DIABETES MEDICAL MANAGEMENT PLAN (DMMP)
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1 ESUBMIT Reset Form Print Form DIABETES MEDICAL MANAGEMENT PLAN (DMMP Date of Plan: This plan is valid for the current school year: STUDENT INFORMATION Name DOB Type of Diabetes Insulin Program Type 1 Type 2 Continuous insulin infusion therapy Grade 6FKRRO Other: Injection insulin therapy Other: CONTACT INFORMATION ParentGuardian ParentGuardian Emergency Contact Health Care Provider Fax ( DIABETES HISTORY Brief hisry of diagnosis (including recent hospitalizations: BLOOD GLUCOSE MONITORING Target Range: mgdl Other Range: mgdl Continuous Glucose Moniring Before breakfast Other testing times: Before AM snack Before lunchrecess Before PM snack Before phy ed Phy ed day: A B (Secondary After phy ed Phy ed day: A B C D E F (Elementary Before dismissal DIABETES MEDICATION No insulin at school Current insulin at home: Oral medication(s at school: Insulin at school [list type(s]: Insulin Delivery: Syringe & insulin vial Insulin pen Insulin pump (insulin sensitivity: Correction Scale (use with fastacting insulin before mealssnacksother: Yes No Parent provide insulincorrection scale dosages and changes of insulin dosages in writing school. MEAL PLAN Exchange Variable carbohydrate Fixed carbohydrate EXERCISEACTIVITY CONSIDERATIONS Carry treatment for low blood glucose Consider decreasing appropriate insulin dose before exercise Consider eating an extra snack before or during exercise Page 1 PIDiabetes Medical Management Plan rev
2 DIABETES MEDICAL MANAGEMENT PLAN (DMMP LOW BLOOD GLUCOSE (hypoglycemia Cold, clammy skin Personality change Headache SIGNS: Shakiness Confusion Weakness Sleepiness Uncontrollable behavior INSTRUCTIONS: Test Blood Glucose if signs of low blood glucose Give 15 grams carbohydrates (juice, 34 glucose tabs, or other 15 g carb: Wait 15 minutes Recheck Blood Glucose: If less than, give 15 more grams of carbohydrates Wait 15 minutes Recheck Blood Glucose Continue until Blood Glucose is or more and student is more alert. Student may need a snack if their next meal is over an hour away. Return student class. EMERGENCY PROTOCOL FOR LOW BLOOD GLUCOSE: If student is unable eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions (jerking movements, administer: GLUCAGON* ½ mg 1 mg route: Turn student on side CALL 911 and the student s parent(sguardian(s Call Licensed School Nurse Stay with student *GLUCAGON can only be administered by a nurse. If a nurse is not available, 911 will be called. HIGH BLOOD GLUCOSE (hyperglycemia SIGNS: Feeling unwell Increased thirst andor increased urination Kenes in urine Blood Glucose greater than 240 (2 or more consecutive readings Nausea andor vomiting *** If the student has moderate or large kenes in their urine, call parentguardian. The child s pediatric endocrinologisthealth care provider should also be notified *** INSTRUCTIONS: Test urine kenes for blood glucose greater than: Offer drinks that do NOT contain carbohydrates, (e.g., water, sugarfree soda, Crystal Light Call parent Other: EMERGENCY PROTOCOL FOR HIGH BLOOD GLUCOSE: If student has sympms of a hyperglycemia emergency, including dry mouth, extreme thirst, nausea andor vomiting, severe abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness or lethargy, or depressed level of consciousness: CALL 911 and the student s parentsguardian Call Licensed School Nurse Stay with student Page 2 PIDiabetes Medical Management Plan rev
3 DIABETES MEDICAL MANAGEMENT PLAN (DMMP CLASSROOM ACCOMMODATIONS Unlimited access drinking water (if a container is needed, parent is provide Bathroom privileges when medically necessary Send child office with staffbuddy if possible low blood glucose Retake tests as needed for blood glucose imbalances Other: Extra snacksparties (check all that apply: Child will eat treat Teacherstaff will notify parent prior activity Treat will be replaced with alternative snack provided by parent Schedule extra insulin per prearranged plan Child will eat treat and administer pump insulin bolus per pump calculation Field Trips: Totally independent ParentGuardian accompanies child on trip STUDENT TRANSPORTATION CONSIDERATIONS STUDENTS WHO RIDE THE BUS: If a low blood glucose episode occurs 30 minutes or less prior departure, the designated staff or nurse will: Call parent inform of low blood glucose episode (regardless if blood glucose returns normal Allow child ride the bus home if blood glucose returns normal Call parent pick up child (students will not be sent on the bus with a low blood glucose If student is tally independent in diabetes management, it is the student s responsibility alert staff of high or low blood glucose occurring 30 minutes or less before the end of the day. STUDENTS WHO DRIVE TO SCHOOL (high school only: If a low blood glucose episode occurs 30 minutes or less prior departure, the student will: Treat mild hypoglycemia, wait 15 minutes and retest. If blood glucose returns normal, student will drive home. Call parent inform of low blood glucose episode Call parent pick up child if blood glucose does not return normal. (*students with low blood glucose or high blood glucose with a large amount of kenes will not be allowed drive home If student is tally independent in diabetes management, it is the student s responsibility alert staff of high or low blood glucose occurring 30 minutes or less before the end of the day. EQUIPMENT AND SUPPLIES PROVIDED BY PARENT Blood glucose meter kit (includes all blood testing supplies for use at school Insulin (in unopened original container Kestix Glucagon if ordered by physician and parent makes it available Fast acting carbohydrate drink and glucose tablets or glucose gel product 56 prepackaged snacks (e.g., crackers and cheese, peanut butter Signed and d insulin order(s, sliding scale, bolus correction Page 3 RPSDiabetes Medical Management Plan rev
4 DIABETES MEDICAL MANAGEMENT PLAN (DMMP STUDENT S ROLE IN DIABETES MANAGEMENT Place a in each box that describes your child s role in the management of their diabetes: S S If an activity is marked as independent, the Licensed School Nurse will verify competency with your child. In order for an activity be marked as independent, your child must be able perform the task without reminders or assistance. Independent With Supervision With Assistance Health Staff Performs Washes hands Hands Puts strips in meter Pricks finger Lancet changed: Reads meter Records reading Tests for kenes INSULIN SYRINGEVIAL USERS Calculates amount of insulin based on reading Prepares and draw up correct amount of insulin INSULIN PEN USERS Prime and dial up correct amount of insulin Change insulin cartridge INSULIN SYRINGEVIAL & PEN USERS Selects insulin injection site Injects insulin INSULIN PUMP USERS Enters from meter in pump Determines amount of carbs Gives correct bolus for carbs Calculate & administer correction bolus Calculate & set temporary basal rate Recognize signs of site infection Disconnect pump if necessary Reconnect pump infusion set Insert new infusion set Give injection with syringepen if needed Troubleshoot alarms & malfunctions The student has demonstrated competency in the activities marked as independent above. LSN Signature Reset Table SIGNATURES I give S S consent the release of the information contained in this DMMP RPS professional staff who have responsibility for my child and who may need know this information maintain my child s health and safety. I give consent for RPS professional staff release information andor request information from prescribing Health Care Provider (HCP related this DMMP. I give consent for prescribing Health Care Provider (HCP release information andor request information from RPS professional staff related this DMMP. Parent Signature LSN Signature Page 4 PIDiabetes Medical Management Plan rev
5 INSULIN THERAPY CORRECTION & BASE DOSAGES Date of plan: This plan is valid for the current school year: STUDENT INFORMATION Name: DOB Grade 6FKRRO INSULIN CORRECTION SCALE Name of Insulin List times use correction scale: < mgdl mgdl mgdl mgdl 0 (goal mgdl + mgdl + mgdl + > mgdl + Kenes moderate or large + INSULIN BASE DOSE prebreakfast prelunch presnack prebreakfast prelunch presnack prebreakfast prelunch presnack prebreakfast prelunch presnack Revised PIinsulincorrectionbasedosages Page 5 ESUBMIT Reset Form Print Form
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Student s Name: LEON COUNTY SCHOOLS DIABETES MEDICAL MANAGEMENT PLAN & NURSING CARE PLAN (School Year -) Plan Effective Date(s): Date of Diabetes Diagnosis: Type 1 Type 2 School Name: Date of Birth: School
Date of birth: Type 2 Other: Parent/guardian 1: Address: Telephone: Home: Work: Cell: address: Camper physician / health care provider:
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