Insulin & Blood Sugar Documentation
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Traverse Bay Area Intermediate School District 1101 Red Drive, P. O. Box 6020 Traverse City, MI 49696-6020 (231) 922-6200 FAX: (231) 922-6270 INSULIN & BLOOD SUGAR DOCUMENTATION www.tbaisd.k12.mi.us _______________________________________ Birthdate: ______________ Physician: ________________________________________
Student: School: ________________________________________ School Year: ____________ Witness: __________________________ Initials: _________ Teacher: _______________________________________ Initial: ________ Witness: __________________________________ Initials: _________ 1 2 3 5 6 7 4 8 Glucometer Control Solution Test: Monthly_________________ left hand
Date
AM Snack
right hand
Blood Sugar Test before Lunch
Time
Site:
Results
Staff initials
Correction (BS minus 120) Every 40 give one unit !!
(A) Insulin dose
Test strip expiration date: ________ ________ ________ ________
List food eaten for lunch
Carb count
Coverage (B) Insulin dose (carbs รท 10 = 1 unit) Insulin dose
Add correction plus coverage insulin dose (A) + (B)
Staff Initials (2)
Insulin & Blood Sugar Documentation 2/2009
! If less than 50, give 8 oz of juice + 30gm protein/carb snack (8 peanut butter crackers)
AS NEEDED BLOOD SUGAR TEST
! If less than 70 give 15gm snack = 4 oz juice and 15gm snack protein/carbs (6 peanut butter crackers)
BLOOD SUGAR BEFORE BUS
! For a blood sugar less than 70, recheck blood sugar in 15 minutes - if less than 70 give another 15gm carb snack and NO BUS, call mother ! If 70-90 give 15gm high carb snack (6 peanut butter crackers ! If 90-120 give light snack (3 peanut butter crackers)
Signs of hypoglycemia ! ! ! ! ! ! ! !
hunger weakness irritable drowsy personality change confusion combative seizure
Signs of hyperglycemia ! ! ! ! ! !
thirst frequent urination increased hunger excessive talking & laughing vomiting dry mouth
! If greater than 280, give correction dose to 120 Date
Time
Site
Results
Staff initials (2)
Treatment if Needed
Date
Time
Site
Results
Staff initials (2)
Treatment if Needed
Insulin & Blood Sugar Documentation 2/2009
Student: School: ________________________________________ School Year: ____________ Witness: __________________________ Initials: _________ Teacher: _______________________________________ Initial: ________ Witness: __________________________________ Initials: _________ 1 2 3 5 6 7 4 8 Glucometer Control Solution Test: Monthly_________________ left hand
Date
AM Snack
right hand
Blood Sugar Test before Lunch
Time
Site:
Results
Staff initials
Correction (BS minus 120) Every 40 give one unit !!
(A) Insulin dose
Test strip expiration date: ________ ________ ________ ________
List food eaten for lunch
Carb count
Coverage (B) Insulin dose (carbs รท 10 = 1 unit) Insulin dose
Add correction plus coverage insulin dose (A) + (B)
Staff Initials (2)
Insulin & Blood Sugar Documentation 2/2009
! If less than 50, give 8 oz of juice + 30gm protein/carb snack (8 peanut butter crackers)
AS NEEDED BLOOD SUGAR TEST
! If less than 70 give 15gm snack = 4 oz juice and 15gm snack protein/carbs (6 peanut butter crackers)
BLOOD SUGAR BEFORE BUS
! For a blood sugar less than 70, recheck blood sugar in 15 minutes - if less than 70 give another 15gm carb snack and NO BUS, call mother ! If 70-90 give 15gm high carb snack (6 peanut butter crackers ! If 90-120 give light snack (3 peanut butter crackers)
Signs of hypoglycemia ! ! ! ! ! ! ! !
hunger weakness irritable drowsy personality change confusion combative seizure
Signs of hyperglycemia ! ! ! ! ! !
thirst frequent urination increased hunger excessive talking & laughing vomiting dry mouth
! If greater than 280, give correction dose to 120 Date
Time
Site
Results
Staff initials (2)
Treatment if Needed
Date
Time
Site
Results
Staff initials (2)
Treatment if Needed
Insulin & Blood Sugar Documentation 2/2009
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