School District of Altoona th St W Altoona, WI School Health Service
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- Eustacia Newton
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1 Date Dear Dr., Enclosed you will find an Individualized Healthcare Plan for Diabetes Management to be used in the school setting. This plan will be used for, (DOB ). This student attends. Your signature is required on the following form(s): Individualized Health Care Plan for Diabetes Management Authorization/Signatures Physician s Order for Medication Administration / Medication Consent Form. Please review the entire plan and add any necessary changes. This plan will be shared with appropriate school /transportation staff. I can be reached at ex 246 for questions. Thank you for your prompt response. Sincerely, Anita E-B Schubring RN BSN MEPD NCSN School District of Altoona Nurse (715) ext 246 aschubring@altoona.k12.wi.us
2 INDIVIDUALIZED EMERGENCY SCHOOL HEALTH PLAN FOR DIABETES MANAGEMENT Student Name Grade Teacher Date Student picture I have INSULIN-DEPENDENT DIABETES which means I must take insulin every day along with balancing diet and exercise. At school I may need to check my blood sugar levels and take insulin. I need to be able to eat snacks or drink beverages throughout the day to keep my blood sugar levels stable. See my INDIVIDUALIZED HEALTH CARE PLAN FOR DIABETES MANAGEMENT. I manage my diabetes independently. Emergency Contact Information Name Mother Home Phone Work Cell Name-Father Home Phone Work Cell Other Relationship Home Other Doctor Office Phone Preferred Hospital Occasionally my blood sugar may be too low. This can be very dangerous. Low blood sugar can be the result of too much insulin, skipping a meal or snack, or increasing exercise. If you think my blood sugar is low, have me check it. DO NOT LET ME TO GO ANYWHERE WITHOUT ADULT SUPERVISION. Symptoms of low blood sugar may be: Shaking Changes in personality Confusion Fast Heartbeat Looking pale or flushed Feeling low Feeling hungry Headache Feeling tired or weak Blurred vision Dizziness Irritability If my blood sugar is low ( mg/dl) or I have any of the above symptoms and am unable to check my blood sugar, I NEED FAST-ACTING SUGAR QUICKLY. You can give me. I should start to feel better in 10 to 15 minutes. If I do not feel better or my blood sugar level is still low, call my parents and do the following. If my blood sugar level drops too low, I may become unconscious or have a seizure. If this happens 1. CALL Give GLUCAGON by injection. Glucagon is not life threatening even if it is given when not needed. I have a prescription for Emergency Glucagon. My Glucagon is kept in. The following staff are trained to administer this medication:. I do not have a prescription for Emergency Glucagon. 3. Call my parents.
3 INDIVIDUALIZED HEALTH CARE PLAN FOR DIABETES MANAGEMENT Student Name Date of Birth Date School Grade Teacher BLOOD SUGAR TESTING (Check ALL that apply) Will not test at school. Will be done at school by student without assistance. Will need assistance from a staff member. The following form must be completed: Will be done everyday at. Will be done as needed when symptoms are present. Testing supplies will be kept at school in. INSULIN NEEDS (Check ALL that apply). Will not need insulin at school. Will not need assistance with insulin at school. Will need assistance with insulin at school. The following forms must be completed: PHYSICIAN S ORDER FOR MEDICATION ADMINISTRATION/MEDICATION CONSENT Will be using an insulin pump and is self-sufficient in its use. Will be using an insulin pump and will need assistance. The following form must be completed: FOOD PLAN : (Check ALL that apply) Independent in all food choices. Allow to consume snacks/beverages as needed to maintain appropriate blood sugar levels. Will bring daily morning snack of carbohydrates to be eaten at. Will bring daily afternoon snack of carbohydrates to be eaten at. On special occasions, student can eat same snack provided to classmates. On special occasions, student will select alternate snack provided by parent. NOTE* Parents will be responsible for packing a lunch from home or selecting appropriate food choices from school lunch menu WITH CARBOHDRATE COUNTS included on a piece of paper. Parents will provide all snacks.
4 HIGH BLOOD SUGAR SYMPTOMS AND TREATMENT High blood sugar (hyperglycemia) can be the result of too much food, not enough insulin, stress, illness, not enough exercise. Common symptoms are: Blurred vision Frequent Urination Nausea/Vomiting Extreme thirst Hunger Drowsiness Heavy, labored breathing Stomachache Dry skin Always allow use of water bottle in class, and use of the restroom as needed. If routine testing, and no symptoms, follow sliding scale for insulin administration. Call parents if over. If signs and symptoms occur: Test blood sugar. If over, student should drink large amounts of water. Call parents. INSULIN PUMP BOLUS SCHEDULE : Sliding Scale (S/S) Blood sugar Blood Glucose Target Range: mg/dl Insulin bolus LOW BLOOD SUGAR TREATMENT Students with symptoms of low blood sugar MUST be escorted in the building. If student is experiencing symptoms, TEST BLOOD SUGAR. Common symptoms are: Shaking Changes in personality Confusion Fast Heartbeat Looking pale or flushed Feeling low Feeling hungry Headache Feeling tired or weak Blurred vision Dizziness Irritability For blood sugar give 15 gms (1 carb) fast acting carbohydrate like. For blood sugar give 30 gms (2 carbs) fast acting carbohydrate like. If lunch or snack time, allow child to follow normal diet plan. Call parents if. If not lunch or snack time, call parents if. If student becomes unconscious or has a seizure due to severe low blood sugar, CALL 911 Give GLUCAGON by injection if prescribed CALL PARENTS. Student has a prescription for Emergency Glucagon. The following forms must be completed: PHYSICIAN S ORDER FOR MEDICATION ADMINISTRATION/MEDICATION CONSENT Student does not have a prescription for Emergency Glucagon.
5 Student name Date of birth School Grade Date Authorized School I have reviewed and approved the Individualized Health Care Plan for Diabetes Management. I understand the following health care procedures will be performed by designated assistive school personnel under the training and supervision of the School Nurse (RN) that provides nursing services. Emergency Glucagon Injection See Physician s Order for Medication Administration // Medication Consent form. Blood Glucose Testing Insulin Injection/Monitoring See Physician s Order for Medication Administration // Medication Consent form for insulin injection schedule. Ketone Monitoring Other This consent shall remain in effect through the end of the current school year unless discontinued or changed in writing. The plan, or appropriate parts of the plan will be shared with relevant school/transportation staff. SIGNATURE Physician SIGNATURE Parent SIGNATURE Nurse SIGNATURE Teacher
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