NR 601 Final exam review

Weeks 5-8 content Week Topics

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5

Dunphy:

Chapter 58: Diabetes

Mellitus p. 909-938

Kennedy:

 Chapter 14:

Endocrine,

Metabolic, and

Nutritional

Disorders (p.369-

376)

 Obesity (p. 392-396)

Glucose metabolism disorders

Types of diabetes (prediabetes, type 1 and type 2)

 PreDmM = glucose intolerance, Islet cell–specific antibodies, Screening for

prediabetes and DM should be considered in all individuals who are

overweight or obese, regardless of age, and for all adults aged 45 years and

older.

 Type I - severe insulin deficiency resulting from beta cell destruction, which

produces hyperglycemia due to the altered metabolism of lipids,

carbohydrates, and proteins

 Type II - abnormal secretion of insulin, resistance to the action of insulin in the

target tissues, and/or an inadequate response at the level of the insulin

receptor.

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Types of diabetes- Two types: Type 1 and Type 2- Improper function of the hormone insulin,

secreted by the pancreas. Hyperglycemia is a hallmark sign of diabetes.

Prediabetes: Impaired glucose tolerance (IGT) describes a prediabetic state of hyperglycemia

where a 2-hour post-glucose load glycemic level is 140 to 199 mg/dL.

 Type 1 (insulin deficiency)- Presents mostly during childhood. Genetic predisposition

plus some sort of environmental trigger. Results in an auto-immune disorder in which

the immune system attacks the beta cells of the pancreas to prevent them from

producing insulin (decreases production). Inhibits this first step in the insulin

pathway.

 Type 2- Presents mostly during adulthood. Strongly associated with a genetic

predisposition. Accompanied with other predisposing conditions, such as obesity or

hypertension. Inability of these cells throughout the body to respond to insulin. The

pancreas continues to secrete insulin. The cells throughout the body that are unable

to adequately respond to it.

 Miscellaneous

 Drug-induced diabetes- caused by medications Most commonly occurs with a group

of medications that are known as glucocorticoids (steroids) such as in asthma or

chrons.

 Gestational diabetes

Presentation: acute, subacute, and asymptomatic

 Acute: most severe presenting situation and can be life threatening for both type I

and type II diabetes. very sick over a relatively short period of time, usually only a

couple of days.

S/S: nausea, vomiting, and abdominal pain leads to severe dehydration. Confusion or

unconscious as a result. In type I diabetes, this is known as diabetic ketoacidosis. 30% of

individuals with type I diabetes will initially present before diagnosis. DKA- acidotic due

to the production of ketoacids

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Type 2 diabetes: 2% of individuals hyperosmolar nonketotic state- ketones are not

produced. Can occur with either type I or type II diabetes.

 Subacute: mild to moderate presentation that occurs over a period of weeks to

months.

S/S: Generally, just not feeling as well. Fatigue, increased thirst, frequent urination, or

even weight loss. Most common form of presentation in Type 1 diabetes (70%).

 Asymptomatic screening tests: Type II diabetes affects nearly 10% of the population.

Those with the risk factors of type II diabetes should be routinely screened. Most

common means by which type II diabetes is diagnosed.

 Diagnostic criteria - ADA criteria for diagnosing DM-

 Random BG >200 (week 5 quiz question)

 3 Ps of DM: polyphagia, polydipsia, polyuria (week 5 quiz question)

 FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at

least 8 hrs

 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be

performed as described by the WHO, using a glucose load containing the

equivalent of 75-g anhydrous glucose load dissolved in water.

 A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory

using a method that is NGSP certified and standardized to the DCCT assay.

 In a patient with classic s/s of hyperglycemia or hyperglycemic crisis (polyuria,

poly dipsia, weight loss), a random plasma glucose ≥200 mg/dL (11.1 mmol/L)

Current guidelines for the diagnosis of DM include any one of the following:

• Glycosylated hemoglobin (A1C) of 6.5% or higher

• Symptoms of diabetes (e.g., polyuria, polydipsia, weight loss) plus a random plasma

glucose level of 200 mg/dL or higher

• Fasting plasma glucose level of 126 mg/dL or higher (following 8 hours of no caloric intake)

• Two-hour plasma glucose level of 200 mg/dL or higher during an oral glucose tolerance

test (OGTT) with a 75-g glucose load

Diagnostic testing: laboratory tests. The hyperglycemia and the hemoglobin A1C are tested

for in the blood to aid in the diagnosis of diabetes mellitus.

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Hemoglobin A1C: greater than or equal to 6.5%

Blood glucose levels: greater than or equal to 200 mg/dL.

 Random- cannot be used to diagnose pre-diabetes.

 Fasting- slightly lower, then the level is 126 mg/dL.

 Two-hour glucose tolerance test

 Initial treatment recommendations

 If FPG is above 126, next action: order A1C (week 5 quiz question)

 Treatment goals for older adults (Kennedy table 14-2) 

 Hbg A1C goals based on complications (Dunphy p.925)

 An A1C value of less than 7% indicates strong control; however, a value of less

than 6.5% has been shown to significantly decrease the occurrence of

complications, provided this can be achieved without hypoglycemia or other

adverse effect.

 Weight loss recommendations (Kennedy)

 modest weight loss of 5% can improve glycemic control

Risk factors (Dunphy p.922)

 Family history (first-degree relative)

 Body mass index >25 kg/m2 (lower for Asian Americans)

 Age >45 years

 Impaired fasting glucose or A1C >5.7%

 History of gestational diabetes

 Hypertension (> 140/90 mm Hg or on antihypertensive therapy)

 Hyperlipidemia (high-density lipoprotein <35 mg/dL, triglycerides >250

mg/dL)

 Women with polycystic ovarian syndrome

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 Race/Ethnicity

• African American

• Latino

• Native American

• Asian American

• Pacific Islander

Complications (Dunphy p.919)

 Type 1 DM, the risk of development or progression of retinopathy,

nephropathy, hyperlipidemia, and neuropathy

 Most common s/e of DM: Yeast infections (week 5 quiz question)

: page 932 Dunphy

• Retinopathy - Optimizing blood pressure and lipid levels can reduce the risk or slow

the progression of retinopathy.

• Hyperlipidemia - an annual fasting lipid profile, including serum cholesterol,

triglyceride, HDL, and calculated LDL cholesterol measurements. Lifestyle

management (i.e., modifications to diet and physical activity), pharmacologic

therapy. The purpose of treatment is to reduce cardiovascular events.

• Diabetic Kidney disease - A routine spot UACR (normal < 30 mcg albumin/mg 

creatinine) and eGFR should be performed annually on all diabetic patients.

Maintaining normal serum glucose levels, controlling BP is the most effective method

to slow or reduce the risk of diabetic kidney disease. ACEIs or ARBs are the

recommended treatment for patients with DM and hypertension, abnormally high

UACR, or a lower than normal eGFR.

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• Hypertension - Systolic blood pressure should be less than 140 mm Hg and diastolic

blood pressure below 90 mm Hg. A lower blood pressure goal of 130/80 mm Hg may

be appropriate for patients at high risk for cardiovascular events. Treatment can be

with ACEIs, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers.

• Macrovascular disease - Evidence of uncontrolled angina, carotid bruits, or ECG

abnormalities may require advanced intervention and calls for referral to a

cardiologist. Daily aspirin is recommended for cardiac prophylaxis in patients with a

10-year risk of CVD greater than 10% at a dose of 81 to 165 mg/day. Given the

increased risk of bleeding due to its antiplatelet effects, aspirin is not recommended

in low-risk patients with a 10-year CVD risk of less than 5%.

• Neuropathy - All patients should be screened for neuropathic symptoms at the time

of diagnosis and then at least annually. Patients with significant urinary symptoms or

impotence should be referred to a urologist.

• Pregnancy- every pregnancy in a woman with type 2 DM should be planned. Insulin

is the first-line medication for the treatment of diabetes in pregnancy.

• Hypoglycemia

• DKA – Dunphy pg 914 table 58.2

• HHS – Dunphy pg 920 table 58.4

Treatments for complications

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 Metformin – contraindicated in renal disease, abnormal creatinine clearance,

acute MI, or septicemia (week 5 quiz question)

Hypoglycemia is a medical emergency because of the seriousness of potential sequelae (e.g.,

seizures, coma, cardiovascular dysfunction, death). Initial testing for suspected hypoglycemia

includes measurement of the blood glucose level. Hypoglycemia is typically diagnosed if the

patient experiences a decrease in blood glucose concentration of greater than 100 mg/dL per

hour or a blood glucose level of less than 50 mg/dL at any point during the test. The

treatment of acute hypoglycemia for alert patients who can ingest by mouth is 6 to 12

ounces of orange juice or other fruit juice without additional sugar. The long-term

management of hypoglycemia includes treatment of its underlying causes and dietary

modifications as needed. SMBG is the cornerstone of long-term self-management of

hypoglycemia.

Treatment of choice for insulinoma is surgical resection

Obesity

o Comorbidities related to obesity

 type 2 diabetes, hypertension, sleep apnea, nonalcoholic fatty liver disease,

hyperlipidemia, osteoarthritis, or heart disease

Coronary heart disease/congestive heart failure

• Hypertension

• Dyslipidemia/hyperlipidemia

• Type 2 diabetes mellitus/insulin resistance

• Metabolic syndrome

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