SCHOOL: ______________________________________________________________ GRADE: _____________________
STUDENT: _______________________ ADDRESS: ___________________________________ DOB: ________________
PHYSICIAN/PHONE: _________________________________________________________________________________
MEDICATIONS: Insulin:_______________________________________________________________________________
PARENT'S PHONES: Home: __________________ Mom's work: _________________ Dad's work: ________________
HEALTH CONCERN: INSULIN-DEPENDENT DIABETES DATE OF DIAGNOSIS ______________________________

1) ROUTINE MANAGEMENT:

• Morning snack: (time: __________) snacks to be kept in the classroom and in the clinic
• Test blood sugar daily (time: prior to lunch or anytime there are symptoms of low blood sugar).
• Exercise should be delayed or avoided if the blood sugar level is lower than 60 mg/dl (3.25 mmol/L).

2) LOW BLOOD SUGAR OR HYPOGLYCEMIA:
Can be a result of receiving too much insulin, skipping a meal or snack, or an unusual amount of exercise. Hypoglycemia can happen quickly and must be corrected immediately. Look for these symptoms:

• shakiness
• "feels low"
• "feels hungry"
• very tired
• looks dazed
• sweaty
• confused
• pale or flushed face
• __________________
• _________________

INTERVENTION: A blood sugar should be done, ideally in the classroom so that energy is not spent going elsewhere. If it is necessary to go elsewhere, someone must accompany the student.

The target range of blood sugar is 70-180 mg/dl (3.9-10.0 mmol/L)

• If blood sugar is 60-70 mg/dl (3.25 mmol/L-3.9 mmol/L):
  • Give four ounces (one small can) of juice OR 2-3 oz of sugar pop
  • Follow with snack (crackers) in 5-10 minutes
  • Symptoms should subside in 10-15 minutes
• If blood sugar is below 60 mg/dl (3.25 mmol/L):
  • Give four ounces juice and one glucose tablet, or 2-3 oz sugar pop
  • Follow in 10-15 minutes with a snack of crackers or dried fruit, etc.
  • Symptoms should subside in 10-15 minutes
  • Do not allow adult supervision to leave
  • Re-test blood sugar in 15-30 minutes
  • Let parents know
  • If unable to take the juice:
    • Administer 1/2-3/4 tube of glucose gel or 2-4 tsp cake decorating gel
    • Place between cheek and gum and massage the outside of cheek with head elevated
    • Follow this treatment in 10 minutes with a small snack if symptoms have subsided
    • Call parents

IF ANY OF THE FOLLOWING OCCUR, PLEASE CALL 911 AND THE PARENTS (if RN in school, give 0.5cc (0.5 mg) glucagon subcutaneous or intramuscular)

• Loss of consciousness
• Seizure
• If to be taken to the hospital, preferred hospital: _________________________________________________________

3) HIGH BLOOD SUGAR:
Especially with stress or illness, the blood sugar may be high and extra insulin may be needed.
Instructions for insulin supplements are: _________________________________________________________________________________
(to be given by: child ___, parent ___, school RN ___, school staff ___). A child should be supervised. (If the blood sugar is above 300 mg/dl [16.65 mmol/L], urine ketones should also be checked and the parent may wish to leave foil-wrapped ketostix at school _____ or to be called to come and do the test _____.) If ketones are present, drinking extra fluids is also helpful. Extra bathroom privileges will be needed.
Physician's signature (for insulin): ________________________________________________

4) FIELD DAYS OR TRIPS:

• Notify parents ahead of time so insulin dose can be reduced
• Extra snacks, glucose monitoring kit, and glucose gel should be taken
• Copy of Health Plan with emergency numbers should be carried by staff

As parent/guardian of the above named student, I give my permission for use of this plan in my child's school and for the school to contact the above named physician if necessary to complete the Health Care Plan.