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Diabetic Ketoacidosis DKA Inpatient Orders Glucose

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					DIABETIC KETOACIDOSIS (DKA)                                                                PLACE LABEL HERE
INPATIENT ORDERS

 Orders with a “” are choices and are NOT implemented unless checked. All may be altered at physician’s discretion.
DIAGNOSIS: ____________________________________________________________________________
1.     Admit Inpatient to ICU/IMCU for ______________________________________(Reason for admission)
       Mild diabetic ketoacidosis: CO2 equal to 21 to 28 mEq/L and /or pH 7.3
       Moderate diabetic ketoacidosis: CO2 equal to 11 to 20 mEq/L and/or pH 7.1 to 7.3
       Severe diabetic ketoacidosis: CO2 less than 10 mEq/L and/or venous plasma pH less than 7.1
       Hyperosmolar Hyperglycemic State (HHS) is characterized by severe dehydration, with absent or small
        ketones. This pre-printed order can be used with modifications for patients with HHS

2.    Consults:_______________________________________________________________________
      Consult diabetes educator and clinical dietitian for new onset diabetes.

3.      Laboratory:
         Chem 7, magnesium, phosphorus, STAT, if not done in ED
         Chem 7, and magnesium q 4 hrs x 3, then q 6 hrs x 4
         ABG, upon admission, if not done in ER
         TSH (for new onset of DM)
         Serum HCG, for females of childbearing age
         HbA1C
         CBC, CMP q AM
         Serum ketones q                hrs x ________
         Urine analysis
         Urine culture and sensitivity
        Radiology:_______________________________________________________________________
        Other: __________________________________________________________________________
4.      On admission, if wearing insulin pump, remove insulin pump, and consult with Diabetes Educator.
5.      Vital signs per unit routine
6.      Oxygen per Respiratory Care Protocol
7.      Cardiac monitoring:  May be off monitor for tests
8.      Fingerstick glucose checks every hr until Blood Glucose (BG) within target range x 3 readings, then q 2
        hrs until BG within target range x 3 consecutive readings, then q 4 hrs as long as glucose remains
        within target range while on insulin infusion
9.      Call physician if 50% or more glucose readings in 24 hrs are over 180
10.     Call physician when anion gap <13. Anion Gap = Na - (Cl + HCO3)
        Once DKA is resolved: Glucose < 250 and one of the following:
                                 Sodium bicarbonate > 18 or Anion gap < 13 or Venous pH > 7.3
               Call physician for subcutaneous insulin orders once DKA is resolved
               Initiate Subcutaneous Order Set (seq # 20383)
11.     Diet: Clear liquids when anion gap is less than or equal to 13. If patient tolerates non caloric liquids, call
        physician for subcutaneous insulin order. Advance to consistent carbohydrate diet (replaces ADA diet).
12.     Do not stop insulin infusion for NPO status
13.     Activity:  Bedrest         BSC       BRP      Up ad lib


*3-11367*                          FORM 3-11367 REV. 10/2009                     Send copy to
pharmacy__________(initials)
                                                                                                             Page 1 of 2
DIABETIC KETOACIDOSIS (DKA)                                                                 PLACE LABEL HERE
INPATIENT ORDERS

  Orders with a “” are choices and are NOT implemented unless checked. All may be altered at physician’s discretion
SCHEDULED MEDICATIONS
14.     Stress ulcer prophylaxis: Pepcid (famotidine) 20 mg po or IV twice a day
15.     DVT prophylaxis:  Fragmin (dalteparin) 5,000 units subcutaneous q 24 hrs
                            SCDs                     TED hose
16.     IVF:
         NS at ______ml/hr for ______liters, then ½ NS or _______ at _________ml/hr for ________liters
         NS with KCL 20 mEq/liter at _____ml/hr for _____liters,
              then ½ NS with KCL 20 mEq/liter at _________ml/hr for ________liters
               Ringers Lactate at __________ ml/hr
               Magnesium (Mg) < 1.8; Magnesium sulfate 2 gm IV in pre-mix solution over ____hrs
              Recheck Mg             after infusion completed and repeat prn if Mg < 1.8.
               Potassium (K) < to 3.5: KCL ____ mEq premix solution IV over ____ hrs
              Recheck K after infusion completed and repeat prn if K < 3.3.
               Potassium (K) < to 3.5: KCL 40 mEq po now x 1 dose
        If potassium (K) > 5 on serial Chem 7 results; delete K from maintenance IV and check K q 2 hrs
17.     When blood glucose < 250 mg/dL, change to:
         D5 ½ NS at _______ml/hr x 1 liter            D5 ½ NS with KCL 20 mEq/liter at ____ml/hr x 1 liter
         D5 NS at _____ml/hr x 1 liter                D5 NS with KCL 20 mEq/liter at ______ml/hr x 1 liter
DKA INSULIN PROTOCOL
19.     Regular insulin 100 units in NS 100 ml (1 unit/ml); use IV pump to infuse Insulin drip into IV fluids
20.     Target Blood Glucose Level: 100 – 150 mg/dl
21.     If Blood Glucose > 300 mg/dl, prior to starting IV insulin drip give following bolus:
        patient’s weight_____kg x 0.1 units = number of units regular insulin IV
22.     Initiate Diabetic Ketoacidosis IV Insulin Flowsheet (seq # 20559)
23.     Start insulin infusion on pump at rate determined by this formula:
        (BG – 60) x 0.03 = number of units insulin/hr (BG = current blood glucose; 0.03 is the “multiplier”)
        Adjust multiplier in drip formula using the following directions:
                 When BG is > 150 target: increase multiplier by 0.01
                 When BG is < 100 target: decrease multiplier by 0.01
                 When BG is within target range: no change in multiplier
        If glucose decreases > 15 % between glucose checks, do not increase insulin infusion rate.
24.     If glucose is < 60 mg/dl initiate Hypoglycemia Protocol Orders (seq # 2513) and stop insulin infusion.
        Recheck blood glucose every hr until blood glucose is > 100 mg/dl.
PRN MEDICATIONS:
25.     Mild pain/temp >100.5F/HA: Tylenol (acetaminophen) 650 mg po q 4 h
26.     Nausea/Vomiting (Choose one if needed):
        Zofran (ondansetron) 4 mg IV q 6 hrs prn
        Reglan (metoclopramide) 10 mg po or IV q 6 hrs prn (5 mg if greater than 65 y/o)
        Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________

______________              ___________________        _________________________________              __________
FORM 3-11367 REV. 10/2009                                               Send copy to pharmacy__________(initials)
                                                                                                             Page 2 of 3
DIABETIC KETOACIDOSIS (DKA)                                         PLACE LABEL HERE
INPATIENT ORDERS
Date                        Time   Physician Signature                       MD Number




FORM 3-11367 REV. 10/2009                         Send copy to pharmacy__________(initials)
                                                                                   Page 3 of 3

				
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