Healthservices.ccs.k12.nc.us

STUDENT WITH DIABETES
Target range for blood sugar (BS): > mg/dl to < . Monitor Blood
As needed for signs/symptoms of low or high blood sugar Blood sugar (BS) at which parent/guardian should be notified: LOW < mg/dl or HIGH > mg/dl. Hyperglycemia: If blood sugar (BS) >300mg/dl with ketones or 2
Hypoglycemia: Do not send student unaccompanied to the office if
consecutive unexplained BS >250 mg/dl (with or without ketones), i.e. symptomatic or blood sugar (BS) < 70mg/dl. malfunctioning pump the student may require insulin via injection and/or new infusion site/set.
First contact parent/guardian, if not available call school nurse who Test blood sugar if blood glucose meter not available, treat symptoms. will call health care provider for further instructions.  Blood sugar < 70mg/dl and/or symptomatic: treat with 10 to 15 grams  An order for insulin specific to the incident may be faxed from the carbohydrate snack (juice, sugar tabs, etc.) and recheck BS in 15 health care provider. Verbal orders may be taken only by the RN and only in the event a fax is unavailable.  Mild symptoms: treat with snack, juice, sugar tabs, etc., recheck and repeat every 15 minutes until BS> 70mg/dl, then give snack with  Check blood ketones if BS> mg/dl. and recheck in 1 hour.  Moderate symptoms: if able to swallow, administer glucose gel,  If ketones are present call parent/guardian, provide water and student frosting, etc. Repeat until BS is above 70mg/dl, then give snack with should remain under medication clerk observation until  Call 911: if severe symptoms (which may include seizures,  Student will be sent home from school when ketones are moderate/ unconscious) or unable/unwilling to take gel or juice: administer large or shows symptoms of nausea, vomiting, tired, thirsty, dry Glucagon mg(s) by IM and contact parent/guardian. mouth, difficulty breathing, fruity breath, or confused. Diabetes Medications: to be given at school
Method of insulin delivery during school hours: Medications: Sliding Scale for BS correction (may be used every hours).
Sliding Scale BS Target Range:
Carbohydrate counting: unit(s) of insulin per grams of
Insulin must be given anytime the child eats. Parent/guardian authorized to increase or decrease insulin to carbohydrate ration within the following range: 1 unit per prescribed grams of carbohydrates +/- 5 grams of carbohydrates. Student’s Self Care: ability level determined by health care provider with input from school nurse and parent/guardian.
Totally independent management
Self-injects with trained staff supervision Assist/testing to be done by trained staff Tests and interprets urine/blood ketones Release of Liability: Realizing the importance of administering medication to my child as prescribed by the child’s physician, do hereby agree to relieve designated
school personnel of any liability from any potential ill effects as a result of their injecting or giving my child medication prescribed by the child’s physician. I have discussed
this with my physician and/or legal counsel (lawyer) and realize its ramifications and thoroughly understand the meanings of these statements. I consent for the medical
provider to disclose health or medical information regarding medication prescribed. I understand that I may revoke this consent at any time, except to the extent action has been
taken in reliance on it. This form is valid for the term of one year or the annual IEP or 504 Accommodations review, whichever occurs first.
SIGNATURES: Parent/Guardian:
FOR SCHOOL USE ONLY:
No Date of plan: / /
Please fax completed form to CCS Health Services: 910-483-7835 CUMBERLAND COUNTY SCHOOLS
HYPOGLYCEMIA OR HYPERGLYCEMIA RECORD Page 2 of 2
BLOOD SUGAR LOG Rev. 6/2013

Source: http://healthservices.ccs.k12.nc.us/files/2013/07/Health-Care-Provider-Order-Student-with-Diabetes.pdf