Barren River District Health Department

Site:______

Barren River District Health Department

Please fax back to:______

Butler, Edmonson, Hart, Logan, Metcalfe, Simpson, Warren Counties

Primary Care Provider (PCP) Authorization: Diabetes/ Blood Glucose Monitoring(use only if the Endocrinologist doe not supply their own IHP/ orders)

Student Name: ______Date of Birth: ______

Classroom: ______Hospital of Choice:______

Breakfast Time______Lunch Time______

DIAGNOSIS:

_____Type I Diabetes_____ Type II Diabetes_____ Pre-Diabetes ______Other Condition Requiring Glucose Monitoring

Where should blood glucose monitor & equipment be?

_____classroom_____office_____nurse’s office_____backpack

Required blood sugar testing/monitoring at school:

_____Trained personnel must perform blood sugar test

_____Trained personnel must supervise blood sugar test

_____Student can perform testing independently

Times blood sugar monitoring to be done?

____Breakfast ______Lunch ______PRN_____Other______

Does this student require insulin/Bolus during school?

____YES_____ NO

Can this child administer his/her own insulin/Bolus independently if needed at school?

____YES _____NO

Trained personnel must supervise insulin/Bolus administration:

____YES _____NO (A non-licensed person must have completed the KBN training for administration of insulin)

Student can calculate his/her own insulin/Bolus dose:

_____YES____ NO

Insulin/ Bolus to be administered:

_____ Before breakfast _____After breakfast_____Before lunch______After lunch

______with snacks_____with classroom parties

Does this student have an insulin pump?

_____ YES_____ NO

Insulin/Carbohydrate ratio dose:

___ unit for every ___gram(s) of carbohydrate eaten,

plus ___ unit(s) for every ____ mg/dl points above _____ mg/dl

Should insulin dose calculations be rounded?____ YES____ NO ____Half Unit _____Whole Units

____Correction Dose:

Insulin (subcutaneous injection) _____Humalog____NovoLog ____Apidra____Regular ____Other______

_____Unit(s) if blood sugar is between _____ and _____

Special Diet Requirements:

****Please complete Special Needs Diet Form for KY and forward to cafeteria manager*****

______Carbohydrate Count ______carbs/meal should be offered to child

Does student require a SCHEDULED snack during the school day?_____ Yes_____ No

 If yes, do they need insulin with snack? (See Insulin dose on back)_____ Yes_____ No

HYPERGLYCEMIA (HIGH BLOOD SUGAR): SIGNS & SYMPTOMS: dry mouth, increased urination, tired, thirsty, hungry, sleepy, headache * If symptoms persist – can lead to nausea, vomiting, stomach pain, fruity smelling breath

IF BLOOD SUGAR IS GREATER THAN ______, DO THE FOLLOWING INTERVENTIONS:

_____Encourage extra liquids without sugar such as water. No extra juice or milk.

_____Allow frequent trips to the restroom.

_____Ketone monitoring: ______

(If student is positive for ketones, MUST notify parent/guardian)

Other: ______

HYPOGLYCEMIA (LOW BLOOD SUGAR):SIGNS & SYMPTOMS: hunger, staring, becoming very quiet, dizzy, crying, headache, clammy sweat, nervous, unable to think clearly, shaky, blurry vision, restless, weak, unusually sleepy, pale, confused or disoriented, stumbling around,change in personality (mean/hateful)

IF BLOOD SUGAR IS LESS THAN______, DO THE FOLLOWING INTERVENTIONS:

Provide one of the examples of a simple sugar:

____ 3-4 glucose tablets _____1 small tube of glucose gel _____ 3-5 small sugar cubes _____ 2-3 packs of table sugar

Provide one of the 15 gram complex carbohydrates:

_____ 4 peanut butter or cheese crackers _____½ sandwich _____carton of orange juice ____lunch

_____recheck in 15 minutes then follow immediately with a 15 gram snack of complex carbohydrate or lunch. If no improvement within 15 minutes, then repeat simple sugar.

_____Staff/student may check blood sugar 30 minutes after initial treatment.

_____Call parent if the blood sugar does not rise above ______mg/dl.

_____Allow 30-60 minutes for complete recovery before resuming normal school activities (tests, PE). It may not be necessary to send the student home.

Other: ______

EMERGENCY PLAN OF ACTION:

Emergency Glucagon: Given only if ordered for a student when that student is having a seizure, unconscious or severely neurologically impaired related to severe hypoglycemia or low blood sugar.

Glucagon kits are to be provided by the parent/guardian.

1.If student becomes unconscious or unresponsive, administer GLUCAGON ______cc, if kit provided by parent/guardian.

2. Call 911.

3. Notify school personnel trained in CPR/first aid to respond and initiate CPR if needed prior to EMS arrival.

4. Contact parent/guardian or emergency contact immediately.

5. If EMS is called the student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and then parent/guardian assumes responsibility for student. The student may not return to school that day.

6. When student is transported via EMS, staff must accompany student to ER unless parent and/or emergency contact accompanies them.

6. If student requires medical treatment while on the bus, the driver will contact EMS.

7. Other: ______

______

PRINTED NAME OF PHYSICIAN, ARNP PHONE NUMBER DATE

______

SIGNATURE OF PHYSICIAN, ARNP FAX NUMBER

______

ADDRESS OF PHYSICIAN, ARNP

I give permission for (name of child) ______to receive the above stated medication at school according to standard school policy. I release the ______School Board and its employees from any claims or liability connected with its reliance on this permission

______

Signature of Parent/ Guardian Phone number Date

This order and plan of care is valid for the current school year only.

Parent to supply all medications, diabetic supplies and snacks.

Reviewed by School Nurse______

Copy to pertinent school staff______

(4-2014) 6A-4