Individual Health Care Plan-Diabetes

Transcription

1 Individual Health Care Plan-Diabetes Effective Date: School Year: 20 to 20 This plan should be completed by the student s diabetes care aide/health clerk and parents/guardians. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the health clerk/diabetes care aide 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 Father/Guardian: Address: Telephone: Home Work Cell Student s Physician: Name: Address: Telephone: Emergency Number: Other Emergency Contacts (English-speaking): Name: Address: Telephone: Home Work Cell Notify parents/guardians or emergency contact in the following situations:

2 Individual Health Care Plan-Diabetes page 2 Blood Glucose Monitoring: Target range for blood glucose is other Usual times to check blood glucose Times to do extra blood glucose checks (check all that apply) before exercise after exercise before lunch after lunch before boarding the school bus 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 Dosing: 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 of carbohydrate. Use of other insulin at lunch: (circle type of insulin used): intermediate/nph/lente units or basal/lantus/ultralente units. Insulin Correction Dosing: Parental authorization should be obtained before administering a correction dose for high blood glucose levels. Yes No Can student give own injections? Yes No Can student determine correct amount of insulin? Yes No Can student draw correct dose of insulin? Yes No Parents are authorized to adjust the insulin dosage under the following circumstances: For Students with Insulin Pumps: Type of pump: Basal rates: 12am to to to Type of insulin in pump: Type of infusion set: Insulin/carbohydrate ratio: Correction factor:

3 Individual Health Care Plan -Diabetes page 3 Student Pump Abilities/Skills: Needs Assistance: Count carbohydrates Yes No Bolus correction amount for carbohydrates consumed Yes No Calculate and administer corrective bolus Yes No Calculate and set basal profiles Yes No Calculate and set temporary basal rate Yes No Disconnect pump Yes No Reconnect pump at infusion set Yes No Prepare reservoir and tubing Yes No Insert infusion set Yes No Troubleshoot alarms and malfunctions Yes No For Students Taking Oral Diabetes Medications: Type of medication: Timing: Other medications: Timing: 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): Exercise and Sports: A fast-acting carbohydrate such as should be available at the site of exercise or sports. Restrictions on activity, if any: Student should not exercise of blood glucose level is below mg/dl or above mg/dl or if moderate to large urine ketones are present.

4 Individual Health Care Plan - Diabetes page 4 Hypoglycemia (Low Blood Sugar): Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow. Route, dosage, site for glucagon injection: arm, thigh, other. If glucagon is required, administer it promptly. Then call 911 and the parents/guardians. 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 cartridge Fast-acting source of glucose Carbohydrate containing snack Glucagon emergency kit This Individual Health Care Plan has been approved by: Student s Physician Date Acknowledged and received by: I give permission to the health clerk/diabetes care aide and other designated staff members of School to perform and carry out the diabetes care tasks as outlined by s Individual Health Care Plan. I also consent to the release of the information contained in this Individual Health Care Plan 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. Pursuant to the authority granted under Section 105 ILCS 5/22-30 of the Illinois School Code, I hereby authorize my son/daughter,, to self administer diabetes

5 Individual Health Care Plan - Diabetes page 5 medications at school or school-sponsored activities while under the supervision of school s health clerk/diabetes care aide. I agree to indemnify and hold harmless the School District, its Board of Education and the Board s members, officers, employees, and volunteers from any claim, liability, loss or expense, including reasonable attorneys fees, suffered by any of the foregoing indemnitees and arising out of a claim related directly or indirectly to my son/daughter s self-administration of diabetes medication brought by me, any other parent or guardian of my student or another student, or by or on behalf of my student or another student. I understand that the School District and the foregoing individuals are to incur no liability as a result of any injury arising from the selfadministration of medication, regardless of whether authorization was given by my student s parents or guardians or by my student s physician, physician's assistant, or advanced practice registered nurse, provided, however, this indemnity and hold harmless commitment does not apply to the willful and wanton conduct of the foregoing indemnitees. This form shall be effective for the current school year only, and must be renewed each subsequent school year. Student s Parent/Guardian Student s Parent/Guardian Date Date

6 Emergency Action Plan - Diabetes Photo Hypoglycemia (Low Blood Sugar) Student's Name Grade/Teacher Emergency Contact Information: Date of Plan Mother/Guardian Father/Guardian Home phone Work phone Cell Home phone Work phone Cell Health Clerk/Diabetes Care Aide Contact Number(s) Never send a child with suspected low blood sugar anywhere alone. Causes of Hypoglycemia Too much insulin Onset Missed food Delayed food Sudden Too much or too intense exercise Unscheduled exercise Symptoms Mild Moderate Severe Hunger Dizziness Headache Blurry vision Loss of consciousness Shakiness Sweating Behavior Weakness Seizure Weakness Drowsiness change Slurred Speech Inability to swallow Paleness Personality change Poor Confusion Anxiety Inability to coordination Irritability concentrate Other Other Actions Needed Notify Health Clerk/Diabetes Care Aide. If possible, check blood sugar, per Individual Health Care Plan. When in doubt, always TREAT FOR HYPOGLYCEMIA. Mild Moderate Severe Student may/may not treat self. Someone assists. Call 911. Provide quick-sugar source. 3-4 glucose tablets Give student quick-sugar source per Contact parents/guardian. or MILD guidelines. 6 oz. regular soda Stay with student. or Wait 10 to 15 minutes. 3 teaspoons of glucose gel Don't attempt to give anything by mouth. Wait 10 to 15 minutes. Recheck blood glucose. Recheck blood glucose. Position on side, if possible. Repeat food if symptoms persist or Repeat food if symptoms persist or blood glucose is less than. blood glucose is less than. Contact health clerk/diabetes care aide. Follow with a snack of carbohydrate and Follow with a snack of carbohydrate and Administer glucagon, as prescribed. protein (e.g., cheese and crackers). protein (e.g., cheese and crackers).

7 Emergency Action Plan - Diabetes Photo Hyperglycemia (High Blood Sugar) Student's Name Grade/Teacher Date of Plan Emergency Contact Information: Mother/Guardian Father/Guardian Home phone Work phone Cell Home phone Work phone Cell Health Clerk/Diabetes Care Aide Contact Number(s) Causes of Hyperglycemia Too much food Too little insulin Decreased activity Illness Infection Stress Onset Over time -- several hours or days Symptoms Mild Moderate Severe Thirst Weight loss Mild symptoms plus: Mild and moderate symptoms plus: Frequent urination Stomach pains Dry mouth Labored breathing Fatigue/sleepiness Flushing of skin Nausea Very weak Increased hunger Lack of concentration Stomach cramps Confused Blurred vision Sweet, fruity breath Vomiting Unconscious Other Other Actions Needed Allow free use of the bathroom. Encourage student to drink water or sugar-free drinks. Contact the health clerk/diabetes care aide to check urine or administer insulin, per student's Individual Health Care Plan. If student is nauseous, vomiting, or lethargic, call the parents/guardian or call for medical assistance if parent cannot be reached.