Diabetes Care Plan Template
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1
2Diabetes Care Plan
for education, child/care and community support services *
CONFIDENTIAL
To be completed by the PARENT/GUARDIAN and the TREATING MEDICAL PROFESSIONAL/CREDENTIALED DIABETES EDUCATOR
This information is confidential and will be available only to supervising staff and emergency medical personnel.
Name of child/student/client
Date of birth
Family name (please print)
First name (please print)
MedicAlert Number (if relevant)
Date for next review
EMERGENCY MANAGEMENT
A LOW BLOOD GLUCOSE (hypo) requires URGENT TREATMENT (see attached flowchart)
The student must not be left unattended. If in doubt it is safest to treat.
A high blood glucose level does not usually require urgent attention unless the student is unwell or
is using an insulin pump (see attached flowchart).
ROUTINE MANAGEMENT
Ensure all supervising staff are aware of the student’s diabetes and their emergency and routine management plans
Ensure meals and snacks provided are eaten on time
Younger students (Yrs R-2) require supervision to ensure all food provided is eaten
Allow food to be eaten at additional times, especially in relation to exercise
Allow free access to drinking water and the toilet (high blood glucose levels cause increased thirst and urination)
MANAGEMENT OF EXERCISE
Always have emergency treatment for low blood glucose on hand
For vigorous exercise that lasts more than 30 minutes, give the following food/drink to prevent low blood glucose:
___________________________________________________________
(or other as advised by parent/guardian)
Children on insulin pumps may safely disconnect their pumps for 1-2 hours for swimming or contact sports
BLOOD GLUCOSE MONITORING
Yes
No
Is this student usually able to perform their own blood glucose monitoring?
If no, please detail assistance requested from staff to support safety and develop self-management.
Note: Supervision of all blood glucose monitoring is recommended for all primary school students, to ensure
correct technique and accurate documentation.
Routine blood glucose monitoring times at school (may be renegotiated with family for excursions etc):
1.
_________________________________________
2.
_______________________________________
3.
_________________________________________
If possible, blood glucose monitoring should also be performed when the student has signs of low blood glucose or feels unwell.
The student must not be left unattended in these circumstances.
If blood glucose is low (< 4 mmol/L), see attached flowchart
If blood glucose is high (>15mmol/L), see attached flow chart
Refer to attached blood glucose levels chart for individual student information
DECS Diabetes care plan 2009
Updated Dec 2010
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