(Pediatric Education for Diabetes in Schools) program. The procedures for diabetes care at school are based on research and provide for …
Reviewed by Camp RN initial ____ date _____
Diabetes Management for River Valley Ranch Health Services
If the participant has been diagnosed with diabetes and is under the age of 18, this form must be completed and signed by both the physician and the parent or legal guardian Participants Name:____________________________________DOB___________Camp/program_______________ 1 Authorized Health Care Provider Verification: The participant can self-perform the following: Blood glucose testing Measuring insulin Injecting insulin Determining dose Operating insulin pump Other_________
Self-performance of these tasks will be observed and monitored using a double check system between the camper and either an RN or a Certified Medication Technician 2 Blood Glucose Testing: check all that apply
Additional Orders/Notes
Target range for blood glucose at camp__________ AC and HS AC, PC HS PC and HS Before snacks At campers discretion Other_________ 3 Snack times: check all that apply Mid morning Afternoon Bedtime Other________ 4 Insulin Orders: Short acting: Brand name and type:________________________ Administration times: check all that apply AC and HS AC, PC HS PC and HS
Before snacks Other___________________________________ Insulin Administration via: Syringe and vial Insulin pump Insulin pen Other_________ Insulin Dosing: Written Sliding Scale as follows: Blood Glucose________to________________units Blood Glucose________to________________units Blood Glucose________to________________units Blood Glucose________to________________units Blood Glucose________to________________units Blood Glucose________to________________units
__________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________
Add Carb calculation insulin
dose to Sliding Scale
Insulin to carbohydrate ratio: ________units insulin per________Carbs gms Long acting: Brand name and type:________________________ Dose/Route:________________________________ Administration times:________________________
5 Hypoglycemia: from______to______ Treatment for mild lows: _____________________________________ ____________________________________ Treatment for moderate lows: from______to______ _____________________________________ ____________________________________ Treatment for severe lows with unconsciousness _____________________________________ ____________________________________ 6 Hyperglycemia: If blood glucose ________initiate insulin orders If blood glucose ________or exhibit symptoms of ketosis, check urine ketones Other:_________________________________
Doctors stamp
Doctors Signature:____________________________Date:__________
I understand that any child with a chronic health condition is more at risk in a new environment to have changes in their health status I have been informed that the camp health center is a basic first aid station and NOT equipped for medical emergencies of a catastrophic nature Im aware that River Valley
Ranch has physician approved emergency protocols in place for treatment of hypoglycemia and hyperglycemia These protocols will be initiated in the event the above orders do not improve the status of my childs condition I know my child has a pre-existing condition and I will fully accept any financial responsibility incurred as a result of a decision by the staff of River Valley Ranch to seek outside medical attention I agree to allow my child to attend camp with the knowledge I have of my childs condition and the camp setting I further understand that non-compliance with Doctors orders and/or camp policies will result in my childs dismissal from camp without refund I also agree to provide the necessary supplies and equipment needed for treatment
Parent/guardian signature:_________________________________________________ Date:____________________
Source:wrbs.com
