Student Name
|Student Name |Sex |Date of Birth |
| |( Female | |
| |( Male |_______/_________/_____________ |
| | |Month Day Year |
|School |Grade |Counselor/Teacher |
|( MAS ( CENT ( MUR ( CHATS ( HMX ( HS ( Other: | | |
|EMERGENCY SITUATIONS |Diagnosis ( Type 1 Diabetes ( Type 2 Diabetes |
| |( Other |
|Severe Hypoglycemia |Risk for Diabetic Ketoacidosis (DKA) |Blood Glucose Monitoring & Insulin Orders |
|( Give Glucagon and Call 911 |( Ketones: Test ketones if hyperglycemic*, vomiting, |Student |
|PRN for unconsciousness, |or fever ≥ 100.5. If initial or retest ketones are |May check bG without supervision |
|unresponsiveness, seizure, or |moderate or large, give water and: |May check bG with supervision |
|inability to swallow EVEN if the |( Call parent and/or MD ( No PE |Must have school personnel check bG |
|bG is unknown. Turn onto left |( If vomiting, unable to take PO, and MD not available, |May give insulin without supervision |
|side to prevent aspiration. |CALL 911 |May give insulin with supervision |
|1 mg SC/IM |( Give insulin, if ordered below |Must have school nurse give insulin |
|_______ mg SC/IM | | |
| |( Lunch |( Snack |( PE |( PRN |
| | | | | |
|Hypoglycemia |For bG < _____ mg/dL |For bG < _____ mg/dL |For bG < _____ mg/dL |For bG < ______ mg/dL |
| |Give ______ oz juice, |Give ______ oz juice, |Give ______ oz juice, |Give ______ oz juice, |
| |or ______ glucose tabs, or ______ |or ______ glucose tabs, or ______ |or ______ glucose tabs, or ______ |or ______ glucose tabs, or gm |
| |gm carbs |gm carbs |gm carbs |carbs |
| |Recheck in ______ minutes; |Recheck in ______ minutes; |Recheck in ______ minutes; |Recheck in ______ minutes; |
| |If bG < ______, repeat carbs and |If bG < ______, repeat carbs and |If bG < ______, repeat carbs and |If bG < ______, repeat carbs |
| |recheck until bG > ______. |recheck until bG > ______. |recheck until bG > ______. |and |
| |THEN |THEN | |Recheck until bG > ______. |
| | | |( If initial bG < ______, No PE | |
| |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |( Give snack AFTER treatment THEN |( Give snack after treating |
| |( Give insulin AFTER lunch |( Give insulin AFTER snack |send student to PE |hypoglycemia |
|Between |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |( Give snack BEFORE PE | |
|Hypo-and | | | | |
|Hyperglycemia |( Give insulin AFTER lunch |( Give insulin AFTER snack |( Send to PE | |
| | | | | |
|Hyperglycemia |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |
| |Treat as per Risk for DKA above |Treat as per Risk for DKA above |Treat as per Risk for DKA above |Treat as per Risk for DKA above |
|* bG > ______ | | |For bG > ______ mg/dL, no PE |For bG > ______ mg/dL, no PE |
| |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |For bG > ______ mg/dL, AND at least |For bG > ______ mg/dL, AND at |
| | | |______ hours since last insulin, |least ______ hours since last |
| |( Give insulin AFTER lunch |( Give insulin AFTER snack |give insulin according to: |insulin, give insulin according to: |
| | | |( Correction Dose, OR |( Correction Dose, OR |
| | | |( Sliding Scale |( Sliding Scale |
| | | |(orders below) |(orders below) |
|Carb Coverage |( Carb coverage only |( Carb coverage only | | |
|Insulin |( Carb coverage PLUS Correction |( Carb coverage PLUS Correction | | |
|Instructions |Dose when bG > Target bG |Dose when bG > Target bG | | |
|INSULIN ORDERS ( Carb Coverage (plus Correction Dose ( Sliding Scale ( Carb Coverage plus Sliding Scale ( No Insulin at School |
|(CHECK ONE BOX ONLY) if ordered above) for Correction |
|Glucose Monitoring ONLY |
|( Syringe / ( Pen |Name of Insulin |( Insulin Pump (Brand & Model) |
|Target (Single #) |Sensitivity Factor (Correction) |Insulin:Carb For LUNCH For SNACK |Basal In School | ( Disconnect |
| | | |Rate ______ units/hour |pump for PE |
|bG = ______ mg/dL |1 unit will decrease bG by ______ mg/dL |Ratio: (I:C) 1: ______ gms 1: ______ | | |
| | |gms | | |
| |For Pump: |
|Round DOWN the insulin dose to the closest 0.5 units for syringe/pen |( Follow Pump recommendation for bolus |
| |dose [If not using Pump recommendation, |
| |round DOWN the dose down to the nearest |
| |0.1 unit] |
| |( For bG > ______ mg/dL that has not |
| |decreased ______ hours after correction, |
|Example: Current bG = 250 Target bG = 150 Sensitivity Factor = 100 Insulin:Carb ratio = 1:20 Lunch carbs = 60 |consider pump failure. Notify parent. |
|gms |( For suspected pump failure: |
| |DISCONNECT pump and give insulin by |
|Carb Coverage 60 gms carb |syringe or pen. |
|250 — 150 | |
|Plus 20 | |
|100 | |
|Correction Dose TOTAL DOSE: 3 + 1 = 4 UNITS | |
|SLIDING SCALE |( Pre lunch bG Range Insulin |( Other time bG Range Insulin |
|Name of Insulin |Units |Units |
| |To |To |
|_________________________________ |To |To |
|Please do NOT overlap ranges (e.g. 100-200, 200-300, |To |To |
|etc.). |To |To |
|If ranges overlap, the lower dose will be given. | | |
|SNACK: |HOME MEDICATIONS: |OTHER DIABETES ORDERS: |
|Time of day: ____________________ | | |
|Type & Amount: | | |
| | | |
| | | |
|( Student may carry and self administer snacks | | |
| |Insulin (Dose, Frequency and Time): | |
| | | |
| |Oral Medications (Dose, Frequency, and Time): | |
| | | |
|Health Care Practitioner Name (Please Print) |Tel No. |Parent Signature( |
|Health Care Practitioner Signature |Fax No. |Date |
|Address |Date | |
| | |( Parent signature denotes permission to share the above |
| | |student’s medical information with staff on a |
| | |need-to-know basis and also gives permission to speak to |
| | |child’s physician/practitioner as needed. |
|PLACE OFFICE STAMP HERE | | |
-----------------------
Carb Coverage =
# gms carb in meal bG — Target bG
# gms carb in I:C Sensitivity Factor
Correction Coverage =
= # units
insulin
= # units insulin
Carb Coverage:
= 1 unit
= 3 units PLUS Correction Dose:
................
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