Puyallup School District Special Services - DOC

							                             Puyallup School District Special Services
                           DIABETES EMERGENCY MEDICAL PLAN
                                                                                        Section 504 Plan
Student Name: ____________________________Date of Birth: _____________ Grade/Teacher: _________
Student Address: ___________________________________________________ Bus Route #: ____________
Parent/Guardian: ___________________________ Phone: _________________Cell: ___________________
Parent/Guardian: ___________________________ Phone: _________________Cell: ___________________
Physician: _______________________________________Phone: ___________________________________
Normal Range of Blood Sugar: _______________________ Student uses an insulin pump: _______________
Medications: _________________________________________ Dosage/Time given: ___________________
NEVER SEND A CHILD HAVING DIABETIC SYMPTOMS TO THE HEALTH ROOM ALONE
                      WHEN IN DOUBT- TREAT FOR LOW BLOOD SUGAR
Emergency Response

         LOW BLOOD SUGAR                                         HIGH BLOOD SUGAR
           Hypoglycemia Symptoms                                   Hyperglycemia Symptoms
                 Shaking                                              Extreme Thirst
              Fast Heartbeat                                        Frequent Urination
                Sweating                                                Dry Skin
                 Anxious                                                 Hunger
                Dizziness                                             Blurred Vision
                 Hunger                                                Drowsiness
            Impaired Vision                                              Nausea
            Weakness/Fatigue
                Headache
                 Irritable
          Loss of Consciousness
             Stops Breathing

                  Treatment                                               Treatment
Test blood sugar                                    Test blood sugar
Give glucose gel/frosting or 4 oz juice/quick       Test ketones
acting sugar                                        Give non-sugar liquids like water
Give glucagon if ordered and LPN/RN present         Check Physician’s Order for specific instructions
Call Parent & School Nurse                          Check insulin pump for working order, if applicable
If no improvement after 10-15 minutes, give         Call Parent & School Nurse
more sugar
Check Physician’s Order for specific instructions
If unconscious- CALL 911
Stops Breathing- Start CPR & Call 911


PARENT/GUARDIAN SIGNATURE: ________________________________________DATE: __________
PHYSICIAN SIGNATURE: ________________________________________________ DATE: _________
5/11