Healthcare Provider Orders/diabetes Medical Management Plan Form - Student With Diabetes Using Insulin Pump
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1
2H
P
O
/D
M
M
P
EALTHCARE
ROVIDER
RDERS
IABETES
EDICAL
ANAGEMENT
LAN
S
TUDENT WITH DIABETES USING INSULIN PUMP
(M
F
V
3/23/2015)
ONTANA
ORM
ERSION
E
D
:
End Date:
FFECTIVE
ATE
S
’
:
Date of Birth:
TUDENT
S NAME
D
H
P
IABETES
EALTHCARE
ROVIDER INFORMATION
Name:
Phone #:
Fax #:
Email:
S
:
CHOOL
School Fax:
See accompanying Algorithm for Blood Glucose Results as supplement to these orders***
Monitor Blood Glucose
–
Check as needed if student has symptoms of high or low blood glucose or does not feel well
Before lunch
Other: ____________________________________________________________
Before PE
Other: ____________________________________________________________
Before leaving school
Other: ____________________________________________________________
Where to check:
Anywhere
Classroom
Health office
Other: ___________________________________
Insulin Pump Information:
Humalog or NovoLog or Apidra by pump
Other: ________________________
Carbohydrate Coverage:
Correction Bolus for Hyperglycemia:
All blood glucose results should be entered into pump.
Give 1 unit of insulin per:
Times given:
Before am snack
Before lunch
gm carbohydrate at breakfast
Before pm snack
Use pump suggested correction
gm carbohydrate at AM snack
Other: ______________________________________
gm carbohydrate at lunch
______________________________________
Give 1 unit of insulin for every _________mg/dl, with a target blood
gm carbohydrate at PM snack
glucose of _________________________mg/dl.
Bolus should occur:
before eating, or
other: ___________
Formula used to calculate correction:
Blood glucose _______ minus (-) target blood glucose ________ = _________.
Then divide (÷) by correction factor (_______) = ____________.
Check Ketones if nauseated, vomiting or has abdominal pain, or if blood glucose > 300 twice when tested 2-3 hours apart.
Use correction formula via syringe/pen.
Use correction formula via syringe/pen, and give an additional _____ units of insulin for moderate ketones, and _______ units
for large ketones.
*** Repeat ketone check in 2 hours, and repeat additional insulin if moderate or large ketones are still present.
* Basal insulin will be running continuously during school. Notes: _________________________________________________
* If infusion set comes out or needs to be changed:
Insulin via syringe every 3 hours
Change set at school
Moderate Exercise (lasting 30 minutes or more) and Sports with Pump:
Temporary Basal Decrease:
No
Yes (_______% for _______ minutes OR
for duration of exercise)
Student should monitor blood glucose hourly or when there are signs/symptoms of low/high blood glucose.
Diabetes Medications:
Glucagon (for emergency low blood glucose) - Dose: 0.5 mg
1.0 mg
Given IM or SC per thigh or arm
Medication: ________________________ Dose: ______________________ Times to be given: _________________
Medication: ________________________ Dose: ______________________ Times to be given: _________________
HCP Assessment of Student’s Diabetes Management Skills:
Parent/Guardian Authority:
* To adjust insulin dose: Yes No
Skill
Independent
Needs supervision
Cannot do
* To change frequency of blood glucose
Check blood glucose
Count carbohydrates
monitoring: Yes No
Deliver insulin bolus
Notes:
Change infusion set
Calculate dose & inject
Trouble shoot alarms,
malfunctions
Student may advance in independence through school year if school/parent agrees.
H
P
Date:
EALTHCARE
ROVIDER
S
/S
:
IGNATURE
TAMP
P
/ G
ARENT
UARDIAN
Date:
S
:
IGNATURE
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