2. Diagnosis: Diabetic ketoacidosis
4. Vital signs: q1h, postural BP and pulse. Call physician if BP >160/90, <90/60; P >140, <50; R >30, <10; T >38.5°C; or urine output < 20 mL/hr for more than 2 hours.
5. Activity: Bed rest with bedside commode.
6. Nursing: Inputs and outputs. Foley to closed drainage. Record labs on flow sheet.
7. Diet: NPO for 12 hours, then clear liquids as tolerated.
1-2 L NS over 1-3h (>16 gauge), infuse at 400-1000 mL/h until hemodynamically stable, then change to 0.45% saline at 125-150 cc/hr; keep urine output >30-60 mL/h.
Add KCL when serum potassium is <5.0 mEq/L. Concentration 20-40 mEq KCL/L
May use K phosphate, 20-40 mEq/L, in place of KCL if low phosphate.
Change to 5% dextrose in 0.45% saline with 20-40 mEq KCL/liter when blood glucose 250-300.
9. Special Medications: -Oxygen at 2 L/min by NC.
-Insulin Regular (Humulin) 7-10 units (0.1 U/kg) IV bolus, then 7-10 U/h IV infusion (0.1 U/kg/h); 50 U in 250 mL of 0.9% saline; flush IV tubing with 20 mL of insulin sln before starting infusion. Adjust insulin infusion to decrease serum glucose by 100 mg/dL or less per hour. When bicarbonate level is >16 mEq/L and anion gap <16 mEq/L, decrease insulin infusion rate by half
-When the glucose level reaches 250 mg/dL, 5% dextrose should be added to the replacement fluids with KCL 20-40 mEq/L. -Use 10% glucose at 50-100 mL/h if anion gap persists and serum glucose has decreased to less than 100 mg/dL while on insulin infusion. -Change to subcutaneous insulin when anion gap cleared; discontinue insulin infusion 1-2h after subcutaneous dose.
10. Extras: Portable CXR, ECG.
11. Labs: Fingerstick glucose q1-2h. SMA 7 q4-6h. SMA 12, pH, bicarbonate, phosphate, amylase, lipase, hemoglobin A1c; CBC. UA, serum pregnancy test.
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