Download Insulin SQ / Pump Orders

PLACE LABEL HERE
INSULIN SQ / PUMP
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
If patient is receiving U-500 insulin, must use paper form # 28587.
For patients on insulin therapy prior to admission (Type 1 or 2 and insulin pump patients). These
patients MUST be managed with basal and mealtime bolus insulin.
1.  Consult Diabetes Educator, Reason:  insulin pump  new to insulin  new onset diabetes  Other: ______
2.  Hemoglobin A1c
3. Fingerstick Blood Glucose (BG) Schedule:
 Before meals and at bedtime
 Before meals, bedtime, and 3 am (0300)
 Every 6 hrs, recommended for patients NPO, on tube feedings (TF), or on hyperalimentation (TPN)
4. Hypoglycemia (BG < 70 mg/dl): Implement Hypoglycemia Standing Orders (form # 2513)
5. Do not hold basal insulin without a physician order
6. For patients with Type 1 diabetes and not receiving basal insulin: notify attending physician request basal
insuln order. If unable to obtain order, contact Hospitalist Medical Director.
7.  SQ dosing:
BASAL INSULIN
 LANtus (glargine)
 Other: __________________
 Humulin 70/30 (NPH/Regular)
MEALTIME BOLUS
(Hold if NPO)
 HumaLOG (lispro)
 Regular (Humulin R)
TPN/TF BOLUS
 HumaLOG (lispro)
 Regular (Humulin R)
BREAKFAST ______ units SQ
BEDTIME ______ units SQ
BREAKFAST ______units SQ
DINNER ______ units SQ
BREAKFAST
LUNCH
DINNER
_________ units SQ
_________ units SQ
_________ units SQ
give at 0600
give at 1200
give at 1800
give at 2400
_________ units SQ
_________ units SQ
_________ units SQ
________ units SQ
*If continuous enteral feeding or TPN is stopped or interrupted hold MEALTIME BOLUS insulin.
Give the BASAL and CORRECTION dose (Sliding Scale) insulin.
CORRECTION DOSE INSULIN
Use when BG is
 > 140 mg/dL
 >160 mg/dL
 >180 mg/dL
Give before meals and bedtime or q 6 hrs if NPO

 HumaLOG (lispro)
 Regular (Humulin R)
 Other: BG – 100 /____ = # units SQ
 BG – 100 / 40 = # units SQ
 BG – 100 / 30 = # units SQ
 BG – 100 / 20 = # units SQ
Copy to pharmacy
*3-36796*
Order writer’s initials _______
FORM 3-36796 REV. 01/2017
Page 1 of 2
PLACE LABEL HERE
INSULIN SQ / PUMP
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
8.
 Admission with an insulin pump:
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Patient to manage insulin pump
Patient to sign Patient Agreement Patient Owned Insulin Pump During Hospitalization
(form # 26063)
Type of insulin used in pump:
 Humalog (lispro)
 Novolog (aspart)
 Apidra (glulisine)
 Other: _____________
Dispense one 10 ml vial for patient use or patient can use home insulin supply if not
available from pharmacy.
Continue current insulin pump programmed rates
Document mealtime and correction insulin delivered by insulin pump
Document site assessment every shift
Patient to change insertion site every 72 hrs
Patient to remove insulin pump during any radiology procedures (including MRI, CT
scan, and X-Ray). Patient to reconnect to usual settings immediately following
procedure.
Prior to stopping or suspending insulin pump for greater than 2 hours, call the physician
for replacement insulin orders
Notify physician if patient is no longer able to manage insulin pump. Replacement
insulin must be ordered and initiated at the time of the pump being discontinued.
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
Date
_____________
Time
_________________________________
Physician Signature
___________
PID Number
Copy to pharmacy
FORM 3-36796 REV. 01/2017
Page 2 of 2