Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE / TIME / ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICYDiabetic Patient Pre Printed Orders
1.Level of service:
Outpatient
Monitored OP (indicate nursing area): Med/Surg Telemetry
Inpatient (indicate nursing area): Med/Surg Telemetry ICU
2.Diet: Nothing by Mouth Clear Liquid Regular ADA ______calories
Other______
3. Allergies: ______
4.Physician to contact concerning patient’s diabetes care:
5.Peripheral blood glucose:
AC(before meals) and HS (at bedtime) (routinely for patient’s using insulin)
BID (am, pm) (routinely for patients using oral agents)
every ______hours
other (please specify):
6.Aloe Vesta 2-n-1 Skin Conditioner/Protectant – Apply to feet BID after bath and at bedtime, avoiding areas between toes.
7.Critical Blood Glucose Values – If peripheral blood glucose is less than 50 mg/dl or greater than 500mg/dl.
- If blood glucose value is less than 50mg/dl, RR-LO (results reported) = less than 30mg/dl or LO = less than 10mg/dl, repeat point of care blood glucose an follow hypoglycemia patient care protocol. Notify physician.
- If blood glucose value is RR-HI = greater than 500mg/dl or HI=greater than 600mg/dl. draw stat plasma glucose and notify physician.
8.Consult Diabetes Educator if admitted with any of the following diagnoses.
Hyperosmolar Non-Ketotic Syndrome (Type II)
Diabetic Ketoacidosis (Type I)
Hypoglycemia
Newly diagnosed Diabetes (Type I or Type II)
9.Nutrition Services Consult: (check one)
ADA Diet Guidelines
Carbohydrate Counting
Other (please specify): ______
10.Please have patient view the following Video(s) (located in “Diabetes in the Box”)
Hypoglycemia
Drawing Up and Injecting Insulin
Foot Care
(Continued)
Allergies / Intolerances
Height ______Weight ______ kg lbs gms
Latex Allergy Yes No /
DANGEROUS ABBREVIATIONS – DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD, q.o.d. or QOD, U or u, IU / Affix Patient Label To ALL PagesPage 1 of 3
SLS-DM-956 (Rev. 01/02/07) /
Never use zero after decimal point (1.0 mg)
Always use zero before decimal point (0.5 mg)
Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE / TIME / ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICYDiabetic Patient Pre Printed Orders (Continued)
Hypoglycemia Treatment:
If blood glucose is 70 mg/dl or less (WITH or WITHOUT symptoms **) or 80 mg/dl (WITH symptoms ) [**symptoms include shakiness, sweating, cool/clammy skin, extreme hunger, confusion, seizures, and/or unconscious]
A blood glucose 50 mg/dl or less is considered severe hypoglycemia
The following action should be taken; Treat for hypoglycemia before giving the patienttheir oral agent or insulin and contact the physician managing the patient’s diabetes care for possible medication changes.
Patients who arearousable:
A.If patient is NPO
- initiate an IV
- If glucose 70-50 mg/dl. Repeat blood glucose point of and care and administer 25ml of 50 % dextrose IV. Notify physician.
- IF blood glucose 50 mg/dl or less, RR-LO (results reported) = less then 30mg/dl or LO = less than 10mg/dl, Repeat point of care blood glucose and administer 50 ml 50% dextrose IV. Notify physician
Repeat blood glucose test on patient 15 minutes following treatment. If level continues to be 70 mg/dl or less repeat above steps every 15 minutes until blood sugar is greater then 80 mg/dl OR a reduction in symptoms is observed
B.If not NPO
- Blood glucose of 70-50 mg/dl administer of 15 grams carbohydrate to the patient.
- Blood glucose 50mg/dl or less administer 30 grams of carbohydrate to the patient
- 3 B-D Glucose tablets or 15 grams of glucose gel
- 4 oz orange or apple juice
- 8 oz skim milk
- 4-5 oz REGULAR soda (not diet)
C.Retest the patient’s blood glucose in one hour and call the physician if less than 70 mg/dl for further instruction
(Continued)
Allergies / Intolerances
Height ______Weight ______ kg lbs gms
Latex Allergy Yes No /
DANGEROUS ABBREVIATIONS – DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD, q.o.d. or QOD, U or u, IU / Affix Patient Label To ALL PagesPage 2 of 3
SLS-DM-956 (Rev. 01/02/07) /
Never use zero after decimal point (1.0 mg)
Always use zero before decimal point (0.5 mg)
Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE / TIME / ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICYDiabetic Patient Pre Printed Orders (Continued)
11.If the patient is unarousablewith a blood glucose less than 70 mg/dl
a.Initiate an IV and administer 50ml of 50% dextrose IV. Notify physician. If IV access is difficult to obtain, administer 1 mg (1 unit) dose of Glucagon (per package insert instructions). Turn the patient on their side in case of vomiting. Contact CRN or House Supervisor to start IV stat.
b.Recheck blood glucose test on patient 15 minutes following treatment. If level continues to be less then 70 repeat above step every 15 minutes until blood glucose is greater than 80mg/dl OR a reduction of symptoms is observed and notify physician
12.For a hyperglycemia critical blood sugar level of RR-HI (results recorded) = greater then 500mg/dl or HI = greater than 600mg/dl.
- Draw STAT plasma glucose
Reference: Lab, blood glucose monitoring: Accu-check Inform, A core curriculum for Diabetes Education
Physician Signature/Date:______
Allergies / Intolerances
Height ______Weight ______ kg lbs gms
Latex Allergy Yes No /
DANGEROUS ABBREVIATIONS – DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD, q.o.d. or QOD, U or u, IU / Affix Patient Label To ALL PagesPage 3 of 3
SLS-DM-956 (Rev. 01/02/07) /