Diabetes Individual Healthcare Plan

Transcription

1 Henry P. Becton Regional High School/Health Department Diabetes Individual Healthcare Plan Date of Plan: Effective for the school year Student s Name: Date of Birth Grade: Date of Diabetes Diagnosis: Type 1 Type 2 (check one) Contact Information Mother/Guardian: Address: Telephone:Home Work Cell Father/Guardian: Address: Telephone:Home Work Cell Student s Physician/Healthcare Provider: Address: Telephone: Emergency Number: Other Emergency Contacts: Name: Relationship Telephone:Home Work Cell Name: Relationship: Telephone:Home Work Cell Notify parents/guardian or emergency contact in the following situations (i.e.; blood glucose number low): ***************Please Complete Both Sides*************** 1 of 4

2 Blood Glucose Monitoring Diabetes IHP Target range for blood glucose is Other Usual times to check blood glucose Times to do extra blood glucose checks (check all that apply) before exercise after exercise when student exhibits symptoms of hyperglycemia when student exhibits symptoms of hypoglycemia Other (explain): Can student perform own glucose checks? Yes Is nurse supervision needed? Yes Exceptions: Type of blood glucose meter student uses: Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog/Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is units OR does flexible dosing using units/ grams carbohydrate. Use of other insulin at lunch: (circle type of insulin used): intermediate/nph/lente units OR Basal/Lantus/Ultralente units. Insulin Correction Doses Parental authorization should be obtained before administering a correction dose for high blood glucose levels: Yes units if blood glucose is to mg/dl units if blood glucose is to mg/dl units if blood glucose is to mg/dl units if blood glucose is to mg/dl Can student give own injections? Yes Can student determine correct amount of insulin? Yes Can student draw correct dose of insulin? Yes Is nurse supervision needed? Yes 2 of 4

3 Diabetes IHP For Students With Insulin Pumps Type of pump: Basal rates: units /hr at 12am to ; units at to ; units at to Type of insulin in pump: Type of infusion set: Insulin /carbohydrate ratio: Correction factor: Student Pump Abilities/Skills: Needs Assistance(check one) Count carbohydrates Yes Bolus correct amount for carbs consumed Yes Calculate and administer corrective bolus Yes Calculate and set basal profiles Yes Calculate and set temporary basal rate Yes Disconnect pump Yes Reconnect pump at infusion site Yes Prepare reservoir and tubing Yes Insert infusion set Yes Troubleshoot alarms and malfunctions Yes For Students Taking Oral Medications Type of medication: Timing: Other medications: Timing: Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? Yes Mid- morning:time content Lunch:time content Mid-afternoon:time content Snack before exercise? Yes Snack after exercise? Yes Other? Exercise and Sports Type of fast-acting carbohydrate to be available at site: Activity restrictions? Student should not exercise if blood glucose level is below mg/dl or above mg/dl, Or if moderate to large urine ketones are present. ********Please Complete Both Sides******** 3 of 4

4 Diabetes IHP Hypoglycemia (Low Blood Sugar) Usual symptoms: What glucose level mandates treatment if no symptoms? Treatment of hypoglycemia Glucagon to be given if student is unconscious, having a seizure (convulsion), or unable to swallow. Dose: Route: site: If glucagon is required, administer promptly. Then call 911 and the parents/guardian. Hyperglycemia (High Blood Sugar) Usual symptoms: Treatment of hyperglycemia: Urine should be checked for ketones when blood glucose levels are above mg/dl. Supplies to be Kept at School Blood glucose meter, blood glucose test strips, batteries for meter Lancet device, lancets, gloves, etc urine ketone strips Insulin vials and syringes Insulin pump and supplies Insulin pen, pen needles, cartridges Fast-acting source of glucose carbohydrate containing snack Glucagon emergency kit This Diabetes Individual Healthcare Plan Has Been Approved By: Signature of Physician/Healthcare Provider Date Physician/Healthcare Provider Stamp: Signature of Parent/Guardian Date Permission to Release and Exchange of Confidential Information I hereby authorize an exchange of medical information to occur between the School Nurse and the appropriate staff involved in my student s education, health, and safety. (i.e.; class teachers, counselors, bus driver). I also permit the exchange of medical information between the School Nurse and my student s Physician/Healthcare Provider. I agree to provide the necessary equipment and supplies, including snacks, glucose tabs, or glucagon that may be needed by my student in school or at school activities. I also understand that this authorization is in effect for the school year, and must be renewed on an annual basis. As the parent/guardian, I am responsible for updating the school nurse of any changes in my student s condition or orders. Signature of Parent/Guardian: Date: 4 of 4

5