My Emergency Plan
In the case of an emergency, this plan will help you decide when and who to call. Keep it where you can find it.
Our agency has nursing staff on call 24 hours a day including nights, weekends, and holidays.
Nurse/Therapist Name: __________________________________________________ Phone Number: _________________________
PROBLEM
Breathing/Lungs
CALL NURSE AT AGENCY
CALL 911
Increased () shortness of breath
Difficulty breathing
A cough that gets worse
Severe shortness of breath or wheezing that does not
Change in color, thickness, odor, or amount of sputum
respond to inhalers or breathing treatments
You become restless or agitated
Change in the color of your skin to gray or blue OR if you
 fatigue/weakness
become blue around your lips
Loss of appetite or weight
You develop confusion
Fever – oral temperature greater than 100.5 degrees F
Heart Failure
 weight of __ pounds in 1 day OR 3 pounds in ______
Severe shortness of breath
 shortness of breath, especially when you lie flat
Fainting
A productive, frothy cough or new coughing at night
Sudden or severe chest pain or pressure
New congestion, not related to a cold
Frothy sputum
More swelling in your legs or feet than usual
 fatigue/weakness
Dizziness/lightheadedness when you get up
Irregular or rapid heartbeat
Chest pain or tightness RELIEVED by rest or medication
Chest pain, pressure, or tightness that medication
PROBLEM
CALL NURSE AT AGENCY
Chest Pain
CALL 911
(Nitroglycerin) does not help OR
Chest pain that goes away and comes back
Pain/discomfort in neck, jaw, the back, one or both arms, or
stomach
Chest discomfort with shortness of breath, sweating, or
nausea
Blood Pressure
Stroke
Repeated blood pressure readings above:
Sudden numbness or weakness of the face, arm or leg – may
_____________________________________________
be on one side of the body
Sudden confusion, trouble talking, or understanding
Symptoms may include headaches, nose bleeds, blurred vision,
Sudden trouble seeing in one or both eyes
ringing in ears, lightheadedness, heart palpitations (fluttering)
Sudden trouble walking, dizziness, loss of balance or
coordination
Sudden, severe headache with no known reason
Blood Thinner
Bleeding
Black/dark or blood tinged bowel movements
Vomiting blood
Bleeding from gums, nose, mouth, or surgical site
Unusual bruising
Blood in urine
Urinary Catheter Urinary
Infection
Catheter is leaking, blocked, or dislodged (out)
Urge to urinate frequently, in small amounts, or unable to urinate
Burning when urinating
Bloody, cloudy, or change in urine color or foul odor
Low back pain
May have fever greater than 100.5 degrees or chills
Bleeding you can’t control
PROBLEM
Wound/Skin
CALL NURSE AT AGENCY
CALL 911
Change in amount, color, or odor of wound drainage
Increase in pain at wound site
Increase in redness/warmth at wound site
Fever greater than 100.5 degrees/chills
New skin problem
Diabetes
High blood sugar symptoms:  thirst, frequent urination,  hunger,
Nausea and vomiting, shortness of breath, fruity breath
blurred vision, weakness, dry, itchy skin
Repeated blood sugars greater than ___________mg/dl
Blood sugar greater than 450 mg/dl
Low blood sugar symptoms: Shakiness, sweating, hunger,
Unconsciousness
headache, fast heartbeat, confusion, changes in vision, irritability
Unable to treat low blood sugar at home
Repeated blood sugars less than _____________mg/dl
Seizures
If experiencing above symptoms, test blood sugar first (if possible), Low blood sugar not responding to treatment
then treat with some form of sugar such as: 3 glucose tablets, or ½
glass of juice, or 5-6 pieces of hard candy; wait 15 minutes and recheck blood sugar; if your blood sugar is still low and symptoms do
not go away, eat a light snack such as ½ peanut butter or meat
sandwich and ½ glass of milk. Recheck blood sugar in 15 minutes, if
still low, call 911
Fall
Other
Fall with no serious injury
Fall with suspected injury (broken bone or wound)
New symptoms
Unable to wake patient
Healthcare concerns – pain, no BM in 3 day, other
Severe or prolonged pain
Adapted by Deborah Chisholm, RN, BSN, CPHQ, COS-C from tools developed by Healthcare Partners, Inc., Southfield, MI and Simple Emergency Plan-Carolina Medical Review.