Diabetes Forms
by Kellie Bamford
August 11, 2011
Students with diabetes are welcome to use the following form for physican Diabetic Care orders during school hours. In addition the Medication Order form can be found on this website under medications. Please discuss your child's plan with your School Nurse.
Andover Public Schools
DEPARTMENT OF HEALTH SERVICES
Medical Management for Diabetes
To be completed by parents/school nurse and physician. (Physician must sign)
Diabetes Care Plan for _____ School Effective Date:
(Name of Pupil)
Date of Birth: _________ Age of Onset: Grade: Homeroom Teacher:
Contact Information:
Parent/guardian #1: Address:
Telephone – Home: Work: Cell Phone:
Parent/guardian #2: Address:
Telephone – Home: Work: Cell Phone:
Pupil’s Doctor/Health Care Provider: Phone:
Nurse Educator: Phone:
Parent designee: Relationship:
Telephone – Home: Work: Cell Phone:
Hospital Choice: Known Allergies:
Blood Glucose Monitoring ___ No, will be managed at home. Type of blood glucose meter student uses:_____________________________________________
Target range for blood glucose: ____ mg/dl to ____ mg/dl
Times to test must be checked below:
Usual times to check blood glucose
mid-morning before exercise/PE when student exhibits symptoms of hyperglycemia
pre-lunch after exercise when student exhibits symptoms of hypoglycemia
mid-afternoon other (explain):
Can student perform own blood glucose tests? _____ Yes _____ No Exceptions:
Insulin ____ No, will be managed at home. ____ Routine Insulin (supplemental on next page)
BREAKFAST – give: LUNCH – give:
_______units OR _______units OR
_______units/_______grams of carbohydrates OR _______units/_______grams of carbohydrates OR
_______units/_______calories _______units/_______calories
Type: Type:
Other (e.g., pre-lunch supplemental):
Can student give own injections? ___ Yes ___ No
Can student determine correct amount of insulin? ___ Yes ___ No
Can student draw correct dose of insulin? ___ Yes ___ No
Home insulin: Type ______________ Dose __________________ Frequency ___________________
For Students with Insulin Pumps:
Type of pump:
Insulin/carbohydrate ratio:
Correction factor:
Is student competent regarding pump? ___Yes ___No
Can student effectively troubleshoot problems (e.g.
ketosis, pump malfunction)? ___Yes ___No
Comments:
Meals and Snacks Eaten at School (The carbohydrate content of the food is important in maintaining a stable blood glucose level.)
Time Food content/amount
Breakfast
A.M. snack
Lunch
P.M. snack
Other times to give snacks and content/amount:
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For Hypoglycemia – when blood sugar is below
Common symptoms:
Oral Treatment/Amount:
Glucagon ordered? No Yes 1 unit (1mg) 1/2 unit (1/2 mg)
Recheck Blood Glucose 15 minutes following oral treatment. If blood glucose is still below 70, may repeat oral treatment and recheck blood glucose again in 15 minutes.
* If blood glucose is still below 70, repeat oral treatment and notify a parent or parent designee to pick
up the pupil and care for him/her until blood glucose has been above 90 for at least 1 ½ hours.
* If blood glucose is above 70, follow with a protein snack. Pupil may return to class if he/she is not
experiencing any symptoms of hypoglycemia.
• Glucagon should be given if the student is unconscious, having a seizure, or is unable to
swallow.
° Give Glucagon (School Nurse will administer Glucagon IM; designated trained
school personnel will administer Glucagon SubQ).
° Call 911
° Notify parent or parent-designee (see page 1)
° Notify physician if unable to reach parent or parent-designee (see page 1)
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For Hyperglycemia – when blood sugar is above (always check for ketones)
NO exercise if any ketones or if BS is > . NO SPORTS/Extracurricular activities if BS is >________. NO Sports/Extracurricular activities if ketones are present and BS is > ________.
When supplemental insulin is NOT ordered:
A. If blood glucose is 250 or above with ketones, encourage water.
B. If blood glucose is 250-300 without ketones, encourage water and mild exercise.
C. If blood glucose is >300, with or without ketones, encourage water.
D. If blood glucose is >350 encourage water. Recheck in 60 minutes. If level is still elevated, parent or
parent-designees will be notified to pick pupil up from school and care for him/her
until level is below 300.
E. Student should be sent home for glucose above ______ and / or (circle one) _____ amt. of ketones.
When supplemental insulin is given at school:
Administer supplemental insulin when Blood Sugar is > .
Amount of Insulin:
Can administration of insulin be repeated? Yes If yes, frequency No
Indications and amount:
Other:
When supplemental insulin is given, blood sugar should be rechecked 60 minutes after insulin administration.
Student should be sent home for glucose above ________ and / or (circle one) _______amt. of ketones.
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Supplies to be kept at school:
Parent comments/concerns:___________________________________________________________________
___________________________________________________________________________________________
Signatures: Please write any additional orders/comments on back
Approved by:
(Physician’s Signature) (date)
(Physician printed name) (Phone #)
Acknowledged/received by:
(Guardian)
