A new insulin order form should be completed for subsequent changes to type of insulin and/or frequency of administration
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1 of nurse A new insulin order form should be completed for subsequent changes to type of insulin and/or frequency of administration 1. Check times for point of care meter blood glucose testing. Pre-Breakfast Post-Breakfast Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime 0300hrs All Other (specify): 2. Insulin Regimen: Select type of insulin and indicate dose (See reverse for guidelines) Lunch Basal Insulin Breakfast Dinner Bedtime Lantus (glargine) Levemir (detemir) Humulin N (NPH) Novolin ge NPH Mealtime Insulin Breakfast Lunch Dinner Bedtime Humalog (lispro) NovoRapid (aspart) Apidra (glulisine) Humulin R (regular) Novolin ge Toronto (regular) Premixed Insulin (Mealtime+Basal) Humalog Mix 25 (lispro mix) NovoMix 30 (aspart mix) Humulin 30/70 (regular/nph) Novolin ge 30/70 (regular/nph) Breakfast Lunch Dinner Bedtime Doctor s : PRINT NAME: Pager: PR Page 1 of 3
2 Guidelines for Use of the Orders For Non-pregnant Patients SLIDING SCALE INSULIN refers to a treatment regimen that provides NO basal insulin and provides ONLY short acting insulin if needed according to blood glucose test results. This is a reactive way of managing hyperglycemia and should NOT be used as the sole means of controlling blood glucose unless absolutely necessary. How to use this form: A new insulin order form should be completed for major changes to insulin orders (eg. type of insulin and/or frequency of administration). Exceptions include: (a) ONE-time insulin orders (e.g., give 5 units immediately) can be ordered on blank doctor s orders sheet (b) To discontinue insulin or make minor dose adjustments to a single insulin, use blank doctor s orders sheet 1. Tick the boxes to indicate times blood glucose is to be tested. (Note: correction doses should not be given at 0300hrs. This test is only to assess night time basal doses). Target values are 5.0 mmol/l 11.0 mmol/l. Notify MD if blood glucose is below 4.0 mmol/l or above 20.0 mmol/l. 2. Basal Insulin: Insulin required to cover a rise in blood glucose between meals and overnight. To estimate the initial empiric dose to be administered at breakfast, dinner, or bedtime (lunchtime not : (a) Type 1 Diabetes - start at 0.25 units/kg/day (Lantus or Levemir once daily) (NPH twice daily) (b) Type 2 Diabetes in patients on oral antidiabetic agents start at 0.15 units/kg/day at bedtime (any basal insulin) Adjust dose to reach target blood glucose based primarily on fasting blood glucose results (pre-breakfast) Mealtime Insulin: Insulin required to cover a rise in blood glucose due to meals. To estimate the initial empiric dose, start at 0.1 units/kg tid (for Type 1 or 2 Diabetes). Adjust dose to reach target blood glucose according to post-meal blood glucose results. Bedtime administration of short acting insulin is not recommended. For continuous enteral feeds or TPN, mealtime insulin may not be necessary; however correction dose insulin (as per algorithm) may be used to control blood glucose. Premixed Insulin (Mealtime + Basal): Used in patients with type 2 diabetes not requiring intensive therapy or patients on enteral feeds/tpn. May be administered either once or twice daily pre-breakfast, or pre-dinner, or at both times, as follows: (a) Once daily regimen: Start with an initial empiric dose of 0.15 units/kg at dinner or at breakfast (b) Twice daily regimen: Start with an initial empiric dose, of 0.1 units/kg at breakfast and 0.1 units/kg at dinner Adjust dose to reach target blood glucose according to fasting (pre-breakfast) and/or pre-dinner blood glucose results. Administration is not recommended at lunch or bedtime. Mealtime Correction Dose Used to determine if any extra rapid or short-acting insulin is to be given in addition to the scheduled dose in order to treat ( correct for ) hyperglycemia (blood glucose 8.0 mmol/l or greater). 3. Physician to select times for correction doses and type of insulin to be given. 4. Physician to select one algorithm: low-dose, medium-dose, high-dose, or individualized (indicate doses). Administration: 1. Before meals (or qid if on enteral feeds or TPN) test blood glucose by point of care meter and determine the correction dose using the Mealtime Correction Dose selected by physician. 2. Add the correction dose to any existing routine mealtime dose. DO NOT DRAW CORRECTION DOSE INTO SAME SYRINGE AS PREMIXED INSULIN. Hypoglycemia Treatment Orders for Non-pregnant patients 5. (a) Monitor for hypoglycemia: (1) test blood glucose by point of care meter; and (2) observe for/inquire about symptoms (see below). Trembling Hunger Anxiety Weakness Difficulty speaking Palpitations Nausea Difficulty concentrating Drowsiness Headache Sweating Tingling Confusion Vision changes Dizziness (b) Determine treatment route for patient and follow treatment orders. 6. Determine if patient requires an Endocrinology consult. The Endocrinology Division welcomes all consults for patients with DIABETES MELLITUS, especially the following: 1. Admission for Diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State 2. Patient with Type 1 Diabetes or genetic cause of diabetes 3. Using insulin pump 4. Pregnant or planning pregnancy 5. Hemoglobin A1C greater than 8% 6. On 3 or more oral anti-hyperglycemia agents 7. 2 or more episodes of hypoglycemia in hospital 8. Glucose greater than 14 mmol/l on 3 or more occasions in hospital 9. Perioperative patients with difficult to control diabetes 10. Consider if patient has diabetes and is on corticosteroids or enteral feeds 11. Consider if patient does not have endocrinologist and is on insulin 7. The Sunnybrook Diabetes Education (SUNDEC) program, offers group sessions and individual appointments with a Dietitian and a Nurse Educator. Referrals are available on the intranet. Fax referrals to or call PR 15010
3 Extra Mealtime Insulin if needed as per blood glucose (Correction Dose Insulin) 3. Check times and insulin to be given. a. ac meals qid for enteral feeds or TPN only b. Humalog (lispro) NovoRapid (aspart) Apidra (glulisine) Humulin R (regular) Novolin ge Toronto (regular) 4. Check and initial one algorithm to be followed. Test blood glucose to decide on dose. Measured Premeal blood glucose (mmol/l) Low-Dose Total 40 units/d or less OR 70 kg or less Medium-Dose Total units/d OR kg High-Dose Total 100 units/d or greater OR 100 kg or greater Individualized of nurse 3.9 or less Follow Hypoglycemia Treatment Orders on page 3 and contact physician to reassess insulin dosing. 4.0 to units + 0 units + 0 units + 0 units 8.0 to units + 1 units + 2 units + units 11.0 to units + 3 units + 4 units + units 14.0 to units + 5 units + 7 units + units 17.0 to units + 7 units + 10 units + units 20 or greater + 5 units and + 8 units and + 12 units and + units and Doctor s : PRINT NAME: Pager: PR Page 2 of 3
4 Hypoglycemia Treatment 5. a. For patients with oral or enteral access: Test blood glucose by point of care meter. If blood glucose is 3.9 mmol/l or less, or if patient is symptomatic (see reverse for details), follow table below according to patient needs. Patient Attribute Treatment for Hypoglycemia Can chew tablets glucose (dextrose) tablets 4 g each Patient to chew 4 tablets, then swallow with water (available in Hypoglycemia Kit) Cannot chew tablets Fruit juice apple preferred; orange acceptable Can swallow liquids 2 mini-cartons or 2 Dixie Cups (approximately 200 ml) glucose gel (Insta-Glucose ) Contents of 1 tube (24 g glucose) squeezed into mouth and swallowed (available in Hypoglycemia Kit) Dysphagic (requires thickened liquids) Enteral Feeding Tube Fruit juice apple preferred; orange acceptable 2 mini-cartons or 2 Dixie Cups (approximately 200 ml) Flush tube before and after juice with 30 ml of water to reduce risk of clogging due to interaction of juice with feeds b. For patients who are NPO without enteral access: Test blood glucose by point of care meter. If blood glucose is 3.4 mmol/l or less on two consecutive tests (over 10 minutes), follow table below according to patient needs. Patient Attribute NPO No Enteral Feeding Tube No IV Access NPO No Enteral Feeding Tube IV Access Treatment for Hypoglycemia glucagon injection 1 mg (1 unit) subcutaneously (available in Hypoglycemia Kit) IV dextrose 12.5 g given by either of these methods: Hang a bag of D10W (dextrose 10%) and infuse 125 ml as fast as possible (over 5-10 min). OR Using a pre-filled syringe of dextrose 50%, add 25 ml to 100 ml minibag of D5W and infuse over 5 min. 6. Re-test blood glucose by point of care meter 15 min after treatment. 7. If blood glucose is 4.0 mmol/l or greater, do not re-test. If available, offer a snack if meal not due within 1 hr. 8. If blood glucose is 3.9 mmol/l or less after oral or enteral glucose/juice or IV dextrose, repeat treatment and re-test in 15 min. If blood glucose remains 3.9 mmol/l or less, notify physician. 9. If blood glucose remains 3.9 mmol/l or less after sc glucagon treatment, notify physician. 10. Document hypoglycemic episode and treatment, notify physician. 11. Indicate whether patient requires Endocrinology consult. See reverse for criteria. Yes No 12. Refer to Diabetes Education Centre upon discharge: Sunnybrook Diabetes Education (SUNDEC) Other: of nurse Doctor s : PRINT NAME: Pager: PR Page 3 of 3
5 Guidelines for Use of the Orders For Non-pregnant Patients SLIDING SCALE INSULIN refers to a treatment regimen that provides NO basal insulin and provides ONLY short acting insulin if needed according to blood glucose test results. This is a reactive way of managing hyperglycemia and should NOT be used as the sole means of controlling blood glucose unless absolutely necessary. How to use this form: A new insulin order form should be completed for major changes to insulin orders (eg. type of insulin and/or frequency of administration). Exceptions include: (a) ONE-time insulin orders (e.g., give 5 units immediately) can be ordered on blank doctor s orders sheet (b) To discontinue insulin or make minor dose adjustments to a single insulin, use blank doctor s orders sheet 1. Tick the boxes to indicate times blood glucose is to be tested. (Note: correction doses should not be given at 0300hrs. This test is only to assess night time basal doses). Target values are 5.0 mmol/l 11.0 mmol/l. Notify MD if blood glucose is below 4.0 mmol/l or above 20.0 mmol/l. 2. Basal Insulin: Insulin required to cover a rise in blood glucose between meals and overnight. To estimate the initial empiric dose to be administered at breakfast, dinner, or bedtime (lunchtime not : (a) Type 1 Diabetes - start at 0.25 units/kg/day (Lantus or Levemir once daily) (NPH twice daily) (b) Type 2 Diabetes in patients on oral antidiabetic agents start at 0.15 units/kg/day at bedtime (any basal insulin) Adjust dose to reach target blood glucose based primarily on fasting blood glucose results (pre-breakfast) Mealtime Insulin: Insulin required to cover a rise in blood glucose due to meals. To estimate the initial empiric dose, start at 0.1 units/kg tid (for Type 1 or 2 Diabetes). Adjust dose to reach target blood glucose according to post-meal blood glucose results. Bedtime administration of short acting insulin is not recommended. For continuous enteral feeds or TPN, mealtime insulin may not be necessary; however correction dose insulin (as per algorithm) may be used to control blood glucose. Premixed Insulin (Mealtime + Basal): Used in patients with type 2 diabetes not requiring intensive therapy or patients on enteral feeds/tpn. May be administered either once or twice daily pre-breakfast, or pre-dinner, or at both times, as follows: (a) Once daily regimen: Start with an initial empiric dose of 0.15 units/kg at dinner or at breakfast (b) Twice daily regimen: Start with an initial empiric dose, of 0.1 units/kg at breakfast and 0.1 units/kg at dinner Adjust dose to reach target blood glucose according to fasting (pre-breakfast) and/or pre-dinner blood glucose results. Administration is not recommended at lunch or bedtime. Mealtime Correction Dose Used to determine if any extra rapid or short-acting insulin is to be given in addition to the scheduled dose in order to treat ( correct for ) hyperglycemia (blood glucose 8.0 mmol/l or greater). 3. Physician to select times for correction doses and type of insulin to be given. 4. Physician to select one algorithm: low-dose, medium-dose, high-dose, or individualized (indicate doses). Administration: 1. Before meals (or qid if on enteral feeds or TPN) test blood glucose by point of care meter and determine the correction dose using the Mealtime Correction Dose selected by physician. 2. Add the correction dose to any existing routine mealtime dose. DO NOT DRAW CORRECTION DOSE INTO SAME SYRINGE AS PREMIXED INSULIN. Hypoglycemia Treatment Orders for Non-pregnant patients 5. (a) Monitor for hypoglycemia: (1) test blood glucose by point of care meter; and (2) observe for/inquire about symptoms (see below). Trembling Hunger Anxiety Weakness Difficulty speaking Palpitations Nausea Difficulty concentrating Drowsiness Headache Sweating Tingling Confusion Vision changes Dizziness (b) Determine treatment route for patient and follow treatment orders. 6. Determine if patient requires an Endocrinology consult. The Endocrinology Division welcomes all consults for patients with DIABETES MELLITUS, especially the following: 1. Admission for Diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State 2. Patient with Type 1 Diabetes or genetic cause of diabetes 3. Using insulin pump 4. Pregnant or planning pregnancy 5. Hemoglobin A1C greater than 8% 6. On 3 or more oral anti-hyperglycemia agents 7. 2 or more episodes of hypoglycemia in hospital 8. Glucose greater than 14 mmol/l on 3 or more occasions in hospital 9. Perioperative patients with difficult to control diabetes 10. Consider if patient has diabetes and is on corticosteroids or enteral feeds 11. Consider if patient does not have endocrinologist and is on insulin 7. The Sunnybrook Diabetes Education (SUNDEC) program, offers group sessions and individual appointments with a Dietitian and a Nurse Educator. Referrals are available on the intranet. Fax referrals to or call PR 15010
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