ࡱ> pso[ bjbjmm 40bb NNNbbb8L,bvV((((uuuuuuu$Wx {uN"u((du^8(N(tpunlA6D(p< RtB su0vB{^{@D{NDt/uuf v{B :  SAMPLE EMERGENCY CARE PLAN OF HYPOGLYCEMIA Student: __________________________ Grade: _____ School: ________________________ DOB:_______ Parent/Guardian Name _________________________ Phone #:_______________________ ( Check if cell Parent/Guardian Name _________________________ Phone #:_______________________ ( Check if cell Emergency Contact if Parent/Guardian cannot be reached: ________________________________________ Relationship:____________________________ Phone:______________________________ ( Check if cell Parent /Guardian Signature: _______________________________________________ Date: ___________ This plan will be reviewed with appropriate school staff on a need to know basis to maintain student safety  SYMPTOMS OF A HYPOGLYCEMIC EPISODE MAY INCLUDE ANY/ALL OF THESE: Shaking, fast heartbeat, sweating, anxiety, irritability, dizzy Complaints of hunger, impaired vision, weakness or fatigue Onset may be sudden and symptoms may progress rapidly SEVERE SYMPTOMS INCLUDE: Inability to swallow, seizure activity, loss of consciousness STAFF MEMBERS INSTRUCTED: ( Classroom Teacher(s) ( Special Area Teacher(s) ( Administration ( Support Staff ( Transportation TREATMENT: Stop any activity immediately. Accompany the student to the Health Office. Notify school nurse immediately. If off school grounds, provide a source of glucose: -3/4 cup juice, glucose tabs, hard candy, regular soda (not diet), or glucose gel. PROCEDURE FOR EMERGENCY TRANSPORT (IF NEEDED): Glucagon ordered: ( No - Activate EMS per District Policy ( Yes- Follow Steps Below Position student on side if possible. If student is unconscious, unresponsive or having a seizure glucagon should be given by a willing trained school staff member. After glucagon is given call 911. Notify parents. Students receiving glucagon without their parent or guardian present should be transported to the hospital by ambulance. A staff member should accompany the student to the emergency room if the parent, guardian or emergency contact is not present and adequate supervision for other students is present. 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