HEALTH CARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS STUDENT’SNAME____________________________Student’sbirthdate___/___/___School_____________Grade___ Emergency numbers for parents (phone) ____-_____-_____ (Cell contact 2) ____-_____-_____ (Cell) ____-_____-____ Doctor’s phone number_____-_____-______ Other contacts________________________________, _____-_____-______ HYPOGLYCEMIA (fill in individualized instructions on line or use those in parenthesis) Unconscious--___________________________________________(phone 911) (Other orders)___________________ Blood sugar < 60 and symptomatic _______________________(juice, pop, candy) _______________________________ Blood sugar < 100 and symptomatic _______________________(crackers/cheese) _______________________________ Blood sugar < 80 and asymptomatic ______________________(feed partial meal) _______________________________ Blood sugar > 100 and symptomatic _______________________(feed partial meal) Blood sugar at which parent should be notified–low ____________ high ___________ BLOOD SUGAR AND INSULIN DOSAGE prior to lunch (R is regular and H is lis-pro,) _____________ any other insulin requested Blood sugar < 100
____________ units R - H - other __________________ (see hypoglycemia above)
____________ units R - H - other __________________
____________ units R - H - other __________________
____________ units R - H - other __________________
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
____________ units R - H - other __________________ (check ketones)
• Licensed medical personnel allowed to give _____ units (minimum) of insulin to _____ units (maximum) of R, H, other _________ insulin after consultation with the parent/guardian. • Other insulin instructions (i.e., CHO counting):______________________________________________________ • If urine ketones (trace, small, moderate, large) call parents (circle one or more) DISASTER INSULIN DOSAGE-in case of disaster how much insulin should be given? Recommend 80% of usual dose. A.M.
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
units R - H - other _______________ units Lente NPH Ultralente Lantus other
STUDENT’S SELF-CARE (ability level) Totally independent management or
student needs verification of number by staff or
assist/testing to be done by school nurse
2. Student administers insulin independently or
student self-injects with verification of number or
student self-injects with nurse supervision or
3. Student self-treats mild hypoglycemia
4. Student monitors own snacks and meals
5. Student tests and interprets own urine ketones
6. Student tests and interprets own blood ketones
HCP _______________________________ (print/type) _________________________signature _____/_____/_____ date Parent ______________________________ (print/type) _________________________signature _____/_____/_____ date School Nurse _________________________ (print/type) _________________________signature _____/_____/_____ date Start date: ____day ____mo. ____yr. Termination date: _____day _____mo. _____yr. or End of school year: _____ Must be renewed at beginning of each school year.
CONGRESSO NACIONAL DE ENFERMAGEM DE REABILITAÇÃO O ENFERMEIRO ESPECIALISTA E A SEXUALIDADE RESPOSTAS! Célia Mota – Enfª Especialista em Reabilitação – CoimbraO conceito de sexualidade humana engloba a forma como se pensa, sente e actua como um ser sexuado, com necessidades e impulsos, expressões de virilidade ou de feminilidade, papeis associados aos géneros, inter
Kenneth Sharp, DO NEW PATIENT MEDICAL HISTORY AND QUESTIONNAIRE The information on this form is part of your confidential medical record. Please be honest with your responses. Please be advised that, for identification and part of your medical record, your photograph will be taken during your first visit. Name: ____________________________________Male / Female Date of Birth: _____/