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Insulin Injection & Medication Administration AddendumInsulin to be given for: FORMTEXT ????? (lunch, snack, etc)Student: FORMTEXT ?????DOB: FORMTEXT ?????School: FORMTEXT ?????Grade: FORMTEXT ?????Physician/Provider: FORMTEXT ?????Phone: FORMTEXT ?????Diabetes Educator: FORMTEXT ?????Phone: FORMTEXT ?????Insulin & Oral Medications: FORMCHECKBOX Oral Medication: FORMTEXT ????? FORMTEXT ?????mg by mouth Time: FORMTEXT ????? FORMCHECKBOX NPH InsulinDose: FORMTEXT ????? units SQTime: FORMTEXT ????? Rotate site FORMCHECKBOX Rapid Acting/Short Acting) Insulin Type: FORMTEXT ????? Blood Glucose Correction and Dosing using Rapid Acting Insulin Injection site: FORMCHECKBOX Abdomen FORMCHECKBOX Arm FORMCHECKBOX Buttock FORMCHECKBOX ThighInjections should be given subcutaneously & rotatedLunchtime Correction: Give FORMCHECKBOX Prior to lunch FORMCHECKBOX Split ? before lunch & ? after lunch FORMCHECKBOX Immediately after lunch FORMCHECKBOX Other : FORMTEXT ????? FORMCHECKBOX Sensitivity/Correction Factor: FORMTEXT ????? unit insulinfor every FORMTEXT ?????mg/dl above target BG range starting at FORMTEXT ?????Blood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketonesBlood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketonesBlood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketonesBlood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketonesBlood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketonesBlood Glucose Range: FORMTEXT ?????mg/dl to FORMTEXT ?????mg/dlAdminister: FORMTEXT ????? units FORMCHECKBOX Check ketones FORMCHECKBOX Parent/guardian authorized to increase or decrease sliding scale +/- 2 units of insulin per Guidelines for Insulin Management*When hyperglycemia occurs other than at lunchtime: FORMCHECKBOX If it has been greater than 3 hours since the last dose of insulin, the student may be given insulin via injection using the indicated correction factor on the provider orders if approved by the school nurse and parent is notified. FORMCHECKBOX Notify School Nurse, Parents (who may come and give insulin) or School Nurse will contact Health Care Provider for One-time order as needed. Other: FORMTEXT ?????NOTE: Insulin Pen/Vial expires 28 days after it is opened and use is beganCarbohydrates and Insulin Dosage: FORMCHECKBOX Breakfast FORMCHECKBOX Snack FORMCHECKBOX Lunch FORMCHECKBOX Other: FORMTEXT ?????Insulin to Carbohydrate Ratio: FORMTEXT ????? unit(s)for every FORMTEXT ????? grams of carbohydrate to be eaten FORMCHECKBOX Parent/guardian authorized to increase or decrease insulin to carb ratio 1 unit +/- 5 grams of carbohydratesCarb FORMTEXT ????? gmAdminister FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gmAdminister FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gmAdminister FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsCarb FORMTEXT ????? gm Administer FORMTEXT ????? unitsComments: FORMTEXT ?????*Per Guidelines for Insulin Management (FEB 2013): Adjustments should not exceed three times per week for correcting BGs below target range, & not exceed two times per week for correcting BGs above the target range.Parent Signature: FORMTEXT ?????Date: FORMTEXT ?????School Nurse Signature: FORMTEXT ?????Date: FORMTEXT ????? ................
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