Equipment and Supplies Checklist for Parents Student: DOB: School: Grade: Equipment and Supplies to be Provided by Parent. Parent Signature Date
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1 Equipment and Supplies Checklist for Parents Student: DOB: School: Grade: Equipment and Supplies to be Provided by Parent Parent Signature Date Daily Snacks (for AM/PM snack times): Specify: Extra Snacks (for before, after, and/or during exercise) Specify type of snacks: Glucose Meter Kit Brand/Model: (Includes meter, testing strips, lancing device with lancet, cotton balls, spot bandages). Low Blood Glucose Supplies (Provide item from selected category 5 day supply preferable) Fast acting carbohydrate drinks: (Apple juice and/or orange juice, sugared soda -NOT diet) Glucose tablets: 1-2 packages preferred Glucose gel products: (Insta-Glucose, Monogel or Glutose/25-31gms.) 1-2 preferred Gel Cakemate :(not frosting), (19 gm., mini-purse size), 1-2 preferred Prepackaged snacks: (such as crackers with cheese or peanut butter, Nite-Bite, etc.) High Blood Glucose Supplies (Check those that apply) Ketone test strips/bottle or meter kit Urine cup Water bottle Note: Timing device may be wall clock or watch worn by pupil or personnel. Insulin Supplies Insulin pen Insulin and syringes Extra pump supplies, such as infusion set Vial of insulin, syringes Pump cartridge Batteries Tape Insertion device Insulin supplies storage location: 13
2 Emergency Supplies Glucagon kit stored: Expiration date of glucagon vile: Recommended 3 Day Disaster Diabetes Supplies (Check those that apply) Vial of insulin; 6 syringes, or Insulin pen with cartridge and needles Blood glucose testing kit (testing strips, lancing device with lancets) if authorized Glucose gel product and glucose tablets Glucagon kit Food supply (include daily meal plan) stored as follows: Ketone strips/plastic cup if authorized Pump supplies, as listed above Extra battery for pump Other Supplies specify: For the school nurse to complete Date Form sent home Date Form returned to school School will include a copy of the IHP for diabetes management with the disaster supplies. Stored as follows: 14
3 Individualized Plan of Care for Students with Diabetes Instructions Every student with diabetes must provide a written order from their physician/health provider for the school nurse to carry out the plan of care. The Individualized Plan of Care for Students with Diabetes is suggested as a standard plan to be used for all students with diabetes. Instructions: The plan of care is to be developed by the physician/health provider and updated as needed but at least annually. The adjustments for illness/activities provides an order for the school nurse to change the insulin dose to accommodate the student s need for dose adjustment during illness or changes in physical activity. Although this is a physician order for the school nurse, it is recommended that changes in insulin dose be made in consultation with the parent/guardian. The school nurse is responsible for actions taken to carry out the plan. If the school nurse has concerns or questions in providing care to the student, contact should be made with the provider or diabetes center. Possible Side Effects Insulin Possibility of low blood sugar Glucagon The student may vomit following Glucagon administration. If unconsciousness, turn child on side to protect the airway. If student is seizing, do not attempt to put anything in their mouth. 15
4 INDIVIDUALIZED PLAN OF CARE FOR STUDENTS WITH DIABETES Home and School Care Instructions Name: Date: Weight: Height: DOB: School School Nurse School Fax PLAN: Multiple Daily Injections: Pump: Adjustment for illness / activity / other factors affecting BG values (+/- 50%) Basal Bolus: Base Dose Basal Bolus: Base Dose or or Insulin to Carb Rato Insulin to Carb Ratio Breakfast AM Snack Lunch PM Snack Supper Bedtime Pump Basal Rates: Time Units/hr Time Units/hr 12 MN 12 MN Total Basal = units Total Basal = units Supplemental (Correction) Scale: Day Evening and 2-3 AM Other Blood sugars need to be checked before: Brkfst. Bus AM Snack Lunch PM Snack PE Getting on the bus Supper Bedtime Other Meal Plan (Optional): Urine Ketones: Target Blood Sugar: Total Carbs Check for urine Before Meals = Breakfast ketones if Blood Sugar AM Snack Lunch is > 240 or if child is 2 Hours After Meals/snacks and/or Correction = PM Snack ill. Contact parent if Dinner Moderate to 3 Hours After Meals/snacks HS Snack Large ketones. and/or Correction = Glucagon: Dose: Route: Call parent immediately after giving. I authorize the exchange of information about my child s diabetes between the Physician s Office and the school nurse. Parent signature: Date: I authorize the school nurse to carry out the orders defined in the plan of care. Physician/Provider Signature: Date: Phone: Fax: Next App t: Other: 16
5 INDIVIDUALIZED PLAN OF CARE FOR STUDENTS WITH DIABETES Home and School Care Instructions Name: James Smith Date: 9/4/04 Weight: 60 Kg Height: 140 cm DOB: 11/14/93 School George E Jack School Nurse School Fax PLAN: Multiple Dose Injection: _X Pump: Adjustments for illness/activity/other factors affecting BG values (+/- 50%) Basal Bolus Basal Bolus Breakfast 8 units Novolog +/- 4 units AM Snack 0 units Novolog +/- 0 Lunch 7 units_novolog +/- 3.5 PM Snack 3 units_novolog +/- 1.5_ grms CHO Supper 15 units Lantus 8 units Novolog +/- 7.5 unit L +/- 4 Bedtime 2 units Novolog +/- 1 *Low blood sugar is a possible side effect of giving insulin. Pump Basal Rates: 12 MN _0.9, 12 MN AM AM AM AM AM AM PM PM PM PM Total Basal: _24 units Total Basal units Supplemental (Correction) Scale: Daytime _1 unit/40mg/dl_> 200 +/- 20/dl Bedtime and 2 3 AM Unit/40 mg/dl > 200 NA Other Blood Sugar checked before: Brk AM Bus AM Snack Lunch PM Snack PE PM Bus Supper Bedtime Other Meal Plan: Urine Ketones Target Blood Sugar: Breakfast AM Snack Lunch PM Snack Dinner HS Snack Total Carbs 45 g 15 g 60 g 30 g 75 g 30 g Check for urine ketones if Blood Sugar is >240 or if child is ill. Contact Before Meals + _80_ - _150_ 2 Hours After Meals and/or Correction = _180 3 Hours After Meals and/or Correction = _80_ - _150 Glucagon: Dose: 1 mg Route: SC Call Parent immediately. after administering. *Possible side effect: Child may vomit following Glucagon administration. If unconscious, turn child on side to protect airway. If child is seizing, do not attempt to put anything in child s mouth. I authorize the exchange of information about my child s diabetes between the Physician s Office and the School Nurse. Parent Signature Date I authorize the school nurse to carry out the orders defined in the Individulized Plan of Care. Physician/Provider Signature: Date: Phone: Fax: Next App;t: 17
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