Diabetes Health Care Plan Insulin Dosing Guidelines District Nurse Phone: 262-560-2104 District Nurse Fax: 262-560-2106 Date: School Year: School: Grade:,, DOB: was diagnosed with Diabetes Type 1 Type 2 on / NAME OF STUDENT Practitioner: Practitioner phone: This student will need insulin at school. Give U-100 Humalog Insulin at lunch daily or Give Novolog Insulin at lunch daily or Insulin to be given by: Approved school personnel The Student The Parent Student may self administer and self dose insulin Dosage Preparation: Student drawn independently By Parent Prefilled Syringe Insulin Pen Blood sugar from to = units Insulin Dosage (Per Sliding Scale) Humalog Novolog Insulin Dosage: Humalog Novolog Unit for carb servings or grams of carbs Add (+/-) correction Humalog Or Novolog for blood sugar Total Dosage = Humalog/Novolog for food AND for Blood Sugar Extra Insulin Dosages: Non-applicable Applicable Criteria for extra insulin: Extra insulin is given if it has been more than 2 hours since last shot was given AND it is not a meal. Blood sugar is over mg/dl. Blood sugar must be checked 2 hours after correction shot is given. Do not exceed 2 extra dosages of insulin in one school day. Always notify parent if extra dosages were given at school. Give the following amount of insulin for high blood sugar U-100 Humalog Insulin Novolog Insulin ~ 1 of 5~
All students with diabetes need to able to do a blood test at any time during school if not feeling well. The school must have a sharps container available and gloves for school personnel who may need to assist with testing young children. The student requires the following supplies: Yes No Blood glucose monitor and strips Lancets and lancets device Urine ketone strips Glucagon Emergency Kit Fast acting sugar source Complex carbohydrate snack Insulin Pen Insulin Pen Needles Extra Insulin cartridge Sharps Box Gloves Food at School With diabetes, the student is highly encouraged to eat a well balanced diet, which includes both meals and snacks. Insulin and food must be given on time to keep the child safe. Meals and snacks should always be given at the right time. Parents will bring all snacks to the school. If parties, field trips, or other special events are planned, please call the parent before so that adjustments can be made with the student s meal plan. The student will eat breakfast: At home At the school breakfast program The student will participate in: Hot lunch program Bring a lunch from home The student is on a: Flexible Fixed meal plan The snack and meal plan is outlined below: Carb serving, 1Carb = grams Meal/ snack Time Carbohydrate /Grams eaten at a meal or snack Breakfast Morning Snack Lunch Afternoon Snack In addition to the above meal plan the student may require an extra snack: Before gym After gym only when needed Other instructions ~ 2 of 5~
Low Blood Sugar SYMPTOMS: Hunger Sweating Trembling or Shaking Pale Appearance Confusion Crying Inability to concentrate Fast Heart Beat Sleepiness Headache Dizziness Slurred Speech Poor Coordination Personality Change Complaints of feeling LOW Other Any time the student s blood sugar is less than and/or is having symptoms of a low blood sugar reaction: Give the student one of the following: 4oz Juice; 4-6oz Regular Soda 3-4 glucose tablets OR. If the student is not feeling better in 15 minutes, repeat: one of the above OR If it is more than 1 hour before the next meal or snack give and extra snack, such as Do not leave student alone or allow them to leave the classroom without an adult to accompany them. If the student is not responding t the treatment, Call parent right away. If student is not able to eat or drink, experiencing a seizure, and/or is unconscious: Call 911. Notify the operator the student has diabetes, report level of consciousness. Give Glucagon Injection. Glucagon Emergency Kit Using the glucagons emergency kit takes less than one minute to use and is the safest was to treat a child with diabetes when they experience a Severe low blood sugar. If the student is not able to eat or drink anything safely without the risk of choking, experiencing a seizure, or is unconscious Emergency personnel must be alerted and Glucagon administered. Mix the Glucagon injection. Each kit contains 1mg of glucagon. Give on the top and cent of the thigh at a 90 angle. Give the entire dosage: Give 1mg to children over the age of 4. Give half the dosage 0.5mg to children under the age of 4. Turn student on side and keep airway clear. Do not insert objects into mouth or between teeth. The student may vomit never leave the child unattended. The child will need to go to the nearest emergency room to be evaluated after receiving glucagon. The child s parent/guardian must be notified. ~ 3 of 5~
High Blood Sugars SYMPTOMS: Dehydration Sleepiness Confusion Blurred Vision Dry Skin Inability to concentrate Hungry Irritability Frequent Urination Increase Thirst All student with high blood sugars will need to drink extra sugar-free fluids (water or diet drinks) and will need to use the bathroom more often. Along with monitoring for high blood sugars the student will need to do further testing for ketones. Ketone formation can be an emergency and attention needs to be given to the student. A high blood sugar for this student is a blood sugar over mg/dl. Check for ketones if blood sugars are above mg/d. School staff trained in diabetes care will will not need to assist with ketone testing and insulin administration. The treatment you need to assist in providing for high blood sugars in insulin administration. Insulin is given in the form of a correction factor. See the student s individual insulin dosing guidelines sheet for specific information. Important facts to remember with HIGH BLOOD SUGARS. Parents need to be notified if: If student s blood sugar is above. If moderate or large ketones are present. If high blood sugar symptoms worsen or if the student begins vomiting. Extra syringe or pen injections are given. The student has difficulty breathing and/or lethargy. Remember a student with diabetes can participate in all activities or sports unless ill, and should not be absent more than any other student. No two students with diabetes will have the same health plan at school. It is recommended that parents, health staff and teaching staff meet with the parents prior to school starting to set up the appropriate diabetes care, and as needed if questions or issues arise. ~ 4 of 5~
Responsibilities of the Family Keep emergency phone numbers current. Ensure ALL Diabetes IHP s from Practitioner are reviewed with school personnel, and provides updates to it as necessary. Provide snacks to the school. Responsibilities of the Student Has read the school plan and is willing to follow it. Understands the importance of communication the signs and symptoms of hypo or hyperglycemia with school personnel. Follow the snack and meal plan as ordered. Documents blood sugars and other required information. (Student Signature) If appropriate Responsibilities of the School Keep all diabetes supplies easily available for the students. Support frequent blood sugar testing. Assure that the student is permitted to have water and bathroom privileges. Have a reliable individual to monitor for signs of hypo and hyperglycemia and be knowledgeable of appropriate treatment responses. Communicate with families as to issues that arise at school. PARENTS CONSENT FOR DIABETES MANAGEMENT IHP I, the undersigned, as the parent/guardian of the above named student, request that specialized physical health care services for diabetes Management IHP be provided for my child. I will 1) provide the necessary supplies and equipment, 2) notify the health services staff if there is a change in students health status or attending physician, and 3) notify the school nurse immediately of any changes in practitioner s orders. This request includes the authorization for School personnel to contact the practitioner when necessary. On the last day of school how should medications be returned home? Sent home with Student Parent/Guardian Pick-Up Parent/Guardian Signature Date: PHYSICAN CONSENT FOR DIABETES MANAGEMENT IHP I have reviewed and approved the Diabetes management IHP and have included any recommended modifications. I understand that specialized physical health care services for Diabetic Management IHP will be preformed by trained personnel. This consent is for a maximum of one year. This school plan will expire on:. Practitioner Name (Print): Practitioner Signature Date: ~ 5 of 5~