Diabetic Medical Management Plan for Schools

DIABETIC MEDICAL MANAGEMENT PLAN FOR SCHOOLS

School Year:______(Note: this order is good for the maximum of one year)

Student’s Name______Date of Birth:______

School Name: ______Grade: _____ Plan Effective Date: ______

Diagnosis: Diabetes □ Type 1 □ Type 2 Date of Diagnosis: ______

Doctor: ______DM Educator: ______

TO BE FILLED OUT BY DIABETIC HEALTH CARE PROVIDER

BLOOD GLUCOSE MONITORING

Time(s) to be performed: □ Before Breakfast □Before PE

□ Mid-morning/ before snack □ After PE

□ Before Lunch □ Mid afternoon

□ Dismissal □ Other:______

**Always test for signs and symptoms of high or low blood glucose**

TargetRange for Blood Glucose:______mg/dl to ______mg/dl

INSULIN THERAPY

Patient uses Adjustable Insulin Therapy while in school: Y/ N

(If student is to have scheduled, standard insulin dose at school daily you may fill out an order and submit to school)

Insulin Delivery System: □ Syringe/Vial □ Pen □Pump

Type of Insulin: □ Humalog□ Regular□ Novolog Other:______

Time to be given at school: □Prior to lunch □Immediately After Lunch □ Other:______

Correction Dose of Insulin:

□ Use formula: (Actual Blood Glucose – Target Blood Glucose)/Blood Glucose Correction /Insulin Sensitivity = units of insulin

Target Blood Glucose:______mg/dl

Blood Glucose Correction Factor/Insulin Sensitivity Factor= ______

□ Use Sliding Scale:

Blood Glucose: ______Insulin Dose: ______

Carbohydrate Intake and Insulin Coverage:

Does this student cover their carbohydrate intake with insulin? □ Yes □ No

Cover Carbohydrates at □ Lunch □Snack Other:______

______# unit(s) per ______grams of carbohydrates (□ Add to corrective dose of insulin)

Exercise, Sports, and Other Physical Activity:

Child should not exercise if blood glucose level is below ______mg/dl

If student has low blood glucose treat in accordance with Emergency Car Plan (allow student to have snack).

□Parent may recommend lower dose of insulin before and/or after unusual exercise (example sports day)

□Parent is authorized to change the target blood glucose, correction factor, or insulin to carb ration as follows (amount or conditions):______

______

Emergency Medication at School: Glucagon □0.5 mg or □1mg IM to be used for treatment of severe hypoglycemia as indicated as the inability to swallow oral treatment, seizing, or unconscious.

Call 911 immediately and notify parents (Note: Glucagon to be provided by parents)

Physician’s Signature: ______Date: ______

Diabetic Educator Signature:______Date:______

Parent’s Signature: ______Date: ______

School Nurse Signature:______Date: ______

Great Falls Public Schools Nursing Department ●2400 Central Avenue, Great Falls, MT59405

Phone: 268-7700Fax: 268-7004