Insulin, Subcutaneous NPO or Continuous Enteral Feeding Orders

NPO
INSULIN, SUBCUTANEOUS NPO OR CONTINUOUS
ENTERAL FEEDING ORDERS
Adult, Non-Pregnant Patients
PATIENT INFORMATION
Orders preceded with a box must be checked to activate. All other orders are effective unless modified.
Complete blanks to specify information not predefined. Modification of orders, i.e., additions, deletions,
strikeouts of components that do not apply should be initialed.
TARGET GOAL: Pre-prandial BG 100-140 mg/dL and Random BG 180mg/dL).
2. Discontinue all previous insulin, diabetes agents (includes oral hypoglycemics), and blood glucose testing.
3. Obtain Hemoglobin A1c level (If not already done during this hospitalization).
4. If NPO, start low dose dextrose infusion: ____________________________(solution) at ________mL/hr.
5. Consults: Nutrition Diabetes Education
6. Finger-stick blood glucose Q 6 hours.
Additional Testing ______.
7. Notify physician: Blood glucose greater than 400 mg/dL or
Blood glucose less than 70 mg/dL and implement Hypoglycemia Treatment.
8. Insulin Basal (Long Acting):
Insulin Glargine (LANTUS®) subcutaneously ____ units daily at 2100.
Insulin Glargine (LANTUS®) subcutaneously ____ units BID at 0900 and 2100.
Insulin Glargine (LANTUS®) subcutaneously _____units at ______ (time) and ____units at ______(time) daily.
9. Nutrition Coverage if patient is receiving continuous enteral feeding > 40 mL/hr and blood glucose is
greater than 70 mg/dL: Give Insulin Regular subcutaneously Q 6 hours per selected scale:
Very Low Low Moderate High Custom Order
3 units 4 units 5 units 6 units _____units
10. Correction Coverage: Insulin Regular subcutaneously Q 6 hours per below selected insulin scale and blood glucose value:
Blood Glucose
Insulin Scale Custom
(Default Scale) Very Low Low Moderate High Insulin Blood glucose
141-200 mg/dL 1 unit 2 units 3 units 4 units ___ units ____-___ mg/dL
201-250 mg/dL 2 units 4 units 6 units 8 units ___ units ____-___ mg/dL
251-300 mg/dL 3 units 6 units 9 units 12 units ___ units ____-___ mg/dL
301-350 mg/dL 4 units 8 units 12 units 16 units ___ units ____-___ mg/dL
351-400 mg/dL 5 units 10 units 15 units 20 units ___ units ____-___ mg/dL
> 400 mg/dL
Notify Physician
6 units 12 units 18 units 24 units ___ units ____-___ mg/dL
11. Start D10W at 40 mL/hr, if interruption of greater than 2 hours of continuous enteral feeding, and if insulin given
within past 24 hours. Discontinue D10W when feeding is resumed.
12. If patient begins eating > 50% of meals:
a.) Initiate Eating or Bolus Tube Feeding Subcutaneous Insulin Orders using current basal dose and correction
coverage scale.
b.) Notify physician to obtain order for nutrition coverage and order to d/c dextrose containing IV fluid or enteral
feeding as appropriate.
Nurse Signature Date/Time Transcriber Signature Date/Time Physician Signature Date/Time
Print Name or ID # Print Name or ID # Print Name or ID #
*3PO*
*3PO*
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Target Inpatient
Blood Glucose
Levels: All
preprandial 100-
140 mg/dL, all
random 30), or those receiving high doses or corticosteroids – use 0.5 units/
kg/day (or more).
Step 3: Determine the distribution of the TDD calculated above based on nutritional regimen.
Note: if basal insulin exceeds 50% of the TDD, the pt is at higher risk for hypoglycemia for
longer periods of time if the nutrition source is stopped.
If patient receiving continuous infusions of tube feeds:
If patient NPO :
Check blood glucose every 6 hours.
Check blood glucose every 6 hours.
Basal insulin: Glargine (Lantus®) = 0.5 x TDD, given once daily,
Start low dose dextrose infusion (D5 0.45% NaCl at 75 mL/hr) if no
dosed at bedtime.
other dextrose infusion running.
Nutritional insulin: Regular insulin = give the remainder of the TDD in Basal insulin: Glargine (Lantus®) = 0.5 x TDD, given once daily, dosed
4 equally divided doses Q 6 hrs, if rate of tube feed is 40 mL/hr. at bedtime.
Correctional insulin, in addition to nutritional insulin: Use very
Nutritional insulin: None (discontinue previous).
low (Known severe insulin sensitivity), low (Insulin sensitive: lean, Correctional insulin: Consider use of very low or low dose algorithm.
malnourished, elderly, kidney disease) moderate (Not insulin
Adjust based on insulin requirements.
sensitive/not insulin resistant: average weight) or high (Likely insulin
resistant: obese, receiving high dose corticosteroids) dose or custom
algorithm based on BMI and/or insulin requirements.
Step 4: Evaluate the insulin dose DAILY. Determine the total dose received for the previous day and adjust.
If any glucose >180 mg/dL and no hypoglycemia increase TDD by 10%.
If any glucose < 100 mg/dL) decrease TDD by 10%.
If any episodes hypoglycemia (glucose < 70 mg/dL) decrease TDD by 20%.
Discharge Considerations
Based on admission A1C
• A1C < 7% give insulin in hospital but at discharge consider return to preadmission medication.
• A1C 7-8% increase dose of home oral agents or insulin, add a third agent, or add basal insulin.
• A1C >8% continue orals and add/increase basal insulin.
• A1C >9% use basal bolus insulin regimen.
If patient has history of hyperglycemia in hospital follow up with PCP to evaluate (BG>180).
Backer Page of 1 100-7071-202SW (3/10/11)