Diabetes Action Plan Template
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1
2Diabetes 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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