Diabetes Medical Management Plan

School Year: ___________________________________

Student’s Name: __________________________________ Date of Birth: ______

Diabetes: □ Type 1 □ Type 2 Date of Diagnosis: _____

School Name: ________________________________________ Grade: ______ Homeroom: _______________

Plan Effective Date(s): _______________

Contact Information

• Parent/Guardian #1: ________________________________
  • Phone Numbers:
    • Home: ______________
    • Work: ______________
    • Cell/Pager: __________
• Parent/Guardian #2: ______________________________
  • Phone Numbers:
    • Home: ______________
    • Work: ______________
    • Cell/Pager: __________
• Diabetes Healthcare Provider: _________________________
  • Phone Number: ____________________________________________________________
• Other Emergency Contact: _________________________
  • Relationship: ____
    • Phone Numbers:
      • Home: _____________
      • Work/Cell/Pager: _________

Emergency Notification

Notify parents of the following conditions (If unable to reach parents, call Diabetes Healthcare Provider listed above):

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

Meals/Snacks

Student can:

• Determine correct portions and number of carbohydrate servings
• Calculate carbohydrate grams accurately

Time/Location	Food Content and Amount
Breakfast	_________________
Midmorning	_________________
Lunch	_________________
Mid-afternoon	_________________
Before PE/Activity	_________________
After PE/Activity	_________________

If outside food for party or food sampling provided to class: ____________________________________________________________________

Blood Glucose Monitoring at School

Can student ordinarily perform own blood glucose checks? □ Yes □ No

Interpret results □ Yes □ No Needs supervision? □ Yes □ No

Time to be performed:

• Before breakfast
• Before PE/Activity Time
• Midmorning: before snack
• After PE/Activity Time
• Mid-afternoon
• Dismissal
• As needed for signs/symptoms of low/high blood glucose

Place to be performed:

• Classroom
• Clinic/Health Room
• Other: ________________________________

Optional: Target Range for blood glucose: ___________ mg/dl to __________________ (Completed by Diabetes Healthcare Provider).

Insulin Injections During School

Can student:

• Determine correct dose? □ Yes □ No
• Draw up correct dose? □ Yes □ No
• Give own injection? □ Yes □ No
• Needs supervision? □ Yes □ No

Insulin Delivery:

• Syringe/Vial
• Pen
• Pump (If pump worn, use “Supplemental Information Sheet for Student Wearing an Insulin Pump”)

Standard daily insulin at school: □ Yes □ No

Type	Dose	Time to be given
__________	_______________	_____________________
__________	_______________	_____________________

Calculate insulin dose for carbohydrate intake: □ Yes □ No

Correction dose of insulin for high blood sugar: □ Yes □ No

If yes, use:

• Regular
• Humalog
• Novolog

If yes: □ Regular □ Humalog □ Novolog Time to be given: _____

____________# unit(s) per _________ grams Carbohydrate

Use Formula: (BG-_______) / ________ = Units of insulin

□ Add carbohydrate dose to correction dose

If student uses a sliding scale please attach to DMMP.

Other Routine Diabetes Medications at School

□ Yes □ No

Name of Medication	Dose	Time	Route	Possible Side Effects
_________________________________	_____________________	____________	____________	__________________
_________________________________	_____________________	____________	____________	__________________

Exercise, Sports, and Field Trips

Blood glucose monitoring and snacks as above. Quick access to sugar-free liquids, fast-acting carbohydrates, snacks, and monitoring equipment.

A fast-acting carbohydrate such as ______________________ should be available at the site.

Child should not exercise if blood glucose level is below ___________________________ mg/dl OR if _____________________________________.

Supplies to be Furnished/Restocked by Parent/Guardian

• Blood glucose meter/strips/lancets/lancing device
• Fast-acting carbohydrate: ________________
• Insulin vials/syringe
• Ketone testing strips
• Carbohydrate-containing snacks
• Insulin pen/pen needles/cartridges
• Sharps container for classroom
• Carbohydrate-free beverage/snack
• Glucagon Emergency Kit

504 Testing Parameters

Blood Glucose should be between ___________ and __________ for school tests.

Management of High Blood Glucose

(over ______ mg/dl)

Usual signs/symptoms for this student:

• Increased thirst, urination, appetite
• Tiredness/sleepiness
• Blurred vision
• Warm, dry, or flushed skin
• Other: __________________________________

Indicate treatment choices:

• Sugar-free fluids as tolerated: ________ mg/dl
• Check urine ketones if blood glucose over
• Notify parent if urine ketones positive.
• May not need snack: call parent
• See “Insulin Injections: Correction Dose of Insulin for High Blood Glucose”
• Other: _________________________________________

Management of Very High Blood Glucose

(over ____________ mg/dl)

Usual signs/symptoms for this student:

• Nausea/vomiting
• Abdominal pain
• Rapid, shallow breathing
• Extreme thirst
• Weakness/muscle aches
• Fruity breath odor
• Other: __________________________

Indicate treatment choices:

• Carbohydrate-free fluids if tolerated
• Check urine for ketones
• Notify parents per “Emergency Notification” section
• If unable to reach parents, call diabetes care provider
• Frequent bathroom privileges
• Stay with student and document changes in status
• Delay exercise.
• Other: ______________

Management of Low Blood Glucose

(below ____________ mg/dl)

Usual signs/symptoms for this child:

• Hunger
• Change in personality/behavior
• Paleness
• Weakness/shakiness
• Tiredness/sleepiness
• Dizziness/staggering
• Headache
• Rapid heartbeat
• Nausea/loss of appetite
• Clamminess/sweating
• Blurred vision
• Inattention/confusion
• Slurred speech
• Loss of consciousness
• Seizure
• Other: ___________________________________

Indicate treatment choices:

If student is awake and able to swallow, give ____ grams fast-acting carbohydrate such as:

• 4 oz. Fruit juice or non-diet soda
• 3-4 glucose tablets
• Concentrated gel or tube frosting
• 8 oz. Milk
• Other: ________________________

Retest BG 10-15 minutes after treatment. Repeat treatment until blood glucose over 80 mg/dl. Follow treatment with snack of ______________________________ if more than 1 hour till next meal/snack or if going to activity.

Other: _____________________________________________

Important

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

• Call 911 immediately and notify parents.
• Glucagon 1/2 mg or 1 mg (circle desired dose) 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 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 trained unlicensed assistive 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: _____________________

This document follows the guiding principles outlined by the American Diabetes Association.

Revised December 5, 2003