NR 601 Final exam review
Weeks 5-8 content Topics
Week
5 Glucose metabolism disorders
Dunphy: Types of diabetes (prediabetes, type 1 and type 2)
Chapter 58: Diabetes
Mellitus p. 909-938 ★ PreDmM = glucose intolerance, Islet cell–specific antibodies, Screening for
Kennedy: prediabetes and DM should be considered in all individuals who are overweight or
⮚ Chapter 14: obese, regardless of age, and for all adults aged 45 years and older.
Endocrine, ★ Type I - severe insulin deficiency resulting from beta cell destruction, which produces
Metabolic, and
Nutritional hyperglycemia due to the altered metabolism of lipids, carbohydrates, and proteins
Disorders (p.3
★ Type II - abnormal secretion of insulin, resistance to the action of insulin in the target
69-376)
⮚ Obesity (p. tissues, and/or an inadequate response at the level of the insulin receptor.
Types of diabetes- Two types: Type 1 and Type 2- Improper function of the hormone insulin,
392-396)
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
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 commonform 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.
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
★ 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.
• 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
★ 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
Weeks 5-8 content Topics
Week
5 Glucose metabolism disorders
Dunphy: Types of diabetes (prediabetes, type 1 and type 2)
Chapter 58: Diabetes
Mellitus p. 909-938 ★ PreDmM = glucose intolerance, Islet cell–specific antibodies, Screening for
Kennedy: prediabetes and DM should be considered in all individuals who are overweight or
⮚ Chapter 14: obese, regardless of age, and for all adults aged 45 years and older.
Endocrine, ★ Type I - severe insulin deficiency resulting from beta cell destruction, which produces
Metabolic, and
Nutritional hyperglycemia due to the altered metabolism of lipids, carbohydrates, and proteins
Disorders (p.3
★ Type II - abnormal secretion of insulin, resistance to the action of insulin in the target
69-376)
⮚ Obesity (p. tissues, and/or an inadequate response at the level of the insulin receptor.
Types of diabetes- Two types: Type 1 and Type 2- Improper function of the hormone insulin,
392-396)
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
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 commonform 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.
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
★ 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.
• 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
★ 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
