Inpatient Antiemetic Order and Discharge Insulin Prescription
Immediate Inpatient Antiemetic Order
For acute vomiting in this hospitalized patient unable to tolerate oral medications, administer ondansetron 4 mg IV push now, which can be repeated every 8 hours as needed for nausea/vomiting. 1
Complete Inpatient Order:
Ondansetron 4 mg IV push
- Administer immediately for nausea/vomiting
- May repeat every 8 hours PRN nausea/vomiting
- Maximum 3 doses per 24 hours
- Monitor for response at 30 minutes
- If inadequate response after 30 minutes, may give metoclopramide 10 mg IV as rescue medication 1, 2
Alternative if ondansetron unavailable: Metoclopramide 10 mg IV push (standard dose is equally effective as higher doses and has fewer side effects) 2
Important consideration: Given his penicillin allergy history, ondansetron is preferred as it has no cross-reactivity concerns and is well-tolerated 1
Discharge Insulin Prescription
Based on his 120 units total daily dose (TDD) over 24 hours, prescribe a basal-bolus regimen with approximately 50% basal and 50% prandial insulin. 3, 4
Prescription #1: Basal Insulin
Insulin Glargine (Lantus) 100 units/mL
- Dose: 60 units subcutaneously once daily at bedtime
- Quantity: 2 vials (10 mL each)
- Refills: 3
- Instructions: Inject 60 units under the skin of abdomen, thigh, or upper arm at the same time each evening. Rotate injection sites within the same region. Do not mix with other insulins.
Rationale: 50% of TDD (120 units) = 60 units for basal coverage 3, 4
Prescription #2: Prandial Insulin
Insulin Lispro (Humalog) 100 units/mL
- Dose: 20 units subcutaneously before each meal (breakfast, lunch, dinner)
- Quantity: 2 vials (10 mL each)
- Refills: 3
- Instructions: Inject 20 units under the skin of abdomen, thigh, upper arm, or buttocks within 15 minutes before each meal. Rotate injection sites. Total of 3 injections daily with meals.
Rationale: Remaining 50% of TDD (60 units) divided by 3 meals = 20 units per meal 3, 4
Critical Discharge Instructions
Glucose Monitoring
- Check blood glucose before each meal and at bedtime (4 times daily) 3
- Target range: Fasting 80-130 mg/dL, pre-meal 80-130 mg/dL 3
- Call physician if: glucose <70 mg/dL or >250 mg/dL on two consecutive readings 3
Hypoglycemia Management
- Recognize symptoms: shakiness, sweating, confusion, rapid heartbeat 4
- Treat immediately with 15 grams fast-acting carbohydrate (4 glucose tablets, 4 oz juice, or 3-4 hard candies) if glucose <70 mg/dL 4
- Recheck glucose in 15 minutes and repeat treatment if still <70 mg/dL 4
- Do not skip meals - this is critical with this insulin regimen 4
Sick Day Management
- Continue basal insulin (glargine) even if not eating 3
- May need to hold or reduce prandial insulin (lispro) if unable to eat 3
- Check glucose every 4-6 hours during illness 3
- Increase fluid intake with electrolyte-containing beverages 3
- Call physician if: vomiting persists >24 hours, glucose >300 mg/dL, or unable to keep fluids down 3
Insulin Adjustment Guidelines
- If fasting glucose consistently >130 mg/dL: Increase bedtime glargine by 2 units every 3 days 3
- If pre-meal glucose consistently >130 mg/dL: Increase corresponding meal lispro by 1-2 units 3
- If experiencing hypoglycemia (<70 mg/dL): Reduce corresponding insulin dose by 10-20% 3
Common Pitfalls to Avoid
Never stop basal insulin during illness or fasting - this is the most common error leading to DKA recurrence, even in type 2 diabetes 5, 6
Do not administer prandial insulin without eating - lispro has rapid onset (15 minutes) and will cause severe hypoglycemia if meal is skipped 4
Rotate injection sites within the same anatomical region (e.g., different areas of abdomen) to prevent lipodystrophy, which impairs insulin absorption 4
Ensure patient demonstrates proper injection technique before discharge - this is non-negotiable for safety 5
Provide glucagon emergency kit prescription for severe hypoglycemia episodes where patient cannot self-treat 4