Diabetes Action Plan Template (Page 2 of 2) in pdf

Types of insulin taken:

 Insulin

Usual times of insulin injections:

Basil Rate if on pump: __________

Amount of insulin to give (if a sliding scale is used, physician must order below):

Can child give his/her own injections? ____Yes _____No ______ With Assistance

1Using the glucose meter, check the blood sugar. Be sure to follow the checklist for “Procedure for Recording

 Insulin

and Reporting.”

Administration

2 Document the observed blood sugar in the log book and NOTIFY PARENT/GUARDIAN!

3 Administer the insulin using the following calculations:

Units of Insulin to Give

PLUS*

Carbohydrate Intake to Give

*Carbohydrate intake units

are to be used only for the

Based on

Based On

lunch hour blood sugar check.

Sliding Scale of Blood Sugar Reading

Units of Insulin Given

For all other checks, use only

Blood Sugar < 200 = ___ Units

8-15mg Carb = ___Units

8-55mg Carbs= ___Units

the sliding scale units to

Blood Sugar 200-300 = ___Units

16-23mg Carbs = ___Units

56-63mg Carbs= ___Units

determine how much insulin to

Blood Sugar 300-400 = ___Units

24-31mg Carbs = ___ Units

64-71mg Carbs= ___nits

administer.

Blood Sugar > 400 = ___ Units

32-39mg Carb = ___Units

72-79mg Carbs= ___Units

40-47mg Carbs = ___Units

Staff qualified to use glucose meter:

 Qualified Staff

Staff qualified to give insulin injections:

Diabetes care supplies are kept:

 Supplies Location

Supplies of snack foods kept :

Nutrition and Exercise

Times of meals and snacks and indications for additional snacks for exercise:

 Meals & Snacks

Breakfast time __________________am

Dinnertime __________________pm

Midmorning snack __________________am Bedtime snack __________________pm

Lunch time __________________am

Snack before exercise _________________am/pm

Mid-afternoon snack ________________am Snack after exercise __________________am/pm

Other times to give snacks: ________________________________________________________________

Preferred snack foods: ____________________________________________________________________

Suggested treats for in-school parties: _______________________________________________________

Foods to avoid, if any: ___________________________________________________________________

Physician’s order required

 Exercise and

Physical activity restrictions / limitations: ______________________________________________________

Sports or Activity

_______________________________________________________________________________________

Restrictions

_______________________________________________________________________________________

Special activity accommodations that must be made? ____________________________________________

_______________________________________________________________________________________

Child should not participate in active play if blood sugar is below ______mg/dl or above _____mg/dl.

Adapted by the NC Child Care

Health Consultants Association

Diabetes Action Plan Template Page 2

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