School Diabetes Action Plan Form (Page 3 of 4) in pdf

DUBLIN UNIFIED SCHOOL DISTRICT

SCHOOL DIABETES ACTION PLAN

 Insulin at School:

Name: __________________________________

_____ Not at school

_____ Routine lunchtime dose

_____Correction lunchtime dose

If insulin at school, brand name and type:_______________________________________________

 Dose Preparation By:

Form Used:

Unit Dosage determined by:

____ Student

____ Pre-filled syringe

____Student

____ Parent

____ Insulin pen

____Parent

____ Parent designee

____ Insulin pump

(Phone request acceptable)

____ Licensed nurse

____Licensed Nurse

 Written sliding scale as follows:

Blood Glucose from _________mg/dl to ________mg/dl = __________Units of Insulin

 SQ or Insulin Pump Insulin Administered By:

____ Student

____ Parent

____ Licensed Nurse

____ Student with staff verification of the number of prescribed insulin units.

____ Parent designee

(All parent designees are trained by the parent and are not school or district employees)

Designee name: __________________________________ Phone: _____________________

 Treatment of LOW BLOOD GLUCOSE: (See signs & symptoms of low blood glucose)

Low Blood Glucose must be treated immediately. An adult must stay with student until all

signs and/or symptoms of low blood glucose are gone and blood glucose is 70mg/dl or higher.

THIS IS AN EMERGENCY. IMMEDIATE TREATMENT IS NEEDED.

Student’s blood sugar is considered low if BS ______ mg/dl or lower.

If the student is conscious and able to swallow give one of the following:

ITEM

AMOUNT

ROUTE

____________________

______________

____________________

______________

Recheck blood glucose every ______ minutes. Student may return to class when blood glucose is

______ or should be sent home when: ______________________________________________.

If student is less cooperative, then give one of the following:

ITEM

AMOUNT

ROUTE

____________________

______________

____________________

______________

If student begins to lose consciousness or is having a seizure, immediately lay on side and:

□ 0.5 mg

□1.0 mg (may give IM or SQ)

_____Give glucagon injection:

_____Call 911, notify parents immediately

Health/Diabetic Action Plan 7/10

School Diabetes Action Plan Form Page 3

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