Diabetes Health Care Plan Template (Page 2 of 2) in pdf

MANAGEMENT OF HIGH BLOOD GLUCOSE (over ___________mg/dl)

Usual signs/symptoms for this child:

Indicate treatment choices:

 Increased thirst, urination, appetite

 Sugar-free fluids as tolerated

 Tiredness/sleepiness

 Check urine ketones if blood glucose over _______mg/dl

 Blurred vision

 Notify parent if urine ketones positive.

 Warm, dry, or flushed skin

 May not need snack: call parent

 Other ___________________________

 See “Insulin Injections: Correction Dose of Insulin for High Glucose”

 Other ____________________________________________________________

________________________________

MANAGEMENT OF VERY HIGH BLOOD GLUCOSE (over ___________mg/dl)

Usual signs/symptoms for this child

Indicate treatment choices:

 Nausea/vomiting

 Carbohydrate-free fluids if tolerated

 Abdominal pain

 Check urine for ketones

 Rapid, shallow breathing

 Notify parents per “Emergency Notification” section

 Extreme thirst

 If unable to reach parents, call Diabetes Health Care Provider

 Weakness/muscle aches

 Frequent bathroom privileges

 Fruity breath odor

 Stay with student and document changes in status

 Other ____________________________

 Delay exercise

 Other ____________________________________________________________

MANAGEMENT OF LOW BLOOD GLUCOSE (below __________________mg/dl)

Usual signs/symptoms for this child

Indicate treatment choices:

 Hunger

 Change in personality/behavior

If child is awake and able to swallow,

 Paleness

give _____________grams fast-acting carbohydrate such as:

 Weakness/shakiness

 4oz. fruit juice or non-diet soda or

 Tiredness/sleepiness

 3-4 glucose tablets or

 Dizziness/staggering

 Concentrated gel or tube frosting or

 Headache

 8 oz. milk or

 Rapid heartbeat

 Other __________________________________________________________

 Nausea/loss of appetite

 Clamminess/sweating

Retest BG 10-15 minutes after treatment.

 Blurred vision

Repeat treatment until blood glucose over 80 mg/dl.

 Inattention/confusion

Follow treatment with snack of ______________________

 Slurred speech

if more than 1 hour till next meal/snack or if going to activity

 Loss of consciousness

 Other ____________________________________________________________

 Seizure

___________________________________________________________________

 Other ____________________________

___________________________________________________________________

IMPORTANT!!

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

Call 911 immediately and notify parents.



Glucagon ½ mg or 1 mg (circle desired dose) should be given by trained personnel.



Glucose get 1 tube can be administered inside cheek and massaged from outside while waiting or during administration of

Glucagon by staff member at scene.



Glucagon/Glucose gel could be used if child has documented low blood sugar and is vomiting or unable to swallow.

Child 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 child and/or trained staff within the child care or by EMS in the event of loss of consciousness or seizure.

I also understand that the child care 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 provides written instruction to be followed by child car personnel/staff.

Parent’s Signature: ___________________________________________

Date: ________________

Physician’s Signature: ________________________________________

Date: ________________

Child Care Staff Signature: _____________________________________

Date: ________________

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

Diabetes Health Care Plan 2/07