nr 601 final exam study guide version 2 nr601 final exam study guide newest
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NR 601 FINAL EXAM STUDY GUIDE
Week 5: Glucose metabolism disorders
Types of DM
1. Type 1- severe insulin deficiency resulting in reduction or absence of functioning beta cells in
the pancreatic islets of Langerhans. This leads to hyperglycemia due to altered metabolism of
lipids, carbs, and proteins. Initial s/s of hyperglycemia. Subjective findings- polyuria, polydipsia,
nocturnal enuresis and polyphagia with paradoxical weight loss, visual changes and fatigue.
Objective-dehydration(poor skin turgor and dry mucous), wt loss despite normal/increase
appetite, reduction in muscle mass. DKA-fatigue, cramping, abnormal breathing
2. Type 2- Type 2 DM is characterized by the 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. A patient may, however, present with pruritus, fatigue, neuropathic complaints such
as numbness and tingling, or blurred vision.
3. Prediabetic- fasting glucose consistently elevated above the normal range but less than 100-
125. Impaired glucose tolerance (IGT) state of hyperglycemia where 2 hr post glucose load
glycemic level is 140-199
Diagnostic criteria- there are 4 lab-based criteria to confirm DM: A1C, random plasma glucose, fasting
plasma glucose, and 2-hr post load plasma glucose
AIC of 6.5 or higher=diabetes
Random plasma glucose level of 200 WITH classic symptoms of hyperglycemia or a
hyperglycemic crisis
Fasting plasma glucose level of 126 or higher on TWO occasions(fasting is defined as no caloric
intake for at least 8 hrs
2-hour post load plasma glucose level of 200 or higher during an OGTT, following consumption
of a glucose load containing the equivalent of 75g of anhydrous glucose dissolved in water
(OGTT is also used to screen for diabetes during pregnancy)
*** In the absence of unequivocal hyperglycemia results should be confirmed by repeat testing on a
new blood sample without delay, preferably using the same type of test.***
*All above-but confirmation of type 2 diabetes mellitus requires: two fasting blood glucoses
≥126 mg/dL or two random blood glucoses ≥200 mg/dL.
You do not screen for type 1 diabetes but you do screen for type 2 if an individual is overweight
or obese, regardless of age, and for all adults aged 45 years and older. Tests should be repeated
at a minimum of 3 year intervals
Initial Treatment-
Type 1- FIRST LINE: INSULIN. The initial goal of treatment for type 1 DM is to normalize the
elevated blood glucose level. This is best accomplished by intensive insulin regimens to achieve
1
, the following goals: plasma glucose levels of 80 to 130 mg/dL before meals, peak postprandial
(1–2 hours after the beginning of a meal) glucose levels of less than 180 mg/dL, and an A1C
below 7% for adults with type 1 DM. A comprehensive treatment plan requires exogenous
insulin, frequent self-monitoring of blood glucose (SMBG), medical nutrition therapy, regular
exercise, continuing education in prevention and treatment of diabetic complications, and the
periodic reassessment of treatment goals. (Type 1A: insulin dependent, Type 1B: variably insulin
dependent). The ADA Standards of medical care in diabetes states that the majority of patients
with type 1 DM, should be treated with multiple daily injections of prandial insulin and daily
basal insulin or with a continuous subcutaneous insulin infusion pump. INITIATION OF INSULIN
THERAPY IN NEWLY DIAGNOSED TYPE 1 DM, SHOULD BE MANAGED BY OR IN CLOSE
COLLABORATION WITH AN ENDOCRINOLOGIST.
Type 2-FIRST LINE: LIFESTYLE MANAGEMENT. Interventions should include treatments directed
at both risk reduction and glycemic control. Lifestyle management is an important part of
treatment and comprises nutrition therapy, activity prescriptions for exercise, decreased
prolonged sitting, and in older adults, training in balance and flexibility. Lifestyle management
should focus on mental health, sleep, and smoking cessation. Obesity management has become
a high-level target in the treatment of pts with type 2 DM. ADA states that every patient should
receive diabetes self-management education and diabetes self-management support at the time
of diagnosis.
Pharmacological therapy for type 2 DM is required when lifestyle management does not result
in adequate blood glucose control. Drug therapy should always be considered an adjunctive
therapy to lifestyle management, as the latter is typically initiated first. The ADA and AACE
recommend metformin if there are no contraindications, such as renal disease or abnormal
creatinine clearance, acute myocardial infarction, or septicemia.
The AACE recommends adding a second agent to lifestyle treatment and metformin if the A1C is
more than 7.5% at the time of diagnosis or after 3 months of monotherapy without
achievement of the patient’s blood glucose goals. Metformin can be used as a monotherapy
unless the patient has contraindications or intolerance. Although metformin is the first-line
medication recommended by the ADA and the AACE for DM type 2, it should be used only in
patients with adequate renal function and should not be used in patients with an eGFR below 45
mL/min/1.73 m2.
• Immediately upon diagnosis of type 2 DM, begin lifestyle therapy with medically assisted
obesity treatment.
• If glycemic goals are still not met 3 months later, begin single-agent or dual therapy with oral
antidiabetic agents, depending on whether A1C is less than or greater than 7.5%.
• If glycemic goals are not met in 3 months, initiate triple therapy.
• If after 3 additional months (or at the time of diagnosis) A1C is 9.0% or higher and the patient
is symptomatic, add insulin therapy.
A1c-Gyycemic level over 2-3months and is helpful is documenting control and
continuing care.
A1c less than 7% indicate strong control
2
, 6.5%or less decrease occurrence of complications achieved w/o hypoglycemia or other
adverse effect.
Medication Side Effects
-Type 1:
Hypoglycemia is a common occurrence in patients with type 1 DM and occurs for a variety of reasons:
excessive exogenous insulin, missed meals or inadequate food intake, excessive exercise, alcohol
ingestion, drug interactions, or decreases in liver or kidney function. Signs and symptoms: diaphoresis,
tachycardia, hunger, shakiness, altered mentation (ranging from an inability to concentrate to frank
coma), slurred speech, and seizures. The ADA classifies hypoglycemia as a plasma glucose level of < 54 as
serious, clinically significant hypoglycemia. A blood glucose level of 70 is considered a threshold level
that requires intervention. Examples of appropriate foods: #1 choice: pure glucose, ½ cup fruit juice, 6oz
regular soda (not diet or sugarless), 1 cup milk, or glucose tabs. Candy is only a last resort. Recheck
glucose 15 minutes after treatment. Additional carbs can be given if glucose is still less than 70
-Type 2:
Metformin can cause: hypoglycemia esp in older adults, adverse reactions such as GI disturbances and
metallic taste, and is contraindicated in renal disease so assess renal function prior to prescribing.
- Metformin also has a boxed warning in its FDA-approved prescribing information for lactic
acidosis, although this side effect is very rare. Metformin should be discontinued 24 to 48 hours
before diagnostic and surgical procedures due to the risk of decreased kidney function, and its
administration should not be resumed for at least 6 hours after these procedures or until the
patient is adequately hydrated. Initial dosing is 500 mg once a day with breakfast or dinner for 1
week, then twice daily with breakfast and dinner. Several weeks of therapy may be needed to
achieve maximum effects of the given dose. Common adverse reactions include diarrhea,
nausea, anorexia, and abdominal discomfort, which usually resolve with a gradual increase of
dosage. Metformin has been shown to cause decreased vitamin B 12 absorption, and patients on
long-term metformin therapy should undergo periodic testing for B 12 deficiency, especially if the
patient complains of peripheral neuropathy. At the maximum dose, the monthly cost of
metformin in the United States is approximately $4 on many generic formularies. Metformin is
currently found in 20 combination formulations with other medications.
*For other noninsulin agent adverse reactions see pg 929 Dunphy book*
SINGLE-DOSE THERAPY
Single Injection
• Intermediate or long-acting insulin with or without regular insulin in the
morning or Intermediate or long-acting insulin at bedtime
• Recommend at a minimum SMBG in the morning and at bedtime
CONVENTIONAL SPLIT-DOSE THERAPY
Two Injections
• Mixture of NPH and regular insulin in the morning and evening
• Recommend at a minimum SMBG before each dosing and at bedtime
3
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