Physician'S Orders Adult Subcutaneous Insulin Order Sheet
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2UMASS MEMORIAL MEDICAL CENTER
PHYSICIAN’S ORDERS
ADULT SUBCUTANEOUS INSULIN
NAME:
ORDER SHEET
Height
Weight
ADDRESS:
Inches ________ Cm. ________
Lbs. ________ Kg. ________
ALLERGIES:
YES (LIST BELOW) OR
LISTED PREVIOUSLY
NONE KNOWN
BIRTHDATE/AGE:
SEX:
House staff coverage?
Y
/
N
(patient uncovered)
UNIT NUMBER:
Attending:
Pager:
Intern/NP (First Call):
Pager:
Resident:
Pager:
PRINT CLEARLY IN INK OR IMPRINT WITH PATIENT’S CARD
Overnight coverage:
Pager:
PROVIDER TO SIGN AND PLACE PAGER NUMBER LEGIBLY UNDER EACH ORDER SET
T
INDICATE CHOICE OF ORDER OPTIONS BY USING X IN CHECK BOXES
Date: ____________________ Time: ____________________
PROOF ONLY
Fingerstick Blood Glucose (BG) Monitoring:
Before meals (within 30 minutes) and at bedtime
Every 6 hours (if NPO)
_______ hours after meals
Other: ____________________________________________________
REV 12/6/05
0300 (3:00 AM)
BG Goal Premeal = ______________ (usually 80-150)
NovoLIN is the approved UMMMC substitution for HumuLIN and NovoLOG for HumaLOG
SCHEDULED INSULIN DOSE
For patient specific use in HumuLIN or HumaLOG, write “Do not substitute”
Breakfast
Lunch
Supper
Bedtime
Other (specify time)
Prandial Insulin
GIVE _____ UNITS OF
GIVE _____ UNITS OF
GIVE _____ UNITS OF
GIVE _____ UNITS OF GIVE _____ UNITS OF
NovoLOG
NovoLOG
NovoLOG
(meal insulin for the food)
NovoLIN R
NovoLIN R
NovoLIN R
Basal Insulin
GIVE _____ UNITS OF
GIVE _____ UNITS OF
GIVE _____ UNITS OF
GIVE _____ UNITS OF GIVE _____ UNITS OF
NovoLIN N
NovoLIN N
NovoLIN N
(for basic insulin needs
Lantus *
Lantus *
other than food)
* DO NOT mix Lantus in a syringe with any other insulin; for others, mix prandial and basal insulins in a single syringe.
Other (Specify)
Suggested dose times for Prandial Insulin:
NovoLOG/HumaLOG ...................... 0-15 minutes before eating
Regular............................................ 30 minutes before eating
CORRECTION INSULIN DOSE
CHECK ONE:
NovoLOG preferred
NovoLIN R
Other (Specify): ____________
Sliding Scale insulin is a supplement to the patient’s basic program.
Use sliding scale for: Check All That Apply:
Pre-meals
Bedtime
Every 6 hours
Other: ____________________________________
Caution: Reduce dosage or avoid HS sliding scale in elderly patients, especially those on once daily steroids.
REGIMENS
Refer to suggestions under dosing title
TDD = total daily dose of all insulins (home program)
Fingerstick Glucose
Low Dose
Medium Dose
High Dose
Very High Dose
Other
Thin and elderly
Average weight
Obese
Patients with infections
Range (mg/dl)
TDD < 40 units
TDD >40 units & <80 units
TDD > 80 units
or receiving steroids
Glucose < 60 or
Refer to Hypoglycemia (Adult) Procedure for treatment options.
symptomatic
60-150
0 units
0 units
0 units
0 units
0 units
151-200
1 unit
2 units
3 units
5 units
units
201-250
2 units
4 units
6 units
10 units
units
251-300
3 units
6 units
9 units
15 units
units
301-350
4 units
8 units
12 units
20 units
units
> 350
5 units
10 units
15 units
25 units
units
For critical value, FSBS < 50 or > 450, repeat FSBS on same machine. If confirmed, CALL MD/LIP with results.
Signature of MD/DO/NP/PA:________________________________ Printed Name: ____________________ Pager:__________ Date: ____________
Signature of RN: ________________________________________ Printed Name:______________________________________ Date: ____________
Prohibited Abbreviations: U, qd, qod, IU, .1 (write 0.1), 1.0 (write 1), MS, MSO4, MgSO4, µ µ g, AS, AD, AU, OS, OD, OU, tiw
Rev 12/05
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