Diabetes Care Plan For Child/student On An Insulin Pump Template
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1
2Diabetes Care Plan
for child/student on an insulin pump
in education, child/care and community support services
CONFIDENTIAL
To be completed by the PARENT/GUARDIAN and the TREATING MEDICAL PROFESSIONAL/CREDENTIALLED DIABETES EDUCATOR
This information is confidential and will be available only to supervising staff and emergency medical personnel.
Name of child/student/client
Date of birth
____________________________________________________________________________________________________
_______________________________________
Family name (please print)
First name (please print)
EMERGENCY MANAGEMENT
Both LOW BLOOD GLUCOSE and HIGH BLOOD GLUCOSE levels require URGENT
TREATMENT (see attached flowcharts). The student must not be left unattended.
If in doubt it is safest to treat a low blood glucose.
ROUTINE MANAGEMENT
Ensure all supervising staff are aware of the student’s diabetes and emergency and routine management plans
Ensure meals and snacks provided are eaten on time
Younger students (Yrs R-2) require supervision to ensure all food provided is eaten
Allow food to be eaten at additional times, especially in relation to exercise
Allow free access to drinking water and the toilet (high blood glucose levels cause increased thirst and urination)
MANAGING CHANGES IN ROUTINE (EXCURSIONS, SWIMMING, CAMPS)
Planning with parents well before the activity is important
The student will need to eat meals and snacks at the usual school times (e.g. special permission to eat on the bus)
The student may need to eat extra food if more active than usual
Additional supervision will be required for swimming and aquatics activities
Seek parents’ advice regarding appropriate foods for parties and celebrations
Early and careful planning with both parents and medical team is required prior to school camps, and a specific
care plan for camp may be required.
MANAGEMENT OF EXERCISE
Always have emergency treatment for a low blood glucose immediately available
For vigorous exercise that lasts for more than 30 minutes, manage as follows to prevent low blood glucose:
__________________________________________________________ (or other as advised by parent/guardian)
Children may safely disconnect their insulin pumps for 1-2 hours for swimming or contact sports
BLOOD GLUCOSE MONITORING
Supervision of blood glucose monitoring is recommended for all primary school students, to ensure
correct technique and accurate documentation
Yes
No
Is supervision of blood glucose monitoring required for the student?
Yes
No
Is this student usually able to perform their own blood glucose monitoring?
Staff to supervise and support as follows:
Routine blood glucose monitoring times at school:
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
If possible, blood glucose monitoring should also be performed when the student has signs of low blood glucose or feels
unwell. The student must not be left unattended in these circumstances.
Refer to attached flow charts for treatment of low and high blood glucose levels.
Please inform the parents/caregivers if recurrent low and/or high blood glucose levels are recorded.
DECD Diabetes care plan insulin pump June 2013
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