Diabetes Management Plan2

Section 3 tools
for
ffective Diabetes
Management in Schools
This section contains examples of two important tools to help
the school health team in managing the student with diabetes:
The Sample Diabetes Medical Management Plan is
completed by the students parents/guardian and personal health care team

and can be used as the basis for developing education plans and nursing
care plans for students with diabetes.
The Sample Quick Reference Emergency Plan addresses

management of hypoglycemia and hyperglycemia emergencies. This plan
should be completed for each student with diabetes and both pages should
be copied and distributed to all relevant personnel, in accordance with
the students Diabetes Medical Management Plan, 504 Plan, IEP, or other
education plan.
48 Helping the Student with Diabetes Succeed
Date of Plan:
Diabetes Medical Management Plan

Effective Dates:
This plan should be completed by the students personal health care team and parents/guardian. It should be
reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school
nurse, trained diabetes personnel, and other authorized personnel.
Students Name:
Date of Birth:
Date of Diabetes Diagnosis:
Grade:
Homeroom Teacher:
Physical Condition: Diabetes type 1 Diabetes type 2
Contact Information
Mother/Guardian:
Address:
Work
Cell
Work
Cell
Father/Guardian:
Address:
Telephone: Home
Students Doctor/Health Care Provider:
Name:
Address:
Telephone:
Emergency Number:
Other Emergency Contacts:

Name:
Relationship:
Telephone: Home
Work
Cell
Notify parents/guardian or emergency contact in the following situations:
Helping the Student with Diabetes Succeed 49
Tools
Telephone: Home
Diabetes Medical Management Plan Continued

Blood Glucose Monitoring
Target range for blood glucose is 70-150 70-180 Other
Usual times to check blood glucose
Times to do extra blood glucose checks (check all that apply)
before exercise
after exercise
when student exhibits symptoms of hyperglycemia
when student exhibits symptoms of hypoglycemia
other (explain):
Can student perform own blood glucose checks? Yes No
Exceptions:
Type of blood glucose meter student uses:
Insulin
Usual Lunchtime Dose
Base dose of Humalog/Novolog /Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is
_____ units or does flexible dosing using _____ units/ _____ grams carbohydrate.
Use of other insulin at lunch: (circle type of insulin used): intermediate/NPH/lente _____ units or basal/
Lantus/Ultralente _____ units.
Insulin Correction Doses
Parental authorization should be obtained before administering a correction dose for high blood
glucose levels. Yes No
_____ units if blood glucose is _____ to _____ mg/dl
Can student give own injections? Yes No
Can student determine correct amount of insulin? Yes No
Can student draw correct dose of insulin? Yes No
_____ Parents are authorized to adjust the insulin dosage under the following circumstances:______________
For Students With Insulin Pumps
Type of pump:
Type of insulin in pump:

Type of infusion set:
Insulin/carbohydrate ratio:
Basal rates: _____ 12 am to _____

_____ _____ to _____
_____ _____ to _____
Correction factor:

Student Pump Abilities/Skills:
Count carbohydrates
Bolus correct amount for carbohydrates consumed
Calculate and administer corrective bolus
Calculate and set basal profiles
Calculate and set temporary basal rate
Disconnect pump
Reconnect pump at infusion set
Prepare reservoir and tubing
Insert infusion set
Troubleshoot alarms and malfunctions
Needs Assistance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
For Students Taking Oral Diabetes Medications

Type of medication:
Other medications:
Timing:
Timing:
Meals and Snacks Eaten at School

Is student independent in carbohydrate calculations and management? Yes No
Meal/Snack
Time
Food content/amount
Exercise and Sports

A fast-acting carbohydrate such as
available at the site of exercise or sports.
Restrictions on activity, if any:
Student should not exercise if blood glucose level is below
or if moderate to large urine ketones are present.
should be
mg/dl or above
mg/dl
Tools
Breakfast
Mid-morning snack
Lunch
Mid-afternoon snack
Dinner
Snack before exercise? Yes No
Snack after exercise?
Yes No
Other times to give snacks and content/amount:
Preferred snack foods:
Foods to avoid, if any:
Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event):

Hypoglycemia (Low Blood Sugar)
Usual symptoms of hypoglycemia:
Treatment of hypoglycemia:
Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow.
Route_______, Dosage_______, site for glucagon injection: _______arm, _______thigh, _______other.
If glucagon is required, administer it promptly. Then, call 911 (or other emergency assistance) and the
parents/guardian.
Hyperglycemia (High Blood Sugar)
Usual symptoms of hyperglycemia:
Treatment of hyperglycemia:
Urine should be checked for ketones when blood glucose levels are above _________ mg/dl.
Treatment for ketones:
Supplies to be Kept at School
_______Blood glucose meter, blood glucose test
strips, batteries for meter
_______Lancet device, lancets, gloves, etc.
_______Urine ketone strips
_______Insulin vials and syringes
_______Insulin pump and supplies

_______Insulin pen, pen needles, insulin cartridges
_______Fast-acting source of glucose
_______Carbohydrate containing snack
_______Glucagon emergency kit
Signatures
This Diabetes Medical Management Plan has been approved by:
Students Physician/Health Care Provider
Date
I give permission to the school nurse, trained diabetes personnel, and other designated staff members of
______________________________ school to perform and carry out the diabetes care tasks as outlined by
________________s Diabetes Medical Management Plan. I also consent to the release of the information
contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial
care of my child and who may need to know this information to maintain my childs health and safety.
Acknowledged and received by:
Students Parent/Guardian
Date
Students Parent/Guardian
Date
Quick Reference Emergency Plan

for a Student with Diabetes
Hypoglycemia
(Low Blood Sugar)
Photo
Students Name
Grade/Teacher
Emergency Contact Information:
Date of Plan
Mother/Guardian
Father/Guardian
Home phone
Work phone
Cell
Home phone
School Nurse/Trained Diabetes Personnel
Work phone
Cell
Contact Number(s)
Never send a child with suspected low blood sugar anywhere alone.
Causes of Hypoglycemia
Too much insulin
Missed food
Delayed food
Too much or too intense exercise
Unscheduled exercise
Onset
Sudden
Symptoms
Mild
Sweating
Drowsiness
Personality change
Inability to
concentrate
Other: ___________
Moderate
Headache
Blurry vision
Behavior
Weakness
change
Slurred Speech
Poor
Confusion
coordination Other ___________
Severe
Loss of consciousness
Seizure
Inability to swallow
_________________
__________________
Circle students usual symptoms.
Actions Needed
Notify School Nurse or Trained Diabetes Personnel. If possible, check blood sugar, per Diabetes Medical
Management Plan. When in doubt, always TREAT FOR HYPOGLYCEMIA.
Mild
Student may/may not treat self.
Provide quick-sugar source.
3-4 glucose tablets
or
4 oz. juice
or
Moderate
Someone assists.
Give student quick-sugar source
per MILD guidelines.
6 oz. regular soda
Wait 10 to 15 minutes.
3 teaspoons of glucose gel

Wait 10 to 15 minutes.
Recheck blood glucose.
Repeat food if symptoms persist
or blood glucose is less than
______.
Follow with a snack of
carbohydrate and protein (e.g.,
cheese and crackers).
Recheck blood glucose.
or
Repeat food if symptoms persist

or blood glucose is less than
______.
Follow with a snack of
carbohydrate and protein (e.g.,
cheese and crackers).
Severe
Dont attempt to give anything
by mouth.
Position on side, if possible.
Contact school nurse or trained
diabetes personnel.
Administer glucagon, as
prescribed.
Call 911.
Contact parents/guardian.
Stay with student.
Tools
Hunger
Shakiness
Weakness
Paleness
Anxiety
Irritability
Dizziness
Quick Reference Emergency Plan

for a Student with Diabetes
Hyperglycemia
(High Blood Sugar)
Photo
Students Name
Grade/Teacher
Emergency Contact Information:
Date of Plan
Mother/Guardian
Father/Guardian
Home phone
Work phone
Cell
Home phone
Work phone
Cell
School Nurse/Trained Diabetes Personnel

Contact Number(s)
Causes of Hyperglycemia
Too much food
Illness
Too little insulin Infection
Decreased activity Stress
Onset
Over timeseveral hours or days
Symptoms
Mild
Thirst
Frequent urination
Fatigue/sleepiness
Increased hunger
Blurred vision
Weight loss
Stomach pains
Flushing of skin
Lack of concentration
Sweet, fruity breath
Other: __________________
Moderate
Mild symptoms plus:
Dry mouth
Nausea
Stomach cramps
Vomiting
Other:_______________
Severe
Mild and moderate
symptoms plus:
Labored breathing
Very weak
Confused
Unconscious
Actions Needed
Allow free use of the bathroom.
Encourage student to drink water or sugar-free drinks.
Contact the school nurse or trained diabetes personnel to check
urine or administer insulin, per students Diabetes Medical
Management Plan.
If student is nauseous, vomiting, or lethargic, ____ call the
parents/guardian or ____ call for medical assistance if parent
cannot be reached.

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Section 3 tools

completed by the students parents/guardian and personal health care team

The Sample Quick Reference Emergency Plan addresses

48 Helping the Student with Diabetes Succeed

Diabetes Medical Management Plan

Date of Diabetes Diagnosis:

Other Emergency Contacts:

Notify parents/guardian or emergency contact in the following situations:

Helping the Student with Diabetes Succeed 49

Diabetes Medical Management Plan Continued

Type of insulin in pump:

Basal rates: _____ 12 am to _____

50 Helping the Student with Diabetes Succeed

Diabetes Medical Management Plan Continued

For Students Taking Oral Diabetes Medications

Meals and Snacks Eaten at School

Exercise and Sports

Helping the Student with Diabetes Succeed 51

Diabetes Medical Management Plan Continued

_______Insulin pump and supplies

52 Helping the Student with Diabetes Succeed

Quick Reference Emergency Plan

School Nurse/Trained Diabetes Personnel

Circle students usual symptoms.

Circle students usual symptoms.

Circle students usual symptoms.

6 oz. regular soda

3 teaspoons of glucose gel

Recheck blood glucose.

Repeat food if symptoms persist

Helping the Student with Diabetes Succeed 53

Quick Reference Emergency Plan

School Nurse/Trained Diabetes Personnel

Circle students usual symptoms.

Circle students usual symptoms.

54 Helping the Student with Diabetes Succeed

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Basal rates: _ 12 am to _