[IP] Give Them a Writen List of Your Medicines ER LETTER
Pumpers and Friends,
I have been using a letter like this from the time I start on a pump. First
one my doctor wrote up for me then later there was one in ADA mag. , I
worked them together to get this one. I clean it up abit , gave a sample of
things to add. I hope it helps :-) I update when needed, use it to show when
I going in hopsital or doctor office save a lot of time with check in.
REMEMBER TO SMILE AND BE HAPPY
TO: EMERGENCY CARE PERSONNEL
NAME uses and insulin pump to meet his needs for insulin
because of Type 1 Diabetes Mellitus. The insulin pump delivers insulin in a
way that more closely mimics release by the normally functioning pancreas
than does one or two injections a day. NAME 's pump matches his
insulin needs as determined by history, blood glucose levels, food to be
eaten, and expected exercise. Normally, NAME checks his blood
glucose levels with a home glucose meter and adjusts insulin deliver to
maintain as near normal blood glucose levels as possible.
Insulin is given two ways via the insulin pump:
Basal Rate: a continuous insulin infusion, the amount of insulin the patient
requires to maintain a normal metabolic state when not eating.
Bolus: the insulin infused with food intake. NAME has been taught to
adjust this depending on blood glucose levels, food to be eaten, and
Leave pump in place. Continue basal rate, even if NAME is unable to
eat. NAME is infusing NovoLog Human Insulin Analog U100.
His set basal rates are as follows:
23:59 to 04:00 units per hour 12:00 to 13:00 units per hour
04:00 to 06:00 units per hour 13:00 to 18:00 units per hour
06:00 to 08:00 units per hour 18:00 to 19:00 units per hour TOTAL
08:00 to 11:00 units per hour 19:00 to 20:00 units per hour
units per month to fill tubing
11:00 to 12:00 units per hour 20:00 to 24:00 units per hour
basal bolus =/-9% = Units
Allow NAME to test his own blood glucose levels with a glucose
meter and adjust bolus as he has been taught. Bolus will be adjusted as
1 unit insulin to grams of carbohydrate High blood sugar bolus 1 unit
BLOOD GLUCOSE ADJUSTMENT
<70 mg/dl Subtract 1 unit from bolus
70 to 100 mg/dl No Adjustment
Every mg/dl above mg/dl Add unit
Every mg/dl above md/dl Add units
If NAME need to bolus to counteract a high blood glucose condition,
NAME will check his blood glucose levels every two hours until it
returns to normal plus 4 hours
If NAME is ketotic, it probably means that his pump is not
functioning properly or is blocked or been removed. Have NAME do a
site and pump check, if problem is found he will do a change as he has been
taught. Have NAME check his blood glucose every 2 hours and bolus as
As noted previously, continue the basal rates if NAME is unable to
eat. Blood glucose levels should be checked, by NAME if possible,
every 3 hours, and boluses adjusted as above.
*DO NOT DISCONTINUE PUMP without giving insulin by another means. Otherwise,
NAME will have no insulin and will develop ketoacidosis. If pump is
discontinued, NAME will immediately need Regular Insulin.
*Blood glucose measurements used to determine bolus adjustments must be
current. It's much safer to make adjustments from NAME's reading than to
wait for blood glucose results from the lab. NAME has been trained to do
this, and routinely does 15 times a day, so it is second nature to him.
*The exceptions to this rule are if there is a doubt about NAME's
ability to perform intelligently or if there is concern about the accuracy
of the glucose meter.
*If NAME has an infection or is under stress, blood glucose levels
may go up. Continuing the basal dose and covering high blood glucose levels
with boluses is a reasonably safe way of doing things.
NAME's Medical Problems:
Type 1 Diabetes Mellitus, treated by external pump delivering continuous
subcutaneous insulin infusion.
Gastrointestinal autonomic neuropathy, with severe Gastroparesis and bowel
Diabetic Peripheral Neuropathy.
Frequent and severe hypoglycemia and the induction of seizure activity, this
being precipitated in large part by the erratic and unpredictable absorption
of foodstuffs induced by the gastrointestinal motility disorder.
Loss of Left Eye.
Omaha, NE 68105-2315
Health Insurance Info:
Birthday birth place mother name
TO HAVE OPERATOR TO PAGE DOCTOR
MEDICAL HISTORY: (SAMPLE OF THINGS)
Tonsils & Adenoids (1968)
Nose DS at (1976)
Diabetes Mellitus Type 1 (5-20-77)
Severe Gastroparesis at (1980)
Started on Insulin Pump 10-7-1980
Hands: Carpal Tunnel in 1991 RIGHT - 1992 LEFT
Stopped working April 10, 1998 on Total Disability Social Security.
Pick-lines since 1987 for Erythromycin IV on/off since.
Port left side placed in 1998 for TPN
Major infections 5 times in 1998
J-tube placed 1998
Drugs & Meds: (SAMPLE OF THINGS) Drug dose
Minimed 508 insulin pump S
Infusion Set (Silhouette or Quickset) 1 every 3 days SHIP
Batteries as needed SHIP
Cartridge 1 every 3 days SHIP
Skin Preparation: SHIP
Skin Prep as needed
I.V. Prep as needed SHIPN
Unsolve as needed SHIPN
Hibiclens Soap as needed SHI
Transparent Dressing as needed SHIN
Glucometer Elite Meter & Strips 14 AVE daily SAN
Glucagon ER Kit 1mg as needed SN
Acetaminophen 500mg as needed HUS
Enteric Coated Aspirin 325mg 1 daily HUS
Vitamin C 500I.U. 1 - 3 x daily HUS
Vitamin E 400I.U. 1 - 3 x daily HUS
Centrum Vitamin 1 daily HUS
Flonase 0.05% 1 - 2 x daily HUS
Allegra 180mg 1 daily HS
Pancrease Capsules as needed Ave 12 DISE
Metronidazole 500mg 1 - 3 x daily DIE
Doxycycline 100mg 1 - 2 x daily DIE
Lac_Hydrin 12% lotion 400gm 1 daily PAAN
Outgoing mail is certified Virus Free.
Checked by AVG anti-virus system (http://www.grisoft.com).
Version: 6.0.483 / Virus Database: 279 - Release Date: 5/19/2003
for HELP or to subscribe/unsubscribe, contact: