Diabetes Health Care Plan Template printable pdf download

Student Name: _____________________________ DOB: _________________ School: _______________________

School Nurse: ______________________________ Date of IHP: ___________________

Physician Name: ___________________________ Ph. #: ___________ Parent signature: _______________________

Nursing Diagnosis/Concern

Educational Goal

Plan of Action

By Whom/When

Knowledge deficit related to: balance of

Student will increase under-

School Nurse, Physician,

1. Instruct student (age appropriate) in the patho-physiology of diabetes

Diabetes Educator, Parents,

insulin, diet and exercise; insulin administra-

standing of pathophysiology

2. Monitor blood glucose levels at school/

Teaching Staff- as necessary

tion; dietary regimen; blood sugar monitoring

of diabetes and develop or

A. Arrange space and time for student to perform blood glucose

levels, insulin injection, diet inventory and snack consumption.

and exercise requirements.

improve the skills necessary

to manage diabetes.

B. Maintain Blood Glucose record and send to physician as needed-

appointments or concerns. PRN Weekly Monthly (circle)

C. Obtain insulin order from physician for sliding scale.

D. Parent/guardian will provide BG testing equipment, insulin

supplies and snacks.

Student will improve self-

Alteration in self-care due to: difficulty

E. Other:

care management skills.

accepting lifestyle change; knowledge defi-

___________________________________________________

cit; insufficient resources; dysfunctional

grieving.

School nurse, healthcare

Provide teachers/ other staff with information related to Diabetes

provider, diabetes educator

through formal/informal inservicing.

as needed

4. Provide classroom presentation on diabetes when indicated age-

appropriate.

Student/School Nurse/Staff

5. Student will come to the Nurse’s Office for supervised self-

administration of the following sliding scale according to physician’s

orders:

(Medication Authorization Policy)

For Blood glucose

> _________ but < __________ Give: __________________

For Blood glucose < ______ :

For Blood glucose > ______ :

Diabetes Health Care Plan Template

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