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The record should clearly indicate the measures staff in residential services have taken and account for all of the medicines which have been managed for residents best extra super avana 260 mg erectile dysfunction walmart. The service provider should determine the way in which the service keeps their records generic extra super avana 260mg erectile dysfunction in diabetes mellitus pdf. Whatever format is chosen buy 260mg extra super avana erectile dysfunction treatment protocol, the records must be complete, legible, up-to-date, dated and signed to show who has made each record. An up-to-date list of current medicines prescribed for each resident is essential. The resident’s care plan should make it clear whether the resident needs support to look after and take some or all of their medicines or whether staff are responsible for administering them. In residential settings, it is important to record when the resident first arrives with supplies of medicine from home, hospital or another social care setting. Registered nurses must comply with the most recent guidance published by An Bord Altranais agus Cnáimhseachais na hÉireann regarding records and record-keeping. Medication incidents can also include near misses and incidents that do not result in harm. Arrangements for the identification, recording, investigating andlearning from adverse incidents involving residents are fundamental principles of risk management. It is important that all medication incidents are identified, recorded and the cause investigated so that the service can learn from the incident and prevent a similar error happening in the future. Where a medication incident occurs, a resident, or their representative where appropriate, should be informed. When a medication incident is identified, appropriate interventions should be implemented immediately to limit potential adverse effects or reactions. Training should include all relevant aspects of the medicines management cycle, including ordering, receipt, storage, administration and monitoring of medicines. Training should be provided by a suitably competent healthcare professional with the appropriate clinical and educational training. Training should be supplemented by competency assessment and refresher training completed at appropriate intervals, in line with residents’ changing needs. Registered providers must ensure that staff who do not have the skills to administer medicines, despite completing the required training, are not allowed to administer medicines to residents. This should be a review of knowledge, skills and competencies in relation to managing and administering medicines, where appropriate. Medical, health and social care professionals working in, or providing services to, residential services should work to standards set by their professional body and ensure that they have the appropriate skills, knowledge and expertise in the safe use of medicines for residents living in residential services. Audit: The assessment of performance against any standards and criteria (clinical and non-clinical) in a health or social care service. Competence: The knowledge, skills, abilities, behaviours and expertise sufficient to be able to perform a particular task and activity. Effective: A measure of the extent to which a specific intervention, procedure, treatment, or service, when delivered, does what it is intended to do for a specified population. Homely residential facilities: Residential facilities provided in a home-like environment. Prescription Sheet: The current report that records the medicines prescribed by a registered prescriber to be administered to a resident. Pharmacist: A person registered with the Pharmaceutical Society of Ireland to prescribe drugs. Policy: A written operational statement of intent which helps staff to make sound decisions and take actions that are legal, consistent with the aims of the centre, and in the best interests of residents. Procedure: A written set of instructions that describe the approved steps to be undertaken to fulfil a policy. Risk management: The systematic identification, evaluation and management of risk. It is a continuous process with the aim of reducing risk to an organisation and individuals. Service provider: Any person, organisation, or part of an organisation delivering healthcare services, as described in the Health Act 2007 section 8(1)(b)(i)–(ii). This includes individuals who are employed, self-employed, temporary, volunteers, contracted or anyone who is responsible or accountable to the organisation when providing a service to residents. Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children and Adults) with Disabilities) Regulations 2013. Irish Medicines Board Miscellaneous Provisions Act, 2006 Medicinal Products (Prescription and Control of Supply) Regulations, 2003 (S. Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2003 (S. Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2007. Irish Medicines Board (Miscellaneous Provisions) Act 2006 (Commencement) Order 2007 (S. Medicinal Products (Prescription and Control of Supply) Regulations 2003, as amended Waste Management Act 1996. Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority. Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority. A report for the project: ‘Working together to develop practical solutions: an integrated approach to medicines in care homes’. Managing Medicines for residents of care homes and children’s homes – a follow up study. D O’Mahony, P Gallagher, C Ryan, S Byrne, H Hamilton, P Barry, M O’Connor, J Kennedy. Use of Medicines in nursing homes for older people: Advances in Psychiatric Treatment. Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013). National Quality Standards for Residential Care Settings for older People in Ireland. National Standards for Residential Services for Children and Adults with Disabilities. National Guidelines – Communicating with service users and their families following adverse events in healthcare. How-to Guide: Prevent Adverse Drug Events by Implementing Medicines Reconciliation. Miscellaneous Provisions Act, 2006 Medicinal Products (Prescription and Control of Supply) Regulations, 2003 (S. Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations (S.

Daytime Activities and Daytime Function: Daytime strategies to combat the sleep problem order 260 mg extra super avana free shipping impotence forums, such as spending more activities and behaviors may provide clues to potential causes time in bed in an effort to “catch up” on sleep purchase extra super avana 260mg with mastercard erectile dysfunction when drunk. Napping (frequency/day order 260 mg extra super avana overnight delivery erectile dysfunction exercises dvd, in bed or in the bedroom that are incompatible with sleep may times, voluntary/involuntary), work (work times, work type include talking on the telephone, watching television, computer such as driving or with dangerous consequences, disabled, use, exercising, eating, smoking, or “clock watching. Sleep-Wake Schedule: In evaluating sleep-related sleepiness should prompt a search for other potential sleep symptoms, the clinician must consider not only the patient’s disorders. The number, duration, and timing of naps should “usual” symptoms, but also their range, day-to-day variability, be thoroughly investigated, as both a consequence of in- and evolution over time. Table 6—Common Comorbid Psychiatric Disorders and Symptoms Category Examples Mood disorders Major depressive disorder, bipolar mood disorder, dysthymia Anxiety disorders Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive compulsive disorder Psychotic disorders Schizophrenia, schizoaffective disorder Amnestic disorders Alzheimer disease, other dementias Disorders usually seen in childhood and adolescence Attention defcit disorder Other disorders and symptoms Adjustment disorders, personality disorders, bereavement, stress Journal of Clinical Sleep Medicine, Vol. Conditions often comorbid with insomnia, such as venlafaxine, duloxetine, monoamine oxi- mood and anxiety disorders, may also have familial or genetic dase inhibitors components. Social and occupational histories may indicate not Stimulants Caffeine, methylphenidate, amphetamine only the effects of insomnia on the individual, but also possible derivatives, ephedrine and derivatives, co- contributing factors. Occupational assessment should specif- caine cally include work around dangerous machinery, driving duties, Decongestants Pseudoephedrine, phenylephrine, phenyl- regular or irregular shift-work and transmeridian travel. However, these exams may Pulmonary Theophylline, albuterol provide important information regarding comorbid conditions Alcohol and differential diagnosis. A physical exam should specifcally evaluate risk factors for sleep apnea (obesity, increased neck • Mood disturbances and cognitive diffculties. Complaints circumference, upper airway restrictions) and comorbid medi- of irritability, loss of interest, mild depression and anxi- cal conditions that include but are not limited to disorders of ety are common among insomnia patients. Patients with pulmonary, cardiac, rheumatologic, neurological, endocrine chronic insomnia often complain of mental ineffciency, (such as thyroid), and gastrointestinal systems. The mental sta- diffculty remembering, diffculty focusing attention, and tus exam should focus on mood, anxiety, memory, concentra- diffculty with complex mental tasks. Conversely, in- sis is further aided by the use of sleep logs, questionnaires for terpersonal diffculties may be an important contributor to sleep quality, sleepiness, psychological assessment and quality insomnia problems for some individuals. The daytime activities and exercise may in turn contribute to choice of assessment tools should be based on the patient’s pre- insomnia. Likewise, (1) A general medical/psychiatric/medication questionnaire poor sleep may exacerbate symptomatology of comorbid (to identify comorbid disorders and medication use) conditions. Sleep complaints may herald the onset of mood (2) The Epworth Sleepiness Scale or other sleepiness assess- disorders or exacerbation of comorbid conditions. Other History: A complete insomnia history also in- (3) A two-week sleep log to identify sleep-wake times, gen- cludes medical, psychiatric, medication/substance, and family/ eral patterns, and day-to-day variability. Primary baseline measures obtained from a sleep and potentially on family, friends, coworkers and caretakers. Self medication with times 100) alcohol, over-the-counter medications, prescription medica- • Nap times (frequency, times, durations) tions, and melatonin account for millions of dollars annual- Sleep logs may also include reports of sleep quality, daytime ly. Genetics: With the exception of fatal familial insomnia, a Objective Assessment Tools: Laboratory testing, polysom- rare disorder, no specifc genetic associations have been identi- nography and actigraphy are not routinely indicated in the eval- fed for insomnia. A familial tendency for insomnia has been uation of insomnia, but may be appropriate in individuals who observed, but the relative contributions of genetic trait vulner- present with specifc symptoms or signs of comorbid medical ability and learned maladaptive behaviors are unknown. For example, changing to a less stimulating antidepres- rhythm sleep disorders; sant or changing the timing of a medication may improve sleep  Insomnia due to medical or psychiatric disorders or to or daytime symptoms. It should be Before consideration of treatment choices, the patient and noted that comorbid insomnias and multiple insomnia diagno- physician should discuss primary and secondary treatment goals ses may coexist and require separate identifcation and treat- based on the primary complaint and baseline measures such as ment. After discussing treatment options tailored to address the primary complaint, a specifc follow-up Indications for Treatment plan and time frame should be outlined with the patient, regard- less of the treatment choice. Treatment is recommended when the chronic insomnia has Quantifying sleep quality, daytime function, and improve- a signifcant negative impact on the patient’s sleep quality, ment in comorbid conditions requires more involved assess- health, comorbid conditions, or daytime function. It is essential ment, often using specifc questionnaires for specifc insomnia to recognize and treat comorbid conditions that commonly oc- problems (Table 8). If the clinician is unfamiliar with these tests, cur with insomnia, and to identify and modify behaviors and administration and monitoring of these measures may require medications or substances that impair sleep. By defnition, and behavioral interventions show short and long term effcacy Journal of Clinical Sleep Medicine, Vol. When using this diagram, the clinician should be aware that the presence of one diagnosis does not exclude other diagnoses in the same or another tier, as multiple diagnoses may coexist. Acute Adjustment Insomnia, not a chronic insomnia, is included in the chronic insomnia algorithm in order to highlight that the clinician should be aware that extrinsic stressors may trigger, perpetuate, or exacerbate the chronic insomnia. Psychological and behavioral interventions and phar- with psychological and behavioral therapies. Treatments which macological interventions may be used alone or in combination address these core components play an important role in the man- (Figure 2). Regardless of treatment choice, frequent outcome agement of both primary and comorbid insomnias. In addition, periodic clinical reassessment following While most effcacy studies have focused on primary insomnia completion of treatment is recommended as the relapse rate for patients, more recent data demonstrate comparable outcomes in chronic insomnia is high. In co- psychological and Behavioral Therapies morbid insomnias, treatment begins by addressing the comorbid condition. This may include treatment of major depressive dis- Current models suggest that physiological and cognitive hy- order, optimal management of pain or other medical conditions, perarousal contribute to the evolution and chronicity of insom- elimination of activating medications or dopaminergic therapy nia. In addition, patients typically develop problematic behaviors for movement disorder. In the past, it was widely assumed that such as remaining in bed awake for long periods of time, often treatment of these comorbid disorders would eliminate the in- resulting in increased efforts to sleep, heightened frustration and somnia. However, it has become increasingly apparent that over anxiety about not sleeping, further wakefulness and negative the course of these disorders, numerous psychological and be- expectations, and distorted beliefs and attitudes concerning the havioral factors develop which perpetuate the insomnia problem. Negative learned responses may These perpetuating factors commonly include worry about in- Journal of Clinical Sleep Medicine, Vol. The sleep disturbance has a relatively short duration (days-weeks) and is expected to resolve when the stressor resolves. Psychophysiological Insomnia The essential features of this disorder are heightened arousal and learned sleep-preventing as- sociations. Arousal may be physiological, cognitive, or emotional, and characterized by muscle tension, “racing thoughts,” or heightened awareness of the environment. Individuals typically have increased concern about sleep diffculties and their consequences, leading to a “vicious cycle” of arousal, poor sleep, and frustration. Paradoxical Insomnia The essential feature of this disorder is a complaint of severe or nearly “total” insomnia that greatly exceeds objective evidence of sleep disturbance and is not commensurate with the re- ported degree of daytime defcit. To some extent, “misperception” of the severity of sleep disturbance may characterize all insomnia disorders. Idiopathic Insomnia The essential feature of this disorder is a persistent complaint of insomnia with insidious on- set during infancy or early childhood and no or few extended periods of sustained remission. Idiopathic insomnia is not associated with specifc precipitating or perpetuating factors. Insomnia Due to Mental Disorder The essential feature of this disorder is the occurrence of insomnia that occurs exclusively during the course of a mental disorder, and is judged to be caused by that disorder.

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A prisoner of war awarded disciplinary punishment may not be deprived of the prerogatives attached to his rank buy extra super avana 260mg online top erectile dysfunction doctor. Prisoners of war awarded disciplinary punishment shall be allowed to exercise and to stay in the open air at least two hours daily cheap extra super avana 260 mg free shipping impotent rage man. They shall be allowed generic extra super avana 260 mg free shipping erectile dysfunction treatment forums, on their request, to be present at the daily medical inspections. They shall receive the attention which their state of health requires and, if necessary, shall be removed to the camp infirmary or to a hospital. They shall have permission to read and write, likewise to send and receive letters. No moral or physical coercion may be exerted on a prisoner of General war in order to induce him to admit himself guilty of the act of principles which he is accused. No prisoner of war may be convicted without having had an opportunity to present his defence and the assistance of a qualified advocate or counsel. The death sentence cannot be pronounced on a prisoner of war unless the attention of the court has, in accordance with Article 87, second paragraph, been particularly called to the fact that since the accused is not a national of the Detaining Power, he is not bound to it by any duty of allegiance, and that he is in its power as the result of circumstances independent of his own will. A prisoner of war shall from not be confined while awaiting trial unless a member of the armed sentence, forces of the Detaining Power would be so confined if he were treatment) accused of a similar offence, or if it is essential to do so in the interests of national security. Any period spent by a prisoner of war in confinement awaiting trial shall be deducted from any sentence of imprisonment passed upon him and taken into account in fixing any penalty. The provisions of Articles 97 and 98 of this Chapter shall apply to a prisoner of war whilst in confinement awaiting trial. This period of three weeks shall run as from the day on which such notification reaches the Protecting Power at the address previously indicated by the latter to the Detaining Power. The said notification shall contain the following information: 1) surname and first names of the prisoner of war, his rank, his army, regimental, personal or serial number, his date of birth, and his profession or trade, if any; 2) place of internment or confinement; 3) specification of the charge or charges on which the prisoner of war is to be arraigned, giving the legal provisions applicable; 4) designation of the court which will try the case, likewise the date and place fixed for the opening of the trial. The same communication shall be made by the Detaining Power to the prisoners’ representative. If no evidence is submitted, at the opening of a trial, that the notification referred to above was received by the Protecting Power, by the prisoner of war and by the prisoners’ representative concerned, at least three weeks before the opening of the trial, then the latter cannot take place and must be adjourned. Failing a choice by the prisoner of war, the Protecting Power shall find him an advocate or counsel, and shall have at least one week at its disposal for the purpose. The Detaining Power shall deliver to the said Power, on request, a list of persons qualified to present the defence. Failing a choice of an advocate or counsel by the prisoner of war or the Protecting Power, the Detaining Power shall appoint a competent advocate or counsel to conduct the defence. The advocate or counsel conducting the defence on behalf of the prisoner of war shall have at his disposal a period of two weeks at least before the opening of the trial, as well as the necessary facilities to prepare the defence of the accused. He may also confer with any witnesses for the defence, including prisoners of war. He shall have the benefit of these facilities until the term of appeal or petition has expired. Particulars of the charge or charges on which the prisoner of war is to be arraigned, as well as the documents which are generally communicated to the accused by virtue of the laws in force in the armed forces of the Detaining Power, shall be communicated to the accused prisoner of war in a language which he understands, and in good time before the opening of the trial. The same communication in the same circumstances shall be made to the advocate or counsel conducting the defence on behalf of the prisoner of war. The representatives of the Protecting Power shall be entitled to attend the trial of the case, unless, exceptionally, this is held in camera in the interest of State security. He shall be fully informed of his right to appeal or petition and of the time limit within which he may do so. This communication shall likewise be sent to the prisoners’ representative concerned. The Detaining Power shall also immediately communicate to the Protecting Power the decision of the prisoner of war to use or to waive his right of appeal. Furthermore, if a prisoner of war is finally convicted or if a sentence pronounced on a prisoner of war in the first instance is a death sentence, the Detaining Power shall as soon as possible address to the Protecting Power a detailed communication containing: 1) the precise wording of the finding and sentence; 2) a summarized report of any preliminary investigation and of the trial, emphasizing in particular the elements of the prosecution and the defence; 3) notification, where applicable, of the establishment where the sentence will be served. The communications provided for in the foregoing sub- paragraphs shall be sent to the Protecting Power at the address previously made known to the Detaining Power. These conditions shall in all cases conform to the requirements of health and humanity. A woman prisoner of war on whom such a sentence has been pronounced shall be confined in separate quarters and shall be under the supervision of women. In any case, prisoners of war sentenced to a penalty depriving them of their liberty shall retain the benefit of the provisions of Articles 78 and 126 of the present Convention. Furthermore, they shall be entitled to receive and despatch correspondence, to receive at least one relief parcel monthly, to take regular exercise in the open air,to have the medical care required by their state of health,and the spiritual assistance they may desire. Penalties to which they may be subjected shall be in accordance with the provisions of Article 87, third paragraph. Throughout the duration of hostilities, Parties to the conflict shall endeavour, with the co-operation of the neutral Powers concerned, to make arrangements for the accommodation in neutral countries of the sick and wounded prisoners of war referred to in the second paragraph of the following Article. They may, in addition, conclude agreements with a view to the direct repatriation or internment in a neutral country of able- bodied prisoners of war who have undergone a long period of captivity. No sick or injured prisoner of war who is eligible for repatriation under the first paragraph of this Article, may be repatriated against his will during hostilities. The conditions which prisoners of war accommodated in a neutral country must fulfil in order to permit their repatriation shall be fixed, as shall likewise their status, by agreement between the Powers concerned. In general, prisoners of war who have been accommodated in a neutral country, and who belong to the following categories, should be repatriated: 1) those whose state of health has deteriorated so as to fulfil the conditions laid down for direct repatriation; 2) those whose mental or physical powers remain, even after treatment, considerably impaired. If no special agreements are concluded between the Parties to the conflict concerned, to determine the cases of disablement or sickness entailing direct repatriation or accommodation in a neutral country, such cases shall be settled in accordance with the principles laid down in the Model Agreement concerning direct repatriation and accommodation in neutral countries of wounded and sick prisoners of war and in the Regulations concerning Mixed Medical Commissions annexed to the present Convention. The appointment, duties and functioning of these Commissions shall be in conformity with the provisions of the Regulations annexed to the present Convention. Prisoners of war who do not belong to one of the three foregoing categories may nevertheless present themselves for examination by Mixed Medical Commissions, but shall be examined only after those belonging to the said categories. The physician or surgeon of the same nationality as the prisoners who present themselves for examination by the Mixed Medical Commission, likewise the prisoners’ representative of the said prisoners, shall have permission to be present at the examination. Prisoners of war detained in connection with a judicial prosecution or conviction and who are designated for repatriation or accommodation in a neutral country, may benefit by such measures before the end of the proceedings or the completion of the punishment, if the Detaining Power consents. Parties to the conflict shall communicate to each other the names of those who will be detained until the end of the proceedings or the completion of the punishment. In the absence of stipulations to the above effect in any agreement concluded between the Parties to the conflict with a view to the cessation of hostilities, or failing any such agreement, each of the Detaining Powers shall itself establish and execute without delay a plan of repatriation in conformity with the principle laid down in the foregoing paragraph. In either case, the measures adopted shall be brought to the knowledge of the prisoners of war. The costs of repatriation of prisoners of war shall in all cases be equitably apportioned between the Detaining Power and the Power on which the prisoners depend. This apportionment shall be carried out on the following basis: a) If the two Powers are contiguous, the Power on which the prisoners of war depend shall bear the costs of repatriation from the frontiers of the Detaining Power. The Parties concerned shall agree between themselves as to the equitable apportionment of the remaining costs of the repatriation. The conclusion of this agreement shall in no circumstances justify any delay in the repatriation of the prisoners of war. On repatriation, any articles of value impounded from prisoners of war under Article 18, and any foreign currency which has not been converted into the currency of the Detaining Power, shall be restored to them.

Lower blood pressure levels may S118 Management of Diabetes in Pregnancy Diabetes Care Volume 40 buy extra super avana 260 mg visa erectile dysfunction treatment spray, Supplement 1 purchase extra super avana 260mg without a prescription best herbal erectile dysfunction pills, January 2017 be associated with impaired fetal growth generic 260 mg extra super avana fast delivery erectile dysfunction treatment diet. Mayo K, Melamed N, Vandenberghe H, In a 2015 study targeting diastolic blood 450 Berger H. Preprandial ver- Preventive Services Task Force and the National hypertension (52). Metformin they may cause fetal renal dysplasia, oli- versus insulin for the treatment of gestational Postprandial versus preprandial blood glucose gohydramnios, and intrauterine growth monitoring in women with gestational diabetes diabetes. Metformin vs insulin in known to be effective and safe in preg- 1995;333:1237–1241 the management of gestational diabetes: a 13. A comparison of glyburide and and infant birth weight: the Diabetes in Early diuretic use during pregnancy is not rec- Pregnancy Study. The National Institute of Child insulin in women with gestational diabetes mel- ommended as it has been associated Health and Human DevelopmentdDiabetes in litus. N Engl J Med 2000;343:1134–1138 with restricted maternal plasma volume, Early Pregnancy Study. The pharmaco- in early diabetic pregnancy and pregnancy out- logic basis for better clinical practice. Clin References comes: a Danish population-based cohort study Pharmacol Ther 2009;85:607–614 of 573 pregnancies in women with type 1 dia- 1. Diabetes Care 2006;29:2612–2616 Diabetes and Pre-eclampsia Intervention Trial M, Gich I, Corcoy R. Optimal glycemic control, pre- and insulin for the treatment of gestational dia- control during early pregnancy and fetal malfor- eclampsia, and gestational hypertension in betes: a systematic review and meta-analysis. Glycemic targets in the sec- trauterine exposure to diabetes conveys risks analysis of randomized controlled trials. J Clin for type 2 diabetes and obesity: a study of dis- ond and third trimester of pregnancy for Endocrinol Metab 2015;100:2071–2080 cordant sibships. Association of adverse pregnancy outcomes congenital anomalies in the offspring of women levels are significantly lower in early and late with glyburide vs insulin in women with ges- with prepregnancy diabetes. Placental passage of metformin in women with pregnancy outcome in 933 women with type 1 Clin Chem 2006;52:1138–1143 polycystic ovary syndrome. Diet and exercise interventions Metformin versus placebo from first trimester Care 2013;36:3870–3874 for preventing gestational diabetes mellitus. Am J Obstet Gynecol 2015; by lifestyle intervention: the Finnish Gestational Cooperative Multicenter Reproductive Medi- 212:74. Diabetes Care 2016;39: both for infertility in the polycystic ovary syn- and Reproductive Health for Girls. Pregnancy outcome follow- Fifth International Workshop-Conference on double-dummy controlled clinical trial compar- ing exposure to angiotensin-converting enzyme Gestational Diabetes Mellitus. Diabetes Care ing clomiphene citrate and metformin as the inhibitors orangiotensinreceptorantagonists: a 2007;30(Suppl. J Clin Endocrinol Metab causes of pregnancy loss in type 1 and type 2 Metab 2008;93:4774–4779 2005;90:4068–4074 diabetes. Duration of lactation The effect of lifestyle intervention and metformin ovarian diathermy in clomiphene citrate-resistant and incidence of type 2 diabetes. J Clin Endocrinol Metab 2004; breastfeeding influence the risk of developing 89:4801–4809 Study 10-year follow-up. American College of Obstetricians and Gy- bolic control and progression of retinopathy. National necologists; Task Force on Hypertension in diabetes and the incidence of type 2 diabetes: a Institute of Child Health and Human Develop- Pregnancy. Diabe- of the American College of Obstetricians and 1862–1868 tes Care 1995;18:631–637 Gynecologists’ Task Force on Hypertension in 47. Healthful dietary pat- Medicine; Food and Nutrition Board; Board on 1131 Children, Youth, and Families; Committee to Re- terns and type 2 diabetes mellitus risk among women with a history of gestational diabetes 52. Arch Intern Med 2012;172:1566–1572 Less-tight versus tight control of hypertension Weight Gain During Pregnancy: Reexamining 48. J Obstet Gynaecol Can 2007;29: Care 2005;28:323–328 of gestational diabetes: effects of metformin 906–908 S120 Diabetes Care Volume 40, Supplement 1, January 2017 American Diabetes Association 14. B c Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL (10. C c Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E c Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and cor- rection components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A c Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A c A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypo- glycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E c The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is ,70 mg/dL (3. C c There should be a structured discharge plan tailored to the individual patient with diabetes. B In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes including death (1,2). Therefore, inpatient goals should include the pre- vention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest, safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes (3,4). To correct this, hospitals have estab- Suggested citation: American Diabetes Associa- tion. In lished protocols for structured patient care and structured order sets, which include Standards of Medical Care in Diabetesd2017. Because inpatient insulin use (5) and discharge orders for profit, and the work is not altered. More infor- (6) can be more effective if based on an A1C level on admission (7), perform an A1C mationisavailableathttp://www. In addition, diabetes self- persistently above this level may require porated into the day-to-day decisions re- management knowledge and behaviors alterations in diet or a change in medica- garding insulin doses (2). Previously, In the patient who is eating meals, glu- taking antihyperglycemic medications, hypoglycemia in hospitalized patients cose monitoring should be performed monitoring glucose, and recognizing has been defined as blood glucose before meals. A Cochrane review poglycemia is defined as that associated glucose monitoring that prohibit the of randomized controlled trials using with severe cognitive impairment regard- sharing of fingerstick lancing devices, computerized advice to improve glucose less of blood glucose level (see Section 6 lancets, and needles (17). Electronic insulin order Moderate Versus Tight Glycemic questions about the appropriateness of templates also improve mean glucose Control these criteria, especially in the hospital levels without increasing hypoglycemia A meta-analysis of over 26 studies, in- and for lower blood glucose readings in patients with type 2 diabetes, so struc- cluding the Normoglycemia in Intensive (18).