter used at school _____________________________ Insulin Times, types, and dosages of insulin injections Time ________________ ________________ ________________ ________________ Type ________________ ________________ ________________ ________________ Dosage ________________ ________________ ________________ ________________
Current level of students ability to self administer insulin: _______Independent _______Needs assistance Meals and snacks Meal and snack times: Time Food content/amount: Breakfast _____________ _____________________ Midmorning snack _____________ _____________________ Lunch _____________ _____________________ Midafternoon snack _____________
_____________________ Snack before exercise __________yes _________no Snack after exercise __________yes _________no Other times to give snacks ________________________________________ List parent provided snacks _______________________________________ Can child eat same snacks/party treats that classmates are offered? ______yes _____no If no parent will provide the following substitutes _______________________________ _______________________________________________________________________ Exercise and sports Student may carry a parent provided snack for exercise and sports Child should not exercise if blood glucose is below _____ mg/dl or above _____
Page 2 of Diabetes Care Plan Hypoglycemia low blood sugar Students especially those under the age of 7 years may have no symptoms prior to a hypoglycemic episode Usual symptoms of hypoglycemia: ____________________________________ Treatment of hypoglycemia: ____________________________________ When Glucagon administration has been authorized in writing by parents and the students physician, Glucagon will be utilized If student becomes unconscious and/or seizures, 9 -911 will be called, Glucagon will be administered, and parent will
be notified Hyperglycemia high blood sugar Usual symptoms: __________________________________________________ Treatment of hyperglycemia: _________________________________________ Usual times to test urine ketones: ________________ ________________ Treatment for ketones: ______________________________________________ School To be filled in at time of conference with school personnel Where are the diabetes care supplies kept? _____________________________ Where are the supplies of snack foods kept?_____________________________ Field trip accommodations: __________________________________________ Other: ___________________________________________________________ Parent/guardians must notify school nurse of changes in diabetic routine and/or medications so that care plan can be updated as appropriate Signature of parent/guardian: ____________________________Date ________ Signature of physician: _________________________________Date ________ Received by certified school nurse: ________________________Date________ Updates: _________________________________________________________ _________________________________________________________________________
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