ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked

Transcription

1 Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status ***(NOTE)***For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS than 12 mmol/l Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8) Place in Observation Patient Status: Outpatient- Refer for Observation Status, Level of Care: Intensive Care (8) Nursing Orders Notify Physician See Order Comments Comments: Notify ordering MD if patient is scheduled for surgery or any procedure where patient is NPO for GREATER than 4 hours, if an alternative insulin source is ordered (ie: TPN), or if feedings, TPN or steroids are started, stopped or changed; for hypoglycemia that does not respond to treatment of if IV access lost. Notify Physician See Order Comments Comments: Notify ordering physician and discontinue Insulin Infusion orders if insulin infusion is off for 6 hours Notify Physician See Order Comments Comments: Notify MD if more than two consecutive BG values are LESS than 70 mg/dl Medications ***(NOTE)***Target Glucose mg/dl SUB Insulin Infusion Regimen for DKA Patients (SUB)* ***The above subphase is available at the end of the plan*** ***(NOTE)***Target Glucose mg/dl SUB Insulin Infusion Regimen for Hyperosmolar Hyperglycemic State (HHS) (SUB)* ***The above subphase is available at the end of the plan*** potassium chloride 10 meq/100 ml (DKA) 10 meq IVPB premix, PRN Other (see comment) Comments: To be used only if urinary output GREATER than 0.5 ml/kg/hour and BUN LESS than 30 mg/dl AND serum Creatinine LESS than 2 mg/dl. Call physician if patient is excluded. meq over 3 hours meq/l 40 meq over 4 hours meq/l 50 meq over 5 hours meq/l 60 meq over 6 hoursless than 2.3 meq/l 60 meq over 6 hours and notify MD Laboratory Basic Metabolic Panel (CHEM 7) Timed Study, Blood, Q6H, 24 hour Comments: Notify Physician if K+ LESS than 3.5 or GREATER than 5.5 Betahydroxybutyrate Early AM, Blood Page 1 of 7

2 CMP Early AM, Blood Phosphorus Early AM, Blood Hgb A1C Routine, Blood, ONCE Comments: If not already done on admit Consults Consult Physician Endocrinology, Insulin Infusion Initiated Consult Diabetes Adult. Routine Comments: Med teaching, Insulin Infusion orders initiated. Consult Dietitian Diet Education, DKA/HHS patient Consult Pharmacy Routine, Medication Reconciliation Comments: Discontinue all other medications for hyperglycemia due to insulin infusion initiated. SUB Insulin Infusion Regimen for DKA Patients Nursing Orders Insulin Infusion Adjustment Tables Blood Glucose Monitor POC Q1H, Check finger stick blood glucose every hour while on insulin infusion. Obtain lab Glucose if finger stick blood glucose does NOT agree with clinical assessment. When fingerstick blood glucose is LESS THAN 250 mg/dl, change IV fluids to D5 NS. Medications IV Solutions ***(NOTE)***Cancel all prior IV fluid and insulin orders. Insulin (Regular) 100 units/ns 100mL (IVS)* NS (Insulin) Initial Multiplier: IV iv Titrate per algorithm Comments: ********Initial Rate in units/hour = (BG-60) x 0.03********Adjust multiplier as follows:if BG is GREATER than 180 mg/dl, increase the multiplier by If BG is LESS than 140 mg/dl reduce multiplier by If BG is within target range, do not change multiplier but do recalculate dose. Flush tubing with 10mL of Insulin Infusion PRIOR to starting. Administer via an infusion device piggybacked into IV fluids. For BG GREATER Than 400 mg/dl, use 400 as Maximum BG for calculation. Insulin dose MUST be calculated hourly even if multiplier does not change Refer to Insulin Infusion Nomogram Reference Text for rate verification insulin regular (human) IV drip 100 unit Page 2 of 7

3 glucose (D50W (Insulin Infusion Orders)) 50 ml IV PUSH syringe ASDIR, PRN Other (see comment) Comments: For BG less than 70, give Dextrose 50% as follows: Amount in ml = (100-BG) x 0.31) 1) Reduce Insulin Multiplier by 0.01 and recheck BG in 15 minutes. 2) If BG remains less than 70, Give Dextrose 50% and follow instructions above. 3) Contact MD if more than two consecutive BG values are less than 70 mg/dl. 4) Blood glucose monitoring every 30 minutes for BG values between mg/dl5) Resume hourly blood glucose monitoring once blood glucose is 90 mg/dl or GREATER for BG target range ( mg/dl)6) Resume the above IV Insulin Therapy orders once BG is 90 mg/dl or GREATER for BG target range ( mg/dl). Sodium Chloride 0.9% (Normal Saline) IV bag Rate: 150 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than (DEF)* IV bag Rate: 200 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 125 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 100 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 75 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 50 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than Sodium Chloride 0.9% + potassium chloride 20 meq/l (Normal Saline + KCl 20 meq 1000 ml) Sodium Chloride 0.45% (1/2 NS) Page 3 of 7

4 Sodium Chloride 0.45% + potassium chloride 20 meq/l (1/2NS + KCl 20 meq) ***(NOTE)***Start maintenance IV fluid once fingerstick blood Dextrose 5% with 0.9% NaCl, Clinical Instructions: Start maintenance IV fluid once fingerstick blood glucose is LESS than 250 mg/dl. (DEF)* IV bag Rate: 200 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 125 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 100 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 75 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 50 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood Dextrose 5% w/ Sodium Chloride 0.9% + potassium chloride 20 meq/l Dextrose 5% with 0.45% NaCl Dextrose 5% w/ Sodium Chloride 0.45% + potassium chloride 20 meq/l Page 4 of 7

5 SUB Insulin Infusion Drip Regimen for Hyperosmolar Hyperglycemic State (HHS) Nursing Orders Insulin Infusion Adjustment Tables - Hyperosmolar Blood Glucose Monitor POC Q1H, Check finger stick blood glucose every hour while on insulin infusion. Obtain lab Glucose if finger stick blood glucose does NOT agree with clinical assessment. When fingerstick blood glucose is LESS THAN 300 mg/dl, change IV fluids to D5 NS. Medications IV Solutions ***(NOTE)***Cancel all prior IV fluid and insulin orders. Insulin (Regular) 100 units/ns 100mL (IVS)* NS (Insulin) Initial Multiplier: IV iv Titrate per algorithm Comments: *******Initial Rate in units/hour = (BG-60) x 0.03********Adjust multiplier as follows: If BG is GREATER than 300 mg/dl, increase the multiplier by If BG is LESS than 250 mg/dl reduce multiplier by If BG is within target range, do not change multiplier but do recalculate dose. Flush tubing with 10mL of Insulin Infusion PRIOR to starting. Administer via an infusion device piggybacked into IV fluids. For BG GREATER Than 300 mg/dl, use 400 as Maximum BG for calculation. Insulin dose MUST be calculated hourly even if multiplier does not change Refer to Insulin Infusion Nomogram Reference Text for rate verification insulin regular (human) IV drip 100 unit glucose (D50W (Insulin Infusion Orders)) 50 ml IV PUSH syringe ASDIR, PRN Other (see comment) Comments: For BG less than 70, give Dextrose 50% as follows: Amount in ml = (100-BG) x 0.31) 1) Reduce Insulin Multiplier by 0.01 and recheck BG in 15 minutes. 2) If BG remains less than 70, Give Dextrose 50% and follow instructions above. 3) Contact MD if more than two consecutive BG values are less than 70 mg/dl. 4) Blood Glucose monitoring every 30 minutes for BG values between mg/dl5) Resume the above IV Insulin Therapy orders once BG in target range ( mg/dl). 6) Continue hourly Blood Glucose once BG in target range ( mg/dl) Sodium Chloride 0.9% (Normal Saline), Clinical Instructions: When fingerstick blood glucose is LESS than 300mg/dL, change IV fluid to 150 ml/hour (DEF)* IV bag Rate: 200 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 125 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 100 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 75 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than IV bag Rate: 50 ml/hour, Clinical Instructions: When fingerstick blood glucose is LESS than Page 5 of 7

6 Sodium Chloride 0.9% + potassium chloride 20 meq/l (Normal Saline + KCl 20 meq 1000 ml) Sodium Chloride 0.45% (1/2 NS) Sodium Chloride 0.45% + potassium chloride 20 meq/l (1/2NS + KCl 20 meq) ***(NOTE)***Start maintenance IV fluid once fingerstick blood Dextrose 5% with 0.9% NaCl, Clinical Instructions: Start maintenance IV fluid once fingerstick blood glucose is LESS than 300 mg/dl. (DEF)* IV bag Rate: 200 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 125 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 100 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 75 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood IV bag Rate: 50 ml/hour, Clinical Instructions: Start maintenance IV fluid once fingerstick blood Dextrose 5% w/ Sodium Chloride 0.9% + potassium chloride 20 meq/l Page 6 of 7

7 Dextrose 5% with 0.45% NaCl Dextrose 5% w/ Sodium Chloride 0.45% + potassium chloride 20 meq/l Page 7 of 7