Patient/Family Education Record Factors that impact teaching: Communication/language Physical Cognitive Emotional Cultural Motivation Identify family strengths and stressors including cultural beliefs that may impact living with diabetes: All primary caretakers will need to attend diabetic education. Who else do you think needs to know your child s care plan and/or attend diabetic education? Childcare provider School nurse In what ways do you learn best? (circle 1 or more) reading listening pictures demonstration doing Diabetes pathophysiology; type 1 and type 2 understanding of or demonstrate the Effects of insulin, diet, and exercise on blood sugar needs and expected outcomes (52068) 12/01 Page 1 or 5
Signs, symptoms, causes, and treatment of hyperglycemia Signs and symptoms of ketoacidosis When to test for ketones Demonstration of urine ketone testing Use of glucometer Goal for glycemic control. Finger poke demonstration Record keeping in logbook Types of insulin, insulin actions, insulin storage, insulin expiration, needle disposal Administration of insulin: drawing up dose, mixing insulins, SQ injections, site rotation, and recording dose in log book Signs, symptoms, causes and treatment of hypoglycemia (52068) 12/01 Page 2 or 5
Glucagon injection, including demonstration and discussion of when and how to administer Sick day management Long term complications, prevention Carbohydrate counting Meal and snack planning Exercise and diabetes management (52068) 12/01 Page 3 or 5
The patient and family will have the opportunity to express their concerns about how diabetes will affect patient and family life. Participant Parent Child Counseling approach Listening Problem solving Offering guidance **Level of Participation Date Time Limited readiness Partially engaged Fully engaged Date Time Initials **Please summarize outcomes for each session in progress note The patient/family will express understanding of parenting strategies and developmental issues as they relate to optimizing emotional adjustment to diabetes. Participant Counseling approach Parent Listening Child Problem solving Offering guidance **Level of Participation Limited readiness Begin to identify parenting strategies to diabetes management and adjustment Fully ready to apply strategies to diabetes management and adjustment Date Time Initials **Please summarize outcomes for each session in progress note Readiness for discharge: Home schedule Supplies checklist Endocrine phone numbers and contacts Follow up plans School forms Medic Alert (52068) 12/01 Page 4 or 5
PATIENT AND FAMILY EDUCATION SUMMARY NOTES DATE/TIME NOTES DATE/SIGNATURE (52068) 12/01 Page 5 or 5