Hands in silicone gloves with a syringe against the background of a glucometer and test strips. Installing the needle on the syringe pen

INSULIN SLIDING SCALE DOSE

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VIEW COMPLETED NOTE

Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. Blood-sugar was checked via by finger-stick, blood sugar level 120 mmol/l. SN prepared and administered 15 Units of Lantus Sub-Q to right upper thigh plus sliding scale coverage of 5 Units of Novolog Sub-Q to right lower quadrant (RLQ) of abdomen. Procedures were done following standard and universal precautions. Patient tolerated injection well without bleeding at site, complaint or complication. Patient is incapable of BS testing and or administer own insulin due complexity of procedure. Patient is unable to learn the technique to safely inject insulin due functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. Instructed patient/caregiver on food and diabetes, tips to manage Blood sugar following a proper diet. Instructed to use sugar substitutes instead or regular sugar. To watch for added sugar in juice and powdered drinks. Patient/caregiver verbalized understanding teaching.

MED PASS TECHNIQUES. SUB Q INJECTIONS:

Check the physician’s order. Check which site is appropriate for this injection? Insure product is correct and the expiration date is appropriate.
1. Wash hands and apply gloves.
2. Roll insulin. (Avoids creating air bubbles)
3. Clean vial top with an alcohol wipe.
4. Draw up medication into a syringe according to product instruction and The Doctor’s order. Double check for accurate measurement. Tap out any air bubbles and fill the syringe to the proper level. (Insulin, Clear before Cloudy). Set on a disposable tray, Scoop technique to cap the needle only on a clean surface if needed. (syringes without safety pull ups). Never RECAP after though.
5. Cleanse the administration site with an alcohol wipe.
6. Pinch and fold skin with one hand. With the other hand, hold the syringe like a dart and insert the needle into the skin at a 45-90 degree angle and then release the skin. Reposition your hands so you can inject with the plunger. Inject all the medication using a steady slow technique. Do not withdraw the needle right away because you risk leakage. Count 6 seconds. Withdraw and do not rub afterwards.
Do NOT RECAP the needle after use. If there is a safety cap you may set it. Dispose immediately into a SHARPS container.
7. Wash hands prior to charting
8. FOR LOVENOX and other PREFILLED, DO NOT EXPEL AIR. ADMINISTER AROUND ABDOMINAL AREA ONLY. DO NOT RUB. Rotate, site, and chart. (remember safety cap)

MEDICARE DOCUMENTATION FOR DIABETES

  • Vital signs
  • Diet, intake, appetite
  • Signs & symptoms of hypo or hyperglycemia, action and response
  • Blood glucose check, frequency, result, action
  • Signs of infection
  • Skin care
  • Lab work