Quick Reference Emergency Plan
Emergency Care Plan for Transportation Provider of a Student with Diabetes
Hypoglycemia
(Low Blood Sugar) BUS#/CAR# _________
Student’s Name: _________________________________________ Self Care: Y / N
Grade/Teacher: ____________________________________ Date of Plan: ____________
Emergency Contact Information:
Mother/Guardian: _______________________________________________________________
Home phone: __________________ Work phone: ______________ Cell phone: ____________
Father/Guardian: ________________________________________________________________
Home phone: __________________ Work phone: ______________ Cell phone: ____________
School Name: School Phone:
School Nurse: ______________________ Clinic Phone: ______________________
Other Trained personnel:
Never send/leave a student with suspected low blood sugar anywhere alone
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(Continued from previous side / over)
Emergency Care Plan for Transportation Provider of a Student with Diabetes
Hyperglycemia
(High Blood Sugar)
Please See Side A for bus#/car# and contact information
Never send/leave a student with suspected high blood sugar anywhere alone
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Onset
• Sudden – symptoms may progress rapidly
Causes of Hypoglycemia
• Too much insulin
• Missed or delayed food
• Not eating enough (carbs)
• Too much, too intense or unplanned exercise
• Illness, especially stomach
Symptoms
Mild
|(Hunger |(Sweating |
|(Shakiness |(Drowsiness |
|(Weakness |(Personality change |
|(Paleness |(Unable to concentrate |
|(Anxiety |(Irritability |
|(Dizziness |(Other:_____________ |
circle student’s usual symptoms, if known
Moderate
|(Headache |(Blurry vision |
|(Behavior change |(Weakness |
|(Poor coordination |(Slurred speech |
|(Able to swallow |(Confusion |
|(Other: _________ | |
circle student’s usual symptoms, if known
Severe
(Loss of consciousness
(Seizure
(unresponsive
(Inability to eat or drink
circle student’s usual symptoms
Actions Needed
WHEN IN DOUBT, ALWAYS TREAT FOR HYPOGLYCEMIA
Mild / Moderate
• Call Dispatch to contact school, parent/guardian, school nurse
• Ask student if quick sugar source is in backpack
Provide quick sugar source:
4-6 Life savers
or 3 teaspoons of glucose gel
or 3-4 glucose tablets
or 4 oz juice
or 6 oz regular (not diet) soda
• Repeat quick-sugar source if symptoms persist
• If student is self-care, allow student to check blood sugar and eat a quick sugar source if necessary, according to plan of care
•
Severe
• Call Dispatch to Contact 911/EMS, school, parent/guardian, school nurse
• Do NOT attempt to give anything by mouth
• If unconscious, position on side, if possible
• Stay with student until EMS or parent/guardian arrive
•
Symptoms
Mild
• Thirst
• Frequent Urination
• Fatigue/sleepiness
• Increased hunger
• Blurred vision
• Stomach pains
• Flushing of skin
• Lack of concentration
• Other: _________________
circle student’s usual symptoms, if known
Moderate
Mild symptoms plus:
• Dry mouth
• Stomach cramps
• Other: __________________
circle student’s usual symptoms, if known
Severe
Mild and Moderate symptoms plus:
• Labored breathing
• Very weak
• Confused
• Unconscious
• Nausea and Vomiting
• extreme thirst and dehydration
• Chest Pain
• Severe Abdominal Pain
• Sweet, fruity breath
• Increased lethargy
circle student’s usual symptoms
Mild/Moderate
• On long trips, provide frequent bathroom breaks
• Encourage student to drink water or sugar-free drinks
• If student is self-care, allow student to check blood sugar and administer insulin if necessary, according to plan of care
• Restrict participation in physical activity
Causes of Hyperglycemia
• Too much food
• Too little insulin
• Decreased activity
• Illness/Infection/Stress
• Injury (or Pump issue)
Onset
• Over several hours or days
Severe
• Call Dispatch to contact 911/EMS, school, parent/guardian, school nurse
• Do NOT attempt to give anything by mouth
• If unconscious, position on side, if possible
• Stay with student until EMS or parent/guardian arrives
Actions Needed
WHEN IN DOUBT, ALWAYS TREAT FOR HYPOGLYCEMIA (see over)
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