IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN

IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN OVERVIEW This form is intended to help standardize information for students with diabetes. It has bee...
Author: Charleen Heath
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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN OVERVIEW This form is intended to help standardize information for students with diabetes. It has been designed to cover situations that may apply to the student while at the Idaho Youth ChalleNGe Academy (IDYCA). In most cases, the majority of the blank space will not need to be filled-in or the answer may be similar to the previous space. Generally, the plan should be worked out between the parent and the IDYCA Medical Staff and then submitted to the HCP to authorize. The following is a brief description of each section: Hypoglycemia (low blood sugar) The blank lines are for treatment plans for various situations. The information in parenthesis are guidelines that can either be used or crossed out if another treatment is desired. Blood Sugar and Insulin Dosage Various situations are supplied. Not all require a response with an injection of insulin. Many situations will have the same response. “Other” is for the new forms of insulin that may soon be available. The last two lines of this section are included to allow the IDYCA Medical Staff and the parent/guardian some degree of flexibility under the HCP’s supervision and written orders. Although ketone testing is recommended, cross out “(check ketones)” if this test will not be done. In this situation, do not fill in “If urine ketones….” Disaster Insulin Dosage This includes doses of insulin that are normally not given at IDYCA, but that during a disaster situation may be needed. Since the food supply may be limited, it is recommended that the usual dosage be reduced to 80%. A copy of this order form should be included in the Disaster Kit. Alternately, the disaster dose can be recorded on the form found in Appendix N. Disaster dosages must be reviewed and updated anytime the student’s insulin requirements change. Self-Care The intent is to document agreement as to the extent to which the student can manage her or his own care and to clarify to what degree the IDYCA is responsible for care. If the student is totally independent, the first statement only needs to be initialed. The blank at the bottom of this section allows for other situations that might arise regarding the student’s diabetes management. Signatures and Start/Termination Dates Each person involved in verifying the student’s ability to participate in self-care should sign and date the form. Start and review termination dates must be noted.

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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN Student’s Name: DOB:

Flight:

Allergies:

IDCYA Medical Staff: Rod Hickman, PA-C

Office #: (208) 464-1253

Parent/Guardian Consent Date:

Physician Authorization Date:

Cell #:

Parent Signature: Mother:

Home #:

Work #:

Pager/Cell #:

Father:

Home #:

Work #:

Pager/Cell #:

Guardian:

Home #:

Work #:

Pager/Cell #:

Home Address:

City:

Zip:

Other Contact (Relationship):

Home #:

Work #:

Physician:

Phone #:

Fax #:

Physician Address:

City:

Zip:

Healthcare Service Needed at IDYCA Purpose of an ISHP

Management of Diabetes at IDYCA and IDYCA Off-Campus Activities: 1. The purpose of an Individualized School Healthcare Plan (ISHP) is to provide safe management of healthcare needs and services for students at the IDYCA and during off-campus activities. 2. The IDYCA Medical Staff, in collaboration with the student and the student’s parent/guardian, healthcare providers, and the IDYCA team, is responsible for: a) Development, implementation, and revisions of the ISHP. b) The training and supervision of all designated personnel who will provide healthcare according to the ISHP and standard procedures. 3. ISHP revisions must be directed to the IDYCA Medical Staff prior to implementation. All physician changes must have a written physician authorization and written parent consent. Revisions, not requiring physician authorization, may be made with written parent consent. 4. ISHP review must occur annually and whenever necessary to ensure provision of safe care.

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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN Student’s Name: Diabetic Routines at the IDYCA per Parent Request/Consent

DOB:

Daily Snacks:

Flight:

Allergies:

Time(s): ___________________________________________ Place specified: _____________________________________ □ Done independently □ Needs reminder



Extra Snacks:

□ Before exercise □ After exercise □ 10 g CHO every 30-minutes during vigorous exercise

Daily Blood Test:

□ Before Meals □ Prior to Exercise - Location for testing:

□ As Needed

□ Health Office Student is to be tested where they are at if Hypoglycemic □ By pupil independently □ Needs assistance (specify) If nurse is off campus call 911 □ Refer to Algorithms for Blood Glucose Results (See attached sheet) Exercise:

□ None if blood glucose test results are below _________ mg/dl

Lunch Eaten At (time) 1130-1230 Regardless of schedule changes, field trips, disaster, etc. □ Needs daily verification of meal eaten □ Written consent with schedule changes with snack and meal and times In Event of Off-Campus Activities, all diabetic supplies are taken and care is provided according to this ISHP (A copy is taken on trip.) The IDYCA Medical Staff Must Be Notified Two Weeks Before The Off-Campus Activity To Plan For Qualified Personal To Provide Procedures In Event of Classroom/IDYCA Parties, food treats will be handled as follows: □ Pupil will eat the treat. □ Replace with parent supplied alternative □ Modify the treat as follows □ Do not eat snack. In Event of Bus Transportation: □ Blood test given 10 to 20 minutes before boarding. If 70 or less, provide care per Procedure For Mild to Moderate Low Blood Glucose and call parent(s) to provide transportation home. □ Blood test not required. Scheduled Off-Campus Activities: _______________________________________________________________________

Training and Notification of IDYCA Staff of Diabetes Basic Training Program Other

The following personnel will be notified of my child’s medical condition and participate in Diabetes Basic Training Program: □ All IDYCA Personnel □ IDYCA Personnel that have contact with my child □ Cafeteria Staff □ Other: _____________________________________________________________________________________________

(Specify): _____________________________________________________________________________________________ Student has unrestricted use of the bathroom and water.

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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN Student’s Name: Equipment and Supplies

DOB:

Flight:

Daily Snacks: (for a.m./p.m. snack times) Specify: ______________________________________ Extra Snacks: (for before, after, and/or during exercise) Specify: ______________________________________ Provided By Parent: Blood Glucose Meter Kit: (Includes meter, testing strips, lancing device with lancet, cotton balls, spot Band-Aids) Brand/Model: __________________________ Low Blood Glucose Supplies: (5-day supply) □ Fast Acting Carbohydrate Drinks: (Apple juice and/or orange juice, sugared soda pop-NOT diet), at least 6 containers. □ Glucose Tablets, 1 package or more. □ Glucose Gel Products (Insta-Glucose, Monogel or Glutose/25--31 g), 2 or more. □ Gel Cakemate (not frosting), (19 g, mini-purse size), 2 or more. Note: Not used in Emergency Procedure of Severe Low Blood Sugar. □ Prepackaged Snacks (such as crackers with cheese or peanut butter, nite bite, etc.), 5 - 6 servings or more. High Blood Glucose Supplies: □ Ketone Test Strips/Bottle(parents supply) □ Urine cup □ Water bottle Note: Timing device may be wall clock or watch worn by pupil or personnel.

STUDENT’S SELF-CARE (ability level) Initials of: Totally independent management or 1. Student tests independently or Student needs verification of number by staff or Assist/Testing to be done by IDYCA Medical Staff 2. Student administers insulin independently or Student self-injects with verification of number or Student self-injects with nurse supervision or Injection to be done by IDYCA Medical Staff 3. Students self-treats mild hypoglycemia 4. Student monitors own snacks and meals 5. Student tests and interprets own urine ketones

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Parent

___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Allergies: Provided By Parent: (Continued) Insulin Supplies: □ Insulin pen □ Pre-filled syringes (labeled per dose) □ Insulin and syringes □ Extra pump supplies such as: □ Vial of insulin, syringes □ Pump syringe □ Pump tubing/needle □ Batteries □ Tape □ Sof-Serter Insulin supplies stored: □ Dispensary locked cabinet/refrigerator Emergency Supplies: □ Glucagon kit stored: ______________________________________ □ 3 day disaster food supply stored: ______________________________________ 3-Day Disaster Diabetes Supplies: □ Vial of insulin; 6 syringes □ Insulin pen with cartridge and needles □ Blood glucose testing kit (testing strips lancing device with lancets □ Glucose gel product and glucose tablets □ Glucagon kit □ Food supply (include daily meal plan) stored as follows: __________________________________ □ Ketone strips/plastic cup IDYCA will include a copy of the ISHP for Diabetes Management with the Disaster Supplies. Stored as follows: □ Dispensary cabinet and/or refrigerator ISHP located in Medication Binder

HCP

____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________

IDYCA Medical

____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________

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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN Student’s Name: Breakfast

DOB: Snack

Flight:

Allergies:

CARBOHYDRATE (CHO) COUNTING (15 g) Lunch Snack Dinner

Snack

CHO:

___________ ___________ ___________ ___________ ___________ ___________ MILK (12 grams CHO): Standard serving size - 1 cup  1 cup (8 oz.) of skim or 1% milk  1 cup light yogurt (8 oz.)  1 cup low-fat buttermilk FRUIT (15 grams CHO): Standard serving size - 1 small piece, 1/2, or 1/2 cup  ½ cup any fresh, frozen, unsweetened canned fruit  1 small (4 oz.) apple, pear, peach, banana (or ½ large), or nectarine  1 cup melon  1 cup berries  15 grapes or raisins  1/2 cup orange, grape fruit, or apple juice  1/3 cup grape, prune, or cranberry juice  1/4 Tbsp. dried fruit  12 cherries BREAD / STARCH (15 grams CHO): Standard serving size - 1 slice, 1/2, or 1/2 cup  1 slice light bread  1/2 cup noodles or rice  1 oz. any cereal or bread product  1/2 bagel, English muffin, burger bun, or hot dog bun  1/2 c. cooked cereal  3/4 oz. pretzels  3/4 oz. pretzels  3 cups popcorn  6 saltine  1 cup soup (broth type) (~6 oz.)  1/2 cup light ice cream or sugar-free pudding  6 inch tortilla  1/2 cup potatoes, corn, peas  1/3 cup cooked dried beans, sweet potatoes, or yams  1 cup winter squash NO CHO  AFFECTS HEART AND WEIGHT  EAT SMALL PORTIONS PROTEIN: Limit to________ oz. per day. Includes lean beef, pork, veal, chicken, fish, cottage cheese, cheeses, eggs, peanut butter FAT:

Limit to servings per . 1 Serving = 1 tsp. Margarine, butter, oil, 1Tbsp regular salad dressings. 1 strip bacon, 2 olives, 1/6 avocado Nuts, olives, and avocados are very high in fat and calories, but the fat is heart-healthy.

VEGETABLES (5 g CHO): Standard Serving Size - 1/2 cup cooked or 1 cup raw Count CHO if you eat more than 3 servings per meal. (1 serving = 5 g CHO) Examples: Tomatoes, salad greens, spinach, peppers, onions, mushrooms, broccoli, cauliflower, green beans, zucchini, cabbage, carrots, asparagus, beets, celery, Swiss chard, mustard greens, kale, bean sprouts HCP: ________________________________ (Print/Stamp) Signature: ________________________________ Date: _____/_____/_____ Parent: ______________________________ (Print/Stamp) Signature: ________________________________ Date: ____/_____/_____ IDYCA Medical Staff: ___________________ (Print/Stamp) Signature: ________________________________ Date: _____/_____/_____ Start date: _____Day _____Mo. _____Yr. Termination date: _____Day _____Mo. _____Yr. or end of IDYCA 22-week program _______

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IDAHO YOUTH CHALLENGE ACADEMY DIABETES CARE PLAN Signs of Low Blood Sugar: Fatigue, excessive sweating, trembling, clammy, dizziness, headache, hunger pangs, visual impairment, accelerated heartbeat, anxiety, difficulty concentration, blackouts, confusion, crying, irritability, poor coordination, nausea, inappropriate behavior.

Signs of High Blood Sugar: Early Symptoms: Thirsty/dry mouth, frequent urination, fatigue/sleepiness, increased hunger, blurred vision, lack of concentration. Symptoms Progressively Become Worse: Sweet breath, nausea/stomach pains, vomiting, weakness, confusion, labored breathing, unconsciousness/coma.

Algorithms for Blood Glucose Results Check Blood Glucose

Below 70

70-90

91-125

Above 240

126-240

Check Ketones (If ordered) (Cannot exercise unless urine is negative for Ketones.)

Provide extra water. 1. 2. 3.

4. 5.

Give fast Acting sugar source and carbohydrate*. Observe for 15 minutes. Retest Blood Glucose, if less than 70 repeat sugar source. If over 70 give carbohydrate and protein snack (e.g. Crackers and cheese) if not eating within 15 minutes. Notify IDYCA Medical Staff. Notify Parent if less then 50.

If Student Becomes Unconscious, Seizures, or is Unable to Swallow: 1. Call 911 2. Turn student on side to ensure open airway. 3. Give glucose gel and glucagons if ordered. 4. Notify IDYCA Medical Staff & parents.

1.

Give fast acting carbohydrate. If meal or snack is within 30 minutes, no additional carbs are needed. If student is not going to eat within 30 minutes additional carb and protein snack is to be given.

If exercise is planned before a snack or a meal, including recess, the student must have a snack before participating.

Student is fine.

Ketones Present – Notify IDYCA Medical Staff Immediately. Notify Parents. Provide 1-2 glasses of water every hour. Do not exercise.

If student’s blood sugar result is immediately following strenuous activity, give an additional fast acting sugar.

If at any time student vomits, becomes lethargic, and/or has labored breathing CALL 911.

Fast Acting Sugar Sources (Do not give chocolate)    

15 gm. glucose tablets 15 gm. glucose gel 1/3 c. sugared soda ½ c. orange juice

   

½ c. apple juice ¼ c. grape juice ½ tube cake mate gel 3tsp. sugar (in water)

Student’s Name: Flight: IDYCA Medical Staff:

(208) 464-1253

Physician’s Number: Parents Phone Numbers: 01/2014 ****Never

send a child with suspected low blood glucose anywhere alone.

Page 6 of 6Contact Info: Parent’s