INDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH INJECTION HEALTHCARE PROVIDER ORDERS

Transcription

1 INDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH INJECTION HEALTHCARE PROVIDER ORDERS EFFECTIVE DATE: STUDENT S NAME: DIABETES HEALTHCARE PROVIDER INFORMATION Phne #: Fax #: SCHOOL: STUDENTS WITH DIABETES TREATED BY INJECTION Name: End Date f Birth: Schl Fax: Mnitr Bld Glucse test... If student has symptms f high r, withut mving student, lw bld glucse Befre breakfast After lunch Befre exercise/pe Befre mid-mrning snack Befre afternn snack After exercise/pe Befre lunch Befre leaving schl Other: Where t test: Classrm Health ffice Other: Withut mving student if has lw bld glucse symptms Rutine Daily Insulin Injectin: Crrectin insulin dse fr high bld glucse: Insulin Delivery: Syringe/vial Pen Type: rapid acting (Humalg / NvLg / Apidra) regular r ther: Calculate insulin dse fr carbhydrate intake: OR Give fr Give at: unit(s) f rapid-acting insulin grams f carbhydrate. breakfast AM snack lunch PM snack parties. Standard daily insulin injectin: Type Dse Time _ Time t be given: Befre lunch Other: Exercise and Sprts Student shuld mnitr bld glucse hurly. Parent/Guardian Authrity t Adjust Insulin Dse Dse adjustment allwed up t 20% higher r lwer Yes N Other Health Cncerns and Medicatins Other health cncerns: Allergies: Glucagn Dse: IM r SC per thigh r arm Oral diabetes medicatin(s)/dse: _ Times t be given: Other medicatin(s)/dse: _ Times t be given: HCP Assessment f Student s Diabetes Management Skills: Skill Independent Needs supervisin Cannt d Check bld glucse Cunt carbhydrates Calculate insulin dse Injectin HEALTHCARE PROVIDER SIGNATURE/STAMP: Times t be given: Nte UPDATED Change Date Initials HEALTH FORM 104 A (10/2016) D nt give insulin crrectin dse mre than nce every 2 t 3 hurs. Use crrectin scale Bld glucse range Insulin units Check ketnes if nausea, vmiting r abdminal pain OR if bld glucse >300 twice when tested 2 hurs apart. Give f rapid-acting insulin fr mderate ketnes, r _ fr large. Repeat ketne test in 2 Use Frmula t calculate crrectin hurs, and repeat dse additinal insulin as abve if mderate r large (Bld glucse- _ _) = ketnes are still present. units f insulin. Carbhydrate cverage and pre-meal crrectin dses may be cmbined. If BG <70 befre a meal treat with carbhydrate per algrithm. Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area Revised 8/2016

2 INDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH PUMP HEALTHCARE PROVIDER ORDERS EFFECTIVE DATE: STUDENT S NAME: DIABETES HEALTHCARE PROVIDER INFORMATION STUDENTS WITH DIABETES TREATED BY PUMP Name: End Date f Birth: Phne #: Fax #: SCHOOL: Schl Fax: Mnitr Bld Glucse test... If student has symptms f high r lw bld glucse Befre breakfast After lunch Befre exercise/pe Befre mid-mrning snack Befre afternn snack After exercise/pe Befre lunch Befre leaving schl Other: All test results shuld be entered int pump t determine need fr blus crrectin. Where t test: Classrm Health ffice Other: Withut mving student if has lw bld glucse symptms Insulin Pump Infrmatin Humalg r NvLg r Apidra by pump Basal rates during schl: _ Place pump n suspend when bld glucse is less than and re-activate it when bld glucse is at least. Pump settings shuld nt be changed by schl staff. Carbhydrate Blus Crrectin Blus fr Hyperglycemia Give 1 unit f insulin per Blus shuld ccur: befre eating, r ther: Time t be given: Befre lunch Other: D nt give crrectin dse f insulin mre than nce every 2 t 3hrs Give units f insulin fr each f bld glucse with a target bld glucse f. Check ketnes if nausea, vmiting r abdminal pain OR if bld glucse >300 twice when tested 2 hurs apart. Via syringe, give rapid-acting insulin fr mderate ketnes, r fr large. Repeat bld glucse test in 2 hurs, and repeat additinal insulin as abve if mderate r large ketnes are still present. If BG <70 befre a meal treat with carbhydrate per algrithm. If infusin set cmes ut r needs t be changed: Change set at schl Insulin via syringe every 3 hurs Exercise and Sprts with Pump Temprary Basal Decrease: N Yes ( _% r _ units fr _ minutes r duratin f exercise) Student shuld mnitr bld glucse hurly. HCP Assessment f Student s Diabetes Management Skills: Nte Skill Independent Needs supervisin Cannt d Check bld glucse Cunt carbhydrates Calculate insulin dse Change infusin set Injectin Truble sht alarms, malfunctins Ntes: Parent/Guardian Authrity t Adjust Insulin Dse Dse adjustment allwed up t 20% higher r lwer Yes N Other health cncerns: Allergies: Glucagn Dse: IM r SC per thigh r arm Oral diabetes medicatin(s)/dse: _ Times t be given: Other medicatin(s)/dse: _ Times t be given: HEALTHCARE PROVIDER SIGNATURE/STAMP: gm carbhydrate at breakfast gm carbhydrate at AM snack gm carbhydrate at lunch gm carbhydrate at PM snack HEALTH FORM 105 A (10/2016) UPDATED Change Date Initials Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area Revised 8/2016

3 STUDENT S NAME: Student s usual LOW _ Shaky r jittery _ Sweaty _ Hungry _ Pale _ Headache _ Blurry visin _ Sleepy _ Dizzy bld glucse symptms: _ Uncrdinated _ Irritable, nervus _ Argumentative _ Cmbative _ Changed persnality _ Changed behavir _ Unable t cncentrate _ Weak, lethargic HEALTH FORM A2 (10/2016) ALGORITHMS FOR B LOOD GLUCOSE RESULTS CHECK BLOOD GLUCOSE Student s usual HIGH bld glucse symptms: Hyperglycemia Emergency levels _ Increased thirst, dry _ Extreme thirst muth _ Nausea, vmiting _ Frequent r increased _ Severe abdminal urinatin pain _ Change in appetite, _ Fruity breath nausea _ Heavy breathing, _ Blurry visin shrtness f breath _ Fatigue _ Increasing sleepiness, Other lethargy BELOW ABOVE Give 15 gm fast-acting carbhydrate withut insulin cverage. Observe fr 15 minutes then retest bld glucse. a. If less than 70, repeat 15 gm carbhydrate and retest in 15 min. b. If ver 70 and nt eating a meal within an hur, give carbhydrate and prtein snack withut insulin cverage. Ntify schl nurse and parent if n imprvement Student shuld nt exercise. CALL 911 if student becmes uncnscius, has seizures, r is unable t swallw Turn student n side t ensure pen airway Give glucagn as rdered. Keep student in recvery psitin n side. If n insulin pump, either place it in suspend r stp mde, discnnect it at the pigtail r clip, r cut tubing. If pump was remved, send it with EMS t the hspital. Ntify schl nurse, parent and HCP Wait 15 minutes; if n respnse, repeat glucagn. If respnsive, ffer juice. Wait 15 minutes and give prtein & carbhydrate snack If prir t exercise r immediately fllwing strenuus activity and NO meal/snack is planned within 30 minutes, give 15 gm carbhydrate and prtein snack. If NOT exercise-related and student is symptmatic, bserve and recheck in 15 minutes. If NOT exercise-related and is NOT symptmatic, return t class. 15 GM FAST-ACTING CARBOHYDRATE = ½ c. juice 3-4 glucse tablets Tube f glucse gel ½ c. regular (nt diet) sda 6-7 small sugar candies (t chew) 1 c. skim milk D nt give chclate Student may eat befre exercising r recess. STUDENT TREATED BY INJECTION N actin needed. 1. Use crrectin scale r frmula at lunch r every 2-3 hurs 2. Check ketnes if symptms r if bld glucse>300 twice in a rw: a. If ketnes are absent r small, encurage exercise and water b. If ketnes mderate r large: N exercise; give water Add units f insulin per rders 3. Ntify schl nurse and parent 4. Prvide free, unrestricted access t water and the restrm. STUDENT TREATED BY PUMP 1. If 2-3 hurs since last blus, treat with crrectin blus via pump. Re-check in 2-3 hrs. Truble sht pump functin. Check fr redness at site, tubing fr kinks r air bubble, insulin supply 2. If bld glucse still 300 and nt explained, check ketnes: a. If ketnes are absent r small, encurage exercise and water b. If ketnes mderate r large: Give insulin crrectin dse per rders via syringe. N exercise; encurage water 3. Change infusin set r cntinue insulin injectins every 2-3 hurs via syringe. 4. Ntify schl nurse and parent 5. Prvide free, unrestricted access t water and the restrm. CALL 911 if the student vmits, becmes lethargic and/r has labred breathing. Ntify schl nurse, parent and HCP. EXERCISE AND SPORTS Assure has quick access t water fr hydratin, fast-acting carbhydrates, snacks and mnitring equipment. Student shuld nt exercise if bld glucse level is belw 70 r if has mderate t large ketnes. *Never send a child with suspected lw bld glucse anywhere alne.* Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 2 Revised

4 INDIVIDUALIZED HEALTHCARE PLAN - DIABETES SCHOOL AND PARENT PART HEALTH FORM B (10/2016) STUDENT S NAME: Diabetes infrmatin Date f Diagnsis: Diabetes Type 1 Diabetes Type 2 Other SCHOOL INFORMATION PLAN EFFECTIVE DATE: Grade: Teacher: 504 plan n file: Yes N CONTACT INFORMATION: Student s pht Parent/Guardian 1: Name Call first Phne numbers: Hme Wrk Cell Other Parent/Guardian 2: Name Call first Phne numbers: Hme Wrk Cell Other Other/emergency: Name: Relatinship: Phne numbers: Hme Wrk Cell Other Additinal Times t Cntact Parent... Student treated by injectin Bld Glucse test ut f target range Rutine Daily Insulin injectins Crrectin dse STUDENT DIABETES SELF-MANAGEMENT PLAN Student will manage diabetes independently Student has signed Agreement fr Student Independently Managing Diabetes Trained staff will supervise student self-care Verify bld glucse test Check carbhydrate cunt Cnfirm dse Supervise insulin self-injectin Mnitr blus administratin Truble sht pump alarms, malfunctin Watch infusin set change Student treated by pump: Bld Glucse test ut f target range Carbhydrate blus Crrectin blus Infusin set cmes ut/needs t be replaced Trained staff will prvide care Test bld glucse Cunt carbhydrates Calculate insulin dse and inject as abve Prvide insulin injectin Administer blus Truble sht pump alarms, malfunctin Change infusin set FOOD PLAN Time Ntes Mnitr/Remind Student Fd at a classrm/schl party: Yes N Student will eat treat Breakfast Mrning snack Lunch Afternn snack Extra snack Befre exercise After exercise Replace the treat with a parent-supplied alternative BUS TRANSPORTATION PLAN Bus transprtatin: T schl Hme Student may test bld glucse and Test bld minutes befre barding schl bus hme. Student must have bld glucse > self-manage 70 t bard bus; if 70, prvide care based n algrithm and call t have student picked up. diabetes while n Bld test nt required. the bus. Put in baggie t take hme with teacher nte Student shuld nt eat treat Mdify the treat as fllws: FIELD TRIPS Schl nurse t be ntified tw weeks befre the field trip t assure qualified persnnel are available. All diabetes supplies are taken and care is prvided accrding t this Plan (cpy t accmpany trip). Lunch and snack times shuld nt change. SCHEDULED AFTER- OR BEFORE-SCHOOL ACTIVITIES anticipates: List f clubs, sprts, etc. that student If parent wants trained staff cverage fr an activity, parent will ntify schl nurse tw weeks befre it begins Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 3 Revised

5 HEALTH FORM C (10/2016) ADDITIONAL NOTES STUDENT S NAME: SUPPLY LOCATIONS SUPPLY LIST Bld Glucse Test Kit Meter Test strips Lancing device and lancet Insulin Means student uses this item AND parent will prvide. Sharps cntainer Anti-bacterial cleaner/alchl swabs PLAN EFFECTIVE DATE: cttn balls spt band-aids Glucse meter brand/mdel: Treatment by Injectin Treatment by Pump Insulin pen Pump syringe Sf-serter Infusin set type: Pre-filled syringes (labeled Pump tubing/needle Insulin vial and per dse) Batteries syringes Insulin vials and syringes Tape Pump type Medtrnic MiniMed (800) Animas (877) Omnipd (800) Lw Bld Glucse (5-day supply) Fast-acting carbhydrate drink (apple juice, range juice, regular sda pp NOT diet), 6 cntainers Pre-packaged snacks (e.g., crackers with cheese r peanut butter, nite bite), 5 servings Supply f fast-acting glucse at least equal t 15 gm per day fr 5 days (e.g., 75 gm ttal) Glucagn Kit High Bld Glucse Urine ketne test strips/bttle Urine cup Water bttle (Timing device may be wall clck r watch) 3-day Disaster Kit Cmplete daily insulin dse schedule (separate page) Bld glucse test kit (testing strips, lancing device, lancets, meter batteries) Vial f insulin and 6 syringes; insulin pens and supplies Insulin pump and pump supplies Hypglycemia treatment supplies, 3 episdes Other Daily breakfast, snacks and lunch Extra snacks Lw bld glucse supplies High bld glucse supplies Other With student In classrm In health ffice Other Bld glucse test kit Extra kit Pump supplies Insulin Daily use Extra/emergency Disaster Disaster fd Other medicatins, including glucagn kit Urine ketne strips/plastic cup Antiseptic wipes r hand sanitizer 3-day fd supply with meal plan Other: With student In classrm SIGNATURES As parent/guardian f the abve-named student, I give permissin fr the schl nurse and/r ther trained staff f (schl) In health ffice Other t perfrm and carry ut the diabetes care tasks as utlined in this Individualized Healthcare Plan. I have reviewed this plan and agree with the indicated instructins. I understand that the schl is nt respnsible fr equipment lss r damage, r expenses assciated with these treatments and prcedures. I understand that the infrmatin cntained in this plan will be shared with ther schl staff n a need-t-knw basis. I understand that the schl nurse may cntact my child s physician/health care prvider and discuss my child s care related t this plan. I will ntify the schl nurse whenever there is any change in my child s health status r care. My child and I are respnsible fr maintaining the necessary supplies, snacks, bld glucse meter, medicatins and ther equipment. Student s parent/guardian Date Student s parent/guardian Date Schl nurse Date Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 4 Revised

6 AGREEMENT FOR STUDENTS INDEPENDENTLY MANAGING THEIR DIABETES Student: Grade: Student HEALTH FORM D (10/2016) I agree t dispse f any sharps either by keeping them in my kit and taking them hme, r placing them in the sharps cntainer prvided at schl. If s indicated in my Individualized Healthcare Plan, I will ntify the health ffice if my bld sugar is belw r abve. I will nt allw any ther persn t use my diabetes supplies. I plan t keep my diabetes supplies: With me In the schl health ffice In an accessible and secure lcatin ( ) I will seek help in managing my diabetes frm if I need it. I understand that the freedm t manage my diabetes independently is a privilege and I agree t abide by this cntract. Student s signature: Parent/Guardian I agree that my child can self-manage his/her diabetes and can recgnize when he/she needs t seek help frm a staff member. I authrize my child t carry and self-administer diabetes medicatins and management supplies and I agree t release the schl district and schl persnnel frm all claims f liability if my child suffers any adverse reactins frm self-management r strage f diabetes medicatins and bld glucse management prducts. I will prvide back-up supplies t the health ffice fr emergencies. I understand that this cntract is in effect fr the current schl year unless revked by my sn/daughter s physician r my sn/daughter fails t meet the abve safety guidelines. Parent s signature: Schl nurse I will assure that schl staff members that have the need t knw abut the student s cnditin and the need t carry their diabetes supplies with them have been ntified. Schl Nurse s signature: Based n a frm psted n the Clrad Kids with Diabetes website ( Files.html) Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 5 Revised

7 ALASKA INDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH INJECTION OR WITH PUMP Instructins Purpses: This healthcare plan is fr all students with diabetes that mnitr bld glucse at schl and/r are n insulin r ther hypglycemic medicatin and/r have a glucagn prescriptin. 1. Healthcare prviders shuld use it t prescribe a particular treatment regimen including medicatin(s) fr schl (HEALTHCARE PROVIDER ORDERS pages) a. It dcuments the ability level f the student t self-manage their diabetes. b. It prvides the medical parameters fr management f an individual student s diabetes in the schl setting. 2. It describes the standard f care fr schl staff t fllw based n bld glucse test results and is the Emergency Care Plan fr students with diabetes. (ALGORITHMS FOR BLOOD GLUCOSE RESULTS page) NOTE: The standard f care represents the care t fllw in mst cases; any individualizatin f clinical care fr the student will be reflected in the HEALTHCARE PROVIDER ORDERS. 3. Schl nurses and parents shuld use it t plan and implement individualized health interventins in the schl setting, based n the Healthcare Prvider Orders page. (SCHOOL AND PARENT PART pages) a. T supprt quality assurance f schl health services. b. T dcument parental wishes fr diabetes management-related cntact by schl staff. c. T dcument diabetes supplies needed at schl, their lcatins and parental respnsibility fr maintaining certain supplies at schl. d. T facilitate a safe prcess fr the delegatin f diabetes-management tasks t trained unlicensed schl staff, as needed. While current, this frm shuld be kept in the schl health ffice r with the staff member wh is assisting with the health management f the student. Prcess: 1. Healthcare prvider cmpletes either the WITH INJECTION r the WITH PUMP page f the frm t describe anticipated medicatins/treatment needs fr the entire schl year, and sends it t the schl nurse (if knwn) and/r the student s parent t bring int the schl. a. If medicatins and/r treatment change during the schl year, a new frm shuld be cmpleted. Fax nly the page with new rders t the schl. b. Mst categries are self-explanatry. On either frm, check all bxes that apply and add infrmatin as apprpriate. DIABETES WITH INJECTION ntes: In the Rutine Daily Insulin Injectin bx, there are three ptins fr Type. NPH and Lantis are examples f ther. The relevant dses/times fr these injectins wuld be listed in the Standard daily insulin injectin table. Instructins in the Crrectin insulin dse fr high bld glucse bx are fr a rutine day as crrectin dsing is generally given at mealtime, which means that: Actin directed by the algrithm page supersedes befre lunch nly when it is checked because it is based n the student s symptms and bld glucse levels. Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 6 Revised

8 The D nt give insulin crrectin dsing mre ften than every 2 t 3 hurs statement applies t symptmatic treatment based n bld glucse levels in mst instances. In the Parent/Guardian Authrity t Adjust Insulin Dse bx, parental authrity t adjust the dse up t 20% higher r lwer allws the parent t recmmend dse adjustments t the nurse which the nurse culd fllw withut cntacting the health care prvider if the dse is within 20% f the range rdered by the prvider. If the dse recmmended by the parent falls utside f the range, either higher r lwer, the nurse wuld need t cntact the health care prvider t verify the dse. c. Healthcare prvider signs and dates the WITH INJECTION r WITH PUMP page and faxes r sends the rders t the schl. 2. While meeting with the schl nurse, the parent uses the bxes at the tp f the ALGORITHMS page t indicate which f the symptms f lw and high bld sugar generally ccur fr their child. 3. Tgether, the schl nurse, parent and the student, if student is self-managing his/her diabetes, cmplete the SCHOOL AND PARENT PART f the frm. a. Mst categries are self-explanatry. Check all bxes that apply and add infrmatin as apprpriate. In the Student Diabetes Self-Management Plan bx: The repeated skills list (frm the healthcare prvider sectin) allws parent input and schl nurse assessment f the student skill level and the level f supervisin r assistance needed. If the student skill level increases during the schl year, this sectin allws the schl nurse and parent t adjust the self-management plan accrdingly. Trained staff (right-side clumn) in this instance includes the schl nurse. Fr Change infusin set under Trained staff will prvide care, the schl nurse is typically the nly trained staff changing the infusin set fr a student n a pump. Add this cmment when needed. The SUPPLY LIST is intended t prmte best practice. Generally, it shuld be interpreted by the nurse and the parent as a guide. If the parent is unable t prvide urine ketne test strips, cntact the American Diabetes Assciatin ( ). They will send sme. b. Parents and Schl Nurse sign and date the SCHOOL AND PARENT PART. If student will be self-managing, student signs the STUDENT SELF-MANAGEMENT AGREEMENT. c. Update as needed and/r n a yearly basis. 4. File the entire dcument with student s health recrd at the end f the year r upn student withdrawal. Created by the Alaska Divisin f Public Health and the American Diabetes Assciatin, Alaska Area 7 Revised