Diabetes Health Care Plan Template Page 2
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Student Name: ______________________________ DOB: ____________________ School: _____________________
School Nurse: _________________
___________ Date of IHP: _____________________
Nursing Diagnosis/Concern
Educational Goal
Plan of Action
By Whom/When
Parent will be notified if there are any concerns regarding the medica-
School Nurse
tions which might require medical follow-up.
All LLS procedures/policies will be followed for administration of
medication.
Student is on the following medications being taken at home:
Medication(s)
Dose
Time
Student will be reminded to come to nurse’s office for medication if
the student does not report within ______ minutes of scheduled time.
Monitor diet adherence, reinforce and instruct as appropriate.
A. Arrange dietary consult when needed.
Teacher/Staff/School Nurse-
ongoing basis
Provide praise and reinforcement for self-management skills.
A. Provide referral and access to youth diabetes group.
B. Promote verbalization of feeling re: illness.
C. Monitor and support behaviors of positive adaptation
Provide opportunities for student to become more self-sufficient in
self-care.
Physiological injury due to:
Student (parent) will recog-
development of acute complications related
nize and treat early signs of
School Nurse
Instruct teachers/staff on signs and symptoms of hypoglycemia /
to hypoglycemia (insulin shock) or ketoaci-
insulin shock appropriately
insulin reaction (low blood sugar):
dosis.
and know how to recognize
__ headache
__ Feels “low” or not well
and respond to early signs
__ moist skin, sweating
__ Loss of coordination and slurred
of ketoacidosis
__ pale skin
speech
__ shakiness
__ Confusion, progressing to seizure
__ dizziness
or unconsciousness
__ sudden hunger
__ weakness
__ droopy eyelids
__ Change in behavior (inability to concentrate, short temper,
irritability, out of control crying or laughter, etc)
***Follow Individual Emergency Health Plan for Student
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