Diabetes Medical Management Plan Supplement For Students Wearing Insulin Pump Form
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1
2North East Independent School District
DIABETES MEDICAL MANAGEMENT PLAN SUPPLEMENT FOR STUDENTS WEARING INSULIN PUMP
School Year ____________ - _____________
Student Name: _____________________________ DOB: ______________ Pump Brand/Model: ________________________
Pump Resource Person: ______________________ Phone/Cell: ____________________
(See basic diabetes plan for parent phone #)
Child Lock On?
YES
NO
How long has student worn an insulin pump? ________________________
Blood Glucose Target Range __________________ Pump Insulin: Humalog
Novolog
Regular
Insulin: Carbohydrate Ratios: ______________________________________________________________________________
(Student to receive carbohydrate bolus immediately before / ____________________________________ minutes before eating)
Lunch/Snack Boluses Pre-programmed? YES
NO
Times: ___________________________________________
Insulin Correction Formula for Blood Glucose Over Target: ______________________________________________________
Extra Pump supplies furnished by parent/guardian: infusion sets
reservoirs
batteries
dressings/tape
insulin
syringe/pen
NEEDS HELP?
IF YES, TO BE ASSISTED BY AND COMMENTS
STUDENT PUMP SKILLS
1. Independently count carbohydrates
Yes
No
2. Give correct bolus for carbohydrate
Yes
No
consumed
3. Calculate and administer correction
Yes
No
bolus
4. Recognize signs/symptoms of site
Yes
No
infection
5. Calculate and set a temporary basal
Yes
No
rate
6. Disconnect pump if needed
Yes
No
7. Reconnect pump at infusion set
Yes
No
8. Prepare reservoir and tubing
Yes
No
9. Insert new infusion set
Yes
No
10. Give injection with syringe or pen,
Yes
No
if
11. Troubleshoot alarms and
Yes
No
malfunctions
12. Pre-program basal profiles if
Yes
No
needed
MANAGEMENT OF HIGH BLOOD GLUCOSE Follow instructions in basic diabetes medical
management plan, but in addition:
If blood glucose over target range ________ hours after last bolus or carbohydrate intake, student should
receive a correction bolus of insulin using formula;
Blood glucose - _________ ÷ __________ = _________ units insulin
If blood glucose over 250, check urine ketones
1. If no ketones, give bolus by pump and recheck in 2 hours
2. If ketones present or _______________________, give correction bolus as an injection immediately
and contact parent/health care provider
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