PHYSICIAN S ORDERS Page 1 of 1 Providence Hospital ICU Insulin Drip Protocol

Transcription

1 DTE PROVIDENCE HOSPITL 6801 irport Boulevard, Mobile L 36608, PHYSICIN S ORDERS Page 1 of 1 Providence Hospital ICU Insulin Drip Protocol 1. Discontinue all previous insulin and oral diabetic medications 2. Verify a continous source of glucose (TPN, continuous tube feeding or dextrose) 3. If no continuous source of glucose available, start D5 1/2 NS at 30 ml per hour 4. Start 100 units of Regular Insulin in 100 ml of Normal Saline infusion Blood Glucose 140 to to to to 400 Greater than 400 INITIL INFUSION PROTOCOL (Table 1) (For initiation or resuming drip only, not for titration) Initial Rate Bolus (Initial one time bolus) Begin at 1 unit per hour 4 units regular insulin Begin at 2 units per hour 6 units regular insulin Begin at 3 units per hour 8 units regular insulin Begin at 4 units per hour 12 units regular insulin Begin at 5 units per hour 16 units regular insulin TITRTION PROTOCOL (Table 2) Blood Glucose: (Goal:140 to 180) Insulin Drip Infusion Rate Below 140 Hold Drip (See #5) 140 to 180 No change 181 to 200 Increase by: 0.5 units per H 201 to 220 Increase by: 1 unit per H 221 to 250 Increase by: 1.5 units per H 251 to 300 Increase by: 2 units per H 301 to 350 Increase by: 2.5 units per H 351 to 400 Increase by: 3 units per H Greater than 400 Increase by: 5 units per H If the BG drops more than 50 mg per dl within a 4 hour period, decrease the rate of drip by 1/4 the current rate. (New rate = current rate x 0.75). Do not up titrate until next BG. If the BG drops more than 100 mg per dl within a 4 hour period, decrease the rate of drip by 1/2 the current rate. (New rate = current rate x 0.5). Do not up titrate until next BG. 5. Hypoglycemia Protocol Drip should be held for any BG below 140. If BG drops below 70 give 12.5 grams dextrose IV. Check BG s every 15 minutes until above 70 Resume drip with the Initial Infusion Protocol (Table 1) (do not rebolus) when BG is above 140. Developed: September 2007 Revised: Sept 2011 Revised: March 2013 PH IIDP 0313PH BLOOD GLUCOSE FREQUENCY RTE (Table 3) Below 70 Every 15 minutes until above to 140 Every 1 hour until 3 consecutive BGs are within goal 141 to 180 Every 2 hours while within goal bove 181 Every 1 hour until 3 consecutive BGs are within goal 6. Transition to Subcutaneous Insulin: See transition recommendations on back of this page. Physician will write orders to discontinue IV insulin drip. Insulin drip should not be discontinued until 2 hours after first dose of basal insulin is given. Pharmacy to calculate initial dose of long acting subcutaneous insulin; physician will adjust dosing daily thereafter. First dose of long acting insulin to be given 2 hours before insulin drip stopped. Pharmacy to start sliding scale as well. RN/P Signature Date Time Physician s Signature Date Time Date Printed: PHY00291

2 PROVIDENCE HOSPITL 6801 irport Boulevard, Mobile L 36608, r*pm1169*r PM1169 IV Insulin Record Goal: 140 to 180 Document all IV insulin blood glucoses here. When the insulin drip is discontinued, document BGs on the Diabetic MRS. Current Status Providence Hospital ICU Insulin Drip Record Changes To Drip New Rate Nurses Initials Date Time BG Results (mg per dl) Insulin Drip Rate (Units/H) BG 50 to 100 mg per dl in last 4 H? Yes or No Rate Change New Insulin Drip Rate Primary Nurse Making Rate Change Witnessing Nurses Initials NOTE: Be sure to write and scan order to pharmacy when insulin drip has been discontinued. If basal insulin is ordered give 2 hours before discontinuing drip. Print Name and Credentials Initials Print Name and Credentials Initials Print Name and Credentials Initials Rev: 10/11 When complete, place in the chart with the Diabetic MRS Date Printed: NSG00112

3 DTE PROVIDENCE HOSPITL 6801 irport Boulevard, Mobile L 36608, PHYSICIN S ORDERS Page 1 of 2 dult Insulin Sliding Scale Goal: to maintain fasting blood glucose (BG) 90 to 130 mg per dl. The use of intermediate or long acting insulin on a scheduled basis is highly recommended to prevent hyperglycemic episodes in patients whose blood glucose is not controlled by the insulin sliding scale. Providence Hospital hypoglycemia protocol will be automatically initiated for patients whose bedside blood glucose (BG) is below 70 mg per dl. 1. Discontinue all previous insulin sliding scale orders 2. Rapid acting analog (NOVOLOG) insulin to be used for sliding scale: 3. If no sliding scale is specified in the original order the routine/regular sliding scale will automatically be implemented. BG (mg per dl) Below to 149 No Insulin SUBQ Insulin Sliding Scale (check order desired): 4. Bedside Blood Glucose (BG) Monitoring (check order desired): ** RN should use discretion to change between appropriate times to check BGs unless specifically ordered by a physician. * Eating: QID C & HS and PRN (0659, 1100, 1600, 2100) Use C & HS correction dose of insulin for patients eating unless specifically ordered otherwise. (Use HS dose for BGs timed ) * NPO: Q 6 H and PRN (use C correction dose of insulin for all BGs) * Tubefeedings: Continuous tube feeding: Check BG Q 6 H (Use C correction dose of insulin for all BGs) Bolus tube feedings: Check BG immediately prior to each feeding (Use C correction dose of insulin for all BGs) Renal/Brittle Routine/Regular Insulin Resistant Individualized Follow Hypoglycemia Protocol, and notify Physician. 150 to units none 4 units 2 units 5 units 3 units units 201 to units 1 unit 6 units 3 units 8 units 4 units units 251 to units 2 units 8 units 4 units 12 units 6 units units 301 to units 3 units 12 units 6 units 18 units 9 units units bove 450 C HS C HS C HS C 12 units 6 units 26 units 13 units 38 units 19 units units Order stat BG from Lab to confirm results and call physician. 351 to units 4 units 16 units 8 units 24 units 12 units units 401 to units 5 units 20 units 10 units 30 units 15 units units QID C & HS, with PRN checks if patient shows clinical signs of hypo or hyperglycemia. Q 4 H at 0200, 0600, 1000, 1400, 1800, and 2200, with PRN checks if patient shows clinical signs of hypo or hyperglycemia. Individualized as follows: HS 5. Do not hold sliding scale insulin if the patient is NPO, at HS or if meals or tube feedings are held, unless the physician specifically orders. PH PHSS 0113PH Date Printed: PHY00190

4 DTE PROVIDENCE HOSPITL 6801 irport Boulevard, Mobile L 36608, PHYSICIN S ORDERS Page 2 of 2 Providence Hospital Hypoglycemia Treatment Protocol Symptoms of Hypoglycemia Mild: Pallor, tachycardia, shakiness, anxiety, hunger, diaphoresis, paresthesias Moderate: Confusion, behavioral changes, irritability, staggering gait, slurred speech, extreme fatigue, double/blurred vision Severe: Disorientation, cognitive dysfunction, inability to arouse, loss of consciousness, seizure, coma Documentation:Times and BG results are to be documented in HED. Symptoms, Nursing actions, and patient response should be documented in the nursing focus notes. 1. Treatment for BG below 70 mg per dl: IF THEN Conscious patient, able to take PO, or has other GI access Give 15 g glucose gel, or 4 oz apple juice or 4 oz lemon/lime soda or 8 oz skim milk. (liquids will work best for non oral routes) Conscious patient, NOT able to take PO Give 12.5 g (25 ml) IV push of D50. Unconscious patient, IV in place Give 25 g (50 ml) IV push of D50. Unconscious patient, no IV access Give glucagon (GLUCGEN) 1 mg SUBQ or IM (Give 0.5 mg if child less than 25 kg). 2. BG below 40 mg per dl: If POC BG is below 40, and the patient is symptomatic, treat the BG according to the treatment protocol above (step 1) ND notify the Physician. If POC BG is below 40, and the patient is not symptomatic, repeat POC BG. If still below 40, treat the BG according to the treatment protocol above (step 1) ND notify the Physician. Order blood glucose STT. Nurse to draw and send blood to the lab. Document in Nursing Focus Note and notify the ttending Physician and/or Endocrinologist in the M. BG between 40 to 69 mg per dl: If POC BG is below 70, and the patient is symptomatic, treat the BG according to the treatment protocol above (step 1). If POC BG is below 70, and the patient is not symptomatic, repeat POC BG. If still below 70, treat the BG according to the treatment protocol above (step 1). Document in Nursing Focus Note and notify the ttending Physician and/or Endocrinologist in the M. 3. Recheck BG 15 minutes after treatment. If BG remains below 70 mg per dl after treatment then repeat step 1. If the 2 nd BG treatment is unsuccessful call the physician. Order blood glucose STT. Nurse to draw and send blood to the lab. Once BG is above 70 mg per dl ND patient has returned to baseline status, recheck blood glucose Q 1 H x 2 and move to step # Resume previous BG monitoring schedule. 5. Notify the Physician immediately for any of the following events: If BG below 40 (step 2) If patient severely symptomatic (no matter the BG) If the 2 nd BG treatment is unsuccessful (step 3) RN/P Signature Date Time Developed: May 1998 Revised: September 2012 Revised: January 2013 Physician s Signature Date Time PH PHSS 0113PH Date Printed: PHY00190PG2

5 DTE PROVIDENCE HOSPITL 6801 irport Boulevard, Mobile L 36608, PHYSICIN S ORDERS Providence Hospital Hypoglycemia Treatment Protocol Page 1 of1 Symptoms of Hypoglycemia Mild: Pallor, tachycardia, shakiness, anxiety, hunger, diaphoresis, paresthesias Moderate: Confusion, behavioral changes, irritability, staggering gait, slurred speech, extreme fatigue, double/blurred vision Severe: Disorientation, cognitive dysfunction, inability to arouse, loss of consciousness, seizure, coma Documentation:Times and BG results are to be documented in HED. Symptoms, Nursing actions, and patient response should be documented in the nursing focus notes. 1. Treatment for BG below 70 mg per dl: IF THEN Conscious patient, able to take PO, or has other GI access Give 15 g glucose gel, or 4 oz apple juice or 4 oz lemon/lime soda or 8 oz skim milk. (liquids will work best for non oral routes) Conscious patient, NOT able to take PO Give 12.5 g (25 ml) IV push of D50. Unconscious patient, IV in place Give 25 g (50 ml) IV push of D50. Unconscious patient, no IV access Give glucagon (GLUCGEN) 1 mg SUBQ or IM (Give 0.5 mg if child less than 25 kg). 2. BG below 40 mg per dl: If POC BG is below 40, and the patient is symptomatic, treat the BG according to the treatment protocol above (step 1) ND notify the Physician. If POC BG is below 40, and the patient is not symptomatic, repeat POC BG. If still below 40, treat the BG according to the treatment protocol above (step 1) ND notify the Physician. Order blood glucose STT. Nurse to draw and send blood to the lab. Document in Nursing Focus Note and notify the ttending Physician and/or Endocrinologist in the M. BG between 40 to 69 mg per dl: If POC BG is below 70, and the patient is symptomatic, treat the BG according to the treatment protocol above (step 1). If POC BG is below 70, and the patient is not symptomatic, repeat POC BG. If still below 70, treat the BG according to the treatment protocol above (step 1). Document in Nursing Focus Note and notify the ttending Physician and/or Endocrinologist in the M. 3. Recheck BG 15 minutes after treatment. If BG remains below 70 mg per dl after treatment then repeat step 1. nd If the 2 BG treatment is unsuccessful call the physician. Order blood glucose STT. Nurse to draw and send blood to the lab. Once BG is above 70 mg per dl ND patient has returned to baseline status, recheck blood glucose Q 1 H x 2 and move to step # Resume previous BG monitoring schedule. 5. Notify the Physician immediately for any of the following events: If BG below 40 (step 2) If patient severely symptomatic (no matter the BG) nd If the 2 BG treatment is unsuccessful (step 3) RN/P Signature Date Time Developed: May 1998 Revised: pril 2012 Revised: September 2012 Physician s Signature Date Time PH HYPO 0912PH Date Printed: PHY00532