Diabetic care plan

****Emergency names and phone numbers are on computer health record****
Diabetes Orders
Student's Name
Effective Date
Physician Phone
Type of insulin: (circle one) Rapid or Short Acting: Apidra/Humalog/Novolog/Regular

Intermediate or Long-acting given at home: (cirlce one) NPH/Lantus/Levemir Insulin to carbohydrate ratio (I:CR):
grams or Fixed insulin lunch dose
Parent may adjust I:CR by +/- 1 to 5 grams Yes/No (circle one) Correction Factor (CF) (insulin sensitivity): CF:
units per
mg/dl over
(Correction Factor Formula: Student's BG minus Target BG ÷ correction factor = insulin dose) Usual Insulin Dose Range
Target blood glucose range: 70-110 pre-meal. Other:
Blood Glucose Monitoring (in classroom if possible) or
Insulin Pump: (if applicable)
Child is able to:
Exercise and Sports
Student should not exercise if blood glucose is
Supplies to be provided by parents: Blood Glucose Monitor and all monitoring supplies, Insulin and administration supplies, Glucagon emergency kit, snack foods, fast-acting glucose source, Ketone testing supplies, Insulin pump supplies if appropriate. High blood glucose Management/Preventing Diabetic Ketoacidosis
If BG is above 250 mg/dl, wash hands and recheck. If still above 250: →If less than 2 hrs since last dose of Apidra, Humalog or Novolog, *
recheck at 2 hrs after the last dose and continue as below.
lf 2 hrs or more since the last dose of Apidra, Humalog, or Novolog*
give a correction dose using the correction factor formula.
→Check urine for ketones. If positive, drink 6-8 oz liquid with no calories →Blurred vision . →Speech Impairment :every 30 minutes (e.g. water, diet soda) Hypoglycemia protocol: the rule of 15
If moderate or large ketones at any time, call parent.
If blood glucose is less than 70 mg/dl or symptomatic (70 to 100 →Check BG and ketones every 2 hrs and give correction dose until BG →If BG and ketones are not decreasing after 4 hrs, call parent. →Check BG again in 15 minutes; if not above 70 mg/dl repeat treatment Additional Instructions for Insulin Pump Users:
→Check BG again in 15 minutes; if not above 70mg/dl repeat treatment →If ketones are negative, check pump and site. If okay, give correction ) These items have 15 grams of carbohydrate: →If ketones are positive, give correction bolus by syringe (not by pump) and → 3 Glucose tablets. →4 oz of juice or soda (not diet) have student change infusion set/site if able or call parent. →If initial correction bolus was given by pump, recheck BO in 1 hr. If BG has not decreased, give correction bolus by syringe and have student change infusion set/site if supplies are available or call parent. Glucagon: If child becomes unconscious, unable to cooperate, or
→Check BG and ketones every 2 hrs and give correction dose until BG has a seizure, give glucagon 0.5/1.0 mg subcutaneously. (Please circle
reaches target range and ketones clear, by syringe until site is changed. dose) Call 911 and parents. Do not force eating or drinking. Turn
If taking Regular, NPH or NPH mix insulin, call parent for direction. I hereby certify that the above information is complete and I have provided the school with all information that they will need to reasonably care for and monitor my child's health related to his/her diabetes. I give permission for the school to talk to my doctor, nurse practitioner, and/or physician's assistant and/or nurse. Above I hereby certify that my child can monitor and manage his/her care without supervision from school personnel except in emergencies Diabetic Care Plan

To be completed by parent/guardian and the health care team. This document should be reviewed with
necessary school staff and kept with the child's health records.
Emergency Information


Emergency Contacts

Notify parent/guardian in the following situations

Medical Alert


Hypoglycemia (low blood sugar)
-please check the symptoms that apply to your child
At what time of day is the student most likely to have hypoglycemia?

Hyperglycemia (high blood sugar)
please check the symptoms that apply to your child
Please add anything that you would like school personnel to know about your student's diabetic/health

Parent/guardians must notify school nurse of changes in diabetic routine and/or medications and care plan will
be updated to reflect changes.
Signature of parent/guardian

Received by school nurse

Source: http://c1.cusdsandbox.schoolwires.net/23531021102629590/lib/23531021102629590/Diabetic_Care_Plan.pdf

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