Date/

NOTE: NURSE MUST INITIAL EACH INDIVIDUAL ORDER
(All orders to be deleted are to be crossed out with a single line and initialed by the physician)
1. Finger sticks blood glucose monitoring. 2. For Blood Glucose (BG) less or equal to 60 or symptoms of hypoglycemia, follow “Hypoglycemia Protocol Order Set” on page 2
3. Scheduled Insulin Therapy subcutaneously as shown below (Select desired agent):
Suggested time for mealtime (prandial) insulin administration: Regular 30 minutes before
eating, and rapid acting insulin (i.e. lispro) 0-15 minutes before eating).
Before Breakfast
Before Lunch
Before Dinner
Mealtime
Hold if patient
4. Subcutaneous REGULAR INSULIN Sliding Scale -or- † Lispro (Humalog)
Sliding Scale is NOT recommended for use alone. Some form of basal insulin coverage
is recommended for patients who require daily insulin therapy.
† A - Mild † B - Moderate † C- Aggressive † D - Custom
Follow Hypoglycemia Protocol on pg.2
Call Physician and Obtain STAT Blood Glucose by Lab.
-OR-T.O.:
PHYSICIAN ORDERS
ADULT- INSULIN THERAPY
C-290LA Rev.
NOTE: NURSE MUST INITIAL EACH INDIVIDUAL ORDER
(All orders to be deleted are to be crossed out with a single line and initialed by the physician)
Hypoglycemia Protocol Order Set
1. If blood glucose is less or equal to 60 mg/dL or symptoms of hypoglycemia such as weakness, sweating, shakiness, pallor, slurred speech, change in personality, confusion,
seizures, and or loss of consciousness):
Hold all insulin and/or oral hypoglycemic agents until hypoglycemia event is resolved
(i.e. glyburide, glipizide, glimepiride, acarbose, miglitol) and follow instruction below.
2. Document initial patient symptoms, response, all blood glucose, and intervention given on the patient’s flow sheet and/or nurse’s progress notes. 3. Treatment for Blood Glucose less or equal to 60 mg/ dL 1. Give 15 grams of carbohydrate orally stat [4 ounces of juice (orange, apple, cranberry), or regular soda, or 8 ounces of milk]. Patients taking acarbose (Precose®) or miglitol (Glyset®) give only milk since juice or soda will not be rapidly effective due to the actions of these drugs. Conscious
2. Check finger stick blood glucose in 15 minutes. a. If blood glucose remains equal or less than 60 mg/dL, repeat 15 grams of Able to Eat
b. Repeat finger stick blood glucose in 15 minutes and notify prescriber for Once glucose is greater than 70 mg/dL and if the episode occurs within 1 hour prior to mealtime, allow patient to eat without delay. If the next meal is not within 1 hour, give a snack (milk and crackers). 1. Start an intravenous line if not already present. 2. Give 25 mL (1/2 vial) of Dextrose- 50% in Water (D50) by slow intravenous Conscious
3. Check finger stick blood glucose in 15 minutes. a. If blood glucose remains below or equal to 60 mg/dL repeat 25 mL of NPO, Vomiting, or
b. Repeat finger stick blood glucose in 15 minutes and notify physician for Unable to Swallow
(i.e. pt with stroke
or neurological
4. If unable to start an intravenous line, deficit)
glucagon 1 mg subcutaneously or intramuscularly x 1 dose and establish intravenous access. Notify prescriber for further orders. a. Turn patient on the side as vomiting may occur. 1. Administer 50 mL of Dextrose- 50% in Water (D50) by slow intravenous 2. Observe patient closely, assess vital signs and level of consciousness and Unconscious
3. Recheck finger stick blood glucose in 5 minutes. If blood glucose remains less than or equal to 60 mg/dL, repeat 50 mL of Dextrose 50% in Water (D50) by slow intravenous push and refer to physician for further orders. 4. If unable to start an intravenous line, glucagon 1 mg subcutaneously or intramuscularly x 1 dose and establish intravenous access. Notify prescriber for further orders. a. Turn patient on the side as vomiting may occur. -OR-T.O.:
PHYSICIAN ORDERS
ADULT- INSULIN THERAPY
C-290LA Rev.

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