_____________________________ Brand/model of CGM: _____________________________ Nursing Sample Interventions Date Sample Outcome Date Diagnosis and Activities Implemented Indicator Evaluated (continued) (continued) (continued) (continued) (continued) Supporting the Hypoglycemia Management Monitors blood glucose Independent STUDENT WILL: and appropriately Check blood glucose when Student responds to results hypoglycemia suspected (effective Treat hypoglycemia Percentage of time therapeutic (follow Emergency Care Plans for 0% 25% 50% 75% 100% regimen Hypoglycemia and Hyperglycemia) management) Take action following a hypoglycemia episode Keep quick-acting glucose product to treat on the spot Type: _______________________ Routinely monitor hypoglycemia trends r/t class schedule (e.g., time of PE, scheduled lunch, recess) and insulin dosing Report to and consult with parents/ guardians, school nurse, HCP, and school personnel as appropriate Supporting Create Positive School Environment Demonstrates positive Positive Coping Ensure confidentiality coping Skills Discuss with parents/guardians and student preferences about Percentage of time (readiness for how the school can support 0% 25% 50% 75% 100% enhanced student’s coping skills coping) Collaborate with parents/guardians and school personnel to meet student’s coping needs Collaborate with school personnel to create an accepting and understanding environment
_____________________________ Brand/model of CGM: _____________________________ Nursing Diagnosis (continued) Sample Interventions and Activities (continued) Date Implemented (continued) Sample Outcome Indicator (continued) Date Evaluated (continued) Supporting the Independent Student (effective therapeutic regimen management) Hypoglycemia Management STUDENT WILL: Check blood glucose when hypoglycemia suspected Treat hypoglycemia (follow Emergency Care Plans for Hypoglycemia and Hyperglycemia) Take action following a hypoglycemia episode Keep quick-acting glucose product to treat on the spot Type: _______________________ Routinely monitor hypoglycemia trends r/t class schedule (e.g., time of PE, scheduled lunch, recess) and insulin dosing Report to and consult with parents/ guardians, school nurse, HCP, and school personnel as appropriate Monitors blood glucose and appropriately responds to results Percentage of time 0% 25% 50% 75% 100% Supporting Positive Coping Skills (readiness for enhanced coping) Create Positive School Environment Ensure confidentiality Discuss with parents/guardians and student preferences about how the school can support student’s coping skills Collaborate with parents/guardians and school personnel to meet student’s coping needs Collaborate with school personnel to create an accepting and understanding environment Demonstrates positive coping Percentage of time 0% 25% 50% 75% 100%
IHP_Word_Version_FOR_POSTING_5-10-17.docx