Date Plan was Developed
Call School Nurse
DIABETES
Emergency Care Plan
Never send student with suspected low blood sugar anywhere alone!!!!!!!!!!!!
Student Name;________________________________________DOB:______________________________
Parent/Guardian:_____________________________ Home Phone:_______________ Work Phone: _____________
Emergency Contact: __________________________ Home Phone:_______________ Work Phone: _____________
Emergency Contact: __________________________ Home Phone: _______________ Work Phone:______________
Student Picture
Physician: __________________________________ Phone:_____________________
Preferred Hospital: ___________________________
Current Medication:______________________________________________________________________________________________
Allergies:______________________________________________________________________________________________________
SYMPTOMS AND SIGNS OF LOW BLOOD SUGAR
MILD
Unable to concentrate
Hunger
Shakiness
Weakness
Sweaty
Dizziness
MODERATE
Personality
change:
Behavior change:
Poor coordination
Blurry vision
Weakness
Headache
Confusion
Drowsy
Pale
Irritable
Anxious
*Student’s usual signs/symptoms
*Student’s usual signs/symptoms
IF YOU SEE THIS
SEVERE
Loss of consciousness
Seizures
Stops breathing
* Student’s usual signs/symptoms
DO THIS
Never send student anywhere alone!!!!!
MILD
TO MODERATE
If unable to go to health office, have meds brought to student
Sit student in upright position, offer water
Instruct to breathe in through nose and out through pursed lips slowly and deeply
Check peak flow. Reading:__________ Check time of last does of medication
Give medication by inhaler or nebulizer (Specify medication, dose, route)
Assist student to inhale medication slowly and fully.
Student becomes worse:
Will not or cannot
Drink or swallow
CALL 911
Pull lower lip down and squeeze (glucose gel) between the lower lip and
the gum. If student is lying down, turn on side to prevent choking
Glucose gel located _______________________________________
Call parent
SEVERE
SEIZURE
BREATHING STOPS
TIME
Initial
Call 911
If possible, adult trained in CPR/Rescue Breathing stays with student until
911 arrives
Clear area to prevent injury, place soft material under head
Do not hold student down. Do not put anything in mouth.
Begin CPR/Rescue Breathing
Note time of arrival and departure of ambulance; complete this form, initial, and send a copy of form with the ambulance.
The following staff members are trained to deal with an emergency, and initiate the appropriate procedures:
1:________________________________________ 2:____________________________________3:_____________________________
__________________________________________
Registered Nurse’s Signature
___________________________
Date
__________________________________________
Parent/Guardian Signature
___________________________
Date