Appendix 2 Variable Dose Insulin Chart Patients NHS number: Date of birth: name: RiO number: Responsible clinician: Date URINE BLOOD Insulin Dose in Time Route Prescriber Administration & (Specify exact Units Signature Time Time Glucose Sign Nurse Signature Time Time preparation) % + mmol/L Management of Blood Glucose Monitoring Results 15.1mmol/L- higher Refer to care plan. Contact doctor immediately if any signs of ketoacidosis. Doctor to review dose of insulin/oral antidiabetic medication – 10.1 15.0 mmol/L refer to care plan, monitor more frequently. Doctor to review insulin/oral antidiabetic medication dose. – – 4.0 10.0 mmol/L acceptable range no action required – – – 0 3.9 mmol/L Follow Trust guidelines for treatment of hypoglycaemia. (Appendix 3 NTW C 38 PPT PGN 06) – – –
Appendix 2 Variable Dose Insulin Chart Patients name: NHS number: Date of birth: RiO number: Responsible clinician: Date & Time URINE BLOOD Insulin (Specify exact preparation) Dose in Units Time Route Prescriber Signature Administration Time % + Time Glucose mmol/L Sign Nurse Signature Time Management of Blood Glucose Monitoring Results 15.1mmol/L- higher – Refer to care plan. Contact doctor immediately if any signs of ketoacidosis. Doctor to review dose of insulin/oral antidiabetic medication 10.1 – 15.0 mmol/L – refer to care plan, monitor more frequently. Doctor to review insulin/oral antidiabetic medication dose. 4.0 – 10.0 mmol/L – acceptable range – no action required 0 – 3.9 mmol/L – Follow Trust guidelines for treatment of hypoglycaemia. (Appendix 3 – NTW C 38 PPT PGN 06)
PPT-PGN-06-App-2-Variable-dose-insulin-chart-V02-Oct17.docx