HEALTH CARE PLAN



Name: _________________________DOB: _______________Age: _________Grade: ____School: ________________________Provider Name/Phone: ______________________________Emergency Contact: ________________________ Relationship: _____________Phone: ______________Emergency Contact:________________________ Relationship: _____________Phone: _______________List medications taken by student: ________________________________________________________________________________Allergies: ____________________________________________________________________________________________________ Does this student ride the bus to school? Y /N Bus #: _______(If yes, this plan will be shared with transportation)School Nurse/contact number: ________________________________________________Health Concern #1: LOW BLOOD SUGAR (HYPOGLYCEMIA)NEVER LEAVE A DIABETIC SUSPECTED OF LOW BLOOD SUGAR ALONE SYMPTOMSACTIONSMILDHunger, paleness, dizziness, shakiness, poor concentration, headache, irritability, fatigue, weakness, personality changeHave student check blood sugar If BS <70 mg/dl OR <____give fast acting sugar 2-4 glucose tabs6 0z juice or sodaRetest blood sugar in 15 minutesRepeat if Necessary until BS is >70 mg/dlHave student eat a snack if no lunch/meal within 60 minMODERATESevere confusion, blurry vision, weakness, disorientation, poor coordinationGive student one of the following:1/2 -1 tube glucose gel OR ?-1 tube cake gel/frosting applied between teeth and gumsWait 10-15 minutes and check blood sugarRepeat if necessary until BS is >70 mg/dl OR >_____Notify parent or guardianHave student eat snack SEVEREInability to swallowUnconsciousSeizure***Give nothing by mouth***Place student in side lying positionTrained personnel administers GlucagonCall 911Notify parents Location of student’s emergency supplies (glucose tabs, etc):____________________________________________ Health Concern #2: HIGH BLOOD SUGAR (HYPERGLYCEMIA)SYMPTOMSACTIONSMild/ModerateThirst, frequent urination, stomach pains, fatigue, flushing of skin, sweet/fruity breath, dry mouth,Blurred visionCheck blood sugar and administer insulin per MD order (DMMP). Recheck BS every 1-2 hours as directed. (Notify parents if BS >______ /per parent)Encourage to drink waterCheck Urine Ketones if BS >300? Y/NContact School Nurse for assistance if needed.SevereMild/moderate symptoms plus…Labored breathing, confusion, very weakNotify parentsCheck blood sugar and administer insulin per DMMPIf parents are unavailable and/or if student is lethargic or vomits call 911Planning Participants (signatures)______________________________________________________________________Healthcare ProviderParent______________________________________________________________________Building AdministratorSchool Nurse ................
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