AGNP COMPREHENSIVE TEST QUESTIONS AND
SOLUTIONS
Subcutaneous Insulin Dosing - Patients at risk for hypoglycemia 0.3 units/kg
Elderly
Renal impairment
Hepatic dysfunction
Patients without serious risk 0.5 units/kg
Patients with special issues 0.7 units/kg
Obese
Metabolic Syndrome
Infections
Open wounds
✔✔Diabetic Ketoacidosis (DKA): Differences - ✔✔Occurs in Type I
Distinguished by metabolic acidosis (ph < 7.3)
Ketones in blood and urine
Develop within 24 hours
Mortality rate <5%
✔✔Hyperosmolar Hyperglycemic State (HHS): Differences - ✔✔Occurs in Type II
Severe hyperglycemia (>600)
Severe dehydration
Insidious onset
Mortality rate 15%
✔✔Diabetic Ketoacidosis (DKA): S&S - ✔✔Hyperglycemia >250
Metabolic acidosis < 7.3
Ketosis (plasma and urine)
Nausea and vomiting
Abdominal pain
Polyuria
Fruity breath
Kussmaul's respirations (severe acidosis)
✔✔Hyperosmolar Hyperglycemic State (HHS): S&S - ✔✔Severe hyperglycemia (600-
1,200)
Hyperosmolarity (Serum osmo 320-380)
Severe dehydration (Hemodynamic instability, pre-renal acotemia, decreasing urine
output)
Altered mental status
✔✔Mild DKA - ✔✔Glucose >250
Arterial pH 7.25-7.30
,Bicarb 15-18
Anion gap > 10
Ketones +
Serum osmo <320
Serum Na 125-135
Serum K Normal to Increase
✔✔Moderate DKA - ✔✔Glucose >250
Arterial pH 7.0-7.25
Bicarb 10-14
Anion gap >12
Ketone +
Serum osmo <320
Serum Na: 125-135
Serum K: Normal to Increase
✔✔Severe DKA - ✔✔Glucose: > 250
Arterial pH <7.0
Bicarb < 10
Anion gap >12
Ketones +
Serum osmo <320
Serum Na 125-135
Serum K Normal to Increase
✔✔HHS - ✔✔Glucose: > 600
Arterial pH >7.3
Bicarb > 15
Anion gap Variable
Ketones: Trace/small
Serum osmo: 330-380
Serum Na: 135-145
Serum K: Normal
✔✔DKA & HHS Tx - ✔✔Immediate hospitalization
Insulin
Fluids
Electrolyte replacement
Treating the underlying cause
✔✔Insulin - ✔✔Add 5% dextrose to IVs when glucose < 250mg/dl
✔✔When to start insulin - ✔✔Start subcutaneous insulin when:
-Anion gap is closed (DKA)
-Serum bicarbonate is > 15 mEq/l (DKA)
-Patient is able to eat
, -Mental status improves (HHS)
✔✔Initial bloodwork - ✔✔Basic metabolic panel
Arterial blood gases
Magnesium
Phosphorus
✔✔SubQ Insulin - ✔✔Give short-acting aspart or lispro dose that is twice the current
infusion dose (eg. 4 Units/hr drip; give 8 Units Aspart SQ)
Give long-acting (NPH, glargine, detemir) at 0.2 - 0.3 Units/kg or previous home dose
✔✔Blood work q 2-4 hours - ✔✔Basic metabolic panel
Magnesium
Phosphorus
✔✔Electrolyte Management - ✔✔Na+ low in hyperglycemia
Replace initially with 0.9 N.S 1-3L than 0.45 N.S
Measured Na+ [ Measured BG-100)/100
✔✔Electrolyte Management: Bicarb - ✔✔Replace only with severe acidosis in DKA
-ph <7 stop when >7.1
✔✔Treat underlying precipitating factor: DKA/HHS - ✔✔Infection
Stroke
MI
ETOH abuse
Anorexia or bulemia
Inadequate insulin administration
-Intentional
-Unintentional
-Insulin pump failure
Pancreatitis
Trauma
✔✔Osteoarthritis: Incidence/ Prevalence - ✔✔50% adults 55-78
Women more than men
Advancing age
✔✔Osteoarthritis: Molecular- level pathology - ✔✔Prolonged period
Associated with initiating events of OA
Changes are only detectable by serologic analyses.
✔✔Osteoarthritis: Pre-radiographic - ✔✔Joint abnormalities are detectable only by MRI
SOLUTIONS
Subcutaneous Insulin Dosing - Patients at risk for hypoglycemia 0.3 units/kg
Elderly
Renal impairment
Hepatic dysfunction
Patients without serious risk 0.5 units/kg
Patients with special issues 0.7 units/kg
Obese
Metabolic Syndrome
Infections
Open wounds
✔✔Diabetic Ketoacidosis (DKA): Differences - ✔✔Occurs in Type I
Distinguished by metabolic acidosis (ph < 7.3)
Ketones in blood and urine
Develop within 24 hours
Mortality rate <5%
✔✔Hyperosmolar Hyperglycemic State (HHS): Differences - ✔✔Occurs in Type II
Severe hyperglycemia (>600)
Severe dehydration
Insidious onset
Mortality rate 15%
✔✔Diabetic Ketoacidosis (DKA): S&S - ✔✔Hyperglycemia >250
Metabolic acidosis < 7.3
Ketosis (plasma and urine)
Nausea and vomiting
Abdominal pain
Polyuria
Fruity breath
Kussmaul's respirations (severe acidosis)
✔✔Hyperosmolar Hyperglycemic State (HHS): S&S - ✔✔Severe hyperglycemia (600-
1,200)
Hyperosmolarity (Serum osmo 320-380)
Severe dehydration (Hemodynamic instability, pre-renal acotemia, decreasing urine
output)
Altered mental status
✔✔Mild DKA - ✔✔Glucose >250
Arterial pH 7.25-7.30
,Bicarb 15-18
Anion gap > 10
Ketones +
Serum osmo <320
Serum Na 125-135
Serum K Normal to Increase
✔✔Moderate DKA - ✔✔Glucose >250
Arterial pH 7.0-7.25
Bicarb 10-14
Anion gap >12
Ketone +
Serum osmo <320
Serum Na: 125-135
Serum K: Normal to Increase
✔✔Severe DKA - ✔✔Glucose: > 250
Arterial pH <7.0
Bicarb < 10
Anion gap >12
Ketones +
Serum osmo <320
Serum Na 125-135
Serum K Normal to Increase
✔✔HHS - ✔✔Glucose: > 600
Arterial pH >7.3
Bicarb > 15
Anion gap Variable
Ketones: Trace/small
Serum osmo: 330-380
Serum Na: 135-145
Serum K: Normal
✔✔DKA & HHS Tx - ✔✔Immediate hospitalization
Insulin
Fluids
Electrolyte replacement
Treating the underlying cause
✔✔Insulin - ✔✔Add 5% dextrose to IVs when glucose < 250mg/dl
✔✔When to start insulin - ✔✔Start subcutaneous insulin when:
-Anion gap is closed (DKA)
-Serum bicarbonate is > 15 mEq/l (DKA)
-Patient is able to eat
, -Mental status improves (HHS)
✔✔Initial bloodwork - ✔✔Basic metabolic panel
Arterial blood gases
Magnesium
Phosphorus
✔✔SubQ Insulin - ✔✔Give short-acting aspart or lispro dose that is twice the current
infusion dose (eg. 4 Units/hr drip; give 8 Units Aspart SQ)
Give long-acting (NPH, glargine, detemir) at 0.2 - 0.3 Units/kg or previous home dose
✔✔Blood work q 2-4 hours - ✔✔Basic metabolic panel
Magnesium
Phosphorus
✔✔Electrolyte Management - ✔✔Na+ low in hyperglycemia
Replace initially with 0.9 N.S 1-3L than 0.45 N.S
Measured Na+ [ Measured BG-100)/100
✔✔Electrolyte Management: Bicarb - ✔✔Replace only with severe acidosis in DKA
-ph <7 stop when >7.1
✔✔Treat underlying precipitating factor: DKA/HHS - ✔✔Infection
Stroke
MI
ETOH abuse
Anorexia or bulemia
Inadequate insulin administration
-Intentional
-Unintentional
-Insulin pump failure
Pancreatitis
Trauma
✔✔Osteoarthritis: Incidence/ Prevalence - ✔✔50% adults 55-78
Women more than men
Advancing age
✔✔Osteoarthritis: Molecular- level pathology - ✔✔Prolonged period
Associated with initiating events of OA
Changes are only detectable by serologic analyses.
✔✔Osteoarthritis: Pre-radiographic - ✔✔Joint abnormalities are detectable only by MRI
