Individualized Health Plan (IHP) for Students with Diabetes Using Insulin

DIABETES PLAN
Photo / STUDENT INFORMATION / MEDICAL INFORMATION
Name: / Primary HCP:
DOB: / Phone #:
Address: / Specialist:
Phone #: / Phone #:
Parent/Guardian: / Nurse:
Home #: / Phone #:
Work/Cell #: / Hospital:
Parent/Guardian: / *Medication/Insulin
delivery:
Home #:
Work/Cell #:
Teacher’s Name/Homeroom:

*Insulin delivery system/type of insulin:

  • If pump, give brand of pump and insulin used in pump
  • If injections, list name of short and/or long-acting insulin and method of delivery

504 plan: Yes / No If yes, annual plan date:

Last A1C/Date: A1C Goal:

Hypoglycemia (low blood sugar): This can be a medical emergency. All staff working with a student with diabetes should be alert to the following symptoms(check all those that apply to this student):

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Individualized Health Plan (IHP) for Students with Diabetes Using Insulin

shakiness

dizziness

sweating

hunger

headache

pale skin color

sudden moodiness or behavior changes such as crying for no apparent reason

clumsy or jerky movements

difficulty paying attention

confusion

tingling sensations around the mouth

other:

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Individualized Health Plan (IHP) for Students with Diabetes Using Insulin

All students with possible low blood sugar should be accompanied to the Health Office if that is where they check blood sugar (BS) and are treated.

Treatment for hypoglycemia

General rule is treat low BS with 15 Gm of fast-acting carbohydrate (CHO), recheck in 15 minutes and retreat with 15 Gm of CHO if still low.

Blood sugar ranges / Treatment recommendations / Comments

Emergency treatment of low blood sugar

A tube of glucose gel can be useful if student is still able to swallow, but having difficulty following directions. Squirt some gel inside the mouth at the gum line and massage, allowing for faster absorption.

If student is unable to swallow, is unconscious or having a seizure:

  • Give Glucagon 0.5 mg or 1 mg (check one)
  • Place student on the side
  • Have someone call 911
  • Have someone call family
  • Check blood sugar.

Hyperglycemia (high blood sugar)

This may be treated at lunch time if taking injections or at other times if wearing an insulin pump. Not usually a medical emergency unless blood sugar is quite high >250 mg/dl and student is vomiting or short of breath. Check symptoms that apply to this student:

Increased thirst

dry mouth

frequent urination

Treatment for hyperglycemia

Blood sugar (BS) ranges / Ketones if ordered / Treatment recommendations

Trace/Small Ketones: Usually can be managed at school. May need to use bathroom more often; encourage fluids; recheck BS in 2 hours.

Moderate/Large Ketones: In addition to above recommendations, call parent/guardians. Arrange for family to manage care at home with communication to health care provider.

Emergency treatment of high blood sugar

  • Emergency signs/symptoms=shortness of breath &/or nausea & vomiting
  • Call parent/guardian
  • If unable to reach responsible adult, call 911

Routine Blood Sugar checks(check all that apply & list times)

Before breakfast

Before morning snack

Before lunch

Before afternoon snack

End of school day

Additional glucose monitoring at school (check all that apply):

Before physical activity/physical education

During physical activity/physical education

After physical activity/physical education

Symptoms of low blood glucose

Symptoms of high blood glucose

Student becomes sick or is sick

Other

Have student change the lancet after every poke.

Insulin for meals/snacks

Type of Insulin(s) required (list):

Insulin delivery (check): Syringe/Vial Insulin Pen

Insulin Pump (name) Other:

Insulin required (check): Breakfast AM Snack Lunch PM Snack

Other

Other insulin required at school; type time dose

Student skills for using insulin (check all that apply):

Counts carbohydrates

Calculates correct insulin dose

Draws up correct insulin dose

Independently gives own injection

Uses pump independently

Other

Student needs assistance with (list):

FLEXIBLE Insulin Dose: Not applicable

Total dosage of insulin = insulin for meal + correction insulin dose

Insulin/Carbohydrate ratios:

Breakfast / units per / Gram Carbohydrate
AM Snack / units per / Gram Carbohydrate
Lunch / units per / Gram Carbohydrate
PM Snack / units per / Gram Carbohydrate
Dinner / units per / Gram Carbohydrate

Insulin Correction ScaleNot applicable

(Correction dose is added to the meal dose of insulin)

Blood Glucose is / less than / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units
Blood Glucose is / to / = units

EXTRA INSULIN: NON-MEAL TIME ONLY Not applicable

Criteria for giving extra insulin (all apply):

• Extra insulin is given if it has been more than 2 hours since last dose was given

• Blood glucose must be checked within 2 hours after correction dose is given

• Blood glucose level is over mg/dL

• Notify parents when extra doses are given at school

• Do not exceed 2 extra doses in one school day

•Other:

Options: Use insulin correction scale above

Carbohydrate counts for all MMSD menus are on the Food and Nutrition web page under Nutrition and Special Dietary Needs.

Field Trips

Pack:

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Individualized Health Plan (IHP) for Students with Diabetes Using Insulin

glucose meter (to check blood sugar)

hand sanitizer

glucose tablets

glucose gel

insulin

syringes

glucagon

copy of IHP

Other:

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Individualized Health Plan (IHP) for Students with Diabetes Using Insulin

Delegated staff (who are trained to help with medications) include:

Name / Job Description
Nurse’s Assistant

CONTINUOUS GLUCOSE MONITORS (CGM)Not applicable

Treatment decisions and diabetes care plan adjustments should always be made based upon a meter blood glucose reading.

Name of CGM:

CGM alert for low blood glucose is set at mg/dL

CGM alert for high blood glucose is set at mg/dL

Check blood glucose by finger stick in these situations (all apply):

  • Any high or low glucose alert
  • Before insulin or medication is used to lower glucose
  • Any symptoms of low or high blood glucose
  • Any time the CGM system is not working
  • CGM readings are questionable
  • Other:

Signature-Parent/Guardian______Date ______

Signature-School Nurse______Date ______

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