322-0971 SUBCUTANEOUS INSULIN ORDERS rev 03-10

SUBCUTANEOUS INSULIN
PHYSICIAN’S ORDERS
Stat finger stick blood sugar for any neurologic change
BLOOD GLUCOSE MONITORING SCHEDULE
Q6 hr when NPO AC & HS when eating OTHER ______________________________________________________________
TARGET BLOOD GLUCOSE
Fasting Blood Glucose (FBG) Pre-Meal Random Blood Glucose (RBG) HS (fill in)
80 mg/dl 100 mg/dl _______________ 120 mg/dl 140 mg/dl ________________ __________
MUST BE RENEWED AFTER 48 HOURS OR
ADVANCE TO OPTION #B
INSULIN RENEWAL - ACUTE CARE Q 4 DAYS
LTC Q 80 DAYS
OPTION A: BOLUS HYPERGLYCEMIA CORRECTION DOSE ONLY; NOT FOR USE AT HS
(for use alone w/out a basal/bolus meal schedule)
SCHEDULE Q6 hr when NPO, AC when eating
INSULIN TYPE Novolog Other _________________________________________
BG mg/dl
60-110
111-149
150-199
200-249
250-299
300-349
>350 Call MD
Low-Dose no Basal
2 units
4 units
6 units
8 units
10 units
12 units
Mod-Dose no Basal
NO INSULIN
4 units
8 units
10 units
12 units
14 units
16 units
High-Dose no Basal
6 units
10 units
12 units
15 units
18 units
20 units
OPTION B: SET MAINTENANCE BASAL AND BOLUS SCHEDULE
SINGLE DAILY DOSE ADMINISTERED AT BREAKFAST IS THE PREFERRED STARTING BASAL SCHEDULE
Insulin type : time : dose
Basal Insulin Schedule
Levemir
Other __________________________
Bolus Meal Insulin Schedule
Novolog
Other __________________________
60-149
150-199
200-249
250-299
300-349
>350 call MD
1 unit
2 units
3 units
4 units
5 units
Breakfast Lunch Dinner
Bolus Hyperglycemia Correction Schedule TO BE ADDED WITH MEAL BOLUS DOSE, NOT FOR USE AT HS
BG mg/dl
Units
_______________ SubQ
Units
_______________ SubQ
Correction insulin type is the same as bolus insulin above
Level 1-Dose
Basal / Bolus
(TDD 40-50 units/day)
Units
_______________ SubQ
Level 2-Dose
Basal / Bolus
(TDD 51-80 units/day)
NO INSULIN
1 unit
3 units
5 units
6 units
7 units
Units
_______________ SubQ
Units
_______________ SubQ
Level 3-Dose
Basal / Bolus
(TDD >81 units/day)
2 units
4 units
6 units
8 units
10 units
HYPOGLYCEMIA
• For any blood glucose

HYPOGLYCEMIA
TREATMENT PROTOCOL
Always report hypoglycemic episodes to attending physician.
Resume insulin orders with next scheduled dose.
Do not withhold treatment for hypoglycemia pending laboratory values or
awaiting response from the physician.
Physical Symptoms of Hypoglycemia
Mild
Moderate
Severe
• Sweating • Sudden Weakness • Dizziness & Confusion
• Any mild or moderate symptoms, and
• Shaking • Fast Heart Rate • Difficulty swallowing • Nausea or • Combative
• Seizures
• Irritability • Blurred Vision • Numbness of the lips Vomiting • Loss of Consciousness • Difficulty swallowing
Moderate to severe symptoms should be treated regardless of the blood glucose level
HIGH ALERT: Hypoglycemia Treatment
High alert condition:
1. For any BG drop >100 mg/dl in 1 hour and patient with any symptoms of hypoglycemia
2. If the finger stick blood glucose (FSBG) is ▼ 40 mg/dl with or without symptoms of hypoglycemia
3. For hypoglycemia that has not resolved within 20 minutes of repeating treatment
4. Patients receiving insulin AND IV fluids, TPN, enteral feeding, or oral intake suddenly changes or is discontinued
5. Patient receiving insulin AND scheduled for surgery or other NPO orders and no glucose: insulin replacement ordered
6. Patient receiving insulin AND treated for hypoglycemia >2 two times in a 24-hour period
Nursing intervention
1. Notify physician when any of the above alert conditions occur
2. If the FSBG ▼ 40 mg/dl, get stat laboratory glucose
3. If not existing IV, establish IV access with saline lock when: any of the high alert conditions occur AND patient has
hypoglycemic symptoms AND physician can not be contacted immediately for alternate orders
All patients having hypoglycemia or on high alert: monitor FSBG q4hr for 24-hours.
Resume previous FSBG orders if no further hypoglycemic episodes occur.
Able to Swallow
Blood glucose Treatment