International School Bangkok Diabetes Management Plan 2018/19

Transcription

1 International School Bangkok Diabetes Management Plan 2018/19 Student Family Name: Given Names: Date of Birth (dd/mm/yyyy): Grade at ISB (2018/19): Date of Plan (dd/mm/yyyy): Mother s Name: Phone: Father s Name: Phone: Other Emergency Contact Name: Phone: Physician s Name: Phone: Year of Diabetes diagnosis: Type 1 Type 2 Other: BLOOD GLUCOSE MONITORING Blood glucose measurements in mmol/l mg/dl Target range of blood glucose: - Check blood glucose Level: Before Lunch Hours after lunch 2hrs after dose correction Mid-morning Before PE After PE Before dismissal Other: As needed for signs/symptoms of low/high blood glucose As needed for signs/symptoms of illness Preferred site of Blood Glucose testing: Fingertip Other: Brand/Model of Blood Glucose Meter: Student s self-care blood glucose checking skills: Independently checks own blood glucose Yes No May check blood glucose with supervision Yes No Requires school nurse to check blood glucose Yes No Continuous Glucose Monitor (CGM)? Yes No If yes, Brand/Model: Alarm set for (low) (high) Note: High/low CGM levels will be confirmed with blood glucose monitor prior to treatment. MEALS Student s self-care nutrition skills: Independently counts carbohydrates Yes No May count carbohydrates with supervision Yes No Requires nurse to count carbohydrates Yes No Meal Plan: Mid-morning snack Lunch Special event/party food permitted: Carbohydrate content (grams) to to Parent discretion Student discretion Page 1 of 5 Diabetes Management Plan 2018/19

2 INSULIN THERAPY Insulin delivery device: Syringe Insulin Pen Insulin Pump (see below) Insulin dose determined by Student Parent School Nurse Student s self-care insulin administration skills: Independently calculates and gives own injections Yes No May calculate/give own injections with supervision Yes No Requires school nurse to calculate/give injections Yes No Appropriate therapy section to be filled out 1) ADJUSTABLE INSULIN THERAPY Name of insulin: Insulin to Carbohydrate Ratio: Snack 1 unit of insulin per grams of carbohydrate Lunch 1 unit of insulin per grams of carbohydrate Correction dose scale: When to give insulin: Snack: No coverage for snack Carbohydrate coverage only Carbohydrate coverage plus correction dose when blood glucose greater than and hours since last insulin dose Other: Lunch: Carbohydrate coverage only Carbohydrate coverage plus correction dose when blood glucose greater than and hours since last insulin dose Other: Correction dose only: For blood glucose greater than AND at least hours since last insulin dose. Other: 2) FIXED INSULIN THERAPY Name of insulin: Regime: Pre-snack units of insulin Pre-lunch units of insulin Other: If blood glucose outside target range contact: Parent Doctor Correction scale Correction dose scale: 3) INSULIN PUMP Page 2 of 5 Diabetes Management Plan 2018/19

3 Brand/Model of pump: Type of insulin in pump: Type of infusion set: How long has student used insulin pump? Is there a child lock on? Yes No Basal rate during school: Bolus dose? Time before eating bolus should be given: minutes Snack/Lunch boluses pre-programmed? Yes No Times: Insulin correction formula for blood glucose over target? During physical activity: Student may disconnect pump? Yes No Set a temporary basal rate? Yes No If yes, set temporary rate at % usual basal rate for hours Suspend pump? Yes No Extra pump supplies provided by parents: Infusion sets Reservoirs Batteries Dressing tapes Pen/syringe Student s self-care pump skills Independent? Count carbohydrates Yes No Bolus correct amount for carbohydrates consumed Yes No Calculate and administer correction bolus Yes No Calculate and set basal profiles Yes No Calculate and set temporary basal rate Yes No Change batteries Yes No Disconnect pump Yes No Reconnect pump to infusion set Yes No Prepare reservoir and tubing Yes No Insert infusion set Yes No Troubleshoot alarms and malfunctions Yes No Self-inject with syringe or pen if needed Yes No HYPOGLYCAEMIC TREATMENT Student s usual symptoms of hypoglycemia are: Hunger Change in personality/behavior Clamminess Nausea/loss of appetite Paleness Blurred vision Weakness/shakiness Inattention/confusion Slurred speech Tiredness/sleepiness Dizziness/staggering Headache Loss of consciousness Seizure Other: Management of hypoglycemia If blood glucose < Page 3 of 5 Diabetes Management Plan 2018/19

4 Give g carbohydrate Notify school nurse Recheck blood glucose every 15mins (x3) Notify parents Provide snack with carbohydrate, fat and protein after treating if no meal scheduled for next hour If pump notify parent/doctor for instructions regarding need to suspend pump Other: If severe hypoglycemia (decreased level of consciousness, seizure) Call nurse immediately Open airway/put in recovery position Apply glucose gel to inner cheek if available (and waiting for glucagon) Give Glucagon mg into Route IM SC Notify parents If pump, stop pump via stop or suspend or disconnecting pump Other: HYPERGLYCAEMIC TREATMENT Student s usual symptoms of hyperglycemia are: Increased thirst/urination/appetite Tiredness/sleepiness Blurred vision Warm, dry or flushed skin Nausea/vomiting Abdominal pain Rapid shallow breathing Weakness/muscle ache Fruity breath odor Other: Management of hyperglycemia (blood glucose over ) Call nurse Check urine for ketones If using injection treatment give insulin correction dose as per scale above If using pump and blood glucose over give a bolus of units (ENSURE pump is working) Recheck blood glucose and ketones every hours Contact parents Contact doctor PHYSICAL ACTIVITY AND SPORTS Student should eat grams of carbohydrate before every 30 minutes during after vigorous activity Other: If most recent blood glucose is less than, student can participate in physical activity when blood glucose is corrected and above. Student must not participate in physical activity when blood glucose is above and mod/large ketones in urine. Medical Practitioner Certification Page 4 of 5 Diabetes Management Plan 2018/19

5 (Student s name) is Able to carry his/her diabetes supplies at school? Yes No Able to manage their diabetes without nurse supervision? Yes No This diabetic management plan has been approved by Signature of Medical Practitioner: Name of Medical Practitioner: Qualifications: Date (dd/mm/yy): Official Stamp: Parental Consent I/We give permission for the school nurse to perform and carry out the diabetes care tasks outlined in this management plan. I/We undertake that I/we have given ISB authority to administer medication on my/our behalf and accept full responsibility for the same in the event that my child has any adverse reaction to this medication, provided that the medication was administered in accordance with my instructions. I/We will provide required medications/equipment to the school. I/We give permission for our child to carry his/her own insulin at school Yes No Signed: Name: Date (dd/mm/yyyy): Signed: Name: Date (dd/mm/yyyy): Student Consent to Carry Medication I (Student name), agree to carry my own medication/supplies for the treatment of my diabetes. I have been instructed in the proper use of my medication and fully understand how and when it is administered. I will keep this medication with me and on my person at all times (at school and whilst on trips off campus). I will not allow another student to use my medication under any circumstances. I also understand that should another student use my medication, the privilege of carrying my medication may be reassessed and/or revoked. I also accept the responsibility for notifying the Nurse if I have any problems/concerns when I measure my blood glucose level or take my medication. I understand I am responsible for looking after my medication and ensuring it has not expired. I will have my blood glucose meter and rescue carbohydrates available to me at all times. Signed: Date (dd/mm/yyyy): Page 5 of 5 Diabetes Management Plan 2018/19