North Hanover Township School District 351 Monmouth Road, Wrightstown, NJ 08562

Transcription

1 Diabetes Medical Management Plan/Individualized Healthcare Plan Part A: Contact Information must be completed by the parent/guardian. Part B: Diabetes Medical Management Plan (DMMP) must be completed by the student s physician or advanced practice nurse and provides the medical orders for the student s care. This section must be signed and dated by the medical practitioner. Part C: Individualized Healthcare Plan must be completed by the school nurse in consultation with the student s parent/guardian and healthcare provider. It focuses on services and accommodations needed by the student at school or during school-sponsored activities. Part D: Authorizations for Services and Sharing of Information must be signed by the parent/guardian and the school nurse. Part E: Shelter in Place Orders must be completed by parent/guardian and health care provider in order to provide care in the event of an emergency in the school district. PART A: Contact Information to be completed by the parent/guardian Student s Name: Gender Date of Birth: Date of Diabetes Diagnosis: Grade: Homeroom Teacher: Mother/Guardian: Address: Telephone: Home Work Cell Address Father/Guardian: Address: Telephone: Home Work Cell Address Student s Physician/Healthcare Provider Name: Address: Telephone: Emergency Number: Other Emergency Contacts: Name: Relationship: Telephone: Home Work Cell

2 PART B: Diabetes Medical Management Plan for School THIS FORM MUST BE COMPLETED BY PHYSICIAN/LICENSED MEDICAL PROVIDER Student Name: DOB: Effective Date: SCHOOL: Type of Diabetes: Type 1 Type 2 Other: Date of Diagnosis: Blood Glucose Monitoring Meter Type: Blood Glucose target range: - mg/dl Blood glucose monitoring times: For suspected hypoglycemia At student s discretion excluding suspected hypoglycemia No blood glucose monitoring at school Supervision of monitoring and results Permission to monitor independently Check Blood glucose before Physical Education Assistance with monitoring and results Check Blood Glucose after Physical Education Check blood glucose 10 to 20 minutes before boarding bus Diabetes Medication No insulin at school: Current insulin at home: Oral diabetes medication at school: Insulin at school: Humalog Novolog Apidra Other: Insulin delivery device: Syringe and vial Insulin Pen Insulin Pump Insulin dose for school: Standard lunchtime dose: Meal bolus: units of insulin per grams of carbohydrate Correction for blood glucose: units of insulin for every md/dl above mg/dl. (Correction bolus can be given with meals or every 3 hours if blood glucose levels are high) Correction Scale Units of Insulin Less than More than 400 Note: Insulin dose is a total of meal bolus and correction bolus Blood Glucose Value (mg/dl) Parent/Guardian may adjust insulin doses within the following range: Adapted with permission from National Association of School Nurses H.A.N.D.S., 2010

3 Meal Plan Insulin to Carbohydrate ratio: 1 unit of insulin to grams of carbohydrates or 1 carbohydrate choice = Grams of carbohydrate Meal plan prescribed (see below) Meal plan variable Breakfast Time: # of carb choices = Morning Snack Time: # of carb choices = Lunch Time: # of carb choices= Afternoon Snack Time: # of carb choices= Plan for pre-activity: Plan for afterschool activities: Plan for class parties: Extra food allowed: Parent/guardian s discretion Student s discretion Hypoglycemia Blood Glucose < mg/dl Self treatment of mild lows Assistance for all lows Immediately treat with 15 gm of fast-acting carbohydrate (e.g. 4 oz juice, 3-4 glucose tabs, 6 oz regular soda, 3 tsp glucose gel) Recheck blood glucose in 15 minutes and repeat 15 gm of carbohydrate if blood glucose remains low. If more than 1hour until next meal or snack student should have another 15 gm of carbohydrate. If child will be participating in additional exercise or activity before the next meal, provide an additional carbohydrate choice. If student is using an insulin pump, suspend pump until blood glucose is back in goal range. Severe Hypoglycemia If the child is unconscious or having seizures due to low blood glucose immediately administer injection of: Glucagon mg (glucagon emergency kit) --Immediately after administering the Glucagon, turn the student onto their side. Vomiting is a common side effect of Glucagon. --Notify parent/guardian and EMS per protocol. Hyperglycemia Blood Glucose> mg/dl Check ketones when blood glucose > mg/dl or student is sick. Use Correction Scale insulin orders when blood glucose is mg/dl. Unlimited bathroom pass. Notify parent immediately of blood glucose > or if student is vomiting. If student is using insulin pump, follow DKA prevention protocol. Special Occasions Arrange for appropriate monitoring and access to supplies on all field trips Signature of Physician/Licensed Provider Printed name of Physician/Licensed Provider Date Address Phone Fax Adapted with permission from National Association of School Nurses H.A.N.D.S., 2010

4 PART D: Authorization for Services and Release of Information 1. Permission for Care I give permission to the school nurse to perform and carry out the diabetes tasks outlined in the Diabetes Medical Management Plan (DMMP), Individualized Health Care Plan (HIP), and Individualized Emergency Health Care Plan (IEHP) designed for my child. I understand that no school employee, including the school nurse, a school bus driver, a school bus aide, or any other officer or agent of a board of education, shall be held liable for any good faith act or omission consistent with the provision of N.J.S.A. 18A: Student s Parent/Guardian Date 2. Permission for Glucagon Delegate I give permission to to serve as the trained glucagon delegate(s) for my child,, in the event that the school nurse is not physically present at the scene. I understand that no school employee, including the school nurse, a school bus driver, a school bus aide, or any other officer or agent of a board of education, shall be held liable for any good faith act or omission consistent with the provision of N.J.S.A. 18A: Student s Parent/Guardian Date Note: A student may have more than one delegate, in which case this form needs to be completed for each delegate. 3. Release of Information I authorize the sharing of medical information about my child,, between my child s physician or advanced practice nurse and other health care providers in the school. I also consent to the release of information contained in this plan to school personnel who have responsibility for or contact with my child,, and who may need to know this information to maintain my child s health and safety. Student s Parent/Guardian Date

5 PART E. Shelter in Place or Disaster Plan In the unlikely event that an emergency situation should arise, the North Hanover Township School District may have to declare a Shelter in Place. In such a circumstance, students might need to be sheltered in place for a length of time longer than the normal school day. Additional medical orders, supplies and supplementary items will be required in order to properly care for your child. Medication: It may be essential to continue giving medication that is normally given at home outside of the regular school day. Supplementary health care provider orders will be needed to provide nursing care and medication administration for hours in the event of such an unforeseen occurrence. Medical Supplies: Additional syringes, insulin, pump batteries, infusion sets, glucagon, ketone testing strips and other items as deemed necessary for appropriate care. Emergency Food Supply: Examples: Carbohydrate Foods Shelf/boxed milk Canned milk Carnation instant breakfast Rice cakes Combination Foods Granola bars Cheese and crackers pkg Protein Foods pull top cans of tuna or chicken pull top cans of Vienna sausage peanut butter beef jerky Fluids bottled water juice boxes or cans Peanut butter and crackers pkg The disaster supplies should be assembled and labeled as Diabetes Emergency Supply and stored in the health office. See reverse side for medical authorization form and parental consent.

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7 Shelter in Place or Disaster Plan Parent Consent and Authorized Health Care Provider Orders Pupil: DOB: Date: Dose administered via prefilled syringe insulin pen syringe insulin pump RECOMMENDATIONS For students who do not count carbohydrates: if insulin is available but there is a limited food supply then consider decreasing the usual dose of NPH,Lente, Ultralente or Lantus by 25%. Regular or rapid-acting insulins may not be needed. Initial the space below if in agreement. If there is a limited food supply, decrease dose of long acting insulin by 25% and do not use short acting insulin. Usual daily insulin regimen (decrease the following doses if limited food supply): Insulin Brand Name and Type(s): Breakfast Lunch Dinner Bedtime Time of Day Units of NPH. Lente, Ultralene or Lanus decrease 20-30% decrease 10% Units of Regular, Hyumalog or Novalog Omit decrease 25% For students who are on pumps, count carbs, and/or use multiple injections use the following calculations with (circle one) Regular Humalog Novolog Insulin to carbohydrate ratio: #unit(s) insulin per gms Carbohydrate Correction calculation (complete only those that supply): Give unit(s) for every mg/dl above mg/dl Decrease correction by % unit(s) if PE or increased activity is anticipated after dose, or last dose was given less than 2 hours before OR Written sliding scale as follows: Blood glucose from to = Units Blood glucose from to = Units Blood glucose from to = Units Blood glucose from to = Units Add carbohydrate calculation insulin dose and correction calculation for total insulin dose/bolus HEALTH CARE PROVIDER AUTHORIZATION My signature below provides authorization for the above written orders. I understand that all procedures will be implemented in accordance with state law governing school health services. This authorization is for a maximum of one school year. If changes are indicated, I will provide new written authorization (may be faxed). Authorized Health Care Provider Signature: Date: Address: City Zip (Use office stamp) Phone Number PARENT OR GUARDIAN CONSENT We(I), the undersigned, the parent(s)/guardian of the above named pupil, request that the above defined insulin doses be given during a disaster for our (my) child in accordance with State laws and regulations. Parent/guardian Signature: Date: Reviewed by School Nurse (signature): Date: Reviewed by Principal (signature): Date: Note: Completion of this form is for disaster purposes only. Failure to complete this form does not give reason for school exclusion

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