Diabetes Medical Management Plan (Dmmp) Template Page 3
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7Hypoglycemia treatment
Student’s usual symptoms of hypoglycemia (list below): _____________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
If exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than ______ mg/dL, give a quick-acting glucose
product equal to ______ grams of carbohydrate.
Recheck blood glucose in 15 minutes and repeat treatment if blood glucose level is less than ______ mg/dL.
Additional treatment: __________________________________________________________________________________
_____________________________________________________________________________________________________
If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions
(jerking movement):
•
Position the student on his or her side to prevent choking.
•
Other (dose) __________
Give glucagon:
1 mg
½ mg
•
Route:
Subcutaneous (SC)
Intramuscular (IM)
•
Site for glucagon injection:
Buttocks
Arm
Thigh
Other: __________
•
Call 911 (Emergency Medical Services) and the student’s parents/guardians.
•
Contact the student’s health care provider.
Hyperglycemia treatment
Student’s usual symptoms of hyperglycemia (list below): ___________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
•
Check
Urine
Blood for ketones every ____ hours when blood glucose levels are above ______ mg/dL.
•
For blood glucose greater than ______ mg/dL AND at least ____ hours since last insulin dose, give correction dose of
insulin (see correction dose orders).
•
Notify parents/guardians if blood glucose is over ______ mg/dL.
•
For insulin pump users: see
.
Additional Information for Student with Insulin Pump
•
Allow unrestricted access to the bathroom.
•
Give extra water and/or non-sugar-containing drinks (not fruit juices): _____ ounces per hour.
Additional treatment for ketones: ___________________________________________________________ ______________
•
Follow physical activity and sports orders. (See Physical Activity and Sports)
If the student has symptoms of a hyperglycemia emergency, call 911 (Emergency Medical Services) and contact the student’s
parents/guardians and health care provider. Symptoms of a hyperglycemia emergency include: dry mouth, extreme thirst,
nausea and vomiting, severe abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness
or lethargy, or depressed level of consciousness.
Insulin therapy
Insulin delivery device:
Syringe
Insulin pen
Insulin pump
Type of insulin therapy at school:
Adjustable (basal-bolus) insulin
Fixed insulin therapy
No insulin
Page 3 of 7, DMMP
Tools for Effective Diabetes Management
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