Quick Reference Emergency Plan - Bishop England High School
OFFICE OF CATHOLIC SCHOOLS DIOCESE OF CHARLESTON
QUICK REFERENCE EMERGENCY PLAN
Part A of Diabetes Medical Management Plan
HYPOGLYCEMIA
(Low Blood Sugar)
____________________________________ ___________________ ____________
Student Name School Teacher/grade
_________________________________________________ __________________________________________________
Mother/Guardian Father/Guardian
_________________________________________________ __________________________________________________
Home phone Work phone Cell Home phone Work phone Cell
_________________________________________________ __________________________________________________
Trained Diabetes Personnel Contact Number(s)
NEVER SEND A CHILD WITH SUSPECTED LOW BLOOD SUGAR ANYWHERE ALONE.
OFFICE OF CATHOLIC SCHOOLS DOCESE OF CHARLESTON
QUICK REFERENCE EMERGENCY PLAN
Part B of Diabetes Medical Management Plan
HYPERGLYCEMIA
(High Blood Sugar)
__________________________________________________ _______________________________ _____________
Student Name School Teacher/grade
This quick reference emergency plan reflects orders stated in the Diabetes Medical Management plan and is authorized by;
____________________________________________ ____________________ _____________________
Licensed Health Care Provider Telephone Date
____________________________________________ ____________________ _____________________
Parent Telephone Date
Source: Helping the Student with Diabetes Succeed: A Guide for School Personnel
-----------------------
CSO/15-H4
See reverse for Part B and signatures
Onset
• Sudden
Causes of Hypoglycemia
• Too much insulin
• Missed food
• Delayed food
• Too much or too intense exercise
• Unscheduled exercise
Symptoms
Mild
• Hunger • Sweating
• Shakiness • Drowsiness
• Weakness • Personality change
• Paleness • Inability to concentrate
• Anxiety
• Irritability • Other: ___________
• Dizziness __________________
Circle student’s usual symptoms.
Severe
• Loss of consciousness
• Seizure
• Inability to swallow
Circle student’s usual symptoms.
Moderate
• Headache • Blurry vision
• Behavior • Weakness
change • Slurred Speech
• Poor • Confusion
coordination • Other ___________
_________________
Circle student’s usual symptoms.
Actions needed
Notify School Nurse, Trained Diabetes Personnel or Designated School Personnel. If possible check blood sugar, per Diabetes Medical Management Plan. When in doubt, always TREAT FOR HYPOGLYCEMIA
Severe
• Don’t attempt to give anything
by mouth.
• Position on side, if possible.
• Contact school nurse or trained
diabetes personnel.
• Administer glucagon, as
prescribed.
• Call 911.
• Contact parents/guardian.
• Stay with student.
Moderate
• Someone assists.
• Give student quick-sugar source
per MILD guidelines.
• Wait 10 to 15 minutes.
• Recheck blood glucose.
• Repeat food if symptoms persist
or blood glucose is less than
______.
• Follow with a snack of
carbohydrate and protein (e.g.,
cheese and crackers).
Mild
• Student may/may not treat self.
• Provide quick-sugar source.
3-4 glucose tablets
or
4 oz. juice
or
6 oz. regular soda
or
3 teaspoons of glucose gel
• Wait 10 to 15 minutes.
• Recheck blood glucose.
• Repeat food if symptoms persist
or blood glucose is less than
______.
• Follow with a snack of
carbohydrate and protein (e.g.,
cheese and crackers).
Onset
• Over time—several hours or days
Causes of Hyperglycemia
• Too much food
• Illness
• Too little insulin
• Infection
• Decreased activity
• Stress
Symptoms
Severe
• Mild and moderate
symptoms plus:
• Labored breathing
• Very weak
• Confused
• Unconscious
Circle student’s usual symptoms.
Moderate
• Mild symptoms plus:
• Dry mouth
• Nausea
• Stomach cramps
• Vomiting
• Other:_______________
Circle student’s usual symptoms.
Mild
• Thirst
• Frequent urination
• Fatigue/sleepiness
• Increased hunger
• Blurred vision
• Weight loss
• Stomach pains
• Flushing of skin
• Lack of concentration
• Sweet, fruity breath
• Other: __________________
Circle student’s usual symptoms.
Actions Needed
• Allow free use of the bathroom.
• Encourage student to drink water or sugar-free drinks.
• Contact the school nurse or trained diabetes personnel to check urine or administer insulin, per student’s Diabetes Medical Management Plan
• If student is nauseous, vomiting, or lethargic, ____ call the parents/guardian or ____ call for medical assistance if parent cannot be reached.
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