Diabetes Management Plan- Insulin Injection

Diabetes Management Plan- Insulin Injection

Student ______Birth date ______Age when diagnosed ______

Teacher/Team ______Grade _____ Transportation: □ bus # _____ □ car rider

Blood Sugar Monitoring:

Test Blood Sugar: Before meal After meal Before ExerciseAfter Exercise Before snack Before bus/dismissal

Ifsymptoms of low or high BS

Notify parent is blood sugar below mg/dl and higher than mg/dl.

Target range for blood sugar is mg/dl to mg/dl.

Type of Meter: Meter to be stored in: Health Office Classroom Student’s book bag

Continuous Glucose Monitor (CGM): Yes No

Brand/Model: Alarms set for: (low) and (high)

**Note: Confirm CGM results with blood glucose meter check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM.

Hypoglycemia (Low blood sugar): Student should be sent to office accompanied by an adult if symptomatic or if BS is less than 80 mg/dl.

This student’s most common complaint(s) when BS is low or dropping is:

Test blood sugar if complaints- if blood glucose meter not available, treat symptoms.

For blood sugar less thanmg/dl: Treat with 15 gram carbohydrate snack (juice, glucose tab, etc) and recheck every 10-15 minutes until above 70mg/dl, then treat with protein snack or lunch and notify parent.

If unable to drink juice: Administer glucose gel or cake icing. Recheck and retreat every 10-15 minutes until BS >70 mg/dl, then snack/lunch.

Carbohydrates that were used to bring blood sugar up to within target range should NOT be covered with insulin.

If unconscious, seizing, unable or unwilling to take glucose gel or juice: AdministerGlucagon mg(s) IM or SQ and call 911, position student on side because may vomit, then notify parent/guardian. When regains consciousness follow with fast sugar.

Hyperglycemia (high blood sugar):

This student’s most common complaint(s) when BS is high is:

If elevated Blood sugar, encourage water or sugar free fluids. Allow unrestricted bathroom privileges.

Use correction scale with: meals snacks. May be used at unscheduled times if blood sugar >____, AND 2 hours from prior/next scheduled insulin dose

Check urine ketones if blood sugar is over 250 mg/dl or with symptoms of nausea/vomiting. If ketostix not available, treat with correction scale insulin and give water and call parent. Recheck blood sugar in: 1hour 2 hours.

If ketones present, call parent, provide water and student should NOT exercise.

If student having symptoms of nausea and vomiting call parent/guardian to pick up in order to be treated and monitored more closely and encourage to call to doctor.

No exercise blood sugar is higher than mg/dl with or without ketones.

Insulin Administration:Correction Scale may be used every 2 hours.

Type of Insulin: Administered via: Syringe yes no Insulin pen yes no

Blood Sugar Range mg/dl Administer units

Parent/guardian authorized to increase or decrease correction scale within the following range: +/- 2 units of insulin. yes no

Carbohydrate counting:

Meals: Carbohydrate recommendation for meals: units of insulin per grams of carbohydrates at meals

Bolus for carbs eaten (or to be eaten) should occur immediately Before meal After meal ½ bolus before & ½ bolus after

Snacks: Student to have scheduled snack: yes no If yes, when?

Cover carbs in snacks No insulin coverage for snacks.Cover snacks if over ______grams carbs

Parent/guardian authorized to increase or decrease insulin to carbohydrate ratio within the following range: 1 unit per prescribed grams of carbohydrates +/- 5 grams of carbohydrates. yes no

Student ______Birth date ______

Student’s Ability to Self Manage Diabetes:

Totally independent in all aspects of care Yes NoIf you answered yes, skip to signatures

Tests blood sugar independently Yes NoInjections to be done by trained staff Yes No

Needs verification of blood sugar by staff Yes NoSelf treats mild hypoglycemia Yes No

Student can assist/testing by trained staff Yes NoMonitors own snacks and meals Yes No

Administers insulin independently Yes NoCounts carbohydrates independently Yes No

Self injects with verification of dose Yes NoTests and interprets urine/blood ketones Yes No

Self injects with trained staff supervision Yes No

Signatures:

1.Physician Authorization for Medication Administration and Specialized Health Care Procedures:

Physician’s signature: ______Physician’s name printed: ______

Office telephone: ______Date: ______

2.Parent Authorization for Medication Administration and Specialized Health Care Procedures:

Student’s parent/guardian knows of this request and is in full agreement of the plan of care, the administration of the medications and procedures specified above during the school day. He/She agrees to provide all necessary supplies needed to test blood sugar and to treat high or low blood sugars on the first day back to school. He/She further understands that this should include blood sugar monitor, test strips and lancets, insulin administration supplies, ketostix, snacks, juice and a water bottle and understands that all insulin vials or insulin pen refills must be replaced every 30 days once opened.

The parent/guardian releases the School Board, its agents and employees, from any and all liability that may result from his/her child taking these prescription medications and/or receiving these specialized health care procedures and is aware that these orders expire no later than the last day of school this year.

Parent/Guardian’s signature: ______Parent/Guardian’s name printed: ______Date: _____

Reviewed by School Nurse: ______Date: ______

3. Parent Authorization for the Release of Information:

I hereby give permission for my child’s school to exchange specific, confidential medical information with the physician listed above on my child, ______, to develop more effective ways of providing for the healthcare needs of my child in school.

Parent Signature: ______Date: ______

4. Student contract for Self-Administered Medication:

oI will be responsible for my own diabetic supplies at school. Where are the diabetic supplies kept during the school day?

______

I agree to use my diabetic supplies/medication in a responsible manner, in accordance with my doctor’s orders.
I will notify the school nurse or main office if I am having more difficulty than usual with my diabetes.
I will not allow any other person to use my diabetic supplies/medication.

Student’s signature: ______Date: ______

Contact Information:

Father’s Name: ______

Daytime telephone: ______Cell phone: ______

Mother’s Name: ______

Daytime telephone: ______Cell phone: ______

Emergency Contact: ______

Daytime telephone: ______Cell phone: ______3/16apl