(33038) Insulin Continuous Self Administered SQ Pump

Please note bolded orders are preselected in Excellian.

Continuous Self-Administered Subcutaneous Insulin Pump
Diagnosis

Allergies

Metered Glucose (Single Select Section)

Metered Glucose - Scheduled QID, AC and HS and 2 AM.
1. And PRN if patient symptomatic or as requested by patient.
2. Bedside blood glucose meters are not reliable when glucose
greater than 500. Obtain serum glucose until glucose less
than 500.
3. Use facility glucose meter

Metered Glucose NPO 1. Leave insulin pump in place and infusing hourly basal rate
and check metered glucose every *** hours.
2. Bedside blood glucose meters are not reliable when glucose
greater than 500. Obtain serum glucose until glucose less
than 500.
3. Use facility glucose meter.
Nursing
Blood Glucose Greater Than Or Equal To 1. Have patient administer insulin via pump (amount to be
250 mg/dL determined by patient).
2. Recheck blood glucose in 1 hour.
3. If blood glucose is greater than or equal to 250, provide
subcutaneous insulin coverage as specified in orders, and
troubleshoot potential pump problems.
4. If problem unresolved and unless otherwise specified,
contact physician for subcutaneous insulin orders.
Insulin Pump Agreement - Patient to Sign Scan into medical record.
Continuous Self-Administered Subcutaneous
Insulin Pump Agreement
Insulin Pump Worksheet - Patient to Complete and Every shift. Verify and document the patient reported insulin
Nurse to Review and Document pump setting and dosing on eMAR. Scan worksheet into
medical record.

Provider Initials Page 1 of 3

Patient Name _________________________________________

Medical Record # _________________ Date of Birth _________

Date of Surgery/Admission ______________________________

PROVIDERS ORDERS 02/07/2012

 (33038) Insulin Continuous Self Administered SQ Pump
Please note bolded orders are preselected in Excellian.
Insulin Pump Use / Site - Assessment 1. Nurse to assess, every shift and with changes in clinical
condition, the patient's ability to meet criteria for operating
pump independently throughout hospitalization.
2. If patient status changes, call physician to change insulin
administration to subcutaneous or intravenous insulin.
3. Assess infusion site every shift for inflammation or
irritation.
Insulin Pump Maintenance - Patient to Perform All Including refilling of pump, tubing changes, site care, and
Maintenance rotation.
Medications Hypoglycemia
hypoglycemia protocol See Facility Specific Protocol.

Medications Insulin BASAL and BOLUS (Single Select Section)

Provider: Please document settings in progress note.
insulin aspart (NOVOLOG) BASAL and BOLUS CONTINUOUS, Subcutaneous.
Turn off insulin pump immediately if blood glucose is less than
[ ] and follow hypoglycemia protocol.
insulin lispro (HUMALOG) BASAL and BOLUS CONTINUOUS, Subcutaneous.
Turn off insulin pump immediately if blood glucose is less than
[ ] and follow hypoglycemia protocol.
insulin regular U-500 CONCENTRATED CONTINUOUS, Subcutaneous.
(HUMULIN) - BASAL and BOLUS Note: Medication is 5 times the concentration of other insulins
Turn off insulin pump immediately if blood glucose is less than
[ ] and follow hypoglycemia protocol.
Medications Insulin: Coverage for Off Pump > 1 hour or Suspected Pump Malfunction
(Consider adding basal insulin if off pump greater than 4 hours) (Single Select Section)
insulin aspart (NOVOLOG) EACH TIME PRN, Subcutaneous, Dose: [ ] units.
PRN x1 for each occurrence for suspected pump malfunction or
at time of pump removal if patient is to be off pump for over 1
hour.
insulin lispro (HUMALOG) EACH TIME PRN, Subcutaneous, Dose: [ ] units.
PRN x1 for each occurrence for suspected pump malfunction or
at time of pump removal if patient is to be off pump for over 1
hour.
Laboratory
Serum Glucose PRN, STAT. If bedside metered glucometer results are greater
than 500 ml/dl obtain serum glucose every hour until glucose
less than 500 ml/dl. Nurse to release order.
Hemoglobin A1c ONE TIME. Today.

Provider Initials Page 2 of 3

Patient Name _________________________________________

Medical Record # _________________ Date of Birth _________

Date of Surgery/Admission ______________________________

PROVIDERS ORDERS 02/07/2012

 (33038) Insulin Continuous Self Administered SQ Pump
Please note bolded orders are preselected in Excellian.
Consults It is suggested to Consult an Endocrinologist if available at your site.
Consult to Physician (Specify) Reason for consult: [ ].
Indicate the physician or group [ ].
Staff to call consulting office, add provider to the treatment
team, and update order with date and time of call.
Consult to Diabetes Nurse Educator ONE TIME. Today.

Additional Orders

________________________________ ________ __________

Provider Signature Date Time

Provider Initials Page 3 of 3

Patient Name _________________________________________

Medical Record # _________________ Date of Birth _________

Date of Surgery/Admission ______________________________

PROVIDERS ORDERS 02/07/2012