Diabetes Medical Management Plan (DMMP) Step 1 of 7 14% This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. It should be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse, doctor, trained diabetes personnel and other authorized personnel. Date of plan:* MM slash DD slash YYYY This plan is valid for the current school year:School Year:*2020 – 20212021 – 20222022 – 2023Student InformationStudent Name:* Date of Birth:* MM slash DD slash YYYY Date of diabetes diagnosis* MM slash DD slash YYYY Diagnosis Type* Type 1 Type 2 Other Diagnosis Type Other: HiddenSchool HiddenSchool Phone Number: Grade* Homeroom Teacher School nurse/doctor HiddenPhone Contact InformationParent/ Guardian 1* Email* Contact Number:* HiddenWork Contact Number: HiddenCell Number: HiddenAddressParent/ Guardian 2 Email Contact Number: HiddenWork Contact Number: HiddenCell Number: HiddenAddressEmergency Contact Email Relationship Contact Number: HiddenCell Number: 1.Checking blood glucoseTarget range of blood glucose: Before meal:* 90–130mg/dl Other target blood glucose range other: Check blood glucose level:* Before Breakfast After Breakfast __ Hours after Breakfast 2 hours after a correction dose Before Lunch After Lunch __ Hours after Lunch Before dismissal Mid-morning Before PE After PE Other As needed for signs/symptoms of low or high blood glucose As needed for signs/symptoms of illness Hours after BreakfastPlease enter a number from 1 to 24.Hours after LunchPlease enter a number from 1 to 24.Other: Preferred site of testing:Note: The site of the fingertip should always be used to check blood glucose level if hypoglycemia is suspected. Side of fingertip Other Other: Student's self-care blood glucose checking skills:* Independently checks own blood glucose May check blood glucose with supervision Requires a school nurse or doctor or trained diabetes personnel to check blood glucose Uses a smartphone or other monitoring technology to track blood glucose value Continuous glucose monitor (CGM): Yes No Brand Model: Alarm set for: Servere Low: Low: High: Predictive alarm: Low High Rate of change: Low High Threshold suspend setting CGM may be used for insulin calculation if glucose is between CGM Glucose frommgdl CGM Glucose to– mgdl CGM insulin calculation Yes No CGM may be used for hypoglycemia management: Yes No Additional information for student with CGM Insulin Injections should be given at least three inches away from the CM insertion site. Do not disconnect from the CGM for sports activities. If the adhesive is peeling , reinforce it with approved medical tape. If the CGM becomes dislodged, return everything to the parents/guardians. Do not throw any part away. Refer to the manufacturer’s instructions on how to use the student’s device. Student’s self -care CGM skills Independent? (Required)The student troubleshoots alarms and malfunctions.The student troubleshoots alarms and malfunctions. indepent* Yes No The student knows what to do and is able to deal with a high alarm.The student knows what to do and is able to deal with a high alarm. independent?* Yes No The student knows what to do and is able to deal with a Low alarm.The student knows what to do and is able to deal with a Low alarm. indepent* Yes No The student can calibrate the CGM.The student can calibrate the CGM. indepent* Yes No The student knows what to do when the CGM indicates a rapid trending rise or fall in the blood glucose level.The student knows what to do when the CGM indicates a rapid trending rise or fall in the blood glucose level. indepent* Yes No The student should be escorted to the nurse if the CGM alarm goes off:* Yes No Other instructions for the school health team: 2. Hypoglycemia treatmentStudent’s usual symptoms of hypoglycemia (list below)*If exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than,*mg/dl, give a quick-acting glucose product equal to*grams of carbohydrate. Recheck blood glucose in 15minutes and repeat treatment if blood glucose is less than*mg/dl Additional treatment:If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions(jerking movement): Position the student on his or her side to prevent choking. Administer glucagon Name of glucagon used: Injection: 1 mg 1/2 mg Other (dose) Injection Other(dose): Route Subcutaneous (SC) Intramuscular (IM) Site for glucagon injection: Buttocks Arm Thigh Other Site for glucagon injection (Other) : Nasal route: 3mg Route: Intranasal (IN) Site: Nose Contact the student’s health care provider. If on an insulin pump, stop by placing mode in suspend or disconnect. Always send pump with EMS to hospital. 3. Hyperglycemia treatmentStudent’s usual symptoms of hyperglycemia (list below):• Check for ketones Urine Blood EveryHour when blood glucose levels are abovemg/dL • For blood glucose greater than*mg/dl AND at Least*hours since the last insulin dose, give correction dose of insulin(see correction dose orders). • Notify parents/guardians if blood glucose is over*mg/dl • For insulin pump users: see Additional Information for student with InsulinPump. • Allow unrestricted access to the bathroom. • Give extra water and/or non-sugar-containing drinks (not fruit juices):ounces per hour. Additional treatment for ketones: Follow physical activity and sport orders. (See Physical Activity and Sports) If the student has symptoms of a hyperglycemia emergency, contact the student’s parents/guardians and health care provider. Symptoms of a hyperglycemia emergency include: dry mouth, extreme thirst, nausea and vomiting, abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness or lethargy or depressed level of consciousness. 4. Insulin therapyInsulin delivery device:* syringe Insulin pen Insulin pump Type of insulin therapy at school:* Adjustable Insulin Therapy Fixed Insulin Therapy No insulin Carbohydrate Coverage/ Correction Dose:Name of Insulin: Insulin-to-CArbohydrate Ratio:Lunch: 1 unit of insulin per Lunch: 1 unit of insulin per gram grams of carbohydrateSnack: 1 unit of insulin per Snack: 1 unit of insulin per gram grams of carbohydrateBlood Glucose Correction Factor/ Insulin Sensitivity Factor=Target blood glucose=mg/dL Correction dose scaleBlood glucose tomg/dL Giveunits Blood glucose tomg/dL Giveunits Blood glucose tomg/dL Giveunits Blood glucose tomg/dL Giveunits INSULIN PUMPBrand/Model of pump: Type of insulin in pump: Basal rates during school: Type of Infusion set: Pump Instructions For blood glucose greater than _____mg/dL that has not decreased within ____hours after correction, consider pump failure or infusion site failure. Notify Sponsor/ parents/ guardian. For infusion site failure :Insert new infusion set and/or replace reservoir. For suspected pump failure:suspend or remove pump and give insulin by syringe or pen. Other pump instructions Blood Glucosemg/dl Hour: Other Pump Instructions Student’s self-care insulin administration skills: Independently calculates and give own injections. may calculate/give own injections with supervision. Requires school nurse, doctor or trained diabetes personnel to calculate dose and student can give own injection with supervision. Requires school nurse, doctor or trained diabetes personnel to calculate dose and give the injection. Student’s self-care pump skills Independent?Counts carbohydratesCounts carbohydrates. Independent? Yes No Calculates correct amount of insulin for carbohydrates consumedCalculates correct amount of insulin for carbohydrates consumed Independent? Yes No Administers correction bolusAdministers correction bolus. Independent? Yes No Calculates and sets basal profilesCalculates and sets basal profiles. Independent? Yes No Calculates and sets temporary basal rateCalculates and sets temporary basal rate. Independent? Yes No Changes batteriesChanges batteries. Independent? Yes No Disconnect pumpDisconnect pump. Independent? Yes No Reconnects pump to infusion setPrepares reservoir, pod and/or tubing. Independent? Yes No Prepares reservoir, pod and/or tubingPrepares reservoir, pod and/or tubing. Independent? Yes No Inserts infusion setInserts infusion set. Independent? Yes No Troubleshoots alarms and malfunctionsTroubleshoots alarms and malfunctions. Independent? Yes No When to give insulin:Breakfast Carbohydrate coverage only Carbohydrate coverage plus correction dose when blood glucose is greater than ____mg/dL and ______hours since last insulin dose. Other mg/dL Hours Other Lunch Carbohydrate coverage only Carbohydrate coverage plus correction dose when blood glucose is greater than ____mg/dL and ______hours since last insulin dose. Other mg/dL Hour Other Snack No coverage for snack Carbohydrate coverage only Carbohydrate coverage plus correction dose when blood glucose is greater than ____mg/dL and ______hours since last insulin dose. Correction dose only:For blood glucose greater than ____mg/dL at least _____hours since last insulin dose. Other Carbohydrate coverage plus correction dose: mg/dL Carbohydrate coverage plus correction dose: Hour Correction dose only: mg/dL Correction dose only: Hour* Other Fixed Insulin TherapyName of insulin Fixed Insulin Instruction ______Units of insulin given pre-breakfast daily ______Units of insulin given pre-lunch daily ______Units of insulin given pre-snack daily Other Units of insulin given pre-breakfast daily Units of insulin given pre-lunch daily Units of insulin given pre-snack daily Other Basal Insulin TherapyName of insulin To be given during school hours: Pre-breakfast dose Pre-lunch dose Pre-dinner dose Pre-brakfast dose Units Pre-lunch dose Units Pre-dinner dose Units Other diabetes medications:Name Dose Route Times Given Name Dose Route Times Given 5. Physical activity and sportsA quick -acting source of glucose such as glucose tabs and/or sugar containing juice must be available at the site of physical education activities and sports Student should eat* 15 grams of carbonhydrate 30 grams of carbohydrate Other Other Student should eat time* Before every 30 minutes during. every 60minutes during after vigorous physical activity others Other If most recent blood glucose is less than*mg/dL student can participate in physical activity when blood glucose is corrected and above*mg/dL Avoid physical activity when blood glucose is greater than*mg/dL or if urine/blood ketones are moderate to large. DISASTER PLANTo prepare for an unplanned disaster or emergency(72HOURS), obtain emergency supply kit from sponsor/parent/guardian.* Continue to follow orders contained in this DMMP. Additional insulin orders Other Additional insulin orders as follows Other HiddenStudent’s Primary Care ProviderHiddenDate MM slash DD slash YYYY I, (parent/ guardian:)* Parent/ Guardian Email* give permission to the school nurse or doctor or trained diabetes personnel to perform and carry out the diabetes care as outlined in this care plan. I also consent to the release of the information contained in this plan to all school staff members who have responsibility for my child and who may need to know this information to maintain my child’s health and safety.Parent/Guardian Signature*Date* MM slash DD slash YYYY