#1 #2. How should insulin be ordered? 1) Click the Add Order icon 2) Type insulin 3) Select Insulin Subcutaneous Orderset

Transcription

1 Insulin Subcutaneus Orderset In the past, insulin sliding scales were the standard methd f cntrlling bld sugars in the hspital. Hwever, sliding scales were develped fr regular and NPH insulins. Since emulating the bdy s physilgic insulin secretin has becme mre feasible with the develpment f lng-acting basal and rapid-acting insulins, sliding scale terminlgy is nt applicable fr thse utilizing this regimen. The new insulin standard f lng-acting basal insulin and rapid-acting insulin allws fr patient-specific care and is nw available in CIS. This article will prvide an verview fr the new subcutaneus insulin rderset. Hw shuld insulin be rdered? 1) Click the Add Order icn 2) Type insulin 3) Select Insulin Subcutaneus Orderset D nt select any f the individual insulins abve the rderset unless circumstances warrant the selectin (e.g. rdering snacks.) Always lk fr the icn #1 #2 #3

2 The Ttal Daily Dse (TDD) f insulin is typically 0.5 t 1 unit/kg/day fr diabetic patients and is determined by the attending physician. Mst patients regimens will cnsist f a basal lng-acting insulin and a rapid-acting insulin fr meals, bedtime, and snacks. Hwever, if a patient is stable n a nnbasal blus hme insulin regimen, it may be cntinued in the hspital. The basal insulin requirement is usually 40-50% f the TDD. The rapid-acting mealtime insulin dse cnsists f 2 key cmpnents shwn in the equatin belw: TOTAL mealtime Amunt f insulin t cver grams Mealtime insulin insulin dse f carbhydrates cnsumed crrectin dse This value is utilized t COVER grams f carbhydrates cnsumed. It is used when calculating rapid-acting insulin dses fr meals, bedtime, and snacks. This value is the amunt f insulin the patient shuld receive t CORRECT a high glucse. It is utilized when calculating rapid-acting insulin dses fr meals and bedtime NOT USED FOR SNACKS!!! Only give the crrectin if the measured bld sugar is ABOVE the patient-specific target MAX bld sugar. DO NOT give a crrectin dse if it has been less than 3 hurs since the last rapid-acting injectin. At bedtime, nly HALF f this value shuld be administered if the bld sugar is >300 mg/dl. (Nthing shuld be administered fr this value if the bld sugar is <300 mg/dl.) 4) T rder the apprpriate insulin, fllw these steps fr mst patients: A. Order a lng-acting insulin regimen B. Order rapid-acting insulin fr mealtimes C. Order rapid-acting insulin fr bedtime D. Order rapid-acting insulin fr snacks A. Order a lng-acting insulin regimen < 8 years ld: Once-daily AM Glargine dsing is recmmended t avid night-time hypglycemia 8 years ld: Once-daily BEDTIME Glargine dsing Nte Sme patients may need twice daily Glargine dsing B. Order rapid-acting insulin fr MEALTIMES Select ne f the fllwing ptins fr mealtimes: When the insulin:carbhydrate rati (defined n next page) is the same at all meals Give insulin befre meals Fr patients under 3 years f age r wh have unpredictable carbhydrate intake Give insulin after meals When the insulin:carbhydrate rati varies ver the curse f the day, separate rders must be placed fr each meal Give insulin befre/after breakfast Give insulin befre/after lunch Give insulin befre/after dinner

3 After the mealtime insulin is selected, three yellw, highlighted areas appear: 1. Insulin:carbhydrate rati (1 unit cvers X grams) Insulin:carbhydrate rati is defined as 1 unit f insulin will cver X grams f carbhydrates. Frmula fr insulin:carbhydrate rati 500 TDD=X (where X=the insulin:carbhydrate rati) Fr example: Patient FD is a 14-year-ld female wh weighs 55 kg. Her TDD f insulin is ~0.7 units/kg/day. What is her insulin:carbhydrate rati? TDD is ~0.7 units/kg/day, which is 38.5 units/day; therefre, =X, which makes X=13. When rdering insulin fr FD, her rati is 13, which means 1 unit f insulin will cver apprximately 13 grams f carbhydrates. When entering the insulin:carbhydrate rati int CIS, nly 13 needs t be entered fr X. 2. MAX target bld sugar (mg/dl) MAX target bld sugar is defined as the patient-specific target bld sugar. Ideally, all f the bld sugars fr a patient will be belw his r her target number. The attending will select a patient-specific target bld sugar within the ranges shwn belw. (NOTE: IF A TARGET IS NOT SELECTED, THE COMPUTER DEFAULTS TO THE AGE-SPECIFIC TARGET MAX.) Age-Specific Target Bld Sugars Patient Age Bld Sugar Target Usual Target MAX Range (mg/dl)* 0 t 5 years t 12 years Abve 12 years Insulin CORRECTION FACTOR (X mg/dl decrease per 1 unit insulin) Insulin CORRECTION FACTOR is defined as hw many mg/dl the bld glucse will decrease when the patient is given 1 unit f insulin Frmula fr Insulin CORRECTION FACTOR 1800 TDD=X (where X=Insulin CORRECTION FACTOR) In ur example f FD with a TDD f 38.5, what is her insulin CORRECTION FACTOR? Fr FD, =X, which makes X=47 r X 50. FD s insulin CORRECTION FACTOR f 50 means 1 unit f insulin will drp her bld sugar by 50 mg/dl. When entering the insulin CORRECTION FACTOR int CIS, nly 50 needs t be entered fr X.

4 PRACTICE: If FD had a MAX target bld sugar f 150 and an insulin CORRECTION FACTOR f 50, at what bld sugar wuld she begin t receive a mealtime insulin crrectin dse fr a high bld sugar? At what bld sugar wuld she begin t receive a mealtime insulin crrectin dse if her insulin CORRECTION FACTOR changed t 20 and her target remained at 150? Part A: If her insulin CORRECTION FACTOR was 50 and her target was 150, she wuld receive insulin when bld sugars were >200. Part B: If her insulin CORRECTION FACTOR was 20 and her target stayed at 150, she wuld receive insulin when bld sugars were >170. Hw d I enter an insulin rder if the patient shuld receive insulin in 0.5-unit increments? 3 extremely imprtant steps: 1) In the special instructins field, state the fllwing: Administer insulin in 0.5-unit increments 2) Insulin:carbhydrate rati: Since this rati is recrded as 1 unit cvers X grams f carbhydrates, the rati must be dubled when entering it int CIS. Fr instance, if 0.5 units f insulin cvers 10 grams f carbhydrates, then 1 unit f insulin cvers 20 grams f carbhydrates. The insulin:carbhydrate rati shuld be entered int CIS as 20. 3) Insulin CORRECTION FACTOR: Since this factr is recrded as 1 unit f insulin drps the bld sugar X mg/dl, the factr must be dubled when entering it int CIS. Fr example, if 0.5 units f insulin drps the bld sugar by 40 mg/dl, then 1 unit f insulin decreases the bld sugar by 80. The insulin CORRECTION FACTOR shuld be entered int CIS as 80.

5 C. Order rapid-acting insulin fr BEDTIME Fr mst patients, rder the bedtime dse utilizing the same values stated in the mealtime rderset fr the fllwing: 1. Insulin:carbhydrate rati (1 unit cvers X grams) 2. MAX target bld sugar (mg/dl) 3. Insulin CORRECTION FACTOR (X mg/dl decrease per 1 unit insulin) Remember the rder states the nurse will give HALF the mealtime insulin dse at bedtime. This means if the patient has a snack, all the carbhydrates frm the snack are cvered, but the nurse will nly cver HALF the bedtime crrectin dse f insulin t crrect fr the high bld sugar. The insulin crrectin dse will nly be administered fr bld sugars greater than 300 mg/dl. D. Order rapid-acting insulin fr SNACKS The 3-hur rule When giving insulin fr snacks, DO cver the carbhydrates, but DO NOT crrect fr a high bld glucse if it has been less than 3 hurs since the last rapid-acting injectin. Snack rderset cming sn and hw t rder snacks in the meantime! DO NOT select the rderset!! DO select a rapid-acting insulin Select prn and a prn reasn f ther. In the PRN instructins, specify with snacks. Fr the yellw, highlighted values, see belw: 1. Insulin:carbhydrate rati (1 unit cvers X grams) Order the same rati as fr mealtime rder set. 2. MAX target bld sugar (mg/dl) Write N/A because bld sugars are nt usually crrected when giving snacks (think f the 3-hur rule). 3. Insulin CORRECTION FACTOR (X mg/dl decrease per 1 unit insulin) Write N/A because bld sugars are nt usually crrected when giving snacks (think f the 3-hur rule).

6 Practice: Kylie is a 9-year-ld female weighing 26.5 kg. 1. Calculate her TDD. 2. Her father states her usual insulin glargine dse is 9 units. Is this apprpriate? Kylie s physician states her TDD is 18 units and her MAX target bld sugar is 150 mg/dl. 3. Calculate insulin:carbhydrate rati 4. Calculate insulin CORRECTION FACTOR If the attending wanted the insulin t be given in 0.5-unit increments instead f 1-unit increments as abve, hw wuld each f the fllwing differ and what value wuld the physician enter int CIS fr prblems 5 and 6? 5. Calculate the insulin:carbhydrate rati utilizing 0.5-unit increments 6. Calculate the insulin CORRECTION FACTOR utilizing 0.5-unit increments 7. It is 11:30 AM and Kylie wants t eat lunch. The last mealtime insulin dse was given at 8:00 AM. Current bld sugar is 205. Hw much insulin shuld Kylie receive if she is ging t eat 76 grams f carbhydrates? Remember the fllwing equatin: TOTAL mealtime Amunt f insulin t cver grams Mealtime Insulin insulin dse f carbhydrates cnsumed crrectin dse 8. If Kylie ate lunch at 11:30 AM and received a crrectin blus and a carbhydrate blus at that time, hw much insulin shuld be administered if she wants t eat 30 grams f carbhydrates at 1:00 PM and has a bld sugar f 355? 9. It s 9 PM. Kylie had dinner at 6 PM. She wants a bedtime snack f 30 grams f carbhydrates and has a bld sugar f 355. Hw much insulin shuld be administered?

7 Answers: 1. TDD mg/kg/day; therefre, Kylie s TDD is units/day. 2. This insulin glargine dse IS apprpriate because the dse is usually ½ f the TDD = 28; therefre, Kylie s insulin:carbhydrate rati is 28, which means 1 unit f insulin cvers 28 grams f carbhydrates. In practice, 28 wuld be runded up t = 100; therefre, Kylie s insulin CORRECTION FACTOR is 100, which means 1 unit f insulin will decrease Kylie s bld sugar by 100 mg/dl. Since 1 unit f insulin decreases Kylie s bld sugar by 100 mg/dl, mst likely the physician wuld rder the insulin t be given in 0.5-unit increments. 5. The insulin:carbhydrate rati wuld be 15 because 0.5 units f insulin wuld cver 15 grams f carbhydrates; hwever, the physician wuld enter 30 int CIS fr the insulin:carbhydrate rati because the rati must be entered int CIS in 1-unit increments. 6. The insulin CORRECTION FACTOR wuld be 50 because 0.5 units f insulin wuld decrease the bld sugar by 50 mg/dl; hwever, the physician wuld enter 100 int CIS fr the insulin CORRECTION FACTOR because the factr must be entered int CIS in 1-unit increments. 7. Fr the TOTAL mealtime insulin dse, the carbhydrates must be cvered and the bld sugar must be crrected. a. Cvering carbhydrates Kylie will eat 76 grams f carbhydrates. (76 30 =2.5 units) The nurse shuld give 2.5 units t crrect fr the carbhydrates. b. Crrecting bld sugar Since Kylie is receiving her insulin in 0.5-unit increments, she will receive 0.5 units f insulin t decrease her bld sugar by 50 units t her target f 150 mg/dl. c. Her TOTAL mealtime insulin dse will be 3 units f insulin. 8. Fr the TOTAL snack insulin dse, the carbhydrates must be cvered and the bld sugar is usually NOT crrected. a. Cvering carbhydrates T cver her 30 grams f carbhydrates, 1 unit f insulin shuld be administered. b. Crrecting bld sugar N crrectin dse fr her bld sugar shuld be administered because it has been <3 hurs since her last rapid-acting insulin dse. Remember the crrectin factr is nt generally utilized fr snacks. c. Her TOTAL snack insulin dse will be 1 unit f insulin. 9. Fr the TOTAL bedtime insulin dse, the carbhydrates must be cvered and the bld sugar must be crrected. a. Cvering carbhydrates T cver her 30 grams f carbhydrates, 1 unit f insulin shuld be administered. b. Crrecting bld sugar Since it has been 3 hurs since she ate, a crrectin blus shuld be administered. When crrecting fr a bld sugar at bedtime, ALWAYS be sure the bld sugar is greater than 300 AND use ½ f the usual crrectin dse t avid lw bld sugars vernight. T crrect fr the bld sugar f 355, 2 units f insulin wuld decrease the bld sugar t apprximately 150; therefre, nly 1 unit shuld be administered t crrect fr the bedtime bld sugar. c. Fr the TOTAL bedtime dse, administer 2 units f insulin: 1 unit t cver the 30 grams f carbhydrates and 1 unit t crrect the bld sugar f 355.