Healthcare Provider Order & Care Plan For Student With Diabetes Form printable pdf download

HEALTHCARE PROVIDER ORDER & CARE PLAN FOR STUDENT WITH DIABETES

(1 of 2)

TO BE FILLED OUT BY PARENT/GUARDIAN:

Student:______________________________ DOB:___________ School:_______________________ Grade:______

Type____ Diabetes/Year of Diagnosis:_______ This plan is only valid for the current school year:_______--________

IF STUDENT IS SENT TO THE HEALTH ROOM THEY MUST BE ACCOMPANIED BY AN ESCORT .

HYPOGLYCEMIA: blood sugar less than 80mg/dl

Signs and symptoms of hypoglycemia:



Dizziness

Hunger

Headache

Loss of



consciousness

Shaking

Blurry vision

Behavior changes



Seizure

Anxiety

Weakness/fatigue

Pallor

1. Check blood sugar. If meter is not available and child has any of the above symptoms, proceed to step 2.

2. If blood sugar less than 80 mg/dl: Treat with 15 grams of fast acting carbohydrate (4 oz juice, 6 oz regular soda,

3-4 glucose tablets, 3-4 pieces of hard candy, 3 tsp of sugar, ________________________________________).

If unable to swallow safely, administer 1 tube of glucose gel to inside of cheek.

3. Recheck and retreat every 15 minutes until blood sugar greater than 80 mg/dl.

4. When blood sugar is above 80 mg/dl give a complex carbohydrate (crackers with cheese, granola bar, trail mix

etc.), if it is going to be more than an hour until the next meal or snack.

5. If unable/unwilling to take fast acting carbohydrate, having seizures, or is unconscious:

Administer Glucagon by trained staff, call 911, and contact parent/guardian.

If student has an insulin pump, suspend or remove pump.

HYPERGLYCEMIA: blood sugar greater than 300mg/dl

Signs and symptoms of hyperglycemia



Increased thirst

Hunger

Irritability

Nausea/Vomiting



Frequent urination

Fatigue

Double vision

Abdominal pain

Check blood sugar.

If blood sugar is over 300 mg/dl and greater than 2 hrs since last insulin dose, give insulin per sliding scale or

bolus via pump.

Check ketones. If ketones are present, call parents. STUDENT SHOULD NOT EXERCISE.

Give 8-16 oz. of water per hr.

5. Recheck blood sugar in 2 hrs and treat with sliding scale insulin, as needed. * See below for pump.

When having symptoms of nausea and vomiting student will be released from school to parent/guardian.

* When student has insulin pump:

Blood sugar greater than 300 mg/dl with ketones or 2 consecutive unexplained blood sugars greater than 300 mg/dl

(with or without ketones), may indicate a malfunction in the pump. Student may require insulin via injection and/or

new infusion site. PARENTS MUST BE NOTIFIED.

SIGNATURES

My signature below provides authorization for the above written orders. I understand that all procedures will be

implemented in accordance with state laws and regulations and may be performed by unlicensed designated school

personnel under the training and supervision provided by the school nurse.

I authorize the Diabetes Care Team to notify me/leave message via:

Voice mail

Text

E-mail: _______________________________ Cell Phone________________________

Parent

Date _______________ Alternate Phone____________________

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School Health Nurse Review: __________________________________________Date: _____________________

Healthcare Provider Order & Care Plan For Student With Diabetes Form

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