This plan should be completed by the student’s personal health care team and parents/guardian. 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. Student’s Name: _______________________________________________________________ Grade: ___________
Date of Birth: ________________________________ Date of Diabetes Diagnosis: ______________________________
CONTACT INFORMATION: Mother/Guardian: _________________________________________________________________________________ Telephone: Home - ________________________ Work - ___________________________ Cell -__________________________ Father/Guardian: __________________________________________________________________________________ Telephone: Home - ________________________ Work - ___________________________ Cell -__________________________ Student’s Doctor/Health Care Provider: Name: _________________________________________________________
Emergency Number: ________________________________________________________________________________
Notify parents/guardian in the following situations: _________________________________________________________
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), the school nurse, and the parents/guardian.
HYPERGLYCEMIA (High Blood Sugar) Usual Symptoms of hyperglycemia: ___________________________________________________________________
Treatment of hyperglycemia: _________________________________________________________________________
Urine should be checked for ketones when blood glucose level is above _________ mg/dl. Treatment for ketones: None Present: _____________________ Small: _______________________
Moderate: ________________________ Large: _______________________
BLOOD GLUCOSE MONITORING
Target range for blood glucose is: □ 70-150
Usual times to check blood glucose: ___________________________________________________________________ Times to do extra blood glucose checks (check all that apply) □ before exercise
□ other (explain) ______________________________
□ when student exhibits symptoms of hyperglycemia
□ when student exhibits symptoms of hypoglycemia
Can student perform own blood glucose checks?
Exceptions: ______________________________________________________________________________________ Type of blood glucose meter student uses: ______________________________________________________________
INSULIN Usual Mealtime Dose Base dose of regular Humalog/Novalog (circle type) insulin at breakfast is ____ units or does flexible dosing using ____ units/____grams of carbohydrate.
Use of other insulin at breakfast: intermediate NPH/Lente (circle type) ____ units or basal Lantus/Ultralente ____ units.
Base dose of regular Huma log/Novalog (circle type) insulin at lunch is ____ units or does flexible dosing using ____ units/ ____ grams carbohydrate.
Use of other insulin at lunch: (circle type) : intermediate NPH/Lente ____ units or basal Lantus/Ultralente ____ units.
Use of other insulin in evening: (circle type): intermediate NPH/Lente ____ units or basal Lantus/Ultralente ____ units. PHYSICIAN AUTHORIZATION FOR INSULIN ADJUSTMENT: Parents are authorized to adjust the insulin dosage under the following circumstances: ---------------------------------------------- _________________________________________________________________________________________________ INSULIN CORRECTION DOSES: ____ 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 ____ units if blood glucose is _____ to _____ mg/dl
Can student determine correct amount of insulin?
Can student draw correct dose of insulin?
FOR STUDENTS WITH INSULIN PUMPS: Type of pump: ___________________________
Type of insulin in pump: _________________________________________________________________________ Type of infusion set: ____________________________________________________________________________ Insulin/carbohydrate ratio: _________________________________ Correction factor: ____________________
Student Pump Abilities/Skills:
Bolus correct amount for carbohydrates consumed
Calculate and administer corrective bolus
FOR STUDENTS TAKING ORAL DIABETES MEDICATIONS: Type of medication: _____________________________________
Other medications: ______________________________________
MEALS AND SNACKS EATEN AT SCHOOL:
Is student independent in carbohydrate calculations and management? □ Yes □ No Meal/Snack
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 __________________ or if moderate to large urine ketones are present. SUPPLIES TO BE KEPT AT SCHOOL ________
Blood glucose meter, blood glucose test strips, batteries for meter
LOCATION OF SUPPLIES AT SCHOOL
Insulin pen, pen needles, insulin cartridges
SIGNATURES: This Diabetes Action Plan has been approved by: _________________________________________________________________________
Student’s Physician/Health Care Provider
I give permission to the school nurse, trained diabetes personnel, and other designated staff members of St. Catherine School to perform and carry out the diabetes care tasks as outlined by this Diabetes Action Plan. I also consent to the release of the information contained in this Diabetes Action 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. I also authorize the school nurse to discuss this Diabetes Action Plan and matters pertinent to this action plan with the above named health care provider. Acknowledged and received by: ____________________________________________________________________
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