Diabetes Emergency Action Plan for:____________________
Emergency Contact Information (Call in this order)
Nurse: (919)228-4562 or Cell #: (919)302-8210
Parents:
Phone Numbers:
Diabetes Emergency Procedures
Mild Hypoglycemia

Signs and Symptoms
Signs in ________vary, and may
include:
 Quiet, not focused, sleepy
looking, poor concentration
 Very grouchy and mean
 Very hungry
 Inappropriate emotional
responses (i.e. uncontrollably
silly, hyperactive
 Headache or dizziness
 Face looks pale


Treatment
______ will handle mild hypoglycemia
without assistance. If you ever see signs of
hypoglycemia in ______ , simply ask him to
test his blood sugar.
Never send ________ to the Nurses office if
you suspect that he has a low blood sugar. If
you need help, send someone else for the
nurse.
Moderate Hypoglycemia

Signs and Symptoms
__________ has never had
Moderate Hypoglycemia, but here
are some of the possible symptoms,
just in case:
 Staggering walk
 Uncontrollable crying episode
 Slurred speech
 Blank stare
 Refusal to take anything by
mouth
Treatment
 Moderate hypoglycemia is handled like mild
hypoglycemia, with the following
exceptions:




If _______ is unable or unwilling to take
carbohydrates (he may become irrational
or uncooperative and may not be able to
follow directions), slowly squirt an entire
tube of cake icing (found in his
) in
between his cheek and gums – even if he
resists. This may require assistance.
Rub the cheeks gently to make sure the
sugar is absorbed.
Check Blood Sugar again _____ minutes
after treatment, and retreat if necessary.
_____ should not be allowed to play
sports or be highly active for the next
hour after a Moderate Hypoglycemia.
Notify __________’s parents as soon as
possible.
Severe Hypoglycemia
This is a Medical Emergency!

Signs and Symptoms
_______ has never had Severe
Hypoglycemia, but here are some
of the possible symptoms, just in
case:
 Unconscious
 Unresponsive
 Convulsion-like movement
 Failure to respond to ca-e icing







Treatment
Be sure _______ is lying down in a safe area,
protected from head or bodily injury.
Position _______ on his side.
Call 911.
Inject Glucagon (get help from the nurse)
Do not attempt to put anything between
_____’s teeth.
As ______ regains consciousness, nausea
and vomiting may occur.
Notify __________’s parents immediately.
Hyperglycemia

Signs and Symptoms
________ does occasionally
experience Hyperglycemia.
Symptoms vary, and may include:
 Increased thirst
 Frequent urination
 Sluggishness
 Stomach Ache
 Headache
 Fruity Odor to the Breath
Reviewed and Signed:





Treatment
_________ will handle any treatment of mild
to moderate Hyperglycemia with minimal
interruption to his school activity. He can
calculate his insulin requirements with no
assistance.
If Blood Sugar (BS) is above ______, he
may need to go to the nurse’s office.
Write plan here____________________
These supplies are kept in the nurse’s office.
______ needs free access to the bathroom
and water fountain, especially during
hyperglycemia.
_______________________
Parent
_________
Date
_______________________
School Nurse
_________
Date
_______________________
Doctor
________
Date