School Care Plan Diabetes Details

As a teacher, when you have a student with diabetes in your care, you will need to complete a School Care Plan Diabetes Form. This form is designed to help ensure that the school has all of the information they need to provide appropriate care for the student while they are at school. The form can be completed by either the parents or the doctor, and it provides information on everything from how the student will manage their diabetes while at school to what type of supplies they will need. completing this form is an important step in ensuring that your student with diabetes has a safe and successful experience at school.

You could find it useful to understand the amount of time you'll need to prepare this school care plan diabetes and just how long the form is.

QuestionAnswer
Form NameSchool Care Plan Diabetes
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdiabetes school care plan vanderbilt, nursing care plan for diabetes mellitus, individualized school care, diabetic school health care plan

Form Preview Example

INDIVIDUALIZED SCHOOL HEALTH CARE PLAN: DIABETES

CONFIDENTIAL

Student____________________DOB: ____________Grade/Teacher _________________________

School:____________________Parents:

___________________________

 

Phone (H) - ________________(W)______

Cell# _______________

 

Emergency Contact/Phone ________________________ _____________________________

Physician_______________________________Phone_________________________________

Diabetes Nurse Educator

Hospital of choice_______________________________________________________________

DIABETES: Type 1 diabetes is a chronic metabolic condition. Diabetes can be controlled with insulin, diet, and exercise. People with diabetes can be expected to participate in all activities and lead a normal, active life intellectually, socially, and physically. The most frequent complication of diabetes is low blood sugar or hypoglycemia. This can be caused by: inadequate intake of food, emotional stress, too much exercise, receiving too much insulin. The emergency response plan for hypoglycemia is attached.

Target Blood Sugar Range______________to_______________

BLOOD SUGAR CHECKS (Check all that apply):

____Student can perform checks independently or _____Staff must supervise blood sugar checks

Times to do blood sugar checks ____Before lunch, ____After lunch, ____Before PE, ____After PE,

___As needed for signs of low or high blood sugar, Other_________________________________

Place (in school) to check blood sugar____________________________________

Glucometer Type/Brand_________________________________________

Supplies/glucometer will be kept:

______________________________________________________________

MEDICATIONS TO BE GIVEN DURING SCHOOL HOURS

Student can give his/her own insulin? ____yes ____ (Responsible secondary students may administer their

own insulin provided the school has Dr.’s order and authorization. Otherwise, a parent will need to come to the school to administer the insulin since this cannot be delegated to school staff.)

Insulin administered by (check): ____pen ____syringe ____insulin pump

Type of insulin ____Humalog ____Novolog ____Regular

Time(s) insulin to be given:_________________________________________________________________

Student calculates Insulin/Carb Ratio ____yes

___no

 

___Unit for every ____grams of carbohydrate eaten

 

Student calculates correction dose _____yes

____no

 

_____unit(s) for every ___mg/dl points above _____mg/dl

 

Student has pump that calculates correction dose and insulin/carb ratio? _____yes

_____no

Other medications/allergies_______________________________________________

 

 

 

 

DIET

 

 

Lunch time_______________

 

 

Physical Education is scheduled at ___________am/pm, Days M T W Th F

 

Snack: _____is not necessary before PE.

 

Snack times____________________ Will student need to be reminded? _n/a___yes

_____no

Preferred snacks/parent instruction for class parties : Call

 

parent______________________________________________

 

 

 

 

FIELD TRIPS: Extra snacks, glucose monitoring kit, copy of health plan, glucose gel or other emergency supplies must accompany student on field trip.

Confidential

EMERGENCY RESPONSE PLAN: DIABETES

Student_____________________________DOB____________Grade/Teacher_

Notify parent if child’s blood sugar is below__________or above__________mg/dl.

HYPOGLYCEMIA – INSULIN REACTION (LOW BLOOD SUGAR)

Student to be treated when blood sugar is below ____________________________________

MILD LOW BLOOD SUGAR Signs/Symptoms may include hunger, irritability, shakiness, sleepiness, sweating, pallor, uncooperative, crying or other behavioral changes. Additional student symptoms_______________________________________________________________________

Treatment:

Never leave student unattended. If treated outside the classroom, a responsible person must accompany student to health office.

Give juice (1 carton), or regular pop (1 cup), or 2-3 glucose tabs; (1 small tube of cake decorating gel can also be placed between cheek and gum with head elevated)

Wait 10-15 minutes. Recheck blood sugar. Retreat as above if still below 75, or if symptoms persist.

When symptoms improve or blood sugar is >75, give substantial snack (carbohydrate and protein) or lunch.

Comments:_____________________________________________________________________

SEVERE LOW BLOOD SUGAR:

Signs/Symptoms: Seizure or loss of consciousness or student unwilling/unable to take gel or juice. Treatment:

CALL 911

- Stay with student

Place student on side

- Do not put anything in mouth

Comments:________________________________________________________________________

HYPERGLYCEMIA – HIGH BLOOD SUGAR

Student must be treated when blood sugar is above ___________.

Signs/Symptoms may include: extreme thirst, headache, abdominal pain, nausea, increased urination Treatment:

-Drink 6-8 ounces of water every hour. Allow student to carry water bottle with them.

-Use restroom as needed.

-Do not allow exercise.

-Student to administer insulin if ordered by health care provider

-For pumps, will student be able to change infusion set, or have an alternate source of insulin at school?________________________________________________________________________

-If student exhibits nausea, vomiting, stomachache or is lethargic, notify parents and school nurse ASAP.

-Send student back to class if none of the above symptoms are present.

Comments:_______________________________________________________________________

I understand that all monitoring equipment, snacks, glucose are to be provided by the family. In case of an emergency, contact the 911 emergency response team for further evaluation.

If parents are unavailable, the physician or diabetic nurse educator may be contacted for specific information. If transportation by ambulance is necessary, parents will assume responsibility for payment.

Parent(s) Signature:______________________________________ Date:_________________

Nurse Signature:________________________________________ Date:_________________

Confidential