DIABETES. Student DOB School Grade. Doctor Phone Diabetes Phone Student is on oral diabetes medication(s) Dose: Times to be given . Student is on insulin. …
HEALTHCARE PROVIDER ORDER FOR STUDENT WITH DIABETES
Student DOB School Grade
Doctor Phone Diabetes Phone
Educator
Monitor Blood Glucose Before lunch After lunch Before PE After PE
Before snack Before getting on bus/going home As needed for
signs/symptoms of low or high blood glucose
Blood glucose at which parent should be notified Low mg/dl
and High mg/dl
Target range for blood glucose mg/dl to mg/dl
Hypoglycemia Student should not be sent to office unaccompanied if
symptomatic or BS less than 70 mg/dl
Check blood glucose - if blood glucose meters not available, treat
symptoms
Blood glucose between 60 to 70 mg/dl and symptomatic Treat with 10 to
15 gram carbohydrate snack
Mild symptoms: Treat with juice, glucose tabs, etc until above 70
mg/dl, then snack or lunch
Moderate symptoms if unable to drink juice: Administer glucose gel
Retreat until above 70 mg/dl, then snack or lunch
Severe symptoms which may include seizures, unconscious, unable or
unwilling to take gel or juice:
Administer Glucagon mgs IM or ____ units SQ if trained staff
available and call 911
Hyperglycemia
Check urine ketones if blood glucose is over 300 mg/dl or with symptoms of
illness/vomiting If ketones present, call parents,
provide water and student should not exercise Student may need
insulin via injection
Use sliding scale insulin orders when blood glucose is
______________mg/dl
? Recommend student be released from school when ketones are
moderate/large or symptoms of illness in order to be treated and
monitored more closely by parent/guardian
Medication
Student is on oral diabetes medications Dose:
Times to be given
Student is on insulin Type: Dose:
Times to be given
Blood Glucose Correction and Insulin Dosage using Rapid Acting Insulin:
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
Blood Glucose Range mg/dl Administer units
and check ketones
Blood Glucose Range
mg/dl Administer units
and check ketones
Blood Glucose Range mg/dl Administer units
and check ketones
Blood Glucose Range mg/dl Administer units
and check ketones
If ketones present, call parents, provide water and student should not
exercise
Carbohydrate counting units of insulin per grams
of carbohydrate with lunch
Parent/guardian authorized to increase or decrease sliding scale within
the following range: /- 2 units of insulin
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
Students Self Care ability level
Totally independent management Yes No Self injects with trained
staff supervision Yes No
Monitors independently Yes No Injections to be done by trained
staff Yes No
Needs verification of blood glucose by staff Yes No Self treats
mild hypoglycemia Yes No
Assist/testing to be done by trained staff Yes No Monitors own
snacks and meals Yes
No
Administers insulin independently Yes No Independently counts
carbohydrates Yes No
Self injects with verification of dose Yes No Monitors and interprets
urine/blood ketones Yes No
SIGNATURES
My signature below provides authorization for the above written orders and
exchange of health information to assist the school nurse in developing an
Individualized Health Plan I understand that all procedures will be
implemented in accordance with state laws and regulations and may be
performed by unlicensed designated school personnel under the training and
supervision provided by the school nurse This order is for a maximum of
one year
Physician Date
Parent Date
School Nurse Date
Source:d49.org
