Healthcare Provider Order & Care Plan For Student With Diabetes Form Page 2

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HEALTHCARE PROVIDER ORDER & CARE PLAN FOR STUDENT WITH DIABETES (2 of 2)
FOR LICENSED HEALTHCARE PROFESSIONAL USE ONLY:
Student:______________________________ DOB:___________ School:_______________________ Grade:______
Type____ Diabetes/Year of Diagnosis:_______ This plan is only valid for the current school year:_______--________
Trained School Diabetes Care Providers: ______________________________, _______________________________
Test Blood Sugar:
Before lunch
2 hours after lunch
Before exercise
After exercise
Before snack
Before getting on bus
As needed for signs/symptoms of low or high blood sugar
INSULIN ADMINISTRATION
GLUCAGON ADMINISTRATION
Pump – Type: ________________
Route:
Pen
Injection
.5 mg (less than 10 years)
If pump failure, use sliding scale
1.0 mg (more than 10 years)
Insulin type:
Lantus: _____________________units daily at__________________________
Insulin type: For Sliding Scale insulin dosage and blood sugar correction. ONLY to be used every 2 hours.
Humalog
Novolog
Apidra
Parent/guardian authorized to increase/decrease sliding scale within the following range: +/- 2 units of insulin.
If blood sugar greater than 300 mg/dl, check ketones.
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
Blood Sugar Range
mg/dl Administer
units
INSULIN/CARBOHYDRATE RATIO
Breakfast: 1 unit of insulin per
grams of carbohydrate
Mid Morning Snack: 1 unit of insulin per
grams of carbohydrate
Lunch: 1 unit of insulin per
grams of carbohydrate
Afternoon Snack: 1 unit of insulin per
grams of carbohydrate
Parent/guardian authorized to increase or decrease insulin to carbohydrate ratio within the following range: 1 unit per
prescribed grams of carbohydrates +/- 5 grams of carbohydrates.
STUDENT’S SELF CARE
Totally independent management.
Yes
No
Self injects with trained staff supervision.
Yes
No
Tests blood sugar independently.
Yes
No
Injections to be done by trained staff.
Yes
No
Tests and interprets urine/blood ketones.
Yes
No
Self treats mild hypoglycemia.
Yes
No
Needs verification of blood sugar by staff.
Yes
No
Monitors own snacks and meals.
Yes
No
Administers insulin independently.
Yes
No
Independently counts carbohydrates.
Yes
No
Self injects with verification of dose.
Yes
No
SIGNATURES
Parent _________________________________ Date_________
Physician
Date
Phone_________________ Fax_________________
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
School Health Nurse Review: ____________________________ ____________ Date: _________________

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