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