Diabetes Treatment Plan
*Please note that this EMERGENCY ACTION PLAN will be shared with South Hackensack Memorial School staff members that are DIRECTLY involved in your child’s daily activities. This sharing of information is to ensure the safety and health of your child.
STUDENTS NAME: ________________          GRADE: _______       TEACHER:____________
Emergency Contacts
PARENT # 1	PARENT # 2	
Name:	Name:	
Address:
	Address:	
Work #:	Work #:	
Cell #:	Cell #:	
Alternate Emergency Contact # 1	Alternate Emergency Contact # 2	
Name:
Relationship to Student:	Name:
Relationship to Student:	
Cell #:	Cell #:	

BLOOD GLUCOSE MONITORING
To Be Filled Out By Physician Only

•	Date of Plan: ________
•	Name of physician ordering the plan: ________________________________

Target range of blood glucose:	70-130 mg/dL     70-180 mg/dL
 Other: 	
Check blood glucose level:  Before lunch 	Hours after lunch
 2 hours after a correction dose   Mid-morning (snack time @ 10am)   Before PE	   After PE
 Before dismissal    Other:	
 As needed for signs/symptoms of low or high blood glucose
 As needed for signs/symptoms of illness

Student's self-care blood glucose checking skills:
 Independently checks own blood glucose in the health office
 May check blood glucose with the school nurse supervising
 Requires school nurse or trained diabetes personnel to check blood glucose 

INSULIN THERAPY
Insulin delivery device:   syringe     insulin pen    insulin pump
Type of insulin therapy at school:
 Adjustable Insulin Therapy
 Fixed Insulin Therapy
 No insulin
Expiration Date:____________ Lot #: _______________ # of syringes provided: ____________
BASAL RATE	TIME	

		
Correction Factor: 
•	1 unit of insulin lowers blood glucose by _____________mg/dl
•	Breakfast: 1 unit covers ___________ grams of carbohydrates
•	Lunch: 1 unit covers _____________ grams of carbohydrates
•	Dinner: 1 unit covers _____________ grams of carbohydrates
•	Snacks: 1 unit covers ____________ grams of carbohydrates
•	If blood glucose <70mg/dL, treat low blood glucose using the rule of 15: 
•	Give 15 grams of fast acting carbohydrates (juice) only and recheck in 15 minutes
•	Repeat until blood glucose is > 80mg/dL then follow up with a meal or snack. DO NOT give insulin for the first 15 grams of carbohydrates.
•	GLUCAGON: Give glucagon injection 1mg IM if student is > 20kg or 0.5mg IM if student is < 20kg for the following emergencies: UNCONSCIOUS, UNRESPONSIVE OR SEIZING… THEN CALL 911!
•	Check ?ketones when blood glucose is > 300mg/dL and when child is ill
•	Ketones moderate-large, CALL PARENTS
•	If ketones are present or blood glucose remains high after ONE correction bolus, do NOT give insulin via pump; ONLY GIVE INSLUIN VIA SYRINGE AND CALL PARENTS
•	Check blood sugar before gym, if gym is more than one hour after a meal or snack. If blood glucose is < 120mg/dL, give a 15 gram carbohydrate snack WITHOUT insulin.
•	Child should NOT exercise if ketones are moderate-large

ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP
•	*Glucose Monitor is continuous?   YES or NO
•	*Brand/Model of blood glucose meter: ______________________________________________	
•	*Type of insulin in pump: __________________________
•	*Basal rates during school: ____________________________________________________
•	*Type of infusion set: ________________________________________________________
•	*Student can manipulate/change infusion set at school if needed WITHOUT supervision? (The school nurse is NOT responsible for changing infusion sets, adding insulin to cartridge or manipulating the pump in any way)   YES or NO
Consent & Signatures
By signing below, I am hereby acknowledging that I, the parent/legal guardian of the above named Diabetic Treatment Plan, have read and discussed this plan thoroughly with my child and the physician. I am granting permission for the above name physician to speak with the school nurse on my child’s behalf regarding health concerns related to my child’s diabetes management while in school. I am in agreement with this plan and understand that it is MY responsibility to supply the school nurse with syringes, insulin, and any other supplies that she will need to treat my child’s diabetes while in school. 

Signature of Parent/Legal Guardian: __________________________________ Date: ___________
Signature of School Nurse: _______________________________________ Date: ______________
Signature of School Physician: ____________________________________ Date: ______________