Henry P. Becton Regional High School/Health Department

Diabetes Individual Healthcare Plan Date of Plan:_____________________ Effective for the____________________________school year Student’s Name:________________________________________________Date of Birth_____________ Grade:__________Date of Diabetes Diagnosis:________________Type 1_____Type 2______(check one) Contact Information Mother/Guardian:______________________________________________________________________ Address:_______________________________________________________________________________ Telephone:Home_______________________Work______________________Cell____________________ Father/Guardian:_________________________________________________________________________ Address:________________________________________________________________________________ Telephone:Home______________________Work_______________________Cell____________________ Student’s Physician/Healthcare Provider:______________________________________________________ Address:________________________________________________________________________________ Telephone:______________________________________Emergency Number:_______________________ Other Emergency Contacts: Name:___________________________________________Relationship_____________________________ Telephone:Home______________________Work_______________________Cell_____________________ Name:___________________________________________Relationship:_____________________________ Telephone:Home______________________Work_______________________Cell_____________________ Notify parents/guardian or emergency contact in the following situations (i.e.; blood glucose number low):

***************Please Complete Both Sides*************** 1 of 4

Diabetes IHP Blood Glucose Monitoring Target range for blood glucose is  70-150

 70-180

 Other__________________________________

Usual times to check blood glucose___________________________________________________________ Times to do extra blood glucose checks (check all that apply)

 before exercise

 when student exhibits symptoms of hyperglycemia

 after exercise

 when student exhibits symptoms of hypoglycemia

 Other (explain):_________________________________________________________________________ Can student perform own glucose checks?

 Yes  No

Is nurse supervision needed?  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 _______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 give own injections?  Yes

 No

Can student determine correct amount of insulin? Can student draw correct dose of insulin?  Yes Is nurse supervision needed?  Yes

 Yes  No  No

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Diabetes IHP For Students With Insulin Pumps Type of pump: ____________________________________________________ Basal rates:_____units /hr at_____12am to______; ______units at _______to_______; units at _____to_____ Type of insulin in pump:___________________________________Type of infusion set:________________ Insulin /carbohydrate ratio:______________________________Correction factor:______________________ Student Pump Abilities/Skills:

Needs Assistance(check one)

 Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes

Count carbohydrates Bolus correct amount for carbs consumed Calculate and administer corrective bolus Calculate and set basal profiles Calculate and set temporary basal rate Disconnect pump Reconnect pump at infusion site Prepare reservoir and tubing Insert infusion set Troubleshoot alarms and malfunctions

         

No No No No No No No No No No

For Students Taking Oral Medications Type of medication:___________________________________Timing:___________________________ Other medications:____________________________________Timing:___________________________ Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management?

 Yes

 No

Mid- morning:time__________________________content________________________________________ Lunch:time________________________________content________________________________________ Mid-afternoon:time_________________________content_________________________________________ Snack before exercise?

 Yes

 No

Snack after exercise?  Yes  No

Other?________________________________ Exercise and Sports Type of fast-acting carbohydrate to be available at site:___________________________________________ Activity restrictions?______________________________________________________________________ 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. ********Please Complete Both Sides******** 3 of 4

Diabetes IHP Hypoglycemia (Low Blood Sugar) Usual symptoms:_________________________________________________________________________

What glucose level mandates treatment if no symptoms?__________________________________________ Treatment of hypoglycemia__________________________________________________________________

Glucagon to be given if student is unconscious, having a seizure (convulsion), or unable to swallow. Dose:___________________________Route:__________________site:_____________________________ If glucagon is required, administer promptly. Then call 911 and the parents/guardian. Hyperglycemia (High Blood Sugar) Usual symptoms:__________________________________________________________________________

Treatment of hyperglycemia:_________________________________________________________________

Urine should be checked for ketones when blood glucose levels are above____________________mg/dl. 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 vials and syringes

_______Insulin pump and supplies _______Insulin pen, pen needles, cartridges _______Fast-acting source of glucose _______carbohydrate containing snack _______Glucagon emergency kit

This Diabetes Individual Healthcare Plan Has Been Approved By:

Signature of Physician/Healthcare Provider__________________________________Date_________________

Physician/Healthcare Provider Stamp:

Signature of Parent/Guardian______________________________________________Date________________ Permission to Release and Exchange of Confidential Information I hereby authorize an exchange of medical information to occur between the School Nurse and the appropriate staff involved in my student’s education, health, and safety. (i.e.; class teachers, counselors, bus driver). I also permit the exchange of medical information between the School Nurse and my student’s Physician/Healthcare Provider. I agree to provide the necessary equipment and supplies, including snacks, glucose tabs, or glucagon that may be needed by my student in school or at school activities. I also understand that this authorization is in effect for the school year, and must be renewed on an annual basis. As the parent/guardian, I am responsible for updating the school nurse of any changes in my student’s condition or orders. Signature of Parent/Guardian:_______________________________________________Date:_______________ 4 of 4