Diabetes Medical Management Plan for: Grade:

Transcription

1 SCHOOL YEAR: KINGSWAY REGIONAL SCHOOL DISTRICT SCHOOL HEALTH SERVICES 201 Kings Highway Woolwich Township, NJ HIGH SCHOOL: Phone (856) Fax (856) MIDDLE SCHOOL: Phone (856) Fax (856) Diabetes Medical Management Plan for: Grade: The student s personal health care team and parents/guardian should complete this plan. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. Effective s: of Birth: _ of Diabetes Diagnosis: Physical Condition: Diabetes type 1 Diabetes type 2 Contact Information Mother/Guardian: Address: Telephone: Home Work Cell Father/Guardian: Address: Telephone: Home Work Cell Student s Doctor/Health Care Provider: Name: Address: Telephone: Emergency Number: Other Emergency Contacts: Name: Relationship: Telephone: Home Work Cell Notify parents/guardian or emergency contact in the following situations:

2 Blood Glucose Monitoring 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 blood glucose checks? Yes No 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 No Can student give own injections? Yes No Can student determine correct amount of insulin? Yes No Can student draw correct dose of insulin? Yes No Parents are authorized to adjust the insulin dosage under the following circumstances:

3 For Students with Insulin Pumps Type of pump: _ Basal rates: 12 am to to to Type of insulin in pump: Type of infusion set: Insulin/carbohydrate ratio: Correction factor: Student Pump Abilities/Skills: Needs Assistance Count carbohydrates Yes No Bolus correct amount for carbohydrates consumed Yes No Calculate and administer corrective bolus Yes No Calculate and set basal profiles Yes No Calculate and set temporary basal rate Yes No Disconnect pump Yes No Reconnect pump at infusion set Yes No Prepare reservoir and tubing Yes No Insert infusion set Yes No Troubleshoot alarms and malfunctions Yes No For Students Taking Oral Diabetes Medications Type of medication: Timing: Other medications: Timing: Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? Yes No Meal/Snack Time Food content/amount Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

4 Snack before exercise? Yes No Snack after exercise? Yes No Other times to give snacks and content/amount: Preferred snack foods: Foods to avoid, if any: Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): Exercise and Sports A fast-acting carbohydrate such as should be available at the site of exercise or sports. Restrictions on activity, if any: 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. Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow. Route, Dosage, site for glucagon injection: arm, thigh, other. If glucagon is required, administer it promptly. Then, call 911 (or other emergency assistance) and the parents/guardian. Hyperglycemia (High Blood Sugar) Usual symptoms of hyperglycemia: Treatment of hyperglycemia: Urine should be checked for ketones when blood glucose levels are above mg/dl. Treatment for ketones:

5 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 pump and supplies Insulin pen, pen needles, insulin cartridges Fast-acting source of glucose Carbohydrate containing snack Glucagon emergency kit Additional necessary accommodations Bus rides to away athletic events & field trips: 1. Student will test blood sugar before getting on bus and will notify the Certified Athletic Trainer or School Nurse and follow orders for blood sugar parameters as per Dr s orders. The coaches for a student athlete and Field Trip Chaperone will be notified if blood sugar was not within normal limits (80 240). 2. Student will take a glucose meter to the away events and field trips and self-test as needed and as per Dr. s orders. Student will communicate blood sugar test results with coach, chaperone, or athletic trainers during an athletic event or field trip. 3. Coaches / Chaperones will be taught signs and symptoms of Hypoglycemia (low blood sugar) and Hyperglycemia (high blood sugar) levels. A coach or chaperone will be trained to be a Glucagon administration delegate. 4. While on the bus, should the student s blood sugar be slow to rise to normal levels above 80 after taking 4 oz of juice or 4 glucose tablets, give an additional 15 grams of carbohydrage (or 4 oz. Juice) and recheck blood sugar in 15 minutes. 5. If the student is confused or unable to eat or drink, the coach or chaperone will administer Glucagon as per training protocol, CALL 911, and stay with the student until EMS arrives. 6. Notify parent and school administration. I give permission to the school nurse, trained diabetes personnel, and other designated staff members of Kingsway Regional High School to perform and carry out the diabetes care tasks as outlined by Garrett Paoletti s physicians. I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child s health and safety. Student s Parent/Guardian Signature _

6 DIABETIC STUDENTS PARTICIPATING IN SPORTS FOR KRHS This Diabetes Medical Management Plan & IHP for received and accepted by Athletic staff listed below: Certified Athletic Trainer Certified Athletic Trainer Student s Coach - Signature Student s Coach Signature Student s Coach Signature School Nurse Signature _ Glucagon Delegate Training Documentation: Name of Delegate Signature of Delegate of Training Training provided by Name of Delegate Signature of Delegate of Training Training provided by Name of Delegate Signature of Delegate of Training Training provided by

7 KINGSWAY REGIONAL SCHOOL HEALTH SERVICES 201 KINGS HIGHWAY WOOLWICH TOWNSHIP, NJ : To Parent/Guardian of Student Athlete: Gr: School Year: This letter is to document the plan to be in effect to meet all of your child s medical needs while participating as an athlete for the Kingsway Regional High School. Our concern has been meeting the medical needs as outlined by your child s doctor when participating in all home and away athletic events when a parent, or immediate family member designated as a caregiver, cannot attend. In the event a parent/guardian or caregiver is not present at an athletic event and Glucagon needs to be administered, a coach and the athletic trainers are trained as Glucagon Administration Delegates. We understand that there may be times when you are unable to attend all athletic events. 1. In the event that a parent, or immediate family member designated as caregiver by the Parent or Guardian, cannot attend an away sporting contest, parents or guardians will notify the Health Office, the Certified Athletic Trainers, and the Head Coach that they are unable to attend. A trained Glucagon delegate will be assigned to your child. 2. Parents will notify the Athletic trainer if there is to be a designated caregiver at the away event, and that caregiver will communicate with the Head Coach that they are present at the event. We are confident that we can always work together to accomplish our goal, which is to ensure that your child will participate in their choice of activities and that all of their medical needs and concerns will be addressed and met to ensure safe participation in the Kingsway Regional High School sports programs. Thank you again for your consideration and assistance with this plan for your child. Cc: Mr. Robert Baerman, Athletic Trainer Ms. Chrissy Ludlum, Athletic Trainer Appropriate Coaches