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[IPp] Copy of Matthews IHP


Here is the IHP (health care plan) to go along with the IEP:

Individual Health Care Plan For: Matthew Ashley
(To be included in the IEP as a medical plan)
    School: Henry A. Wolcott Elementary School
        School Year:  2002-2003

Bolus (es):
Give 1 unit per 20 grams of carbs
(take total amount of carbs and divide by 20 for exact bolus amount. EX:  
74grams divided by 20 = 3.7 bolus )

Correction Bolus:
Under 80: Subtract 0.3
200-249:  Add 0.5
250-299:  Add 0.8
300-349:  Add 1.1
350-399:  Add 1.3
Over 400: Add 1.6
***Target blood sugar range is 80-180***

1.  Snacks
Matthew is to have a snack with the rest of the class.  The snack will be 
provided by his mother and it will be labeled as snack in a see thru 
container.  The snack will also be labeled with the total amount of 
carbohydrates and the bolus amount that will be required upon completing the 
snack.  Upon completing the snack Matthew will need to be given a bolus by 
the school nurse or other trained adult.  This should be done in the 
classroom to avoid Matthew missing class time.  In the event that the nurse 
cannot leave her office, another responsible adult is to escort Matthew to 
the nurse to receive his bolus and then return him to his classroom.
It is important that Matthew is watched to be sure that he completes his 
entire snack so that he is given the correct bolus amount. His bolus amount 
is calculated by the amount of carbohydrates he eats.  1 unit per 20g of 

2. Lunch
Lunch is at _______ daily.
Matthew will need a blood glucose test before eating his lunch. This should 
be done in the classroom to avoid missing class time.  In the event that the 
nurse is unable to leave her office, another responsible adult is to escort 
Matthew to the nurse and then bring him to lunch.  Upon completion of his 
lunch he will need a bolus of insulin to cover his meal.  Again if possible 
the nurse should come to Matthew, otherwise a responsible adult is to escort 
him to the nurse's office and then return him to class.   A note will be sent 
daily in Matthew's lunch box informing the nurse of the contents in his lunch 
with the total amount of carbohydrates, including his insulin dose (bolus 
amount).  If he does not complete his entire lunch, the nurse must call his 
mother to recalculate the carbohydrates and bolus amount.
Matthew will need to be re-tested after lunch if he was low before lunch to 
be sure that the blood sugar is rising to a safe level.
All blood glucose tests, bolus amounts, and total carbohydrates eaten at 
lunch are to be recorded on a Log Sheet and given to Matthew's mother every 
Friday via Matthew's homework folder.
Whenever in doubt of how to treat Matthew, contact his mother immediately for 
advice before making any adjustments to his pump or treating an episode of 
either high or low blood sugar.

3.  Signs of Low Blood Sugar (hypoglycemia)
A.  Sweating
B.  Shakiness
C.  Pupils will be large
D.  Pale, moist skin
E.  Cold and clammy
F.  Extreme hunger
G.  Weakness/Dizziness
H.  Fatigue/tired
I.  Rapid pulse rate
J.  Shallow breathing
K.  Inability to concentrate
L.  Loss of coordination
M.  Loss of consciousness

4. Signs of High Blood Sugar (hyperglycemia)
A.  Weakness and Fatigue
B.  Frequent urination
C.  Excessive thirst
D.  Pupils are sometimes small
E.  Hyper
F.  Loss of appetite

5.  Lunch Time Blood Sugars:

 Under 70 at lunch time                   Give Matthew a 4oz juice box
                                                     and send to lunch.  
Re-test blood                                                                 
                                                     Sugar immediately after 
he eats.
                                 Call his mother if his blood sugar           
                                                         Does not rise to a 
safe level after
                                                         Lunch.  The juice 
box is not to be
                                            Included as part of his carbs.

Blood sugars 71 to 80                      Matthew can go directly to 
At lunch time                                   Lunch.  However, when
                                                         He returns to have a 
                                                         It must be reduced 
by 0.3 to treat
                                                         Or prevent a 
continued low blood  

Blood sugars 81 to 200                 Matthew can go to lunch and 
At lunch time                                   Return to have a bolus after
                                                      He eats.

Over 200 at lunch time                     Matthew may go to lunch but        
                                                      He will need a 
correction bolus before he 
                               Goes to lunch and then he will need his
                                                      Lunch bolus AFTER he 
                                                      Over 250, Matthew's 
will need to 
                                                      be tested for Ketones.

                                                    Note:  Matthew may 
confuse being this 
                                                                   High with 
being low, since many 
                                                                   Of the 
symptoms are the same.

Following an episode of low blood sugar, it can take several hours to fully 
recover.  Following an episode of high blood sugar it may also take extra 
time to recover since it is very draining to Matthew's body when experiencing 
both high and low blood sugars.  Hence, Matthew should not be expected to 
perform at optimal levels.                                               

6.  Low Blood Sugars other than at lunch time:

Blood sugars Less than 70 at any time other than lunch time
**Suspend the pump for 15 minutes
**Give a 4oz juice box and re-test in 15 minutes
**If blood sugars go up to target range (80-180) resume pump
**If blood sugars do not go up, give another 4oz. juice box and keep pump     
suspended for another 15 minutes.
Call Matthew's mother so that she is aware of the situation.

7.  High Blood Sugars above 200:

Take a correction bolus and re-test in an hour and a half.
(see above for correction bolus)
If blood sugar is coming down, you're all set
If blood sugar is NOT coming down or is going up, check for Ketones.
An insulin injection is required by syringe and the site needs to be changed. 

Call Matthew's mother immediately.

8.  Buying Lunch 
On days when Matthew will buy his lunch at school, his mother will send a 
note to school in the homework folder for his teacher to forward to the 
school nurse and email his teacher at school and at home (if email is 
available) informing her of what he can eat for lunch and  of the amount of 
carbohydrates in the lunch with the amount of bolus to give him.  In the even 
that Matthew does not complete his entire lunch, please call Matthew's mother 
for the corrected bolus amount.  Any uneaten lunch should stay in the lunch 
box until the nurse can see what he has not finished, then it may be thrown 

A teacher or other adult must supervise Matthew at lunch in the cafeteria to 
be sure that he has completed his entire lunch and that nothing has been 
thrown away unfinished.   This is important because Matthew is given insulin 
according to the total amount of carbohydrates he has eaten.  If he is given 
too much or too little insulin it can be very dangerous to his health.

9.  Gym Days
On gym days, Matthew will need to go to the nurse right after physical 
education class so that he can have an extra blood sugar test.  This will 
need to be done because if his blood sugar is low an adjustment may be needed 
on the days he has gym class to prevent future low blood sugars.  With warmer 
weather this is important, since Matthew tends to sweat more.  A juice box or 
extra snack may need to be given if he is low. Follow steps #5 and #6.  And 
call parent.
Any exercise out of the ordinary, the teacher will need to let the parent 
know so that accommodations can be made with either extra snacks or an 
adjustment to Matthew's pump.  Such as field trips, extra recess time, etc.   
** An extra 10 minutes on the playground can cause a low blood sugar for 
Matthew **


10.  School Nurse (Diane Mancuso) in the event of her absence:
Please notify Matthew's Mother in the event that the regular school nurse is 
absent.  The school must then provide a trained adult of substitute nurse to 
administer his bolus amounts and blood glucose tests.  

11.  Special Treats
The teacher will notify Matthews mother ahead of time for Matthew to be able 
to enjoy a special treat.  His  parent needs to know what special treat will 
be given and at what time.  A days notice would be appreciated.  A note to 
the other parents in the class should be sent home making them aware that 
there is a child with Diabetes in the class and that unplanned special snacks 
will not be given. Matthew is on a strict meal plan so unplanned special 
snacks make it difficult to maintain proper health and blood sugars for 

In the event that the teacher or school nurse is absent, they should have 
written instructions for the substitute on Matthew's needs and schedule.

All other teachers that will be working with Matthew must be informed on 
warning signs of low and high blood sugars and what do to if they suspect 
either. This is to include the physical education teacher, art teacher, 
librarian, music teacher, speech teacher, reading teacher, and most 
importantly the other teachers on duty out at recess.  All of these teachers 
will have an in-service day with the school nurse at the start of each school 
year on how to recognize warning signs of both high and low blood sugars.  
The school nurse will send out reminders to the staff on low and high blood 
sugar warning signs every three months.

12.  Field Trips
In the event that Matthew's mother cannot attend a field trip, the school 
must provide a trained adult or have the school nurse attend to test Matthew 
and give his bolus.  His testing kit and Glucagon injection kit must be 
brought on the trip.
For trips to Wolcott Forest the teacher will carry a two way radio and 
Matthew will have a blood test prior to leaving for the Forest.  The Glucagon 
kit does not need to go to the Wolcott Forest Trips.

13.  Educating Children in Class

At the beginning of each school year Matthew's mother will speak to the class 
to educate them on Diabetes and Matthew's insulin pump.  This is to prevent 
curiosity and the other children from touching Matthew's pump.  No one is to 
touch Matthew's insulin pump except for the school nurse or other trained 

14. Future Meetings or Parent Conferences
     Matthew's mother may request a future meeting to discuss any changes in 
Matthew's medical condition or treatment plan.  Prior to the start of each 
school year Matthew's mother will meet with his teacher to discuss Matthew 
and his needs while he is at school.  This is to be done before the first day 
of school. Also the class schedule is to be given to Matthew's mother before 
the first day of school so that adjustments can be made to Matthew's medical 

15. In the event of an Emergency
     In the event of an emergency 911 is to be called immediately. Followed 
by a call to Matthew's mother and so on down the list of emergency numbers.

Emergency Numbers

Sarah Ashley (mother)
Home 233-0833
Cel  729-3488  during the hours of 2-4pm in case of emergency call Sarah's 
work number below and have them get in touch with her on the two way radio.
Work  523-9317

Tom Ashley (father)
Home  643-7940
Cel  916-1615

Michelle Marques (aunt)
Work 953-9999
Home 521-4969
Cel 573-9570

Dr. Ratzan (Endocrinologist)                  Dr. Harvey (Pediatrician)       
CT Children's Medical Center                  666-5601
545-9370 or 545-9600

Signed in agreement by:

___________________                     _____________________
Parent                                                    Date

___________________                     ______________________
School Official                                       Date

Physician                                               Date
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