Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 > 101F. 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