Livingston Public Schools

Livingston Public Schools

Diabetes Careplan

Student’s Name:______School:______

Parent Guardian:______

Home phone:______Dad work:______Mom work:______Cell: ______

Alternate Emergency Contact: ______Phone:______

Physician:______Phone:______

Diabetes Specialist:______Phone:______

Insulin:

Morning type and amount:______

______

Noon type and amount:______

______

Evening type and amount:______

______

Diet:

Lunch:______

Snack:______

Preferred treats for parties: ______

Monitoring:

Will require routine glucose monitoring at school? ______yes ______no

Will require assistance with monitoring ______yes ______no

Prefer monitoring to be done in: ______health room ______classroom

Check blood glucose at (time)______and record results.

Insulin:

Will require insulin administration at school? ______yes _____no

Will require assistance with insulin administration? ______yes _____no

Will require assistance with determination of insulin dosage? ______yes _____no

If assistance with insulin dosage is needed, the student will first call the parents, and if parents are unavailable, then will contact the school nurse

Prefer administration of insulin done in ______health room _____ class room

Insulin given at (time):______

Potential Problems:

Hypoglycemia: Signs my child may exhibit are: (Check all that may apply)

______hunger ______headache

______Irritability ______Shakiness

______Sleepiness\ ______Confusion

______Impaired vision

Other:______

Treatment for hypoglycemia, blood sugar value of:______

Use the following in the prescribed amounts (check all that apply), if the student is able to chew and swallow.

_____ Glucose tablets, amount______

_____ Juice, amount ______

_____ Hard candy, amount ______

_____ Sugared pop, amount ______

_____ Other ______

_____ If student is unable to swallow, but still conscious, insert 1 tbsp frosting between cheek and gum and massage. Call 911 and parent.

_____If student unconscious, administer Glucagon as prescribed in physician authorization form and call 911. Staff in building designated by parent to administer Glucagon are:______

______

______If seizure activity noted, follow seizure protocol.

Hyperglycemia:

Signs my child may exhibit are: (check all that apply)

_____ extreme thirst _____ Blurred vision

_____ Frequent urination _____ Drowsiness

_____ Dry Skin _____ Nausea _____Hunger

Treatment for Hyperglycemia:

_____ Test blood glucose

_____ Test for Ketones if blood sugar above:______

_____ NoPE if blood glucose above:______

_____Administer insulin correction dose as ordered in physician authorization form

_____ Encourage drinking water

P.E. and Field trips:

Scheduled time for P.E. is ______

Snack is necessary before participation _____ yes _____ no

Field trips: Take extra snacks and watch for signs of low or high blood sugar.

Substitute teachers: Make aware of routine and signs of low and high blood sugar.

My signature below verifies the above information to be accurate. I also permit the school nurse to share information with the school staff, as deemed appropriate by the school nurse, to provide for my child’s health and safety.

______

Parent Signature Date

I approve of the care plan as written, for this student.

______

Physician signature Date

Diabetes ID Card

My name is ______. I am ______years old and I have diabetes.

This means that my pancreas does not make insulin. Without insulin, the food I eat cannot be used for energy. To treat diabetes, I must take insulin everyday and also try to balance my activity level and the food I eat. Several times a day, I must check my blood sugar level using a special meter I always have with me. It is important that you understand some facts about diabetes while I’m in your care. Please read this and keep it nearby.

Meals and activities:

My blood sugar is affected by the food I eat, the amount of activity I get and the amount of insulin I take. Please make sure that

-My meals and snacks are eaten on time.

-I eat my meals at : ______

-I may need an extra snack before, during or after a strenuous activity. I will check my blood sugar to see if I need to eat, so please allow me to do this.

Low blood sugar reactions:

Occasionally my blood sugar may be too low. A reaction is most likely to occur just before lunch, right after strenuous activity, if my meal is delayed or if I don’t eat enough food. If my blood sugar goes too low, I will have the following symptoms or signs: ______

______

If this happens, I need sugar immediately. Please call the office and have the office staff come and get me, or if possible accompany me yourself to the office.

-If my blood sugar is low, you can give me :______

-You can find this : ______

-If I am not better, in 10-15 minutes, give me : ______

-I will need to check my blood sugar if possible.

-If my blood sugar becomes too low, I may become sleepy, unconscious, or have a seizure. If this happens, do not try to feed me. Instead, call 911 or call ______to give me a Glucagon injection. If this happens please call my parents.

High blood sugar reactions:

Occasionally, my blood sugar may be too high. This may happen if I have not gotten enough insulin for the food I eat. If my blood sugar goes too high, I may have the following symptoms: ______

______

If this happens, I need to test my blood sugar immediately and may need a correction dose of insulin. Please call the office staff and they will come get me or accompany me yourself if possible. I may have to test for Ketones in my body and if they are present, I will be unable to participate in PE or any strenuous activities. I may need to use the bathroom more often and may need to keep a bottle of water or diet soda with me to help bring my blood sugar down.

Emergency Numbers:

Mother: ______Home Phone ______Work phone ______Cell phone ______

Father : ______home phone ______Work phone ______Cell phone ______

Emergency contact: ______phone ______