Endocrinologic Disorders

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Diabetic Ketoacidosis
1.Admit to:
2.Diagnosis: Diabetic ketoacidosis
3.Condition:
4.Vital Signs: q1-4h, postural BP and pulse. Call
physician if BP >160/90, <90/60; P >140, <50; R >3
<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.
8.IV Fluids:
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 >3
60 mL/h.
Add KCL when serum potassium is <5.0 mEq/L.
Concentration.......20-40 mEq KCL/L
Use K phosphate, 20-40 mEq/L, in place of KCL if
hypophosphatemic.
Change to 5% dextrose in 0.45% saline with 20-40 mE
KCL/liter when blood glucose is 250-300 mg/dL.
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
in 250 mL of 0.9% saline; flush IV tubing with 20
mL of insulin solution before starting infusion.
Adjust insulin infusion to decrease serum glucos
by 100 mg/dL or less per hour. When bicarbonat
level is >16 mEq/L and the anion gap is <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 flui
with KCL 20-40 mEq/L.
-Use 10% glucose at 50-100 mL/h if anion gap
persists and serum glucose has decreased to les
than 100 mg/dL while on insulin infusion.
-Change to subcutaneous insulin when the anion g
has cleared; discontinue insulin infusion 1-2h afte
subcutaneous dose.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV q12h.
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h pr
headache.
11. Extras: Portable CXR, ECG.
12. Labs: Fingerstick glucose q1-2h. SMA 7 q4-6h. S
12, pH, bicarbonate, phosphate, amylase, lipase,
hemoglobin A1c; CBC. UA, serum pregnancy test.
Nonketotic Hyperosmolar
Syndrome
1.Admit to:
2.Diagnosis: Nonketotic hyperosmolar syndrome
3.Condition:
4.Vital Signs: q1h. Call physician if BP >160/90,
<90/60; P >140, <50; R>25, <10; T >38.5  C; or uri
output <20 cc/hr for more than 4 hours.
5.Activity: Bed rest with bedside commode.
6.Nursing: Input and output measurement. Foley to
closed drainage. Record labs on flow sheet.
7.Diet: NPO.
8.IV Fluids: 1-2 L NS over 1h ( 16 gauge IV catheter
then give 0.45% saline at 125 cc/hr. Maintain urine
output  50 mL/h.
-Add 20-40 mEq/L KCL when urine output adequate
9.Special Medications:
-Insulin regular 2-3 U/h IV infusion (50 U in 250 mL
0.9% saline).
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg PO qd.
-Heparin 5000 U SQ q12h.
10. Extras: Portable CXR, ECG.
11. Labs: Fingerstick glucose q1-2h x 6h, then q6h.
SMA 7, osmolality. SMA 12, phosphate, ketones,
hemoglobin A1C, CBC. UA.
Thyroid Storm and
Hyperthyroidism
1.Admit to:
2.Diagnosis: Thyroid Storm
3.Condition:
4.Vital Signs: q1-4h. Call physician if BP >160/90,
<90/60; P >130, <50; R>25, <10; T >38.5 C.
5.Activity: Bed rest
6.Nursing: Cooling blanket prn temp >39 C, inputs and
outputs. Oxygen 2 L/min by nasal canula.
7.Diet: Regular
8.IV Fluids: D5 ½ NS at 125 mL/h.
9.Special Medications:
Thyroid Storm and Hyperthyroidism
Subtotal Thyroidectomy: Indicated in patients with
large goiter that extends retrosternally, in pregnant
patients, and children who have major adverse
reaction to medications.
-Methimazole (Tapazole) 30-60 mg PO, then
maintenance of 15 mg PO qd-bid OR
-Propylthiouracil (PTU) 1000 mg PO, then 50-250 mg
PO q4-8h, up to 1200 mg/d; usual maintenance
dose 50 mg PO tid AND
-Iodide solution (Lugol’s solution), 3-6 drops tid; one
hour after propylthiouracil AND
-Dexamethasone (Decadron) 2 mg IV q6h AND
-Propranolol 40-160 mg PO q6h or 5-10 mg/h, max 2-
5 mg IV q4h or propranolol-LA (Inderal-LA), 80-120
mg PO qd [60, 80, 120, 160 mg].
-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn
temp >38 C.
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia OR
-Lorazepam (Ativan) 1-2 mg IV/IM/PO q4-8h prn
anxiety.
10. Extras: CXR PA and LAT, ECG, endocrine consult.
11. Labs: CBC, SMA 7&12; sensitive TSH, free T4. UA.

Myxedema Coma and
Hypothyroidism
1.Admit to:
2.Diagnosis: Myxedema Coma
3.Condition:
4.Vital Signs: q1h. Call physician if BP systolic
>160/90, <90/60; P >130, <50; R>25, <10; T
>38.5 C.
5.Activity: Bed rest
6.Nursing: Triple blankets prn temp <36 C, inputs and
outputs, aspiration precautions.
7.Diet: NPO
8.IV Fluids: IV D5 NS TKO.
9.Special Medications:
Myxedema Coma and Hypothyroidism:
-Volume replacement with NS 1 L rapid IV over 1 hour,
then 125 mL/h.
-Levothyroxine (Synthroid, Levoxine) 300-500 mcg IV,
then 100 mcg PO or IV qd.
-Hydrocortisone 100 mg IV loading dose, then 50-100
mg IV q8h.
Hypothyroidism in Medically Stable Patient:
-Levothyroxine (Synthroid, T4) 50-75 mcg PO qd,
increase by 25 mcg PO qd at 2-4 week intervals to
75-150 mcg qd until TSH normalized.
11. Extras: ECG, endocrine consult.
12. Labs: CBC, SMA 7&12; sensitive TSH, free T4. UA,
rheumatoid factor, ANA.