Date of Plan:
Diabetes Management and Treatment Plan Effective Dates: This plan should be completed by the student’s personal health team and parents...
Diabetes Management and Treatment Plan Effective Dates: This plan should be completed by the student’s personal health 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: Date of Birth:
Date of Diabetes Diagnosis:
Grade:
Homeroom Teacher:
Physical Condition:
□
□
Diabetes type 1
Diabetes type 2
Contact Information Mother/Guardian: Address: Telephone: Home
Work
Cell
Work
Cell
Father/Guardian: Address: Telephone: Home Student’s Doctor/Health Care Provider: Name: Address: Telephone:
Emergency Number:
Other Emergency Contacts: Name: Relationship: Telephone: Home
Work
Notify parents/guardian or emergency contact in the following situations:
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Cell
Diabetes Management and Treatment Plan Continued Indicate the student’s current ability to manage and understand the student’s diabetes treatment: YES NO N/A Totally independent management (requires adult ____ ____ ____ assistance only during hypoglycemia) Independent blood glucose monitoring
____
____
____
Needs assistance with blood glucose monitoring Verification of blood glucose monitor by nurse/TDA Monitoring to be done by nurse or TDA
____ ____ ____
____ ____ ____
____ ____ ____
Administers insulin independently
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____
Self-administers insulin with verification of dosage by nurse or TDA
____
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Needs nurse or TDA to administer insulin
____
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Independently programs pump
____
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Needs assistance programming pump
____
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Independently changes infusion sets and can refill and prime pump reservoir
____
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Needs assistance to change infusion sets and refilling and priming pump reservoir
____
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Can independently change pump reservoir
____
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Needs assistance with troubleshooting pump alarms and reservoir
____
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Self-treats mild hypoglycemia
____
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Requires assistance to treat mild hypoglycemia
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Monitors own snacks and meal
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Snacks and meals to be supervised
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Checks and interprets own ketones results
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Implements universal precautions
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Universal precautions to be supervised
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Diabetes Management and Treatment Plan Continued Blood Glucose Monitoring Target range for blood glucose is: 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.
Insulin Correction Doses Parental authorization should be obtained before administering a correction does for high blood glucose levels. __ Yes
__ No
_____units if blood glucose _____ to _____ mg/dl _____units if blood glucose _____ to _____ mg/dl _____units if blood glucose _____ to _____ mg/dl _____units if blood glucose _____ to _____ mg/dl _____units if blood glucose _____ to _____ mg/dl Can student give own injections? __ Yes __No Can student determine correct amount of insulin? __Yes __No Can student draw correct does of insulin? __Yes __No _____Parents are authorized to adjust the insulin dosage under the following circumstances: ___________ _____________________________________________________________________________________
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Diabetes Management and Treatment Plan Continued Student Pump Abilities/Skills: Count carbohydrates Bolus correct amount for carbohydrates consumed Calculate and administer corrective bolus Calculate and set basal profiles Calculate and set temporary basal rate Disconnect pump Reconnect pump at infusion set Prepare reservoir and tubing Insert infusion Set Troubleshoot alarms and malfunctions
Needs Assistance □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No
For Students Taking Oral Diabetes Medications Type of medication:
Timing:
Other medications:
Timing:
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: __________________________ 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 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):
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Diabetes Management and Treatment Plan Continued Exercise and Sports A fast-acting carbohydrates such as exercise or sports.
should be available at the site of
Restrictions on activity, if any: Student should not exercise if blood glucose level is below mg/dl, or if moderate to large urine ketones are present.
mg/dl or above
Hypoglycemia (Low Blood Sugar) Usual symptoms of Hypoglycemia: _________________________________________________________ _______________________________________________________________________________________ Treatment of Hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure, or unable to swallow: Dosage:________. Site for injection _____arm; _____thigh; ______other. If glucagon is required, administer it promptly. Then, call 911 and the parent or 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:____________________________________________________________________ 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, insulin cartridges _____Fast-acting source of glucose _____Carbohydrate containing snack _____Glucagon emergency kit
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This Diabetes Management and Treatment Plan has been approved by: ________________________________________________
_______________________________
Student’s Physician/ Health Care Provider
Date
I give my permission to the school nurse, trained diabetes personnel and other designated staff members of ________________ school to perform and carry out the diabetes care tasks as outlined by _________________’s Diabetes Medical Management Plan (DMMP). I also consent to the release of the information contained in this DMMP 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. ________________________________________________
