SLIDING SCALE INSULIN REGULAR PLAN



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PHYSICIAN S Weight Allergies DETAILS Patient Care POC Blood Sugar Check Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h Sliding Scale Insulin Regular Guidelines Follow SSI Regular Reference Text Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. insulin regular () 0-10 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters 0-10 units, subcut, inj, BID, PRN glucose levels - see parameters 0-10 units, subcut, inj, TID, PRN glucose levels - see parameters Continued on next page...

PHYSICIAN S DETAILS 0-10 units, subcut, inj, q6h, PRN glucose levels - see parameters 0-10 units, subcut, inj, q4h, PRN glucose levels - see parameters 0-10 units, subcut, inj, q2h, PRN glucose levels - see parameters TO Read Back Scanned Powerchart Scanned PharmScan Order Taken by Signature: Date Time Physician Signature: Date Time Page: 2 Sliding Scale Insulin Regular Plan Version: 3 Effective on: 08/27/14 1201

PHYSICIAN S DETAILS insulin regular () 0-12 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters 0-12 units, subcut, inj, BID, PRN glucose levels - see parameters 0-12 units, subcut, inj, TID, PRN glucose levels - see parameters 0-12 units, subcut, inj, q6h, PRN glucose levels - see parameters Continued on next page...

PHYSICIAN S DETAILS 0-12 units, subcut, inj, q4h, PRN glucose levels - see parameters 0-12 units, subcut, inj, q2h, PRN glucose levels - see parameters insulin regular () 0-14 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters 0-14 units, subcut, inj, BID, PRN glucose levels - see parameters Continued on next page...

PHYSICIAN S DETAILS 0-14 units, subcut, inj, TID, PRN glucose levels - see parameters 0-14 units, subcut, inj, q6h, PRN glucose levels - see parameters 0-14 units, subcut, inj, q4h, PRN glucose levels - see parameters 0-14 units, subcut, inj, q2h, PRN glucose levels - see parameters Continued on next page...

PHYSICIAN S DETAILS insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels - see parameters If blood glucose is less than mg/dl, initiate hypoglycemia guidelines and notify provider. 70-139 mg/dl - units 140-180 mg/dl - units subcut 181-240 mg/dl - units subcut 241-300 mg/dl - units subcut 301-350 mg/dl - units subcut 351-400 mg/dl - units subcut If blood glucose is greater than 400 mg/dl, administer units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dl, then HYPOglycemia Guidelines HYPOglycemia Guidelines See Reference Text glucose 15 g, PO, gel, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and able to swallow. See hypoglycemia guidelines. glucose (D50) 25 g, IVPush, syringe, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and unable to swallow / NPO with IV access. See hypoglycemia guidelines. glucagon 1 mg, IM, inj, as needed, PRN glucose levels - see parameters Use if patient is symptomatic and unable to swallow / NPO WITHOUT IV access. See hypoglycemia guidelines. TO Read Back Scanned Powerchart Scanned PharmScan Order Taken by Signature: Date Time Physician Signature: Date Time Page: 6 Sliding Scale Insulin Regular Plan Version: 3 Effective on: 08/27/14 1201

Adult Sliding Scale for Insulin Regular (Novolin R) Blood Glucose (mg/dl) LOW DOSE MODERATE DOSE HIGH DOSE Less than 70 Initiate HYPOglycemia Guidelines Initiate HYPOglycemia Guidelines Initiate HYPOglycemia Guidelines 70-139 0 units 0 units 0 units 140-180 2 units subcut 3 units subcut 4 units subcut 181-240 3 units subcut 4 units subcut 6 units subcut 241-300 4 units subcut 6 units subcut 8 units subcut 301-350 6 units subcut 8 units subcut 10 units subcut 351-400 8 units subcut 10 units subcut 12 units subcut Greater than 400 Administer 10 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dl, then resume normal POC blood sugar check and insulin regular sliding scale. Administer 12 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dl, then resume normal POC blood sugar check and insulin regular sliding scale. Administer 14 units subcut, notify provider, and repeat POC blood sugar check in 1 hour. Continue to repeat 10 units subcut and POC blood sugar checks every 1 hour until blood glucose is less than 300 mg/dl, then resume normal POC blood sugar check and insulin regular sliding scale. Source: UMC Pharmacy Version: 2 Reviewed: 11.19.2015 Adult Sliding Scale for Insulin Regular (Novolin R) Page 1 of 1

Symptoms of HYPOglycemia Mild: Moderate: Diaphoretic Tachycardia Blurred Vision Sudden Weakness Shaking Dizziness Confusion Numbness of the lips Nausea/Vomiting Difficulty Swallowing Severe: (May be combined with mild or moderate) Combative Seizures Loss of Consciousness HYPOglycemia Guidelines SYMPTOMATIC PATIENT ABLE TO SWALLOW Blood Glucose Level Treatment Follow Up If blood glucose is less than 70 mg/dl and patient is symptomatic Give 6 oz. of juice or 1 tube (15 gms) of glucose gel Recheck blood glucose in 15 20 minutes Repeat treatment until blood glucose greater than 100 mg/dl Contact provider if blood glucose is less than 70 mg/dl for two consecutive measurements and patient is symptomatic. SYMPTOMATIC PATIENT UNABLE TO SWALLOW / NPO WITH IV ACCESS Blood Glucose Level Treatment Follow Up If blood glucose is less than 70 mg/dl and patient is symptomatic Dextrose 50% as ordered IV* Recheck blood glucose in 15 20 minutes Repeat treatment until blood glucose greater than 100 mg/dl Contact provider if blood glucose is less than 70 mg/dl for two consecutive measurements and patient is symptomatic SYMPTOMATIC PATIENT UNABLE TO SWALLOW / NPO without IV ACCESS If blood glucose is less than 70 mg/dl and patient is symptomatic Glucagon as ordered IM or Subcut* * Dextrose and glucagon administration must be documented on the MAR Contact physician for further orders Establish IV access Recheck blood glucose every 15 20 minutes Use aspiration precautions as glucagon may cause nausea and vomiting Source: UMC Pharmacy Version: 2 Reviewed: 11.19.2015

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