Individualized Health Plan (IHP) for Students with Diabetes Using Insulin
DIABETES PLAN
STUDENT INFORMATION
Name:
DOB:
Photo
Address:
Phone #:
Parent/Guardian:
Home #:
Work/Cell #:
Parent/Guardian:
Home #:
Work/Cell #:
Teacher’s Name/Homeroom:
*Insulin delivery system/type of insulin:


MEDICAL
INFORMATION
Primary HCP:
Phone #:
Specialist:
Phone #:
Nurse:
Phone #:
Hospital:
*Medication/Insulin
delivery:
If pump, give brand of pump and insulin used in pump
If injections, list name of short and/or long-acting insulin and method of delivery
504 plan:
Yes /
Last A1C/Date:
No
If yes, annual plan date:
A1C Goal:
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
student):
shakiness
dizziness
sweating
hunger
headache
pale skin color
(check all those that apply to this
sudden moodiness or behavior changes
such as crying for no apparent reason
clumsy or jerky movements
difficulty paying attention
confusion
tingling sensations around the mouth
other:
All students with possible low blood sugar should be accompanied to the
Health Office if that is where they check blood sugar (BS) and are treated.
1
Individualized Health Plan (IHP) for Students with Diabetes Using Insulin
Treatment for hypoglycemia
General rule is treat low BS with 15 Gm of fast-acting carbohydrate (CHO),
recheck in 15 minutes and retreat with 15 Gm of CHO if still low.
Blood sugar ranges
Treatment recommendations
Comments
Emergency treatment of low blood sugar
A tube of glucose gel can be useful if student is still able to swallow, but
having difficulty following directions. Squirt some gel inside the mouth at
the gum line and massage, allowing for faster absorption.
If student is unable to swallow, is unconscious or having a seizure:
 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.
Hyperglycemia (high blood sugar)
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 or short of breath. Check symptoms that apply to this student:
Increased thirst
dry mouth
frequent urination
Treatment for hyperglycemia
Blood sugar (BS)
ranges
Ketones if
ordered
Treatment recommendations
2
Individualized Health Plan (IHP) for Students with Diabetes Using Insulin
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
Routine Blood Sugar checks (check all that apply & list times)
Before breakfast
Before morning snack
Before lunch
Before afternoon snack
End of school day
Additional glucose monitoring at school (check all that apply):
Before physical activity/physical education
During physical activity/physical education
After physical activity/physical education
Symptoms of low blood glucose
Symptoms of high blood glucose
Student becomes sick or is sick
Other
Have student change the lancet after every poke.
Insulin for meals/snacks
Type of Insulin(s) required (list):
Insulin delivery (check): Syringe/Vial
Insulin Pump (name)
Insulin required (check): Breakfast
Other
Other insulin required at school; type
Insulin Pen
Other:
AM Snack
time
Lunch
PM Snack
dose
3
Individualized Health Plan (IHP) for Students with Diabetes Using Insulin
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
Other
Student needs assistance with (list):
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
Insulin Correction Scale
Not applicable
(Correction dose is added to the meal dose of insulin)
Blood Glucose is less than
=
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
Blood Glucose is
to
=
units
EXTRA INSULIN: NON-MEAL TIME ONLY
Not applicable
Criteria for giving extra insulin (all apply):
• Extra insulin is given if it has been more than 2 hours since last dose was given
• Blood glucose must be checked within 2 hours after correction dose is given
• Blood glucose level is over
mg/dL
• Notify parents when extra doses are given at school
• Do not exceed 2 extra doses in one school day
•Other:
Options: Use insulin correction scale above
Carbohydrate counts for all MMSD menus are on the Food and Nutrition web page under
Nutrition and Special Dietary Needs.
4
Individualized Health Plan (IHP) for Students with Diabetes Using Insulin
Field Trips
Pack:
glucose meter (to check blood sugar)
hand sanitizer
glucose tablets
glucose gel
insulin
syringes
glucagon
copy of IHP
Other:
Delegated staff (who are trained to help with medications) include:
Name
Job Description
Nurse’s Assistant
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
mg/dL
CGM alert for high blood glucose is set at
mg/dL
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
 Other:
Signature-Parent/Guardian___________________________________ Date ___________
Signature-School Nurse_____________________________________ Date ___________
5