Individualized Health Plan (IHP) for Students with Diabetes using Insulin
DIABETES PLAN
Name:
DOB:
Parent/Guardian:
Home #:
Work/cell #:
Teacher Name/Homeroom:
Check if
applies
Activity
HCP:
Phone:
Parent/Guardian:
Home #:
Work/cell #:
Routine Blood Sugar Checks
Approximate Target range or Comments
time
Before breakfast
Before AM snack
Before lunch
Before PM snack
Before recess
Before phy ed
Before dismissal
Additional time…
 It is recommended that student change lancet after every poke.
Hypoglycemia (low blood sugar): This can be a medical emergency. All staff working with a
student with diabetes should be alert to the following symptoms: List those seen most often:
If exhibiting symptoms of low blood sugar, OR if blood sugar level is less than
mg/dL, give
a quick-acting glucose equal to
grams of carbohydrate. List preferred treatment snack:
Recheck blood sugar in 15 minutes and repeat treatment if blood sugar is less than
mg/dL.
Additional treatment or comments:
See page 3 for treatment recommendations for severe hypoglycemia.
Type of Insulin(s) required (list):
Insulin delivery (check):
Syringe/Vial
Insulin required (check):
Breakfast
Insulin Pen
AM Snack
Insulin Pump (name)
Lunch
PM Snack
Other
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Individualized Health Plan (IHP) for Students with Diabetes using Insulin
Breakfast:
Carbohydrate coverage only
Carbohydrate coverage + correction dose when blood sugar is greater than
mg/dL and
hours since last insulin dose (see correction scale below).
Additional comments/instructions:
Snack:
None at snack time
Carbohydrate coverage only
Additional comments/instructions:
Lunch:
Carbohydrate coverage only
Carbohydrate coverage + correction dose when blood sugar is greater than
mg/dL and
hours since last insulin dose (see correction scale below).
Additional comments/instructions:
Other insulin required at school; type
time
dose
Student skills for using insulin (check all that apply):
Counts carbohydrates
Calculates correct insulin dose
Draws up correct insulin dose
Independently gives own injection
Uses pump independently. Pump determines correct amount of insulin once blood sugar and
carbohydrate content are entered.
Insulin dosages should be checked by two individuals prior to being
administered.
FLEXIBLE Insulin Dose:
Not applicable
Total dosage of insulin = insulin for meal + correction insulin dose
Insulin/Carbohydrate ratios:
Breakfast
units per
AM Snack
units per
Lunch
units per
PM Snack
units per
Dinner
units per
Gram Carbohydrate
Gram Carbohydrate
Gram Carbohydrate
Gram Carbohydrate
Gram Carbohydrate
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Individualized Health Plan (IHP) for Students with Diabetes using Insulin
Insulin Correction Scale
Not applicable
(Correction dose is added to the meal dose of insulin)
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Blood Glucose is
to
=
units
Carbohydrate counts for all MMSD menus are on the Food and Nutrition web page under
Nutrition and Special Dietary Needs.
Student with insulin pump:



For blood sugar greater than
mg/dL that has not decreased within
hours
after correction, consider pump failure or infusion site failure. Notify parent/guardian.
For infusion site failure, choose one:
student is independent with changing site, or
parent/guardian will need to come to school.
For suspected pump failure, contact parent/guardian.
Typically, it is not recommended to disconnect or suspend the pump at school. Temporary
basal rates may be recommended during physical education.
Additional comments/recommendations:
Treatment for severe hypoglycemia:
If student is unable to eat or drink, is unconscious or unresponsive, or is having a seizure
(jerking movements):
 Give Glucagon 0.5 mg or 1 mg (check one)
 Place student on the side
 Have someone call 911
 Have someone call family
 Check blood sugar.
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Individualized Health Plan (IHP) for Students with Diabetes using Insulin
Hyperglycemia (high blood sugar)
Symptoms may include: increased thirst, dry mouth, frequent urination.
This may be treated at lunch time if taking injections or at other times if wearing an insulin
pump. Not usually a medical emergency unless blood sugar is quite high >250 mg/dl and
student is vomiting, has severe abdominal pain or is short of breath.
Treatment for hyperglycemia
Blood sugar (BS) ranges
Ketones if
ordered
Treatment recommendations
Trace/Small Ketones: Usually can be managed at school. May need to use bathroom more
often; encourage fluids; recheck BS in 2 hours.
Moderate/Large Ketones: In addition to above recommendations, call parent/guardians.
Arrange for family to manage care at home with communication to health care provider.
Emergency treatment of high blood sugar



Emergency signs/symptoms=shortness of breath &/or nausea & vomiting
Call parent/guardian
If unable to reach responsible adult, call 911
CONTINUOUS GLUCOSE MONITORS (CGM)
Not applicable
Treatment decisions and diabetes care plan adjustments should always be made based
upon a meter blood glucose reading.
Name of CGM:
CGM alert for low blood glucose is set at
CGM alert for high blood glucose is set at
mg/dL
mg/dL
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Individualized Health Plan (IHP) for Students with Diabetes using Insulin
Check blood glucose by finger stick in these situations (all apply):





Any high or low glucose alert
Before insulin or medication is used to lower glucose
Any symptoms of low or high blood glucose
Any time the CGM system is not working
CGM readings are questionable
Field Trips
Be sure to include: Glucose meter, hand sanitizer, glucose tabs or other short-acting sugars,
insulin if needed, syringes if needed, glucagon, copy of IHP.
Delegated staff (who are trained to help with medications) include:
Name
504 Plan: ____ Yes / ____ No
Job Description
Nurse’s Assistant
If yes, annual plan date: ____________________.
Signature-Parent/Guardian_______________________________ Date ___________
Signature-School Nurse_________________________________ Date ___________
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