Insulin Adjustment Module

March 2009
Saskatchewan Insulin Adjustment Module Page 2

March, 2009
March, 2009
TABLE OF CONENTS
Introduction ........................................................................................................... 5
Development Background .................................................................................... 5
Purpose .............................................................................................................. 5
Developing the Policies, Procedures and Learning Package ..................................... 6
The Outcome ...................................................................................................... 6
Revisions for 2009 ............................................................................................... 7
How To Use the Template.................................................................................... 8
Resource Personnel ........................................................................................... 11
Policy For Transfer Of Medical Function For Basic Insulin Dose Adjustment (IDA)....... 12
Purpose ............................................................................................................ 12
Personnel ......................................................................................................... 12
Policies ............................................................................................................. 12
Procedures........................................................................................................ 15
Policy Appendix .................................................................................................... 16

Appendix A - Advanced Certification................................................................... 16
Appendix B - Sample Physician/Registered Nurse Signature Sheet ......................... 16
Appendix C - Sample Competency Performance Checklist...................................... 17
Competency Performance Checklist.................................................................... 18
Appendix D – Detailed Competencies For Self Assessment .................................... 19
Appendix E - Sample Progress Report ................................................................ 28
Appendix F - Commonly Asked Questions and Answers......................................... 29
Learning About And Procedures For Insulin Dose Adjustment ................................... 33

Endogenous Insulin ........................................................................................... 33
Exogenous Insulin ............................................................................................. 35
Insulin Approved For Use in Canada.................................................................... 35
Potential Adverse Effects of Subcutaneous Insulin Use.......................................... 36
Drugs That May Inhibit or Potentiate Insulin Action .............................................. 36
Insulin Requirements ......................................................................................... 37
Practical Aspects Of Insulin Management................................................................ 38

Variables Influencing Glycemic Control [Procedure] ............................................. 38
Useful Therapeutic Approaches Useful in The Prevention and Treatment of
Hypoglycemia [Procedure] ................................................................................. 40
Causes Of Fasting Hyperglycemia ....................................................................... 41
Switching to a Long-Acting Basal Insulin Analogue [Procedure] ............................. 43
March, 2009
Insulin Regimens And Adjustments ........................................................................ 45

Insulin Regimens............................................................................................... 45
Carbohydrate Counting ...................................................................................... 47
Insulin Dose Adjustments (IDA) [Procedure]........................................................ 48
Pattern Management ......................................................................................... 50
Variable Insulin Dose Adjustments ...................................................................... 51
Use of Correction Factors ................................................................................... 51
Teaching Procedure For Self-Adjustment of Insulin .................................................. 60
Practice Cases ...................................................................................................... 63
Answers to Practice Cases ..................................................................................... 81
References ........................................................................................................... 95
Additional Resources ............................................................................................. 97

Client Handouts on Insulin/Insulin Adjustment ..................................................... 97
Diabetes and Pregnancy..................................................................................... 97
Acknowledgements ............................................................................................... 98
March, 2009
ORGANIZATION OF THE SASKATCHEWAN INSULIN DOSE

ADJUSTMENT (IDA) MODULE
The Saskatchewan Insulin Dose Adjustment (IDA) Module was created in 2002. With
changes in care and practice and to align with current Clinical Practice Guidelines,
revisions have been made in 2005 and 2009.
For ease of use, the 2009 Module is divided into three separate documents:
1. Introduction and Policy Template
2. Learning Module and Procedures
3. Practice Case and Answers
INTRODUCTION
Recent advances in diabetes care have enabled clients using insulin to attain near normal blood
glucose control by means of self blood glucose monitoring (SBGM) and self-adjustment of
insulin dosage. This level of self-care is encouraged because the Diabetes Control and
Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have
demonstrated that improved glucose control reduces the risk of long-term complications of
diabetes. Finally, the ability to adjust insulin dosages enables the person with diabetes to enjoy
a more varied and flexible lifestyle while maintaining acceptable blood glucose control.
It is recognized that clients require support while learning to self-adjust their insulin dosage.
This support may require recommendations for appropriate IDA 1 .
DEVELOPMENT BACKGROUND
In April 2000 the Saskatchewan Advisory Committee on Diabetes presented its report, Diabetes
2000, to the Chief Medical Health Officer and the Deputy Minister of Health.
To action Goal 5, Objective 5.4 a working group was formed in 2000. The membership of the
group was voluntary and consisted of Certified Diabetes Educators from northern and southern
Saskatchewan, representing both urban and rural diabetes education programs. The Canadian
Diabetes Association facilitated the process. A member of the Saskatchewan Pharmaceutical
Association audited the process in 2001.
PURPOSE
The Transfer of Medical Function policy and procedures template was developed to facilitate
and ensure
• development and continuing competency for the Registered Nurse who meets the
qualifications to adjust insulin
• promotion of self-care management and/or enhancing quality of life for people with diabetes
• achievement of optimal blood glucose control
1
Many professionals have the capacity to adjust insulin dosages. At present in Saskatchewan only the
scope of practice of Registered Nurses permits this type of medication adjustment by Transfer of
Medical Function.
March, 2009
DEVELOPING THE POLICIES, PROCEDURES AND LEARNING PACKAGE

In the preparation of this material consideration was given to several variables:
• needs and safety of clients who will benefit from the Registered Nurse practicing under this
Transfer of Medical Function
• scope of practice of Registered Nurses
• experience needed to perform the procedures
• working relationships needed between the Registered Nurse practicing with a delegated
medical function and the physician(s)
• applicability of a template for Transfer of Function to Health Regions 2 in Saskatchewan
• access (or not) by the Registered Nurse to lab data and medical history of clients
The following steps were completed in the preparation of the original provincial template
(2001):
1. Review of the Saskatchewan Registered Nurses’ Association (SRNA) Registered
Nurse Scope of Practice documents: Special Nursing Procedures and Nursing
Procedures by Transfer of Medical Functions (1993) and Guidelines for Nurses
Prescribing and/or Distributing Drugs by Transfer of Function (1997).
2. Review of existing policies and procedures from Saskatchewan and other provinces,
and review of selected literature and web sites.
3. Development of draft policies and procedures.
4. Review of policies and procedures by:
• Membership of the Diabetes Educator Section in Saskatchewan
• Saskatchewan Registered Nurses’ Association
• Dr. M. Boctor, Endocrinologist and Professor of Medicine, University of
Saskatchewan.
THE OUTCOME
As a result of above, the Working Group made decisions about both the policies and the
procedures. These decisions have been reviewed and affirmed for the 2009 edition of the
template. A few of the most significant decisions are outlined below:
Experience: IDA requires clinical experience beyond that of most Registered Nurses.
Particularly, IDA requires that the Registered Nurse already have a sound foundation in
the basics as a diabetes educator. In the 2009 edition of the Module more detailed
competencies have been provided (Appendix E).
The policy template continues to suggest two alternatives to equate experience: 2000
hours of practice as a diabetes educator or national certification as a diabetes educator
(CDE). We recognize that CDECB 3 has reduced the qualifying practice hours to write the
certification exam from 2000 to 800, but feel for competence and confidence in
implementation of a Transfer of Function, more clinical practice and experience are
needed. Therefore, we have retained our original recommendation of CDE status or 2000
hours of practice as a diabetes educator. Health Regions may choose to adjust the level
of required experience for their own policy.
2
Health Region will be used throughout the document. The policy and procedures can also be applied by
other health care organizations such as Tribal Councils.
3
Certified Diabetes Educator Certification Board www.cdecb.ca
March, 2009
Basic Competencies: For the template to apply in most/all areas of the province, it was
decided to define both basic and advanced competencies. This package only applies to
the basic competencies. Not all diabetes educators will have sufficient exposure to or
experience with some of the specialty areas such as pediatrics, insulin pumps or
pregnancy to make advanced competencies an option.
Region Decisions A critical aspect of the implementation process is the review and, as
needed, customizing of the policy and procedures, by each Health Region. The Transfer
of Medical Function is a Region-specific process. There are several options for the actual
process. Registered Nurses and physicians in each Region must agree and be
comfortable with the parameters that are Region specific.
The policy, as currently written, applies only for clients whom the Registered Nurse assesses,
teaches and reviews directly. The Transfer does not include the Registered Nurse doing IDA for
clients of other health care providers such as Home Care Nurses, Dietitians, Pharmacists etc.
If an organization wishes to extend the Transfer so that the Registered Nurse provides guidance
to specific health care professionals then an additional policy will be needed.
REVISIONS FOR 2009

The template was revised in 2009 to be congruent with the 2008 Clinical Practice Guidelines 4
and current diabetes care practices.
The definition of “basic” IDA has been modified to address issues encountered by Registered
Nurses who already practice under this delegated medical function.
In the policy, “basic” continues to refer to IDA for adults with either type 1 or type 2 diabetes.
The Registered Nurse, who has met the basic competencies, will consider IDA for:
• routine situations when the person with diabetes is in the community setting and
well.
• any insulin schedule including intensive therapy/multiple injections, carbohydrate
counting and development of carbohydrate to insulin ratios.
• management of insulin for exercise.
In 2009 the module will contain the option for RNs to add the IDA for clients who must fast for
outpatient procedures or tests to their Transfer of Function 5 . This will be an optional part of the
Transfer and RNs should only include this in their Transfer if they have sufficient experience and
opportunity to use this aspect of the Transfer. To implement this aspect of the Transfer, the
usual process for adding and implementing a change to the Health Region or organization’s
policy would be followed.
4
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes
Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada.
Can J. Diabetes. 2008;32(suppl 1):S1-S201.
5
This section of the Module will be available in fall, 2009. Using quality improvement methods, the
section is being reviewed with different client situations.
March, 2009
Situations for IDA considered “advanced” and thus not covered by this module include:
• children with diabetes
• insulin pumps
• sick day management
• pregnancy in women with pre-existing diabetes (type 1 or type 2)
• gestational diabetes
• special circumstances (travel, shift work)
HOW TO USE THE TEMPLATE

The purpose of the template is to provide guidance for Health Regions and other health care
organizations to have the Registered Nurse, who meets the required competencies, adjust
insulin doses.
The following steps are helpful in applying the template:
1. Review the full module

The module includes the policy template, the procedure module and the practice cases. As
these is a guide, you may have to customize either the policy and/or the procedures to
suit the particular organizational policies and/or client needs.
For example, using insulin to carbohydrate ratios and/or correction factors for intensive IDA
may not currently be common practice by physicians in the area and the Registered Nurse
may not be exposed frequently to this as part of usual IDA. An organization may decide to
exclude this component of the module from the Transfer of Medical Function.
2. Write the policy as it applies to the organization. If you are not familiar with the policies and
procedures for a Transfer of Function within the organization, consult within the Nursing
and/or Medical Departments for advice. Most health organizations will have guidelines for
obtaining the Transfer of Function through a Medical Advisory Committee or a similar
process.
3. Implement a process for the Registered Nurse to learn about IDA. The Registered Nurse
must demonstrate competency to perform IDA. To learn more about IDA a Registered
Nurse may do all or some of the following:
a. The procedures are written to provide guidelines and to serve as a study guide. The
Registered Nurse will need to read several of the references as well as the
information in the procedures. In some cases, as the references are very detailed,
only a summary is provided within the procedures section. To have the appropriate
degree of understanding and skill necessary to achieve the competencies IDA, more
detailed reading will be necessary.
b. Some Registered Nurses may find it beneficial to take the Advanced Diabetes
Education Certificate program at SIAST 6 . Or, there is also the option of taking a
single module through this program such as the one on medications. Obtaining the
6
For information about the SIAST diabetes program see
http://programs.siast.sk.ca/vc/cont_ed_programs_courses/healthsciences/advanceddiabetes.htm
Cited 23 December 2008.
March, 2009
SIAST Advanced Diabetes Education Certificate does not mean the Registered Nurse
is able to adjust insulin. The requirements of The Transfer of Medical Function must
be completed.
c. Complete the practice cases. The answers are found at the end of module. If you
are unsure about an area talk with Registered Nurses who are already practicing
with a delegated medical function for IDA and/or your local physicians.
d. Attend a provincial workshop on IDA when it is available.
Implement a process for the Registered Nurse to demonstrate competency in IDA

There are two steps to demonstrate competency as part of the provincial template:
1. Write and successfully pass the provincial exam. The exam can be obtained from
Primary Health Services Branch, Saskatchewan Health and is issued by the Branch and
written in a supervised situation. The completed exam is returned to the Branch, marked
and the results are sent to the candidate. A pass mark is 80%. Successful candidates
will receive written documentation to use as part of their Transfer process.
2. Complete physician-supervised cases. The successful delegation of a medical function

requires a good working relationship between the Registered Nurse and the physician(s)
who participates. The Registered Nurse and physician(s) need to feel confident that
clients with diabetes will receive optimal diabetes management.
Therefore, the provincial template suggests that the Registered Nurse be supervised by a
physician with a minimum of 3 client cases before obtaining the Transfer of Function.
Ideally the 3 cases will represent a diversity of client situations which are likely to be
encountered in practice. Through this practice supervision, the physician will be able to
ensure the Registered Nurse demonstrates the required competencies.
The supervising physician may be an endocrinologist, an internist or a family physician with

an interest in diabetes management and a willingness to provide the supervision.
Sign and Implement the Transfer of Function. A sample signature form for Transfer of Medical
Function is provided in the policy template.
Each organization will need to decide on the best implementation method to meet the needs of
the Registered Nurse, the physician and the person with diabetes. In each situation below, the
policy template was adapted to reflect the method chosen.
Examples of implementation include:

• The Diabetes Program has a Medical Director who provides the case supervision for the
Registered Nurse. The Director signs the competency sheet and the Transfer of Medical
Function is authorized for all physicians in the Region. Physicians have the choice to “opt
out” of the Transfer of Medical Function and may state that they do not wish to have the
Registered Nurse provide the IDA service for their clients.
• The Diabetes Program may not have a Medical Director. A physician with an interest in
diabetes management is asked to provide the supervision for the Registered Nurse. This
March, 2009
physician signs the competency sheet to complete the Transfer of Function. The
Registered Nurse then approaches individual physicians or physician group practices,
explains the policy and procedures and requests their signatures for participation in the
IDA service.
Establish a policy for annual demonstration of competency. The competency performance

checklist should be signed annually to ensure continuing competency. Ideally, the signing
physician will be familiar with the practice of the Registered Nurse in IDA.
There are several options to ensure continuing competency:

• A physician who is very familiar with the Registered Nurse’s practice can complete the
performance checklist based on ongoing and regular review over the year.
• A physician could complete a chart audit of 3-5 recent cases where the Registered Nurse
was adjusting insulin.
• A physician could provide practice supervision similar to the initial competency assessment.
March, 2009
RESOURCE PERSONNEL
The following are Registered Nurses and/or Managers, who have experience with the Transfer
of Medical Function and are willing to talk with others who are in the process of developing this
delegation model.
NAME HEALTH REGION TELEPHONE EMAIL
Karen Butler Regina Qu’Appelle 766-3777 Karen.Butler@rqhealth.ca
Betty Deschamps Kelsey Trail 873-3760
Bev Kernohan Heartland 948-3323 bev.kernohan@hrha.sk.ca
Nola Kornder Saskatoon 655-2147 nola.kornder@sasaktoonhealthregion.ca
Carlene Schmaltz Kelsey Trail 862-7251 CSchmaltz.kthr@shin.sk.ca
Judi Whiting Saskatoon 655-7406 judi.whiting@saskatoonhealthregion.ca
For more information about the provincial template or to apply for the IDA
exam, contact:
Leanne Neufeld
Primary Health Services Branch
Saskatchewan Health Ph: 787-0886
3475 Albert Street Fax: 787-0890
Regina SK S4S 6X6 email: lneufeld@health.gov.sk.ca
March, 2009
POLICY FOR TRANSFER OF MEDICAL FUNCTION FOR

BASIC INSULIN DOSE ADJUSTMENT (IDA)
PURPOSE
A Registered Nurse, who has demonstrated competence to adjust insulin doses, may make
changes to insulin doses and assist clients to make their own changes. Insulin doses will be
adjusted for the purposes of optimizing blood glucose control, promoting self-care management
and/or enhancing safety and quality of life.
PERSONNEL
A Registered Nurse who meets the criteria and demonstrates competency in IDA is eligible to
obtain the Transfer of Medical Function.
POLICIES
Adjustment of insulin dosages may be done by a Registered Nurse who demonstrates
competency and completes all the requirements for the Transfer of Function. Extensive
experience in educating clients in diabetes self-care and demonstrated competence for
adjusting insulin dosages are prerequisites. See Appendix E for a detailed overview of RN
competencies for a Transfer of Function.
Transfer of Function may be granted for Nurses to provide BASIC insulin dose adjustment. With
additional training and experience, appropriate Registered Nurses may obtain an ADVANCED
Transfer of Function. This policy defines both basic and advanced Transfer of Function, but
applies only to the basic process.
Experience
To obtain the Transfer of Function, a Registered Nurse must have a minimum of two years of
practice in the profession. In addition, the Registered Nurse must have at least 2000 hours of
work time in diabetes education or hold national certification as a diabetes educator (CDE).
To be prepared to write the provincial exam, obtain the Transfer of Function and implement it,
Registered Nurses need to master several competencies. These are detailed in Appendix E. The
major competency areas are:
• Works within professional and organization standards for Insulin Dose Adjustment
(IDA) by Registered Nurses.
• Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA.
• Understands meal planning principles and carbohydrate counting in relation to
insulin and uses these in assessment, education and recommendations for IDA.
• Assesses blood glucose and appropriately interprets information to make changes to
insulin doses(s) or other components of the diabetes treatment plan.
• Understands various insulin schedules and principles for IDA for conventional and
intensive therapy.
• Assesses and addresses diabetes self-care learning needs and readiness to learn
IDA.
• Communicates with the patient/client and other team members toward the goal of
appropriate IDA.
March, 2009
Basic Transfer of Medical Function 7

The basic delegation of medical function will apply to IDA for adults, with either type 1 or type
2 diabetes, for:
• routine situations when the person with diabetes is in the community setting and well
• any insulin schedule including intensive therapy/multiple injections
• management of insulin for exercise.
• IDA for tests and procedures (to be added June, 2009)
Maintenance of Transfer of Function

Maintenance of the Transfer will be completed annually by the Registered Nurse.
Physician-Registered Nurse Collaboration

• The Physician retains responsibility for the insulin schedule that is ultimately selected –
initial dose (amount, type of insulin, timing) and any subsequent adjustments to insulin type
and/or timing; for example, moving an insulin dose from supper to bedtime or switching
from a pre-mixed to short and intermediate-acting insulins.
• The Registered Nurse, Physician and client will collaborate to establish the appropriateness
for both Registered Nurse involvement and client participation in IDA.
• The Registered Nurse and Physician will collaborate on a regular basis to ensure that the
client is receiving optimal insulin doses.
Conditions – Registered Nurses and Physicians

This procedure will only be considered for specific clients referred by a Physician who is willing
to be available to provide ongoing advice and support to the Registered Nurse. Both parties
must mutually agree to this.
Neither a Physician nor a Registered Nurse will be obliged to participate in this particular
delegation of a medical function unless there is mutual agreement.
A Registered Nurse and Physician(s) who wish to use this Transfer of Medical Function will sign
an agreement to indicate their mutual willingness to participate in all the responsibilities of the
delegation of the medical function. 8
When a medical function has been delegated and accepted by Nursing, the Registered Nurse is
responsible and accountable for competent performance.
The Transfer of Medical Function is applied only with clients whom the Registered Nurse
assesses, teaches and reviews directly. The delegation of this medical function does not include
the Registered Nurse doing IDA for other health care providers such as Home Care Nurses,
Dietitians, Pharmacists etc.
Insulin doses will be changed according to the IDA guidelines. There will be appropriate
resources to facilitate client learning.
The Registered Nurse will continuously assess a client’s metabolic status and refer a client to
their physician in all situations that are beyond their scope of practice, and/or situations where
7
Advanced Transfer of Function is not covered by this policy. See Policy Appendix for skills covered in
Advanced Transfer. Health Regions have the option of defining ‘basic’ to suit their needs.
8
A sample form is provided in the Policy Appendix B. The Registered Nurse and Physician signatures
mean the Transfer applies to all the appropriate clients as designated in the Health Region Policy
March, 2009
the clients’ metabolic control is deteriorating despite adjustments made to the insulin or other
components of the treatment plan.
If the client is seen for periodic follow-up or returns to the Diabetes Education Program, the
Registered Nurse may continue to guide the client who requires ongoing interventions to
maintain blood glucose control with agreed periodic contact with the physician of record.
If the client does not demonstrate the potential for, or interest in safe self-adjustment of
insulin, the attending Physician will resume responsibility for the client’s insulin dosage.
It is understood by all parties that the Registered Nurse will only be available to support clients
in IDA during regular working hours [insert Region schedule].
Conditions – Clients
The policy applies to clients who are living independently in the community and do not reside in
an acute care setting or long term care facility.
To receive education about IDA and/or support in actually making the adjustments, clients will
meet the following conditions:
• Able and willing to frequently monitor blood glucose, record and report the results.
• Able and willing to contact the Registered Nurse on a regular basis for assistance and
further education regarding IDA.
• Not acutely or severely ill (examples: immediately post-op, end stage renal disease).
• Demonstrate an interest in improving control and having regular follow-up.
• Has had a consultation with a Dietitian and has a suitable nutrition strategy to support IDA.
Client Assessment
The process of teaching clients to adjust insulin will include the following:
• Initial assessment of the client’s learning needs, style, barriers and resources.
• Provision of self-education materials appropriate to the individual needs of the client.
• Confirmation of the accuracy of the client’s self blood glucose monitoring results by means
of an annual laboratory to meter comparison and periodic observation of the client’s
technique.
• Confirmation that the client is aware of the symptoms of hypoglycemia and demonstrates
an understanding of the appropriate treatment and prevention of hypoglycemia.
• Confirmation that the client is aware of insulin action (onset, peak, duration).
• Client has the knowledge and skill level to either follow a diet which is consistent in
carbohydrate intake or can accurately determine his carbohydrate intake of foods.
Precautions
There is a potential for hypoglycemia or hyperglycemia when adjusting insulin doses.
Documentation and Reporting

A detailed note will be written for each client’s outpatient visit. This will contain relevant data,
assessment and plan including any changes in insulin dose. A copy of the note will be sent to
the client’s physician. 9
If the client’s visits are frequent and close together, as a minimum, a summary letter will be
written monthly and sent to the client’s physician.
9
See sample form in Appendix D
March, 2009
PROCEDURES
Transfer of Medical Function

The following diagram outlines the process to achieve a Transfer of Medical Function.
Health Region reviews provincial guidelines/template +

revises as needed
Region Medical Advisory Committee approves Transfer
Registered Nurse who meets criteria
Reviews policy + procedures
Attends provincial course 10 (if available)

AND/OR
Completes self study program
Writes exam and submits to Primary Health Services Branch, Saskatchewan Health
After successful completion of the exam, the Registered Nurse

is supervised by local Physician(s) for a minimum of
3 appropriate client cases
Physician(s) signs documentation of Registered Nurse’s

competency for IDA according to
the Health Region’s policy and Transfer is completed
Health Region’s policy determines procedure for implementation

within Region with some/all physicians
Procedures for Adjusting Insulin Doses

A Registered Nurse practicing a delegated medical function to adjust insulin doses will follow
the procedures outlined in the Saskatchewan Insulin Dose Adjustment Module. If the
procedures are amended by the Health Region, changes will be documented in the Module.
10
Registered Nurses are encouraged to invite a physician to attend with them
March, 2009
POLICY APPENDIX
APPENDIX A - Advanced Certification

Advanced certification is NOT included in this provincial template.
Advanced certification may include some or all of the following specialty areas of IDA. Inclusion
of these areas in an individual Registered Nurse’s certification will depend on the experience of
the Registered Nurse with the IDA specialty and the frequency that s/he will perform the dose
adjustments. The advanced certification areas include:
a. Children with diabetes
b. Insulin pumps
c. Sick day management
d. Pregnancy in women with pre-existing diabetes (Type 1 or Type 2)
e. Gestational diabetes
f. Special circumstances (travel, shift work)
APPENDIX B - SAMPLE PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET

The following is a SAMPLE sheet which may be used within a Health Region for the Registered
Nurse and Physician(s) to sign once the Registered Nurse has successfully demonstrated the
competencies for IDA.
March, 2009
_____________ HEALTH REGION
PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET
TRANSFER OF FUNCTION
INSULIN DOSE ADJUSTMENT
____________________ has achieved competency to adjust insulin for clients with

[Name of Registered Nurse]
diabetes according to policy _______. We have read the Health Region policy for insulin dose
adjustment and agree to the conditions outlined in the policy.
Signed: _________________________ Physician
Signed: _________________________ Diabetes Nurse Educator
Date: ___________________
APPENDIX C - SAMPLE COMPETENCY PERFORMANCE CHECKLIST

On the following page is a sample sheet to be used within a Health Region for the Registered
Nurse and Physician(s) to sign for annual Transfer of Function of the Registered Nurse for IDA.
March, 2009
COMPETENCY PERFORMANCE CHECKLIST

Registered Nurse: __________________________
PERFORMANCE CRITERIA NOT

OBSERVED OBSERVED COMMENTS
1 Identifies variables in
diabetes management
which may be appropriate
alternatives to IDA eg.
diet, exercise, injection
sites
2 Insulin increase is based
on a pattern of blood
glucose readings above
target.
3 Insulin decrease is based

on a pattern of blood
glucose readings below
target, unexplained
hypoglycemia or change
in routine which would
necessitate an insulin
reduction
4 Insulin to carbohydrate
ratios are created
according to guidelines
5 Insulin correction factors

or insulin grids are
created according to
guidelines
4 Physician is consulted for

non-standard situations
and/or failure of IDA to
improve control.
6 Documentation is
completed according to
established standards.
___ Acceptable competency ___ Competency NOT acceptable
Physician Signature: __________________________ Date: _________________________

March, 2009
APPENDIX D – DETAILED COMPETENCIES FOR SELF ASSESSMENT
The following resources have been adapted, with permission, from tools in development by the
British Columbia Registered Nurses Insulin Dose Adjustment Working Group in preparation for
Insulin Dose Adjustment (IDA) by Registered Nurses in BC.
What is beyond the scope of practice of the Registered Nurse?

Once an RN has obtained a basic Transfer of Function for Insulin Dose Adjustment (IDA) in
Saskatchewan, there still may be quandaries about the extent of the scope of practice. To
provide clarification, the following has been adapted from the BC IDA document.
IDA is beyond the scope of nursing practice in the following situations:
Insulin initiation. A physician order is required for initiation of insulin doses in all
insulin–naïve people with diabetes.
Intravenous (IV) insulin
During Diabetic Ketoacidosis (DKA)
Surgery (pre, intra or post operatively)
During labor & delivery
During inpatient hospitalization. Physicians are responsible for insulin orders and
IDA for inpatients.
In any situation which exceeds the RN’s level of competency.
If a physician is unable to provide consultation for IDA as required (see
consultation list below) and / or if a physician or alternate RN is not available to
do IDA in the RN’s absence.
Physician Consultation Required:

Physician must be consulted and notified regarding IDA in the following
situations:
Insulin doses dropping with no apparent cause
Recurrent or severe hypoglycemia with no apparent cause
Glycemic control is not improving or is deteriorating despite adjustments made to
insulin or other components of the treatment plan.
Total daily dose exceeds what is generally expected for age / body type
Client shows signs/symptoms of DKA, dehydration or other serious problems
Recurring / persistent vomiting or diarrhea
Disordered eating pattern
Significant error in dose or timing of insulin administered by person or caregiver
Situations requiring prolonged fasting (eg for religious or medical purposes)
Change in brand or type of insulin
Change in frequency of injections; for example BID to MDI
Change to different regimen (e.g. conventional therapy to basal-bolus with MDI
or pump)
For clients with additional complex medical or endocrine conditions which may
influence insulin requirements or client safety
In all situations that are beyond the RN’s scope of practice and/or competency
level
March, 2009
Note:
Client education regarding IDA is an important component of nursing practice.
However, when the client does not demonstrate the potential for, or interest in, safe
self-adjustment of insulin, the RN will formulate a plan for ongoing reassessment of the
client's insulin dosage, learning needs and potential for learning IDA, in collaboration
with the physician.
COMPETENCY FRAMEWORK
The purpose of the following competency framework and experience record is to help guide
and support Registered Nurses in their scope of practice for IDA. 11
This framework and experience record provides a template that can be customized to:
• suit the needs and policies of practice settings / organizations
• assist RNs and organizations with assessing, developing and/or tracking RN
competencies for IDA.
Space is included for making notes relevant to each competency.
Competencies in this framework are organized according to the main, overarching

competencies required for IDA. Each main competency is accompanied by indicators
which will enable an individual or organization to observe and track competency. The
competencies and indicators can also serve as a guide for self study, professional
development, and may assist individuals preparing to write the IDA competency exam.
Competencies for IDA include knowledge and application competencies. RNs must
develop and maintain both types of competencies in order to perform IDA as part of
their nursing practice. Knowledge competencies can be acquired through self study,
which includes but is not limited to the reading material and learning activities and/or
attending relevant workshops. Application competencies require clinical experience,
including observation of a competent practitioner (RN or Physician), supervised/joint
practice, and independent practice.
11
The original framework was developed by British Columbia Registered Nurses Insulin Dose Adjustment
Working Group for use within British Columbia’s Health Regions where RNs are authorized under the
Health Professions Act (2005) and CRNBC to perform insulin dose adjustment with limits and
conditions. http://www.crnbc.ca/downloads/433-scope.pdf cited 26 march 2009
March, 2009
Competency
PROFESSIONAL STANDARDS
Works within professional and organization standards for IDA by RNs
Joint Practice
Joint Practice
Independent
Observe
or
Complete
Self-
Competency Indicator Study
Notes
Date/Initial Date/Initial Date/Initial Date/Initial
Accepts responsibility for performing IDA

and understands the professional and legal
implications of doing so
Identifies and works within the scope of
practice for Registered Nurses as defined
by the SRNA and the employing health
agency / organization
Identifies limits of own knowledge and skill
and works within them
Demonstrates initiative to advance and
maintain knowledge and skills needed for
safe IDA
Performs IDA often enough to maintain
confidence and competence
Records accurate, clear and timely clinical
notes of insulin dose adjustments and
related patient education or advice
Learning Activities and Experiences completed in this competency area. YES: _____
Date: __________ Signature of RN: ___________________________________
Date: __________ Signature of Mentor(s) ____________________________________
Date: __________ Signature of Mentor(s) ____________________________________

March, 2009
Competency
CLINICAL AND PHARMACOKINETIC KNOWLEDGE
Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA
Joint Practice
Joint Practice
Independent
Observe
or
Complete Notes
Competency Indicator Self-
Study
Describes the major types of diabetes

including basic pathophysiology,
distinguishing characteristics, and rationale
for different treatment plans according to
type of diabetes.
Identifies non-pharmacological and
pharmacological approaches to treating
different types of diabetes
Describes the pharmacokinetics and action
time of all insulins available in Canada
including onset, peak, duration and how
these may be altered (e.g. by
lipohypertrophy, age, pregnancy, renal
impairment etc)
Identifies drugs that may inhibit or
potentiate the action of insulin
Identifies potential side effects of insulin
therapy and how to avoid/minimize and
manage them (e.g. hypoglycemia,
lipohypertrophy, weight gain, in rare cases
allergy)
Describes basic physiologic insulin
requirements in type 1 and type 2 diabetes
in adults as well as usual starting doses
based on age, weight, diagnosis etc.
Date: __________ Signature of Mentor(s) ___________________________________

March, 2009
Competency
MEAL PLANNING, CARBOHYDRATE COUNTING AND INSULIN DOSES
Understands meal planning principles and carbohydrate counting in relation to

insulin and uses these in assessment, education, and recommendations for IDA
Practice
Joint
Practice
Joint
Independent
Observe
or
Complete Notes
Study
Describes glycemic responses to different

food groups / types
Describes the purposes of consistent CHO
use and or CHO counting and identifies
potential advantages/disadvantages of
each, according to the client’s situation
Calculates, uses and evaluates insulin:
carbohydrate ratios
Calculates, uses, and evaluates insulin
sensitivity factor, correction doses/or
insulin scales
Identifies dietary, activity, and / or IDA that
can be made to improve blood glucose
excursions associated with food
Identifies dietary and/or IDA for physical
activity
Identifies effect of alcohol consumption on
blood glucose values and provides
education and advice to minimize risk/and
prevent hypoglycemia
Works collaboratively with dietitians and
makes appropriate client referrals for
nutrition education and support

March, 2009
Competency
ASSESSMENT & INTERPRETATION: BLOOD GLUCOSE
Assesses blood glucose and appropriately interprets information to make

changes to insulin dose(s) or other components of diabetes treatment plan
Practice
Joint
Practice
Joint
Independent
Observe
or
Complete Notes
Study
Identifies age appropriate blood glucose

goals and rationale for these
Identifies situations in which standard
blood glucose goals may need to be
modified
Perform a comprehensive assessment of
the client’s blood glucose:
• reviews recorded blood glucose values
• obtains pertinent information regarding
diet, activity, insulin, and any other
factors which may be influencing blood
glucose
• ensures client’s meter accuracy
Identifies patterns of hyperglycemia or
hypoglycemia, or changes in routines
which require adjustment of insulin and/ or
other components of treatment plan
Identifies when, why and how to assess for
nocturnal hypoglycemia and potential
rebound hyperglycemia
Analyzes relationship between blood
glucose levels, insulin or other
medications, nutritional intake/meal plan,
and activity levels and identifies
appropriate adjustments/course of action
Interprets assessment data and plans
appropriate intervention based on data
Communicates assessment findings to
relevant team members as appropriate

March, 2009
INSULIN SCHEDULES AND DOSE ADJUSTMENTS

Understands various insulin schedules and principles for IDA
for conventional or intensive therapy
Joint Practice
Joint Practice
Independent
Observe
or
Complete Notes
Study
Uses established principles and guidelines

for IDA based on patterns
Identifies situations when an insulin scale
or correction dose needs to be used and/
or adjusted
Uses pattern management principles to
establish, adjust and evaluate baseline
doses for different insulin schedules
Identifies when a change in the time of
insulin administration would be appropriate
and consults with MD as required by
organization’s policy
Applies exercise guidelines appropriate to
the patient/client insulin schedule
Applies guidelines appropriate to the client
for short term IDA for a test or procedure
Describes principles and concepts of
basal-bolus insulin therapy
Uses pattern management to evaluate and
adjust basal doses for MDI
Calculates and applies insulin sensitivity
factors, correction doses and/or insulin
scales for MDI
Calculates and uses insulin to
carbohydrate ratios
Integrates pattern management principles
with correction and supplemental doses for
intensive therapy with MDI
Applies principles of basal-bolus therapy to
optimize blood glucose control and/or
quality of life (e.g. increased flexibility) with:
MDI
Completes comprehensive assessment of
learning needs & provides timely, client
centered education for IDA
Provides client/family education, as
appropriate, using sound educational
theories and principles.
March, 2009
Competency
DIABETES SELF-CARE LEARNING NEEDS
Assesses and addresses diabetes self-care learning needs and

readiness to learn insulin dose adjustment
Joint Practice
Joint Practice
Independent
Observe
or
Complete Notes
Study
Assesses knowledge, ability and readiness

to learn principles / guidelines for:
basic IDA according to blood glucose
patterns
intensive therapy with MDI
Identifies specific learning needs and
formulates learning plan with patient/ client
to address basic IDA
Evaluates learning and plans follow-up as
appropriate to patient/family needs and
circumstances.

March, 2009
Competency
COMMUNICATION
Communicates with the patient/client and other team members

towards the goal of appropriate insulin adjustment
Joint Practice
Joint Practice
Independent
Observe
or
Complete Notes
Study
Involves client in reviewing and interpreting

blood glucose values to make informed
decisions about adjustments to the
treatment plan
Deals sensitively with patients’ questions,
emotions and concerns
Assesses learning needs and provides
clear, relevant instructions to the patient
about insulin and IDA (e.g. what insulin(s)
to change, specific doses, and expected
outcomes)
Confirms patient’s understanding of
instruction or advice provided
Builds relationships with patients/clients to
promote self-care and learning and does
not encourage ongoing dependence on
health professionals for IDA
Negotiates learning plan to assist patients/
clients in developing knowledge, skills and
confidence for self-adjusting insulin doses
Notifies and/or consults with other team
members as appropriate
Records relevant data on the appropriate
records

March, 2009
APPENDIX E - SAMPLE PROGRESS REPORT 12

______ Health Region
Progress Report
Date: ___________________ Client: _______________________________
PHN: ________________________________ Date of Birth: _______________________
Physician: ____________________________ Clinic Location: ______________________
Present Insulin Doses: Brand: ______________________

NovoNordisk, Eli Lilly, Sanofi-Aventis
Pre-breakfast Pre-noon Pre-supper Bedtime Other
Write out full name(s) of insulin, do not use abbreviations
Issues with insulin measurement/injection: ___ none
Hypoglycemia:
Physical Activity:
Nutrition:
Usual Pattern of Blood Glucose Readings: Target ac meals: ______ Target post meals: ______
Fast PC brk Lunch PC Lunch Supper PC Supper HS
Other times:
Assessment: [client progress, changes, client concerns]
Plan: [recommended insulin changes, other plans, follow-up]
Educator’s Signature: _________________________________________
12
Adapted with permission from a Heartland Health Region resource
March, 2009
APPENDIX F - Commonly Asked Questions and Answers
1. I have a Transfer of Function for Insulin Adjustment. I am finding that some physicians
expect me to take sole and ongoing responsibility for insulin dose management for their
patients. How do others handle this?
ANSWER
The intent of the Transfer process is to work collaboratively with physicians and teach
people with diabetes and their families to be as independent as possible in diabetes self-
management. If this is an ongoing concern, you may need to
• Have a discussion with the physician about your scope of practice and workload
management
• Involve your supervisor in supporting and explaining the intent of the delegated
medical function
• Use the process of the annual renewal of the delegated function to educate
physicians. Bev Kernohan, Heartland Health Region has found this helpful.
Annually, after she renews her Transfer of Function, she sends a letter to all the
physicians in the Health Region. This letter is reproduced at the end of the
Question/Answer section. Bev has given permission for others to use or adapt
her letter.
2. Why is sick day management not included in the basic competencies? How can I help my
clients with sick day management?
ANSWER
Not having a Transfer does not preclude an educator from teaching someone how to adjust
insulin during illness. This competency is considered ‘advanced’ because a basic premise of
the transfer is management of the ‘well’ adult. Also, most educators work days, Monday-
Friday and would not necessarily be available to take on responsibility for ongoing insulin
adjustments during an inter-current illness.
3. With a Transfer of Function to adjust insulin, can I change the time of day the insulin is
given without contacting a physician? What if I am making this change for client safety?
ANSWER
If your Health Region uses the template developed for the Saskatchewan module, any
change in insulin timing must be done by physician order. It is always an option for a Health
Region to adjust the template to their own needs and, for example, permit changing of the
time of day insulin is given. This could be a general statement or have limitation; for
example, related to client safety. Each Health Region has a procedure for changing policies
and in particular those which involved a delegated medical function. Make sure you are
aware of your Region’s policies and procedures.
March, 2009
4. Now that I have a Transfer of Function other professionals (Home Care Nurse, Pharmacist)
sometimes call me and ask me to make insulin dose adjustments for their patients. Usually I
do not know the patient or have not made a recent assessment. How should I handle this?
Can I make insulin dose recommendations?
ANSWER
The template for the Transfer of Function policy, as written, in the provincial module is clear
that the Transfer only applies to clients actually being seen by the RN. It is not intended to
cover situations where the RN is not involved with the patient and unable to do his/her own
assessment.
Possible options to handle this scenario would be

• Indicate the terms or conditions of your policy with the delegated medical
function and what you can and cannot do
• Make general suggestions, indicating that the calling professional will need to get
a physician order to give the recommendation to the patient. Reinforce your
scope of practice. You may also wish to document the conversation and indicate
not only your suggestions but also the advice to seek a physician order.
• If you, your nursing department and your medical colleagues feel you can give
advice to other professionals, then have a written policy to this effect in your
Health Region/organization.
March, 2009
SAMPLE ANNUAL LETTER TO FAMILY PHYSICIANS 13

Insert Date
Dr ____________
Medical Transfer of Function for insulin adjustment, by the Diabetes Nurse Educator
Bev Kernohan RN, BSN, CDE
This year I have applied with the Senior Medical Manager, Dr. ___________, and have attained
an annual renewal of the Medical Transfer of Function for insulin adjustments with patients who
have Type 1 and 2 diabetes. I have practiced with this Medical Transfer in Heartland Health
Region for the past __ years.
I am sending this letter to all physicians practicing in Heartland Health Region as per
request from Management. If I am not presently involved with the diabetes management of
your clients, this permission will only be applicable if I become involved with their management
in the next year.
This letter is to confirm whether you do or do not wish to have this transfer applied to
the insulin-using patients in your practice, which through the referral process, I become
involved in their diabetes management.
As a physician you retain the responsibility for the insulin regimen that is ultimately
selected - initial dose: amount, type of insulin, timing and any subsequent adjustments to
insulin type/or timing. This Transfer will allow me to adjust the insulin dose only. For the clients
under Home Care, it will not allow me to give the Home Care Nurses an order to change the
insulin; they still require a written order from a physician. If I am working with a client who is
also a client of Home Care and they are pre-filling the syringes, I will send to the physician my
recommendations and he/she will make the final decision and implement the necessary insulin
changes.
I am firmly committed to this process and I will continue to communicate any changes
in doses of insulin back to the physician. I will continue to instruct the client to have regular
contact with their physician for ongoing management of their diabetes.
I, as a Registered Nurse, will refer all clients to their physician in all situations that are
beyond the scope of my practice and/or in situations where the client’s metabolic control is
deteriorating despite adjustments made to the insulin or other components of the treatment
plan.
You are not obliged to participate in this medical transfer of function for insulin
adjustment unless you agree to. I will continue to see patients referred to me for education
purposes even if you opt not to participate in this transfer of medical function.
Continued on next page …
13
Developed by Bev Kernohan, Heartland Regional Health Authority.
Used and adapted with permission. March, 2009
March, 2009
Please indicate below whether you wish to have patients in your practice participate
in this transfer of medical function for insulin adjustment.
I give permission to Bev Kernohan to adjust the dosage of insulin of patients in my

practice.
Name of Physician __________________________________________________

PRINT NAME AND SIGNATURE
Date_______________________
I do not give permission to Bev Kernohan to adjust the dosage of insulin of patients
in my practice.
Name of Physician __________________________________________________

PRINT NAME AND SIGNATURE
Date_______________________
Retain a copy and fax or send a copy back to Bev Kernohan by

May 12th,, 2008
Box 130, Biggar, Sask. S0K-0M0 fax 948-2011, phone 948-6041 if you require info.
March, 2009
LEARNING ABOUT AND PROCEDURES FOR INSULIN DOSE

ADJUSTMENT
Endogenous Insulin
Learning Objectives
Upon completion of this section you will be able to:

• Describe the hormonal regulation of blood glucose in the non-diabetic individual.
• Define key metabolic processes and whether insulin facilitates or inhibits the process.
• Describe briefly insulin's effect on cellular glucose uptake in the following organs/tissues:
brain, liver, muscle, fat.
• Describe how obesity in the non-diabetic may alter normal insulin secretion.
• Name the potential metabolic effects of hyperinsulinemia.
• Describe the metabolic effects of an absolute lack of insulin.
Hormonal Regulation of Blood Glucose in the Individual without Diabetes
Blood glucose levels are constantly monitored by the alpha and beta cells of the Islet of
Langerhans in the endocrine pancreas. If glucose levels are dropping, the alpha cells are
stimulated to secrete glucagon which stimulates certain metabolic processes (glycogenolysis in
the liver primarily) which modulate the blood glucose and keep it in the normal range. If
glucose levels are rising, the beta cells secrete insulin which stimulates certain metabolic
processes (glycogenesis, lipogenesis, cellular glucose uptake) which modulate the blood glucose
and keep it in the normal range.
Other hormones stimulated by dropping blood glucose values are epinephrine, cortisol, and
growth hormone. These hormones and glucagon are termed 'counter-regulatory' in that they
all have 'anti-insulin' action in raising blood glucose values. Insulin secretion is also stimulated
by ingestion of protein because insulin is required for protein synthesis. Average daily insulin
secretion by the non-diabetic pancreas is about 30 units.
Metabolic Definition Stimulated or

Process Inhibited by Insulin
Glycogenesis the formation of glycogen from glucose. Stimulated

Glycogen is stored in the liver and
muscles.
Lipogenesis the formation of fat from its substrates, Stimulated

glycerol and fatty acids.
Gluconeogenesis the breakdown of fat and protein to Inhibited

form glucose and by products.
Glycogenolysis the breakdown of glycogen into glucose. Inhibited

March, 2009
Insulin’s Effect On Cellular Glucose Uptake

• Insulin is not required for glucose uptake by brain cells.
• Insulin facilitates glucose uptake by liver cells.
• Insulin facilitates glucose uptake by muscle cells.
• Insulin facilitates glucose uptake by fat cells.
How Obesity Alters Normal Insulin Secretion in the Non-diabetic Person
Obese individuals may have abnormal insulin secretion, often resulting in:
a. higher circulating insulin levels than a normal weight non-diabetic individual.
b. abnormal timing of post-prandial insulin secretion.
In addition, obese non-diabetic individuals have been shown to have a decreased number of
insulin receptors and decreased sensitivity of receptors to insulin, resulting in a resistance to the
action of insulin.
Potential Metabolic Effects Of Hyperinsulinemia

• Glycogenesis often resulting in a glycogen saturated liver.
• Excessive lipogenesis often resulting in increased adipocyte deposition of lipid.
• Inhibition of lipolysis and glycogenolysis
Hypoglycemia may develop postprandial as a result of the above processes. Eventually there
will be pancreatic ‘burnout’ and insulin levels will drop.
Metabolic Effects Of Lack Of Insulin
An absolute insulin deficiency will cause:

• decreased glucose uptake by liver, muscle, fat cells.
• excessive glycogenolysis, lipolysis, gluconeogenesis.
• inhibited glycogenesis and lipogenesis resulting in hyperglycemia and hyperosmolar
diuresis. Nearly exclusive cellular utilization of fatty acids for energy production results
in accumulation of ketone bodies in the blood causing ketoacidosis.
These metabolic changes eventually lead to either type 1 or type 2 diabetes. With type 2
diabetes, there is often a broader underlying disorder known as metabolic syndrome. Metabolic
syndrome is characterized by several abnormalities including: abdominal obesity, hypertension,
dyslipidemia, insulin resistance and dysglycemia. 14
14
2008 Clinical Practice Guidelines, page S11
March, 2009
Exogenous Insulin
Learning Objectives
• List the sources, manufacturers, and trade names of commercially available insulins in
Canada.
• Describe the action time of the various insulins available in Canada including onset, peak,
and duration of action.
• Describe the potential adverse effects of subcutaneous insulin use.
• Describe other medications which affect insulin action
• Describe insulin requirements in type 1 and type 2 diabetes.
Insulin Approved for Use in Canada

The following table indicates the insulin types currently available in Canada. It is
referenced to the 2008 Clinical Practice Guidelines 15 and may need periodic updating
by users of this module.
TYPES OF INSULIN
Insulin type (trade name) Onset Peak Duration
Prandial (bolus) insulins
Rapid-acting analogues (clear)
• Insulin aspart (NovoRapid) 10-15 min 1-1.5 h 3-5 h
• Insulin lispro (Humalog) 10-15 min 1-2 h 3.5-3.75 h
• Insulin glulisine (Apidra) 10-15 min 1-1.5 h 3-5 h
Short-acting insulins (clear)
• Humulin-R 30 min 2-3 h 6.5 h
• Novolin ge Toronto
Inhaled insulin 10-20 min 2h 6h
Basal Insulins
Intermediate-acting (cloudy)
• Humulin N 1-3 h 5-8 h Up to 18 h
• Novolin ge NPH
Long-acting basal insulin analogues (clear) Up to 24 h
• Insulin detemir (Levemir) 90 min Not (glargine 24 h,
• Insulin glargine (Lantus) applicable detemir 16-24 h)
Premixed Insulins
Premixed regular insulin – NPH (cloudy)
• Humulin 30/70
• Novolin ge 30/70, 40/60, 50/50 A single vial or cartridge contains a fixed ratio
Premixed insulin analogues (cloudy) of insulin
• Biphasic insulin aspart (NovoMix 30) (% of rapid acting-acting or short-acting insulin to
• Insulin lispro/lispro protamine % of intermediate-acting insulin)
(Humalog Mix 25 and Mix 50)
See notes on next page.
15
2008 Clinical Practice Guidelines, page S47.
March, 2009
NOTES:
CPGs recommend reference to the most current edition of the Compendium of Pharmaceuticals and
Specialties (CPS: Canadian Pharmacists Association; Ottawa, Ontario, Canada and product monographs
for detailed information.
* Insulin glulisine (Apidra) Released January 2009 – not covered by Saskatchewan Drug Plan
* Inhaled insulin has been approved for use in Canada, but is not yet commercially available. Its use is
not covered in this module.
Learning Activity
1. Using the above table, draw sample diagrams to use with clients to illustrate the onset, peak
and duration for insulins commonly used in your practice.
2. See the following website and review the current devices for insulin measurement and
injection [resource is updated annually]
http://www.diabetes.ca/about-diabetes/literature/consumer-guide cited 23 Dec 2008
Potential Adverse Effects Of Subcutaneous Insulin Use

Adverse effects of exogenous insulin use may include hypoglycemia, lipoatrophy,
lipohypertrophy (if rotation of sites is not observed), weight gain, insulin resistance (presence of
IgG antibodies), and in rare cases localized insulin allergy (presence of IgE antibodies).
Hypoglycemia will be discussed further in the next section.
Drugs That May Inhibit Or Potentiate Insulin Action
Inhibit Potentiate
Thiazide diuretics Propranolol
Glucagon Alcohol
Prednisone MAO inhibitors
Thyroid Hormone Salicylates (1.5-6 g/day)
Use of Beta Blocking Drugs

Non-selective beta blocking agents such as propranolol (Inderal®) potentiate the action of
insulin by reducing glycogenolysis from the liver. They are also dangerous because they block
the sympathetic nervous system response to epinephrine secreted during a hypoglycemic
episode. They thereby block the early warning signs of hypoglycemia that are mediated by the
sympathetic nervous system.
March, 2009
Learning Activity
1. Review the above medications and be familiar with the effects for insulin users.
Insulin Requirements
Insulin requirements will vary with each individual. The next section provides information on the
options for insulin regimens and the use of insulin with oral anti-hyperglycemic agents. General
guidelines suggest: 16
• For type 1 diabetes, when weight is within 20% of normal, usual insulin requirements
are 0.5 to 0.7 units/kg of body weight per day. These requirements will be lower during
the “honeymoon” phase (0.2-0.6 u/kg).
• For type 2 diabetes the insulin requirement will be individualized depending on the
degree of insulin deficiency and insulin resistance. At the low end requirements may be
only 5-10 unit/day. At the high end insulin requirements may be hundreds of units per
day.
16
Franz, MJ, editor. (2001) A Core Curriculum for Diabetes Education, 4th edition: Diabetes Management
Therapies. American Association of Diabetes Educators, p. 103
March, 2009
PRACTICAL ASPECTS OF INSULIN MANAGEMENT
Learning Objectives
Upon completion of this chapter you will be able to:
• Describe the causes of fasting hyperglycemia
• Describe the indications for insulin use in type 2 diabetes
• Describe and implement the procedures listed below
Procedures
• Variables influencing glycemic control to assess before IDA is performed
• Use of insulin with oral anti-hyperglycemic agents in type 2 diabetes
• Therapeutic approaches useful in prevention and treatment of hypoglycemia in those
prone to asymptomatic hypoglycemia
• Important points to consider when switching a client from short-acting to rapid-
acting insulin
• Important points to consider when switching a client from intermediate-acting insulin
to a long-acting basal insulin analogue
Variables Influencing Glycemic Control [PROCEDURE]

Variables influencing glycemic control which should be assessed before initiating insulin or
changing a dose include:
- diet: carbohydrate content, timing and delayed gastric emptying

- activity
- monitoring technique
- concurrent illness/infection
- concurrent medications
- unusual stresses
- injection site problems
∗ variable absorption
∗ lipodystrophies
- insulin administration problems
∗ inaccurate dose
∗ missed doses, extra doses
∗ timing of dose
- weight changes
- menstrual cycle
- length of time between carbohydrate intake and blood glucose monitoring
- pregnancy
- insulin antibodies
- abnormal glucose counter-regulation
- alcohol use
March, 2009
Using A Combination of Insulin and Oral Antihyperglycemic Agents [AHA]
The 2008 CPGs recommend the timely addition of anti-hyperglycemic agents (either
orally or with insulin) if 17 :
• Glycemic targets are not achieved within 2-3 months of lifestyle management.
• Current agents are not successful in achieving glycemic targets. This may require
medication adjustment and/or additional medications to attain target A1C in 6-12
months.
• There is marked hyperglycemia (A1C > 9%), antihyperglycemic agents need to be
initiated concomitantly with lifestyle management and consideration needs to be
given to initiating combination therapy with 2 oral AHAs or initiating insulin.
LEARNING ACTIVITY
1. Read the CPG pages S53 to S58. Use the current version of the Compendium of
Pharmaceuticals and Specialties (CPS) and create of a table of oral antihyperglycemic
agents and the recommendations for their use with insulin. See the pink-edged pages to
find specific diabetes medications.
2. Discuss your table with other diabetes practitioners and your physician leader to gain
local consensus on current practice, safety issues and important points for client
education when combining insulin with an OAA.
17
2008 CPG, page S53
March, 2009
Useful Therapeutic Approaches Useful In the Prevention And Treatment Of

Hypoglycemia [PROCEDURE]
Learning Activity
Read the following resources:
• 2008 Clinical Practice Guidelines section on hypoglycemia and read the related
guidelines on driving and diabetes
• Begg IS, Yale J-F, Houlden, RL, Rowe RC, McSherry J. 2003. Canadian Diabetes
Association’s Clinical Practice Guidelines for Diabetes and Private and Commercial
Driving. Can J Diabetes. 27;2:128-140. Available at
http://www.diabetes.ca/Files/Diabetes%20and%20Driving%20Guidelines--
June%202003--FINAL.pdf cited 24 Dec 2008.
The following measures are important in the prevention and treatment of hypoglycemia
particularly in those prone to asymptomatic or severe hypoglycemia:
• frequent home blood glucose monitoring (four times daily)

• appropriate self-adjustment of insulin dose
• consistent carbohydrate intake or carbohydrate counting with appropriate
insulin:carbohydrate ratio
• appropriate timing of meals and snacks
• preparation for increase in physical activity and management during and post
activity
• if needed, the target range for blood glucose control should be higher, e.g. instead of 4-
7 ac meals, 6-10. In practice, this should result in downward adjustment of the
appropriate insulin dose if results are less than 6.
• for severe hypoglycemia, family members should be instructed in the administration of
Glucagon
• wear diabetes identification
• teachers, co-workers, family, friends should be informed of potential hypoglycemia, its
signs, and what action to take
• if possible, identify with the client:
• his/her earliest perception/sensation that blood glucose may be dropping and
the usual blood glucose at that time
• the history of hypoglycemia, including the frequency, severity, usual treatment
and usual prevention strategies
• if he/she has hypoglycemia unawareness 18 and how this has been and will be
managed
18
See Jones et al (2009) for more information about hypoglycemia unawareness
March, 2009
Causes Of Fasting Hyperglycemia
There are three potential causes for fasting hyperglycemia:
The Somogyi Phenomenon

The Somogyi phenomenon, also known as rebound hyperglycemia, has been defined as
hyperglycemia (not caused by excessive dietary intake) following a hypoglycemic episode. The
etiology is believed to be increased production of counter-regulatory hormones in response to
hypoglycemia. Not all clients demonstrate this phenomenon.
Signs suspicious of this phenomenon are fasting hyperglycemia, headache or nausea upon
wakening in the morning especially if the client reports nocturnal symptoms such as
nightmares, poor sleep, tossing and turning, and perspiration. In addition, fasting
hyperglycemia unresponsive to increases in the appropriate insulin dose is suspicious of
Somogyi phenomenon. Signs during the waking hours may be hyperglycemia following an
insulin reaction despite appropriate dietary treatment of the hypoglycemic episode.
To rule out or confirm Somogyi phenomenon at night, the client should test their blood glucose
6-8 hours after the p.m. intermediate insulin dose. If this reading is low, it will confirm the
Somogyi phenomenon. If it is normal or high, Somogyi is ruled out. Daytime Somogyi
phenomenon can be confirmed by questioning the client on precisely how they treated the
hypoglycemic episode that precedes hyperglycemia. Difficulty may arise if asymptomatic,
undocumented hypoglycemia during the day results in a rebound hyperglycemia. Additional
blood glucose testing between meals is required to demonstrate this problem. Over-treatment
of hypoglycemia is much more common than daytime Somogyi.
Recent studies have pointed out that although the Somogyi effect causes some degree of
excessive post-prandial hyperglycemia the following morning, it does not cause “extreme
hyperglycemia and instability”. In other words, the magnitude of the Somogyi effect may be
over-estimated.
Waning Insulin
Joslin’s Diabetes Deskbook (2003) notes the waning effect of the insulin dose given the
previous evening can also be a factor in fasting hyperglycemia. The duration of action of the
overnight insulin is insufficient and leads to a gradual rise in blood glucose level from bedtime
to morning. It may be difficult to differentiate this from the Dawn Phenomenon discussed
below.
Dawn Phenomenon
The “Dawn Phenomenon” refers to the increased production of glucose by the liver and
decreased sensitivity to the action of insulin that occurs between 0400 and 0800 hours in
people with and without diabetes. Therefore higher levels of insulin are required to maintain
euglycemia during these hours. Nocturnal surges of growth hormone cause the transient
insulin resistance. These surges are normal physiological events that are not a result of
counter-regulatory responses to hypoglycemia. A bedtime dose of intermediate-acting insulin
would likely reach its peak during the dawn and counteract the hyperglycemic effects of this
phenomenon.
March, 2009
Considerations When Switching From Short-Acting Insulin To a Rapid Acting

Insulin Analogue [PROCEDURE]
Rapid-acting insulin analogues closely duplicate the action of the body’s endogenous insulin in
response to food ingestion. The rapid onset and short duration, as compared to short-acting
insulin, benefit people with diabetes by providing:
• “inject and eat” convenience
• improved post-prandial glucose control
• less risk of hypoglycemia between meals and overnight
Rapid-acting insulin analogues are suited to people who want improved glycemic control and
more flexibility in their schedule. It is beneficial for type 1 or 2, children and adults, those new
to insulin as well as those already using insulin. It is particularly suitable for people on MDI, i.e.
TID or QID regimens or pumps.
When transferring to a rapid-acting insulin analogue:

• The same dose may be used as short-acting insulin, assuming the usual dose is effective
and safe
• Your client, though, may feel more secure taking about 10 to 20% less initially until the
effect can be gauged.
• The dosage of intermediate insulin or long acting basal insulin analogue may have to be
increased and/or divided into two injections per day to provide adequate basal coverage.
Since short-acting insulin has a longer action, it tends to have an overlap in coverage with
the intermediate-acting insulin. A rapid-acting insulin analogue has a shorter duration
which can result in rising blood glucose prior to the next meal.
• Examples of use of a rapid-acting insulin analogue:
• Rapid analogue before meals, Intermediate at bedtime
• Rapid analogue before meals, Intermediate before breakfast and bedtime
• Rapid analogue before meals, Long-acting basal insulin analogue in the evening
Be sure to discuss regimen changes with the client’s physician.
Reminders for Using a Rapid-Acting Insulin Analogue

• When mixing insulins, use only with the same brand of insulin; for example, do not
mix a NovoNordisk brand insulin with an Eli Lilly brand insulin.
• If the rapid analogue is mixed with intermediate-acting insulin, inject immediately to
prevent blunting of the rapid insulin action after mixing.
• Do not mix any insulin with a long-acting basal insulin analogue
• Inject rapid-acting insulin within 15 minutes of a meal.
• Monitor blood glucose regularly. Initially, monitoring 7 to 8 times per day for about
one week (a.c. meal and 2 hours p.c.) may be required to determine the correct
doses.
March, 2009
Precautions
• A rapid-acting insulin analogue is not recommended in conjunction with

acarbose (Prandase) as acarbose slows the digestion of carbohydrate,
possibly resulting in hypoglycemia.
• Advise your client to avoid strenuous exercise within 2 hours after taking a rapid-acting
insulin analogue. If a person must exercise in that timeframe, recommend a reduction
in the rapid analogue dose by 50%. Exercise 2 - 4 hours after rapid analogue may not
result in hypoglycemia.
• People with gastroparesis should use a rapid-acting analogue with caution. Extra
blood glucose monitoring is needed to determine the timing of injection with the rise
of blood glucose after food is absorbed. Insulin may need to be administered after the
meal to match with the rise in blood glucose.
Switching To a Long-Acting Basal Insulin Analogue 19 [PROCEDURE]
Two brands of long-acting basal insulin analogues are available in Saskatchewan: Lantus
(insulin glargine) and Levemir (insulin detemir). Either one can be used as a basal insulin.
Lantus has a duration of up to 24 hours. Levemir has a duration of 16-24 hours. Both are clear
insulins.
Indications for Use

• Can be used with either type 1 or type 2 diabetes where a basal insulin is required
Precautions for Use

• Do not mix with any other insulin
• As with all insulins, long acting insulin analogues may cause hypoglycemia
• For persons with renal or hepatic dysfunction, insulin requirement may be lower due to
decreased insulin metabolism. Frequent blood glucose monitoring is required.
• Use in pregnancy should be cautious and only if clearly needed. Use in lactation has not
been established.
Client Education with Long-Acting Basal Insulin Analogue

• Advise the client not to mix with any other insulin or dilute the long-acting insulin analogue.
• Long-acting insulin analogues are clear insulins and should not be used if cloudy.
• Long-acting insulin should be stored in a refrigerator, 2ºC to 8ºC. It should not be allowed
to freeze. If refrigeration is impossible, the vial can be kept unrefrigerated up to 28 days
away from direct heat and light as long as the temperature is not greater than 30ºC.
Discard after 28 days if unrefrigerated.
• As the insulin is acidic, there may be mild discomfort at the injection site.
• In addition, the usual education related to insulin use should be provided.
Dosage and Administration

• For “insulin naïve” clients with type 2 diabetes already treated with oral anti-hyperglycemic
agents, the recommended starting dose is 10 units once daily with subsequent adjustment
according to client needs.
19
See details about each insulin’s properties in the current version of CPS.
March, 2009
• Change over to a long-acting insulin analogue from intermediate acting insulin:

o in clinical studies when the transfer was from once daily NPH human insulin or
ultralente, the initial dose was not changed.
o in studies where the transfer was from twice daily NPH to once daily long-acting
insulin analogue at bedtime, the initial dose was reduced by a minimum of 20%
of the previous total daily dose of intermediate or long-acting insulin.
March, 2009
Insulin Regimens And Adjustments
Learning Objectives
• Describe the insulin regimens
• Describe carbohydrate counting
• Describe and implement the procedures listed below
Procedures
• Definition and implementation of IDA:
a. Initiating an Insulin Regimen and Establishing Client Goals
b. Pattern management
c. Variable insulin doses:
i) correction factor for low/high glucose readings
ii) use of insulin:carbohydrate ratios
• Principles of IDA for exercise or increased physical activity.
Insulin Regimens
Insulin regimens must be planned to meet the metabolic requirements of the individual while
being able to control the blood glucose level throughout the 24-hour day. Commencing insulin
and stabilizing the glucose levels calls for different approaches depending on individual
requirements and the “intensity” of therapy, considering the client’s lifestyle and routines.
Type 1
The DCCT has shown that individuals with Type 1 diabetes will benefit from metabolic control
as close to normal glucose levels as possible. This level of blood glucose control appears to
slow the auto-immune destruction of beta cells thus leaving well controlled individuals with
greater beta cell reserve one year following diagnosis than individuals with higher blood
glucoses levels. Therefore, newly diagnosed type I individuals may benefit from two to four
injections of insulin per day aimed at keeping pre-prandial glucoses less than 7 mmol/L. To
achieve glycemic targets in adults with type 1 diabetes, multiple daily injections (prandial
[bolus] and basal insulin) or the use of CSII is the treatment of choice. 20
Basal insulin is the amount of insulin required to counteract hormonal and other variables
potentially causing hyperglycemia between meals and overnight.
Bolus insulin is the insulin used to cover glucose rise as a result of food intake. Typically this
can range from 40-60% of the total daily requirement for insulin.
The 2008 CPG recommend a basal/bolus regimen with:

• Rapid-acting insulin analogues (aspart or lispro), in combination with adequate basal insulin,
should be considered over regular insulin to improve A1C while minimizing the occurrence of
hypoglycemia and to achieve postprandial glucose targets. 21
• A long-acting insulin analogue (detemir, glargine) may be considered as an alternative to
NPH as the basal insulin 22 to reduce the risk of hypoglycemia, including nocturnal
hypoglycemia. 23
20
2008 Clinical Practice Guidelines, p. S49. Recommendation 1, Grade A, Level 1A.
21
2008 Clinical Practice Guidelines, p. S49. Recommendation 2, Grade B, Level 2.
March, 2009
A total daily dose of 0.5 - 1.0 units/Kg of body weight is usually required. The total daily dose
is distributed according to the type of insulin regimen initiated 24 .
• It is the physician’s responsibility to determine the initial dose and regimen.

• If the RN practicing under a delegated medical function feels that regimen changes
should be made, i.e. number of injections or type of insulin she/he must do so in
collaboration with the physician.
Insulin action times must be taken into account when deciding which insulin to adjust for a
particular blood glucose problem at one time of day.
Caution must be observed once euglycemia is attained. As glucose toxicity is overcome for
those newly diagnosed with type 1 diabetes, beta cell function improves and may synergistically
work with injected insulin to cause hypoglycemia ie. the honeymoon period has begun. Be
prepared to reduce the injected dosage quickly in these individuals as indicated by blood
glucose results. Requirements may be <0.5 units/kg body weight/day 25 .
Type 2
The individual with type 2 diabetes may benefit from several types of insulin regimens.
• bedtime intermediate-acting or long-acting basal insulin analogue and daytime oral

AHA 26
• a.c. breakfast and supper rapid or short/intermediate mixture including pre-mixed
insulins
• t.i.d. insulin pre-meal (short or rapid acting) and intermediate or long-acting at
breakfast and/or supper. The second injection of intermediate or long-acting may also
be given at bedtime (q.i.d insulin)
If adding h.s. intermediate or long-acting basal insulin analogue to daytime oral AHA, increase
the dosage regularly (every 3-4 days) until the fasting glucose reaches the target range25.
Because of insulin resistance, the dosage requirement may vary widely between clients, but it
will not benefit the client to stop increasing the dose short of the glycemic target.
When using daytime insulin for the type 2 individual, consider insulin action times in deciding
which insulin to increase or whether to add another type of insulin to improve glucose control at
a particular problem time of day. Again because of insulin resistance, very high daily total
doses (100 - 200 units) may be required to achieve the glycemic target range.
A hindrance to stabilizing clients on insulin therapy is that insulin action times may vary from
individual to individual. Use insulin action times as a guideline to adjust your client’s insulin but
be prepared to recognize how the insulin is working in your client.
22
2008 Clinical Practice Guidelines, p. S49. Recommendation 4, Grade B, Level 2.
23
See 2008 CPG p S 40 for levels of evidence.
24
See the above reference for examples of insulin distribution with different regimens. Also see the
chapter on intensifying insulin therapy in The Essentials for examples of calculating insulin doses.
25
2008 Clinical Practice Guidelines, p. S150.
26
See 2008 Clinical Practice Guidelines p S197-198 for guidelines for insulin initiation in people with type
2 diabetes
March, 2009
Carbohydrate Counting
To use insulin to carbohydrate ratios for IDA, the Registered Nurse must be familiar with
carbohydrate counting. Ideally the client will be referred to a Registered Dietitian to learn about
carbohydrate counting. Both the Dietitian and Registered Nurse can support the client in the
learning process and provide reinforcement in preparation for IDA by the client.
There are several criteria to consider when suggesting a client use carbohydrate counting and
subsequently an insulin to carbohydrate ratio to adjust insulin:
• the person’s motivation to learn a new skill.
• ability to perform simple math skills.
• the person’s willingness and ability to use resources (nutrient information, food labels and
tools (measuring cups, weigh scales) ) to accurately determine carbohydrate content of
meals and snacks. For those who have been frustrated by fluctuating blood glucose levels, it
may be helpful for them to use nutritional scales 27 .
• accurate and detailed food records will enhance the process and help assess the client’s
ability to carbohydrate count and support client skill development.
Learning Activities
A. Read the following resources:
1. Ensure you are familiar with the CDA resource, Beyond the Basics and basic carbohydrate
counting resources. You can review the background information at
http://www.diabetes.ca/for-professionals/resources/nutrition/ .
2. If you are a DES member you can view a presentation on basic carbohydrate counting and
complete the exercises at http://www.diabetes.ca/for-professionals/members-only/ You
must sign in using your DES membership number.
3. Learn how to read “Nutrition Facts” labels, see http://www.diabetes.ca/about-
diabetes/nutrition/healthy-eating/ and through this site you can access other resources.
Take the virtual grocery store tour.
4. Obtain a resource for carbohydrate values of common foods such as:
a. Nutrient Value of Some Common Foods (2002). Health Canada.
http://www.publications.gc.ca/pub?id=316070&sl=0 Available free
b. Holzmeister L. The Diabetes Carbohydrate and Fat Gram Guide, 3rd edition.
American Diabetes Association. www.diabetes.org
c. Netzer, CT. The Complete Book of Food Counts, 8th edition. 2008;New York:Dell
Publishing. ~ $10 in paperback.
d. Borushek, Allan. The CalorieKing Calorie, Fat and Carbohydrate Counter, 2009. ~
$11 in paperback
e. For fast foods, treats etc see
http://www.bcchildrens.ca/Services/SpecializedPediatrics/EndocrinologyDiabetes
Unit/ForFamilies/default.htm go to diabetes/nutrition handouts
f. USDA on line nutrient data base
http://www.nal.usda.gov/fnic/foodcomp/search/
f. http://www.elook.org/nutrition/search.php
ALL REFERENCES cited 30 december 2008
27
The Essentials, Chapter 10.
March, 2009
B. Practical Applications
1. Complete the exercises with a resource from selection above.

2. Keep a food record for three days, being as specific as you can with amounts and calculate
your carbohydrate intake for each meal. Consult with a dietitian colleague to get some
feedback or answers to your questions.
Insulin Dose Adjustments (IDA) [PROCEDURE]
Initiating an Insulin Regimen and Establishing Client Goals
A written (in-person or by fax), verbal or telephone order is required from the attending
physician prior to the initiation of insulin therapy, specifying the type, dose and time of insulin.
This order will be discussed with the Registered Nurse and client prior to the initiation of insulin
therapy. Verbal/telephone orders must be signed according to Health Region policy. See an
example of this form on page 45.
Physician’s orders will be documented in the client’s chart
Subsequent alteration in the type of insulin or significant changes in the time at which insulin is
to be given will be discussed with the Registered Nurse, the physician and the client.
Target Blood Glucose Levels – the following can serve as standard reference points
Recommended targets for glycemic control

A1C FPG/preprandial PG 2-hour postprandial
(%) (mmol/L) PG (mmol/L)
Target for most
patients ≤ 7.0 4.0 – 7.0 5.0 – 10.0
(5.0 to 8.0 if A1C
targets not being met)
2008 Clinical Practice Guidelines, page S30.
NOTE: treatment goals and strategies must be tailored to the individual with consideration given to individual risk factors.
Individualized Goals: Individualized goals for blood glucose control will be specified in the
client’s chart and will be determined collaboratively with the physician, the Registered Nurse,
the client, significant others and other health care providers. Factors which may be considered
in setting goals include the age of the client (eg. seniors) and other health problems.
March, 2009
Diabetes & Heart Health Centre 28

Diabetes Educators
xxx, RD xx, BScN, RN, CDE
xxx-xxxx Ext xxx xxx-xxxx Ext xx
FAX FAX BACK

Date: XXXXXXXXXXX Date:
To: XXXXXXXXXX To: Attention: XXX
Fax: XXXXXXXXXX Fax: (306) xxx-xxxx
From: XXX @ xxx-xxxx From:
Please Complete & Return ASAP!
Diabetes Medication/Insulin Review

Client: XXXXXXXXXXXX PHN: XXX XXX XXX DOB: XX XXX XXXX
Background information:
XXXX blood sugar levels are continuing to increase and due to his Humalog Mix 25 we are
unable to “fine tune” his insulin dose to maximize his blood sugar control. His present dose is
Humalog Mix 25 8 units q a.m. and 24 units q p.m.
Recommendation:
• Stop Humalog Mix 25
• Start Humulin N 10 units at breakfast (an ↑ of 4 units) and 10 units at HS (a ↓ of 8
units and moved from supper to HS). Try and be fairly consistent with the time of
this Humulin N insulin.
• Start Humalog 3 units at breakfast ( an ↑ of 1 unit) and 6 units (same dose) at
supper. Take this insulin immediately before eating
XXX is to monitor his blood sugar QID ac and pc on at least 5 days prior to his next appointment
on Feb 11, 2009. XXX was encouraged to call if he had any questions or concerns.
Please sign below and return to me if you wish to initiate this change or wish to make different
recommendations so that I will have a signed record for my files. I will continue to send
progress notes following visits with any insulin adjustments.
□ Yes, please go ahead with the above recommendations:

□ No, I would like to:
Date Signature
28
Developed by Kelsey Trail Health Region Diabetes and Heart Health Centre. Used with permission.
March, 2009
Some special situations which may require individualization of goals include:
• elderly or ill clients The same glycemic targets apply to otherwise healthy elderly individuals
as to younger people. In persons with multiple co-morbidities, a high level of functional
dependency and/or limited life expectancy the goal should less stringent. Try to avoid
symptoms of hyperglycemia and prevent hypoglycemia 29
• Women planning a pregnancy must strive for tighter glucose control (A1C < 7% (<6% if
safely achievable 30 ) to decrease the risk of congenital abnormalities and further problems in
pregnancy.
• Hypoglycemia unawareness (failure to sense hypoglycemia) may place clients at risk of life
threatening hypoglycemia. The target blood glucose levels for therapy for these clients
should be adjusted upward. The goal should be to avoid severe or unrecognized
hypoglycemia.
Pattern Management
Modifications are made in the base (usual) insulin dose based on blood glucose patterns.
Patterns are consistent trends in blood glucose that occur at the same time of day for three to
four days in a row.
This method presupposes that the person has a consistent pattern of meals, carbohydrate
intake and activities, has no concurrent illness and is free from unusual stress.
Basic Principles of Insulin Dose Adjustment
• Make IDA to usual insulin dose based on blood glucose patterns.
• Adjust first to eliminate low blood glucose readings. Remember night time
hypoglycemia may be reported as nightmares, poor sleep, tossing and turning or
perspiration.
• Remember there may be several possible reasons for fasting hyperglycemia.
• Adjust only one insulin dose at a time (unless this will cause a low blood glucose
level at a later time). Consider that when one insulin is increased, another may
need to be decreased.
• Increase insulin when there is a pattern of repeating high glucose results. DO NOT
increase insulin on the basis of sporadic or single high readings.
• Wait at least 3-4 test days between each IDA to have sufficient data to determine a
pattern. Use a combination of pre-prandial and post-prandial blood glucose levels to
guide adjustments.
29
2008 Clinical Practice Guidelines, p. S181
30
2008 Clinical Practice Guidelines, p. S170
March, 2009
• IDA in most circumstances will be by 10% increments. For example:

o Usual dose of less than 10 units, adjust by 1 unit
o Usual dose of 10-20 units, adjust by 1 - 2 units and so on
Assessment of Blood Glucose Patterns
• Assess frequency and timing of any hypoglycemia, including nocturnal hypoglycemia and
possible rebound hyperglycemia.
• Ensure clients are familiar with strategies to prevent and treat hypoglycemia.
• Provide guidelines to monitor ketones (in those who are high risk) during periods of
hyperglycemia or illness.
• Provide the client with guidelines for when to notify the Registered Nurse or physician.
• Ensure the client is aware of the need to contact the physician when one of the following
occurs:
Hyperglycemia with ketones (moderate or large) and/or illness
Experiences recurrent hypoglycemia with no apparent cause or severe
hypoglycemia requiring assistance to treat
Is unable to eat or drink (for any reason)
Is vomiting or has persistent nausea
Blood glucose levels continue to fluctuate with no apparent cause
Hyperglycemia is not responding to increases in insulin dose
Variable Insulin Dose Adjustments

Two types of IDA may be used:
a. Correction Factor - adjustment of the insulin dose to correct for a high or low blood
glucose level.
b. Insulin to Carbohydrate Ratio - adjustment of the insulin dose in advance of
carbohydrate intake based on carbohydrate content of the meal or snack.
Use of Correction Factors 31

Short or rapid-acting insulins may be given according to a correction factor to compensate for
a pre-meal blood glucose above or below target. In some literature this is also referred to as
the insulin sensitivity factor.
For those who eat consistent carbohydrate only, a correction factor guides a person to make
adjustments to the usual dose of short or rapid-acting insulin according to pre-meal blood
glucose levels.
For those who count carbohydrate, the pre-meal dose of short or rapid-acting insulin is
determined by use of both the correction factor for glucose levels above or below the target
AND the amount of carbohydrate to be consumed at the meal.
31
In resources and the literature many terms are used in place of “correction factor”. These include:
insulin sensitivity factor; insulin grid or scale; algorithm.
March, 2009
Correction factors must be designed on an individual basis taking into consideration the
person’s:
• target blood glucose range
• sensitivity to insulin
• total daily dose of insulin
• insulin type – short or rapid acting insulin
IDA to the base insulin dose should not be made if the person has a concurrent illness or is
experiencing stress.
Use of rapid or short-acting insulin at bedtime is not usually recommended because of the risk
of nocturnal hypoglycemia. However, a conservative dose of short or rapid-acting insulin can
be used for an excessively elevated blood glucose reading at bedtime. Use of rapid or short-
acting at bedtime may be indicated if glucose levels are high and ketones are present or if the
individual routinely has a large bedtime snack. Use of this insulin at bedtime should be
discussed with the physician.
Any change to a pre-existing correction factor should be sent to the attending physician using a
progress note or fax information sheet.
Methods to Develop Correction Factors
The basic principles to remember when developing a correction factor are:
1. Consider the individual’s target range for glucose control and willingness to supplement for
values out of the target range.
2. Teach your client to adjust the appropriate basal dose of insulin or the insulin to
carbohydrate ratio if they have to correct regularly.
If your client has not seen a dietitian in some time and you suspect inconsistency in
carbohydrate intake or difficulties with counting carbohydrate, refer the client to a dietitian.
Consider how sensitive your client is to rapid or short-acting insulin when developing the
correction factor. Construct the factor conservatively (that is, err on the hyperglycemic side
initially), evaluate for effectiveness, and revise if necessary.
3. A correction factor is effective when:

• Using short-acting insulin, the blood glucose returns to target range (ideally 4-7 mmol/L)
prior to the next meal/snack ie: in 4 to 6 hours.
• Using rapid-acting insulin, the blood glucose returns to target range as with short-acting
insulin. The 2 hour pc reading is also useful when making initial IDA.
March, 2009
There are two methods which can be used to develop a correction factor 32,33 .
1. The Rule Method

Divide either 100 (for rapid-acting insulin) or 85 (for short-acting insulin) by the person’s
TDD (total daily dose). The resulting number represents the drop in blood glucose for each
unit of insulin.
Note, it may be appropriate to use the rule of 85 for those who are insulin resistant no
matter which type of insulin is being used.
EXAMPLE:
TDD = 48 units
100/48 = 2.08, rounded to 2 mmol/L
This means 1 unit of rapid-acting insulin will drop the blood glucose by 2 mmol/L.
2. Use a pre-set standard of 1 to 3 units for 2.2 to 2.8 mmol/L desired change in the blood
glucose level. Start conservatively using 1 unit and increase based on feedback from the
blood glucose readings.
EXAMPLE:
In the example below, a correction factor of 1 unit has been used for every 2 mmol/L
above the target glucose.
PRE-MEAL GLUCOSE TWO HOURS POST-MEAL

(using rapid-acting insulin and a consistent carbohydrate intake)
10.2 14.6
9.5 15.8
11.3 13.5
If the correction factor is working, the post-meal glucose will be at about the same level or
slightly lower than the pre-meal glucose. This assumes a consistent carbohydrate intake and
that the usual dose provides the correct ratio of insulin to carbohydrate. The next step
would be an increase in the pre-meal correction factor to 2 units for every 2 mmol/L above
the target. Pay attention to the next pre-meal blood glucose as it can be difficult to achieve
target post-meal glucose without making the next pre-meal glucose too low.
32
Sources: Building Competency in Diabetes Education: Advancing Practice, p2-41 to 2-43 and Lightfoot,
C and Pytka ES (2004) Making Carbs Count: Advanced Carbohydrate Counting for Intensive Diabetes
Management. Seminar presented at the 2004 CDA Professional Conference, Quebec City, Quebec.
Available on CDA website, DES members section www.diabetes.ca
33
See practice cases for exercises to develop correction factors.
March, 2009
Using the Correction Factor

Once a correction factor has been determined, the client can use it in two ways. Clients who
find math a challenge will likely prefer the second method.
1. Calculation for each blood glucose reading

To use this method the individual
• does a pre-meal blood glucose test
• subtracts the target blood glucose from the result
• divides by the correction factor
EXAMPLE:
Current blood glucose level pre-noon = 11.9 mmol/L
Target blood glucose level = 7 mmol/L
Correction factor = 2 [one unit of insulin lower glucose by 2 mmol.]

(11.9 – 7)/2 = 2.4 units, rounded to 2 units
This amount of insulin will be added to the usual dose or the amount of insulin being taken for
the carbohydrate to be eaten at the meal.
2. Written grid or scale for insulin IDAs

Using this method the educator will create a grid for the client to use based on the
correction factor. The grid indicates the number of units to be added to or subtracted from
the base dose.
EXAMPLE:
The TDD is 50 units. 100/50 = 2 [rule method]
1 unit will decrease blood glucose by 2 mmol/L
Dose of rapid or short-acting insulin Intermediate or

Long-Acting Insulin
BLOOD GLUCOSE Morning Noon Supper
Lantus 22 units at
< 4.0 -1 -1 -1 bedtime
TARGET RANGE
4.1-7.0 6 10 12 Usual doses
7.1-9.0 +1 +1 +1
9.1-11.0 +2 +2 +2
11.1-13.0 +3 +3 +3
13.1-15.0 +4 +4 +4
>15.1 +5 +5 +5
March, 2009
For some clients it is necessary to write in the actual dose rather than the amount to be added
to the usual dose. In this situation the values in the morning column would read: 5, 6 (usual
dose), 7, 8, 9, 10, and 11 respectively.
Two more rows can be added to the grid for clients who are carbohydrate counting:
• A line for the usual carbohydrate at the meal
• A line for the insulin to carbohydrate ratio
Insulin to Carbohydrate Ratio
If a person is planning to eat a variable amount of carbohydrate at meals he can “anticipate”

the resulting variability in blood glucose and minimize it by decreasing or increasing the pre-
meal dose of short or rapid-acting insulin.
Remember carbohydrate to insulin ratios vary from person to person and may differ from meal
to meal. For example, some individuals are more insulin resistant at breakfast than at supper.
An insulin resistant person may require 5 gms of CHO per unit of insulin as compared to a thin
or fit person or a child needing 20 gms of CHO per unit. Experimenting to get the right ratio
requires some time and effort involving frequent blood glucose monitoring and documentation
of food intake.
The advantages of using the method are:

a. greater flexibility and quality of life
b. decreased risk for disordered eating.
c. reflects more normal eating practices where people gauge how much food they are
hungry for, rather than a set amount they have to eat.
The disadvantages of this method are:

a. hypoglycemia if the anticipated rise in blood glucose does not occur. Clients should be
reminded that a compensatory correction can be safely made at the next meal time.
b. weight gain if a person frequently increases insulin to allow for extra food.
NOTE:
Initially, it is suggested that carbohydrate content at meals and snacks remain consistent when
first establishing insulin to carbohydrate ratios. Once a baseline is established, greater flexibility
and variability of carbohydrate intake will be possible.
There are three methods to determine the insulin to carbohydrate ratio:
1. Pattern Management. This method can be used when the amount of insulin taken provides
adequate control based on changes in pre versus post-meal blood glucose of no more than
3 mmol/L at 1 hour pc .
Divide the number of grams of carbohydrate taken at a meal by the number of units of
insulin given at the meal. The result will yield: 1 unit of insulin per xx grams of
carbohydrate.
March, 2009
EXAMPLE
Meal time carbohydrate = 66 grams
Meal time insulin = 7 units

66/7 = 9.4
Therefore, 1 unit of insulin would be taken for every 9 grams of carbohydrate.
2. Rule of 500
In this method 500 is divided by the TDD
This method will yield the same insulin to carbohydrate ratio for all meals. IDA may be
needed based on actual results, observations of “what works” and use of method #1.
EXAMPLE
TDD = 63 units
500/63 = 7.9
3. Averages of Pre-meal insulin and carbohydrate intake
In this method:
• the bolus or pre-meal insulin doses are added for the full day.
• the amount of carbohydrate average/day is determined.
• the carbohydrate/day is divided by the total pre-meal or bolus insulin.
EXAMPLE:
Total pre-meal or bolus insulin/day = 28 units
Average grams of carbohydrate eaten/day = 140 grams

140/28 = 5.0

March, 2009
1.0 Insulin Dose Adjustment for Exercise or Increased Physical

Activity
IDA for exercise or physical activity depends heavily on your client’s response to insulin, the
intended activity and its timing in relation to food and insulin. Thus, blood glucose monitoring
is required to ensure safe and effective IDA. Physical activity may enhance the effect of
exogenous insulin by increasing glucose uptake by muscle cells and intracellular glucose
metabolism. The temporal effect on blood glucose levels will vary depending on the person and
intensity and duration of activity. Depletion of glycogen stores may occur with moderate to
intense exercise and may result in hypoglycemia many hours after exercise. For some this can
be as long as 24 hours. It is important to note that recognition of hypoglycemia may be delayed
during vigorous exercise due to the masking of early warning signs.
1.1 Guidelines for IDA for exercise are:
a. People with type 1 diabetes who have a urine ketone level > 8.0 mmol/L or blood
ketone level > 3.0 mmol/L 34 should not exercise. Metabolic deterioration will occur
with exercise.
b. Blood glucose monitoring should be employed initially before, during and after new
exercise routines to determine its effect on glycemic levels for the individual.
c. Exercise at consistent times of the day will facilitate more reliable IDA.
d. Compensatory food intake may be used to prevent hypoglycemia without IDA or as

an adjunct. The client should have a source of short-acting glucose available during
exercise. See accompanying table. Adequate hydration is also important.
e. Anticipatory IDA for exercise without compensatory carbohydrate intake may be

recommended as follows 35 . These are guidelines and will need to be evaluated with
each individual.
f. Insulin injection into an exercising limb may speed insulin absorption and action. If
possible, Insulin should be injected into a non-exercised part of the body prior to
exercise; for example, inject in the abdomen rather the leg before running.
g. Following prolonged exercise, subsequent meal doses of rapid or short-acting

insulin may need to be reduced by 20-50%. 36
i. IDA may also be needed to the basal insulin dose(s). The bedtime basal insulin may
need to be decreased by 10-30% followed prolonged endurance exercise, particularly
if this has happened during the evening.
34
2008 Clinical Practice Guidelines, page S48
35
Rabasa-Lohoret R, Bourque J et al. Guidelines for Premeal Insulin Dose Reduction for Postprandial
Exercise of Different Intensities and Durations in Type 1 Diabetic Subjects Treated Intensively with
Basal-Bolus Insulin Regimens (Ultralente-Lispro). Diabetes Care 2001;24(4):625-630.
36
Jones H. editor. (2009). Building Competency in Diabetes Education: The Essentials. Diabetes
Educator Section, Canadian Diabetes Association: Toronto, Ontario.
These are only initial conservative recommendations to be evaluated by blood glucose monitoring and revised as necessary.
Exercise Time Immediately post-meal Morning or Afternoon Very early in morning Post Prolonged activity*
Insulin Type Pre-meal Bolus Morning Basal Previous evening basal Meal or Basal
Intensity of Exercise ↓
Mild 30-50% Post activity pre-meal
Moderate 20-50% Adjust with exercise No more than 50% doses, may reduce by
Strenuous 50% intensity reduction 20-50%
Trained athletes may Adjust with exercise
Prolonged > 3 hours* Up to 80%
require up to 80% intensity Bedtime basal insulin,
reduction may reduce by 10-30%
* Prolonged activity may have a delayed glucose lowering effect.
Source: The Essentials, 2009, Chapter 10.

Extra Food For Extra Exercise 37
Adult Guidelines – must be adjusted for pediatric clients
You may have already taken less insulin. However, you may need to eat extra food depending on
your blood glucose results before you start exercising – always test! The following table tells you
how much food to eat. Remember, these are only guidelines.
Table 2
Exercise Blood Glucose Carbohydrate Amount
Levels
Light Less than 6 mmol/L 15 grams
for one hour
(Walking, Bowling)
Moderate Less than 6 mmol/L 30 grams of carbohydrate

for one hour before exercise. An additional
(Tennis, Cycling, 10–15 grams of carbohydrate is
Swimming, Sexual required for each additional
Intercourse, House hour.
Cleaning, Golfing) 6 – 10 mmol/L 15 grams of carbohydrate
11 – 17 mmol/L Food intake should not be

increased.
Moderate urine Do not exercise until diabetes
ketones >8 mmol/L control improves.
or blood ketones >3
mmol/L are present
Strenuous Less than 6 mmol/L 45 grams of carbohydrate
for one hour before exercise. An additional
(Hockey, 10-15 grams of carbohydrate is
Racquetball, required for each additional
Football, hour.
Competitive Sports) 6 – 10 mmol/L 30 grams of carbohydrate
NB. Small amounts 11 – 17 mmol/L 15 grams of carbohydrate

at frequent intervals [no ketones]
are preferable for
prolonged activity Moderate urine Do not exercise until diabetes
ketones >8 mmol/L control improves.
or blood ketones >3
mmol/L are present
37
Original from Learning to Live With Diabetes Nova Scotia Diabetes Centre. Revised and updated based
on Clinical Practice Guidelines and Beyond the Basics, CDA (2005).
March, 2009
Teaching Procedure For Self-Adjustment Of Insulin
Learning Objectives
Upon completion of this chapter you will be able to:
• Teach clients to self-adjust their insulin taking into consideration their age, concurrent medical
conditions and lifestyle.
Principles
1. Assessment of the client on insulin should include their willingness and ability to learn SMBG,
interpretation of results, and to self-adjust medication when indicated.
Potential barriers to the learning process may preclude the client being able to effectively
adjust their own insulin dosages. These could include but are not limited to:
a. unable to afford SMBG
b. unable to understand necessary concepts, e.g. insulin action times, target
blood glucose range, etc.
c. unable to analyze abstract data, e.g. relationship of SMBG results to
specific insulin action, identification of blood glucose trends, etc.
d. unable to take action to make necessary IDA due to
insecurity or unwillingness to take over perceived medical function.
2. Self-adjustment of insulin can be taught in a group setting or on an individual basis.
3. The 2008 Clinical Practice Guidelines should be used for target ranges for blood glucose
control and IDA subject to individual needs.
These guidelines are subject to individual variation related to factors such as the client’s age,
concurrent medical conditions, long-term complications of diabetes, and ability to perceive
early warning signs of hypoglycemia.
4. Principles for IDA teaching must take into account the individual client’s response to their
insulin. General guidelines based on the usual or ‘mean’ response pattern are useful for group
instruction and for individuals until specific variation in insulin response is determined.
Review the time actions the client’s own insulins and present these in relation to his or her
own lifestyle. Consider usual meal times and insulin injection times. Examples of resources are
in the reference section.
5. General guidelines that can be provided to clients for self-adjustment include:
a. Before making insulin adjustments, review consistency of carbohydrate intake at

meals and snacks and/or accuracy of carbohydrate counting
b. Look for patterns of high/low blood glucose results at specific times of the day.
• If the patterns are explainable, make the appropriate change in diet, activity, etc.
• If the patterns are unexplainable adjust the appropriate insulin by a factor of 10%.
March, 2009
c. Monitor blood glucose before and 2 hours after meals while making IDA and evaluate
the result of specific IDA over the following three to four days.
d. Only make IDA every 3 to 4 days, except in unusual circumstances such as illness,
pregnancy, travel, excessive hyperglycemia, or hypoglycemia. In such cases, consult
your Registered Nurse or doctor.
e. Compensate for high or low blood glucoses if your Registered Nurse or doctor has
provided you with a correction factor for rapid or short-acting insulin. The extra insulin
with the correction factor must be included in your evaluation of patterns of
hypo/hyperglycemia.
f. If self-adjustments do not improve the identified problem consult your Registered Nurse
or doctor.
6. Sick Day Management. Contact your doctor in the event of illness for further specific IDA
guidelines. 38
7. Principles for IDA for exercise include:
Monitoring of blood glucose is essential in determining the need for insulin and/or food
compensation for exercise. Insulin or food adjustments for exercise are best evaluated by
SMBG before, during, and after exercise. Once a satisfactory pattern of glycemic response
to exercise and insulin/food adjustment is obtained, less frequent monitoring is required.
a. Exercise is not recommended if urine ketones are > 8 mmol/L or blood ketones >3
mmol/L.
b. Decrease the insulin that will be working at the time you plan to exercise. Use the
guide from your Registered Nurse or doctor when making changes 39 .
c. Revise IDA as required to optimize blood glucose control.
d. Other information to give clients for exercise:
• When you exercise, always carry some form of sugar, such as glucose tablets,
juice, lifesavers or hard candy.
• Never drink alcohol around the time you exercise as it can result in low blood
sugar.
• Dehydration, especially in hot weather, can be very serious if your diabetes is in
poor control. Prevent dehydration by drinking water before, during and after
exercise.
38
The Registered Nurse receiving such a request will communicate with the physician to coordinate care
relative to the illness and need for additional rapid or short-acting insulin. The additional insulin must
take into account the presence or absence of ketones. Insulin adjustment for acute illness is not part of
the basic Transfer of Medical Function.
39
Refer to information in the Learning/Procedure module which can be modified as a client handout. Also
see Additional Resources at the end of Module
March, 2009
• If you reduce your insulin and are unable to exercise, your blood sugars will be
high that day.
8. Taking extra rapid or short-acting insulin in anticipation of a special meal/food, e.g. birthday,
special meal, etc. can prevent hyperglycemia post meal or later in the day. Blood glucose
monitoring to evaluate effectiveness is recommended.
March, 2009
PRACTICE CASES
The following cases are to be completed after reviewing the Learning and Procedure
Module. If there is a provincial workshop, there will be discussion of the cases at the
workshop. Or, the diabetes educator can review the cases with a qualified physician
and/or an experienced diabetes educator colleague. Answers are provided at the end of
this section for each case.
Review each of the following cases and provide an answer with rationale. Also
consider what questions you might ask a client in each of these situations.
CASE #1
Sarah is 60 years old with type 2 diabetes. She has been using insulin for about one year and has
had diabetes for 8 years. Her eating and activity patterns were recently assessed and are
relatively consistent from day to day. Her last A1C reading was 7.2%. She weighs 165 lbs (75 kg).
INSULIN DOSE: N 15 units at bedtime
Date Before Post Post Noon Post Bedtime

Breakfast Breakfast Supper
June 10 7.6 9.8 7.5 8.1
June 13 8.6 8.6 5.0 5.2 6.0
June 16 7.2 8.8 9.1 9.9
June 20 7.8 7.8 6.9 4.7 6.3
Eating pattern as assessed by a dietitian:

Carbohydrate distribution
- breakfast – 50 grams
- lunch- 60 grams
- pm snack – 15 grams
- Supper – 65 grams
- hs snack – 30 grams
What variables would you consider in client assessment?
What insulin dose adjustments would you consider?

March, 2009
CASE #2
This continues the story with Sarah from Case #1, now 6 months later. She has increased her
bedtime N to 22 units and her fasting blood glucose levels are consistently below 7 mmol/L. The
following pattern has emerged in her blood glucose levels over the past four weeks.
INSULIN DOSE: N 22 units at bedtime
Date Before Before Before Bedtime Other

Breakfast Lunch Supper
Jan 10 6.7 5.0 4.5 8.5
Jan 13 6.8 5.0 5.2 9.0
Jan 16 5.2 5.3 6.0 9.2
Jan 20 5.8 6.9 4.7 9.3
What variables would you consider in client assessment?
What insulin dose adjustments would you consider?

March, 2009
CASE #3
Continuing with Sarah from cases 1 and 2, you have reviewed the variables suggested in the
answer for Case 2 and found she will not be able to decrease the evening glucose level through
changes in eating or activity. You have requested a physician order for pre-supper rapid-acting
insulin. The physician agrees and asks you for your suggestion for an amount of insulin.
You know that Sarah usually eats about 65 grams of carbohydrate at supper and works hard to be
consistent with this amount. She is not physically active in the evening as she does not want to
drive in the evening and has other interests to keep her occupied.
What would you recommend and what would be your rationale for this
recommendation?
What follow-up plan would you make with Sarah for ongoing IDA to the pre-
supper rapid-acting insulin?
March, 2009
CASE #4
John is 50 years old, works as an accountant. He has been on insulin for 10 years and has had
diabetes for 12 years. His BMI is 24.
INSULIN DOSES:
• Breakfast Humalog 7 units
• Noon 0
• Supper Humalog 10 units
• Breakfast Humulin N 28 units

• Bedtime Humulin N 8 units
The following values represent typical log book entries

Oct 24 2.0 4.8 4.8 6.8
Oct 25 16.9 12.2 8.1 5.4 Low during
the night
Oct 26 7.1 7.6 5.9 6.2
His doctor would like to switch him to an extended long-acting insulin analogue (Lantus) and asks
you to recommend a dose. John says he prefers taking the long-acting insulin at bedtime.
State the dose you would recommend and your reasons.
What advice will you give John in terms of what he might expect to see in his
glucose readings when he makes the switch?
March, 2009
CASE #5
This case continues with John from Case #4. He is now using Lantus 32 units at bedtime, no
longer has night-time or fasting hypoglycemia and his fasting glucose levels are usually between
5-6 mmol/L.
However, his pre-supper blood glucose levels are slowly rising. He has omitted his afternoon snack
to help compensate, but the glucose readings at supper remain elevated. Prior to the insulin
change, they were usually below the target of 7, now they are usually 8-9 mmol/L and
occasionally higher. His noon carbohydrate varies from 60-80 grams.
What advice would you give about the amount of H to use at noon?
Explain your recommendation.

March, 2009
CASE #6
John from Cases 4 and 5 has followed your advice and it has worked out well. His usual doses of
insulin in a day are
Breakfast Humalog 7 units
Noon Humalog 8 units
Supper Humalog 10 units
Bedtime Lantus 32 units
He occasionally changes his carbohydrate intake, but adjusts his insulin accordingly. He does not
snack between meals.
He now says he would like to be able to “fix” the high blood glucose levels which he gets from
time to time. Usually he cannot explain them and he finds this frustrating.
Use the “rule method” to calculate the correction factor.
Create a grid for John’s breakfast insulin dose.
If John does not want to carry around a grid, write down the calculation he
would use if his fasting blood glucose reading is 12.6 one morning.
What would be different in this calculation if John was using a short-acting

insulin rather than a rapid-acting insulin?
March, 2009
CASE #7
Mike is 39 years old with type 2 diabetes. In the past two months Mike says that whatever he
tries, he can’t get his blood glucose levels under control. He has gone back to his meal plan and
followed it fairly faithfully. This is confirmed by a visit to the dietitian. He walks in the evening 2-3
days per week. His weight is 165 lbs (75 kg); height is 71 inches (180.3 cm). His A1C one month
ago was 10.5%
INSULIN DOSES
• a.m. Humulin N 30 units
• supper Humulin N18 units

Monday 10.9 8.9 16.4 12.3
Tues 17.2 12.6 11.1 10.9
Wed 15.8 13.2 12.7 14.5
What insulin changes would you recommend to this gentleman?

March, 2009
CASE #8
Milly Smith has had diabetes for 22 years. She has been on insulin for the past 15 years.
She has had high fasting readings for a few weeks. In the last week she has been
increasing her pre-supper N, but the high readings continue in the morning. She also has
been having restless sleeps and morning headaches.
INSULIN DOSES:
• pre-breakfast: Humulin R 6 units and Humulin N 24 units
• pre-supper: Humulin R 3 units and Humulin N12 units
Does Milly need any insulin adjustment?

March, 2009
CASE # 9
Fred is a 58 year old lean male (70 kg.). He has a 6 year history of type 2 diabetes. He tests
regularly and has regular contact with the dietitian who confirms that he has a consistent
carbohydrate intake. It has been 1 year since initiation of insulin therapy. He hates insulin
injections. He has several complaints when he comes to see you:
• morning hyperglycemia
• mid-afternoon hypoglycemia
• nocturia, decreased sleep
INSULIN DOSE:
• single injection NPH 80 units before breakfast
What changes would you consider?

March, 2009
CASE # 10
Joe is a 36 year old sedentary Assistant Manager in a meat packing plant and has had diabetes
since age 24. His sister with diabetes is developing retinopathy and he is anxious to learn more
about his diabetes and improve his control. He has no complaints and feels well.
He is 4 kg. above his healthy weight and would like to lose some weight. He is on no specific diet
and can recall no dietitian contact, but he says that he eats “regular” meals and quantities. He is
taking
• Humulin R10 units and Humulin N 35 units each morning
• Humulin N 25 units at supper.
Glucose patterns on a three day per week before meal and bedtime snack testing routine are as
follows:

4.4 11.1 7.8 8.9
4.4 16.7 7.9 11.1
6.7 15.8 8.9 6.7
4.4 16.7 6.8 11.7
2.2 16.7 9.1 16.7
6.7 11.1 11.1 16.7
What would you discuss with him and what possible recommendations might
you make regarding his insulin dose?

March, 2009
CASE # 11
Joe has decided to do carbohydrate counting and has made some dietary changes to reduce his
weight. Review his food records on the following page and calculate the total carbohydrate intake
for each meal. As a reference use Beyond the Basics (2005).
MEAL FOOD EATEN # grams TOTAL CHO PER

of carbs MEAL/SNACK
Basal Insulin
Breakfast 2 toast, whole wheat
Time: 0615 hrs 2 tsp. jam (regular)
BG: 4.4 6 ounces unsweetened orange juice
Two hour BG:
Activity At work – sitting
Snack Orange
Time:
BG
Lunch Sandwich:
Time: 1200 hrs 2 slices of bread, whole grain
BG: 2 slices cheese or ½ cup salmon
2 tsp margarine
lettuce and tomato slice
Apple, orange or banana, medium
1 cup skim milk
Snack Oatmeal granola bar
Time:
BG
Supper Meat or fish about 3 ounces
Time: 1 cup potatoes
BG: Broccoli , 1 cup
1 slice bread, whole grain
yogurt, skim w artificial sweetener,
¾ cup
½ banana, small
March, 2009
CASE #12
Joe is now comfortable with carbohydrate counting and has started using some pre-meal rapid-
acting insulin based on the amount of carbohydrate he eats. He is now using Lantus at 10 pm as
his basal insulin
• For each meal calculate the insulin to carbohydrate ratio using the food record
below [see bottom] and then fill in the insulin to be taken at the meal.
• Comment on the appropriateness of the calculated ratio. Assume the single bg

values given here represent the usual pattern of bg results.
MEAL FOOD EATEN # grams INSULIN

of carbs TAKEN
Basal Insulin 0
Breakfast 2 toast, Rapid 12 units
Time: 0615 hrs 2 tsp. jam (regular)
BG: 4.4 ½ grapefruit
Two hour BG: 9.8
Snack 1 cup carrot & celery sticks
Time: 2 tbsp low fat dip
BG
Lunch Sandwich: Rapid 10 units
Time: 1200 hrs 2 slices of bread
BG: 5.3 2 slices cheese or ½ cup salmon
2 tsp margarine
lettuce and tomato
Apple, orange or banana
1 cup chocolate milk
Snack
Time:
BG 12.3
Supper Meat or fish about 3 ounces Rapid 10 units
Time: 1 cup potato salad
BG: 10.8 corn, 1 cup
1 slice bread
¾ cup
½ banana, small
2 hour BG: 13.6
Basal Insulin Lantus 32 units
Bedtime 1 apple
Time: 10 p.m.
BG: 6.7
Insulin:carbohydrate ratio is ___ units for ___ grams of carbohydrate or ____units (breakfast)
Insulin:carbohydrate ratio is ___ units for ___ grams of carbohydrate or ____ units (lunch)
Insulin:carbohydrate ratio is ___ units for ___ grams of carbohydrate or ____ units (supper)
Insulin:carbohydrate ratio is ___ units for ___ grams of carbohydrate or ____ units (bedtime)
March, 2009
CASE #13
Joe is getting very good at counting CHO and deciding how much insulin to take. He is
disappointed with some of his pre-meal glucose levels. He asks you what he can do to correct
some of the high pre-meal levels. Assume his
• target glucose level is 7
• insulin:CHO ratio for supper is 1:10
• TDD is usually ~ 70 units/day
What is his correction factor?
Write in any correction insulin doses you would recommend using the same
chart below.

of carbs TAKEN
Supper Meat or fish about 3 ounces Meal Bolus:
Time: 1 cup rice Correction:
BG: 10.8 salad TOTAL Taken:
corn, ½ cup
1 slice bread
¾ cup
½ banana, small
2 hour BG:
Bedtime Time:
10 p.m.
BG: 6.7
March, 2009
CASE # 14
Jeff, a 30 year old salesman is fairly inactive and has type 1 diabetes of ten years duration. He is
moderately obese, some 8 kg. overweight and slowing increasing. He would like to drop a few
pounds. He typically eats three meals and three snacks.
INSULIN DOSES: (Novolin)

Breakfast: Novorapid 10 units
Noon: Novorapid 6 units
Supper: Novorapid 12 units
Bedtime: Levemir 26 units
90% of his blood glucose tests are in the 4-8 range and exceptions are usually explained by
food and activity variations. His last A1C was 6.9%
He plans to take up his old school sport of basketball – two hour practice on Monday from 7-9
p.m. and weekly game 2:30-4:30 p.m. on Saturdays.
What advice does he need to leave him safe for the new exercise pattern?
March, 2009
CASE # 15
Karen is 78 years old, lives alone and has had type 2 diabetes for 12 years. Her weight is ~151 lbs
(68.5 kg) and height is 61” (155 cm). She has had no problems with hypoglycemia recently. In the
past she has had mild hypoglycemia and 6 months ago she had an unrecognized low blood
glucose level. Her neighbor called 911. She has seen a dietitian recently and her carbohydrate
intake is usually consistent from day to day. A daily afternoon snack has been recommended. In
addition to diabetes she has had a myocardial infarct 2 years ago, has hypertension (now
controlled) and dyslipidemia (now controlled).
Present Medications
• Metformin 1000 mg bid
• NovoMix 30, 28 units, pre-breakfast
• NovoMix 30, 16 units, pre-supper
Recent blood glucose readings:

10.5 7.8 3.4 8.0
9.2 8.3 4.0 7.2
11.1 7.1 2.8 6.9
Carbohydrate intake distribution (as assessed by the dietitian)

• Breakfast - 30 grams
• Lunch - 60 grams
• Snack 0 – 15 grams
• Supper - 45 grams
• HS - 30 grams
What target glucose level would you set with Karen and her physician?
What does the current dose of 28 units of NovoMix 30 represent in terms of

types of insulins and how many units of each insulin does this dose represent?
What changes, if any, would you recommend to her current medications?
What might you consider if the first issue or problem you identify is resolved?
March, 2009
CASE #16
Karen has taken care of the first problem you identified in Case #15. All her circumstances remain
unchanged. Use the medication doses from the answer to case #15 here. See the current blood
glucose pattern below.

10.5 7.8 7.4 8.0
9.2 8.3 7.0 7.2
11.1 7.1 7.8 6.9
What suggestions do you have to help Karen achieve target glucose levels?
March, 2009
CASE # 17
Mary is a 65 old female. Her weight is 176 lbs (80 kg) and her height is 63” (160 cm). She has
had type 2 diabetes for 10 years and started insulin one year ago. Her most recent A1C = 9.4%.
She has found blood glucose levels to be increasingly difficult to control and is gaining weight.
Blood glucose readings are 10-12 across the day with little variation. She is already on a maximum
dose of metformin.
INSULIN DOSES: Novolin 30/70 using an insulin pen

• 40 units at breakfast
• 35 units at supper
What changes can you suggest?

March, 2009
CASE # 18
Stan is a 36 year old lean male, weight 147 lbs (67.0 kg), height 68½” (174 cm). He has had
Type 1 diabetes for two years. His carbohydrate intake is consistent at each meal. He has seen a
dietitian recently.
Meal plan - 2500 calories with the following carbohydrate intake:

• Breakfast - 105 grams
• Lunch – 90 grams
• Pm snack – 30 grams
• Supper – 75 grams
• HS - 45 grams
Stan prefers not to have a mid morning snack, but likes having one in the afternoon and a more
substantial one in the evening.
Insulin regime: N 35 units at h.s. and Humalog at each meal using the following grid:
Blood glucose a.m. Noon Supper

<5 10 6 12
5.1 – 7 11 7 13
7.1- 9 12 8 14
9.1- 11 13 9 15
11.1-13 14 10 16
13.1-15 15 11 17
>15 16 12 18
Stan’s present blood glucose pattern is:

• High fasting blood glucose
• High blood glucose at 10 p.m.
• Lows in mid-morning to noon
He monitors his blood glucose closely and frequently and makes insulin changes based on meal
pattern and activity levels. He usually works long hours at a physically demanding job.
What changes would you recommend?
END
March, 2009
ANSWERS TO PRACTICE CASES
ANSWER – CASE #1
As the case states her eating and activity patterns are consistent from day to day, you might also
consider:
• Does she always have the snack at bedtime (30 grams)?
• Accuracy of blood glucose monitoring
• Accuracy in her use of her insulin measurement and delivery system
IDA: increase the bedtime N by 10% or 2 units to reduce fasting glucose. Sarah could be taught
to make changes every 3-4 test days until she finds her fasting blood glucose readings below 7
mmol/L
It would also be important to review the symptoms, treatment and prevention of hypoglycemia
with the anticipated improvement in control.
ANSWER - CASE #2:

Assuming there were no issues with her insulin measurement/injection technique or blood glucose
monitoring, you might also review:
• Her usual food intake at supper is 65 grams of carbohydrate (from case #1)
o Has anything changed recently?
o Is the client accurate with her carbohydrate counting?
o Is the amount consistent from day to day or variable?
• What is her evening activity level? Has this changed in the past month? Has she noticed
that physical activity in the evening will improve her bedtime readings? What evening
activity is she willing to consider, if any?
IDA to consider if improvement in glucose levels at bedtime are not found in eating or activity
strategies: addition of rapid acting insulin pre-supper.
The Transfer of Function does not cover initiation of a new insulin regimen so the Registered
Nurse would need a physician order to make this change.
March, 2009
ANSWER - CASE #3
As Sarah has not taken rapid-acting insulin pre-meal before, her sensitivity to this insulin is not
known. To get a “ball park” idea the amount of insulin you could use the Rule of 500 (see Chapter
IV, Section D in module).
At present her TDD is 22 units.

500 ÷ 22 = 22.7, rounded to 23
Therefore, according to the calculation, Sarah would take 1 unit of insulin for every 23 grams of
carbohydrate.
Her supper carbohydrate is 65 grams

65 ÷ 23 = 2.8
Therefore, you could recommend 2-3 units as the initial dose of rapid-acting insulin pre-supper.
The follow-up plan with Sarah could include the following:

• Record food or grams of CHO eaten at supper for a few days on the new insulin dose
• Test 2 hours post supper and at bedtime to assess the new insulin’s effectiveness
• If post meal glucose levels are not dropping to 10 or less, increase the dose of rapid-
acting insulin by 1 unit after 3 test days
• If evening glucose levels are too low or she has symptoms of hypoglycemia, reduce the
pre-supper dose of rapid-acting insulin by 1 unit
ANSWER - CASE #4
When switching from intermediate-acting insulin to Lantus, it is recommended that the total dose
of intermediate-acting insulin be reduced by 20% and the Lantus be given as a single dose. John
prefers to take this insulin at bedtime. An alternative could be a morning injection of long-acting
as Lantus is usually a once a day injection as long as it is given daily at the same time. The
following recommendations are based on the injection occurring at bedtime.
Total dose of N per day = 36 units

20% of this dose = 7.2 units
Recommended starting dose of Lantus = 29 units
Advice to John
1. First avoid hypoglycemia. If he has night-time or early morning hypoglycemia symptoms,
reduce the Lantus by 10% or 3 units.
2. Check a glucose level around 3 am to ensure he is not missing hypoglycemia.
3. If there is no hypoglycemia and after 3-4 days on the starting dose, the fasting glucose levels
are high (>7 mmol/L), increase Lantus by 3 units. Wait 3-4 days between each insulin
increase. He may wish to check another 3 a.m. glucose level before making further increases.
4. He may find his pre-supper glucose readings become elevated as he no longer has
intermediate acting insulin in morning. He will likely need to start on a pre-noon dose of H.
This change will require a physician’s order. Ask John to do some 2 hr pc lunch and ac supper
results, to determine whether he needs to start a pre-noon dose of H. This information will be
valuable for the physician to determine what he needs to order.
5. If he is presently taking an afternoon snack, keep it in for now, but the need for the snack
should be reassessed.
6. Review the treatment and prevention of hypoglycemia with John.
March, 2009
ANSWER - CASE #5
Using the Rule of 500 to determine how many grams CHO for each unit of insulin.
TDD = 7 + 10 + 32 = 49
500 ÷ 49 = 10.2
Therefore, for every 10 grams CHO he would use 1 unit of insulin.
It will be easier to assess the effectiveness of this recommendation if he agrees to use close to the
same amount of carbohydrate for a few days. So, if he agrees to say about 70 grams, then he
would use 7 units of H pre-noon. Advise John to check his 2 hr pc noon meal blood glucose levels.
If the results fall between the target of 7-10, then it will confirm to John that he is using the
correct amount of insulin for CHO eaten.
If he seems unsure about carbohydrate counting or needs more information/support, make a

referral to the dietitian. . He has the option to add extra carbohydrate at his noon meal to
compensate for the extra calories he has lost with the elimination his afternoon snack.
ANSWER - CASE #6
First calculate John’s total daily dose
TDD = 7+10+8+32 = 57 units
Use the rule of 100 as he is using rapid acting insulin.

100 ÷ 57 = 1.75
This means 1 unit of insulin will drop his blood glucose approximately 1.75 mmol/L
To create a grid the 1.75, could be rounded to up to 2 mmol/L. If John has a history of severe low
glucose levels, hypoglycemia unawareness or is nervous about being “too low” you could use a
larger range for the dose changes; for example, 3 mmol steps. Or, you could set the target
glucose level higher; for example, to 8 mmol/L.
Grid using 1 unit will yield a decrease of approximately 2 mmol/L for morning insulin; the grid
would be as follows:
Blood Glucose Range Insulin Dose

< 4.0* 6
4.1 – 7.0 7
7.1 – 9.0 8
9.1 – 11.0 9
11.1 – 13.0 10
13.1 – 15.0 11
> 15.1 12
• Note: As part of client education, advise treatment of hypoglycemia and stabilization of

blood glucose level before taking insulin and before deciding on the dose. Some clients
may need less than the lowest amount on the grid.
March, 2009
If John does not want to use a written grid, he would proceed as follows:
Blood glucose = 12.6
Target glucose = 7
Difference = 12.6 - 7 = 5.6
Divide the difference by his correction factor: 5.6/1.75 = 3.2, rounded to 3
Add 3 units to his base dose of 7 = 10 units Humalog to be taken pre-breakfast
OR
He could use the rounded correction factor of 2 mmol/L drop for 1 unit of insulin
5.6 ÷ 2 = 2.8, round up to 3 additional units added to the base dose of Humalog.
If John was using a short-acting insulin, the TDD would be divided into 85 instead of 100.
So the calculation would be:
85/57 (total daily dose of insulin) = 1.5
The grid below for short-acting illustrates blood glucose ranges of 1.5 mmol and insulin dose
increments of one unit.
Blood Glucose Range Insulin Dose

< 4.0 6
4.1 – 7.0 7
7.1 – 8.5 8
8.5-10.0 9
10.1-11.5 10
11.6-13.0 11
> 13.1 12
ANSWER - CASE #7
Mike is currently using a TDD of 48 units of insulin. This is about 0.6 units per kg and it is all basal
insulin with no insulin for his meals. The usual expected insulin requirement is about 0.5 to 1.0
units/kg. His BMI is 23 so you would not expect insulin resistance and a higher dose needed
related to his weight.
He could increase his doses of N further, but considering his A1c and his only insulin is basal
insulin, he would likely gain greater benefit from starting to use pre-meal insulin.
Review current his current patterns in his blood glucose records. The overall picture is too high.
• Highest pattern is fasting with a bedtime to fasting rise.
• Breakfast to noon – a decrease by noon although not to target.
• Noon to supper – pattern remains similar (1 elevation by supper, could explore reason).
• Supper to bedtime – general lowering, although not to target.
For extra information to guide IDA, could also suggest Mike check blood glucose 2 hrs pc when
pre-meal blood glucose levels come closer to target.
Discuss with Mike his thoughts on the use of rapid/short-acting insulin with meals. As he has only
used intermediate insulin, he may be anxious about using these insulins.
March, 2009
Possible choices to manage patterns– these may need to be done in steps, as Mike is ready.
• Increased fasting blood glucose level – with an average 5 mmol/l rise overnight, if this was
lowered, it may assist with noon and other times of the day as a domino effect occurs.
Since N at supper is already fairly large, consider moving the N to bedtime. He may be
more comfortable with decreasing it 10% initially until he gains experience with this move.
Consider with this move the effect on the breakfast to noon blood glucose level pattern.
• With this move, some rapid or short-acting insulin will be required at supper. RNs need to
keep current with EDS requirements of the Saskatchewan Drug Plan.
• You will need to determine how much of the short or rapid-acting insulin to start to cover
the supper carbohydrate intake. A dietitian will be able to help you determine his usual
intake. You could begin with a conservative estimate of 1 unit for 20 grams of
carbohydrate and adjust as needed.
• To determine the correction dose of rapid or short-acting insulin, consider the rule of 100
for rapid or 85 for short: 100/48 = 2.08, round to 2. 1 unit of insulin will decrease the
glucose level by 2 mmol/L. His insulin grid will change by 2 unit increments.
• See what this move does however it is likely that Mike will also need to consider using
some meal insulin at other times of the day.
ANSWER - CASE #8
Two things suggest that Milly may be having night-time hypoglycemia: the restlessness during the
night and “new” higher fasting readings. Ideally it would be useful for Milly to test a few glucose
readings at bedtime, 3 a.m. and fasting to see if there is a trend of lower blood glucose overnight.
In your assessment also consider:

• What does Milly eat at bedtime – if she does snack
o Is the carbohydrate consistent?
o How much carbohydrate does she eat?
o Does she use a combination of protein and carbohydrate?
o Does she sometimes miss an evening snack?
o Do any of these variables correlate with the symptoms or high fasting readings?
• Is Milly physically active in the daytime (especially later afternoon) or evenings? Is

anything different on the nights when Milly is active in the day/evenings – lower pre-
bedtime readings, different fasting glucose levels the following mornings, correlation
between evening activity and night-time symptoms?
Also, she could reduce her evening N to see if the night-time symptoms disappear.
If the night-time symptoms disappear and the fastings remain elevated, she may need to move
her N from supper to bedtime to prolong the action towards morning without risking hypoglycemia
with the higher doses. Changing the timing of the insulin requires a physician’s order. She may
need to decrease her dose of N when the timing is changed. Also look at the impact of the
potentially lower fasting reading on the daytime insulin doses.
Milly and her doctor may also consider use of a long-acting insulin analogue as EDS status is now
available in Saskatchewan for Lantus 40
40
See Saskatchewan Exception Drug Status Program for current information:
http://formulary.drugplan.health.gov.sk.ca/ cited 26 march 2009
March, 2009
ANSWER - CASE #9
Consider as you have your discussion with Fred:
• What is Fred willing to do? What are his goals for himself? Is he happy with what is
happening? Does he have some ideas on what he could do?
• Explore his concerns around insulin injections as the options for improving control involving
more injections – what does he currently use – syringes, pens? Injection sites?
Technique? Fears he has?
The large single morning injection of one insulin may be causing some/all of Fred’s complaints.
• The N peaks in the afternoon and could cause mid-afternoon hypoglycemia. Review his
usual food intake and activity habits.
• Even though the dose of N is large, it may not last long enough to control glucose levels
through the night and early morning. This would be responsible for the nocturia and the
high fasting glucose levels.
It is likely that Fred would benefit from spreading out his insulin however this will all depend on
Fred’s readiness and will likely need to be done in a series of steps, as Fred is ready.
Some options for him to consider:

He currently uses 1.1 units/kg per day which is more than usual considering he is lean.
All of his insulin is basal insulin and it is also being used to cover his meals.
The first priority is to reduce the frequency of lows in the afternoon by:
• increasing the carbohydrate taken in the afternoon
• reducing activity
• decreasing insulin dose in the morning
Assume Fred is happy with his carbohydrate intake and activity pattern. Lower the morning N by
10% every 3-4 days until unexplained low blood glucose levels are eliminated.
It is likely that at the same time, some N will need to be added at supper. Split the morning N
dose between morning (2/3 of the NPH dose) and at supper or bedtime (⅓ of the NPH dose).
• You may need to gradually add in pre-meal short or rapid-acting insulin

• If he needs short or rapid-acting insulin later, he could use a syringe to measure to keep
the number of injections at 2 or 3 per day.
March, 2009
ANSWER CASE - #10

The pattern of Joe’s glucose readings shows the supper N lasts until the following morning with
fasting glucose reading at or below the recommended target of 4-7 mmol/L. Glucose levels for the
remainder of the day are usually above target and the blood glucose level does rise from supper
to bedtime.
Before he changes his insulin, it would be beneficial for Joe to see a dietitian. He can decide
whether or not he wants to use an approach of consistent carbohydrate or learn carbohydrate
counting. When he has a meal planning method, the pattern of the glucose levels can be reviewed
again.
Likely the best option for Joe to consider will be pre-meal rapid acting insulin to handle the meal
time carbohydrate. He could consider moving his supper N to bedtime or using extended long-
acting insulin analogue.
Remember he is used to taking insulin twice daily and you may need to approach change
gradually. Depending on his response to proposed changes and options, one choice, initially, may
be to added, one insulin at a time, such as adding R to his supper insulin dose. The N may need
to be reduced as the HS blood glucose levels will likely improve.
March, 2009
ANSWER – CASE #11

Note answers are included in the table.
MEAL FOOD EATEN # grams TOTAL CHO PER

of carbs MEAL/SNACK
Basal Insulin
Breakfast 2 toast, whole wheat 30
Time: 0615 hrs 2 tsp. jam (regular) 10 62.5
BG: 4.4 6 ounces unsweetened orange juice 22.5
Two hour BG:
Snack Orange
Time: 15 15
BG
Lunch Sandwich:
Time: 1200 hrs 2 slices of bread, whole grain 30
BG: 2 slices cheese or ½ cup salmon
2 tsp margarine 60
lettuce and tomato slice
Apple, orange or banana, medium 15
1 cup skim milk 15
Snack
Time: Oatmeal granola bar 28 28
BG
Supper Meat or fish about 3 ounces 0g
Time: 1 cup potatoes 30g
BG: Broccoli , 1 cup 0g 67.5
1 slice bread, whole grain 15g
yogurt, skim w artificial sweetener, 15g
¾ cup
½ banana, small 7.5g
March, 2009
ANSWER – CASE #12

of carbs TAKEN
Basal Insulin 0
Breakfast 2 toast, 30 Meal Bolus: 12
Time: 0615 hrs 2 tsp. jam (regular) 10 Correction:
BG: 4.4 ½ grapefruit 15
55 TOTAL Taken: 12
Two hour BG: 9.8
Snack 1 cup carrot & celery sticks 15
Time: 2 tbsp low fat dip
BG
Lunch Sandwich: Meal Bolus: 10
Time: 1200 hrs 2 slices of bread 30 Correction:
BG: 5.3 2 slices cheese or ½ cup salmon
2 tsp margarine TOTAL Taken: 10
lettuce and tomato
Apple, orange or banana 15
1 cup chocolate milk 30
75
Snack
Time:
BG 12.3
Supper Meat or fish about 3 ounces 0 Meal Bolus: 10
Time: 1 cup potatoes 30 Correction:
BG: 13.6 corn, 1 cup 30
1 slice bread 15 TOTAL Taken: 10
¾ cup 15
½ banana, small 7.5
97.5
2 hour BG: 13.6
Bedtime 1 apple 15
Time: 10 p.m. 0
BG: 6.7
Insulin:carbohydrate ratio is 12 units for 55 grams of carbohydrate or 1:_5 (breakfast)

Insulin:carbohydrate ratio is 10 units for 75 grams of carbohydrate or 1:7.5 (lunch)
Insulin:carbohydrate ratio is 10 units for 75 grams of carbohydrate or 1: 9.7 (supper)
Insulin:carbohydrate ratio is _0 units for 15 grams of carbohydrate or 0:15 (bedtime)
Answered continued on next page
March, 2009
The insulin:CHO ratio seems appropriate for breakfast as the pc reading is 9.8.
The insulin:CHO ratio seems too high for noon as his pc reading is 12.3. The ratio may need to be
lowered to 1:5.
The insulin:CHO ratio cannot be accurately assessed at present as his pre-supper is already
elevated. The ratio may be appropriate if his pre-supper readings were consistently at target.
• First he needs to lower the pc noon reading.
• If pc noon readings are at target and this does not improve the pre-supper reading, he may
need some basal insulin fasting.
• If the pc noon and pre-supper readings are at target, but the pc supper bg remains above
target, he may need to adjust the insulin:CHO ratio to 1:8 or 1:5.
ANSWER – CASE #13
His TDD is 70 units. The rule of 100 applies to use of rapid-acting insulin.
100 ÷ 70 = 1.4 This means that 1 unit of insulin will lower the blood glucose by 1.4 mmol/L
For the pre-supper reading of 10.8 mmol/L, he would calculate the correction by subtracting his
target glucose level (7) from his current reading and then dividing by the correction factor.
10.8 – 7 = 3.8 mmol above target

3.8 ÷ 1.4 = 2.7 additional units – this could be rounded to 3 units.

of carbs TAKEN
Supper Meat or fish about 3 ounces 0 Meal Bolus: 10
Time: 1 cup rice, brown, cooked 45 Correction: 3
BG: 10.8 salad 0 TOTAL Taken: 13
corn, ½ cup 15
1 slice bread 15
yogurt, skim w artificial sweetener, 15
¾ cup
½ banana, small 7.5
97.5
2 hour BG:
Bedtime Time: 1 apple 15
10 p.m. 0
BG:
March, 2009
ANSWER – CASE # 14
Monday evening practices:

The practices will occur during the action time of supper dose of Novorapid. As he wants to lose
weight, it would be preferable to decrease insulin instead of eating extra food.
As the activity is 120 minutes, he could drop his pre-supper Novorapid by 50% or 6 units.
It would be advisable for him to carry extra CHO such as juice and a choice from grains/starches
food group.
He could be advised to check his blood glucose levels:

• Pre-supper
• Pre-practice
• Mid point in the practice
• Post practice
• Bedtime
• Following morning
As there is the possibility of a carry over effect of the evening physical activity, he should also
consider reducing his bedtime Levemir, initially by 20% (mid-point in the suggested reduction
range of 10-30%). Depending on his bedtime glucose reading, he may need additional
carbohydrate at bedtime and he may need to consider also checking a glucose at 3 a.m. until he
learns more about the effects of the practice on his night-time glucose.
Saturday afternoon game, 2:30 to 4:30 p.m.
If Jeff takes his Novorapid at noon, he will be past the peak action time by game time. He could
make a modest reduction in the pre-noon NR, about 20% or 2 units for the first game. He would
check his glucose level at the same times as he did for practices, beginning at pre-noon.
Depending on the pre-game level he may need extra CHO then and/or at the mid-point in the
game. . If he needs extra carbohydrate pre or mid-game, he should take a fast acting
carbohydrate choice.
Post game he will need to consider reducing his pre-supper NR because of the carry over effect of
the exercise. He could begin with a 20% reduction, assuming a pre-supper glucose of 4-7 mmol/L
[see suggested reduction in the Saskatchewan Learning/Procedure Manual]. Depending on his
experience with post-activity glucose levels, he many also need to reduce his bedtime Levemir.
ANSWER – CASE #15

What target glucose level would you set with Karen and her physician?
Due to her age, living alone, experience with unrecognized hypoglycemia and previous medical
history, the recommended target pre-meal glucose level could be raised from 4-7 mmol/L to, for
example; 6-8 mmol/L or slightly higher depending on your assessment of her ability to manage
diabetes and recognize hypoglycemia.
What does the current dose of NovoMix 30 represent in terms of types of insulins and
how many units of each insulin does this dose represent?
NovoMix 30 insulin represents a mixture of 30% NovoRapid (Aspart) and 70% aspart protamine
crystal. The aspart protamine crystal has an activity profile similar to NPH.
28 units of NovoMix 30 insulin is
March, 2009
• 8.4 units of rapid-acting insulin

• 19.6 units of intermediate-acting insulin
16 units of NovoMix 30 insulin is
• 5 units of rapid-acting insulin
• 11 units of intermediate-acting insulin
What changes, if any, would you recommend to her current medications?

Current glucose pattern shows:
• Fasting – above target
• Noon – at or close to target
• Supper – too low
• Bedtime – at target
The first consideration is always prevention of hypoglycemia, so a 10% minimum reduction in the
morning NovoMix 30 would be recommended. 10% is about 3 units or a reduction to 25 units.
This would translate to 7.5 units rapid (previously 8.4) and 17.5 units intermediate-acting
(previously 19.6). Reinforce the consistency of her afternoon snack.
If the above change increases the pre-supper readings to target, then the pattern of glucose
readings can be re-assessed.
What might you consider if the first issue or problem you identify is not resolved?
In some cases, consideration may need to be given to using a different pre-mix (for example,
20/80) or splitting the insulins into their individual components. In order to decide the best action
you will need to consider the client’s ability and willingness to manage the proposed changes,
target blood glucose levels for her age, overall health and symptoms of hypo or hyperglycemia.
ANSWER CASE #16

The only glucose levels which are above target now are the fasting ones.
Before making any changes to insulin:

• Review the amount and type of food she is eating at bedtime.
• Ask her to test her blood glucose level at 0300 a few times to ensure hypoglycemia is not
being missed.
Assuming there are no issues with either of the above, you could consider the following IDA:
1. As bedtime glucose levels are “at target” continue with the amount of rapid-acting insulin
from the NovoMix30 dose (30% of 16 units = 5 units pre-supper). Move the remainder of
the dose, (70% of 16 units = 11 units intermediate-acting insulin; Novolin NPH) to
bedtime. Ask Karen to check a couple of glucose levels at ~3 a.m. If the 3 a.m. glucose
levels are not too low and the fasting glucose levels remain elevated, increase the bedtime
NPH by 10%.
NOTE: This would require 3 different insulins which may be confusing to the client..
2. Change to Levemir or Lantus at HS with short-acting insulin (Novolin Toronto or Humulin

R) at breakfast and supper. The long-acting basal insulin analogue would decrease the
March, 2009
risk of nocturnal hypoglycemia but would provide minimal insulin coverage for meals.
Short-acting insulin could provide insulin coverage for all 3 meals with a total of 3
injections per day and 2 types of insulin. Dose calculations would be as follows:
• Levemir or Lantus = total intermediate dose for the day – 20% of total dose when
moving from a BID to OD dose. Therefore 19.6 + 11.2 = 30.8 – 6.2 (20% reduction in
total intermediate dose) = 24.6 = 25 units at HS
• Short-acting insulin dose could be the same as in the premix. Therefore, the morning
dose would be 7 units and the supper dose would be 5 units, BUT Karen’s blood
glucose levels decrease from breakfast to lunch. Therefore to be cautious, the morning
dose could be decreased by at 2 units to decrease the risk of mid morning
hypoglycemia.
• This regimen would require 3 injections per day with 2 different insulins. Also the
benefits of rapid-acting insulin on post-meal blood glucose levels in the pre-mix will be
lost.
3. Change to Levemir or Lantus at HS (same calculation as above) with rapid-acting insulin

(NovoRapid or Humalog) with all meals.
• Because Karen has a fairly consistent carbohydrate intake from day to day, a routine
dose of insulin with each meal may be an option rather than counting carbohydrates
for each meal. Initiate rapid-acting insulin with meals at 1 unit per 15 grams of
carbohydrates.
• This regimen would require 4 injections per day with 2 different insulins.
NOTE: a physician’s order would be needed to implement any of these changes.
ANSWER CASE # 17
Mary is already using 0.93 units/kg body weight and although she may have insulin resistance,
other variables than lack of insulin may be causing the recent elevation in glucose levels.
Before making any IDA, consider the following with Mary:

• she is gaining weight – what might be different (food intake and/or activity level, her
emotions)?
• a general food intake review paying attention to recent changes, food portions, fat intake,
cooking methods, using food to cope. You might suggest she log her food for about 3
days, as a food review can be 50% inaccurate, especially if she has poor food awareness
or if she is depressed. You might suggest a dietitian consult if there are food issues to be
addressed.
• review a typical day to assess activity level and routines and possible changes.
• assess her quality of sleep.
• screen for depression.
• ask Mary to demonstrate her technique with her insulin pen to ensure accuracy.
• ask Mary to demonstrate her blood glucose monitoring technique.
• ask questions to determine if Mary has any symptoms suggestive of hypoglycemia (even
though it’s unlikely).
• ask about recent infections
If there are no “clues” to improve glucose control in any of the above, then consider an insulin
dose increase. Often it is beneficial to try to improve the fasting blood glucose level first.
March, 2009
ANSWER CASE #18

The first priority will be to eliminate the lows at noon. If these are not related to food or activity
changes, then his pre-breakfast insulin grid could be reduced by 1-2 units. Consider that he may
feel he cannot eat any more for breakfast and he does not want to add a mid-morning snack.
If this change results in elimination of the lows, and high glucose levels persist at 10 p.m. and
fasting, he could look at strategies to reduce his bedtime glucose levels, hoping this would also
reduce his fasting glucose.
He could check his blood glucose about 2 hours after supper to assist in determining the
effectiveness of his pre-supper insulin. If levels are rising > 10 mmol/L (if the pre-supper level is
at target), then he can increase his pre-supper insulin grid by 2 units. If the post supper glucose
level is < 10 and the rise occurs between that time and 10 p.m. then his basal insulin is likely
responsible. His bedtime NPH may not be lasting 24 hours. He could consider two options:
• Try moving the NPH injection to supper time – this may still leave the fasting glucose
levels high.
• Starting a small dose of NPH at breakfast to help later evening basal coverage. Make
sure he understands how to use the insulin grid as less insulin may be needed pre-
noon and/or pre-supper insulin to prevent hypoglycemia.
With improved fasting blood glucose levels, he may need a further reduction in his pre-breakfast
grid to prevent mid-morning or pre-noon hypoglycemia. He may also need to look at the quantity
of his evening snacking. If he needs or wants these calories, he may need a small dose of rapid-
acting insulin at bedtime. To make this change you would need to consult with his physician.
March, 2009
REFERENCES
Educators are strongly advised to use a core text or reference when learning about insulin
and IDA to supplement the module. Two excellent Canadian resources are highlighted in
the references.
___Insulin (2009). In Canadian Pharmaceutical Association, Compendium of Pharmaceuticals and

Specialties Ottawa, Ontario.
Beaser RS, editor. Joslin’s Diabetes Deskbook: A Guide for Primary Care Providers 2nd edition.
2007;Joslin Diabetes Center:Boston. www.joslin.org
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes
Association 2008 clinical practice guidelines for the prevention and management of diabetes in
Canada. Can J Diabetes. 2008;32(suppl 1):S1-S201.
Chapman TM. Insulin Detemir: a review of its use in the management of type 1 and type 2
diabetes mellitus. Drugs 2004;64(22):2577-2595.
Davison KM. Eating Disorders and Diabetes: Current Perspectives. Can J Diabetes. 2003;27;1:62-
73.
Insulin. A Clinical Journal for Health Care Professionals. Free online access.
www.InsulinJournal.com cited 25 February 2009
Jones H. editor. (2009). Building Competency in Diabetes Education: Advancing

Practice. Diabetes Educator Section, Canadian Diabetes Association: Toronto,
Ontario. (in press, March 2009)
Jones H. editor. (2004). Building Competency in Diabetes Education: The Essentials.

Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario NOTE:
a new edition will be available in 2010.
Perkins BA, Riddell MC. Type 1 Diabetes and Exercise: Using the Insulin Pump to Maximum
Advantage. Can J Diab. 2006;30(1):72-79
Riddell MC, Perkins BA. Type 1 Diabetes and Vigorous Exercise: Applications of Exercise
Physiology to Patient Management. Can J. Diabetes 2006;30(1):63-71
RxFiles cited 25 February 2009. RxFiles is an academic detailing program to assist physicians,
pharmacists and other health care professionals to get excellent and objective drug data. This reference
relates to current insulins in Canada. If the resource has been updated since the module was printed,
look at www.rxfiles.ca
Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Guidelines
for Nurses Prescribing and/or Distributing Drugs by Transfer of Functions. 1999. To order:
http://www.srna.org/practice/resources.php
March, 2009
Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Special
Nursing Procedures and Nursing Procedures by Transfer of Medical Functions. 1993. To order:
http://www.srna.org/practice/resources.php
Sclater A. Diabetes in the Elderly: The Geriatrician’s Perspective. Can J Diabetes. 2003;27(2):172-
175.
Swenson K, Brackenridge B. Lispro Insulin for Improved Glucose Control in Obese Patient with
Type 2 Diabetes. Diabetes Spectrum. 1998;11(1):13-15.
Tibaldi J. Initiating and Intensifying Insulin Therapy in Type 2 Diabetes Mellitus. Am J. Medicine.
2008;121(6A):S20-29.
Tibaldi J. Intensifying Treatment in Poorly Controlled Type 2 Diabetes Mellitus: Case Reports. Am
J. Medicine. 2008; 121(6A):S30-34.
Thompson DM, Kozak SE, Sheps S. Insulin Adjustment by a diabetes nurse educator improves
glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ.
1999;161(8):959-962.
White JR, Davis SN, Cooppan R, Davidson MB, Mulcahy K, Manko GA, Nelinson D. Clarifying the
Role of Insulin in Type 2 Diabetes Management. Clinical Diabetes. 2001;21(1):14-21.
March, 2009
ADDITIONAL RESOURCES
1.0 CLIENT HANDOUTS ON INSULIN/INSULIN ADJUSTMENT
Husband A. (2008). Juggling for Control. Eli Lilly Canada, Inc.
B.C. Children’s Hospital, Insulin Dose Adjustment: An Online Education Program for
Parents of Children with Diabetes 16 february 2007. Although this resource is for
pediatrics, it demonstrates useful ways to explain IDA to anyone.
http://www.bcchildrens.ca/Services/SpecializedPediatrics/EndocrinologyDiabetesUnit/ForF
amilies/InsulinDoseAdjustment.htm cited 26 march 2009
BD Diabetes.com (USA) a patient insulin adjustment workbook which may be helpful in

explaining concepts of IDA. NOTE: all the examples are in mg% for blood glucose values
and it would not be appropriate as a Canadian handout as it may cause confusion. The
content may assist care providers to develop explanations and client guidelines.
http://www.bddiabetes.com/us/hcp/main.aspx?cat=3066&id=3120
cited 26 march 2009
2.0 DIABETES AND PREGNANCY
NOTE: The Saskatchewan template for Transfer of Medical Function does not include management of
diabetes during pregnancy. Registered Nurses may refer clients for pre-pregnancy support and
management during pregnancy to one of the clinics below.
Saskatoon Pregnancy Clinic

Linda Bachiu, Diabetes Nurse Educator
Diabetes Education Centre
Royal University Hospital P 655-1571
103 Hospital Drive F 655-6758
Saskatoon, SK S7N 0W8 E linda.bachiu@saskatoonhealthregion.ca
Regina Pregnancy Clinic

Marion Boyd
Metabolic and Diabetes Education Centre
2nd floor, Medical Office Wing P 766-4540
1440-14th Avenue F 766-4178
Regina, Sk. S4P 0W5 E Marion.Boyd@rqhealth.ca
March, 2009
ACKNOWLEDGEMENTS
Saskatchewan Health would like to thank the following individuals who were involved as
either committee members or others who were involved in the design, development,
review or implementation of the Transfer of Medical Function for Insulin Dose Adjustment.
Karen Butler, RD, Regina Qu’Appelle Health Region, reviewer 2005, Working Group 2009
and Provincial Diabetes Advisory Body
Gideon Dala, MD, Diabetologist, LiveWell Diabetes Program, Saskatoon Health Region
Betty Deschamps, RN, Kelsey Trail Health Region, 2001,2005, 2009 Working Group
Bev Kernohan, RN, Heartland Health Region, 2001, 2005, 2009 Working Group
Nola Kornder, RN, Saskatoon Health Region, 2001, 2005, 2009 Working Group
Arlene Kuntz, BSP, Drug Plan and Extended Benefits Branch, Saskatchewan Health, 2009
Working Group
Heather Nichol, RN, Chair, British Columbia Registered Nurses Insulin Dose Adjustment
Working Group
Loren Regier, BSP, Program Coordinator, RxFiles
Greg Riehl, RN, Nursing Practice Advisor, Saskatchewan Registered Nurses’ Association
Carlene Schmaltz, RN, Kelsey Trail Health Region, 2005, 2009 Working Group
Carol Straub, RN, Five Hills Health Region, 2001 and 2005 Working Group
Judi Whiting, RN, Saskatoon Health Region, 2001, 2005, 2009 Working Group
Karie Witte, RD, Saskatoon Health Region, 2005 Working Group

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March 2009

Saskatchewan Insulin Adjustment Module Page 2

Policy Appendix .................................................................................................... 16

Learning About And Procedures For Insulin Dose Adjustment ................................... 33

Practical Aspects Of Insulin Management................................................................ 38

Insulin Regimens And Adjustments ........................................................................ 45

Teaching Procedure For Self-Adjustment of Insulin .................................................. 60

Practice Cases ...................................................................................................... 63

Answers to Practice Cases ..................................................................................... 81

Additional Resources ............................................................................................. 97

ORGANIZATION OF THE SASKATCHEWAN INSULIN DOSE

DEVELOPING THE POLICIES, PROCEDURES AND LEARNING PACKAGE

REVISIONS FOR 2009

HOW TO USE THE TEMPLATE

The following steps are helpful in applying the template:

1. Review the full module

d. Attend a provincial workshop on IDA when it is available.

Implement a process for the Registered Nurse to demonstrate competency in IDA

2. Complete physician-supervised cases. The successful delegation of a medical function

The supervising physician may be an endocrinologist, an internist or a family physician with

Examples of implementation include:

Establish a policy for annual demonstration of competency. The competency performance

There are several options to ensure continuing competency:

NAME HEALTH REGION TELEPHONE EMAIL

Karen Butler Regina Qu’Appelle 766-3777 Karen.Butler@rqhealth.ca

Betty Deschamps Kelsey Trail 873-3760

Bev Kernohan Heartland 948-3323 bev.kernohan@hrha.sk.ca

Nola Kornder Saskatoon 655-2147 nola.kornder@sasaktoonhealthregion.ca

Carlene Schmaltz Kelsey Trail 862-7251 CSchmaltz.kthr@shin.sk.ca

Judi Whiting Saskatoon 655-7406 judi.whiting@saskatoonhealthregion.ca

POLICY FOR TRANSFER OF MEDICAL FUNCTION FOR

Basic Transfer of Medical Function 7

Maintenance of Transfer of Function

Physician-Registered Nurse Collaboration

Conditions – Registered Nurses and Physicians

Documentation and Reporting

Transfer of Medical Function

Health Region reviews provincial guidelines/template +

Region Medical Advisory Committee approves Transfer

Registered Nurse who meets criteria

Reviews policy + procedures

Attends provincial course 10 (if available)

After successful completion of the exam, the Registered Nurse

Physician(s) signs documentation of Registered Nurse’s

Health Region’s policy determines procedure for implementation

Procedures for Adjusting Insulin Doses

APPENDIX A - Advanced Certification

APPENDIX B - SAMPLE PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET

_____________ HEALTH REGION

PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET

____________________ has achieved competency to adjust insulin for clients with

adjustment and agree to the conditions outlined in the policy.

Signed: _________________________ Physician

Signed: _________________________ Diabetes Nurse Educator

APPENDIX C - SAMPLE COMPETENCY PERFORMANCE CHECKLIST

COMPETENCY PERFORMANCE CHECKLIST

PERFORMANCE CRITERIA NOT

3 Insulin decrease is based

5 Insulin correction factors

4 Physician is consulted for

___ Acceptable competency ___ Competency NOT acceptable

Physician Signature: __________________________ Date: _________________________

APPENDIX D – DETAILED COMPETENCIES FOR SELF ASSESSMENT

_ Acceptable competency _ Competency NOT acceptable

Physician Signature: __ Date: _

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) __________________________

Date: Signature of Mentor(s) __________________________

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of RN: _________________________

Date: Signature of Mentor(s) _________________________

Date: Signature of Mentor(s) _________________________

Date: _ Client: _____________

PHN: __________ Date of Birth: _

Physician: ______ Clinic Location: