NR 601 Final exam review
Weeks 5-8 content Week Topics
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
prediabetes and DM should be considered in all individuals who are
Kennedy: overweight or obese, regardless of age, and for all adults aged 45 years and
Chapter 14:
older.
Endocrine,
Metabolic, and Type I - severe insulin deficiency resulting from beta cell destruction, which
Nutritional produces hyperglycemia due to the altered metabolism of lipids,
Disorders (p.369- carbohydrates, and proteins
376)
Obesity (p. 392-396)
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.
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
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.
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
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
Weeks 5-8 content Week Topics
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
prediabetes and DM should be considered in all individuals who are
Kennedy: overweight or obese, regardless of age, and for all adults aged 45 years and
Chapter 14:
older.
Endocrine,
Metabolic, and Type I - severe insulin deficiency resulting from beta cell destruction, which
Nutritional produces hyperglycemia due to the altered metabolism of lipids,
Disorders (p.369- carbohydrates, and proteins
376)
Obesity (p. 392-396)
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.
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
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.
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
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
