Tuscaloosa City Schools
Care Plan and Orders for Diabetes at School
Student______________________________________________DOB_______________
School____________________Physician_____________________Ph_______________
Emergency Contacts:
____________________________________
__________________________________
____________________________________
__________________________________
Glucometer:
Target Range: ________________ to _________________
Blood sugar checked at the following times:
_____before meals
______before getting on bus
______as needed if feeling low or ill
_____before snacks
______before driving
______1-2hrs after lunch
_____before PE
Parent to be notified if blood sugar is <_____________or >______________
Student allowed to check blood sugar:
______ Independently
Keeps glucometer
______ Independently with supervision
_______With assistance
________ in clinic ________ onself
Parent will provide testing supplies
Insulin:
Student allowed to administer insulin:
________ Independently
Keeps Insulin
________ Independently with supervision ________With assistance
_________in clinic _________ onself
Scheduled time for insulin administration at school:______________________________
Insulin dosage calculation:____________________________________________
Correction factor:___________________________________________________
Page 1 of 9
Sliding scale:
If BS ________________ administer_______u
If BS ________________ administer_______u
If BS ________________ administer_______u
If BS ________________ administer_______u
Parent will provide insulin, needles, syringes, supplies
_________ Student uses pump. Pump is set to calculate and deliver insulin
Ketones:
Student allowed to check ketones:
________Independently _________Independently with supervision _________With assistance
Keeps ketone strips
________in clinic ________onself
Check ketones if blood sugar is >_________________________
Student may remain at school if no vomiting is present and feels well enough to stay.
Small ketones:_________________________________________________________________
Moderate ketones:______________________________________________________________
Large ketones:__________________________________________________________________
Parent will provide ketone strips
Meals/Snacks
Student’s lunch time________________
Brings lunch or eats in cafeteria
Counts Carbs? Yes
No
Carb Ratio:____________________________________________________
Snack times (if applicable):__________________________________________
Parent will provide snacks/drinks
Activity:
Check Blood sugar before PE?
Yes
No
PE time:_______________
Blood sugar must be >____________to participate
Page 2 of 9
Student may not participate in any physical activity if ketones are present
Transportation:
Student rides: Car
Bus _______________dismissal time Bus #______________
Blood sugar is checked before bus ride home.
Bus driver notified. Date:___________________
Student cannot ride bus to and from home if
BS <_________or >__________, or ketones present with vomiting or not feeling well.
Field trips, off campus events, class parties:
Teacher to speak with parent and nurse regarding food accommodations
Teacher to notify nurse/parent a minimum of 2 weeks in advance prior to field trip/off campus
event for student coverage.
Signatures:
Parent:
______
Date
Physician:
Date
Page 3 of 9
Plan for Athletes and Extracurricular Activities
School__________________________________________ School Year____________
Student__________________________________________DOB__________________
Extracurricular activity/sport________________________
Coach/Director_____________________
Emergency Contacts:
____________________________________
______________________________________
____________________________________
______________________________________
____________________________________
______________________________________
Blood sugar must be >____________to participate
Before the activity or sport begins:
Meet with the Coach/Director to discuss the emergency plan
Provide a copy of all orders to the Coach/Director and an emergency kit
Contact EMS Director and share student info and after school schedule
Before the activity or sport begins:
The student will be aware of the location of the emergency kit
He/she will know to stop the activity if feeling low and need to check blood sugar, eat a snack,
drink a juice
Before participation:
The student will check blood sugar and report to Coach/Director.
Will eat a snack/juice for blood sugar < 100. Recheck in 15-20min
Check ketones if blood sugar > 300.
Negative ketones: drink water and participate
Ketones present: Notify parents and student will NOT participate in physical activity.
Leaving the activity/sport:
Check blood sugar prior to leaving. Treat if BS <80. Students who drive need a blood sugar of
100 or > prior to driving.
Page 4 of 9
Hypoglycemia:
Mild---If the student is awake and able to swallow, treat with a quick acting glucose (juice, soda,
glucose tabs) followed by a snack. Wait 15-20 min then recheck.
Moderate--If student is alert, you may elevate head and apply ½ tube of cake icing or glucose gel
between the cheek and gum. Massage outside of cheek.
Severe—Student is unable to swallow, disoriented, combative, seizure activity. This is an
emergency! Call 911 and parent. Parent may administer glucagon if present.
Signatures:
Parent:_____________________________________________________
Doctor:____________________________________________________
Coach/Director:______________________________________________
Page 5 of 9
DIABETIC SUPPLIES
Parents are responsible for providing all diabetic supplies.
The following is a list of typical supplies:
ORDERS/FORMS
All Doctor’s orders for medications or procedures (insulin, blood sugar checks, ketone checks,
glucagon), Provider/Prescriber Authorization forms, Emergency contact list, medical consent
release
INSULIN SUPPLIES
Insulin bottle(s)—with prescription label (new bottle or pen every 28 days once opened)
Insulin syringes
Alcohol wipes
Or
Insulin pen(s) with cartridge loaded-- with prescription label
Pen needles
Alcohol wipes
Extra Pump supplies (extra pod, tubing) if needed
BLOOD SUGAR TESTING SUPPLIES
Blood glucose meter and manufacturer’s instructions
batteries
Test strips (with code information, if needed)
penlet
Lancets
Cotton balls/gauze
FOOD SUPPLIES
Snack foods
Low blood sugar (hypoglycemia) supplies; glucose gel/tablets, juice and carbohydrate/protein
snack, bottled water
OTHER
Urine ketone test strips
Glucagon---with prescription label. Check expiration
Please provide a labeled container for these items. The container is for individual student use
only. The school does not have a stock of these supplies/snacks.
Page 6 of 9
Diabetes Emergency Response Plan
Student Name ___________________________
DOB _________
School _________________________________
Grade __________
Mild Low Blood Sugar
Treat when blood sugar is below_________
Symptoms: (circle all that apply) hunger, irritability, shakiness, sleepiness, sweating, pallor, lack of
cooperation, behavior changes
Additional symptoms:_______________________________________________________
Treatment: ** Never leave the student unattended. If treatment is to be provided in the Health Room, a
responsible adult should accompany the student from the classroom to the Health Room.





Test blood sugar. If test equipment unavailable, treat immediately for low blood sugar.
If blood sugar is below_______, give ½ cup of juice, regular soda or 3-4 glucose tablets.
Wait 10–15 minutes. Recheck blood sugar. If blood sugar below _____, repeat juice, soda or
glucose tablets as above.
If blood sugar above _________, give snack or lunch. Make sure student is stable before sending
to lunch.
Notify school nurse and parent.
Comments:__________________________________________________________________
Moderate Low Blood Sugar
Symptoms: (circle all that apply) symptoms of mild low blood sugar, plus may be disoriented, combative or
incoherent
Additional symptoms:__________________________________________________________
Treatment: **
If conscious but unable to effectively drink fluids:
 Give ½ to 1 tube of glucose gel, or ½ to 1 tube of cake decorating gel.
 Place between cheek and gum with head elevated. Massage outside of cheek to facilitate
absorption through the membrane of the cheek. Encourage student to swallow.
 Recheck blood sugar in 10 minutes. If still below _______, re-treat as above.
 Give snack when alert and able to swallow without difficulty.
 Notify school nurse and parents.
Comments:______________________________________________________________
Page 7 of 9
Severe Low Blood Sugar
Symptoms: (circle all that apply) Seizures, loss of consciousness, inability/unwillingness to take gel or juice
Additional Symptoms:__________________________________________________
Treatment:





Stay with student.
Position student on side.
Give glucagon by injection; dose_________.
Call 911.
Notify school nurse and parents.
Comments:______________________________________________________________
High Blood Sugar
Treat when blood sugar is above______. Call parent/guardian when blood sugar is above_______.
Symptoms: (circle all that apply) extreme thirst, headache, abdominal pain, nausea, frequent urination
Additional symptoms:______________________________________________________
Treatment: **






Increase sugar free liquid (e.g. water) intake.
Allow student to use restroom as often as necessary.
Check urine for ketones _____ if sugar is greater than _______ or when ill. If urine ketones are
present, call parent immediately!
Do not allow exercise.
Student or school nurse should administer insulin as ordered in IHP.
If student exhibits nausea, vomiting, stomach ache or is lethargic, notify school nurse and parent
immediately.
Comments:_________________________________________________________
Signatures:
Parent:
______
Date
Physician:
Date
Page 8 of 9
DIABETES TREATMENT/INTERVENTION
STUDENT INFORMATION FORM
Student’s Name: ___________________________________________ Date of Birth: __________
Begin Treatment_________________
Stop Treatment_________________
Date
Date
STUDENT’S SELF-CARE SKILLS:
Ind= independent self-management, supv = self-management with nurse supervision; total = total
care by nurse; kept= Kept on person; NA= my child is not doing or using this
Blood glucose testing ______________________
Ketones testing____________________________
Glucose/gel______________________________
Count carbohydrates___________________________
Determine insulin dose____________________________
Give insulin by injection____________________________
Give insulin by pump______________________________
Change infusion set______________________________
BLOOD GLUCOSE MONITORING:
Check blood glucose before meals and anytime student exhibits signs of high &/or low blood
glucose (see pgs 7-8). Student should also be checked before: _____________________________
URINE KETONES TESTING
Check urine when blood glucose is greater than _____, anytime student is sick, and/or vomiting.
Dip urine and read strip in 15 seconds. Treatment Order for Ketones (see pgs 7-8)
_______________________________________________________________________________
_______________________________________________________________________________
GLUCOSE TABLET/ GEL
Use to treat low blood glucose less than _____ mg/dl on a student who is conscious and can
swallow. Dosage: Gel –15 gram tube or 3-4tablets (15 grams of carbohydrates); Route: mouth;
Frequency/time(s) to be given: As needed; follow the hypoglycemia guidelines for treating low
glucose
Signature of Parent:____________________________________Date:_______________
Provider’s signature: ___________________________________Date:_______________
Page 9 of 9