No decrease in your ability to maintain normal activity level. Green Zone Means: Keep your Home Care Nurse appointments. Keep physician appointments …
AGENCY NAME
Self Management Plan for Diabetes
Name:________________________________________________
Date:________________________
|Green Zone All Clear |Green Zone Means: |
| | |
|Average blood sugars are typically under ____________ |Your symptoms are under control |
|Most fasting blood sugars are under_________________ |Continue taking your medications |
|No decrease in your ability to maintain normal |Continue to follow your diet |
|activity level |Keep your Home Care Nurse appointments |
| |Keep physician appointments |
|Yellow Zone Caution |Yellow Zone Means: |
| |
|
|Average blood sugars are between __________ and |Your symptoms indicate that you may need an |
|_________ |adjustment in your medications |
|Most fasting blood sugars are under _____________ | |
|You are experiencing signs and symptoms of high or low|Call your Home Health Nurse and/or your physician |
|blood sugar |AGENCY NAME 24 hour phone number is: |
|You can not always maintain your ability of normal |XXX-XXXX |
|activity level |Primary MD:_____________________________________ |
| |Phone Number:__________________________________ |
| |Please notify your Home Care Nurse if you contact or|
| |go see your MD |
|Red Zone Medical Alert |Red Zone Means:
|
| | |
|Average blood sugars are above__________ or under |This indicates that you need to be evaluated by a |
|_____________ |physician right away |
|Most fasting blood sugars are well over ___________ or| |
|under ___________ |Primary MD:_____________________________________ |
|You can not maintain your normal activity level |Phone Number:__________________________________ |
|You are unable to stay awake even during the day |AGENCY NAME 24 hour phone number is: |
|Client is not responsive Call 9-1-1 immediately |XXX-XXXX |
| |Please notify your Home Care Nurse if you go to the |
| |emergency room or are hospitalized |
Source:hoover.k12.al.us
