PHYSICIAN ORDERS

DO NOT USE ABBREVIATIONS:

U(unit), IU (international Unit),
Q.D.,QD, q.d., qd (daily), Q.O.D., QOD, I1I1I111111111111111
DTSBB44B
q.o.d., qod (every other day), trailing zero (X.Omg)
Lack of leading zero (.Xmg), MS, MS04 and MgS04
Abbreviations for drug names or slang names like banana
bag.

PHYSICIANS: TIME AND DATE ALL ORDERS

DATE TIME Write legibly and include physician ID# when signing

UNIT STAFF: FAX ALL ORDERS TO THE PHARMACY

ALLERGIES:

AM CBC w/diff, Chem 8,Mg,PO4,iCa,fasting lipid panel

Zofran 4mg IV q6 hrs prn nausea/vomiting
Ambien 5mg po qHS prn insomnia
Tylenol 650 mg po/pr q4 hrs prn headache or temp > 101
Vicodin 5/500 one tab po q4 hrs prn pain
Morphine sulfate 2 mg q2 hrs prn breakthrough pain / chest pain or
Morphine sulfate 4 mg q2 hrs prn breakthrough pain / chest pain

Multivitamin one po QD except on coumadin

Colace (docusate sodium) 100mg po BID prn constipation

All signatures must include credentials of author.

TARRANT COUNTY HOSPITAL DISTRICT Patient Label Here

Fort Worth, Texas 76104
PHYSICIAN ORDER
500440 Orig. 03/01 Rev. 01/07

JohnSons Press
 Order Set for DVT Prophylaxis

DIAGNOSIS: __________________________________________________________________________
DRUG SENSITIVITY: ___________________________________________________________________

Recommended dosing based on normal renal function (at least a Creatinine clearance of greater than 30ml/ min).

DVT Prophylaxis
Check One Category and select options:
1. ___________Low Risk
 Ambulate patient
ƒ Minor surgery (less than 30 minutes) or medical illness with no additional risk factors.
ƒ Less than 40 years of age.
ƒ Laparoscopy, hysteroscopy, D & C.
2. ___________Moderate Risk
 TED Hose or  SCD or  Lovenox 40 mg SQ daily or  Heparin 5000 units SQ BID
ƒ BMI over 25 but less than 30
ƒ Minor surgery with additional risk factors.
ƒ Minor surgery in patients aged 40 to 60 yrs with no additional risk factors
ƒ Major surgery in patients < 40 yrs with no additional risk factors
ƒ Minor medical illness with additional risk factors.
ƒ Hysterectomy, EXP Lap, Pelvic reconstruction.
ƒ Rheumatic, spinal, or neurological disorder causing immobility (bed confinement-confined to the bed more than 2/3 of
the day’s working hours) or paresis
ƒ Estrogen use or HRT, pregnancy, postpartum
ƒ Indwelling Central Venus Access Catheters-central lines
ƒ History of recent/prior major surgery within one month
3. ___________High Risk
( TED Hose or  SCD) AND ( Lovenox 40 mg SQ daily or  Heparin 5000 units SQ Q8 hours)
ƒ BMI greater than 30
ƒ Minor surgery in patients > 60 yrs or with additional risk factors
ƒ Major surgery in patients > 40 yrs or with additional risk factors
ƒ Medical patients admitted with MI, CHF, severe lung disease, chest infection or cancer
ƒ Age > 75 yrs
ƒ Personal history of DVT
ƒ Family History of DVT
ƒ Nephrotic Syndrome
ƒ Inflammatory Bowel Disease
ƒ Acute Severe Infection (Do not use Lovenox with spinal punctures)
4. ___________Very High Risk
5 TED Hose with SCD AND ( Lovenox 30 mg SQ bid or  Heparin 5000 units SQ Q8o)
ƒ BMI greater than 40
ƒ Stroke
ƒ Multiple trauma
ƒ Acute spinal cord injury
ƒ Hip, pelvis or leg fracture
ƒ Knee, hip arthroplasty
5. ___________High Risk Bleeding
 TED Hose  SCD
 Other _________________________________________________

_____/____/______ ________________
DATE TIME
_________________________________ _____________ ______________________________
Physician Last Name (print) Pager Physician Signature
TARRANT COUNTY HOSPITAL DISTRICT
Fort Worth, Texas 76104 Patient Label Here
Order Set for DVT Prophylaxis
70-0901 Orig 4/07
 Potassium (K+) Replacement
Orders for Adults

For use with serum Potassium level 3.7 or less

Enter orders that are initialed and have completed blanks. Physician must
initial orders desired. If blanks are not filled in, the order will not be
considered.
1. Initial one of the following orders:

____ a. a. If patient is on PO diet or tube feedings, administer 40 mEq potassium elixir .

b. Repeat stat serum potassium level 2 hours after any potassium is given.
c. If potassium level remains 3.7 or less, repeat dosing.
d. Do not give more than 200 mEq/24 hours.

or _____b. a. If the patient is not on a PO diet or tube feeding and has only peripheral IV access,
Infuse 40 mEq Potassium Chloride/100 ml sterile water over 4
hours by IV pump.
b. Repeat stat serum potassium level 2 hours after any potassium is given.
c. If potassium level remains 3.7 or less, repeat dosing.
d. Do not give more than 200 mEq/24 hours.

or _____c. a. If the patient is not on a PO diet or tube feeding, is on a cardiac monitor and has a
central line, infuse 40 mEq Potassium Chloride/100 ml sterile water over 2 hours by IV
pump.
b. Repeat stat serum potassium level 2 hours after any potassium is given.
c. If potassium level remains 3.7 or less, repeat dosing.
d. Do not give more than 400 mEq/24 hours.

2. If repeat Potassium level <3.0, follow protocol above and notify physician.

3. If the patient's potassium level is >5.3 mEq/L after replacement, write for discontinuation of these
potassium replacement orders, call the physician and complete the Medication Event Report.

______________________________ _____________________
Physician signature Date Time

______________________________ _____________________
Nurse signature Date Time

TARRANT COUNTY HOSPITAL DISTRICT

Fort Worth, Texas
Potassium Replacement Orders for Adults Patient Label
70-0703 MEDICAL RECORD FORM
Insulin Basal Bolus Guideline/Orders for Hyperglycemic Adults in the
Acute Care Setting **NOT FOR USE IN PREGNANT PATIENTS**

Enter orders that are checked or have completed blank. Provider must check orders desired. If blanks are not
filled in the order will be considered deleted. Do not hold any insulin without discussing with physician.
DATE: TIME:

1. Diet Orders

2. Hg Alc

3. Perform finger stick glucose checks at the following times:

• ac & hs - (if eating or on bolus tube feeding) OR
• Every 6 hours - 0600, 1200, 1800, 2400 (if NPO or on continuous tube feeding or any parenteral nutrition)
• Provider ordered specific times

4. BASAL INSULIN: Target Pre-meal blood glucose (non-critical patients): 90-150 mg/dL (180 Max Random)
SUBCUTANEOUS INSULIN:
Basal Insulin (Choose One):

Insulin Glargine (Lantus ®) Units subcutaneously daily:

At bedtime At:
or
NPH Insulin Units subcutaneously at 0900
Units subcutaneously at 2100
or
70/30 Insulin Units subcutaneously before breakfast
Units subcutaneously before dinner
or
Other Type Units subcutaneously at

5. PRANDIAL (MEAL TIME): Target Pre-meal blood glucose : 80-150 mg/dL (180 Max Random)
Hold if patient is NPO or not eating more than 50% of the meal.
Insulin Aspart (NovoLog ® )
Units subcutaneously at start of breakfast
Units subcutaneously at start of lunch
Units subcutaneously at start of dinner
6. Supplemental Subcutaneous Insulin Orders for Adults
Please check specific dosing order below

Glucose level
Use: (mg/dL)
Insulin Type: Aspart (Novolog) OR Regular Insulin

Standard Correctional Customized by

Scale Provider (DFS-100) ÷ 10 = # Units to be given

< 60 Follow hypoglycemic protocol # 8 below if ordered by provider. If not ordered, notify provider
60-125 0 Coverage
126-150 2 units
151-175 4 units
176-200 6 units
201-225 8 units
226-250 10 units
251-275 12 units
276-300 14 units
301-325 16 units
326-350 18 units
> 350 20 units and call provider
Place Patient Label Below
TARRANT COUNTY HOSPITAL DISTRICT
Fort Worth, Texas 76104
Basal Bolus Insulin Guideline/Orders for Hyperglycemic Adults
in the Acute Care Setting
500119 Orig. 01//08 Page 1 of 4
 INPATIENT MANAGEMENT OF THE PATIENT WITH DIABETES

Step 1. Discontinue oral antidiabetic agents if using this insulin protocol

Step 2: Calculate the estimated total daily dose (TDD) of insulin patient may require;consider
adjusting this up or down based on patient's home regimen and the control they have on it:
• Standard (pt w/normal body habitus): 0.4 units/kg/day
• If pt very lean, on hemodialysis or very sensitive to insulin (hypoglycemia risk factors): 0.3 units/kg/day
• If pt overweight: 0. 5 units/kg/day
• If pt obese, on steroids, or know to be insulin-resistant: 0.6 units/kg/day (or more)
• If transitioning off of an iv insulin infusion, take the average hourly rate over the last 6 hours and
multiply by 20:
-if pt was receiving nutrition (tube feeds, TPN, or eating), this is the estimated TDD
-if insignificant nutrition during the last 6 hours, double the number to determine estimated TDD

Step 3: Determine the distribution of the TDD calculated above based on nutrition regimen.

If pt eating or receiving bolus tube
feeds:
Check glucose qac and qhs
Basal insulin: Glargine -- 0.5 x TDD,
dosed once a day.
Nutritional insulin: Aspart insulin -- 0.5 x
TDD, in 3 divided doses with first bite of
each meal (decrease the dose if
nutritional intake is < 100%)
Correction insulin, in addition to nutritional
insulin: Use default values (adjust if
necessary)
If pt receiving continuous infusions
of tube feeds or parenteral nutrition:
Check glucose q6h
Basal insulin: Glargine -- 0.4 x TDD,
dosed once a day
Nutritional insulin: regular insulin --
0.6 x TDD, in 4 divided doses
(decrease the dose if nutritional
intake is less than 100%)
Correction insulin: use default values
(adjust up or down if necessary)
If pt NPO or nearly NPO taking
clear liquids only):
Check glucose q6h
Start low-dose dextrose infusion
(D5 1/2 NS at 75mL/hr)
Basal insulin: Glargine -- 0.5 x TDD,
dosed once a day
Nutritional insulin: none
(discontinue previous)
Correction insulin: consider
temporary use of regular insulin
correction dose scale

Step 4: Re-evaluate & adjust the TDD daily based on the glycemic control of the
previous 24h:

• If any glucose > 180, and no threat of hypoglycemia, increase TDD by 10-20%
• If glucose consistently > 180 - 200, increase TDD by 30%
• If any episodes hypoglycemia (FS < 70), start D5 1/2 NS at 75mL/hr and
decrease TDD by 20%

Place Patient Label Below

Form # 500119p2 01/2008

Basal Bolus Insulin Guideline/Orders for Hyperglycemic Adults
in the Acute Care Setting

7. Perform finger stick glucose PRN to evaluate hypoglycemic symptoms (shaky, sweaty, altered state of
consciousness, patient reports feeling hypoglycemic).

8. If glucose < 60, use hypoglycemic protocol, the ''Routine 15'', below to reach glucose level >100.

"Routine 15" for the Treatment of Hypoglycemia (Glucose <60)

If the patient CAN take PO or by NGT or G-tube If the patient CANNOT take PO or by NGT or
G-tube
Treat with 15 grams of simple carbohydrates: Give 25 ml (12.5 gm) D50 IV push.
•4-6 ounces of non-sweetened fruit juice (No added sugar)
OR
• 4-6 ounces of regular (non-diet) soda (Coke, Pepsi, etc.)
(No added sugar)
Recheck blood glucose every 15 minutes. Recheck blood glucose every 15 minutes.
Continue to treat with 15 grams of simple carbohydrates, Treat with 25 ml D50 IV after each blood glucose until
checking blood glucose every 15 minutes, until blood glucose blood glucose is > 100.
is >100.

9. Document finger stick glucose results, insulin dose administered, site, time, and initials on medical record.

10. Notify provider:

Do not hold any insulin without discussing with physician
If finger stick glucose <60 or >300 on 3 consecutive measurements.
If TPN or tube feedings are to be started or held
If patient is to be made NPO
If patient started on steroids or steroid (i. e. methylprednisolone, prednisone, hydrocortisone) dose changes

11. Consult Diabetic Educator.

12. Consult Nutritionist

Provider Signature Date Time

Nurse Signature & Credentials Date Time

Place Patient Label Below

TARRANT COUNTY HOSPITAL DISTRICT

Fort Worth, Texas 76104
Basal Bolus Insulin Guideline/Orders for Hyperglycemic
Adults in the Acute Care Setting
500119 Orig. 01/08 Page 3 of 4
INPATIENT MANAGEMENT OF THE PATIENT WITH
DIABETES
Insulin Terminology
Basal insulin: long-acting insulin required in all Type I (and
most Type 2) patients to maintain euglycemia, even when
NPO (hepatic gluconeogenesis can serve as a continuous
source of blood glucose).
Nutritional insulin: scheduled short-acting insulin given just
before a meal, in anticipation of the glycemic spike that
occurs due to carbohydrate ingestion (this dose is given
even when the blood sugar is in the normal range). Also
refers to scheduled insulin given to cover the carbohydrate
load from tube feeds or parenteral nutrition.
Correction insulin: short-acting insulin that is given in addition to
scheduled nutritional insulin (or given at other times of the day) as a
response to preexisting high blood glucose levels. If correction
insulin dose is required, the patient would likely benefit from an
increase in the TDD the following day.
1. Target blood glucose range
Optimal/tightest range is 80 - 150 in patients whose degree of
control is unknown; a less stringent goal of 100 - 180 may be
appropriate in patients w/end-stage disease or in whom
hypoglycemia is a significant concern;
2. Stopping oral medications
The use of this insulin protocol in addition to oral anti diabetic
medicines may lead to hypoglycemia or other complications, and
we therefore recommend that they not be combined. In addition,
metformin should be discontinued in patients with a serum
creatinine > 1. 5 or in whom there is a risk of nephrotoxicity;
sulfonylureas should not be used in the NPO patient; and
glitazones should be discontinued in patients with CHF
exacerbations or volume overload. Adjustments in these oral
medications take too long to be effective in the hospital.
3. For patients eating meals or receiving bolus tube feeds
Peakless long acting insulin (glargine) is the most physiologic basal
insulin and is recommended in these patients. Rapid acting analog
(RAA) insulins are more appropriate than regular insulin for
nutritional doses due to its shorter, more predictable half-life and
correspondence with inpatient meal times. We highly recommend
using RAA insulin in place of regular insulin in this setting. Adjust
dose down if nutritional intake is < 100%.
Form#:500119p4 01/2008
4. For patient's receiving continuous enteral or
parenteral nutrition
A. Consider using an insulin infusion for optimal control in
this setting. Keep insulin separate from PN until a stable
dose is reached.
B. Glargine insulin is the most physiologic basal insulin and
is recommended in these patients, as it has no serum
spikes and can be continued without dose adjustment when
nutrition is suspended. Regular insulin is recommended as
the nutritional insulin rather than RAA insulin in this setting
because of its longer half-life. It can be dosed q6h instead
of q4h. Adjust the dose down if nutritional intake is < 100%.
C. If the tube feeds or parenteral nutrition are held or
interrupted, the nutritional regular insulin doses
should/will also be held.
5. For the NPO patient
A. NPO patients have fewer episodes of hypoglycemia
when given a low-dose dextrose infusion along with their
basal insulin.
B. Glargine is recommended over NPH as the basal insulin
in this setting due to its longer half-life and lack of serum
spike, which mimic physiologic basal insulin secretion.
Nutritional or scheduled short-acting insulin should not be
given to patients without a nutritional source.
6. Special Situations
A. If patient is eating or receiving tube feeds, but intake is
inconsistent or unreliable (''grazing''), continue basal
insulin but decrease or hold the nutritional dose.
B. If patient is receiving nocturnal tube feeds, consider
adding additional NPH or regular insulin when feeds are
started to cover this time period.
C. If transitioning off of iv insulin infusion, see Step 2 of
chart.
7. Discharge Planning
A. Patient receives diabetes education.
B. Take patient's knowledge base, insurance status,
Hb A1C, expected change in medication, and severity of
illness into account when determining discharge
medications/home regimen.
Place Patient Label Below