Protocol for Diabetes Management in hospital – 2014

Name ……………………………….. Hospital No……………….

Age/ Sex …………………Ht/Wt ……………………..

1. Diabetes

1) Known diabetes (Type 1 / Type 2 / Others) duration …………

2) Diabetes – New diagnosis ……………….

3) HbA1C ……………

2. Existing treatment of Diabetes mellitus

Name

Dose

   
   
   

 

Primary Consultant

 

Speciality Nurse –

 

Speciality Consultant

 

Ward Nurse-in-charge please inform the Duty Doctor in case blood sugar reading is out of range

                                                                        DIABETES MANAGEMENT

  1. IV Insulin –

50 units of short acting insulin (…………………………) in 50ml NS

GLUCOMETER SUGAR (mg%)

INSULIN (ml/hr)

<100

Please inform

101 -120

nil

121-140

0.5 ml/hr*

141-160

1.0 ml/hr*

161-200

1.5 ml/hr*

201-240

3ml/hr*

>240

Please inform

  • If three consecutive readings are in the same level, please inform.

B. GIK regimen –                                                                                                                                                                                            

                                                                                                                                                                                                                                        Date …………………………….

BASAL –

               Daytime (8 am till 10 pm) – DNS + KCl …….ml+ Insulin…………….…

               Nighttime (10 pm till 8 am) – DNS + KCl…….ml + Insulin ………………

CORRECTIVE – 4 hourly sc Insulin (…………..……………..)

GLUCOMETER SUGAR (mg%)

Insulin SC

< 100

Please inform

100-120

121 -140

141-160

161-200

201-240

>240

Please inform

Ward Nurse-in-charge please inform the Duty Doctor in case blood sugar reading is out of range

                                                                                                                                                                                                                                       Date ……………………………..

BASAL –

             Daytime (8 am till 10 pm) – DNS + KCl………ml+ Insulin…………………..

             Night time (10 pm till 8 am) – DNS + KCl………ml + Insulin ………………

CORRECTIVE – 4 hourly sc Insulin (…………..……………..)

GLUCOMETER SUGAR (mg%)

Insulin SC

< 100

Please inform

100-120

121 -140

141-160

161-200

201-240

>240

Please inform

                                                                                                                                                                                                                                       Date ……………………………..
BASAL –

Daytime (8 am till 10 pm) – DNS + KCl………ml+ Insulin……………………

Nighttime (10 pm till 8 am) – DNS + KCl…….ml + Insulin ……………..…

CORRECTIVE – 4 hourly sc Insulin (…………..……………..)

GLUCOMETER SUGAR (mg%)

Insulin SC

< 100

Please inform

100-120

121 -140

141-160

161-200

201-240

>240

Please inform

  1. SC Insulin (Multiple SC Insulin injection Regimen)

                                         Date – ………………………

 

Ward Nurse-in-charge please inform the Duty Doctor in case blood sugar reading is out of range

 

 TARGET – Premeal 100-140, Postmeal 140-180 mg

Time

GRBS

Insulin

Dose

Advised

Modified to

Modified by

Fasting

2hrs after bf

Bef lunch

2hrs after lunch

Bef dinner

Bedtime

Other time

                Date – ………………………

 TARGET – Premeal 100-140, Postmeal 140-180 mg

Time

GRBS

Insulin

Dose

Advised

Modified to

Modified by

Fasting

2hrs after bf

Bef lunch

2hrs after lunch

Bef dinner

Bedtime

Other time

                                 Date – ………………………

   TARGET – Premeal 100-140, Postmeal 140-180 mg

Time

GRBS

Insulin

Dose

Advised

Modified to

Modified by

Fasting

2hrs after bf

Bef lunch

2hrs after lunch

Bef dinner

Bedtime

Other time

                           Date – ………………………

 TARGET – Premeal 100-140, Postmeal 140-180 mg

Time

GRBS

Insulin

Dose

Advised

Modified to

Modified by

Fasting

2hrs after bf

Bef lunch

2hrs after lunch

Bef dinner

Bedtime

Other time

Ward Nurse-in-charge please inform the Duty Doctor in case blood sugar reading is out of range

 

                    Date – ………………………

TARGET – Premeal 100-140, Postmeal 140-180 mg

Time

GRBS

Insulin

Dose

Advised

Modified to

Modified by

Fasting

2hrs after bf

Bef lunch

2hrs after lunch

Bef dinner

Bedtime

Other time

Data collection

(Final Diagnosis …………………………………………………..)

1) Discharged / Died

2) Duration of Hospital stay …………….

3) Discharge medication for diabetes

a) tablet …………………………….

b) insulin …………………………….

4) Diabetes control in hospital

A. On IV Insulin – Good/Suboptimal/Poor

Duration ……….., Hypoglycaemia ……, Grade …….

B. On GIK regimen – Good/Suboptimal/Poor

Duration …………, Hypoglycaemia ……, Grade ……

5) Complication related to diabetes on SC Insulin

Ward Nurse-in-charge please inform the Duty Doctor in case blood sugar reading is out of range

a) DKA/HONK – ……….

b) Hypoglycaemia i) no. of episodes

                   ii) Grade of hypoglycaemia 1 / 2 / 3*

                   iii) Corrected per oral or i.v

6) Any other information – ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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