Healthcare Provider Orders/diabetes Medical Management Plan Form - Student With Diabetes On Insulin Injection
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2H
P
O
/D
M
M
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EALTHCARE
ROVIDER
RDERS
IABETES
EDICAL
ANAGEMENT
LAN
STUDENT WITH DIABETES ON INSULIN INJECTIONS
(M
F
3/23/15)
ONTANA
ORM VERSION
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 for signs and symptoms of low or high 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:
Humalog/NovoLog/Apidra
Other: ________________________________________
Insulin Delivery:
Syringe/vial
Pen
Carbohydrate Coverage:
Breakfast: Give 1 unit for _______ grams of carbohydrate
OR
Standard daily insulin injection (please describe):
AM Snack: Give 1 unit for _______ grams of carbohydrate
______________________________________________
Lunch:
Give 1 unit for _______ grams of carbohydrate
______________________________________________
PM Snack: Give 1 unit for _______ grams of carbohydrate
______________________________________________
Correction scale:
OR
Correction Formula:
BG Range: ____________ Give________ units
Give ______ units of insulin for every __________ mg/dl of blood glucose
BG Range: ____________ Give _______ units
above target blood glucose of ___________________mg/dl.
BG Range: ____________ Give________ units
BG Range: ____________ Give _______ units
Formula used to calculate correction:
BG Range: ____________ Give________ units
Blood glucose ______ minus(-) target blood glucose _______ = ________.
BG Range: ____________ Give _______ units
Then divide (÷) by correction factor (__________) = _______________.
Give Correction Scale Before Lunch Only
Other: ____________________________________________________
Do not give insulin correction dose more than once every 3 hours to prevent “stacking” insulin.
Check ketones if nausea, vomiting or abdominal pain OR if blood glucose >300 twice when checked 2-3 hours apart.
Use correction scale OR Use correction scale plus an additional ______ units for moderate and ______ units for large.
Repeat ketone check in 2 hours, and repeat additional insulin if moderate or large ketones are still present.
Exercise and Sports:
Student should monitor blood glucose hourly Other:_____________________________
Parent/Guardian Authority:
To adjust insulin dose:
Yes
No
To change frequency of blood glucose monitoring:
Yes
No
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:
Notes:
Skill
Independent
Needs supervision
Cannot do
Check blood glucose
Count carbohydrates
Calculate insulin dose
Injection
Student may advance in independence through school year if school/parent agrees.
H
P
Date:
EALTHCARE
ROVIDER
S
/S
:
IGNATURE
TAMP
Parent/Guardian
Date:
Signature:
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