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#1 #2. How should insulin be ordered? 1) Click the Add Order icon 2) Type insulin 3) Select Insulin Subcutaneous Orderset

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In the past, insulin sliding scales were the standard method of controlling blood sugars in the hospital. However, sliding scales were developed for regular and NPH insulins. Since emulating the body’s physiologic insulin secretion has become more feasible with the development of long-acting basal and rapid-acting insulins, “sliding scale” terminology is not applicable for those utilizing this regimen. The new insulin standard of long-acting basal insulin and rapid-acting insulin allows for patient-specific care and is now available in CIS. This article will provide an overview for the new “subcutaneous insulin orderset.”

How should insulin be ordered?

1)

Click the “Add Order” icon

2)

Type “insulin”

3)

Select “Insulin Subcutaneous Orderset”

™

Do not select any of the individual insulins above the orderset unless circumstances warrant the selection (e.g. ordering snacks.)

™

Always look for the icon

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™ The Total Daily Dose (TDD) of insulin is typically 0.5 to 1 unit/kg/DAY for diabetic patients and is determined by the attending physician.

™ Most patients’ regimens will consist of a basal long-acting insulin and a rapid-acting insulin for meals, bedtime, and snacks. However, if a patient is stable on a non-basal bolus home insulin regimen, it may be continued in the hospital.

¾ The basal insulin requirement is usually 40-50% of the TDD.

¾ The rapid-acting mealtime insulin dose consists of 2 key components shown in the equation below:

TOTAL mealtime Amount of insulin to “cover” grams Mealtime insulin insulin dose of carbohydrates consumed “correction“ dose

• This value is utilized to

“COVER” grams of

carbohydrates consumed. • It is used when calculating

rapid-acting insulin doses for meals, bedtime, and

snacks.

• This value is the amount of insulin the patient should receive to “CORRECT” a high glucose.

• It is utilized when calculating rapid-acting insulin doses for meals and bedtime…NOT USED FOR SNACKS!!! • Only give the correction if the measured blood sugar is

ABOVE the patient-specific target MAX blood sugar.

• DO NOT give a correction dose if it has been less than 3 hours since the last rapid-acting injection.

• At bedtime, only HALF of this value should be

administered if the blood sugar is >300 mg/dL. (Nothing should be administered for this value if the blood sugar is <300 mg/dL.)

4)

To order the appropriate insulin, follow these steps for most patients:

A. Order a long-acting insulin regimen B. Order rapid-acting insulin for mealtimes C. Order rapid-acting insulin for bedtime D. Order rapid-acting insulin for snacks

A. Order a long-acting insulin regimen

¾ < 8 years old: Once-daily AM Glargine dosing is recommended to avoid night-time hypoglycemia

¾ ≥ 8 years old: Once-daily BEDTIME Glargine dosing

¾ NoteÆ Some patients may need twice daily Glargine dosing

B. Order rapid-acting insulin for MEALTIMES

¾ Select one of the following options for mealtimes:

• When the insulin:carbohydrate ratio (defined on next page) is the same at all meals

o Give insulin before meals

• For patients under 3 years of age or who have unpredictable carbohydrate intake

o Give insulin after meals

• When the insulin:carbohydrate ratio varies over the course of the day, separate orders must be placed for each meal

o Give insulin before/after breakfast o Give insulin before/after lunch o Give insulin before/after dinner

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¾ After the mealtime insulin is selected, three yellow, highlighted areas appear:

1. Insulin:carbohydrate ratio (1 unit covers X grams)

o Insulin:carbohydrate ratio is defined as 1 unit of insulin will cover ‘X’ grams of carbohydrates.

o Formula for insulin:carbohydrate ratio

ƒ 500÷TDD=X (where X=the insulin:carbohydrate ratio) ƒ For example: Patient FD is a 14-year-old female who weighs

55 kg. Her TDD of insulin is ~0.7 units/kg/day. What is her insulin:carbohydrate ratio?

• TDD is ~0.7 units/kg/day, which is 38.5 units/day; therefore, 500÷38.5=X, which makes X=13.

• When ordering insulin for FD, her ratio is 13, which means 1 unit of insulin will cover approximately 13 grams of carbohydrates.

• When entering the insulin:carbohydrate ratio into CIS, only ‘13’ needs to be entered for ‘X.’

2. MAX target blood sugar (mg/dL)

o MAX target blood sugar is defined as the patient-specific target blood sugar. Ideally, all of the blood sugars for a patient will be below his or her target number.

o The attending will select a patient-specific target blood sugar within the ranges shown below.

o (NOTE: IF A TARGET IS NOT SELECTED, THE COMPUTER

DEFAULTS TO THE AGE-SPECIFIC TARGET MAX.)

Age-Specific Target Blood Sugars

Patient Age

Blood Sugar Target

Range (mg/dL)*

Usual Target MAX

0 to 5 years

100 – 200

200

5 to 12 years

80 – 180

180

Above 12 years

80 – 150

150

3. Insulin CORRECTION FACTOR (X mg/dL decrease per 1 unit insulin)

o Insulin CORRECTION FACTOR is defined as how many mg/dL the blood glucose will decrease when the patient is given 1 unit of insulin o Formula for Insulin CORRECTION FACTOR

ƒ 1800÷TDD=X (where X=Insulin CORRECTION FACTOR) ƒ In our example of FD with a TDD of 38.5, what is her insulin

CORRECTION FACTOR?

• For FD, 1800÷38.5=X, which makes X=47 or X≈50. • FD’s insulin CORRECTION FACTOR of 50 means 1 unit of insulin will drop her blood sugar by 50 mg/dL. • When entering the insulin CORRECTION FACTOR

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¾

PRACTICE

: If FD had a MAX target blood sugar of 150 and an insulin CORRECTION FACTOR of 50, at what blood sugar would she begin to receive a mealtime insulin correction dose for a high blood sugar? At what blood sugar would she begin to receive a mealtime insulin correction dose if her insulin

CORRECTION FACTOR changed to 20 and her target remained at 150?

• Part A: If her insulin CORRECTION FACTOR was 50 and her target was 150, she would receive insulin when blood sugars were >200.

• Part B: If her insulin CORRECTION FACTOR was 20 and her target stayed at 150, she would receive insulin when blood sugars were >170.

¾ How do I enter an insulin order if the patient should receive insulin

in 0.5-unit increments?

• 3 extremely important steps:

1) In the special instructions field, state the following: “Administer insulin in 0.5-unit increments”

2) Insulin:carbohydrate ratio: Since this ratio is recorded as 1 unit covers

X grams of carbohydrates, the ratio must be doubled when entering it into CIS. For instance, if 0.5 units of insulin covers 10 grams of

carbohydrates, then 1 unit of insulin covers 20 grams of carbohydrates. The insulin:carbohydrate ratio should be entered into CIS as ‘20.’

3) Insulin CORRECTION FACTOR: Since this factor is recorded as 1 unit

of insulin drops the blood sugar X mg/dL, the factor must be doubled when entering it into CIS. For

example, if 0.5 units of insulin drops the blood sugar by 40 mg/dL, then 1 unit of insulin decreases the blood sugar by 80. The insulin CORRECTION FACTOR should be entered into CIS as ’80.’

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C. Order rapid-acting insulin for BEDTIME

¾ For most patients, order the bedtime dose

utilizing the same values stated in the mealtime orderset for the following:

1. Insulin:carbohydrate ratio (1 unit covers X grams)

2. MAX target blood sugar (mg/dL) 3. Insulin CORRECTION FACTOR

(X mg/dL decrease per 1 unit insulin) ¾ Remember the order states the nurse will give

HALF the mealtime insulin dose at bedtime.

This means if the patient has a snack, all the

carbohydrates from the snack are covered, but the nurse will only cover HALF the bedtime correction dose of insulin to correct for the high blood sugar. The insulin

correction dose will only be administered for blood sugars greater than 300 mg/dL.

D. Order rapid-acting insulin for “SNACKS”

¾ The 3-hour ruleÆ When giving insulin for snacks, DO cover the carbohydrates, but

DO NOT correct for a high blood glucose if it has been less than 3 hours since the

last rapid-acting injection.

¾ Snack orderset coming soon and how to order snacks in the meantime!

• DO NOT select the orderset!! • DO select a rapid-acting insulin

• Select ‘prn’ and a ‘prn reason’ of “other.”

• In the ‘PRN instructions,” specify “with snacks.” • For the yellow, highlighted values, see below:

1. Insulin:carbohydrate ratio (1 unit covers X grams) o Order the same ratio as for mealtime order set. 2. MAX target blood sugar (mg/dL)

o Write “N/A” because blood sugars are not usually corrected when giving snacks (think of the 3-hour rule).

3. Insulin CORRECTION FACTOR (X mg/dL decrease per 1 unit insulin) o Write “N/A” because blood sugars are not usually corrected

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¾ Practice:

• Kylie is a 9-year-old female weighing 26.5 kg. 1. Calculate her TDD.

2. Her father states her usual insulin glargine dose is 9 units. Is this appropriate? • Kylie’s physician states her TDD is 18 units and

her MAX target blood sugar is 150 mg/dL. 3. Calculate insulin:carbohydrate ratio 4. Calculate insulin CORRECTION FACTOR • If the attending wanted the insulin to be given in

0.5-unit increments instead of 1-unit increments as above, how would each of the following differ and what value would the physician enter into CIS for problems 5 and 6?

5. Calculate the insulin:carbohydrate ratio utilizing 0.5-unit increments 6. Calculate the insulin CORRECTION FACTOR utilizing 0.5-unit increments 7. It is 11:30 AM and Kylie wants to eat lunch. The last mealtime insulin dose was

given at 8:00 AM. Current blood sugar is 205. How much insulin should Kylie receive if she is going to eat 76 grams of carbohydrates? Remember the following equation:

TOTAL mealtime Amount of insulin to “cover” grams Mealtime Insulin insulin dose of carbohydrates consumed “correction” dose

8. If Kylie ate lunch at 11:30 AM and received a correction bolus and a carbohydrate bolus at that time, how much insulin should be administered if she wants to eat 30 grams of carbohydrates at 1:00 PM and has a blood sugar of 355?

9. It’s 9 PM. Kylie had dinner at 6 PM. She wants a bedtime snack of 30 grams of carbohydrates and has a blood sugar of 355. How much insulin should be administered?

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¾ Answers:

1. TDD ≈ 0.5-1 mg/kg/day; therefore, Kylie’s TDD is ≈13.25-26.5 units/DAY.

2. This insulin glargine dose IS appropriate because the dose is usually ½ of the TDD. 3. 500÷18 = 28; therefore, Kylie’s insulin:carbohydrate ratio is 28, which means 1 unit of

insulin covers 28 grams of carbohydrates. In practice, 28 would be rounded up to 30. 4. 1800÷18 = 100; therefore, Kylie’s insulin CORRECTION FACTOR is 100, which

means 1 unit of insulin will decrease Kylie’s blood sugar by 100 mg/dL. Since 1 unit of insulin decreases Kylie’s blood sugar by 100 mg/dL, most likely the physician would order the insulin to be given in 0.5-unit increments.

5. The insulin:carbohydrate ratio would be 15 because 0.5 units of insulin would cover 15 grams of carbohydrates; however, the physician would enter 30 into CIS for the insulin:carbohydrate ratio because the ratio must be entered into CIS in 1-unit increments.

6. The insulin CORRECTION FACTOR would be 50 because 0.5 units of insulin would decrease the blood sugar by 50 mg/dL; however, the physician would enter 100 into CIS for the insulin CORRECTION FACTOR because the factor must be entered into CIS in 1-unit increments.

7. For the TOTAL mealtime insulin dose, the carbohydrates must be covered and the blood sugar must be corrected.

a. Covering carbohydratesÆ Kylie will eat 76 grams of carbohydrates. (76÷30 =2.5 units) The nurse should give 2.5 units to correct for the carbohydrates. b. Correcting blood sugarÆ Since Kylie is receiving her insulin in 0.5-unit

increments, she will receive 0.5 units of insulin to decrease her blood sugar by 50 units to her target of 150 mg/dL.

c. Her TOTAL mealtime insulin dose will be 3 units of insulin.

8. For the TOTAL snack insulin dose, the carbohydrates must be covered and the blood sugar is usually NOT corrected.

a. Covering carbohydratesÆ To cover her 30 grams of carbohydrates, 1 unit of insulin should be administered.

b. Correcting blood sugarÆ No correction dose for her blood sugar should be administered because it has been <3 hours since her last rapid-acting insulin dose. Remember the correction factor is not generally utilized for snacks. c. Her TOTAL snack insulin dose will be 1 unit of insulin.

9. For the TOTAL bedtime insulin dose, the carbohydrates must be covered and the blood sugar must be corrected.

a. Covering carbohydratesÆ To cover her 30 grams of carbohydrates, 1 unit of insulin should be administered.

b. Correcting blood sugarÆ Since it has been 3 hours since she ate, a correction bolus should be administered. When correcting for a blood

sugar at bedtime, ALWAYS be sure the blood sugar is greater than 300 AND use ½ of the usual correction dose to avoid low blood sugars overnight. To correct for the blood sugar of 355, 2 units of insulin would

decrease the blood sugar to approximately 150; therefore, only 1 unit should be administered to correct for the bedtime blood sugar.

c. For the TOTAL bedtime dose, administer 2 units of insulin: 1 unit to cover the 30 grams of carbohydrates and 1 unit to correct the blood sugar of 355.

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