Diabetes Insulin Pump Health Care Plan District Nurse Phone: District Nurse Fax:

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1 EMPOW ERING A COMMUNITY OF LEARNERS AND LEADERS Diabetes Insulin Pump Health Care Plan District Nurse Phone: District Nurse Fax: Student DOB School Grade Doctor Phone School Year Phone Pump settings are established by the student s healthcare provider and should not be changed by school staff. Monitor Blood Glucose Before lunch After lunch Before PE After PE Before snack Before getting on bus/driving home, Note: As needed for signs/symptoms of low or high blood glucose Notify parent when blood sugar < or >. Target range for blood sugar > mg/dl to < Hypoglycemia Student should not be sent to office unaccompanied if symptomatic or BS < mg/dl. Check blood glucose - if blood glucose meters not available, treat symptoms. Blood glucose between mg/dl and symptomatic: Treat with 10 to 15 gram carbohydrate snack. Mild symptoms: Treat with juice, glucose tabs, etc. until above mg/dl, then snack or lunch. Moderate symptoms if unable to drink juice: Administer glucose gel. Retreat until above mg/dl, then snack or lunch. Severe symptoms which may include seizures, unconscious, unable or unwilling to take gel or juice: Administer Glucagon mg(s) IM or units on insulin syringe SQ if trained staff available and call 911. Disconnect pump. Do not bolus for carbohydrates given to treat low blood glucose until blood glucose is > 70 mg/dl. Hyperglycemia If BS >300 mg/dl with ketones or 2 consecutive unexplained BS >300 mg/dl (with or without ketones), i.e. malfunctioning pump. Student may require insulin via injection and/or new infusion site/set. First contact parent then healthcare provider for further instructions. May need insulin via syringe. Check Urine Blood ketones if blood glucose > mg/dl If ketones present, call parents, provide water and student should not exercise. Recommend student be released from school when ketones are moderate/large or symptoms of illness in order to be treated and monitored more closely by parent/guardian. Insulin dosing for High Blood Glucose and/or Carbs: Blood glucose correction and insulin dosage via syringe is only to be administered when confirmed by school nurse, parent or healthcare provider for treatment of hyperglycemia. Insulin type: Insulin to Carbohydrate ratio units of insulin per grams of carbohydrate Carbohydrate ratio for snack units per gm of carbs am pm Bolus for carbohydrates (or to be) eaten should occur immediately Before lunch After lunch ½ bolus before & ½ bolus after Scanned 1of 5

2 Student s Self Care: (ability level to be determined by school nurse and parent with input from healthcare provider) Troubleshoots all alarms. Yes No Independently monitors blood glucose. Yes No Administers insulin independently. Yes No Independently counts carbohydrates. Yes No Self injects with verification of dosage. Yes No Needs assistance with pump management. Yes No Injection to be done by trained staff Yes No Independently manages pump boluses. Yes No Self treats mild hypoglycemia. Yes No Inserts new infusion set. Yes No Tests and interprets urine/blood ketones. Yes No All students with diabetes need to able to do a blood test at any time during school if not feeling well. The school must have a sharps container available and gloves for school personnel who may need to assist with testing young children. The student requires the following supplies: Yes No Blood glucose monitor and strips Lancets and lancets device Urine ketone strips Glucagon Emergency Kit Fast acting sugar source (Glucose Gel/Tabs) Jucie Boxes Water Bottle Complex carbohydrate snacks Extra Insulin cartridge Insulin Syringes Pump Batteries Food at School With diabetes, the student is highly encouraged to eat a well balanced diet, which includes both meals and snacks. Insulin and food must be given on time to keep the child safe. Meals and snacks should always be given at the right time. Parents will bring all snacks to the school. If parties, field trips, or other special events are planned, please call the parent before so that adjustments can be made with the student s meal plan. The student will eat breakfast: At home At the school breakfast program The student will participate in: Hot lunch program Bring a lunch from home The student is on a: Flexible Fixed meal plan The snack and meal plan is outlined below: Carb serving, 1Carb = grams Meal/ snack Time Carbohydrate /Grams eaten at a meal or snack Breakfast Morning Snack Lunch Afternoon Snack In addition to the above meal plan the student may require an extra snack: Before gym After gym only when needed Other instructions: 2of 5

3 SYMPTOMS: Low Blood Sugar Hunger Sweating Trembling or Shaking Pale Appearance Confusion Crying Inability to concentrate Fast Heart Beat Sleepiness Headache Dizziness Slurred Speech Poor Coordination Personality Change Complaints of feeling LOW Other Any time the student s blood sugar is less than and/or is having symptoms of a low blood sugar reaction: Give the student one of the following: 4oz Juice; 4-6oz Regular Soda 3-4 glucose tablets OR. If the student is not feeling better in 15 minutes, repeat: one of the above OR If it is more than 1 hour before the next meal or snack give and extra snack, such as Do not leave student alone or allow them to leave the classroom without an adult to accompany them. If the student is not responding to the treatment, Call parent right away. If student is not able to eat or drink, experiencing a seizure, and/or is unconscious: Call 911. Notify the operator the student has diabetes, report level of consciousness. Give Glucagon Injection. Glucagon Emergency Kit Using the glucagons emergency kit takes less than one minute to use and is the safest was to treat a child with diabetes when they experience a Severe low blood sugar. If the student is not able to eat or drink anything safely without the risk of choking, experiencing a seizure, or is unconscious Emergency personnel must be alerted and Glucagon administered. Mix the Glucagon injection. Each kit contains 1mg of glucagon. Give on the top and cent of the thigh at a 90 angle. Give the entire dosage: Give 1mg to children over the age of 4. Give half the dosage 0.5mg to children under the age of 4. Turn student on side and keep airway clear. Do not insert objects into mouth or between teeth. The student may vomit never leave the child unattended. The child will need to go to the nearest emergency room to be evaluated after receiving glucagon. The child s parent/guardian must be notified. 3of 5

4 High Blood Sugars SYMPTOMS: Dehydration Sleepiness Confusion Blurred Vision Dry Skin Inability to concentrate Hungry Irritability Frequent Urination Increase Thirst All student with high blood sugars will need to drink extra sugar-free fluids (water or diet drinks) and will need to use the bathroom more often. Along with monitoring for high blood sugars the student will need to do further testing for ketones. Ketone formation can be an emergency and attention needs to be given to the student. A high blood sugar for this student is a blood sugar over mg/dl. Check for ketones if blood sugars are above mg/d. School staff trained in diabetes care will will not need to assist with ketone testing and insulin administration. The treatment you need to assist in providing for high blood sugars in insulin administration. Insulin is given in the form of a correction factor. See the student s individual insulin dosing guidelines sheet for specific information. Important facts to remember with HIGH BLOOD SUGARS. Parents need to be notified if: If student s blood sugar is above. If moderate or large ketones are present. If high blood sugar symptoms worsen or if the student begins vomiting. Extra syringe or pen injections are given. The student has difficulty breathing and/or lethargy. Remember a student with diabetes can participate in all activities or sports unless ill, and should not be absent more than any other student. No two students with diabetes will have the same health plan at school. It is recommended that you meet with the parents prior to school starting to set up the appropriate diabetes care, and as needed if questions or issues arise. 4of 5

5 Responsibilities of the Family Keep emergency phone numbers current. Ensures ALL Diabetes IHP s from Physician are reviewed with school personnel, and provides updates to it as necessary. Provide snacks to the school. Responsibilities of the Student Has read the school plan and is willing to follow it. Understands the importance of communication the signs and symptoms of hypo or hyperglycemia with school personnel. Follow the snack and meal plan as ordered. Documents blood sugars and other required information. (Student Signature) If appropriate Responsibilities of the School Keep all diabetes supplies easily available for the students. Support frequent blood sugar testing. Assure that the student is permitted to have water and bathroom privileges. Have a reliable individual to monitor for signs of hypo and hyperglycemia and be knowledgeable of appropriate treatment responses. Communicate with families as to issues that arise at school. PARENTS CONSENT FOR DIABETES MANAGEMENT IHP I, the undersigned, as the parent/guardian of the above named student, request that specialized physical health care services for diabetes Management IHP be provided for my child. I will 1) provide the necessary supplies and equipment, 2) notify the health services staff if there is a change in student s health status or attending physician, and 3) notify the school nurse immediately of any changes in doctor s orders. This request includes the authorization for School personnel to contact the physician when necessary. On the last day of school how should medications be returned home? Sent home with Student Parent/Guardian Pick-Up Parent/Guardian Signature Date: PHYSICAN CONSENT FOR DIABETES MANAGEMENT IHP I have reviewed and approved the Diabetes management IHP and have included any recommended modifications. I understand that specialized physical health care services for Diabetic Management IHP will be performed by trained personnel. This consent is for a maximum of one year. This school plan will expire on:. MD Name (Print): MD Signature Date: 5of 5

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