Medication Orders and Guidelines for Diabetic Treatment
Part 1
Name of student: ______Date of Birth ______- ______- ______
Last First MI
School: ______
To the licensed prescriber: The monitoring and treatment of students with diabetes, requires medical clearance and direct written orders from their licensed prescriber. These orders will be carried out for one school year unless otherwise ordered, or there is achange in the student’s health status. Please use this form to indicate treatment that pertains to your patient.
PLEASE COMPLETE THE FOLLOWING: Diagnosis: Diabetes Type 1 Type 2
Finger stick Blood Glucose Testing:
Frequency: before lunch and as needed for symptoms of high or low blood sugar.
Consent for self-testing (provided the school nurse determines it is safe and appropriate):
Yes (No supervision required) Yes, under direct supervision No
Orders and Guidelines for Hypoglycemia (Blood sugar less than 80 mg/dl)
- Treat with fast acting carbohydrate. Blood sugar <50 = 30g CHO and retest in 15 minutes, blood glucose 50-79 = 15 g CHO
- Re-test in 15 minutes. If blood sugar is 80 or above, student may return to class. If blood sugar is not at least 80, retreat with fast acting carbohydrate and then re-test in 15 minutes. Repeat until blood sugar is at least 80.
- If next meal/snack > 60 minutes away, please follow with small snack containing complex carbohydrates with protein, such as cheese crackers, up to approximately ______carbohydrates.
Glucagon:
Route of Administration: SQ/IMDosage: ½ cc (0.5 mg) 1 cc (1mg) N/A
Frequency: as needed for severe low blood sugar with altered consciousness (loss of consciousness, seizure, inability to
swallow).
Call EMS.
Possible side effects, contraindications, or adverse reactions: nausea/vomiting. Position student on side after Glucagon
administration until fully awake.
May not be self-administered.
Other Medications:
Other Diabetes medications being taken by student:
Insulin at home: ______
Oral Diabetes medication: ______
Any Additional Orders: ______
______
Name and Title of Licensed Prescriber (PRINT): ______
Phone: ______Fax: ______
Signature of Licensed Prescriber: ______Date: ______
Medication Orders and Guidelines for Diabetic Treatment
Part 2
Name of student: ______Date of Birth: _____ - _____ - ______
Last First MI
Insulin: Route of Administration: SQ by syringe or insulin pen Pump
Time: Pre-lunch and ______
Insulin Type: Humalog Novolog Regular
Correction Method for Elevated Blood Glucose
A. if blood sugar is ______or above, use the following sliding insulin scale:
Sliding Scale______- ______give ______units ______- ______give ______units
______- ______give ______units ______- ______give ______units
______- ______give ______units ______- ______give ______units
B.Algorithm for bolus/injection:
Formula for high blood glucose (BG) correction: (Current BG) – (Target BG) = Units of insulin to be given
Correction Factor
Blood Glucose Target: ______mg/dl.
Correction Factor: ______
C.Allow Pump Correction Feature (“Bolus Wizard” etc) to determine dosage with input of BG and/or carbohydrate intake.
In event of insulin pump failure revert to Algorithm method above and cover by injections (SQ).
Coverage of Carbohydrate Intake:
Insulin to carbohydrate ratio: ______Units insulin for every ______grams of carbohydrate intake
Snacks and Meals:
AM Snack time _____ / Grams of carbs ______
PM Snack time _____ / Grams of carbs ______
Lunch Recommend carbohydrate range: ______
Additional Treatment Protocol:
Ketone Management
Check ketones when BG >250 mg/dl. Parents will supply ketone strips. Students only need to be sent home if nauseated and/or vomiting.
Strenuous exercise will be permitted when BG > 250 mg/dl only if ketones negative to trace amount.
If ketones are small or trace and student is not nauseated then they should drink extra water.
Ketosis (lasting 4 hours or more) indicates need for q ____ hr. BG monitoring and insulin by injection, not by pump.
Hyperglycemia Management Additional To Mealtime Management
Students should receive additional care at home, at hospital, or through follow-up with physician/practitioner if:
- BG = “HI” at any time
- Persistent hyperglycemia (BG>400 mg/dl) persists after 2-3 hours of treatment and monitoring
School nurse may administer pump bolus or injection of Humalog/Novolog for BG>300 mg/dl q 2 Hr. PRN: Yes No
Other: ______
Insulin Side Effects: Hypoglycemia. Do not correct high blood glucose more frequently than every 2 hours with Humalog or Novolog or every 3 hours with regular insulin.
Any Additional Orders:
Consent for self-administration (provided school nurse determines it is safe and appropriate).
Yes: Yes, under direct supervision of licensed provider, LPN, RN, or parent/guardian: No:
Name and Title of Licensed Prescriber (PRINT): ______
Phone: ______Fax: ______
Signature of Licensed Prescriber: ______Date: ______
I give my permission for my child to be treated per above ordered and for the exchange of pertinent information. I understand it is the parent/guardian’s responsibility to provide insulin and all testing and treatment supplies.
Signature of Parent/Guardian: ______Date: ______