Smith, Adam A. dob 07/01/1959 45 & 6/12 y/o 01-01-05
000-0000 000-0000
Hospital
MR # Clinic MR #
John
Alexander, MD
Mercy Folsom Hospital, Med Surg Ward
983-7460,
Fax 983-7548, ooo@hospital1.com
Orders
Starting to type ketoacidosis
offers the following hospital ICU orders upon reaching “keto”. Other examples are at the bottom of this
page.
Suggested hospital orders for DKA & non-ketonic hyperosmolar syndrome
1
Initially use NS at 1 L/hr × 1-5 L to restore volume;
thereafter, half NS or NS at 250-500 mL/hr; Base on cardiovascular parameters
(e.g., heart rate, blood pressure) and urine output
2
Acidosis: Use
bicarbonate if pH < 7.1, shock, coma, or severe hyperkalemia is present:
a
if acidosis, please do:
1 ampule of NaHCO3
(44 mEq)
Check ABG after 1 hr: if pH > 7.1, stop
b
obtain the following and if abnormal, repeat in 4 hrs
i
ABG's
ii
Bicarbonate
iii
Anion gap
3
Regular insulin:
a
Bolus: 0.1 U/kg
b
IV drip: start at 0.1 U/kg (if HHNS rather
than DKA, 1-2 U/hr)
c
obtain RBS q hourly (Expected rate of fall, 
100 mg/dL/hr; Initial goal: 200-300 mg/dL (to
avoid hypoglycemia)
d
If Blood glucose still elevated or falling slowly:
Increase insulin IV by 50-100% per hr (peak effect of regular insulin is at
about 3 hours.)
4
If Blood glucose < 250 mg/nutrition
outline
a
Start IV dextrose infusion
b
Start SC regular insulin
c
Discontinue IV insulin 2 hr after giving SC insulin
d
Begin clear liquid diet and progress as tolerated
5
obtain Electrolyte panel (Hyperkalemia may be
initially present but Hypokalemia during insulin therapy should be
anticipated)
a
obtain Serum K+, Ca, Mg, phosphate
b
obtain serum K+ q 2 hrs while awake and q 4 hrs
otherwise for first 24 hrs
c
12 lead ECG
d
Record Urine output Q 2 hrs (should be at least
>30 mL/hr)
6
consider prophylactic low dose heparin q 12 hr, cpk
look for other conditions
osmolality formula: The serum osmolality may be calculated by adding Na+ and K+, multiplying by 2, adding glucose (mg/dL) divided by 18, and adding BUN divided by 2.8 (ie, 2 [Na+ + K+] + [mg/dL of glucose/18] + [BUN/2.8]).
fluids before insulin to avoid further intravascular dehydration
target blood glucose
level at 250-300 mg/dL
John Alexander, MD 01-01-05 Saturday 12:38 AM
Example #2:
“jl” becomes joint line
“knee” offers ACL, PCL, MCL, LCL, Apley's grind all wnl; no effusion, heat nor LOM
“hepat” offers labs for hepatitis, Hep A IgM, HepBsAg, hepatitis C Ab & anti-hepatitis B core IgG,
iron, ferritin, ceruloplasmin.
“diarrhea” offers stool
C&S, giardia Ag, stool for wbc exam.
“card” offers CR:
cta & percussion; RSR w/o murmur, gallop, click or altered 2nd sound
etc., etc.