HEALTH CARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS STUDENT’SNAME____________________________Student’sbirthdate___/___/___School_____________Grade___ Emergency numbers for parents (phone) ____-_____-_____ (Cell contact 2) ____-_____-_____ (Cell) ____-_____-____ Doctor’s phone number_____-_____-______ Other contacts________________________________, _____-_____-______ HYPOGLYCEMIA (fill in individualized instructions on line or use those in parenthesis) Unconscious--___________________________________________(phone 911) (Other orders)___________________ Blood sugar < 60 and symptomatic _______________________(juice, pop, candy) _______________________________ Blood sugar < 100 and symptomatic _______________________(crackers/cheese) _______________________________ Blood sugar < 80 and asymptomatic ______________________(feed partial meal) _______________________________ Blood sugar > 100 and symptomatic _______________________(feed partial meal) Blood sugar at which parent should be notified–low ____________ high ___________ BLOOD SUGAR AND INSULIN DOSAGE prior to lunch (R is regular and H is lis-pro,) _____________ any other insulin requested Blood sugar < 100
____________ units R - H - other __________________ (see hypoglycemia above)
____________ units R - H - other __________________
____________ units R - H - other __________________
____________ units R - H - other __________________
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
• Licensed medical personnel allowed to give _____ units (minimum) of insulin to _____ units (maximum) of R, H, other _________ insulin after consultation with the parent/guardian. • Other insulin instructions (i.e., CHO counting):______________________________________________________ • If urine ketones (trace, small, moderate, large) call parents (circle one or more) DISASTER INSULIN DOSAGE-in case of disaster how much insulin should be given? Recommend 80% of usual dose. A.M.
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
STUDENT’S SELF-CARE (ability level) Totally independent management or
student needs verification of number by staff or
assist/testing to be done by school nurse
2. Student administers insulin independently or
student self-injects with verification of number or
student self-injects with nurse supervision or
3. Student self-treats mild hypoglycemia
4. Student monitors own snacks and meals
5. Student tests and interprets own urine ketones
6. Student tests and interprets own blood ketones
HCP _______________________________ (print/type) _________________________signature _____/_____/_____ date Parent ______________________________ (print/type) _________________________signature _____/_____/_____ date School Nurse _________________________ (print/type) _________________________signature _____/_____/_____ date Start date: ____day ____mo. ____yr. Termination date: _____day _____mo. _____yr. or End of school year: _____ Must be renewed at beginning of each school year.
Klaas Akkerman ~ TU Delft ~ 1502182Joop Kok ~ VU ~ 2521706Maurits van Putten ~ VU ~ 2521450Charlotte van Schoonhoven ~ VU ~ 1963511De opdracht om een erfgoedmanifest te schrijven huidige opvattingen aantonen en anderzijds het debat over een Vinex-wijk lijkt in eerste instantie onmogelijk. over erfgoed en architectuur van een nieuw perspectief Echter, als de architectuur van de Vinex-wijk zich
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