Subcutaneous Insulin Therapy Patient Eating Order

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PATIENT CARE ORDERS
Please use black ink ballpoint pen only and press firmly to make copy
Weight
Known Adverse Reactions or Intolerances
TRANSCRIPTION
(kg)
No
Yes (list)
DRUG
No
Yes (list)
FOOD
No
Yes
LATEX
Diabetes Management – Subcutaneous Insulin Therapy
Patient Eating Order Set (Adult)
***See Suggestions for Management on Reverse***
***Non-insulin antihyperglycemic agents or corticosteroid therapy may impact glycemic
control***
Capillary Blood Glucose Monitoring
● Before breakfast, lunch, supper 2200 h and PRN
Scheduled Insulin
● Discontinue all previous insulin orders
Before Breakfast
Before Lunch
Before Supper
At 2200 h
Nutritional
Give _____ units
Give ____ units
Give _____ units
(Bolus)
subcutaneous
subcutaneous
subcutaneous
Insulin:
If it is anticipated that the patient will not eat more than 50% of the meal or
is NPO, do not give mealtime insulin
Aspart
Basal
Insulin:
glargine
Give _____ units
Give _____ units
Give _____ units
detemir
subcutaneous
subcutaneous
subcutaneous
NPH
Premixed
insulin:
Novomix30
Give _____ units
Give _____ units
Other
subcutaneous
subcutaneous
__________
Correction Dose Insulin Algorithms
*** Use Titratable Medication Administration Record***
● Administer insulin aspart subcutaneously in addition to scheduled insulin dose to correct
hyperglycemia: Pre-meal
2200h (2200h correction dose should be 50% of pre-meal correction dose)
Select one of the following algorithms:
Insulin Sensitive: for patients requiring 40 units or less of scheduled insulin/day
Usual: for patients requiring 40 to 80 units of scheduled insulin/day
Insulin Resistant: for patients requiring 80 units or more of scheduled insulin/day
Capillary Blood
Insulin
Usual
Insulin
Individual
Glucose (mmol/L)
Sensitive (units)
(units)
resistant (units)
(units)
Pre-
2200h
Pre-
2200
Pre-
2200 h
Pre-
2200h
meal
meal
h
meal
meal
10.1 to 12.0
2
0
4
2
6
3
12.1 to 14.0
4
2
6
3
8
4
14.1 to 17.0
6
3
8
4
10
5
17.1 to 20.0
8
4
10
5
12
6
Pharmacy Use Only:
20.1 to 22.0
10
5
12
6
14
7
Reviewed by: ____
Over 22
12
6
14
7
16
8
Entered by:
____
Checked by:
____
Page 1 of 1
Prescriber Printed Name
Designation
Signature
Date
Time
(
YYYY/MM/DD)
(HHMM):
KGH Stores
#122262/Org: 04/Nov/Rev: 13/May
C/8/xxxxx/MD/mm-yy/V1/-
Original – Chart
Copy – Pharmacy
Patient Care Orders

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