Physician’s Orders

*2PO* * 2 P O *

Order #I417001 Page 1 of 2 Rev. 1/19/2007

Insulin Sliding Scale Protocol

Dr. Michelle D. Welch

Date Time

Allergies: Ht: Wt:

Pre-meal “correction dose” algorithm for Hyperglycemia. In general, to be

administered in addition to scheduled insulin dose to correct pre-meal hyperglycemia.

1. Type of insulin to be given sc: Novolog Humalog Regular

Give Novolog and Humalog Insulin 0-15 minutes before eating.

Give Regular Insulin 30 minutes before eating.

2. Accu-Cheks (finger sticks):

Before meals and at bedtime (if patient tolerating PO). Before meals, at bedtime and at 3:00am (if patient tolerating PO).

Every 4 hours (if patient is NPO, on continuous tube feeding, or receiving TPN).

Before meal bolus tube feeds.

3. For the level of blood sugar, give the corresponding amount of insulin sc:

Level 1 Algorithm Level 2 Algorithm Level 3 Algorithm

150-200 = 1 unit 150-200 = 2 units 150-200 = 4 units

201-250 = 2 units 201-250 = 4 units 201-250 = 6 units

251-300 = 3 units 251-300 = 6 units 251-300 = 8 units

301-350 = 4 units 301-350 = 8 units 301-350 = 10 units

351-400 = 5 units

And Notify Physician

351-400 = 10 units

And Notify Physician

351-400 = 12 units

And Notify Physician

High Insulin

Sensitivity

Moderate Insulin

Sensitivity

Insulin

Resistant

4. Hypoglycemic Orders:

a. If tolerating PO, 1) If blood sugar < 70 and asymptomatic, give snack of 15 gm carbohydrate (4 oz

fruit juice / non-diet soda, 8 oz nonfat milk, or 3-4 glucose tabs) and re-check blood sugar in 15-30 minutes. Repeat process until blood sugar is over 100.

2) If blood sugar < 70 and symptomatic, give snack of 30 gm carbohydrate (4 oz fruit juice / non-diet soda, 8 oz nonfat milk, or 3-4 glucose tabs) and re-check

blood sugar in 15-30 minutes. Repeat process until blood sugar is over 100.

Notify physician.

(continued…)

Physician’s Orders

Order #I417001 Page 2 of 2 Rev. 1/19/2007

Insulin Sliding Scale Protocol Dr. Michelle D. Welch

Date Time

4. Hypoglycemic Orders continued: b. If NPO or patient has a change in mental status,

1) If blood sugar < 70 give ½ amp D50W, re-check blood sugar q 15 min and repeat

process until blood sugar is over 100. Notify physician. 2) If blood sugar < 60 give ½ amp D50W, re-check blood sugar q 15 min and repeat

process until blood sugar is over 100. Notify physician.

*** Notify Physician if Blood Sugar Consistently over 250 or less than 70. ***

Physician's Signature: Date: