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OXFORDSHIRE CHILDREN’S DIABETES SERVICE
Children’s Hospital, Oxford OX3 9DU
Horton Hospital, Banbury OX16
Care Plan
For Managing the Care of Children with Diabetes in Schools
and Other Childcare Settings (Insulin Pump)
Start date:
Student’s name:
Date of birth:
School:
Address of school:
Contact Information (circle Primary Contact):
Mother/Guardian Name
Father/Guardian
Name
Other Contact Name
Address:
Telephone numbers:
Mother’s/guardian
mobile:
Other mobile:
Father’s/guardian
mobile:
Oxfordshire Children’s Diabetes Team
Consultant:
Dr JulieDr.
Edge,
JulieConsultant
Edge
in Paediatric Diabetes,
Level 2,Oxford
OxfordChildren’s
Children’sHospital
Hospital
Diabetes Nurse
Specialists:
Elaine O’Hickey, Jane Haest, Hannah Powell, Diana Yardley, Sarah
Chapman, Catherine Earnshaw-Crofts
Address: LG1, Oxford Children’s Hospital, Oxford
OX3 9DU
Telephone: 01865 228737
01865 228793
Notify parents/guardian or emergency contact in the following situations: Severe hypoglycaemia,
illness, and/or when staff have concerns.
Paediatric Diabetes Team, May 2013
Review May 2016
2
________________ has Type 1 diabetes, meaning they can no longer produce insulin because the cells in
the pancreas that produce it have been destroyed. Without insulin, the body cannot use glucose.
Diabetes cannot be cured, but it can be treated effectively. The aim of the treatment is to keep the blood
glucose level close to the normal range (_____mmol, rising to no higher than _____ mmol two hours after a
meal) so it is neither too high (hyperglycaemia) nor too low (hypoglycaemia, also know as a hypo).
Glucose Monitoring
The target range for blood glucose is
______ mmol/l
Times to do blood glucose checks (tick all that apply)
Before lunch
Before mid-morning snack
Before mid-afternoon snack
Before games/PE on __________________________________________________(days)
When _______________ is unwell
When showing symptoms of high BG (hyper)
When showing symptoms of low BG (hypo)
Other (explain) ____________________________________________________________
Can _______________ perform own blood glucose checks?
Yes
No
Results of any tests taken should be recorded in the Communication Book and given to the parents at the
end of each day.
Any blood glucose level that is outside of the target range should be acted upon, following the instructions in
this Care Plan.
Type of blood glucose meter/finger prick that is used: _______________________________________
Sharps Disposal
Sharps will be safely disposed of in a yellow container.
Insulin Pump
Name of prescribed insulin: ____________________________________________________________
_______________ wears an insulin pump that is powered by one AAA battery. This delivers insulin
constantly over a 24-hour period (basal rate), and will also, when programmed, provide a meal-time dose of
insulin and a correction dose to correct the current blood glucose level back to the target range.
You will be given clear written instructions on how to give a bolus of insulin. You will not be expected to alter
the basal rate, which just runs throughout the day and night automatically.
If there are any technical problems with the pump, you will need to contact the parents.
Meals/Snacks Eaten at School
The key worker (or an alternative adult) will need to add up the amount of carbohydrate in what ever is eaten
or drunk during this time frame according to the Communication Book provided daily by the parents. A blood
glucose test needs to be done before the meal. The amount of insulin for the carbohydrate and the
correction insulin dose for the BG level need to be added together.
The Roche (Combo) pump will do this, but for the Medtronic pump, you will need to put both values into the
pump. Written instructions on how to do this will be provided.
Correction Boluses at other times
When a BG test is done at any other time (see above list) a correction dose may be necessary to bring the
BG level back into the target range
Paediatric Diabetes Team, May 2013
Review May 2016
3
Parental authorisation should be obtained at the time before administering a correction dose for high blood
glucose levels at times other than with meals or snacks
Yes
No
Student Pump Abilities/Skills:
_______________ able to do on their own with supervision
Count carbohydrates
Yes
No
Bolus correct amount for carbohydrates consumed
Yes
No
Calculate and administer corrective bolus
Yes
No
Disconnect pump
Yes
No
Reconnect pump at infusion set
Yes
No
Prepare reservoir and tubing
Yes
No
Insert infusion set
Yes
No
Troubleshoot alarms and malfunctions
Yes
No
Exercise Management:
BG kit and hypo treatment needs to be readily available during sport/PE.
Is a BG test needed before PE lessons/sport training?
Yes
No
If yes, test blood glucose level and record.
Remove pump, connect the protective site cap and place pump + tubing in a clean environment.
If BG before sport is:

Less than 4 mmols

4 to 7 mmols ____________ needs a carbohydrate snack without a bolus of insulin

7 to 14 mmols
No action

Above 14mmols
Follow the ABCC rule giving ½ the recommended correction (see below
for high BG levels (hyperglycaemia). DO NOT do exercise until BG has
lowered.
Treat as hypoglycaemia and leave for 15 minutes before re-testing
BG test needed ___________minutes after sport?
Is a snack needed after sport routinely (without insulin)?
Yes
Yes
Yes
No
No
No
After PE do not forget to reconnect pump.
Paediatric Diabetes Team, May 2013
Review May 2016
4
Hypoglycaemia (Low Blood Glucose level)
Usual symptoms of hypoglycaemia are:
_________________________________________________________________________________
_________________________________________________________________________________
Treatment of hypoglycaemia:
_________________________________________________________________________________
_________________________________________________________________________________
Hyperglycaemia (High Blood Glucose level)
Usual symptoms of hyperglycaemia are:
_________________________________________________________________________________
_________________________________________________________________________________
Treatment of hyperglycaemia:
_________________________________________________________________________________
_________________________________________________________________________________
IF BG ABOVE 14 PLEASE CHECK BLOOD KETONE, IF ABOVE 1.0 PLEASE CONTACT PARENT/CARER
FOR ADVICE.
Supplies to be kept at School

Spare blood glucose meter, blood glucose test strips, batteries for meter

Lancet device, lancets, gloves, etc.

Fast-acting source of glucose

Carbohydrate containing snack

Glucogel – 3 x 23 gram tubes

Spare cannula

Spare insulin for pump

Glucagon emergency kit (for the use of ambulance staff if necessary)
(Parents to check the expiry dates of medication and medication to be replaced as necessary)
Paediatric Diabetes Team, May 2013
Review May 2016
5
A.B.C.C.
Hyperglycaemia (High Blood Glucose)
If the blood glucose level is above the target range of 14 mmols follow the ABCC (see algorithm below)
Assess
Was a food bolus given within the last 90 minutes?
YES
NO
Is the pump running?
Is there insulin in the pump?
Is the infusion line leaking or damaged?
Is the needle/ cannula OK?
If so, do nothing and retest blood
glucose level again in 1 hour.
Bolus
Give a correction dose of insulin, using the bolus wizard or ROCHE handset (please see additional sheet)
Check
Check blood glucose level 1 hour after this bolus has been given
If blood glucose level is lower than the previous value, no further action is required
Change
If blood glucose level is equal to or higher than the previous value, check blood ketones; if above 1mmol
contact parents, if under 1mmol follow above again.
NB If ketones above 1 mmol/l parents will need to come and give an insulin bolus with a pen.
Paediatric Diabetes Team, May 2013
Review May 2016
6
General Management of Hypoglycaemia (LOW BLOOD GLUCOSE): What to do flow chart
A low blood glucose (hypoglycaemia; less than 4 mmol/l) might happen because:





a meal or snack is missed or delayed
the child/young person hasn’t eaten enough
the child/young person has been exercising a lot with no extra food
the child/young person is getting more insulin than their body needs.
Stress
Follow the flow chart if a child/young person with Diabetes appears to have any of
the following signs:
General Signs of hypoglycaemia
sweaty
sleepy
irritable
pale
uncooperative
shaky
hungry
confused
cold
poor concentration
TEST THE BLOOD GLUCOSE
LEVEL
record time and result
in Communication Book
Is the young person
UNCONSCIOUS?
or having a CONVULSION?
YES
Call for Help
Place in the recovery position
Call 999. State “an unconscious diabetic
young person”
Stay with the young person
Do not try to give food/drink or Glucogel
Ensure that someone alerts the young
person’s parent/carer as soon as
possible
The hypoglycaemia episode should be
recorded in the school/setting’s
Accident/Incident Book, or equivalent
documentation, and in the
Communication Book
dizzy
weak
aggressive
tired
semi-conscious
NO
or if no-one available
who has been trained
to do BG testing
If blood glucose less
than 4 mmol/l
IMMEDIATELY give FAST-ACTING
GLUCOSE.
STEP ONE
 100mls non-diet fizzy drink, fresh fruit
juice or Lucozade Sport
 OR 2-4 glucose tablets
 OR Glucogel massaged between gum
and cheek if drowsy - up to whole tube
STEP TWO.
Wait 10 mins then recheck BG, if above 4mmol give
carbohydrate snack/lunch as per Care Plan.
If under 4mmol repeat Step 1.
If not recovering, repeat steps 1 & 2 and check BG
again after further 10-15 mins to make sure it is now
above 4 mmol/l.
Paediatric Diabetes Team, May 2013
Review May 2016
7
AGREEMENT FOR THE CALCULATION AND ADMINISTRATION OF INSULIN
AND BLOOD GLUCOSE MONITORING TO A CHILD/YOUNG PERSON WITH INSULIN
DEPENDENT DIABETES
NAME: . …………………………………………………………………………………………………….
D.O.B: …….…………………………………………………………………………………………………
SCHOOL/SETTING: …………………………………………………………………………..................
PAEDIATRIC DIABETES SPECIALIST NURSE: ……………………………………………………..
TELEPHONE: ………………………………E-MAIL: ……………………………………………………
Oxfordshire County Council fully indemnifies its employees against claims for alleged
negligence providing they are acting within the scope of their employment. For the
purposes of indemnity, the administration of medicines falls within this definition and
hence employees can be reassured about the protection their employer provides. In
practice the indemnity would cover trained employees for any consequence arising from
either a failure to administer the treatment or the administration of the treatment itself
I confirm that the above named young person has been prescribed INSULIN for the
treatment of INSULIN DEPENDENT DIABETES, to be administered or supervised by trained
volunteers. The volunteers will be trained and signed off as competent by qualified
Paediatric Diabetes Specialist Nurses employed by the Oxford University Hospitals NHS
Trust (OUHT).
MEMBER OF CHILDREN’S DIABETES TEAM
Name (Print):……………………………………………. Designation…………………………………..
Signed: .................................................................... Date: .........................................................
We the undersigned give our consent and professional approval, as appropriate, for trained
volunteers to carry out or to supervise BLOOD GLUCOSE MONITORING and the
CALCULATION AND ADMINISTRATION OF INSULIN as instructed and only after
successfully completing a training programme provided by the OUHT.
HEAD OF ESTABLISHMENT/SETTING Name (Print): .................................................................
Signed: .................................................................... Date: ..........................................................
PARENT/CARER Name (Print): ....................................................................................................
Signed: .................................................................... Date: .........................................................
YOUNG PERSON (where appropriate) (Print): .............................................................................
Signed: ................................................................................................... Date: ..................................................................................
Paediatric Diabetes Team, May 2013
Review May 2016
8
Responsibilities of various parties in the Care Plan
Item
Early Years/School
Responsibility
Parents Responsibility
Child/Young Persons
Responsibility when Deemed
Competent
Paediatric Diabetes
Specialist Nurse
Care Plan
Formulation of plan & to
update information when
necessary
All school personnel to be aware
of plan and what care it includes
Formulation of the plan and to
update information when
necessary
Provide plan to parents and
provide training in order for
information to disseminated
Dietitian – food plan
Emergency Supply
Box
To provide box and contents
To make accessible to
child/YP/Staff
To make parents aware when
supplies low
To make parents aware when
supplies low
To provide training as to the
correct use of the box
Insulin Injection and
Pump Supplies
To provide all supplies of
insulin, pens, needles,
reservoirs and cannulas.
Provision of fridge space for
spare supplies of insulin. Provide
clean and private environment.
To make parents aware when
supplies low
To guide parents as to when
supplies may need to be
replenished
Blood glucose &
ketone testing
supplies
To provide supplies of
lancets, blood glucose strips
and quality control (Q.C)
solutions
To be aware when
replenishment of supplies is
necessary
Provide correct storage of
supplies where necessary and
request for training when further
required. Provide clean and
private environment.
To make parents aware when
supplies low
To provide training in order to
initiate blood glucose testing
Quality Control of
Blood Glucose Meter
Parents responsibility to
carry out this according to
local policy
None
None
To train parents to carry out as
per local guidelines
Sharps Disposal
To provide sharps bin (refer
to local policy) and remove
when full
To provide food for snacks
and exercise as required
To make parents aware when
sharps bin is 2/3 full
To make parents aware when 2/3
full
To provide parents with
information about local policy
To make parents aware if running
out of snacks and exercise food.
To give permission for CYP to
eat whenever required.
To draw up school risk
assessment
To make parents aware when
requires more food supplies
Information can be included
about supply during treatment
To participate in risk assessment
where possible
To provide OUH risk
documentation to assist school
in drawing up local risk
assessment
Extra Food
Risk Assessment
To provide information to
facilitate risk assessment
Paediatric Diabetes Team, May 2013
Review May 2016
9
Appendix
DIABETES TRAINING CHECKLIST – Record Separate Sheet for Each Volunteer
Blood glucose monitoring and insulin calculation and administration
Name:
Date of birth:
School/Establishment/Setting:
TOPIC
Volunteer:
Discussed
Y/N or N/A
NOTES
Parent present for training?
Diabetes



What is Diabetes?
Type 1 & 2
Aims of management
Daily routine





Carbohydrate foods
When to eat
Not eating food
Blood glucose testing
When to inject
Blood Glucose (BG) Testing




Technique
Interpretation of result
Out of range results
Safe disposal of kit
When insulin injections are needed
See individual diabetes medical management plan
Calculation of Insulin Doses




Adding up meal-time dose from
Communication Book
Working out correction dose
Working out total dose
Recording of doses calculated
Insulin injections
 Storage of insulin and pen
 Location of injections
 Use of pen/device/pump
 Injection/bolus Technique
 Safe disposal of sharps
Exercise
Hypoglycaemia (low blood glucose level)
Hyperglycaemia (high blood glucose level)
Illness
Other factors
Responsibility of School/Setting Cocoordinator
Responsibility of Diabetes Specialist Nurse
Responsibility of Volunteer
Responsibility of Parent
Indemnity/insurance
On-going support
Name of trainer (PDSN):
Date :
Signature of Trainer (PDSN):
Signature of Volunteer:
Paediatric Diabetes Team, May 2013
Review May 2016
10
Appendix
DIABETES TRAINING CHECKLIST – Record Separate Sheet for Each Volunteer
Blood glucose monitoring and insulin calculation and administration
Name:
Date of birth:
School/Establishment/Setting:
TOPIC
Volunteer:
Discussed
Y/N or N/A
NOTES
Parent present for training?
Diabetes



What is Diabetes?
Type 1 & 2
Aims of management
Daily routine





Carbohydrate foods
When to eat
Not eating food
Blood glucose testing
When to inject
Blood Glucose (BG) Testing




Technique
Interpretation of result
Out of range results
Safe disposal of kit
When insulin injections are needed
See individual diabetes medical management plan
Calculation of Insulin Doses




Adding up meal-time dose from
Communication Book
Working out correction dose
Working out total dose
Recording of doses calculated
Insulin injections
 Storage of insulin and pen
 Location of injections
 Use of pen/device/pump
 Injection/bolus Technique
 Safe disposal of sharps
Exercise
Hypoglycaemia (low blood glucose level)
Hyperglycaemia (high blood glucose level)
Illness
Other factors
Responsibility of School/Setting Cocoordinator
Responsibility of Diabetes Specialist Nurse
Responsibility of Volunteer
Responsibility of Parent
Indemnity/insurance
On-going support
Name of trainer (PDSN):
Date :
Signature of Trainer (PDSN):
Signature of Volunteer:
Paediatric Diabetes Team, May 2013
Review May 2016
11
Record of Training and Confirmation of Competence
Please complete one of these sheets for EACH volunteer
Name of
Child/young
person
School/setting
Date of Birth
Name of
Volunteer
Employing organisation
Paediatric
Diabetes
Specialist Nurse
Employing organisation
Task
Supervise /
Perform.
Initial Training
Date
Initial Training
given by –
Name
(PDSN)
Initial
Training –
Signature
(PDSN)
Initial
Training –
Signature
(Volunteer)
Competence
confirmed Date
Competence
Confirmed by –
Name
(PDSN)
Competence
Confirmed by Signature
(PDSN)
Measuring Blood
Glucose level
Calculation of
Insulin Dose
Administration of
insulin dose
Treatment of low
BG ( under
4mmol/l)
PLEASE NOTE THAT TRAINED VOLUNTEERS MUST UNDERTAKE THE TASKS TRAINED A MINIMUM OF ONCE A WEEK TO
REMAIN COMPETENT.
Paediatric Diabetes Team, May 2013
Review May 2016
12
Record of Training and Confirmation of Competence
Please complete one of these sheets for EACH volunteer
Name of
Child/young
person
School/setting
Date of Birth
Name of
Volunteer
Employing organisation
Paediatric
Diabetes
Specialist Nurse
Employing organisation
Task
Supervise /
Perform.
Initial Training
Date
Initial Training
given by –
Name
(PDSN)
Initial
Training –
Signature
(PDSN)
Initial
Training –
Signature
(Volunteer)
Competence
confirmed Date
Competence
Confirmed by –
Name
(PDSN)
Competence
Confirmed by Signature
(PDSN)
Measuring Blood
Glucose level
Calculation of
Insulin Dose
Administration of
insulin dose
Treatment of low
BG ( under
4mmol/l)
PLEASE NOTE THAT TRAINED VOLUNTEERS MUST UNDERTAKE THE TASKS TRAINED A MINIMUM OF ONCE A WEEK TO
REMAIN COMPETENT.
Paediatric Diabetes Team, May 2013
Review May 2016