Diabetes Health Care Plan Template printable pdf download

DIABETES HEALTH CARE PLAN (UPDATE ANNUALLY)

Child’s Name:______________________ Date of Birth:________ Diabetes Type 1; Type 2 Date of Diagnosis:__________________________

Child Care Program:_____________________________ Classroom_______________________ Plan Effective Date(s)______________________

CONTACT INFORMATION

Parent/Guardian #1: _________________________________ Phone #’s: Home _______________ Work _______________ Cell _____________

Parent/Guardian #2: _________________________________ Phone #’s: Home _______________ Work _______________ Cell _____________

Diabetes Health Care Provider _____________________________________ Phone Number: _________________________________________

Other Emergency Contact ___________________________ Relationship: ___________________ Phone # ______________or______________

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.

 Determine correct portions and number of carbohydrate serving

 Calculate carbohydrate grams accurately

MEALS/SNACKS: Child can:

Time/Location

Food Content and Amount

Time/Location

Food Content and Amount

 Breakfast

 Mid-Afternoon

_______________

_____________________

________________

______________________

 Midmorning _______________

 Before Activity ________________

_____________________

______________________

 Lunch

 After Activity

_______________

_____________________

________________

______________________

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

BLOOD GLUCOSE MONITORING AT CHILD CARE  Yes  No

Type of Meter: __________________________________

If yes, can child ordinarily perform own blood glucose checks?  Yes  No; Interpret results  Yes  No; Needs supervision?  Yes  No

 Before Breakfast

 Before Activity

Time to be performed:

 Midmorning: before snack

 After Activity

 Before lunch

 Mid-afternoon

 Dismissal

 As needed for sign/symptoms of low/high blood glucose

Place to be performed: _________________________________________________________________________________________________

OPTIONAL: Target Range for Blood glucose: ______________mg/dl to ____________mg/dl (completed by Diabetes Healthcare Provider).

 Yes  No

 Parent/Guardian elects to give insulin needed at child care.

INSULIN INJECTIONS DURING CHILD CARE HOURS:

 Yes  No

Draw up correct dose?  Yes  No

If yes, can child: Determine correct dose?

 Yes  No

Give own injections?

Needs supervision?

Insulin Delivery:  Syringe/Vial

 Pen

 Pump

 Yes  No

 Yes

 No

Standard daily insulin at child care:

Correction Dose of Insulin for High Blood Glucose:

If yes:  Regular  Humalog  Novolog Time to be given: ____________

Type:

Dose:

Time to be given:

_______________

_____________ ______________

 Determine dose per sliding scale below (in units):

 Use formula:

_______________

_____________ ______________

Blood sugar: ________________ Insulin Dose: ________

(Blood glucose -

Calculate insulin dose for carbohydrate intake:  Yes

 No

Blood sugar: ________________ Insulin Dose: ________

___________) +

If yes, use:  Regular  Humalog  Novolog

Blood Sugar: ________________ Insulin Dose: ________

___________ =

_________# unit(s) per _________ grams Carbohydrate

Blood Sugar: ________________ Insulin Dose: ________

units of insulin

 Add carbohydrate dose to correction dose

Blood Sugar: ________________ Insulin Dose: ________

OTHER ROUTINE DIABETES MEDICATIONS AT CHILD CARE  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: (Agreed-upon locations noted on emergency care)

 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

Diabetes Health Care Plan 2/07

Diabetes Health Care Plan Template

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