{"id":529,"date":"2026-09-21T10:10:28","date_gmt":"2026-09-21T14:10:28","guid":{"rendered":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/diabetes-medical-management-plan-supplement-pump-pdf\/"},"modified":"2026-09-21T10:21:33","modified_gmt":"2026-09-21T14:21:33","slug":"diabetes-medical-management-plan-supplement-pump-pdf","status":"publish","type":"savoy_document","link":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/diabetes-medical-management-plan-supplement-pump-pdf\/","title":{"rendered":"Diabetes-Medical-Management-Plan-Supplement-Pump.pdf"},"content":{"rendered":"

Diabetes Medical Management Plan Supplement for Students Wearing an Insulin Pump<\/h1>\n

School Year: ___________________<\/p>\n

Student Information<\/h2>\n

Student Name:<\/strong> ___________________<\/em><\/p>\n

Date of Birth:<\/strong> ___________________<\/em><\/p>\n

Pump Brand\/Model:<\/strong> ___________________<\/em><\/p>\n

Pump Resource Person:<\/strong> ___________________<\/em><\/p>\n

Phone:<\/strong> ___________________<\/em><\/p>\n

Child-lock on?<\/strong> Yes No<\/p>\n

How long has the student worn a pump?<\/strong> ___________________<\/em><\/p>\n

Blood Glucose Target Range:<\/strong> ___________________<\/em><\/p>\n

Pump Insulin:<\/strong> Humalog<\/em> Novolog<\/em> Regular<\/em><\/p>\n

Insulin: Carb Ratio:<\/strong> ___________________<\/em><\/p>\n

Student is to receive carb bolus:<\/strong> immediately before \/ ________<\/em> min before eating<\/p>\n

Lunch\/Snack boluses Pre-Programmed?<\/strong> Yes No<\/p>\n

Times:<\/strong> ___________________<\/em><\/p>\n

Insulin Correction Formula:<\/strong> ___________________<\/em><\/p>\n

Extra Pump Supplies<\/h2>\n

Furnished by parent\/guardian:<\/p>\n

    \n
  • Infusion sets<\/li>\n
  • Reservoirs<\/li>\n
  • Dressing & tape<\/li>\n
  • Insulin<\/li>\n
  • Syringes or insulin pen<\/li>\n<\/ul>\n

    Student Pump Skills Assessment<\/h2>\n

    Needs Help?<\/strong> If yes, assessment and comments:<\/p>\n

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

      Management of High Blood Glucose<\/h2>\n

      Follow instructions in basic DMMP, but in addition:<\/p>\n

      If BG is over target range ___<\/em> hours after last bolus or carb intake, student should receive a correction bolus of insulin using formula:<\/p>\n

      BG – ______<\/em> \/ ______<\/em> = Correction<\/p>\n

      If BG over 250, check urine ketones:<\/p>\n

        \n
      1. If no ketones, give bolus by pump and recheck in 2 hours.<\/li>\n
      2. If ketones present or ______<\/em>, give correction bolus as an injection immediately and contact parent.<\/li>\n<\/ol>\n

        If two consecutive BG readings over 250 (2 hours or more after first bolus given):<\/p>\n

          \n
        1. Check urine ketones.<\/li>\n
        2. Give correction bolus as an injection.<\/li>\n
        3. Change infusion set, call parent.<\/li>\n<\/ol>\n

          Management of Low Blood Glucose<\/h2>\n

          Follow instructions in basic DMMP, but in addition:<\/p>\n

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

          If seizure or unresponsiveness occurs:<\/p>\n

            \n
          1. Call 911 (or designate another to do so).<\/li>\n
          2. Treat with Glucagon (see basic DMMP).<\/li>\n
          3. Stop insulin pump by: place in suspend or stop mode (see manufacturer\u2019s instructions). Disconnect at pigtail or clip (Send pump with EMS). Cut tubing.<\/li>\n
          4. Notify parent.<\/li>\n<\/ol>\n

            Additional Times to Contact Parent<\/h2>\n
              \n
            1. Soreness or redness at infusion site.<\/li>\n
            2. Detachment of dressing\/infusion set out of place.<\/li>\n
            3. Leakage of insulin.<\/li>\n
            4. Insulin injection given.<\/li>\n
            5. Other: ___________________________________<\/em><\/li>\n<\/ol>\n

              Effective Date(s) of Pump Plan<\/h2>\n

              Parent\u2019s Signature:<\/strong> ___________________<\/em> Date:<\/strong> ___________________<\/em><\/p>\n

              School Nurse’s Signature:<\/strong> ___________________<\/em> Date:<\/strong> ___________________<\/em><\/p>\n

              Diabetes Care Provider Signature:<\/strong> ___________________<\/em> Date:<\/strong> ___________________<\/em><\/p>\n

              Revised February 3, 2003 \/ Florida Governor\u2019s Diabetes Council. (SJCSD effective 5\/2017)<\/p>\n","protected":false},"author":429,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-529","savoy_document","type-savoy_document","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/529","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document"}],"about":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/types\/savoy_document"}],"author":[{"embeddable":true,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/users\/429"}],"version-history":[{"count":0,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/529\/revisions"}],"wp:attachment":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/media?parent=529"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}