Diabetes Medical Management Plan

DIABETES MEDICAL MANAGEMENT PLAN

Date of Plan:______This plan is valid from:______- ______

Child’s Name:______Date of Birth:______

Date of Diabetes Diagnosis:______Type 1 Type 2 Other______

CONTACT INFORMATION

Mother / Guardian:______

Address:______

Telephone: Home:______Work:______Cell:______

Email Address:______

Father / Guardian:______

Address:______

Telephone: Home:______Work:______Cell:______

Email Address:______

Physician / Health Care Provider:______

Address:______

Telephone:______

Other Emergency Contacts:

Name:______Relationship:______

Telephone: Home:______Work:______Cell:______

Name:______Relationship:______

Telephone: Home:______Work:______Cell:______

Name:______Relationship:______

Telephone: Home:______Work:______Cell:______

CHECKING BLOOD GLUCOSE

Target range of blood glucose: 70-130 mg/dL 70-180 mg / dL Other______

Check blood glucose level: Before lunch ______Hours after lunch

2 hours after correction dose Mid-morning Before PE After PE

Before dismissal Other:______

As needed for signs / symptoms of low or high blood glucose

As needed for signs and symptoms of illness

Preferred site of testing: Fingertip Forearm Thigh Other______

Brand / Model of blood glucose meter:______

Note: the fingertip should always be used to check blood glucose level if hypoglycemia is suspected.

Client's self-care blood glucose checking skills:

Independently checks own blood glucose

May check blood glucose with supervision

Requires nurse or trained diabetes personnel to check blood glucose

Continuous Glucose Monitor (CGM): Yes No

Brand/Model:______Alarms set for: Low and High

Note: Confirm CGM results with blood glucose meter check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM.

HYPOGLYCEMIA TREATMENT

Client's usual symptoms of hypoglycemia (list below):

______

If exhibiting symptoms of hypoglycemia, OR if blood glucose is less than ______mg/dL, give a
quick-acting glucose product equal to ______grams of carbohydrate.

Recheck blood glucose in 10-15 minutes and repeat treatment if blood glucose level is less than ______mg/DL

Additional Treatment:______

Follow Physical Activity and sports orders

If the client is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions, give:

Glucagon:1mg 1/2 mg Route: Subcutaneous Intramuscular Site for glucagon injection: Arm ThighOther:______

· Call 911 (Emergency Medical Services) and the client's parents / guardians.

· Contact client's health care provider.

HYPERGLYCEMIA TREATMENT

Client'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.

For insulin pump users: see additional information for client with insulin pump.

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.

· Notify parents / guardians of onset of hyperglycemia.

· If the client has symptoms of a hyperglycemia emergency, including 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: Call 911 (Emergency Medical Services) and the client's parents / guardians.

· Contact client's health care provider.

INSULIN THERAPY

Insulin delivery device: Syringe Insulin Pen Insulin Pump

Type of insulin therapy at school / camp:

Adjustable Insulin Therapy

Fixed Insulin Therapy

No Insulin

Adjustable Insulin Therapy

· Carbohydrate Coverage / Correction Dose:

Name of Insulin:______

· Carbohydrate Coverage:

Insulin-to-Carbohydrate Ratio:

Lunch: 1 unit of insulin per ______grams of carbohydrate

Snack: 1 unit of insulin per ______grams of carbohydrate

Dinner: 1 unit of insulin per ______grams of carbohydrate

CARBOHYDRATE DOSE CALCULATION
Grams of carbohydrate in meal
______= _____ units of insulin
Insulin-to-carbohydrate ratio

· Correction Dose:

Blood Glucose Correction Factor/Insulin sensitivity Factor=______

Target blood glucose=______mg/dL

CORRECTION DOSE CALCULATION
ACTUAL BLOOD GLUCOSE - TARGET BLOOD GLUCOSE
______= ______units of insulin
BLOOD GLUCOSE CORRECTION FACTOR/INSULIN SENSITIVITY FACTOR

Correction dose scale (use instead of calculation above to determine insulin correction dose):

Blood glucose______to______give______units

When to give insulin

Breakfast

Carbohydrate coverage only

Carbohydrate coverage plus correction dose when blood glucose is greater than______mg/dL

and______hours since last insulin dose.

Other:______

Lunch

Carbohydrate coverage only

Carbohydrate coverage plus correction dose when blood glucose is greater than______mg/dL

and______hours since last insulin dose.

Other:______

Snack

No coverage for snack

Carbohydrate coverage only

Carbohydrate coverage plus correction dose when blood glucose is greater than______mg/dL

and ______hours since last insulin dose.

Other:______

Dinner

Carbohydrate coverage only

Carbohydrate coverage plus correction dose when blood glucose is greater than______mg/dL

and______hours since last insulin dose.

Other:______

Fixed Insulin Therapy

Name of insulin:______

______Units of insulin given pre-breakfast daily

______Units of insulin given pre-lunch daily

______Units of insulin given pre-snack daily

______Units of insulin given pre-dinner daily

Other:______

Client's self-care insulin administration skills:

Yes No Independently calculates and gives own injections

Yes No May calculate / give own injections with supervision

Yes No Requires school nurse or trained diabetes personnel to calculate/give injections

ADDITIONAL INFORMATION FORCLIENT WITH INSULIN PUMP

Brand/Model of pump:______Type of insulin pump:______

Basal rates during school / programs:______

Type of infusion set:______

For blood glucose greater than______mg/dL that has not decreased within ______hours after correction, consider pump failure or infusion site failure. Notify parents/guardians or physician if client

is a resident.

For infusion site failure: Insert new infusion set and/or replace reservoir.

For suspected pump failure: suspend or remove pump and give insulin by syringe or pen.

Physical Activity: for a client with insulin pump

May disconnect from pump for sports activities Yes No

Set a temporary basal rate Yes No ______% temporary basal for ______hours

Suspend pump use Yes No

Client's self-care pump skills: INDEPENDENT?

Count Carbohydrates Yes No

Bolus Correct amount for carbohydrates consumed Yes No

Calculate and administer correction bolus Yes No

Calculate and set basal profiles Yes No

Calculate and set temporary basal rate Yes No

Change batteries Yes No

Disconnect Pump Yes No

Reconnect Pump to infusion set Yes No

Prepare reservoir and tubing Yes No

Insert infusion set Yes No

Troubleshoot alarms and malfunctions Yes No

OTHER DIABETES MEDICATIONS

Name:______Dose:______Route:______
Times given:______

Name:______Dose:______Route:______

Times given:______

MEAL PLAN (if child is a resident to be filled out by nutritionist / physician)

Meal/Snack TIMECarbohydrate Content (grams)

Breakfast ______to ______

Mid-morning snack ______to ______

Lunch ______to ______

Mid-afternoon snack ______to ______

Dinner ______to ______

Evening snack ______to ______

Other times to give snacks and content:______
amount:______

Special event / party food permitted: Yes No

Client's self-care nutrition skills:

Yes No Independently counts carbohydrates

Yes No May count carbohydrates with supervision

Yes No Requires school nurse / camp nurse / trained diabetes

personnel to count carbohydrates

PHYSICAL ACTIVITY AND SPORTS

A quick-acting source of glucose such as glucose tabs and/or sugar-containing juice must be available at the site of physical education activities and sports.

Client should eat 15 grams 30grams of carbohydrate other______

before every 30 minutes during after vigorous physical activity

other______

If most recent blood glucose is less than ______mg/dL, client can participate in physical activity when blood glucose is corrected and above ______mg/dL.

Avoid physical activity when blood glucose is greater than ______mg/dL or if urine/blood ketones are moderate to large.

(additional information for student with insulin pump is in the insulin pump section)

DISASTER PLAN

To prepare for an unplanned disaster or emergency (72 HOURS), obtain an emergency supply kit from parent/guardian (if resident, pharmacy).

Continue to follow orders in the DMMP.

Additional insulin orders as follows:______

Other:______

SIGNATURES

This Diabetes Medical Management Plan has been approved by:

______

Client's Physician / Health Care Provider Signature(REQUIRED) Date

I, (parent/guardian print name):______give permission to the school nurse / camp nurse or other qualified health care professional or trained diabetes personnel of Green Chimneys Children's Services to perform and carry out the diabetes care tasks as outlined in (client: print name)______'s Diabetes Medical Management Plan. I also consentto the release of information contained in the Diabetes MedicalManagement Plan toall school / camp staff members and other adults who have responsibility for my child and who may need to know this information to maintain my child's health and safety. I also give permission to the school nurse / camp nurseor another qualified health care professional to contact my child's physician / health care provider.

Acknowledged and received by:

______

Client's Parent / GuardianSignatureDate

______

Nurse / Other qualified health care personnelDate

______

WitnessDate