PLACE LABEL HERE
DIABETIC KETOACIDOSIS (DKA)
HYPEROSMOLAR HYPERGLYCEMIA STATE (HHS)
ADMISSION FROM ED
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: q Diabetes Type I q Diabetes Type 2 q Secondary Diabetes q Other: ______
· 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 < 10 mEq/L and/or venous plasma pH 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.
Level of Care: q Critical q Intermediate q Acute Care q Location/Specialty Unit Preference: ______
3. Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. Consults: ______
6. Consult Diabetes Educator and Clinical Dietitian
7. Diagnostics/Lab: Chem 7, magnesium and phosphorous on admission to unit if not done in ED
Chem 7 q 4 hrs x 2, then q 6 hrs x 4
Magnesium (MG++) q 4 hrs x 2, then q 6 hrs x 4 until > 1.8
HbAIC if not done in ED
CBC, CMP q AM
Quantitative hCG for any menstruating female 12 years if no pregnancy test done in ED
q Beta Hydroxbutyrate q ______hrs x ______
Radiology: ______
Other: ______
8. Vital signs per unit routine
9. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
10. Activity: q Bed rest q BSC q BRP q Up ad lib
11. Initiate PT/OT Protocol (form # 32655) if patient has a substantial decrease from base line function that is unlikely to resolve within 48 hrs, or needs replacement and disposition
12. Initiate Sleep Apnea Orders (form # 21266), if OSA screen is positive for suspected or reported sleep apnea
13. Oxygen per protocol (form # 34431)
14. Diet: Clear liquids (No Carbohydrates Low Sugar {Insulin Infusion}). When anion gap is 10 and insulin infusion has been discontinued advance to consistent carbohydrate diet
15. Call physician for GFR < 30 ml/min or serum creatinine 2.5
16. Insulin infusion per ENDOTOOL Insulin Infusion Standing Orders (form # 38635) with BG range 100-150 mg/dl.
a. Regular insulin 100 units in NS 100 ml (1 unit/ml). IV pump to administer Insulin Infusion.
17. If ENDOTOOL unavailable/downtime initiate orders below:
· Initiate or continue insulin infusion (use IV infusion pump) using the following:
o Regular insulin 100 units in NS 100 ml (1 unit/ml concentration)
· Start insulin infusion at rate determined by:
o (BG 0 60) x 0.03 = number of units insulin/hr (BG=current blood glucose; 0.03 is the “multiplier”)
· Finger stick blood glucose (BG) check q 1 hr until BG within 100-150 x 3 readings, then q 2 hrs
Copy to pharmacy Order writer’s initials ______
*3-24148* FORM 3-24148 REV. 06/2017 Page 1 of 3
PLACE LABEL HERE
DIABETIC KETOACIDOSIS (DKA)
HYPEROSMOLAR HYPERGLYCEMIA STATE (HHS)
ADMISSION FROM ED
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Treating q DKA q HHS
· With subsequent hourly glucose checks, adjust multiplier in formula using the following directions:
o BG is < 100 decrease multiplier by 0.01
o BG is 100 – 150 no change in multiplier and recalculate infusion rate
o BG is > 150 increase multiplier by 0.01
· Do not stop insulin infusion for NPO status
· Blood glucose (BG) < 70 mg/dL: initiate Hypoglycemia Standing Orders (form # 25123). Stop insulin infusion.
Recheck BG q 15 min until BG >100 mg/dL then restart insulin infusion at ½ previous rate.
MEDICATIONS
18. IV Fluids for BG > 250 mg/dL:
q NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q NS with KCL 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q ½ NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q ½ NS with KCL 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q LR at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
19. IV Fluids for BG 250 mg/dL:
q D5 NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q D5 NS with KCL 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q D5 ½ NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q D5 ½ NS with KCL 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
20. IV Fluids for BG < 170 mg/dL AND Anion Gap 12:
q NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q NS with KCI 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q ½ NS IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
q ½ NS with KCI 20 mEq/L IV at q 75 ml/hr q 125 ml/hr q 150 ml/hr q 200 ml/hr
21. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
q Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)
or q Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 min)
and/or q Mechanical devices: SCDs
PRN MEDICATIONS (see policy 520-06 for range orders and pain intensity guidelines)
22. Electrolyte Replacement: (Call physician to replete electrolytes if GFR < 30, CrCl < 30 or SCr 2.5)
Potassium(K+) Level (mmol/L) / Potassium Supplementation
Orders / Additional Orders
K+ =
5.0 / · D/C (remove) potassium from maintenance IV fluids / · Notify physician (panic lab value)
· Repeat K+ level in 2 hrs
K+ =
4.0
On insulin infusion
/ · D/C below orders if GFR is < 30 or SCr is ≥ 2.5· KCL 20 mEq/100 ml IVPB over 2 hrs x 2 doses / · Repeat K+ level 2 hrs after the last does
K+ =
3.5
Not on insulin infusion / · D/C below orders if GFR < 30 or SCr is ≥ 2.5· KCL 20 mEq/100 ml IVPB over 2 hrs x 2 doses / · Repeat K+ level 2 hrs after the last dose.
Copy to pharmacy Order writer’s initials ______
FORM 3-24148 REV. 06/2017 Page 2 of 3
PLACE LABEL HERE
DIABETIC KETOACIDOSIS (DKA)
HYPEROSMOLAR HYPERGLYCEMIA STATE (HHS)
ADMISSION FROM ED
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Magnesium(Mg2+) Level (mg/dL) / Magnesium
Supplementation Orders / Additional Orders
Mg2+ =
1.8 / · D/C below orders if GFR is < 30 or SCr is ≥ 2.5
· D/C below orders if patient has myasthenia gravis
· Magnesium sulfate 2 gms IVPB over 1 hr / · Magnesium level after infusion completed
23. Mild pain/temp >100.5°F/HA: q Tylenol (acetaminophen) 650 mg po q 4 hrs prn
24. Nausea/vomiting: q Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
q If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
25. Constipation: q Ducolax 10 mg per rectum daily prn
ADDITIONAL ORDERS:
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Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-24148 REV. 06/2017 Page 3 of 3