Diabetes Management Plan- Insulin Pump
Student ______Birth date ______Age when diagnosed ______
Teacher/Team ______Grade _____ Transportation: □ bus # _____ □ car rider
Blood Sugar Monitoring:
Test Blood Sugar: Before meal After meal Before Exercise After Exercise Before snack Before bus/dismissal
If symptoms of low or high blood sugar
Ø Notify parent if blood sugar below mg/dl or higher than mg/dl.
Ø Target range for blood sugar is mg/dl to mg/dl.
Ø Type of Meter: Meter to be stored in: Health Office Classroom Student’s book bag
Pump info: Type of Pump:
Ø Note: Pump settings are established by the student’s healthcare provider and should not be changed by school staff.
Ø Extra pump supplies furnished by parent/guardian: infusion sets (School Nurse does not change infusion set/site) reservoirs
batteries back up insulin syringes/insulin pen
Ø Contact parent/guardian with any concerns about pump, including redness or soreness at site, pump failure or error messages.
Hypoglycemia: (low blood sugar) Student should be sent to office accompanied by an adult if symptomatic or BS is less than 80 mg/dl.
Ø This student’s most common complaint(s) when BS is low or dropping is:
Ø Test blood sugar - if blood glucose meter not available, treat symptoms.
Ø For blood sugar less than mg/dl: Treat with 15 gram carbohydrate snack (juice, glucose tab, etc) and recheck every 10-15 minutes until above 70mg/dl, then treat with protein snack or lunch and notify parent.
Ø If unable to drink juice: Administer glucose gel or cake icing. Recheck and retreat every 10-15 minutes until BS >70 mg/dl, then snack/lunch.
Ø Carbohydrates that were used to bring blood sugar up to within target range should NOT be covered with insulin
Ø If unconscious, seizing, unable or unwilling to take glucose gel or juice: Administer Glucagon mg(s) IM or SQ and call 911, position student on side because may vomit, then notify parent/guardian. When regains consciousness follow with fast sugar. Disconnect pump and send it with EMS.
Hyperglycemia: (high blood sugar)
Ø This student’s most common complaint(s) when BS is high is:
Ø If elevated Blood sugar, encourage water or sugar free fluids. Allow unrestricted bathroom privileges.
Ø Check urine ketones if blood sugar is over 250 mg/dl or with symptoms of nausea/vomiting. If moderate or large ketones are present give injection using correction scale below. If ketostix not available, treat with correction scale insulin and give water and call parent. Recheck blood sugar in 1 hour.
Ø If ketones present, call parent, provide water and student should NOT exercise.
Ø If student having symptoms of nausea and vomiting call parent/guardian to pick up in order to be treated and monitored more closely and encourage to call to doctor.
Ø All blood sugars should be entered into pump (manually or with a linked meter) and the calculated correction given.
Ø No exercise if blood sugar is higher than mg/dl with or without ketones.
Ø BS above 300 mg/dl with ketones or 2 consecutive unexplained BS greater than 250 mg/dl (with or without ketones), may indicate a malfunctioning pump. Student may require insulin via injection and/or new infusion site/set.
Ø Contact parent, then healthcare provider for bolus instructions. An order for insulin specific to the incident may be faxed from the healthcare provider. Verbal orders must be followed by a faxed order.
Insulin Administration: Correction Scale: Blood sugar correction and insulin dosage for pump malfunction (may be used every 2 hours)
Ø Type of Insulin
Ø Back up insulin to be administered via: Syringe yes no Insulin pen yes no
Blood Sugar Range mg/dl Administer units
Blood Sugar Range mg/dl Administer unit
Blood Sugar Range mg/dl Administer units
Blood Sugar Range mg/dl Administer units
Blood Sugar Range mg/dl Administer units
Blood Sugar Range mg/dl Administer units
Ø Parent/guardian authorized to increase or decrease correction scale within the following range: +/- 2 units of insulin. yes no
Carbohydrate counting:
Ø Meals: Carbohydrate recommendation for meals: units of insulin per grams of carbohydrates at meals
Ø Bolus for carbs eaten (or to be eaten) should occur immediately Before meal After meal ½ bolus before & ½ bolus after
Ø Snacks: Student to have scheduled snack: yes no If yes, when?
If snacks greater than grams of carbohydrates cover with insulin No insulin overage for snacks.
Ø Parent/guardian authorized to increase or decrease insulin to carbohydrate ratio within the following range: 1 unit per prescribed grams of carbohydrates +/- 5 grams of carbohydrates. yes no
Student ______Birth date ______
Student’s Ability to Self Manage Diabetes:
Totally independent in all aspects of care Yes No If you answered yes, skip to signatures
Independently tests blood sugar. Yes No Administers insulin independently. Yes No
Independently counts carbohydrates. Yes No Self injects with verification of dosage. Yes No
Needs assistance with pump management. Yes No Injection to be done by trained staff Yes No
Independently manages pump boluses. Yes No Self treats mild hypoglycemia. Yes No
Independently inserts new infusion set Yes No Tests and interprets urine/blood ketones. Yes No
Troubleshoots all alarms. Yes No
Signatures:
1. Physician Authorization for Medication Administration and Specialized Health Care Procedures:
Physician’s signature: ______Physician’s name printed: ______
Office telephone: ______Date: ______
2. Parent/Guardian Authorization for medication administration and specialized health care procedures:
Student’s parent/guardian knows of this request and is in full agreement of the plan of care, the administration of the medications and procedures specified above during the school day. He/She agrees to provide all necessary supplies needed to test blood sugar and to treat high or low blood sugars on the first day back to school. He/She further understands that this should include blood sugar monitor, test strips and lancets, insulin pump supplies such as infusion sets, reservoirs, batteries and back up insulin with syringes/insulin pen, ketostix, snacks, juice and a water bottle and understands that all insulin vials or insulin pen refills must be replaced every 30 days once opened.
The parent/guardian releases the School Board, its agents and employees, from any and all liability that may result from his/her child taking these prescription medications and/or receiving these specialized health care procedures and is aware that these orders expire no later than the last day of school this year.
Parent/Guardian’s signature: ______Parent/Guardian’s name printed: ______Date: _____
Reviewed by School Nurse: ______Date: ______
3. Parent/Guardian Authorization for the Release of Information:
I hereby give permission for my child’s school to exchange specific, confidential medical information with the physician listed above on my child, ______, to develop more effective ways of providing for the healthcare needs of my child in school.
Parent Signature: ______Date: ______
4. Student contract for Self-administered Medication:
o I will be responsible for my own diabetic supplies at school. Where are Diabetic supplies kept during school day? ______
o I agree to use my diabetic supplies/medication in a responsible manner, in accordance with my licensed health care provider’s orders.
o I will notify the School Nurse or main office if I am having more difficulty than usual with my diabetes.
o I will not allow any other person to use my diabetic supplies/medication.
Student’s Signature: ______Date: ______
Contact Information:
Father’s Name: ______
Daytime telephone: ______Cell phone: ______
Mother’s Name: ______
Daytime telephone: ______Cell phone: ______
Emergency Contact: ______
Daytime telephone: ______Cell phone: ______
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