What orders would you question HELP!

[intensity_too]

Here's the situation we were given:

82 year-old male with a history of renal insufficiency and CHF taking the following PO medication: Lasix 60 mg BID, K-dur 20mgEq Bid, Digoxin 0.125 mg QD, and Niforex (renal multivitamin) QD. He is transferred to the Medical unit with the admission diagnosis of nonketotic hyperosmolar dehydration. He has been unable to eat due to a lack of appetite and has been taking only Ensure. Medical management of this patient includes Glucose monitoring QD, NS @ 125/hr IV, Insulin by Sliding Scale, and regular Diet. Do not assume information that is not provided.

What orders would you question?

Well, the glucose monitoring at QD isn't going to cut it!

I also thought you would question the insulin by sliding scale because he was diagnosed with nonketotic hyperosmalar dehydration. Don't these patients need IV insulin???

I'm clueless as far as the IV fluids. I can't find anything anywhere that helps me answer if this amount is correct. Most things that I have read suggest:

Administer 1-2 L of isotonic saline in the first 2 hours. A higher initial volume may be necessary in patients with severe volume depletion. Slower initial rates may be appropriate in patients with significant cardiac or renal disease or in those who are not urinating. Caution should be taken to not correct hypernatremia too quickly, as this could lead to cerebral edema.

After the initial bolus, some clinicians recommend changing to half-normal saline, while others continue with isotonic saline. Either fluid likely will replenish intravascular volume and correct hyperosmolarity; a good standard is to switch to half-normal saline once blood pressure and urine output are adequate.

Once serum glucose drops to 250 mg/dL, the patient must receive dextrose in the intravenous fluid.

HELP!

[Daytonite, BSN, RN]

what orders would you question?

lasix 60 mg bid

glucose monitoring qd

insulin by sliding scale

regular diet

with hhns (hyperglycemic hyperosmolar nonketotic coma) glucose levels continue to rise as a result of an infection, drugs such as glucocorticoids that interfere with glucose tolerance or increased fluid losses from diuretics so that the metabolism falls behind in processing the glucose and the blood sugar elevates. once the glucose levels are elevated, the body starts to compensate by attempting to dump sugar through the kidneys-->resulting in dehydration

[intensity_too]

what orders would you question?

lasix 60 mg bid

glucose monitoring qd

insulin by sliding scale

regular diet

with hhns (hyperglycemic hyperosmolar nonketotic coma) glucose levels continue to rise as a result of an infection, drugs such as glucocorticoids that interfere with glucose tolerance or increased fluid losses from diuretics so that the metabolism falls behind in processing the glucose and the blood sugar elevates. once the glucose levels are elevated, the body starts to compensate by attempting to dump sugar through the kidneys-->resulting in dehydration

if not a normal diet, then what kind of diet would be appropriate??

[Daytonite, BSN, RN]

This is most likely a Type II diabetic. A diabetic diet that controls the amount of carbs he's getting. The last thing he needs is concentrated sugars in his diet.

[intensity_too]

This is most likely a Type II diabetic. A diabetic diet that controls the amount of carbs he's getting. The last thing he needs is concentrated sugars in his diet.

Thanks Daytonite! This was what I was thinking, but just needed the reassurance. :)

[Daytonite, BSN, RN]

Your instructions were not to assume information not provided, but HHNS really doesn't occur in anyone else but Type II diabetics. The diabetes may be a new diagnosis that is just being discovered now.