Maryland State Management Of Diabetes At School/order Form

Maryland State Management of Diabetes at School/Order Form

Student: ______________________________

Blood Glucose Monitoring:

Target range for blood glucose monitoring at school:_______________________

2 hours or _______ hours after lunch

Before snacks

2 hours or ______ hours after a correction dose

Before meals

As needed for symptoms of hypo/hyperglycemia

With signs and symptoms of illness

Other times: ______________________________________________

Hypoglycemia – blood glucose less than ______

Self treatment for mild lows.

Give _____ grams of fast-acting carbohydrate according to care plan. Recheck BG in 10-15 mins. Repeat treatment if BG less than ___mg/dl

Provide extra protein & carbohydrate snack after treating low if next meal/snack greater than ____ minutes away

Suspend pump for severe hypoglycemia for _____ mins.

If student is unconscious, having a seizure or unable to swallow, presume student is having a low blood sugar and:

Call 911, notify parent

Glucagon injection (1 mg in 1 cc) ______ mg, subcutaneously or intramuscular (IM)

OK to use glucose gel inside cheek, even if unconscious, seizing.

Other: _____________________________________________________________________________

Hyperglycemia – blood glucose greater than ______

Check urine ketones, follow care plan, administer insulin as per orders.

For pumps, insulin may be given by syringe or pen if needed.

Encourage sugar free fluids, at least _____ ounces per ______.

If student complains of nausea, vomiting or abdominal pain; check urine ketones & check insulin administration orders.

Other: _______________________________________________________________________________________

* Transport to local Emergency Room may be needed with vomiting and large ketones.

Meal Plan

AM snack, time: ________

PM snack time: ________

Avoid snack if blood glucose greater than ______ mg/dl.

Lunch: ____________________________________________

Extra food allowed;

Parent’s discretion;

Student’s discretion

Exercise (check and/or complete all that apply)

Fast-acting carbohydrate source must be available before, during and after all exercise.

With student

With teacher

If most recent blood glucose is less than ______, exercise can occur when blood glucose is corrected and above ______.

Eat ______ grams of carbohydrate

Before

Every 30 mins during

After vigorous exercise

Avoid exercise when blood glucose is greater than _______ or ketones are _______

Bus Transportation

Blood glucose monitoring not required prior to boarding bus

Check blood glucose 15 minutes prior to boarding bus

Allow student to eat on bus if having symptoms of low blood glucose

Provide care as follows: ___________________________

Health Care Provider Assessment

Student can self-perform the following procedures (school nurse and parent must verify competency):

Blood glucose monitoring

Measuring insulin

Injecting insulin

Determining insulin dose

Independently operating insulin pump

Other: ______________________________________________________________________________________

Disaster Plan (if needed for lockdown, 24 hr shelter in place):

Follow insulin orders as on Management Form

Additional insulin orders as follows: _________________________________________

Administer long acting insulin as follows: _________________________________________

Other: _____________________________________________________________

Other instructions:

______________________________________________________________________________________________________________

Health Care Providers Signature:__________________________

Phone: ________________

Date: ____________

Parent's Signature: _____________________________________

Phone: ________________

Date: _____________

Order reviewed by School Nurse (per local policy): _________________________________

Date:______________

MSDE6/04

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Maryland State Management Of Diabetes At School/order Form - 2004 Page 2

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