Diabetes Emergency Plan
Student’s Name: ____________________________ D.O.B. ____________
Student’s Photo
School: _________________ Grade: _____ Div: _____ Date of Plan: __________________
PHN Care Card Number # _______________________________________
 Yes  No
Nursing Support Services Diabetes Delegated Care Plan
NSS Coordinator: ____________________________ Phone: __________________
CONTACT INFORMATION
Parent/Guardian 1:
Name:
Phone Numbers:
Cell
Parent/Guardian 2:
Name:
Phone Numbers:
Cell:
Other/Emergency:
Name:
 Call First
Work
Cell:
Other
 Call First
Work:
Home:
Other:
Relationship:
Able to advise on diabetes care:
Phone Numbers:
Home
 Yes  No
Work:
Home:
Other:
Additional times to contact Parent/Guardian (In addition to times indicated in NSS Delegated Care Plan):
Have emergency supplies been provided in the event of a natural disaster?
 Yes  No
If yes, location of emergency supply of insulin: _____________________________________
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TREATING MILD TO MODERATE HYPOGLYCEMIA
STUDENT’S USUAL SYMPTOMS OF
MILD TO MODERATE HYPOGLYCEMIA
 Shaky, sweaty
 Hungry
 Pale
 Dizzy
 Mood changes
 Irritable
 Tired/sleepy
 Blurry/double vision
 Difficulty
concentrating
 Confused
 Poor coordination
 Difficulty speaking
 Headache
Other symptoms:
If mild to moderate hypoglycemia is
suspected, DO NOT leave student
unattended
TREATMENT FOR STUDENTS NEEDING ASSISTANCE
(anyone can give glucose to a student):
Location of fast acting sugar: ____________________________
1. If student able to swallow, give one of the following fast acting
sugars based on student’s weight:
10 grams
 ____ glucose tablets
 1/2 cup of juice or regular
soft drink
OR 15 grams
 ____ glucose tablets
 3/4 cup of juice or regular
soft drink
 10 mL (2 teaspoons) or 2
 15 mL (1 tablespoon) or 3
packets of table sugar dissolved
in water
 2 teaspoons of honey
packets of table sugar dissolved
in water
 1 tablespoon of honey
 10 skittles
 Other (ONLY if 10 grams are
 15 skittles
 Other (ONLY if 15 grams are
labelled on package):
__________________________
labelled on package):
__________________________
2. Contact designated emergency school staff person
3. Blood glucose should be retested in 15 minutes. Retreat as above
if symptoms do not improve or if blood glucose remains below
4mmol/L
4. Do not leave student unattended until blood glucose is over 4
mmol/L
5. Give an extra snack such as cheese and crackers if the planned
meal/snack is not for another 45 minutes or more
TREATING SEVERE HYPOGLYCEMIA
SYMPTOMS OF SEVERE HYPOGLYCEMIA: SEIZURE, UNCONSCIOUSNESS
School staff persons trained to give glucagon: ________________________________________________
________________________________________________________________________________________________
Location of Glucagon kit: __________________________________________________________________________
Glucagon dose: _____ 0.5 mg (5 years old or less)
_______1 mg (6 years or older)
Response:
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Do NOT try to give anything by mouth
Identify someone to call 911 immediately
Identify someone to call the student’s parent/guardian
Turn the student on his/her side and keep them in that position until student is alert
Administer glucagon in the outer thigh as per training and instructions in kit
Stay with student until ambulance arrives
Once student is alert and able to swallow, give juice or fast acting sugar
After fast acting sugar, if the ambulance or parent has not yet arrived, give longer acting carbohydrate such as
cheese and crackers if next meal is more than 30 - 45 minutes away. Other examples include granola bars,
power bars, peanut butter and crackers.
Parent/Guardian Signatures:
Name: _________________________________ Signature: _____________________________ Date: _____________
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