Diabetes Action Plan Template

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Diabetes Action Plan
Date
__________________________’s
: _________
Child’s Date of Birth:
Child’s Name
Child Care Facility: ________________________ Teacher: ______________________________Classroom: ______________
1 Parent/Guardian: ________________________ Phone (w): _________________ (c): _______________
2 Parent/Guardian: ________________________ Phone (w): _________________ (c): _______________
Physician: _______________________________ Phone:___________________
Physician Signature: ________________________________ Date: ____________________
Diabetes Information
Hyperglycemia (High Blood Sugar)
Hypoglycemia (Low Blood Sugar)
Not enough insulin in the body to allow sugar to be used
Usually happens before lunch or after exercise
Excessive thirst
Excessive hunger
Weakness, fatigue
Excessive hunger
Flushed dry skin
Fruity odor to breath
Feeling faint
Abdominal pain
Frequent urination
Fatigue
Dizziness
Confusion
Tired
Weakness
Shaky, trembling
Anxious, Irritability
Blurred vision
Sweaty, Pallor
Vomiting
Nausea
Rapid pulse
Slurred speech
First Aid for High Blood Sugar or Low Blood Sugar
Hyperglycemia (High Blood Sugar)
Hypoglycemia (Low Blood Sugar)
1 Check the blood sugar with a glucose meter if signs & symptoms
1 Check the blood sugar with a glucose meter if signs & symptoms
occur.
occur.
2 Stay with the child.
2 Stay with the child.
3 Give the carbohydrate supplement ordered by the physician if
3 Call parent if blood sugar is above 250
blood sugar is greater than 70 but less than 80 and child is
4 Check urine for ketones. If positive call parent immediately.
conscious, cooperative, and able to swallow.
Give 15 grams of carbohydrates such as 4oz of fruit juice, 6oz of
5 Qualified person to administer insulin per physician’s order.
regular soda, 3 glucose tablets, I box of raisins OR____________
Can be given by parent.
followed by a meal or snack of_________________________
6 Call 911 immediately, if the child is in a coma or symptoms
(peanut better crackers)
do not subside.
4 Check child’s blood sugar level again after 15 minutes.
7 Provide adult supervision for the other children.
If normal and symptoms are gone, child may resume normal
8 Stay with the child continuously.
activities
If blood sugar is still low, repeat supplement and call parent.
If still no improvement within 15–20 minutes, call physician.
5 Call 911, the parents, and the child’s physician, if
the child’s symptoms do not subside
the child loses consciousness
the child has a seizure
6 Give Glucagon ____ mg IM or sq for symptom of low blood sugar
and child is unconscious, experiencing a seizure, or unable to
swallow:
7 If child improves, you may give 4oz of juice until EMS arrives.
Diabetes Management
Normal Blood Sugar Range:
________mg/dl to
________mg/dl
 Blood Glucose
Usual times to check blood sugar at childcare: _______ ________ _________
Monitoring
Other times to do extra checks: Before Active Play___ After Active Play___ Other _________
Can the child check his/her own blood sugar? ______ Yes ______ No _____ With Assistance

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