Diabetes Emergency Care Plan
Individual Health Care Plan
Student Name: _____________________________ Birthdate: _________ Grade: ____ Date: _______
Background information: Diabetes is a chronic illness that results from failure
of the pancreas to make a hormone called insulin. Blood sugars are monitored to
prevent low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia).
Medication: ________________________________________________
Signs and symptoms of Low Blood Sugar (hypoglycemia) can include:
Tired, hunger, dizziness, shakiness, not feeling well, sweaty, drowsy, weak,
headache, irritable, confusion, blurry vision, weakness, slurred speech, behavior
change, poor coordination, labored breathing, loss of consciousness, seizures
Other: ___________________________________________________________
Never send a child with a suspected low blood sugar anywhere alone!
Emergency Action Plan for Low Blood Sugar:
1. Low blood sugar (hypoglycemia) is a medical emergency and requires immediate treatment.
2. If able, have student escorted to the Health Center or Office.
3. If possible, check blood sugar per plan. If you do not know how to test or there is no meter to
test with……TREAT anyway.
4. Always, if in doubt, TREAT.
5. Give quick sugar source: 2 to 3 glucose tablets, 4 to 8 ounces of juice, 4 to 8 ounces of regular
pop (not diet), 3 to 8 lifesavers, glucose gel product.
6. Stay with the child, repeat treatment if necessary in 15 minutes.
6. Call 911 for loss of consciousness or seizure.
7. Call parent/guardian.
NOTE: High blood sugar (hyperglycemia) is a blood sugar reading typically greater than 240. Although
high blood sugars are not good for the child, they do not generally pose the medical emergency that low
blood sugars do. Symptoms can include frequent urination and extremely thirsty. Check blood sugar per
plan. Parents must be notified of blood sugars greater than ________.
Parent/Guardian Emergency Contact Information:
#1 Call ___________________________ Home:___________ Work: __________ Cell: ____________
#2 Call ___________________________ Home: ___________ Work: __________ Cell: ____________
Parent/guardian is responsible for notifying after school activities program staff/adult/coach of all aspects of students diabetes
needs.
*** I understand that the above information may be shared with school district staff s needed to protect the health and safety
of this student and to plan for a safe environment conducive to learning.***
Parent/Guardian Signature: _____________________________________________ Date: _______________
School Nurse Signature: _______________________________________________ Date: _______________
___________________________________________________________________ Date: _______________
5-17-13