BURNETCISDSCHOOL HEALTH SERVICES

INFORMATION SHEET FOR THE SCHOOL MANAGEMENT OF DIABETES MELLITUS

SCHOOL YEAR:

Student’s Name: DOB: Effective Dates:

School Name: Grade:Homeroom:

CONTACT INFORMATION

Parent/Guardian #1:Home#: Work#: _____Cell#:______

Parent/Guardian #2: Home#: Work#: _____Cell#:______

Diabetes Care Provider:Phone Number: ___

Other Emergency Contact:______Relationship:______Home#: Work/Cell# ___

Insurance Carrier:Preferred hospital: ___

EMERGENCY NOTIFICATION: Notify parents of the following conditions (if unable to reach parents: notify diabetes care provider)

  1. Loss of consciousness or seizure (convulsion) immediately after Glucagon given and 911 called
  2. Blood sugars in excess of ______mg/dl.
  3. Positive urine ketones.
  4. Abdominal pain, nausea/vomiting, diarrhea, fever, altered breathing, or altered level of consciousness.

MEALS/SNACKS: Time/LocationFood Content /AmountTime/LocationFood Content/Amount

Breakfast ______Midafternoon______

Midmorning ______Before PE/Activity______

Lunch ______After PE/Activity ______

(Parent to provide and restock needed snacks)

BLOOD GLUCOSE MONITORING: At school: Yes No

To ordinarily be performed by student: Yes No Type of Meter:______

Time to be performed:Before breakfastBefore PE/Activity Time

Midmorning: before snackAfter PE/Activity Time

Before lunchMid-afternoon

DismissalAs needed for signs/symptoms of low/high blood glucose

Place to be performed:School clinicClassroomOther:______

***OPTIONAL: TargetRange for blood glucose: ______mg/dl to______mg/dl (completed by diabetes care provider)

INSULIN INJECTIONS DURING SCHOOL:YesNo

If yes, can student determine correct does? Yes NoDraw up correct dose? Yes No Give own injection? Yes No

Insulin Delivery: Syringe/vial PenPump (if pump worn, use “Supplemental Information Sheet for Student Wearing an Insulin Pump”)

Routine daily insulin at school:

Extra Insulin for High Blood Sugar:Yes No

Type:Dose:Time to be given:If yes,Regular insulinor Humalog

Humalog ______Time to be given:______

Regular ______Blood Sugar:______Amount of Insulin:______

NPH ______Blood Sugar:______Amount of Insulin:______

Lente ______Blood Sugar:______Amount of Insulin:______

Ultralente ____________Blood Sugar:______Amount of Insulin:______

Other ______Blood Sugar:______Amount of Insulin:______

OTHER ROUTINE DIABETES MEDICATION AT SCHOOL : Yes No

Name of MedicationDoseTimeRoutePossible Side Effects

______

______

EXERCISE, SPORTS, AND FIELD TRIPS

Blood glucose monitoring and snacks as above.

Easy access to sugar-free liquids, fast-acting carbohydrates, snacks and blood glucose monitoring equipment.

Child should not exercise if blood glucose level is below ______mg/dl OR if______

LOCATION OF SUPPLIES/EQUIPMENT: To be completed by school health personnel.

Blood glucose testing equipment:______Insulin administration supplies:______

Glucagon emergency kit:______Glucose gel: ______Ketone testing supplies:______

Fast-acting carbohydrate:______Snack foods:______

MANAGEMENT OF HIGH BLOOD GLUCOSE ( over ______mg/dl)

Usual signs/symptoms for this student:Indicate treatment choices:

Increased thirst, urination, appetiteSugar-free fluids as tolerated

Tired/drowsyCheck urine ketones if blood glucose over ______mg/dl

Blurred visionNotify parent if urine ketones positive.

Warm, dry, or flushed skinMay not need snack: call parent

Other:______See “Insulin Injections: Extra Insulin for High Blood Glucose”

______Other:______

MANAGEMENT OF VERY HIGH BLOOD GLUCOSE ( over ______mg/dl)

Usual signs/symptoms for this studentIndicate treatment choices:

Nausea/vomitingSugar-free fluids if tolerated

Abdominal painCheck urine for ketones

Rapid, shallow breathingNotify parents per “Emergency Notification” section

Extreme thirstIf unable to reach parents, call diabetes care provider

Weakness/muscle achesFrequent bathroom privileges

Fruity breath odorStay with student and document changes in status

Other______Delay exercise.

______Other______

MANAGEMENT OF LOW BLOOD GLUCOSE (below ______mg/dl)

Usual signs/symptoms for this childIndicate treatment choices:

Change in personality/behaviorIf Student is awake and able to swallow,

Pallor give ______grams of fast-acting carbohydrate such as:

Weak/shaky/tremulous 4 oz. Fruit juice or non-diet soda or

Tired/drowsy/fatigued 3-4 glucose tablets or

Dizzy, staggering walk Concentrated gel or

Headache 8 oz milk or

Rapid heartbeat Other:______

Nausea/loss of appetite

Clammy/sweatingRetest BG 10-15 minutes after treatment

Blurred visionRepeat treatment until blood glucose over 80 mg/dl

Inattention/confusionFollow treatment with snack of ______

Slurred speechif more than 1 hour till next meal/snack or if going to activity

Loss of consciousness Other:______

Seizures ______

Other:______

IMPORTANT

If student is unconscious or having a seizure, presume the student it having a low blood glucose and:

Call 911 immediately and notify the parents.

Glucagon ______mg should be given by trained personnel.

Glucose gel 1 tube can be administered inside cheek and massaged from outside while awaiting or during administration of Glucagon by any staff member at scene.

Glucagon/Glucose gel could be used if student has documented low blood sugar and is vomiting or unable to swallow.

Student should be turned on his/her side and maintained in this “recovery” position till fully awake.

SIGNATURES

I/we understand that all treatments and procedures may be performed by the student and/or non-medical personnel within the school or by EMS

in the event of loss of consciousness or seizure. I also understand that the school is not responsible for damage, loss of equipment, or expenses utilized in these treatments and procedures. I have reviewed this information sheet and agree with the indicated instructions. This form will assist the school health personnel in developing a nursing care plan.

Parent’s Signature:______Date:______

Physician’s Signature:______Date:______

School Nurse’s Signature:______Date:______

1