Diabetic Lhcp Insulin Pump Authorization/order Form printable pdf download

Everett Public Schools

Blood Sugar at which parent/guardian should be notified:

Health Services

Low: ______ High: ______

DIABETIC LHCP INSULIN PUMP AUTHORIZATION/ORDER (RCW28A.210.320)

For Seizure or Loss of Consciousness: 911 and cut tube to stop pump. Send insulin pump with EMS.

Student’s Name:

DOB:

ID#:

Grade:

____________________________________________

_________________

________________

_________

Parent/Guardian:

Home Phone: _________________ Work Phone: ______________________

____________________________________

Cell Phone: _______________________________________ E-Mail: ________________________________________________

LHCP:

Office name:

Phone:

__________________________

________________________________

____________________ FAX: ________________

How long has student been on insulin pump therapy?

0-6 months

6-12 months

1-2 years

2+ years

Type of insulin in pump:

Pump brand/model:

Child lock on?

YES

________________

_____________________________

Blood glucose at which the parent/guardian should be notified: Low: ______ High: _____

Blood glucose target range: ___________

Basal rates & boluses (meals/snacks/corrections) programmed?

YES

Student to check blood sugar before:

Meals

Recess

Snacks

Other: ____________________________

Insulin dosage: Student to receive carbohydrate bolus:

All before eating

½ before ½ after eating

Other: ______________

See Blood Sugar/Carbohydrate/Insulin Chart attached if needed.

Other dosing protocol attached

Parent/guardian may decrease insulin by _____ units or increase insulin by _____ units without a new LHCP signed order.

DISASTER PLAN: __________________________________________________________________________________________

Student’s Level of Pump/Blood Glucose Monitoring Skills

Student Totally Independent in all areas listed below and understands not to share supplies/medication.

Skill

Independent

Needs

Skill

Independent

Needs

Assistance

2. Independently counts carbohydrates

9. Fills reservoir or cartridge and

primes tubing

3. Gives correct bolus for carbohydrates

10. Inserts infusion set

consumed

4. Calculates and administers correction

11. Trouble shoots all alarms

bolus

5. Sets temporary basal rate

12. Recognizes signs/symptoms of site

infection.

6. Disconnects pump if necessary

Blood Glucose Testing

7. Reconnects pump at infusion site

1. Student tests blood glucose

8. Gives injection with syringe/pen

2. Student needs verification of

blood glucose # by staff.

Hypoglycemia:

Blood glucose below 45: ____________________________________________________________________________________

Blood glucose 45-65: _______________________________________________________________________________________

Blood glucose 65-80: _______________________________________________________________________________________

Blood glucose greater than 80 with symptoms: ___________________________________________________________________

Repeat Test after 15 minutes. If blood sugar is still less than 80, repeat treatment and continue to notify parent.

Hyperglycemia: Contact parent/guardian if blood sugar is greater than desired range.

Ketones: Check ketones if blood glucose is greater than ________, and notify parent/guardian.

Student should go home if ketones are moderate or large.

Exercise (recess/PE) plan:

Student to have 15 grams of carbohydrates before

Recess.

End of school day:

Student should not ride bus or walk home if blood sugar is below _____________.

The above named student is authorized to use an insulin pump and medication in accordance with the instructions indicated

above for the current school year.

►LHCP Signature: ___________________________ LHCP Printed Name: ______________________________ Date: _____

Parent/guardian: The insulin pump and all supplies are to be furnished by me. I understand that my signature indicates my

understanding that reasonable care will be exercised in supporting the usage of the pump at school. The school accepts no

responsibility for adverse reactions when the pump is used in accordance with the LHCP’s directions. I also understand the

importance of being available for consultation and support with my student’s insulin pump.

►Parent/Guardian Signature: _____________________________________________________________ Date: ___________

►Student signature if totally independent: ___________________________________________________ Date: ___________

Diabetic LHCP Insulin Pump 5/07 Reviewed 4/10

RN Signature/Date: ____________________________________

Diabetic Lhcp Insulin Pump Authorization/order Form

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