DIABETES EMERGENCY ACTION PLAN

Date of Plan

Date

Valid for school year

This plan should be completed by the student's health care team and parent/guardian. It should be reviewed with all relevant school/daycare staff and be kept in a place that is easily accessible by those individuals for who it is necessary.

Student's Name

Birth date

Date

Type of Diabetes

Type 1Type 2 Other:Other

Date of Diabetes Diagnosis

Date

Grade

Mother/Guardian

Address

Telephone: Home

Work

Cell

Father/Guardian

Address

Home

Work

Cell

Student's Diabetes Doctor

Address

Telephone: 402-955-3871

Name

Relationship

Home

Work

Cell

Notify parents/guardian or emergency contact in the following situations

Diabetes Medical Management Plan Worksheet

Checking student's blood glucose/sugar:

Target range for blood glucose

70-15070-180Other

Usual times to check blood glucose

Times to do extra blood glucose checks (check all that apply)

Before exercise/Physical EducationAfter exercise/Physical EducationWhen student has signs/symptoms of low or high blood glucoseWhen student has signs/symptoms of illness

Can student perform own blood glucose checks?

YesNo

Exceptions

Type of blood glucose meter student uses

Hypoglcemia Treatment:

Student's usual symptoms of hypoglycemia (list below)

Treatment of hypoglycemia

If Blood Sugar is Less than _______, the student should recheck sugar in min anfter treatment and continue to treat until blood sugar is within range

Glucagon should be given in the student is unconscious, having a seizure, or is unable to swallow. Route of Glucagon?

Dose of Glucagon

Site for Glucagon Injection

If a glucagon dose is required, administer it immediately. Then call 911 (or other emergency assistance) and then parent(s)/guardian(s

Hyperglycemia Treatment:

Student's usual symptoms of hyperglycemia (list below):

Treatment of hyperglycemia

Urine/blood should be checked for ketones when blood glucose levels are above 240 mg/dl.

If urine ketones present, push sugar-free fluids and call parent/guardian. Continue to have student check for ketones every time he/she uses the bathroom.

Additional Treatment for ketones

Insulin Therapy:

For thse students not on Fixed Insulin Therapy or Insulin Pump, please provide adjustable insulin therapy orders for insulin to be administered at school.

Name of student's Insulin

Student's Insulin dosing

Adjustable Insulin TherapyFixed Insulin Therapy

Meal Plan:

Can student be independent in carbohydrate calculations and management?

YesNo

Other times to give snacks and content/amount

A fast-acting source of sugar such as glucose tabs and/or sugar-containing fluids must be available at the site of physical education activities and sports.

Physical Activitiy/ Sports:

Blood sugar should be at least______prior to starting PE or sports if duration of activity is 30 minutes or more.

if urine If most recent blood sugar is ______, or if urine/blood ketones are present, students should avoid physical activity.

Supplies to be kept at school

Blood glucose meter, blood glucose test strips, batteries for meterLancet device, lancets, gloves, etc.Urine ketone stripsBlood ketone meter and blood ketone stripsInsulin pen, pen needles, insulin cartridgesFact-acting source of glucoseCarbohydrate containing snackGlucagon emergency kit

This Diabetes Medical Management Plan has been approved by:

I give permission to the school nurse or another qualified health care professional to perform and carry out the diabetes care tasks outlines in my son's Diabetes Medical Management Plan. I also consent to the release of the outlined in information contained in this Diabetes Medical Management Plan to all school staff members and other adults who have responsibility for my child and who may need to know this information to maintain my child's health and safety. I also give permission to the school nurse or another qualified health care professional to contact my child's physician/health care provider. This form is to be used together with the Endocrine Clinic permission to treat/orders.

Student's Parent/Guardian

Date

Reference: Diabetes Medical Management Plan. American Diabetes Association. www.YourDiabetesInfo.org.