Download/Print Copy of Diabetes Medical Management Plan - Pump

Diabetes Medical Management Plan - Pump

Download/Print Copy of Diabetes Medical Management Plan - Pump

• EFFECTIVE DATE:
  • End Date:
• STUDENT’S NAME:
  • Date of Birth:
• DIABETES HEALTHCARE PROVIDER INFORMATION Name:
  • Phone #:
  • Fax #:
  • Email:
• SCHOOL:
  • School Fax:

See accompanying Algorithm for Blood Glucose Results as supplement to these orders***

Monitor Blood Glucose

Check as needed if student has symptoms of high or low blood glucose or does not feel well

• Before lunch
  • Other:
• Before PE 
  • Other:
• Before leaving school
  • Other:
• Where to check:
  • Anywhere
  • Classroom
  • Health office
  • Other:

Insulin Pump Information: 

• Humalog or NovoLog or Apidra by pump
  • Other: 
• Carbohydrate Coverage:
  • Give 1 unit of insulin per:
    • gm carbohydrate at breakfast
    • gm carbohydrate at AM snack
    • gm carbohydrate at lunch
    • gm carbohydrate at PM snack
• Bolus should occur:
  • before eating, or
  • other: 

Correction Bolus for Hyperglycemia:

All blood glucose results should be entered into pump.

• Times given:
  • Before am snack
  • Before lunch
  • Before pm snack
  • Use pump suggested correction
  •  Other: 

Give 1 unit of insulin for every _________mg/dl, with a target blood glucose of _______mg/dl.

Formula used to calculate correction:

• Blood glucose _______ minus (-) target blood glucose ________ = _________.
• Then divide (÷) by correction factor (_______) = ____________.

Check Ketones if nauseated, vomiting or has abdominal pain, or if blood glucose > 300 twice when tested 2-3 hours apart.

• Use correction formula via syringe/pen.
• Use correction formula via syringe/pen, and give an additional _____ units of insulin for moderate ketones, and _______ units for large ketones.
• *** Repeat ketone check in 2 hours, and repeat additional insulin if moderate or large ketones are still present.

* Basal insulin will be running continuously during school. Notes: 

* If infusion set comes out or needs to be changed:

• Insulin via syringe every 3 hours
• Change set at school

Moderate Exercise (lasting 30 minutes or more) and Sports with Pump:

• Temporary Basal Decrease:
  • No
  • Yes (_______% for _______ minutes OR  for duration of exercise)

Student should monitor blood glucose hourly or when there are signs/symptoms of low/high blood glucose.

Diabetes Medications:

• Glucagon (for emergency low blood glucose)
  • Dose:
  • 0.5 mg
  • 1.0 mg Given IM or SC per thigh or arm
• Medication:
  • Dose:
  • Times to be given:
• Medication:
  • Dose:
  • Times to be given:

HCP Assessment of Student’s Diabetes Management Skills:

Student may advance in independence through school year if school/parent agrees.

Parent/Guardian Authority:

• To adjust insulin dose:
  • Yes
  • No
• To change frequency of blood glucose monitoring:
  • Yes
  • No
• Notes:

 

HEALTHCARE PROVIDER SIGNATURE/STAMP:

• Date:

PARENT/ GUARDIAN SIGNATURE:

• Date:

STUDENT’S NAME:

• Date of Birth:

DIABETES HEALTHCARE PROVIDER INFORMATION

• Name:
• Phone #:
• Fax #:
• Email:
• SCHOOL:
  • School Fax:

Effective Date/Update:

• Healthcare Provider signature:
  • Parent/Guardian signature:
• Healthcare Provider signature:
  • Parent/Guardian signature:
• Healthcare Provider signature:
  • Parent/Guardian signature:
• Healthcare Provider signature:
  • Parent/Guardian signature:
• Healthcare Provider signature:
  • Parent/Guardian signature: