PLACE LABEL HERE

INSULIN SUBCUTANEOUS (SQ) FOR OBSTETRICS

ORDERS

(Not for Intrapartum Use)

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).

Target Blood Glucose (BG): 70 – 90 mg/dl fasting, < 120 mg/dl two hours postprandial

1. Fingerstick Blood Glucose (BG) Schedule:

q Fasting BG q AM q 2 hrs postprandial q at bedtime q at 3 AM

q Every 6 hrs [recommended for patients NPO, on tube feedings (TF), or on hyperalimentation (TPN)]

q Other: ______

Notify Provider for Fasting BG > ______or < ______; 2 hrs postprandial BG > ______or < ______

2.  Hemoglobin A1C level

3.  Consult Diabetes Education

BASAL INSULIN
q NPH
q Levemir (detemir)
q Other: ______ / BREAKFAST ______units SQ / DINNER ______units SQ
q BEDTIME ______units SQ

4.  INSULIN SQ DOSING (if patient has an insulin pump initiate Insulin / SQ Pump Orders # 36796)

MEALTIME BOLUS
(Hold if NPO)
q HumaLOG
(lispro)
q Regular
(Humulin R) / BREAKFAST
If TPN/TF give at 0600
______units SQ / LUNCH
If TPN/TF give at 1200
______units SQ / DINNER
If TPN/TF give at 1800
______units SQ / BEDTIME
If TPN/TF give at
2400
______units SQ
CORRECTION DOSE INSULIN
q HumaLOG (lispro)
q Regular (Humulin R)
Give when blood glucose is:
q greater than 120 mg/dL
q greater than ____ mg/dL / q Antepartum: BG – 100 / 20 = # units SQ
q Postpartum: BG – 100 / 40 = # units SQ
q Other: BG – 100 / ____ = # units SQ

5.  Hypoglycemia (blood glucose < 70 mg/dl): Implement the the Hypoglycemia Treatment Standing Orders # 2513

6.  Do not hold basal insulin without a provider order

7.  If patient is receiving U-500 insulin, must use form # 28587

______

Date Time Physician Signature PID Number

Copy to pharmacy

*1-21502* FORM 1-21502 REV. 10/2017 Page 1 of 1