Diabetes Medical Management Plan Template Page 2
ADVERTISEMENT
1
2Institution Name and Address
Patient Label or MRN, Acct#, Patient name, DOB, Date of Service
DIABETES MEDICAL MANAGEMENT PLAN
Page 2 of 2
Part 3: Insulin Pump Supplement (continued)
Effective Date:
Student Name:
HYPOGLYCEMIA MANAGEMENT (
:
Low Blood Glucose)
Follow instructions in DMMP, but in addition:
If seizure or unresponsiveness occurs:
1.
Treat with Glucagon (See Diabetes Medical Management Plan)
2.
Call 911 (or designate another individual to do so)
3.
Stop insulin pump by any of the following methods (Send pump with EMS to hospital):
Placing in “suspend” or stop mode (See manufacturer’s instructions)
Disconnecting at site, pigtail or clip
Cutting tubing
4.
Notify parent
5.
If pump was removed, send with EMS to hospital
HYPERGLYCEMIA MANAGEMENT (
High Blood Glucose)
Follow instructions in diabetes medical management plan (DMMP), but in addition:
Prevention of DKA
(Diabetic Ketoacidosis)
If Blood Glucose (BG) is >250 mg/dL two times in a row, drink 8-16 oz. of water/hour and follow below:
Check ketones
(urine or blood)
Negative - small ketones (urine)
Moderate – large ketones (urine)
0 - 1.0 mmol/L (blood)
> 1.0 mmol/L (blood)
• Give correction bolus via pump
• Give correction bolus via syringe
• Return to usual activities/class
• Change infusion set
• Call MD/parent
Recheck BG in 1 ½ to 2 hours
Recheck ketones & BG every 2 hours
If BG has decreased:
If BG unchanged or higher:
• Recheck BG in 2
• Check ketones
hours
• Follow second column
Repeat insulin injection every 4 hours
procedure
until ketones are negative
ADDITIONAL TIMES TO CONTACT PARENT/GUARDIAN
Soreness, redness or bleeding at infusion site
Dislodged infusion set
Leakage of insulin at connection to pump or infusion site
Pump malfunction
Insulin injection given for high BG/ketones
Repeated Alarms
Other Instructions:
My signature below provides authorization for the above written orders. I/We understand that all treatments and procedures may be
performed by the school nurse, the student and / or trained unlicensed designated school personnel under the training and supervision
provided by the school nurse (or by EMS in the event of loss of consciousness or seizure) in accordance with state laws & regulations.
:
Date:
Physician/Provider
Provider Printed Name
School plan reviewed by:
Signature:
Parent/Legal Guardian:
Date:
Acknowledged and received by:
Acknowledged and received by:
School Representative:
Date:
Institution Form #
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical