Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE
TIME
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Diabetic Patient Pre Printed Orders
1.
2.
Level of service:
Outpatient
Monitored OP (indicate nursing area):
Med/Surg
Telemetry
Inpatient (indicate nursing area):
Med/Surg
Telemetry
ICU
Diet:
Nothing by Mouth
Clear Liquid
Regular
ADA ______________ calories
Other_________________
3.
4.
Allergies: ________________________
Physician to contact concerning patient’s diabetes care:
5.
Peripheral blood glucose:
AC(before meals) and HS (at bedtime) (routinely for patient’s using insulin)
BID (am, pm) (routinely for patients using oral agents)
every _______ hours
other (please specify):
6. Aloe Vesta 2-n-1 Skin Conditioner/Protectant – Apply to feet BID after bath and at bedtime, avoiding
areas between toes.
7. Critical Blood Glucose Values – If peripheral blood glucose is less than 50 mg/dl or greater than
500mg/dl.
 If blood glucose value is less than 50mg/dl, RR-LO (results reported) = less than 30mg/dl or
LO = less than 10mg/dl, repeat point of care blood glucose an follow hypoglycemia patient
care protocol. Notify physician.
 If blood glucose value is RR-HI = greater than 500mg/dl or HI=greater than 600mg/dl. draw
stat plasma glucose and notify physician.
8. Consult Diabetes Educator if admitted with any of the following diagnoses.
Hyperosmolar Non-Ketotic Syndrome (Type II)
Diabetic Ketoacidosis (Type I)
Hypoglycemia
Newly diagnosed Diabetes (Type I or Type II)
9. Nutrition Services Consult: (check one)
ADA Diet Guidelines
Carbohydrate Counting
Other (please specify): _____________________________
10. Please have patient view the following Video(s) (located in “Diabetes in the Box”)
Hypoglycemia
Drawing Up and Injecting Insulin
Foot Care
(Continued)
Affix Patient Label To ALL Pages
ALLERGIES / INTOLERANCES
Height ______
Weight ______  kg  lbs
gms
DANGEROUS ABBREVIATIONS
– DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD,
q.o.d. or QOD, U or u, IU
Latex Allergy Yes  No 
Page 1 of 3
SLS-DM-956 (Rev. 01/02/07)
Never use zero after decimal point (1.0 mg)
Always use zero before decimal point (0.5 mg)
Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE
TIME
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Diabetic Patient Pre Printed Orders (Continued)
Hypoglycemia Treatment:
If blood glucose is 70 mg/dl or less (WITH or WITHOUT symptoms **) or 80 mg/dl (WITH symptoms )
[**symptoms include shakiness, sweating, cool/clammy skin, extreme hunger, confusion, seizures, and/or
unconscious]
A blood glucose 50 mg/dl or less is considered severe hypoglycemia
The following action should be taken; Treat for hypoglycemia before giving the patient their oral agent or
insulin and contact the physician managing the patient’s diabetes care for possible medication changes.
Patients who are arousable:
A.
B.
C.
If patient is NPO
 initiate an IV
 If glucose 70-50 mg/dl. Repeat blood glucose point of and care and administer 25 ml of 50 %
dextrose IV. Notify physician.
 IF blood glucose 50 mg/dl or less, RR-LO (results reported) = less then 30mg/dl or LO = less
than 10mg/dl, Repeat point of care blood glucose and administer 50 ml 50% dextrose IV.
Notify physician
Note: If IV access is difficult to obtain, administer 15 grams glucose gel between the patient’s cheek
and gum. If the patient needs assistance in swallowing, massage the patient’s cheek and throat
gently. Contact CRN or House Supervisor start an IV STAT.
Repeat blood glucose test on patient 15 minutes following treatment. If level continues to be 70
mg/dl or less repeat above steps every 15 minutes until blood sugar is greater then 80 mg/dl OR a
reduction in symptoms is observed
If not NPO
 Blood glucose of 70-50 mg/dl administer of 15 grams carbohydrate to the patient.
 Blood glucose 50mg/dl or less administer 30 grams of carbohydrate to the patient
Examples of foods that contain 15 grams of carbohydrates:

3 B-D Glucose tablets or 15 grams of glucose gel

4 oz orange or apple juice

8 oz skim milk

4-5 oz REGULAR soda (not diet)
Repeat blood glucose test on patient 15 minutes following treatment. If level continues to be less then
70 mg/dl repeat above step every 15 minutes until blood glucose is greater then 70mg/dl
Retest the patient’s blood glucose in one hour and call the physician if less than 70 mg/dl for further
instruction
(Continued)
Affix Patient Label To ALL Pages
ALLERGIES / INTOLERANCES
Height ______
Weight ______  kg  lbs
gms
DANGEROUS ABBREVIATIONS
– DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD,
q.o.d. or QOD, U or u, IU
Latex Allergy Yes  No 
Page 2 of 3
SLS-DM-956 (Rev. 01/02/07)
Never use zero after decimal point (1.0 mg)
Always use zero before decimal point (0.5 mg)
Saint Luke’s South
Overland Park, KS 66213
Physician Orders
Read Back Verification for Verbal Orders
DATE
TIME
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Diabetic Patient Pre Printed Orders (Continued)
11. If the patient is unarousable with a blood glucose less than 70 mg/dl
a. Initiate an IV and administer 50ml of 50% dextrose IV. Notify physician. If IV access is difficult to
obtain, administer 1 mg (1 unit) dose of Glucagon (per package insert instructions). Turn the
patient on their side in case of vomiting. Contact CRN or House Supervisor to start IV stat.
b. Recheck blood glucose test on patient 15 minutes following treatment. If level continues to
be less then 70 repeat above step every 15 minutes until blood glucose is greater than 80mg/dl OR
a reduction of symptoms is observed and notify physician
12. For a hyperglycemia critical blood sugar level of RR-HI (results recorded) = greater then
500mg/dl or HI = greater than 600mg/dl.
 Draw STAT plasma glucose
Notify physician
Reference: Lab, blood glucose monitoring: Accu-check Inform, A core curriculum for Diabetes Education
Physician Signature/Date:__________________________________________________
Affix Patient Label To ALL Pages
ALLERGIES / INTOLERANCES
Height ______
Weight ______  kg  lbs
gms
DANGEROUS ABBREVIATIONS
– DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD,
q.o.d. or QOD, U or u, IU
Latex Allergy Yes  No 
Page 3 of 3
SLS-DM-956 (Rev. 01/02/07)
Never use zero after decimal point (1.0 mg)
Always use zero before decimal point (0.5 mg)