Diabetes Medical Management Plan Supplement for Students Wearing an Insulin Pump

School Year: ___________________

Student Information

Student Name: ___________________

Date of Birth: ___________________

Pump Brand/Model: ___________________

Pump Resource Person: ___________________

Phone: ___________________

Child-lock on? Yes No

How long has the student worn a pump? ___________________

Blood Glucose Target Range: ___________________

Pump Insulin: Humalog Novolog Regular

Insulin: Carb Ratio: ___________________

Student is to receive carb bolus: immediately before / ________ min before eating

Lunch/Snack boluses Pre-Programmed? Yes No

Times: ___________________

Insulin Correction Formula: ___________________

Extra Pump Supplies

Furnished by parent/guardian:

• Infusion sets
• Reservoirs
• Dressing & tape
• Insulin
• Syringes or insulin pen

Student Pump Skills Assessment

Needs Help? If yes, assessment and comments:

1. Independently count carbs: Yes No
2. Give correct bolus for carbs consumed: Yes No
3. Calculate and administer correct bolus: Yes No
4. Recognize signs/symptoms of site infection: Yes No
5. Calculate and set a temporary basal rate: Yes No
6. Disconnect pump if needed: Yes No
7. Reconnect pump at infusion site: Yes No
8. Prepare reservoir and tubing: Yes No
9. Insert new infusion set: Yes No
10. Give injection with syringe or pen, if needed: Yes No
11. Troubleshoot alarms and malfunctions: Yes No
12. Re-program basal profiles if needed: Yes No

Management of High Blood Glucose

Follow instructions in basic DMMP, but in addition:

If BG is over target range ___ hours after last bolus or carb intake, student should receive a correction bolus of insulin using formula:

BG – ______ / ______ = Correction

If BG over 250, check urine ketones:

1. If no ketones, give bolus by pump and recheck in 2 hours.
2. If ketones present or ______, give correction bolus as an injection immediately and contact parent.

If two consecutive BG readings over 250 (2 hours or more after first bolus given):

1. Check urine ketones.
2. Give correction bolus as an injection.
3. Change infusion set, call parent.

Management of Low Blood Glucose

Follow instructions in basic DMMP, but in addition:

If low blood glucose reoccurs without explanation, notify parent/diabetes provider for potential instructions to suspend pump.

If seizure or unresponsiveness occurs:

1. Call 911 (or designate another to do so).
2. Treat with Glucagon (see basic DMMP).
3. Stop insulin pump by: place in suspend or stop mode (see manufacturer’s instructions). Disconnect at pigtail or clip (Send pump with EMS). Cut tubing.
4. Notify parent.

Additional Times to Contact Parent

1. Soreness or redness at infusion site.
2. Detachment of dressing/infusion set out of place.
3. Leakage of insulin.
4. Insulin injection given.
5. Other: ___________________________________

Effective Date(s) of Pump Plan

Parent’s Signature: ___________________ Date: ___________________

School Nurse’s Signature: ___________________ Date: ___________________

Diabetes Care Provider Signature: ___________________ Date: ___________________

Revised February 3, 2003 / Florida Governor’s Diabetes Council. (SJCSD effective 5/2017)