Glycemic Control-Subcutaneous Regimen Adjustment [1758] · Page 3 of 18 GLYCEMIC CONTROL SUBCUTANEOUS REGIMEN ADJUSTMENT [1758] (11/23/15) PATIENT INFORMATION [ ] Insulin …

Page 1 of 18

1758

(11/23/15)

GLYCEMIC CONTROL SUBCUTANEOUS REGIMEN ADJUSTMENT

PATIENT INFORMATION

Glycemic Control-Subcutaneous Regimen Adjustment [1758] Height_____________________ Weight_____________________ Allergies____________________

NOT for use as Initial Insulin Regimen IMPORTANT: For most patients with hyperglycemia in the hospital setting, it is best practice to use insulin therapy and discontinue certain oral diabetic medications. Per hospital policy, discontinue sulfonylureas and metformin upon admission for all adult patients (exceptions: Mental Health or Rehabilitation units). May resume when patients are eating greater than 75% of meals, have not experienced hypoglycemia within the last 24 hours and are deemed clinically stable by the provider. TARGET BLOOD GLUCOSE RANGE: Fasting blood glucose less than 140 and any random blood glucose less than 180.

Medications

Any previous inpatient insulin orders (except an insulin infusion, when transitioning from IV to SQ insulin) should be discontinued when writing new insulin orders using this order set. NOTE: Correctional insulin only options are not appropriate for type 1 diabetics or for patients with fasting glucose values above 150 mg/dL For those patients transitioning from an insulin infusion: Total Daily Dose (TDD) = average hourly insulin drip rate for last 6 hours, multiplied by 20 (20% reduction). Give basal insulin 2 hours prior to stopping the infusion.

Provider’s Initial:

Page 2 of 18

GLYCEMIC CONTROL SUBCUTANEOUS REGIMEN ADJUSTMENT [1758] (11/23/15)

PATIENT INFORMATION

Glucose Management (Single Response)

( ) Insulin Regimen - Patient eating or Receiving bolus tube feeds (equivalent aspart dosing for each meal)

3 equal-sized meals or tube feeds a day. Treat bolus tube feeds as meals. We use a weight- and BMI-based dosing guideline to estimate the total daily insulin because it accounts for both volume of distribution and presumed insulin sensitivity associated with BMI. Insulin dependent patients need basal, nutritional and correctional insulin. Nutritional insulin for these patients is rapid-acting aspart. Do not rely on only corrective insulin, also known as sliding scale. It promotes hyperglycemia and is associated with more labile blood glucose and greater hypoglycemia risk. Detemir should be 50% of the total daily dose (TDD) of insulin, the remaining 50% of the TDD should be equally distributed among the three pre-meal aspart doses. ________________________________________________________________________________ For insulin detemir: Enter a specific number of units or click one of the weight-based dosing buttons based on the following criteria: BID dosing preferred for less than 10 units or greater than 100 units/day, otherwise detemir can be dosed once daily. A. 50% of home regimen of insulin TDD (TDD = sum of all insulin taken daily at home, all types added together) B. Patients on less than or equal to 2 oral diabetic medications and BG less than 180 within first 24 hours: Use correction scale only x 24 hours. If BG greater than 180 for 2 values after 24 hours, calculate TDD at 0.3 units/kg/day or assess overall correction scale use as a guide for TDD calculations. C. Weight-based dosing - Malnourished, elderly, renal/hepatic impairment, no prior history of diabetes, corticosteroid-induced hyperglycemia, type II DM w/ BMI less than 19: 0.15 units/kg - Normal weight Type II DM, Type 1 DM: 0.2 units/kg - Overweight Type II DM w/ BMI 25-30: 0.25 units/kg - Obese Type II DM w/ BMI greater than 30, sepsis: 0.3 units/kg _______________________________________________________________________________ For insulin aspart: The dose of pre-meal or nutritional aspart should be one-third of the insulin detemir dose ________________________________________________________________________________ For correctional insulin aspart: Select the appropriate correctional scale, based on BMI recommendations. Every 24 hours, the amount of correctional insulin administered should be used as a guide to adjust the basal and nutritional insulin doses.

[X] insulin detemir (LEVEMIR) injection SubCutaneous, Nightly, Starting S Give basal insulin even if patient is NPO. Do not mix with other insulin.

[X] Nutritional Insulin - insulin aspart (NovoLOG) injection SubCutaneous, 3 times daily with meals NUTRITIONAL INSULIN: Give nutritional and correction insulin (if needed) together within 15 minutes prior to or immediately post meal. Give if patient is eating or on bolus tube feeding. HOLD if NPO/clear liquid diet. Note: For patients with variable PO intake, give insulin after every meal and reduce dose proportionately to equal the percentage of carbohydrates consumed. Reduce by the nearest Percentage (e.g., 0%, 50%, 100%). Round to nearest unit. Will this be administered via an insulin pump?


Page 3 of 18


PATIENT INFORMATION

[ ] Insulin aspart (NovoLOG) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (equivalent aspart dosing for each meal) Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

[ ] insulin aspart (NovoLOG) injection (CORRECTION SCALE) medium dose for BMI 25-30

3-15 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (equivalent aspart dosing for each meal) Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 4 of 18


PATIENT INFORMATION

[ ] insulin aspart (NovoLOG) injection (CORRECTION SCALE) high dose for BMI greater than 30

4-18 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (equivalent aspart dosing for each meal) Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

( ) Insulin Regimen - Patient eating or Receiving bolus tube feeds (individualized aspart dosing for each meal)


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PATIENT INFORMATION

3 unequal meals or tube feeds a day, OR medication induced hyperglycemia with predictable peak/trough effects, e.g. steroids. Insulin dependent patients need basal, nutritional and correctional insulin. Distribute the nutritional insulin aspart at meals in proportion to need. When tapering/discontinuing steroids, evaluate insulin regimen for dose reductions (10-20%) and redistribute the meal doses. Detemir should be 50% of the total daily dose (TDD) of insulin, the remaining 50% of the TDD should be equally distributed among the three pre-meal aspart doses. _________________________________________________________________ For insulin detemir: Enter a specific number of units or click one of the weight-based dosing buttons based on the following criteria: BID dosing preferred for less than 10 units or greater than 100 units/day, otherwise detemir can be dosed once daily. A. 50% of home regimen of insulin TDD (TDD = sum of all insulin taken daily at home, all types added together) B. Patients on less than or equal to 2 oral diabetic medications and BG less than 180 within first 24 hours: Use correction scale only x 24 hours. If BG greater than 180 for 2 values after 24 hours, calculate TDD at 0.3 units/kg/day or assess overall correction scale use as a guide for TDD calculations. C. Weight-based dosing - Malnourished, elderly, renal/hepatic impairment, no prior history of diabetes, corticosteroid-induced hyperglycemia, type II DM w/ BMI less than 19: 0.15 units/kg - Normal weight Type II DM, Type 1 DM: 0.2 units/kg - Overweight Type II DM w/ BMI 25-30: 0.25 units/kg - Obese Type II DM w/ BMI greater than 30, sepsis: 0.3 units/kg _________________________________________________________________ For insulin aspart: Pre-meal or nutritional aspart doses should account for 50% of the TDD but should be distributed in proportion to need (e.g. size of meal or bolus tube feed or adjusted for medication induced effects (e.g. Steroids). _________________________________________________________________ For correctional insulin aspart: Select the appropriate correctional scale, based on BMI recommendations. Every 24 hours, the amount of correctional insulin administered should be used as a guide to adjust the basal and nutritional insulin doses.

[ ] insulin detemir (LEVEMIR) injection ____________________________________REQUIRED SubCutaneous, Nightly, Starting S Give basal insulin even if patient is NPO. Do not mix with other insulin.

[ ] insulin aspart (NovoLOG) injection ____________________________________REQUIRED SubCutaneous, Daily with breakfast Will this be administered via an insulin pump?

[ ] insulin aspart (NovoLOG) injection ____________________________________REQUIRED SubCutaneous, Daily with lunch Will this be administered via an insulin pump?

[ ] insulin aspart (NovoLOG) injection ____________________________________REQUIRED SubCutaneous, Daily with dinner Will this be administered via an insulin pump?


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PATIENT INFORMATION

[ ] Insulin Aspart (NovoLOG) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (individualized aspart dosing for each meal) Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


3-15 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (individualized aspart dosing for each meal) Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


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PATIENT INFORMATION


4-18 Units, SubCutaneous, 4 times daily before meals and nightly PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient eating or Receiving bolus tube feeds (individualized aspart dosing for each meal) Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

( ) Insulin Regimen - Patient on 24-Hour Continuous Tube Feeds or TPN


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PATIENT INFORMATION

Most of these patients have very little or no oral intake. Insulin dependent patients need basal, nutritional and correctional insulin. Nutritional insulin for these patients is Novolin R given Q 6 hrs. Nutritional insulin can be held if feeding is interrupted to reduce hypoglycemia risk. When continuous feeding is interrupted, assess the need to replace the dextrose component of the TPN or enteric feed to avoid hypoglycemia. Detemir should be 50% of the total daily dose (TDD) of insulin, the remaining 50% of the TDD should be equally distributed among the every-six-hour regular insulin doses ________________________________________________________________________________ For insulin detemir: Enter a specific number of units or click one of the weight-based dosing buttons based on the following criteria: BID dosing preferred for less than 10 units or greater than 100 units/day, otherwise detemir can be dosed once daily. A. 50% of home regimen of insulin TDD (TDD = sum of all insulin taken daily at home, all types added together) B. Patients on less than or equal to 2 oral diabetic medications and BG less than 180 within first 24 hours: Use correction scale only x 24 hours. If BG greater than 180 for 2 values after 24 hours, calculate TDD at 0.3 units/kg/day or assess overall correction scale use as a guide for TDD calculations. C. Weight-based dosing - Malnourished, elderly, renal/hepatic impairment, no prior history of diabetes, high-dose glucocorticoids, type II DM w/ BMI less than 19: 0.15units/kg - Normal weight Type II DM, Type 1 DM: 0.2 units/kg - Overweight Type II DM w/ BMI 25-30: 0.25 units/kg - Obese Type II DM w/ BMI greater than 30, sepsis: 0.3 units/kg ________________________________________________________________________________ For insulin regular: The dose of regular insulin given every six hours should be one-fourth of the insulin detemir dose. ________________________________________________________________________________ For correctional insulin regular: Select the appropriate correctional scale, based on BMI recommendations. Every 24 hours, the amount of correctional insulin administered should be used as a guide to adjust the basal insulin and nutritional regular insulin doses.


[ ] insulin regular (NovoLIN R) injection 100 unit/ml ____________________________________REQUIRED SubCutaneous, Every 6 hours, Starting S Do not administer scheduled regular insulin if nutrition is interrupted. Will this be administered via an insulin pump?


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PATIENT INFORMATION

[ ] Insulin regular (Novolin R) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient on 24-Hour Continuous Tube Feeds or TPN. Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

[ ] insulin regular (NovoLIN R) injection (CORRECTION SCALE) medium dose for BMI 25-30

3-15 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient on 24-Hour Continuous Tube Feeds or TPN. Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 10 of 18


PATIENT INFORMATION

[ ] insulin regular (NovoLIN R) injection (CORRECTION SCALE) high dose for BMI greater than 30

4-18 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, See admin instructions CORRECTIONAL INSULIN: Insulin Regimen - Patient on 24-Hour Continuous Tube Feeds or TPN. Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

( ) Insulin Regimen - Patient NPO or on Clear Liquids

NPO and clear liquid diets are not equivalent. Clear liquid diets intentionally provide carbohydrate nutrition. Insulin dependent patients on these diets need basal and correctional insulin. Nutritional insulin is not required for NPO diets. If clear liquid diets continue for more than 24 hours, and dietary intake is reliable, consider adding nutritional aspart at meals. A continuous low-rate dextrose infusion is advised in these patients and may be ordered below from within this order group. ________________________________________________________________________________ For insulin detemir: Enter a specific number of units or click one of the weight-based dosing buttons based on the following criteria: BID dosing preferred for less than 10 units or greater than 100 units/day, otherwise detemir can be dosed once daily. A. 50% of home regimen of insulin TDD (TDD = sum of all insulin taken daily at home, all types added together) B. Patients on ? 2 oral diabetic medications and BG less than 180 within first 24 hours: Use correction scale only x 24 hours. If BG greater than 180 for 2 values after 24 hours, calculate TDD at 0.3 units/kg/day or assess overall correction scale use as a guide for TDD calculations. C. Weight-based dosing - Malnourished, elderly, renal/hepatic impairment, no prior history of diabetes, high-dose glucocorticoids, type II DM w/ BMI less than 19: 0.15units/kg - Normal weight Type II DM, Type 1 DM: 0.2 units/kg - Overweight Type II DM w/ BMI 25-30: 0.25 units/kg - Obese Type II DM w/ BMI greater than 30, sepsis: 0.3 units/kg _______________________________________________________________________________ For correctional insulin regular: Select the appropriate correctional scale, based on BMI recommendations. Every 24 hours, the amount of correctional insulin administered should be used as a guide to adjust the basal insulin and nutritional regular insulin doses.


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PATIENT INFORMATION


[ ] Insulin regular (Novolin R) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient NPO or on Clear Liquids. Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

[ ] insulin regular (NovoLIN R) injection (CORRECTION SCALE) medium dose for BMI 25-30

3-15 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient NPO or on Clear Liquids. Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 12 of 18


PATIENT INFORMATION


4-18 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient NPO or on Clear Liquids. Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

[ ] dextrose 5 % and NaCl 0.45 % infusion 75 mL/hr, IntraVENous, Continuous

[ ] dextrose 5 % and NaCl 0.9 % infusion 75 mL/hr, IntraVENous, Continuous


Page 13 of 18


PATIENT INFORMATION

( ) Insulin Regimen - Patient on nocturnal Tube feeds

Test glucose once nocturnally to assess the adequacy of the nocturnal NPH dose. Predominant nutritional intake is delivered nocturnally and is typically ordered for 12 hours. Sometimes patients are also eating during the day. Insulin dependent patients will require basal, nutritional and correctional insulin. NPH insulin is used for basal AND nutritional requirements. Coordinate NPH to be given when tube feeds start. If tube feeds are interrupted, plan to replace the dextrose component of the enteric feed or hypoglycemia could occur. NPH insulin should be dosed depending on insulin-dependence with the addition of daytime insulin as appropriate. Insulin dependent (type 1 or 2) DM: Give 2/3 of TDD as NPH insulin nightly as start of tube feeding initiation and 1/3 of TDD as NPH insulin daily in AM. Additional daytime nutritional insulin orders will depend on oral intake. Non-insulin dependent patients: Give 50% of TDD as NPH insulin nightly at start of tube feeding initiation. Additional daytime orders will depend on oral intake. ______________________________________________________________________________ For NPH Insulin: Enter a specific number of units. NPH requirements are different for Insulin Dependent and non-Insulin Dependent patients. See above for appropriate ratio/percentage of TDD and timing recommendations. A. Total Daily Dose (TDD) calculations: A. Home regimen of insulin: TDD = amount of insulin taken at home daily, all types added together (may adjust 10-20% depending on outpatient control, illness, or complications) B. Patients on fewer than 2 oral diabetic medications and BG less than 180 within first 24 hours: Use correction scale only x 24 hours. If BG greater than 180 for 2 values after 24 hours, calculate TDD at 0.3 units/kg/day or assess overall correction scale use as a guide for TDD calculations. C. If no prior insulin use, weight-based estimation of TDD: Weight Based Dose Patient Features 0.3 units/kg/day Malnourished, elderly, renal/hepatic impairment, no prior history of diabetes, Type II DM w/ BMI less than 19, corticosteroid-induced hyperglycemia 0.4 units/kg/day Normal weight Type II DM, Type 1 diabetes 0.5 units/kg/day Overweight Type II DM w/ BMI 25-30 0.6 units/kg/day Obese Type II DM w/ BMI greater than 30, sepsis _______________________________________________________________________________ For Insulin Aspart: Add pre-meal or nutritional aspart during daytime if appropriate and depending on oral intake. ________________________________________________________________________________ For correctional insulin: Select the appropriate correctional scale, based on BMI recommendations. Every 24 hours, the amount of correctional insulin administered should be used as a guide to adjust the basal insulin and nutritional regular insulin doses. Use regular correction scale if NPO or aspart correction scale if eating during daytime.

[ ] insulin NPH (HumuLIN N,NovoLIN N) injection 100 units/mL

____________________________________REQUIRED SubCutaneous, Nightly, Starting S Do not administer if nutrition is interrupted

[ ] insulin NPH (HumuLIN N,NovoLIN N) injection ____________________________________REQUIRED SubCutaneous, Daily with breakfast, Starting S Do not administer if nutrition is interrupted

Page 14 of 18


PATIENT INFORMATION


[ ] Insulin Aspart (NovoLOG) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


3-15 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 15 of 18


PATIENT INFORMATION


4-18 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?

[ ] insulin regular (NovoLIN R) injection (CORRECTION SCALE) low dose for BMI less than 25

2-10 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] Low Dose 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 16 of 18


PATIENT INFORMATION

[ ] Insulin Regular (Novolin R) injection (CORRECTION SCALE) medium dose for BMI 25-30

3-15 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] Medium Dose 150-200 3 units 201-250 6 units 251-300 9 units 301-350 12 units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


4-18 Units, SubCutaneous, Every 6 hours PRN, high blood sugar, see admin instructions Insulin Regimen - Patient on nocturnal Tube feeds. Blood Sugar [mg/dL] High Dose 150-200 4 units 201-250 8 units 251-300 11 units 301-350 15 units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Use Glycemic Control-Subcutaneous orderset and order Correctional Scale Insulin order for patient condition to get correct scale for admin instructions. If NPO check blood glucose every 6 hours Blood Sugar [mg/dL]. Will this be administered via an insulin pump?


Page 17 of 18


PATIENT INFORMATION

Other Insulin

[ ] Insulin Regular (individualized nutritional dosing)

[ ] insulin regular (NovoLIN R) injection SubCutaneous, Daily with breakfast Will this be administered via an insulin pump?

[ ] insulin regular (NovoLIN R) injection SubCutaneous, Daily with lunch Will this be administered via an insulin pump?

[ ] insulin regular (NovoLIN R) injection SubCutaneous, Daily with dinner Will this be administered via an insulin pump?

[ ] Insulin aspart (carb counting)

[ ] insulin aspart (NovoLOG) injection 1 Units, SubCutaneous, 3 times daily with meals 1 Unit per *** grams of carbohydrates Will this be administered via an insulin pump?

[ ] insulin aspart (NovoLOG) injection 1 Units, SubCutaneous, 3 times daily with snacks 1 Unit per *** grams of carbohydrates Will this be administered via an insulin pump?

[ ] Insulin NPH

[ ] insulin NPH (HumuLIN N,NovoLIN N) injection SubCutaneous, Daily with breakfast

[ ] insulin NPH (HumuLIN N,NovoLIN N) injection SubCutaneous, Nightly

[ ] Insulin NPH-Regular 70/30

[ ] insulin NPH-insulin regular (NovoLIN 70/30) injection SubCutaneous, Daily with breakfast

[ ] insulin NPH-insulin regular (NovoLIN 70/30) injection SubCutaneous, Daily with dinner

[ ] Insulin aspart protamine-aspart 70/30

[ ] insulin aspart protamine-insulin aspart (NovoLOG 70/30) injection

SubCutaneous, Daily with breakfast

[ ] insulin aspart protamine-insulin aspart (NovoLOG 70/30) injection

SubCutaneous, Daily with dinner

[ ] Insulin Detemir (individualized dosing)

[ ] insulin detemir (LEVEMIR) injection SubCutaneous, Daily

[ ] insulin detemir (LEVEMIR) injection SubCutaneous, Nightly


Page 18 of 18


PATIENT INFORMATION

[ ] U500

[ ] insulin regular human U-500 "concentrated" injection SubCutaneous, 3 times daily before meals Will this be administered via an insulin pump?

[ ] insulin regular human U-500 "concentrated" injection SubCutaneous, Daily with breakfast Will this be administered via an insulin pump?

[ ] insulin regular human U-500 "concentrated" injection SubCutaneous, Daily with lunch Will this be administered via an insulin pump?

[ ] insulin regular human U-500 "concentrated" injection SubCutaneous, Nightly Will this be administered via an insulin pump?

[ ] Insulin Pump ____________________________________REQUIRED "And" Linked Panel

[ ] insulin, subcutaneous continuous infusion (CSII) pump Continuous

DATE TIME ORDERING PROVIDER PRINT NAME

PROVIDER SIGNATURE DATE TIME RN ACKNOWLEDGED

Glycemic Control-Subcutaneous Regimen Adjustment [1758] · Page 3 of 18 GLYCEMIC CONTROL SUBCUTANEOUS REGIMEN ADJUSTMENT [1758] (11/23/15) PATIENT INFORMATION [ ] Insulin …

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