*** UNCHECKED BOXES AND LINED THRU ORDERS ARE NOT APPLICABLE
ALLERGIES:
ADMITTING DIAGNOSIS: Diabetic Ketoacidosis
Intrauterine Pregnancy
ADMIT TO:  [  ] ICU     [  ]Antepartum
ACTIVITY:  Bedrest
[  ]Left lateral tilt
[  ]Other:__________________________________________________________________
MONITORING:  Capillary (fingerstick) blood glucose and dipstick urine every ____hour (s), chart glucose and acetone.
Vital signs every hour
Call physician if urine output < 15 mL/hr.
EKG
[  ]Cardiac monitor
[  ]Fetal heart tones every shift
[  ]Continuous fetal monitoring
Maintain flow sheet.
LABS:  

On admission arterial gases, serum Na, K, Cl, HCO3-, glucose,phosphate, magnesium ,calcium ,creatinine, BUN, ketones;. Calculate serum osmolality and anion gap
[  ]Serum beta-hydroxybutyrate
Repeat serum Na, K, Cl, HCO3-, glucose, creatinine,BUN, ketones every ____ hours until anion gap and ketones normal.
CBC with differential, urinalysis with culture and sensitivity, blood cultures.
RADIOLOGY:  [  ] OB Ultrasound for fetal weight and AFI
[  ] CXR
[  ] Echocardiogram
IV THERAPY:  Normal Saline (0.9% saline) to run at 1000 mL per hour for 1 hour
then Normal Saline to run at _____ mL ( 500 mL to 1000 mL) per  hour for ___ hours ( 2h to 4h ) 
then Normal Saline250 mL per hour
Start 5% dextrose in normal saline when plasma level reaches 250 mg/dL (14 mmol/L)
MEDICATIONS:  O2 @      [ ] 2      [ ] 4      [ ] 6       Liters/min via      [ ] NC      or      [ ] FM.
INSULIN
Regular insulin infusion (0.1 U/kg/hr.) ______ U/hr.
Hold insulin if potassium is less than 3.3 mEq/L
[  ] Double infusion rate if no response in 1 hour.
[  ] Adjust insulin infusion according to scale below
Capillary glucose mg/dL    (mmol/L) Regular Insulin Infusion Rate (Units per hour)
0 to 110      (0 to 6.1) 0.5
111 to 140   (6.15 to 7.8) 1
141 to 160   (7.85 to 8.9) 2
161 to 180   (8.95 to 10) 2.5
181 to 200    (10.05 to 11.1) 3
201 to 220   (11.2 to 12.2) 4
over 220  (12.2) CALL PHYSICIAN

Treatment goal is to reduce blood glucose by ~ 100 mg /dl  per hour (5 to 6 mmol/L per ) per hour
Continue infusion 12–24 hours after resolution of ketosis.

POTASSIUM
If serum potassium is less than 3.3 mEq/L then give KCL piggyback TRA 40 mEq/h. Reduce rate by 50% if patient is oliguric.
If Serum potassium is greater than or equal to 3.5 mEq/L and less than 5 mEq/L then 20 mEq/h . Reduce rate by 50% if patient is oliguric.
Hold potassium if potassium is greater than  5 mEq/L

[  ] Bicarbonate one ampule (44 mEq) to 1 L of 0.45 normal saline if pH is <7.1
[  ]Tylenol 500 mg 1-2 PO Q 4-6 hr PRN pain/T > 101°F.
[  ] DVT prophylaxis with Heparin 5000 U SQ bid.
[  ] Add one ampule (44 mEq) to 1 L of 0.45 NS if pH is <7.10
[  ] Rocephin 1 gram IVPB every 24 hours.
[  ]Other: ______________________________________________________________  

DIET:  NPO for 12 hours then clear liquids as tolerated ;Then advance to ________ Calorie Sweet Success diet as tolerated.
[  ] Clear liquid diet
[  ] Other: ______________________________________________________________
CALL PHYSICIAN FOR COMPLAINTS OF:
  Respiratory rate less than 12 or greater than 25 per minute
Complaint of sore throat
Rash
Temperature >100.4 °F
Chest pain
 02 Sat less than 90% on room air
Decreased loss of consciousness
Respiratory distress
OTHER

______________________________________________________
Date:____________    Time:_____________   Physician Signature:_________________________    [  ] RBO

Date:____________    Time:_____________    Noted: _______________________________________
 
PATIENT I.D. LABEL

 

 

DIABETIC KETOACIDOSIS IN PREGNANCY PHYSICIAN ORDERS

1. Mark B. Landon ,  Patrick M. Catalano, and Steven G. Gabbe: Diabetes Mellitus .  In Gabbe ed: Obstetrics - Normal and Problem Pregnancies, 4th ed.new York, NY,Churchill Livingstone, 2002. p 1102
2. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus.PMID: 15738045
3. Chauhan SP, Perry KG Jr. Management of diabetic ketoacidosis in the obstetric patient. Obstet Gynecol Clin North Am 1995;22:143–55
4. Hardern RD, Quinn ND. Emergency management of diabetic acidosis in adults. Emerg Med J 2003;20:210-213.
5. Berg B, et al Reference values for serum components in pregnant women.Acta Obstet Gynecol Scand. 1984;63:583-6. 6. Wallace TM and Matthews DR Recent advances in the monitoring and management of diabetic ketoacidosis.QJM.2004;97:773-80. PMID:15569808

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