Download Diabetic Ketoacidosis

Date:
Name:
Age:
DOB:
Allergies: NKMA
1. Admit to: [ ] Acute Care [ ] Day Bed
2. Attending Dr: Younger
3. Admitting Dx: Diabetic ketoacidosis
4. Contributing Dx:
5. Condition:
6. VS:
7. Activity:
8. Nursing:
[ X ] SCUnit
[ ] Telemetry
[ X ] Stable
[ ] Fair
[ ] Serious
[ ] Critical
Orthostatic BP, pulse and RESP Q 1 hr x 6, then Q 2 hr x 3, then Q 4 hr;
temp Q 4 hr.
Weight on admission and each AM.
Bed rest with bathroom privileges, ad lib beginning tomorrow.
I/O Q 2 hr x 6, then Q 4 hr x 3, then Q shift.
Dipstick urine, chart glucose and acetone Q shift.
Call physician if urine output < 60 mL per 2 hours.
Call MD with results of the chem. 7 and ABGs.
After she is stable and off of the insulin drip, then do glucochecks qid and
follow the following insulin coverage:
Sliding Humalog Insulin Coverage of Glucochecks done ac and hs
Glucocheck value
150 to 169
170 to 189
190 to 209
210 to 219
220 to 239
240 to 259
260 to 279
280 to 299
100 to 149
80 to 99
Humalog by 2 units
60 to 79
Humalog by 4 units
< 60
Humalog by 8 units
Number of units of Humalog Insulin to
give Subcutaneously
In addition to the patient’s usual premeal
doses
one
two
three
four
five
six
seven
eight
no change in the
pre-meal Humalog dosage
decrease the premeal
decrease the premeal
decrease the premeal
1
300 and greater, give 10 units SC and repeat the glucocheck value
and Humalog coverage 2 hours later.
9. Diet:
10. IV:
11. Meds:
NPO for 2 hr, then clear liquids as tolerated for 2 hours and then progress
to 1,800-calorie ADA as tolerated.
#1 – 1000 mL normal saline at 1000mL/hr.
#2 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#3 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.
#4 – 1000 mL NS normal saline with 20 mEq KCl at 250mL/hr.
Continue #4 until glucose is < 250 and the fluid below can be started.
Start 1000 mL D5-1/2 NS with 10 mEq KCl at 250mL/hr when glucose <
250 mg per dL.
Protocol for intravenous insulin infusion
TA B L E 1
General guidelines
• Goal blood glucose level = 100-140 (usually 80–180 mg/dL, 80–110 for
intensive care patients)
• Standard drip: Regular insulin 100 units/100 mL 0.9% NaCl via an
infusion device (1 unit/1 mL)
• The Insulin infusion can be discontinued when a patient is eating, AND
her blood glucose has been in the goal range for 8 hours, AND has
received first dose of subcutaneous insulin as per the sliding Humalog
scale listed under the nursing orders.
Intravenous fluids
Follow the IV fluid orders above.
Initiating the infusion
• Algorithm 1: Start here for most patients (see table below).
• Algorithm 2: Use if she is not controlled with algorithm 1
• Algorithm 3: Use if she is not controlled on algorithm 2.
• Algorithm 4: For patients not controlled on algorithm 3.
PATIENT’S Initial BLOOD
GLUCOSE
INSULIN INFUSION RATE
(U/HOUR)
LEVEL (MG/DL) ALGORITHM 1
ALGORITHM 2
ALGORITHM 3
ALGORITHM 4
< 60 = Hypoglycemia (see below for treatment)
< 70
0
0
0
0
70–109
0.2
0.5
1
1.5
2
110–119
0.5
1
2
3
120–149
1
1.5
3
5
150–179
1.5
2
4
7
180–209
2
3
5
9
210–239
2
4
6
12
240–269
3
5
8
16
270–299
3
6
10
20
300–329
4
7
12
24
330–359
4
8
14
28
> 360
6
12
16
28
Moving from algorithm to algorithm
• Move up to the next higher algorithm if the blood glucose
concentration is above the goal range (see above goal) and does not
change by at least 60 mg/dL within 1 hour.
• Move down an algorithm when blood glucose is < 70 mg/dL X 2.
Patient monitoring
• Goal blood glucose = 100-140 mg/dL
• Check capillary blood glucose every hour until it is within goal range for
4 hours, then decrease to every 2 hours for 4 hours, and if it remains
stable, may decrease to every 4 hours
• Hourly monitoring may be indicated for critically ill patients even if they
have stable blood glucose
Treatment of hypoglycemia (blood glucose < 60 mg/dL)
• Discontinue insulin drip AND
• Give dextrose 50% in water (D50W) intravenously
If patient is awake: 25 mL (1/2 amp)
If patient is not awake: 50 mL (1 amp)
• Recheck blood glucose every 20 minutes and repeat 25 mL of D50W IV
if < 60 mg/dL. Restart insulin drip once blood glucose is > 70 mg/dL X 2
checks. Restart drip with lower algorithm (see “Moving down”)
Notify the physician
• For any blood glucose change greater than 100 mg/dL in 1 hour
• For blood glucose > 360 mg/dL
• For hypoglycemia that has not resolved within 20 minutes of giving 50
mL of D50W IV and discontinuing the insulin drip
Once the IV insulin is discontinued, start Lantus insulin units sc at
bedtime and Humalog insulin units sc before each meal.
For nausea as needed use the following drugs:
Reglan 5 to 10 mg IV every 6 hours.
Zofran 4 mg IV every 6 hours.
The Reglan and the Zofran can be alternated every 3 hours to
3
relieve nausea as needed.
12. X-rays:
13. Labs:
14. Consultants:
15. Other:
Tylenol 500 mg, one tablet by mouth every 4 hours as needed for mild
pain.
Milk of Magnesia, 30 ml by mouth at bedtime as needed for constipation.
Ambien 5 mg, one tablet by mouth at bedtime and may repeat X 1 if
needed for sleep.
ASA 81 mg, one tablet by mouth daily to prevent heart attacks and
strokes.
Make sure a chest x-ray, PA and lateral, has been done.
SMA-7 at admission and then every 2 hours after admission X 4 and then
every 4 hours until on the #5 IV and off any bicarb drips, and then do a
chem 7 in the AM and at 4 PM daily.
Serum ketones with first, second and third blood draw.
CBC and LFTs.
ABGs at admission; PO4, magnesium and calcium at admission.
Please have specialty clinic set up an appointment with Dr. Potichta for
the patient.
Please have Sara Linton, CDE, evaluate and educate the patient about sick
day management/measurement of ketones and review administration of
insulin, how to self-regulate insulin dosages based on carbohydrate
counting, how to make adjustments in Humalog dosages based on the premeal blood glucose, and recalculate the patient’s insulin sensitivity factor
and educate the patient in its proper usage in making adjustments in
insulin dosages.
Call MD if: BP < 90/60 or > 170/110, P 130 or T > 101F.
If magnesium is 1.4-1.8 mg/dL, supplement 1g MgSO4 IVPB over 30
min; if magnesium is less than 1.4 mg/dL, supplement 2g MgSO4 IV
piggyback over 30 to 60 min.
If both magnesium and PO4 are low, supplement magnesium first.
If PO4 is 1.0-1.8 mg/dL, supplement orally if possible with skim milk or
Neutra-Phos; if PO4 is 0.5-1.0 mg/dL, supplement IV with 0.08 mM/Kg
KPO4 in 250cc NS over 4 hr.; if PO4 is < 0.5 mg/dL, supplement IV with
0.16 mM/Kg KPO4 in 250cc NS over 4 hr.
With all IV supplementation check calcium and serum albumen Q 4 hr.
After all infusions complete, immediately check PO4 level.
If calcium supplementation is necessary (after repeating a serum albumin
level call the physician if the serum calcium is less than 7.0), do not give
in same IV line as PO4.
If pH < 7.1, add 1 amp (44meq) of Na Bicarbonate to bag. NS Q 2 hr until
pH > 7.1. ABG Q 4 hr (if treating with bicarbonate).
If the serum potassium drops below 3.5 when on liter #5 or greater, then
double amount of KCl in the IV fluid to 40 mEq/liter. When the potassium
is above 3.5, then decrease the IV potassium back to 20 mEq/liter.
4
16. H&P:
If the serum potassium drops to below 3.0 when on liter #5 or greater, then
in addition to doubling the amount of potassium added to the IV fluids to
40 mEq/liter, also start having the patient take 20 mEq of oral potassium
every 2 hours until the potassium is above 3.5. Then, stop the oral
potassium and continue the IV potassium at 20 mEq/liter.
Please type up the H&P.
________________________________________________
Signature
5