Diabetes Medical Management Plan Supplement For Students Wearing Insulin Pump Form Page 2
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2If two consecutive blood glucose readings over 250 (2 hours or more after first bolus given)
1. Check urine ketones
2. Give correction bolus as an injection
3. Change infusion set
4. Call parent
MANAGEMENT OF LOW BLOOD GLUCOSE Follow instructions in Basic Diabetes Care Plan, but
in addition:
If low blood glucose recurs without explanation, notify parent/diabetes provider for potential
instructions to suspend pump.
If seizure or unresponsiveness occurs:
1. Call 911 (or designate another individual to do so).
2. Treat with Glucagon (See basic Diabetes Medical Management Plan)
3. Stop insulin pump by:
□ Placing in “suspend” or stop mode (See attached copy of manufacturer’s instructions)
□ Disconnecting at pigtail or clip (Send pump with EMS to hospital)
□ Leakage of insulin
4. Notify parent
5. If pump was removed, send with EMS to hospital
ADDITIONAL TIMES TO CONTACT PARENT
□ Soreness or redness at infusion site
□ Insulin injection given
□ Detachment of dressing/infusion set out of place □ Other: ____________________________________
□ Leakage of insulin
____________________________________
Effective Date (s) of Pump plan: __________________
Parents Signature: _________________________________________________ Date: _______________
School Nurse Signature: ____________________________________________ Date: _______________
Diabetes Care Provider Signature: _____________________________________ Date: _______________
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Revised 7/2015
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