Hypoglycemia Treatment Protocol Documentation Form
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1DOCUMENTATION OF HYPOGLYCEMIA
TREATMENT PROTOCOL
(file this form within the Progress Note Section of the Chart)
*1588-01-U*
IMPRINT PATIENT IDENTIFICATION HERE
1588-01-U
General Information:
Check fingerstick BG if patient experiences any symptoms of hypoglycemia including Pallor, Clammy Skin, Hunger, Restless Sleep, Fatigue,
Headache, Confusion, Sweatiness and Irritability
If bedside BG < 70, confirm by repeating bedside test immediately as per policy, and Do Not Delay Hypoglycemia Treatment
If the patient is/was taking oral medication for diabetes in the sulfonylurea class (glipizide [Glucotrol®], glyburide [Glynase®, Micronase®,
DiaBeta®]; glimepiride [Amaryl®], chlorpropramide [Diabinese®], tolazamide [Tolinase®]) then hold the sulfonylurea, follow this algorithm,
check BG every 4 hours X 24 hours and consider immediate Diabetes Consult (Pager #1082)
Document low Blood Glucose (BG):
Date:
Time:
RN:
BG < 70 in a patient with
↓ LEVEL OF CONSCIOUSNESS
BG 50-69 in an ALERT patient
BG < 50 in an ALERT patient
1. Give one of the following
1. Give one of the following
1. Give one of the following
(check the one given):
(check the one given):
(check the one given):
4 oz Orange/Apple Juice
8 oz milk (or Orange/Apple juice)
50 ml D50 IV (1 amp) and start IV
3 Graham Crackers
and 3 Graham Crackers
D5W at 100 mL/hour
1 tube Glucose Gel (if able to
2 tubes Glucose Gel (if able to
if no IV access : glucagon 1mg IM*
swallow thickened liquids)
swallow thickened liquids)
Time given:
if NPO or unable to swallow:
if NPO or unable to swallow:
20 ml D50 IV and start IV
50 ml D50 IV (1 amp) and start IV
2. If there is a change in level of
D5W at 100 mL/hour
D5W at 100 mL/hour
consciousness from baseline,
if unable to swallow AND no
if unable to swallow AND no IV
then call Condition C
IV access: glucagon 1mg IM*
access: glucagon 1mg IM*
Time called:
Time given:
Time given:
2. Notify MD (verify IV solution, volume,
2. Notify MD (verify IV solution,
3. Notify MD (verify IV solution,
rate, and duration, if applicable)
volume, rate, and duration, if
volume, rate, and duration, if
Time:
applicable) Time:
applicable) Time:
MD notified:
MD notified:
MD notified:
3. Recheck BG in 15 min BG:
3. Recheck BG in 15 min BG:
4. Recheck BG in 15 min BG:
1. If BG <70 at 15 minutes, then re-treat & notify MD per algorithm
Document Treatment Given:
2. Document BG 15 minutes after second treatment
BG:__________Time:_____________ RN:_____________________________
1. If still < 70 after second treatment, then re-treat & notify MD per algorithm
Document Treatment Given:
2. Consider Diabetes Consult (Pager #1082)
3. Document BG 15 minutes after third treatment BG:
Time:
RN:
4. If still < 70 after third treatment, individual management is needed. Call Diabetes Consult Service (Pager #1082)
*
If glucagon is used, it should be followed as soon as possible by EITHER oral carbohydrates (if patient can subsequently eat) or by obtaining IV
access and starting D5W as indicated in the box. Glucagon should not be repeated.
Form ID: PUH-1360
Last Revision Date: 12/01/2004
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