Docstoc

DIABETES MEDICAL MANAGEMENT PLAN

Document Sample
DIABETES MEDICAL MANAGEMENT PLAN Powered By Docstoc
					                                                                                 Print              Save
                                                                        Flintwood Disability Services Inc
                                                                        PO Box 2501
                                                                        North Parramatta NSW 1750
                Disability Services Inc.                                Tel: 02 9630 1777 Fax: 02 9630 1788




DIABETES MEDICAL MANAGEMENT PLAN

    Client Name:




                                                                                                           Diabetes Medical Management Plan
    Date of Birth:

    Age:

    Address:




Date of plan:        ______________________________________

Review Dates:        _______________________________

Doctor:              ______________________________________      _____________________________________

Phone:               ______________________________________

Address:             _________________________________________________________________________________

                     _________________________________________________________________________________
                     _________________________________________________________________________________




Diabetes
Educator:            ______________________________________      _____________________________________

Phone:               ______________________________________

Address:             _________________________________________________________________________________

                     _________________________________________________________________________________

                     _________________________________________________________________________________



Dietician:           ______________________________________      _____________________________________

Phone:               ______________________________________

Address:             _________________________________________________________________________________

                     _________________________________________________________________________________

                     _________________________________________________________________________________

.




                                                                                                                   1


    Enhancing Lifestyle Opportunities
                                               Flintwood Disability Services Inc
                                               PO Box 2501
                                               North Parramatta NSW 1750
             Disability Services Inc.          Tel: 02 9630 1777 Fax: 02 9630 1788




INFORMATION ABOUT DIABETES

Description of Diabetes:
Diabetes Diagnosis:




                                                                                 Diabetes Medical Management Plan
[    ] Type 1
[    ] Type 2

Call the Doctor when:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Call an ambulance when:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Blood Glucose Monitoring

The low blood glucose level (hypo) range is:
      Mmol/L

The ideal blood glucose level range is:
      Mmol/L

The high blood glucose level range is:
      Mmol/L

Hypoglycemia

Is the Service User at risk?

[    ] Yes
[    ] No


High Blood Glucose Levels

Is the Service User at risk?

[    ] Yes
[    ] No
                                                                                         2


Enhancing Lifestyle Opportunities
                                                        Flintwood Disability Services Inc
                                                        PO Box 2501
                                                        North Parramatta NSW 1750
               Disability Services Inc.                 Tel: 02 9630 1777 Fax: 02 9630 1788




Usual symptoms are:
_________________________________________________________________
_________________________________________________________________




                                                                                          Diabetes Medical Management Plan
Treatment:
_________________________________________________________________
_________________________________________________________________


List the diabetes items that the Service User needs to carry with him/her when
he/she leaves home:

1)_______________________________________________________________
2)_______________________________________________________________
3)_______________________________________________________________
4)_______________________________________________________________
5)_______________________________________________________________
6)_______________________________________________________________


Blood Glucose Tests

Does the person have blood glucose tests?

[      ] Yes
[      ] No

Blood Glucose Level Test Days:

[      ]   Monday
[      ]   Tuesday
[      ]   Wednesday
[      ]   Thursday
[      ]   Friday
[      ]   Saturday
[      ]   Sunday

Note the specific times for Blood Glucose Testing:

[      ] Before Breakfast
[      ] After Breakfast

                                                                                                  3


    Enhancing Lifestyle Opportunities
                                                               Flintwood Disability Services Inc
                                                               PO Box 2501
                                                               North Parramatta NSW 1750
                 Disability Services Inc.                      Tel: 02 9630 1777 Fax: 02 9630 1788




[      ]   Before Lunch
[      ]   After Lunch
[      ]   Before Dinner




                                                                                                 Diabetes Medical Management Plan
[      ]   After Dinner
[      ]   Before Supper

Blood Glucose Test Procedure

[      ] Service User can do their own blood glucose testing without supervision
[      ] Service User can do their own blood glucose testing with supervision
[      ] Service User cannot do their own blood glucose testing and requires full
         support
[      ] Other

Insulin Injections

Days to take Insulin:

[      ]   Monday
[      ]   Tuesday
[      ]   Wednesday
[      ]   Thursday
[      ]   Friday
[      ]   Saturday
[      ]   Sunday

Note the specific times for Insulin Injecting

[      ]   Before Breakfast
[      ]   After Breakfast
[      ]   Before Lunch
[      ]   After Lunch
[      ]   Before Dinner
[      ]   After Dinner
[      ]   Before Supper

Insulin Procedure

[      ]   Service User can give own injection
[      ]   Service User requires verbal support to give injection
[      ]   A qualified nurse gives the Service User the injection
[      ]   Other – more information
                                                                                                         4


    Enhancing Lifestyle Opportunities
                                                            Flintwood Disability Services Inc
                                                            PO Box 2501
                                                            North Parramatta NSW 1750
               Disability Services Inc.                     Tel: 02 9630 1777 Fax: 02 9630 1788




Diabetes Medication




                                                                                              Diabetes Medical Management Plan
[      ] Service User can take own medication
[      ] Service User requires support to have medication (blister pack)
[      ] Other – more information



EXERCISE
Preferred Exercise:
________________________________________________________________

How long and how often?
________________________________________________________________

Signs and symptoms to STOP exercising:
________________________________________________________________

Times to test blood glucose:
________________________________________________________________

Blood glucose levels for exercise:
   mmol/L
________________________________________________________________

How often to drink water:
________________________________________________________________

When to eat:
________________________________________________________________

Types of food to eat:
________________________________________________________________

Meals:
________________________________________________________________

Is it recommended that the Service User have their meals at the same time each
day?




                                                                                                      5


    Enhancing Lifestyle Opportunities
                                                           Flintwood Disability Services Inc
                                                           PO Box 2501
                                                           North Parramatta NSW 1750
               Disability Services Inc.                    Tel: 02 9630 1777 Fax: 02 9630 1788




At what time should the Service User have their meals at the same time each day?




                                                                                             Diabetes Medical Management Plan
Breakfast:_________________________________________________________

Morning Tea:_______________________________________________________

Lunch:____________________________________________________________

Afternoon Tea:______________________________________________________

Dinner:___________________________________________________________

Supper:___________________________________________________________


How strictly should the healthy eating plan be adhered to?
_________________________________________________________________

What consequences are there if the person does not follow the healthy eating
plan?
_________________________________________________________________

What happens if the Service User is sick i.e. coughs, colds, sore throat, vomiting,
diarrhea etc?
_________________________________________________________________

Service User

Action to Take if the following occurs:

Rejecting very small quantities of food:
_________________________________________________________________
Rejecting all drinks:
_________________________________________________________________
Eating only small amounts of food:
_________________________________________________________________
Rejecting all food:
_________________________________________________________________
Vomiting:
_________________________________________________________________
Diarrhea:
________________________________________________________________
                                                                                                     6


 Enhancing Lifestyle Opportunities
                                                              Flintwood Disability Services Inc
                                                              PO Box 2501
                                                              North Parramatta NSW 1750
               Disability Services Inc.                       Tel: 02 9630 1777 Fax: 02 9630 1788




A high temperature:
________________________________________________________________
Refusing to have diabetes medication:




                                                                                                Diabetes Medical Management Plan
________________________________________________________________
Refusing to have insulin:
________________________________________________________________
Identify how often blood glucose levels should be tested:
________________________________________________________________

Identify when the doctor needs to be contacted:
________________________________________________________________
Indicators of Diabetes Complications Requiring Medical Attention

-      Nerve damage: Numbness, tingling, shooting pain or burning pain
-      Kidneys: Urinary Tract Infections
-      Eyes: Blurred vision or flashes of light or pain
-      Feet: Redness, corns, calluses, cuts and sores
-      Other: Ulcers, sores that don’t heal

Responding to a Diabetic Complication

Procedure summary:

•      Check safety of client
•      Check time complication commences and finishes
•      Check client’s breathing
•      Reassure client
•      Place client in the recovery position or assist to a comfortable position
•      Call ambulance

Advise Manager of all Diabetic Complications requiring transport to Hospital: YES / NO

Advise Manager of all Diabetic Complications resulting in an injury: YES / NO

Plan Approved by GP:________________________________________________
Signed:___________________________Date:____________________________
Client or Parent/Guardian:_____________________________________________
Signed:___________________________Date:____________________________
Manager:__________________________________________________________
Signed:___________________________Date:____________________________


                                                                                                        7


    Enhancing Lifestyle Opportunities
                                                              Flintwood Disability Services Inc
                                                              PO Box 2501
                                                              North Parramatta NSW 1750
              Disability Services Inc.                        Tel: 02 9630 1777 Fax: 02 9630 1788




To be signed by each staff member working with the service user, including regular
casuals:

I have read and understood this Diabetes Management Plan and will implement this




                                                                                                Diabetes Medical Management Plan
Diabetes Management Plan

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:

Name:                                    Signature:                     Date:



Copies of this Diabetes Management Plan are to be provided to all other agencies or
services attended by this service user.
Tick when copied or forwarded:


Day Program               [     ]        Recreation Program   [     ]


School                     [     ]       Other                [    ]


                                                                                                        8


 Enhancing Lifestyle Opportunities

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:61
posted:4/3/2010
language:English
pages:8
Description: DIABETES MEDICAL MANAGEMENT PLAN