Name of institution

Sussex County Public Schools
DIABETES MEDICAL MANAGEMENT PLAN Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
INTENSIVE THERAPY

Part 2: Virginia Diabetes Medical Management Plan (DMMP)
To be completed by physician/provider.
Notice to Parents: Medication(s) MUST be brought to school by the PARENT/GUARDIAN in a container that is appropriately labeled
by the pharmacy or physician/practitioner.
In order for schools to safely administer medication during school hours, the following regulations should be observed:
 A new copy of the DMMP must be completed at the beginning of each school year. This form, an Authorization for Medication Administration form, or MD prescription must be received in order to change diabetes care at school during the school year. Student Name (Last, First, MI)
Student's Diagnosis: DIABETES: ___ Type 1 ___ Type 2
___ Other ________________________
MONITORING
BLOOD GLUCOSE (BG)
___ For symptoms of hypo/hyperglycemia & MONITORING
CONTINUOUS GLUCOSE
Always confirm CGM results with finger stick MONITORING (CGM)
check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check finger stick blood Brand/Model: ________________

Anytime the BG >_______ mg/dL or when student complains of nausea, vomiting,
___ URINE KETONE TESTING
abdominal pain. See page 3 for further instructions under hyperglycemia ___ BLOOD KETONE TESTING
NAME OF MEDICATION
DOSE/ROUTE
___ GLUCAGON - INJECTABLE
control his/her airway or unable to swallow), or seizing POSSIBLE SIDE
TREATMENT OF SIDE

Additional Instructions:
Physician/Provider Signature: Provider Printed Name: Emergency # ________________
Sussex County Public Schools
DIABETES MEDICAL MANAGEMENT PLAN Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
INTENSIVE THERAPY

Page 2 of 3
Student: ____________________________________ Effective date: ___________________________

Definitions

Insulin-to-Carbohydrate Ratio
Insulin Sensitivity
Target Blood Glucose
(CHO Ratio)
(Correction Factor)
• a specific blood glucose value used to prevent hyperglycemia after ingestion of concentration after administration of 1 unit of • usually expressed as "1 unit for every • usually expressed as "1 unit for every ____mg/dl blood glucose is > target" Insulin to be given during school hours: ___ Yes ___ No ___ Requires assistance to calculate/give injections ___ Independently calculates/gives own injection ___ Rapid-acting Insulin Type: ____________ ®
Timing of Insulin Dose:
(all doses to be administered subcutaneously) Rapid-acting Insulin should always be given prior to ___________ ® _____units at _____am or pm
 If CHO intake cannot be predetermined insulin should be given no more than 30 minutes after completion of meal/snack. (all doses to be administered subcutaneously)  Treat hypoglycemia before administration of meal or snack insulin. CALCULATING INSULIN DOSES: According to CHO ratio and Insulin Sensitivity/Correction Factor (if needed) - the student requires meal time
coverage with rapid-acting insulin based on the amount of carbohydrates in the meal and may require additional insulin to correct blood glucose
to the desired range according to the following formula:
Insulin Dose = [(Actual BG - Target pre-meal BG) divided by Insulin Sensitivity] + [# carbohydrates consumed/CHO Ratio]
• Fractional amounts of insulin from correction and carbohydrate calculation, when added together, may yield an even amount of insulin • If uneven, then round to the nearest half or whole unit (May use clinical discretion; if physical activity follows meal, then may round down).
Insulin Sensitivity/Correction Factor:
Target pre-meal BG: mg/dL
___ unit for every > target
CHO Ratio:
Exercise/PE CHO Ratio: / ___ Not Applicable
Less insulin may be required with meals prior to physical activity in order to prevent hypoglycemia. If so, the Exercise/PE CHO 1: to 1:_____ Ratio should be used instead of the CHO Ratio. ___ Correction insulin to be administered for elevated blood glucose if 3 hours or more after last insulin dose • In general, children with diabetes managed using Intensive Therapy/MDI do not require snacks. • Scheduled snacks may be required prior to or after exercise in order to prevent hypoglycemia. Insulin is not administered with these snacks. • Foods may be eaten at unscheduled times. Insulin may be ordered for these snacks in order to prevent post-meal hyperglycemia (see above). • Snack time insulin = # carbohydrates consumed/CHO Ratio. • Never provide insulin coverage for carbohydrate/glucose being used to treat hypoglycemia.
Exercise and Sports
• In general, there are no restrictions on activity unless specifically noted. • A student should not exercise if his/her blood glucose is < ______ mg/dL or > 300 mg/dL (with positive ketones) immediately prior to exercise or until hypoglycemia/hyperglycemia is resolved. • A source of fast-acting glucose & glucagon should be available in case of hypoglycemia. Physician/Provider Signature: Provider Printed Name: Emergency # ________________
Sussex County Public Schools
DIABETES MEDICAL MANAGEMENT PLAN Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
INTENSIVE THERAPY

Page 3 of 3

Student: ____________________________________ Effective date: ___________________________

Hypoglycemia (Low Blood Glucose)
Hypoglycemia is defined as a blood glucose < ______ mg/dL
Signs of hypoglycemia:
• If hypoglycemia is suspected, check the blood glucose level. Severe Hypoglycemia: If student unconscious, semi-conscious (unable to control
his/her airway or unable to swallow) or seizing, administer glucagon.
• Place student in the "recovery position." • If glucagon is administered, call 911 for emergency assistance, and call Parents/Legal Guardian. Mild or Moderate Hypoglycemia: If conscious & able to swallow, immediately give
15 grams fast-acting glucose:
Hypoglycemia
Management
(Low Blood Glucose)
Repeat BG check in 15 minutes
• If BG still low, then re-treat with 15 gram CHO • If BG in acceptable range and at lunch or snack time, let student eat and cover CHO per orders • If BG in acceptable range and not lunch or snack time, provide student slowly-released CHO snack (Example: 3-4 peanut butter or cheese crackers or ½ sandwich) If unable to raise the BG > 70 mg/dL despite fast-acting glucose sources, call: ________________
Hyperglycemia (High Blood Glucose)
Signs of hyperglycemia:
• If hyperglycemia is suspected, check the blood glucose level. If BG > ____ mg/dL, or when child complains of nausea, vomiting, and/or abdominal
pain, ask the student to check his/her urine for ketones
• If urine ketones are trace to small (blood ketones 0 - 1.0 mmol/L), give 8-16 ounces of sugar-free fluid Hyperglycemia
• If correction insulin has not been administered within 3 hours, provide correction insulin according to Management
student's Correction Factor and Target pre-meal BG • Recheck BG and ketones _________________ after administering insulin (High Blood Glucose)
• If urine ketones are moderate/large (blood ketones >1.0 mmol/L), give 8-16 ounces of sugar-free fluid (water) and call ____________________ for instructions concerning insulin administration.
• Recheck BG and ketones _________________ after administering insulin My signature below provides authorization for the above written orders. I/We understand that all treatments and procedures may be performed by the school nurse, the student and / or trained unlicensed designated school personnel under the training and supervision provided by the school nurse (or by EMS in the event of loss of consciousness or seizure) in accordance with state laws & regulations. I also give permission for the school to contact the health care provider regarding these orders and administration of these medications. Physician/Provider Signature: Provider Printed Name:

Source: http://www.sussex.k12.va.us/Departments/Health_Services/SCPS_Health_Forms/DMMPIntensiveTherapyNONElectronic.pdf