Correctional and Prandial Insulin Dosing

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Questions and Answers

What should be done if a patient's blood glucose level is less than 70 mg/dL?

Give a moderate dose of insulin.

Begin hypoglycemic protocol and call provider. (correct)

Administer corrective insulin immediately.

Continue with scheduled blood glucose checks.

What action should be taken if a patient is NPO?

Increase insulin doses due to lack of intake.

Administer prandial insulin as needed.

Follow the NPO grid and use the insulin sensitive/low dose scale. (correct)

Stop all insulin administration.

What should be done for a blood glucose level exceeding 400 mg/dL?

Start emergency correctional protocol.

Call the provider. (correct)

Continue current treatment regime.

Administer high dose insulin.

In which scenario should prandial insulin be held?

For pre-meal glucose levels of less than 70 mg/dL. Signup and view all the answers

What insulin adjustments are allowed for patients on cyclic tube feeding?

Basal and correctional insulin can be prescribed. Signup and view all the answers

Which guideline should be followed for administering insulin to patients receiving intermittent tube feeding boluses?

Basal, prandial, and correctional insulin doses can be prescribed. Signup and view all the answers

What is the maximum dose of insulin for bedtime and midnight coverage unless special feeding conditions are met?

4 units Signup and view all the answers

What is the primary purpose of correctional insulin?

To manage hyperglycemia measured before meals Signup and view all the answers

Which condition qualifies a patient for the 'Insulin Sensitive/Low dose' scale?

Chronic liver failure and age over 70 Signup and view all the answers

What symptom is NOT typically associated with hypoglycemia?

Increased thirst Signup and view all the answers

What is the pre-meal blood glucose goal for patients in this protocol?

Less than 140 mg/dL Signup and view all the answers

Which of the following is NOT an exclusion criterion for the insulin protocol?

Renal failure patients Signup and view all the answers

When is the hypoglycemic protocol triggered?

When blood glucose is less than 70 mg/dL Signup and view all the answers

How is insulin administered to patients on this protocol?

Subcutaneously Signup and view all the answers

Which medication is an example of prandial insulin?

Lispro (Humalog) Signup and view all the answers

What action should be taken when a patient receiving bolus tube feedings is made NPO?

Decrease correctional insulin, stop prandial insulin, and give 50% basal dose unless Type 1. Signup and view all the answers

For a patient with a blood glucose level of 45 mg/dL who is responsive and able to swallow, which treatment is recommended?

4 oz of juice or 37.5 gm of instant glucose. Signup and view all the answers

What is the correct management for a patient who is on continuous tube feedings and those feedings are stopped?

Hold all basal insulin unless Type 1, then give 50% dose. Signup and view all the answers

When a patient receiving both basal and prandial insulin becomes NPO, what actions should be taken?

Hold all prandial insulin doses, continue full basal insulin doses, and adjust NPH accordingly. Signup and view all the answers

What is the primary treatment intervention for a patient with a glucose level of 40 mg/dL and no IV access?

Glucagon 1 mg IM once and call for IV access. Signup and view all the answers

Under what circumstance should a patient remain on the insulin sensitive/low dose scale?

Until the healthcare provider orders otherwise. Signup and view all the answers

When is correctional insulin only adjusted for NPO patients?

As soon as the patient becomes NPO. Signup and view all the answers

If a patient is unresponsive and has no IV access, what immediate action should be taken?

Give 8 oz of juice or 75 gm of instant glucose and call a rapid response team. Signup and view all the answers

Study Notes

Correctional Insulin Dosing Scale

The correctional insulin scale has three dose levels: Low, Moderate and High
Insulin sensitivity is determined by factors such as age, weight, eating habits, presence of certain medical conditions, etc.
The scale is designed to adjust insulin dosage based on blood glucose levels.
Insulin sensitivity/Low dose is the default level in cases like NPO (nothing per mouth) or hypoglycemia
Bedtime insulin coverage is capped at 4 units unless the patient is receiving continuous or cyclic enteral feedings.
The table summarizes the insulin dose ranges for different blood glucose levels.
For readings over 400 mg/dL, contact a medical professional.

Prandial Insulin

Prandial insulin is administered within 10 minutes of a meal, either before or after.
Correctional insulin and prandial insulin doses are given together.
Hold prandial insulin if the pre-meal glucose is less than 70 mg/dL, notify the provider, and initiate hypoglycemic treatment.

Nutritional and NPO (Nothing Per Mouth) Considerations

For patients receiving Total Parenteral Nutrition (TPN), the provider responsible for TPNs manages all insulin added to the TPN.
Continuous Tube Feeding Patients may be prescribed basal and correctional insulin.
Cyclic Tube Feeding Patients may be prescribed basal and correctional insulin.
Bolus Tube Feeding patients may be prescribed basal, prandial, and correctional insulin doses.
NPO patients follow specific blood glucose checks and the Insulin Sensitive/Low dose scale.
Collaboration with the provider is essential for resuming the previous insulin level once the patient resumes eating.

Insulin Order: Patients NPO for Tests or Procedures

Correctional Insulin Only: Decrease to the Insulin Sensitive level as soon as the patient is NPO.
Basal Insulin Only: Give 50% of glargine, detemir, or NPH dose with the next dose. Hold all basal insulin for patients on continuous tube feedings. Type 1 diabetes patients receive 100% of their basal dose.
Basal and Prandial Insulin: Hold all prandial insulin doses. Continue with the full glargine or detemir insulin dose. Give 50% of the AM NPH dose and 100% of the PM NPH dose.
Prandial Only: Hold prandial insulin with the next dose.

Meal Type: All Patients who are NPO for Tests or Procedures

Bolus Tube Feedings: Decrease correctional insulin to the Insulin Sensitive level, stop prandial insulin but continue correctional insulin. Give 50% of the basal dose, unless Type 1 diabetes, then give 100% of the basal dose.
Continuous or Cyclic Tube Feeding Stopped: Hold basal insulin, unless Type 1 diabetes, then give 50% of the dose.

Key Point

The Insulin Sensitive/Low dose scale is maintained until the provider orders advancement.

Hypoglycemia Treatment (for Glucose less than 70 mg/dL)

Responsive patients: 4 oz of juice or Instant Glucose 37.5 gm (1 tube)
Unresponsive patients with IV Access: Dextrose 50% 25 mL IV x1
Unresponsive patients without IV Access: Glucagon 1 mg IM once. Call rapid response team and physician to obtain IV access.

Prandial Insulin Examples

Lispro (Humalog)
Regular insulin (Novolin R)

Correctional Insulin

Short-acting insulin given for hyperglycemia measured before the meal.

Insulin Sensitive

Patients with a single blood glucose below 70 mg/dL or these conditions:
- Kidney failure (creatinine greater than 2)
- Liver failure
- Age 70 or older
- Adult patients under 50 kg
- Erratic eating habits
- Insufficiently treated Addison's disease or other endocrinological glandular failure

Hypoglycemia Symptoms

Mental status changes (concentration, coordination, weakness, lethargy, blurred vision, confusion)
Sweating
Anxiety
Palpitations
Hunger
Tremor

Policy

This protocol is intended for non-ICU patients with diabetes or those without diabetes who may have hyperglycemia due to medical or surgical reasons.
Provides options for short-term correctional (less than 48 hours) or longer-term "Basal-Prandial" approaches to normalize blood glucose.
Assumes the use of basal AND prandial insulin.
Blood glucose goal before meals is less than 140 mg/dL.
All blood glucoses below 70 mg/dL should be treated with the Hypoglycemia Protocol and patients placed on the 'Insulin Sensitive/Low dose' scale.

Exclusion Criteria

Diabetic ketoacidosis
Pancreas transplant patients: Glycemic assessment is required to rule out organ rejection. The Transplant Team Providers will decide if the protocol can be used.

Protocol

The provider orders basal insulin, prandial insulin, initial correctional insulin level, and blood glucose testing schedule via the GPU Glycemic Control - Subcutaneous insulin electronic order set.
Based on these orders, the RN administers the appropriate correctional dose of lispro insulin according to the correctional insulin dosing scale.
Correctional and prandial insulin are administered together subcutaneously.
All patients on the protocol will have a Glycated Hemoglobin (Hemoglobin A1C) measured.

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Description

This quiz covers the principles of correctional and prandial insulin dosing. It includes details on dose levels, insulin sensitivity, and when to contact a medical professional. Test your knowledge on insulin management for blood glucose control.