Microsoft word - diabeticphysicianorders.doc

Diabetes Medical Management Plan
School District: ___________________School: __________________School Year: ___________Grade:_______
Student Name:____________________________________________ Provider Name: ______________________ Office Ph # _________________ Blood Glucose Monitoring at School
Blood Glucose Target Range: _______ - _______ mg/dl
Monitoring Schedule:
□ Before
Student Self Monitoring (check all that apply):
 Can test independently  Needs supervision  Needs assistance with testing and blood glucose management
 Other:___________________________________________________________________________________
Diabetes Medication

Oral medications: Home: ____________________________ School: ___________________________________
Insulin: (opened insulin must be discarded after 28 days)
□ No Insulin at School
Insulin at Home:
Insulin at School:
Insulin delivery device at school:
 Syringe and vial  Insulin Pen  Insulin Pump (see Pump Section) Insulin management at school:
Student is able to:
Independently self manage pump or insulin injection Meals and Snacks at School
Independent in Carbohydrate calculations and management:
Meal/Snack
Carbohydrate
Not on Fixed
Meal/Snack
Carbohydrate
Not on Fixed
Carb Count
Carb Count

Snack before exercise? □ Yes □ No □ As Needed Snack after exercise? □ Yes □ No □ As Needed
Snack/content/amount at other times: □ As Needed OR ________________________________________________

Foods to avoid: Liquid sugars such as fruit juice, regular soda and Gatorade (should be used for low blood sugars only)
Other:______________________________________________________________________
Instructions when food is provided to the class (e.g. as part of a class party or food sampling
event):_____________________________________________________________________________________
Carbohydrate Counting and Correction Sheet
Humalog/Novolog Insulin
Food: _______ units of Humalog/Novolog for every ______ grams of carbohydrate for meals and snacks.
Blood Sugar: _______ units of Humalog/Novolog for every _____mg/dl over ________mg/dl. Correction for blood sugars can be
made every 3 hours if needed.
Daily Lantus/Levemir Insuling: _______units a.m. ________ at bedtime
Insulin Pump: Use pump dosing. Dose listed above to be used in event of pump failure. See insulin pump care.
Parent authorized to adjust insulin dosage under the following circumstances:
_____________________________________________________________________________________________

Precautions:
Unless otherwise stated, cover all carbohydrates/snacks with insulin except those used to treat low blood sugar.
Parents need to communicate modifications of carbohydrates counting/insulin coverage to school nurse in writing.
PRE-MEAL Humalog/Novolog Doses
Blood Sugar Correction + Food Carbohydrate
Exercise and Sports
A fast acting carbohydrate such as Juice, regular soda, Gatorade, glucose tablets should be available at the site of exercise or
Individual Activity Restrictions for Student: □ Y □ N
If yes, list restrictions: _________________________________________________________________
_____________________________________________________________________________________________
General Restriction from Exercising:

• If blood sugar is below 80 mg/dl treat for hypoglycemia with above fast acting carbohydrates.
Snack listed above should be given: □ Yes □ No • If glucose is above 300 mg/dl OR moderate to large urine ketones are present OR blood ketones are>0.6 mmol/l, Notify
Hypoglycemia (Low Blood Sugar) = _____mg/dl and or Physical Symptoms

Symptoms of Hypoglycemia Include:
Shaky Sweaty
Precautions:
Never leave the student unattended. If treatment is to be provided in the Health Office, a responsible adult should accompany the student from
the classroom to the Health Office.
Check Blood sugar if student has not done so and is symptomatic
ƒ Notify School Nurse and Parent when any of the following treatments are performed.

Low Blood Sugar Treatment:
• Give ½ cup (4 oz.) of juice or regular soda or 3-4 glucose tablets (or 15 gms. of fast acting carbohydrate). Do not cover with insulin. The carbohydrate is given to treat the low blood sugar. • Recheck blood glucose in 15 minutes. If blood sugar is still below_____ give another 15 grams of carbohydrate.
• If the student’s blood sugar is above_____, give a 15-30 gram carbohydrate snack or lunch.
• Make sure the student feels well before sending to lunch. • Comments_______________________________________________________________ Treatment of disoriented, combative and incoherent but is conscious:
• Give ½ to 1 tube of glucose gel or cake decorating gel. Place gel between cheek and gum. • Massage the outside of cheek to facilitate absorption through the membrane of the cheek. • If still below ____, repeat treatment as above.
• Give sugar containing liquid and snack when student is alert and able to swallow safely. • Comments_______________________________________________________________
Treatment for seizures, loss of consciousness, inablility/unwillingness to take gel or juice:
• Give glucagon immediately by injection. Dose: □0.3cc □0.5cc □1.0cc
• Call 911
• Notify parents
• Comments__________________________________________________________ Hyperglycemia (High Blood Sugar) =_□250 or □300_ mg/dl

Symptoms of Hyperglycemia Include:
Extreme Thirst
Other________________________________________________________________________________________
Check Ketones:
• Urine should be checked for ketones when blood glucose levels are above 300 mg/dl. • If urine ketones are moderate to large, CALL PARENT IMMEDIATELY! • If student is on pump, and urine ketones are moderate to large OR blood ketones are 0.6mmol/l or more, call parents. Treatment for ketones and/or high blood sugar:
• Allow student to use restroom as often as necessary • Call parents immediately if student is vomiting Treatment for high glucose with ketones, moderate, large or > 0.6 or greater: (check all that apply)
□ Call parents immediately for action plan
□ Parents will determine the insulin coverage needed
□ Follow blood sugar correction guidelines – see dosing sheet
Supplies Kept at School
□ Blood glucose meter, blood glucose test □ Insulin vials and syringes □ Insulin pump and supplies □ Insulin, pen, pen needles, insulin cartridges □ Lancet device, lancets, gloves, etc. Insulin Pump
□ Insulin Pump Care Information Attached Student is able to operate insulin pump

Student can troubleshoot problems
(e.g. Urine ketones, pump malfunction) Comments:___________________________________________________________________________________________________________________________________________________________________________ Insulin Adjustments by Healthcare Provider or Parent (for use by School Nurse)
Date New Orders
Obtained
*Note Change in Care Sheet
Nurse Signature

SIGNATURES:
This Diabetes Medical Management Plan has been approved by:
____________________________
________________ _______________________ I give my permission to the school, school nurse, unlicensed assistive personnel, and other designated staff member(s) to perform and carry out the diabetes care tasks as outlined by this Diabetes Medical Management Plan for my child, ________________________ and I acknowledge that I have received a copy of the signed plan. I also consent to the release of the information contained in this plan to all staff and other adults who have custodial care of my child and who may need to know this information to maintain my child’s health and safety. I will notify extra-curricular staff about health plan and care to be given during after school activities. I give my permission for the school nurse to contact my child’s health care provider(s) regarding the above condition. Acknowledged and received by:
Change in Care Sheet
DOB:_______________ New Order Date:_______________

Carbohydrate Counting and Correction
Food: _______ units of Humalog/Novolog for every ______ grams of carbohydrate.
Blood Sugar: _______ units of Humalog/Novolog for every _____mg/dl over ________mg/dl.
ƒ Correction for blood sugars can be made every 3 hours if needed.
ƒ Unless otherwise stated, cover all carbohydrates and snacks with insulin. Do not cover carbs used to treat
low blood sugar.
PRE-MEAL Humalog/Novolog Doses
Blood Sugar Correction Food Carbohydrate

Lantus dose is: ___________________________AM __________________________ at bed time.
Bed time corrections: ___________________________________________
At bed time correct blood sugar to: ____________________.
Bedtime & 3:00 am Correction:

If blood sugar is less than _____ at bedtime, give _____ grams of carbohydrate + protein without Humalog/Novolog
coverage for this snack.


□ Change in Carb Counting and Blood Sugar correction per parent (if applicable).
□ Change in Carb Counting and Blood Sugar Correction per provider
□ Additional Changes to Initial Orders:
________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature
PREVENTING KETOACIDOSIS IN INSULIN PUMP USERS
Why are insulin pumpers at risk for ketoacidosis?

Pumpers have no long acting insulin in their body (Lantus or Levemir). If the flow of insulin from
the pump stops, the body will make ketones very quickly.
What are the signs of high ketones?
▪ Nausea ▪ Stomach cramps ▪ Vomiting ▪ Trouble breathing Usually blood sugar is high when there are high ketones but ketoacidosis can even occur if the blood sugar is under 200. A person may think they have the stomach flu, when in fact they are becoming sick from high ketones. The symptoms are exactly the same. If insulin is not given immediately, ketoacidosis will result. Test urine or blood for ketones if the following symptoms are present. (Check expiration date on strips; if blood ketone strips are past expiration date, the machine will not read them). ▪ Feeling sick or nauseated ▪ Blood sugar over 300 ▪ Blood sugar over 250 two times in a row Follow directions below if ketones are present.
Less than 0.6 mmol/l Blood Ketones OR Trace/Small Urine Ketones
ƒ ADMINISTER correction bolus through insulin pump.
ƒ RECHECK blood sugar and ketones in 1 hour.
ƒ GIVE 4-8 oz. sugar free liquids by mouth every hour.
ƒ If blood sugar not improved in one hour, ADMINISTER insulin correction
dose by syringe in amount equal to that recommended by the bolus wizard for the current blood sugar level. ƒ REMOVE catheter and REPLACE insulin, cartridge, tubing and catheter. ƒ ADMINISTER next bolus through pump with new set in place.
0.6 mmol/l to 3.0 mmol/l Blood Ketones OR Moderate to Large Urine Ketones
ƒ ADMINISTER correction dose of fresh insulin by syringe immediately in
amount equal to that recommended by bolus wizard for the current blood sugar level. ƒ GIVE 4-8 ounces sugar free liquids by mouth every hour. ƒ REMOVE catheter and REPLACE insulin, cartridge, tubing and catheter. ƒ RECHECK blood sugar and ketones every 2-3 hours. ƒ ADMINISTER next bolus through pump with new set in place.
More that 3.0 mmol/l Blood Ketones
ƒ ADMINISTER double amount of correction insulin dose by syringe
immediately.
ƒ REMOVE catheter and REPLACE insulin, cartridge, tugging and catheter. ƒ CHECK blood sugar and ketones every 2-3 hours and set future correction doses ƒ ADMINISTER 4-8 oz. of sugar free liquids every hour. ƒ CALL the healthcare provider and parent/guardian.

Source: http://health-services.rrps.net/modules/groups/homepagefiles/gwp/2117024/2319746/File/Health%20Docs/DiabeticPhysicianOrders.pdf