ADULT INSULIN PRESCRIPTION AND BLOOD …

1 ADULT INSULIN PRESCRIPTION AND BLOOD GLUCOSE MONITORING CHARTWardWard WardCONSULTANTDATE OF ..yearPlease affix Patient s label herePATIENT OF NUMBER ALLERGY or ADVERSE EFFECT Medicine/OtherIf none known tick box EffectDo not use this chart for patients who have diabetic ketoacidosis (DKA), or for maternity patients- separate charts available If self-administering ensure assessment sheet is section must be completed and signed by a prescriber or Pharmacist before a drug is givenONCE ONLY PRESCRIPTIONS OF INSULINDateTimeInsulin typeDoseRoute Prescriber s signaturePrint nameGiven byTime givenunitsSCunitsSCunitsSCunitsSCONCE ONLY PRESCRIPTION OF GLUCAGON (Prescribed by Dr)DateTimeMedicineDoseRoute Prescriber s signaturePrint nameGiven byTime givenGlucagon1mgIMONCE ONLY GLUCAGON and Fast Acting Glucose gel (PGD)For nurse administration under Patient Group Direction (Trust wide PGD in place)Date administeredTime administeredNurse signatureNurse nameGlucagon1mg IM injectionAccording to PGD instructionsGlucose gel(Glucogel/Dextrogel)2 tubes of 25g orallyAccording to PGD instructionsDecember 2013 review December 2015 NUH02231 SIAP4-J5626 ADULT INSULIN PRESCRIPTION Chart 107/01/2014 17:062 MANAGEMENT OF HYPERGLYCAEMIA (HIGH BG LEVELS) IN PATIENTS WITH DIABETES Pre-meal BLOOD Glucose (BG) > 11mmol/L review the patient, their BG monitoring record and increase BG monitoring.

2 Look for the cause; consider concurrent illness, missed/incorrect dose of oral hypoglycaemic agents or INSULIN . Check for ketones (capillary or urine) in unwell Type 1 DM patient or if BG > 18mmol/L or meter OF HYPOGLYCAEMIA IN PATIENTS WITH DIABETES*Only use PRN doses of INSULIN to reduce high BG if you also review the usual diabetes treatment regimen. The patient s usual fast acting INSULIN (Novorapid, Humalog or Apidra) can be used as an alternative to Actrapid. A minimum of 4 hours should be left before repeating a dose of clinically UNWELLV omiting/NOT eating and drinking OR urinary ketones ++ (capillary ketones ).Check U&E, venous bicarbonate, laboratory glucose (+/- osmolality)Patient NOT acidotic or hyperosmolar. Capillary ketones >3mmol/L (or urinary ketones ++) AND bicarbonate <15 or pH < hypovolaemic, osmolality >320mOSM/kg, BG > 30mmol/L and urinary ketones negative or + (capillary ketones < )BG > 25mmol/L?Manage as DKA See DKA guideline & use DKA treatment pre-meal BG profile, review treatment regimen.

3 Consider giving single dose of 6 -10 units of Actrapid SC*. Check BG after 2 and 4 hours. Patient may need transfer to IV variable rate TO THE DIABETES TEAM IF CONCERNSD iabetes Specialist Nurses via NOTIS (code DIAB) Diabetes Specialist Registrar via pager. Out of hours contact the on-call Medical doses of oral agents or INSULIN as HHS/HONK See variable rate INSULIN (VRIII-See page 3). Look for concurrent clinically WELLE ating and drinking, urinary ketones negative or + (capillary ketones < ). BG > 18mmol/L for 24 hours or >11mmol/L for 48 hours?NONONONOYESYESYESYESYES*Administer via a volumetric pump if co-operative and able to swallowPatient unconscious or aggressiveRepeat CBG after 10-15 minutesBG < 4mmol/L give or repeat IV 20% glucose 100mLs up to 3 cycles (do not repeat Glucagon).If still <4mmol/L contact the diabetes team or the on-call Medical < 4mmol/LRepeat step 1 up to 3 cycles,if still <4 contact (CBG) or laboratory BLOOD glucose <4mmol/LCheck ABCDEGive 100mLs of IV 20% glucose over 10-15 mins* or Glucagon 1mg IM (if no IV access): Can give as PGD (page 1) Arrange urgent medical review: FAST BLEEP DOCTORGive 100mls original Lucozade or2 tubes Glucose gel orOther quick acting carbohydrate (15-20g) of patient s 1 Give 20g long acting carbohydrate 2 biscuits/1 slice bread or a meal with carbohydrate if due.

4 If the patient has had glucagon give a larger (double) carbohydrate 4mmol/LLOOK FOR THE CAUSE AND REVIEW THE USUAL DIABETES REGIMEN. Document the episode and increase BG monitoring. DO NOT omit INSULIN injection if due dose review may be OMIT INSULIN IN TYPE 1 DM. Refer to the diabetes team if severe (requiring IV/IM treatment) hypoglycaemia or frequent mild 3BG 4mmol/L& CBG after 10-15 minutesStep 3 IAP4-J5626 ADULT INSULIN PRESCRIPTION Chart 207/01/2014 17:06 INTRAVENOUS INSULIN SLIDING SCALE PRESCRIPTIONVARIABLE RATE INTRAVENOUS INSULIN infusion (VRIII)Using an INSULIN syringe draw up 50 units human soluble (ACTRAPID ) INSULIN and add to of sodium chloride to give a 1 unit/mL solution or use a prefilled syringe 50 units in 50mL where available. Use a syringe pump to patient normally takes long acting INSULIN (Lantus / INSULIN glargine, Levemir / INSULIN detemir,Insulatard /isophane INSULIN , Humulin l /isophane INSULIN ) it should be continued at the usual dose and time(s).

5 PRESCRIBE EVEN IF THE PATIENT IS NOT EATING OR : sign the sliding scale required. Scale 2 is the most commonly used. If anything needs to be altered, cross out all of that scale and sign for the appropriate daily INSULIN requirements are unit per kgCapillaryBloodGlucose(CBG)Scaleunits/h rScale 2units/hrScale 3units/hrScale 4units/hrInsulinrequirements mayincrease withConcurrent illnessUse if dailyinsulinrequirements<30 unitsUse if dailyinsulinrequirements30-60 unitsUse if dailyinsulinrequirements>60 unitsUse scale 2 in type2 diabetes unlessBMI > 35kg/m2 orsevere illnesswhen scale 3advised< >20456 Check glucoseevery* ..hrsDateSignature*Hourly monitoring is recommended in unstable patients. This may be reduced to every 2-4 hours when patients are under stable control. Once patient is eating and drinking switch to regular SC FLUIDS WHILST ON VRIIIP atients must never receive VRIII without an appropriate substrate-see belowAll patients with K < ,including eGFR 15-30mL/minUse 5% Glucose with 40mmol KCl in 1000mls at 100 the patient needs restricted fluids use 10% Glucose with 20mmolKCl in 500mL at 50mL/hour obtain from use of enteral or parenteral nutritionHyperkalaemia K > OR has End Stage Renal failure OR eGFR < 15mL/min OR on dialysisUse 10% Glucose 500mLs at 50mL/hourDo not use 5% Glucose.

6 Do not use Compound Sodium Lactate(Hartmann s). Do not give additional infusion RECORD Nursing staff must keep this recordInsulin BatchNumberSaline BatchNumberDateTime InfusionstartedStarted byChecked byTime infusionstoppedSTOPPING IV INSULIN : INTRAVENOUS INSULIN SHOULD BE STOPPED 1 HOUR AFTER SUBCUTANEOUS DOSE OF INSULIN HAS BEEN ADULT INSULIN PRESCRIPTION Chart 307/01/2014 17:06 INTRAVENOUS INSULIN AND BG MONITORING RECORD SHEETWhen you have checked or changed the INSULIN infusion rate, initial the capillary glucose hourly. Reduce monitoring to every 2 to 4 hours once and INSULIN may be administered via a Y site connectorReview VRIII after 48 hoursInsulin InfusionDay 1 InfusionDay 2 signCheck2 signBlood/urineketonesDateTimeBGRateUnit /hrCheck1 signCheck2 signBlood/urineketonesALWAYS RUN IV FLUID (OR OTHER SUBSTRATE) AND INSULIN SIMULTANEOUSLYIAP4-J5626 ADULT INSULIN PRESCRIPTION Chart 407/01/2014 17:06 REGULAR SUBCUTANEOUS INSULIN PRESCRIPTION All INSULIN administration must be second checked.

7 This may be the patient if competentto do so. Circle patient s usual needle size: 4mm/ 5mm/ 6mm/ 7mm/ 8mm/ other_____mm INSULIN must not be stopped or omitted in patients with type 1 DM TIMESI nsulin name anddevice type (circlebelow)Pen cartridge/disposablepen/vialTo make a change, cross through previousdoses. A dose range may be prescribed forpre-meal doses if necessaryAdministrationIf patient second checks administration, record as patient If patient is self-administering, document with relevant administration code, and countersign your initialsDose 1 Change 1 & Date ..Change 2 & Date ..Change 3 & Date ..Change 4 & Date ..DateSelfadminlevelBreakfastTYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 TYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 LunchTYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 Evening MealTYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 TYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 BedtimeTYPEU nitsUnitsUnitsUnitsUnitsDose givenUnitsUnitsUnitsUnitsUnitsUnitsUnits UnitsUnitsUnitsUnitsUnitsUnitsUnitsTime 1 Sign 2 IAP4-J5626 ADULT INSULIN PRESCRIPTION Chart 507/01/2014 17.

8 06 BLOOD GLUCOSE MONITORING CHART (for patients not on intravenous INSULIN )Normal range Acceptable range whilst in hospital is , excluding pregnancy. If patient is unwell or has ketones seek advice. Initial monitoring shouldbe before meals and before bed. Review according to clinical condition. All INSULIN must be administered by an approved INSULIN pen device or by an INSULIN and datefor monitoringBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBlood glucoseBlood/ urineketonesBefore breakfastTimeSignBefore LunchTimeSignBefore eveningmealTimeSignBefore BedTimeSignAdditionalmonitoring: Date//////////////LevelTimeSignLevelTime SignLevelTimeSignIAP4-J5626 ADULT INSULIN PRESCRIPTION Chart 607/01/2014 17:06