Diabetes Flow Chart printable pdf download

Diabetes Flow Chart

Name _______________________________________________________ DOB _________

UT Le Bonheur

K = Urine Ketones

Provider ____________________________________ Wt. ___________

Office: 901-287-6949

Pediatric Specialists

Fax: 901-937-6689

Insulin Dose

Correction

Long Acting

51 N. Dunlap • Memphis, TN 38105

Pager: 901-418-0254

w/Meals __________

Dose _____________

Insulin Dose_____________

Breakfast: ______

Snack: ______

Lunch: ______

Snack: ______

Dinner: ______

Bedtime: ______

2-3 a.m.: ______

Insulin

Blood

Date

Carbs

Glucose

Units

Type

Units

Type

Units

Type

Units

Type

Monday

Comments/

_____ /_____

Tuesday

Comments/

_____ /_____

Wednesday

Comments/

_____ /_____

Thursday

Comments/

_____ /_____

Friday

Comments/

_____ /_____

Saturday

Comments/

_____ /_____

Sunday

Comments/

_____ /_____

1. Check blood glucose 15 minutes after a low reading and treatment given.

Check urine or blood ketones if child is sick or blood glucose is more than 240.

2. Check blood glucose 2 hours after an insulin correction is given.

Comments: Insulin Reactions; Exercise/ Meals and Snacks; Stress; Infections; Extra Insulin; Insulin Injection Site

PS005001.0113 REV

Diabetes Flow Chart

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