Prescription And Monitoring Chart For Subcutaneous Insulin Injections printable pdf download

PRESCRIPTION AND MONITORING CHART FOR

HYPOGLYCAEMIA MANAGEMENT

Attach Patient Sticker here or record

•

Record the initial capillary blood glucose reading in the correct

SUBCUTANEOUS INSULIN INJECTIONS

NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

section for capillary blood glucose recording on page 2 or 3. If

less than 4mmol/l refer to WAHT-END-004 for the Treatment of

ALLERGIES/ADVERSE DRUG REACTIONS

Attach Patient Sticker here or record

NHS NO:

Hypoglycaemia Flow Chart below for further guidance.

NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NONE KNOWN

Signature:

Date:

HOSP NO:

•

Treatment for hypoglycaemia should be given under PGD and

DATE

DRUG/FOOD/OTHER

REACTION DETAILS

NHS NO:

recorded in the appropriate section below. Alternatively this can be

D.O.B:

D D M M Y Y Y Y

Male

Female

prescribed by a Doctor.

HOSP NO:

Consultant:............................ Ward:..........................

•

For Paediatric patients (1 up to 16yrs of age) use half

D.O.B:

D D M M Y Y Y Y

Male

Female

the recommended dose in the flow diagram below.

Consultant:............................ Ward:..........................

Hypoglycaemia suspected - Patient complains of sweating, shaking, dizziness, tingling, confusion

PRE-ADMISSION DIABETES REGIMEN:

Wash patient’s hands and check capillary blood glucose

Approved drug name

Form / insulin device

Dose

Frequency

Hypo Treatment can be found

Consider other

Capillary glucose <4mmol/l

on the Resuscitation Trolleys

causes for symptoms

YES

MILD

MODERATE

SEVERE

Patient conscious, orientated and able to swallow

Patient conscious, but confused/disorientated or

Patient unconscious or nil by mouth

aggressive and able to swallow

Diabetic Kit required:

YES / NO

Print Name_________________ Signature________________ Date______________

STEP ONE: GET HYPO BOX

STEP ONE- Check ABC

Give: 5 glucose tablets or 2 x 100mls of orange juice.

If capable/cooperative give: 5 glucose tablets or 2

STOP INTRAVENOUS INSULIN WHILST HYPO

Juice either orally or via ENTERAL TUBE. If allergic to

x 100mls of orange juice (give juice either orally or

Supplied by Pharmacy:

Print Name_________________ Signature________________ Date:_____________

Ring 2222 - GET HYPO BOX

citrus fruit avoid using orange juice.

via ENTERAL TUBE) or if uncooperative but able to

Establish IV access and give 50mls of 10-20% glucose.

swallow give Glucogel 1.5 - 2 tubes

If no immediate IV access consider using Glucgon*.

Consider using Glucagon* 1mg IM (only give once)

INSULIN ADMINISTRATION:

Repeat blood glucose after 10 - 15 minutes - if

1mg IM (only give once)

If allergic to citrus fruit avoid using orange juice

less than 4mmol/l repeat step one up to 3 times - or

consider using Glucogel 1.5 - 2 tubes

Repeat blood glucose after 10 minutes - if still less

Nurse/Midwife* Administration

(Ref: MedPolSOPO9)

Start_________________ Stop_______________

Repeat blood glucose after 10 - 15 minutes - if still

than 4mmols give 50mls of 10-20% glucose until

less than 4mmol/l repeat step one up to 3 times or

If blood glucose remains less than 4mmols after 3

blood glucose is above 4mmols

contact a doctor to establish IV access and give 50mls of

times of treating with rapid acting carbohydrate or

10-20% glucose.

Self Administration

(Ref: MedPolSOPO9)

Start_________________ Stop_______________

Glucogel 1.5 - 2 tubes - CONTACT A DOCTOR

If IV insulin sliding scale stopped, restart once blood

glucose is above 4mmol/l. If NBM give IV10% glucose at

Repeat blood glucose after 10 minutes - if still less

100mls/hr until review by doctor or treat with long acting

Self Management Scheme

(Ref: WAHT-CG-447)

Start_________________ Stop_______________

Consider Glucagon* 1mg IM or establish IV access and give

than 4mmol/l give 50mls of IV 10-20% glucose until blood

carbohydrate as described in flow chart for mild and

50 mls of IV 10-20% glucose

glucose is above 4mmols

moderate hypo.

* For the remainder of the chart where ‘Nurse’ is stated this also implies ‘Midwife’.

Once blood glucose levels are above 4mmols give 20

Glucagon IM is less effective is repeated hypos,

Once blood glucose levels are above 4mmols give 20

HYPERGLYCAEMIA MANAGEMENT:

grams long acting carbohydrates:

patient starved or nil by mouth or with severe hepatic

grams long acting carbohydrate:

2 biscuits or 1 slice toast or normal meal if due within

disease.

2 biscuits or 1 slice toast or normal meal if due within

•

Reference to WAHT-END-001 (Guidelines for the Treatment of Diabetic Ketoacidosis) & WAHT-END-006 (Management

1 hour of hypo or IV 10% glucose at 100ml/hr

of the Initiation of Insulin in Adults.)

MEDICINES GIVEN BY NURSING STAFF TO MANAGE HYPOGLYCAEMIA (under PGD) AS PER FLOW CHART

HYPOGLYCAEMIA MANAGEMENT:

Date

Time

DRUG

Dose

Route

Signature

Print Name

Time

•

Record Management of Hypoglycaemia on page 4 of this document.

•

Refer to WAHT-END-004 (Treatment of Hypoglycaemia Flow Chart on back page)

SAFE PRESCRIBING, ADMINISTRATION, TRANSFER AND STORAGE OF INSULIN

•

When prescribing insulin, the word ‘units’ must never be abbreviated.

•

Insulin doses must never be omitted or delayed unless clearly outlined on the prescription and documented in the

medical notes by the prescriber.

•

Prescribe ‘Insulin as per chart’ on the patient’s main inpatient prescription chart.

DOCUMENTATION OF CAPILLARY BLOOD GLUCOSE MONITORING

•

Prescribe and review insulin doses on a regular basis according to clinical need.

•

After the hypoglycaemic episode has been treated record further capillary blood glucose readings in the table below.

•

Prescribe insulin doses to include all the doses required that day plus the morning dose of the following day

•

Repeat and record capillary blood glucose again 15 minutes after hypoglycaemia treatment is given.

•

Cross through all insulin prescription boxes not required that day.

•

Continue to check and record capillary blood glucose readings every 15 minutes until 3 consecutive readings of 4.1mmol/l or greater

•

Cross off and re-write the prescription if changes are required.

are obtained. Regular blood glucose monitoring is then required every 2 to 4 hours for the next 24 hours.

•

If changes in the patient’s insulin regimen are required, as a general rule, alter one insulin prescription at a time be

•

For recurrent hypoglycaemia refer the patient to the Diabetes Specialist Nurses for review.

roughly 10% of the dose.

DATE

TIME (00:00)

INITIALS CAPILLARY BLOOD GLUCOSE

DATE

TIME (00:00)

INITIALS

CAPILLARY BLOOD GLUCOSE

•

Further dose adjustments should be made no less than 48 hourly.

READING MMOL/L

•

All insulin doses must be measured and administered using either an insulin syringe or a commercial pen device.

•

Whenever a patient is moved between clinical areas, all insulin stored in the patient’s bedside locker and ward fridge

must be transferred with the patient.

•

All insulin devices must be clearly labelled with the patients name and expiry date.

•

Insulin devices in use must be stored in the patient’s bedside locker and have a 4 week expiry from the date first used.

•

Insulin devices not in use by the patient should be stored in the ward fridge. The expiry date for unused insulin will

be the manufacturers.

TO BE FILED IN INPATIENT SECTION OF MEDICAL NOTES

PF WR2169 Monitoring Chart for Subcutaneous Insulin Injections Version 8 Page 1 of 4

PF WR2169 Monitoring Chart for Subcutaneous Insulin Injections Version 8 Page 4 of 4

Prescription And Monitoring Chart For Subcutaneous Insulin Injections

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