NRS 440 exam

Lack of insulin=glucose not properly used for energy so body breaks down fats stores for fuel=excretion of ketones (metabolic acidosis) and electrolytes are depleted. Hyperosmolality, volume depletion, ketoacidosis

• S+S:
• Drowsiness-coma, polyuria-polydipsia, kassmaul breathing-fruity breath, dehydration, glucose >300, metabolic acidosis, hypokalemia

• *Initial goal is to obtain IV access
• 1. Fluid replacement:usually 0.45% or 0.9% NaCl to restore urine output (when glucose reaches 250, 5% dextrose is added to prevent hypoglycemia)
• 2.Insulin Administration: Regular insulin to correct hyperglycemia and hyperketonemia. Goal is to lower sugars by 100mg/hr to prevent cerebral edema
• 3. Electrolyte replacement: Potassium! Do not really do much with Na bicarb bc insulin and fluids should correct it on it's own

• [Hyperosmolor Hyperglycemia NonKetonic Coma]
• *has enough insulin so ketoacidosis and kussmaul breathing does NOT occur. Similar to DKA

• S+S:
• Typically type II diabetic, slower onset, drowsiness, polyuria, VERY HIGH glucose >800, dehydration, usually normal K

*NO Hyperventilation or Kussmaul breathing, or ketoacidosis

• -Immediate IV Fluid intake of 0.9 or 0.45% NaCl (HHNC requires greater fluid replacement)
• -Regular Insulin IV bolus followed by infusion after fluid replacement. Don't drop sugars too fast (100mg/hr at a time)
• -Monitor cardiac and renal status, potential for fluid overload, watch Potassium

• Too MUCH insulin in proportion to available glucose in blood.
• -This causes glucose to drop <70.
• -Can affect mental function bc brain needs constant supply of glucose
• *CAUSES: too much insulin, poor diet, excessive exercise

• S+S:
• confusion, irritibility, diaphoresis, tremors, hungar, weakness. Can mimic alcohol intoxication

• *If conscious, give 15gm of simple carb (6-8 skittles, 4oz OJ, soda, honey). Check sugar in 15 min. and repeat if no change
• *IM glucagon in deltoid (1mg) if unconscious or if above not working

• 1. S+S (polyuria, polydipsia, weight loss) and glucose >200 @ any time of day regardless of meals
• 2. Plasma glucose of 126 or greater after fasting 8 or more hours
• 3. A 2 hour postprandial glucose level of 200 or greater

12 hours

Decreases liver output of glucose and increases insulin sensitivity

• *NOT recommended with kidney/liver problems, CHF, alcohol abuse, or in pts older than 80
• *Can cause gas, bloating, & loose stools
• *Hold for 48 hours after tests with contrast dye
• *CONTRAINDICATED if Creatinine is:
• >1.4 for females & >1.5 in men

** LACTIC ACIDOSIS ** (BIG SIDE EFFECT)

2 hours

Slows absorption of carbs to lessen the rise in post-prandial glucose

• *Take with first bite of each meal
• -DO NOT take if meal is missed
• *Causes gas and bloating
• *Liver tests required every 3 months for first year of therapy
• *NOT recommended in IBD, cirrhosis, malabsorption/intestinal obstruction
• *Hypoglycemia MUST be treated with glucose gel/tablets or milk

16-34 hours

Increase insulin sensitivity

• *takes 6-12 weeks for full effect
• *Liver test every 2 months for first year
• *DO NOT USE in pts with NYHA class III or IV heart failure

[Black Box Warning]

• 1. (Glyburide) 12-24 hours
• -Increases insulin output from pancreas for basal and postprandial control of glucose
• -Cross reactivity with sulfa allergy; metabolized in liver and excreted in urine/bile; Caution in elderly; check renal function with prolonged hypoglycemia; weight gain
• 2. (Glipizide) 10-24 hours
• -Increases insulin output from pancreas
• -Cross reactivity with sulfa; ideal in renal insufficiency since there are NO active metabolites
• 3. (Glimepiride) 24 hours
• -Increases insulin output from pancreas
• -Causes least hypoglycemia out of ALL; avoid use in severe liver disease