• Diabetes Medical Management Plan Worksheet

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  • This plan should be completed by the student's health care team and parent/guardian. It should be reviewed with all relevant school/daycare staff and be kept in a place that is easily accessible by those individuals for who it is necessary.

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  • Diabetes Medical Management Plan Worksheet

  • Checking student's blood glucose/sugar:

  • Hypoglcemia Treatment:

  • If a glucagon dose is required, administer it immediately. Then call 911 (or other emergency assistance) and then parent(s)/guardian(s

     

  • Hyperglycemia Treatment:

     

  • Urine/blood should be checked for ketones when blood glucose levels are above 240 mg/dl.

    If urine ketones present, push sugar-free fluids and call parent/guardian. Continue to have student check for ketones every time he/she uses the bathroom.

  • Insulin Therapy:

     For thse students not on Fixed Insulin Therapy or Insulin Pump, please provide adjustable insulin therapy orders for insulin to be administered at school.

  • Meal Plan:

  • A fast-acting source of sugar such as glucose tabs and/or sugar-containing fluids must be available at the site of physical education activities and sports.

  • Physical Activitiy/ Sports:

  • This Diabetes Medical Management Plan has been approved by:

    I give permission to the school nurse or another qualified health care professional  to perform and carry out the diabetes care tasks outlines in my son's Diabetes Medical Management Plan. I also consent to the release of the outlined in information contained in this Diabetes Medical Management Plan to all school staff members and other adults who have responsibility for my child and who may need to know this information to maintain my child's health and safety. I also give permission to the school nurse or another qualified health care professional to contact my child's physician/health care provider. This form is to be used together with the Endocrine Clinic permission to treat/orders.

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  • Reference: Diabetes Medical Management Plan. American Diabetes Association. www.YourDiabetesInfo.org.

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  • Should be Empty: