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
-
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 |
-
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 |
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