DIABETES EMERGENCY ACTION PLAN
DIABETES EMERGENCY ACTION PLAN
Student Name:_______________________________________________________________________________ DOB __________________________ Grade:______________
Parent/Guardian:________________________________________________ Phone(s):_________________________________________________________________________
|Below 70 (or _____)_ (Hypoglycemia) |70 – 90 |91 – 125 |126 – 250 |Above 250 (or _____) (Hyperglycemia) |
| |or _____--_____ |or ____--____ |or ___--____ | |
|ONSET: Sudden | | | |ONSET: Over time – several hours or days |
| | | | |
|*SEVERE HYPOGLYCEMIA |MODERATE HYPOGLYCEMIA |MILD HYPOGLYCEMIA |If exercise is planned before a snack or meal (including recess)|
|Combative |Blurry Vision |Hunger |the student must have a snack before participating. |
|Inability to swallow |Confusion |Weakness | |
|Unable to control airway | |Paleness | |
|Loss of consciousness |Weakness |Irritability | |
|Seizure |Headache |Dizziness | |
| |Sleepiness |Sweating | |
| |Behavior change |Crying | |
| |Poor coordination |Anxiety | |
| |Slurred speech |Shakiness Headache| |
| | |Poor concentration | |
| | |Personality change | |
| | |Drowsiness | |
|FAST ACTING SUGAR SOURCES: |
|3-4 glucose tablets OR 4 ounces juice OR 6 ounces regular soda OR 3 teaspoons glucose gel OR 3 teaspoons sugar in water |
Never send a child with suspected low blood glucose anywhere alone!!!
Never provide insulin coverage for carbohydrate/glucose being used to treat hypoglycemia.
*Severe symptoms are a life-threatening emergency.
Adapted with permission from National Association of School Nurses H.A.N.D.S. SM 2008
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CHECK BLOOD GLUCOSE
7/29/13
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