20 ENDICOTT ROAD TOPSFIELD, MASSACHUSETTS 01983 (978)887-2323
HS Nurse ext. 6116 Fax # 978 887 7243 MS Nurse ext. 6125
Fax # 978 887-1991
Date of Plan: ______________
This plan should be completed by the student‘s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel.
Student’s Name:______________________________________Date of Birth___________ Grade_____
Date of Diagnosis: ___________ Physical Condition: Diabetes type 1 Diabetes type 2
Hospitalization required in past year? No Yes (when)____________________________________
___________________________________________________________________________________
Mother/Guardian:_____________________________________________________________________
Address:____________________________________________________________________________
Telephone: Home____________________Work___________________Cell______________________
Father/Guardian: _____________________________________________________________________
Address:____________________________________________________________________________
Telephone: Home____________________Work__________________ Cell_______________________
Student’s Doctor/Health Care Provider:
Name_______________________________________________________________________________
Address:____________________________________________________________________________
Telephone:_____________________________ Emergency Number____________________________
Notify parents/guardian or emergency contacts in the following situations:
__________________________________________________________________________________
__________________________________________________________________________________
For Students with Insulin Pumps
Type of pump: ________________________ Basal rates: _____ 12 am to _______
______ ______ to ______
______ ______ to ______
Type of insulin in pump: ____________________________ Type of infusion set: _________________
Insulin/carbohydrate ratio: ________________________ Correction factor:______________________
Student Pump Abilities/Skills: Needs Assistance
Count carbohydrates Yes No
Bolus correct 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
Type of medication: ____________________________________Timing ________________________
Other medications: _____________________________________ Timing________________________
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:
___________________________________________________________________________________
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 if blood glucose is below__________mg/dl or above_________mg/dl or if
moderate to large ketones are present.
Hypoglycemia (Low Blood Sugar)
Usual symptoms of hypoglycemia________________________________________________________
____________________________________________________________________________________
Treatment of Hypoglycemia_____________________________________________________________
____________________________________________________________________________________
Glucagon should be given if the student is unconscious, having a seizure, or unable to swallow________
____________________________________________________________________________________
Route______, Dosage________, Sites for glucagon injection: arm thigh other______________
If glucagon is required, administer it promptly. Then call 911 (or other emergency assistance) and the parent/guardian
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 (equipment and snacks will
be provided by parent)
_______Blood glucose meter, test strips, batteries
_______Lancet device, lancets, etc.
_______Urine ketone strips
_______Insulin pump and supplies
_______Insulin pen, pen needles, insulin cartridges
_______Fast-acting source of glucose
_______Carbohydrate containing snack
_______Glucagon emergency kit
Signatures
This Diabetes Medical Management Plan has been approved by:
_________________________________________________________________________________
Physician/Health Care Provider
Date
I give permission to the school nurse, trained diabetes personnel, and other designated staff members to perform and carry out the diabetes care tasks as outlined in this plan.
I consent to the release of the information contained in this Diabetes Medical Management 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.
This student has permission to self-administer the above medications at school and/or school related events, if the school nurse deems it appropriate.
Acknowledged and received by:
___________________________________________________________________________________
Student’s Parent/Guardian
Date
___________________________________________________________________________________
School Nurse
Date