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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
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 )
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***
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
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)
C. Pupils will be large
D. Pale, moist skin
E. Cold and clammy
F. Extreme hunger
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
F. Loss of appetite
5. Lunch Time Blood Sugars:
Under 70 at lunch time Give Matthew a 4oz juice box
and send to lunch.
Sugar immediately after
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
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
being low, since many
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
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
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.
Sarah Ashley (mother)
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.
Tom Ashley (father)
Michelle Marques (aunt)
Dr. Ratzan (Endocrinologist) Dr. Harvey (Pediatrician)
CT Children's Medical Center 666-5601
545-9370 or 545-9600
Signed in agreement by:
School Official Date
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