Schl Medicatin Authrizatin Frm Student's Name Address Birth Date Hme Phne Schl Grade Teacher Emergency Phne N: T be cmpleted by the student's physician: Name f Medicatin: Dsage Frequency Time t be given in schl Date f prescriptin Date f rder Discntinuatin date Diagnsis requiring medicatin Intended effect f this medicatin Must this medicatin be administered during the schl day in rder t allw the child t attend schl r t address the student's medicatin cnditin? Expected side effects, if any: Time interval fr re-evaluatin: Other medicatins student is receiving: Physician's name signature: Physician's name print: Address: Office Phne: Emergency Phne: Date: Medicatin/treatment rders are included in attached plan. DISTRICT HEALTH SERVICES Greenbrk Spring Wd Waterbury Phne 630-894-4409 Phne 630-894-4044 Phne 630-894-4211 Fax 630-289-1063 Fax 630-894-9658 Fax 630-893-3797
I, (parent), cnfirm that I am primarily respnsible fr administering medicatin t my child. Hwever, in the event that I am unable t d s r in the event f a medical emergency, I hereby authrize Keeneyville Schl District #20 and its emplyees and agents, in my behalf and stead, t administer r t attempt t administer t my child (r t allw my child t self-administer, while under the supervisin f the emplyee and agents f the Schl District), lawfully prescribed medicatin in the manner described abve. I ACKNOWLEDGE THAT IT MAY BE NECESSARY FOR THE ADMINISTRATION OF MEDICATION TO MY CHILD TO BE PERFORMED BY AN INDIVIDUAL OTHER THAN A SCHOOL NURSE, AND SPECIFICALLY CONSENT TO SUCH PRACTICES. I further acknwledge and agree that, when the lawfully prescribed medicatin is s administered r attempted t be administered. I waive any claims I might have against the Schl District, its emplyees and agents arising ut f the administratin f said medicatin. In additin, I agree t hld harmless and indemnify the Schl District, its emplyees and agents, either jintly r severally, frm and against any and all claims, damages, causes f actin r injuries incurred r resulting frm the administratin r attempts at administratin f said medicatin. (PARENT'S/GUARDIAN'S SIGNATURE) (DATE) DISTRICT HEALTH SERVICES Greenbrk Spring Wd Waterbury Phne 630-894-4409 Phne 630-894-4044 Phne 630-894-4211 Fax 630-289-1063 Fax 630-894-9658 Fax 630-893-3797
Diabetes Medical Management Plan (DMMP) This plan shuld be cmpleted by the student s persnal diabetes health care team, including the parents/guardian. It shuld be reviewed with relevant schl staff and cpies shuld be kept in a place that can be accessed easily by the schl nurse, trained diabetes persnnel, and ther authrized persnnel. Date f Plan: This plan is valid fr the current schl year: - Student s Name: Date f Birth: Date f Diabetes Diagnsis: type 1 type 2 Other Schl: Schl Phne Number: Grade: Hmerm Teacher: Schl Nurse: Phne: Tls CONTACT INFORMATION Mther/Guardian: Address: Telephne: Hme Wrk Cell: Email Address: Father/Guardian: Address: Telephne: Hme Wrk Cell: Email Address: Student s Physician/Health Care Prvider: Address: Telephne: Email Address: Emergency Number: Other Emergency Cntacts: Name: Relatinship: Telephne: Hme Wrk Cell: Helping the Student with Diabetes Succeed 99
Diabetes Medical Management Plan (DMMP) Page 2 Checking Bld Glucse Target range f bld glucse: 70 130 mg/dl 70 180 mg/dl Other: Check bld glucse level: Befre lunch Hurs after lunch 2 hurs after a crrectin dse Mid-mrning Befre PE After PE As needed fr signs/symptms f lw r high bld glucse As needed fr signs/symptms f illness Befre dismissal Other: Preferred site f testing: Fingertip Frearm Thigh Other: Brand/Mdel f bld glucse meter: Nte: The fingertip shuld always be used t check bld glucse level if hypglycemia is suspected. Student s self-care bld glucse checking skills: Independently checks wn bld glucse May check bld glucse with supervisin Requires schl nurse r trained diabetes persnnel t check bld glucse Cntinuus Glucse Mnitr (CGM): Yes N Brand/Mdel: Alarms set fr: (lw) and (high) Nte: Cnfirm CGM results with bld glucse meter check befre taking actin n sensr bld glucse level. If student has symptms r signs f hypglycemia, check fingertip bld glucse level regardless f CGM. HYPOGLYCEMIA TREATMENT Student s usual symptms f hypglycemia (list belw): If exhibiting symptms f hypglycemia, OR if bld glucse level is less than mg/dl, give a quick-acting glucse prduct equal t grams f carbhydrate. Recheck bld glucse in 10 15 minutes and repeat treatment if bld glucse level is less than mg/dl. Additinal treatment: 100 www.yurdiabetesinf.rg
Diabetes Medical Management Plan (DMMP) Page 3 HYPOglYCEMIA TREATMENT (Cntinued) Fllw physical activity and sprts rders (see page 7). If the student is unable t eat r drink, is uncnscius r unrespnsive, r is having seizure activity r cnvulsins (jerking mvements), give: Glucagn: 1 mg 1/2 mg Rute: SC IM Call 911 (Emergency Medical Services) and the student s parents/guardian. Cntact student s health care prvider. Site fr glucagn injectin: arm thigh Other: HYPERGLYCEMIA TREATMENT Student s usual symptms f hyperglycemia (list belw): Tls Check Urine Bld fr ketnes every hurs when bld glucse levels are abve mg/dl. Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse, give crrectin dse f insulin (see rders belw). Fr insulin pump users: see additinal infrmatin fr student with insulin pump. Give extra water and/r nn-sugar-cntaining drinks (nt fruit juices): unces per hur. Additinal treatment fr ketnes: Fllw physical activity and sprts rders (see page 7). Ntify parents/guardian f nset f hyperglycemia. If the student has symptms f a hyperglycemia emergency, including dry muth, extreme thirst, nausea and vmiting, severe abdminal pain, heavy breathing r shrtness f breath, chest pain, increasing sleepiness r lethargy, r depressed level f cnsciusness: Call 911 (Emergency Medical Services) and the student s parents/ guardian. Cntact student s health care prvider. Helping the Student with Diabetes Succeed 101
Diabetes Medical Management Plan (DMMP) page 4 INSULIN THERAPY Insulin delivery device: syringe insulin pen insulin pump Type f insulin therapy at schl: Adjustable Insulin Therapy Fixed Insulin Therapy N insulin Adjustable Insulin Therapy Carbhydrate Cverage/Crrectin Dse: Name f insulin: Carbhydrate Cverage: Insulin-t-Carbhydrate Rati: Lunch: 1 unit f insulin per grams f carbhydrate Snack: 1 unit f insulin per grams f carbhydrate Carbhydrate Dse Calculatin Example Grams f carbhydrate in meal Insulin-t-carbhydrate rati = units f insulin Crrectin Dse: Bld Glucse Crrectin Factr/Insulin Sensitivity Factr = Target bld glucse = mg/dl Crrectin Dse Calculatin Example Actual Bld Glucse Target Bld Glucse = units f insulin Bld Glucse Crrectin Factr/Insulin Sensitivity Factr Crrectin dse scale (use instead f calculatin abve t determine insulin crrectin dse): Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units 102 www.yurdiabetesinf.rg
Diabetes Medical Management Plan (DMMP) page 5 INSUlIN THERAPY (Cntinued) When t give insulin: Lunch Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Snack N cverage fr snack Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Crrectin dse nly: Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse. Other: Tls Fixed Insulin Therapy Name f insulin: Units f insulin given pre-lunch daily Units f insulin given pre-snack daily Other: Parental Authrizatin t Adjust Insulin Dse: Yes N Parents/guardian authrizatin shuld be btained befre administering a crrectin dse. Yes N Parents/guardian are authrized t increase r decrease crrectin dse scale within the fllwing range: +/- units f insulin. Yes N Parents/guardian are authrized t increase r decrease insulin-tcarbhydrate rati within the fllwing range: units per prescribed grams f carbhydrate, +/- grams f carbhydrate. Yes N Parents/guardian are authrized t increase r decrease fixed insulin dse within the fllwing range: +/- units f insulin. Helping the Student with Diabetes Succeed 103
Diabetes Medical Management Plan (DMMP) page 6 INSUlIN THERAPY (Cntinued) Student s self-care insulin administratin skills: Yes Yes Yes N N N 104 www.yurdiabetesinf.rg Independently calculates and gives wn injectins May calculate/give wn injectins with supervisin Requires schl nurse r trained diabetes persnnel t calculate/give injectins ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP Brand/Mdel f pump: Type f insulin in pump: Basal rates during schl: Type f infusin set: Fr bld glucse greater than mg/dl that has nt decreased within hurs after crrectin, cnsider pump failure r infusin site failure. Ntify parents/guardian. Fr infusin site failure: Insert new infusin set and/r replace reservir. Fr suspected pump failure: suspend r remve pump and give insulin by syringe r pen. Physical Activity May discnnect frm pump fr sprts activities Yes N Set a temprary basal rate Yes N % temprary basal fr hurs Suspend pump use Yes N Student s self-care pump skills: Independent? Cunt carbhydrates Yes N Blus crrect amunt fr carbhydrates cnsumed Yes N Calculate and administer crrectin blus Calculate and set basal prfiles Calculate and set temprary basal rate Change batteries Discnnect pump Recnnect pump t infusin set Prepare reservir and tubing Insert infusin set Yes Yes Yes Yes Yes Yes Yes Yes N N N N N N N N Trublesht alarms and malfunctins Yes N
Diabetes Medical Management Plan (DMMP) page 7 OTHER DIABETES MEDICATIONS Name: Dse: Rute: Times given: Name: Dse: Rute: Times given: MEAL PLAN Meal/Snack Time Carbhydrate Cntent (grams) Breakfast t Mid-mrning snack t Lunch t Mid-afternn snack t Other times t give snacks and cntent/amunt: Instructins fr when fd is prvided t the class (e.g., as part f a class party r fd sampling event): Special event/party fd permitted: Parents/guardian discretin Student discretin Student s self-care nutritin skills: Yes N Independently cunts carbhydrates Yes N May cunt carbhydrates with supervisin Yes N Requires schl nurse/trained diabetes persnnel t cunt carbhydrates Tls PHYSICAL ACTIVITY AND SPORTS A quick-acting surce f glucse such as glucse tabs and/r sugar-cntaining juice must be available at the site f physical educatin activities and sprts. Student shuld eat 15 grams 30 grams f carbhydrate ther befre every 30 minutes during after vigrus physical activity ther If mst recent bld glucse is less than mg/dl, student can participate in physical activity when bld glucse is crrected and abve mg/dl. Avid physical activity when bld glucse is greater than mg/dl r if urine/ bld ketnes are mderate t large. (Additinal infrmatin fr student n insulin pump is in the insulin sectin n page 6.) Helping the Student with Diabetes Succeed 105
Diabetes Medical Management Plan (DMMP) page 8 DISASTER PLAN T prepare fr an unplanned disaster r emergency (72 HOURS), btain emergency supply kit frm parent/guardian. Cntinue t fllw rders cntained in this DMMP. Additinal insulin rders as fllws: Other: SIGNATURES This Diabetes Medical Management Plan has been apprved by: Student s Physician/Health Care Prvider Date I, (parent/guardian:) give permissin t the schl nurse r anther qualified health care prfessinal r trained diabetes persnnel f (schl:) t perfrm and carry ut the diabetes care tasks as utlined in (student:) s Diabetes Medical Management Plan. I als cnsent t the release f the infrmatin cntained in this Diabetes Medical Management Plan t all schl staff members and ther adults wh have respnsibility fr my child and wh may need t knw this infrmatin t maintain my child s health and safety. I als give permissin t the schl nurse r anther qualified health care prfessinal t cntact my child s physician/health care prvider. Acknwledged and received by: Student s Parent/Guardian Date Student s Parent/Guardian Date Schl Nurse/Other Qualified Health Care Persnnel Date 106 www.yurdiabetesinf.rg