32	TEACH for Nurses for
Antidiabetic Drugs	

OBJECTIVES
1.	Discuss the normal functions of the pancreas.
2.	Contrast age of onset, signs and symptoms, pharmacologic and nonpharmacologic treatment, incidence, and etiology of type 1 and type 2 diabetes mellitus.
3.	Differentiate gestational diabetes from type 1 and type 2 diabetes mellitus.
4.	Discuss the various factors influencing blood glucose level in nondiabetic individuals and in patients with diabetes mellitus.
5.	Identify the various drugs used to manage type 1 and type 2 diabetes mellitus.
6.	Discuss the mechanisms of action, indications, contraindications, cautions, drug interactions, and adverse effects of insulin, oral antidiabetic drugs, and injectable antidiabetic drugs.
7.	Compare rapid-, short-, intermediate-, and long-acting insulins with regard to their onset of action, peak effects, and duration of action.
8.	Compare the signs and symptoms of hypoglycemia and hyperglycemia and their related treatments.
9.	Develop a nursing care plan that includes all phases of the nursing process for patients with type 1 or type 2 diabetes with a focus on drug therapies.

TEACHING FOCUS
•	A review of the actions and functions of the endocrine system, with a focus on the role of insulin, will help students understand the causes of and differences between types 1 and 2 diabetes.
•	Although the chapter covers hypoglycemia and glucose-elevating drugs, the primary focus is diabetes mellitus and its treatment.
•	When discussing the various antidiabetic drugs, stress the significance of the discovery of insulin, which has proven to be a life-saving remedy for millions.
•	It is also important to understand the differences in the various types of insulins available.

KEY TERMS
•	
•	Diabetes mellitus, p. 501
•	Diabetic ketoacidosis (DKA), p. 503
•	Gestational diabetes, p. 503
•	Glucagon, p. 500
•	Glucose, p. 500
•	Glycogen, p. 500
•	Glycogenolysis, p. 500
•	Hemoglobin A1C (A1C), p. 504
•	Hyperglycemia, p. 500
•	Hyperosmolar hyperglycemic syndrome (HHS), p. 503
•	Hypoglycemia, p. 514
•	Insulin, p. 500
•	Ketones, p. 500
•	Polydipsia, p. 500
•	Polyphagia, p. 500
•	Polyuria, p. 500
•	Type 1 diabetes mellitus, p. 502
•	Type 2 diabetes mellitus, p. 503

NURSING CURRICULUM STANDARDS
QSEN
•	Patient-Centered Care
o	Oral Antidiabetic Drugs, p. 508
o	Patient-Centered Care: Patient Teaching, p. 519
•	Evidence-Based Practice
o	Evidence-Based Practice, Sensor-Augmented Insulin Pump Therapy Trumps Multiple Daily Injections, p. 519
•	Teamwork and Collaboration
o	Teamwork and Collaboration: Pharmacokinetic Bridge to Nursing Practice, p. 514
•	Quality Improvement
o	Safety and Quality Improvement: Preventing Medication Errors, p. 516
•	Safety
o	Insulins, p. 504
o	Assessment, p. 514
o	Safety and Quality Improvement: Preventing Medication Errors, p. 516
o	Implementation, p. 516

CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens JR: Concepts in nursing practice, St Louis, 2013, Elsevier. The specific exemplars chosen and listed below for each concept have been tailored specifically to correspond to the Lilley textbook.

THEME: Homeostasis and Regulation
•	Concept: Glucose Regulation
o	Exemplar: Type 1 Diabetes Mellitus, p. 502
o	Exemplar: Type 2 Diabetes Mellitus, p. 503
o	Exemplar: Gestational Diabetes, p. 503

THEME: Homeostasis and Regulation
•	Concept: Fluid and Electrolyte Balance
o	Exemplar: Acute Diabetic Complications: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome, p. 503
•	Concept: Nutrition
o	Exemplar: Pathophysiology of Diabetes Mellitus, p. 500
o	Exemplar: Type 2 Diabetes Mellitus, p. 503
o	Exemplar: Gestational Diabetes, p. 503
o	Exemplar: Nonpharmacologic Treatment Interventions, p. 504
o	Exemplar: Pancreas, p. 500
o	Exemplar: Insulins, p. 504
o	Exemplar: Insulin Use in Special Populations, p. 506
o	Exemplar: Basal-Bolus and Sliding-Scale Insulin Dosing, p. 507
o	Exemplar: Glucose-Elevating Drugs, p. 514
o	Exemplar: Nursing Diagnoses, p. 515
o	Exemplar: Planning: Outcome Identification, p. 516
o	Exemplar: Implementation, p. 516
o	Exemplar: Evaluation, p. 518
o	Exemplar: Patient-Centered Care: Patient Teaching, p. 519
o	Exemplar: Table 32-2: Characteristics of Type 1 and Type 2 Diabetes, p. 502

THEME: Sexual/Reproductive
•	Concept: Reproduction
o	Exemplar: Gestational Diabetes, p. 503
o	Exemplar: Insulin Use in Special Populations, p. 506
o	Exemplar: Assessment, p. 514
•	Concept: Sexuality
o	Exemplar: Table 32-1: Major Long-Term Consequences of Type 1 and Type 2 Diabetes, p. 501

THEME: Protection and Movement
•	Concept: Immunity
o	Exemplar: Pathophysiology of Diabetes Mellitus, p. 500
o	Exemplar: Type 1 Diabetes Mellitus, p. 502
o	Exemplar: Table 32-2: Characteristics of Type 1 and Type 2 Diabetes, p. 502
•	Concept: Sensory Perceptual
o	Exemplar: Pathophysiology of Diabetes Mellitus, p. 500
o	Exemplar: Table 32-1: Major Long-Term Consequences of Type 1 and Type 2 Diabetes, p. 501

THEME: Comfort
•	Concept: Fatigue
o	Exemplar: Pathophysiology of Diabetes Mellitus, p. 500
o	Exemplar: Assessment, p. 514
•	Concept: Pain
o	Exemplar: Implementation, p. 516
o	Exemplar: Patient-Centered Care: Patient Teaching, p. 519
•	Concept: Nausea/Vomiting
o	Exemplar: Biguanide, p. 508
o	Exemplar: Sulfonylureas, p. 509
o	Exemplar: Amylin Agonists, p. 512
o	Exemplar: Incretin Mimetics, p. 513
o	Exemplar: Glucose-Elevating Drugs, p. 514

THEME: Coping and Stress Tolerance
•	Concept: Stress
o	Exemplar: Type 1 Diabetes Mellitus, p. 502
o	Exemplar: Basal-Bolus and Sliding-Scale Insulin Dosing, p. 507
o	Exemplar: Assessment, p. 514
o	Exemplar: Implementation, p. 516
o	Exemplar: Patient-Centered Care: Patient Teaching, p. 519

THEME: Attributes and Roles of the Nurse
•	Concept: Patient Education
o	Exemplar: Patient-Centered Care: Patient Teaching, p. 519

BSN ESSENTIALS
•	Essential II: Organizational and Systems Leadership for Quality Care and Patient Safety
o	Safety and Quality Improvement: Preventing Medication Errors, p. 516
•	Essential III: Scholarship for Evidence-Based Practice
o	Evidence-Based Practice, Sensor-Augmented Insulin Pump Therapy Trumps Multiple Daily Injections, p. 519
•	Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes
o	Teamwork and Collaboration: Pharmacokinetic Bridge to Nursing Practice, p. 514
•	Essential IX: Baccalaureate Generalist Nursing Practice
o	Box 32-1. Criteria for Diagnosis of Diabetes, p. 501
o	Box 32-2. Administration, Handling, and Storage of Insulin, p. 517
o	Table 32-1. Major Long-Term Consequences of Type 1 and Type 2 Diabetes, p. 501
o	Table 32-2. Characteristics of Type 1 and Type 2 Diabetes, p. 502
o	Table 32-3. Comparison of Features of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome, p. 503
o	Table 32-4. Insulin Mixing Compatibilities, p. 504
o	Table 32-6. Diabetes Care: Correlation of Glycosylated Hemoglobin Levels with Mean Serum Glucose Levels, p. 520

STUDENT CHAPTER RESOURCES	
Chap. 32	PREPARE FOR CLASS, CLINICAL, OR LABORATORY
READ – Textbook (pp. 499-522)

REVIEW – Evolve Resources
•	Animations
o	Insulin Function
o	Type 1 Diabetes
o	Type 2 Diabetes
•	Key Points—Downloadable
•	Textbook Case Studies Answer Key
•	Textbook Critical Thinking and Prioritization Questions Answer Key

PREPARE FOR EXAMINATIONS
•	Chapter 32 Review Questions—Preparation for NCLEX® Examination

INSTRUCTOR CHAPTER RESOURCES	
TB	TESTING RESOURCES – Test Bank
•	Test Bank – Chapter 32
•	To access the ExamView format, go to the Downloads section.
	
PPT	TEACHING RESOURCES – Chapter 32: Antidiabetic Drugs 
	
IC	TEACHING RESOURCES – Image Collection
•	Figure 32-1. The pancreas. A, Pancreas dissected to show main and accessory ducts. B, Exocrine glandular cells (around small pancreatic ducts) and endocrine glandular cells of the pancreatic islets (adjacent to blood capillaries). Exocrine pancreatic cells secrete pancreatic enzymes, alpha endocrine cells secrete glucagon, and beta endocrine cells secrete insulin. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.)
•	Figure 32-2. Comparison of the pharmacokinetics of various insulins. (From Messinger-Rapport BJ, Thomas DR, Gammack JK: Clinical update on nursing home medicine: 2008, J Am Med Dir Assoc 9(7):460-475, 2008.)	
ETC.	TEACHING RESOURCES – Chapter 32: Answer Keys—Critical Thinking and Prioritization Questions (also available to students)

TEACHING RESOURCES – Chapter 32: Answer Keys—Textbook Case Studies (also available to students)	

TEACHING STRATEGIES	
CONTENT FOCUS	CONTENT HIGHLIGHTS	
LEARNING ACTIVITIES	
PANCREAS

PATHOPHYSIOLOGY OF DIABETES MELLITUS

Type 1 Diabetes Mellitus

Type 2 Diabetes Mellitus

Gestational Diabetes

Prevention and Screening

Nonpharmacologic Treatment Interventions

Glycemic Goal of Treatment	Hyperglycemia is a state involving excessive concentrations of glucose in the blood and results when the normal counterbalancing actions of glucagon and insulin fail to maintain normal glucose homeostasis.

Diabetes is primarily a disorder of carbohydrate metabolism that involves a deficiency of insulin, a resistance of tissue (e.g., muscle, liver) to insulin, or both.

Two major types of diabetes mellitus are currently recognized and designated by the American Diabetes Association: type 1 and type 2. Type 1 diabetes was previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes. Type 2 diabetes was previously called non–insulin-dependent diabetes mellitus or adult-onset diabetes.

Type 1 diabetes is characterized by a lack of insulin production or by the production of defective insulin, which results in acute hyperglycemia. These patients must take insulin.

The most common type of diabetes is type 2. Type 2 diabetes mellitus is caused by both insulin resistance and insulin deficiency, but there is no absolute lack of insulin as in type 1 diabetes.	•	Small Group Activity: Divide the class into small groups. Have half of the groups each develop a case study of a patient with type 1 diabetes and the other half each develop a case study of a patient with type 2 diabetes. Make sure to include one patient who has developed gestational diabetes and one with insulin resistance. The cases should be brief but specific. Assign topics, if necessary, to ensure that some groups focus on patients who require only nonpharmacologic treatment at this time. Then have the groups exchange case studies (ensuring that type 1 case studies are exchanged for type 2 case studies) and develop: (1) nursing diagnoses, (2) goals, and (3) outcome criteria for each other’s cases.
•	Reflection: Encourage students to discuss how a patient with type I diabetes typically appears differently than someone with type II diabetes. Have students consider why type I diabetes is considered a disease of starvation.
	
PHARMACOLOGY OVERVIEW

INSULINS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages

Insulin Use in Special Populations

Drug Profiles	Insulin is required in patients with type 1 diabetes.

Patients with type 2 diabetes are not prescribed insulin until other measures (lifestyle changes and drug therapy) no longer provide adequate glycemic control.

Students must understand the onset of action, peak of action, and duration of action of each type of insulin.	•	Large Group Activity: Have students complete on the board a chart comparing rapid-acting insulin, short-acting insulin, intermediate-acting insulin, and long-acting insulin in terms of their onset of action, peak of action, and duration of action and the relationship to hypoglycemia.
•	Large Group Activity: If possible, have a glucometer available for students to use to measure their blood glucose levels. You may want them to compare fasting levels (if the timing of the class works out and if they can remember to fast!) and levels right after a meal.
•	Large Group Activity: If possible, demonstrate the use of an insulin pump that is designed to provide continuous, small doses of insulin.
•	Diabetes Pump Presentation: Ask a person who has an insulin pump to present to the class about how it works and the difference it’s made in the diabetes management for him or her.
•	Small Group Activity: Provide the students with a short case study for a patient in diabetic ketoacidosis receiving regular intravenous (IV) insulin. 	
ORAL ANTIDIABETIC DRUGS

BIGUANIDE

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages	Oral medications increase insulin secretion, increase cellular sensitivity, or alter glucose absorption.

Metformin works by decreasing glucose production by the liver. It may also decrease intestinal absorption of glucose and improve insulin receptor sensitivity. This results in increased peripheral glucose uptake and use, and decreased hepatic production of triglycerides and cholesterol. The most common adverse effects of metformin are gastrointestinal.	•	Large Group Activity: Have students complete a table that compares the mechanism of action and indications and timing of administration of the various classes of oral antidiabetic drugs.
•	Pose a Question: Ask the students how heart failure is related to the administration of diabetic medications.
•	Discussion: Have students discuss other implications for metformin:
•	Not given within 48 hours of contrast dye because it competes for excretion out of the kidney.
•	Patients with diabetes who develop heart failure must stop metformin because it accumulates because of  low ejection fraction and will not be excreted by the kidneys. This can cause lactic acidosis and has a 50% mortality rate.	
SULFONYLUREAS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages	Sulfonylureas bind to specific receptors on beta cells in the pancreas to stimulate the release of insulin. In addition, sulfonylureas appear to secondarily decrease the secretion of glucagon. The most common adverse effect of the sulfonylureas is hypoglycemia.	•	Small Group Assignment: Have students develop a teaching plan for a patient with type II diabetes about implications for the sulfonylureas, including the disulfiram reaction with alcohol.
Small Group Assignment: Assign students to compare and contrast hypoglycemia and hyperglycemia, along with treatment for each.	
GLINIDES

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages	Glinides increase insulin secretion from the pancreas. The most commonly reported adverse effect of the glinides is hypoglycemia and weight gain.		
THIAZOLIDINEDIONES (GLITAZONES)

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages	•	The thiazolidinediones work to decrease insulin resistance by enhancing the sensitivity of insulin receptors. The glitazones increase the risk of heart failure and are not recommended for use in patients with symptoms of heart failure.
•	There is some evidence that the thiazolidinediones slow the failure of the pancreas when used early in type 2 diabetes.
	•	Discussion: Have students explore the role and consequence of inflammation and the diabetic patient. Be sure they recognize the glitazones have an antiinflammatory effect and will reduce high-sensitivity C-reactive protein levels.
•	Small Group Activity: Assign students to develop a list of nursing implications and laboratory tests related to the glitazones with key points of fluid volume overload, pulmonary edema, and heart failure.
	
ALPHA-GLUCOSIDASE INHIBITORS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages

Drug Profiles	Alpha-glucosidase inhibitors work by reversibly inhibiting the enzyme alpha-glucosidase that is found in the small intestine. This enzyme is responsible for the hydrolysis of oligosaccharides and disaccharides into glucose. When this enzyme is blocked, glucose absorption is delayed. These drugs can cause a high incidence of flatulence, diarrhea, and abdominal pain. 		
DIPEPTIDYL PEPTIDASE IV (DPP-IV) INHIBITORS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages

Drug Profiles
	DPP-IV inhibitors work by delaying the breakdown of incretin hormones by inhibiting the enzyme DPP-IV. Incretin hormones are released throughout the day and are increased after a meal. When blood glucose concentrations are normal or high, the incretin hormones increase insulin synthesis and lower glucagon secretion. The most common effects are upper respiratory tract infection, headache, and diarrhea. Hypoglycemia can occur and is more common if used in conjunction with a sulfonylurea.		
INJECTABLE ANTIDIABETIC DRUGS

AMYLIN AGONISTS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages	When given before major meals, the amylin agonists work by mimicking the action of the natural hormone amylin that decreases postprandial plasma glucose levels. Adverse effects include nausea, vomiting, anorexia, and headache.		
INCRETIN MIMETICS

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages

Drug Profile
	Incretins stimulate insulin secretion, reduce postprandial glucagon production, slow gastric emptying, and increase satiety. Adverse effects include nausea, vomiting, and diarrhea.	•	Large Group Activity: Demonstrate the “penlike” device used to deliver subcutaneous doses of exenatide (Byetta) and insulin pens that are used to deliver insulin. These devices represent innovations in the delivery of antidiabetic medications.	
SODIUM GLUCOSE COTRANSPORTER INHIBITORS (SGLT2 INHIBITORS)

Mechanism of Action and Drug Effects

Indications

Contraindications

Adverse Effects

Interactions

Dosages

GLUCOSE-ELEVATING DRUGS	Oral and IV glucose are used to treat hypoglycemia. Glucagon, a natural hormone secreted by the pancreas, is useful in the unconscious hypoglycemic patient without established IV access.	•	Discussion: Discuss the situations in which glucose-elevating drugs are indicated and the nursing implications of these drugs.
•	Discussion: Discuss diabetes in a school age-child and implications for having glucagon readily available, recess and physical education classes, illness, hypo- and hyperglycemia, carbohydrate counting, and covering the blood sugar levels with a sliding insulin scale. Also have students address the psychosocial aspects of having diabetes in childhood.	
NURSING PROCESS

Assessment

Nursing Diagnoses

Planning: Outcome Identification

Implementation

Evaluation	The nurse must educate the patient about the need to have serum glucose levels monitored and emphasize instructions that are specific to the patient’s glucometer.

The nurse should stress the importance of exercise, hygiene, foot care, dietary plan, and weight control in the management of diabetes.	•	Discussion: Have a certified diabetes educator nurse speak to the class about his or her role and responsibilities. If available in your area, have students attend a patient teaching class that is offered by this specialized educator.
•	Large Group Activity: Assign two teams to present profiles of patients with types 1 and 2 diabetes. Have them each quiz the rest of the class on the causes of each type. These quizzes may be conducted orally, with the presenting team writing questions on the board, or they may be printed out and distributed to the rest of the class for completion.
•	Large Group Activity: Assign various teams of students to discuss one of the drugs in the chapter and to draw up a teaching plan that would ensure that steps are taken to minimize any adverse reactions, overlooked contraindications, and episodes of toxicity. Make sure to include insulin and oral hypoglycemic drugs. One team should be assigned to investigate how diet therapy is used as an adjunct treatment for diabetes.
•	Large Group Activity: This one will take a little advance preparation—a good critical thinking activity in itself! Ask two students to demonstrate the procedure for administering an insulin injection, with the “nurse” addressing precautions to take and guidelines to follow. Assign two teams to plan ahead of time to “coach” the nurse, while the rest of the class votes on which team’s advice to follow. The trick is this: in their preparation, each coaching team is to come up with some good, convincing red herrings in an attempt to throw the class off and get them to agree with the team. The team who tricks the class into agreeing with the most red herrings wins; on the other hand, if the class resists more of a team’s red herrings than they accept, the class defeats that particular team. That is why you want to give your teams time to prepare particularly reasonable-sounding, highly appealing red herrings!
•	Discussion: As an interesting change, it might be beneficial to invite two well-informed patients—one with type 1 diabetes mellitus and one with type 2—to “teach” students about their experiences with the disorder and how they manage it. They might include how they were taught to manage their disease, including which aspects of patient education were helpful and which were not. They may want to emphasize what they have found most helpful in living with their diabetes.
•	Large Group Activity: Have students investigate local community resources for diabetes mellitus (e.g., local branches of the American Diabetes Association) as well as Internet resources. If possible, have them bring in examples of brochures from these agencies.	

in-class/ONLINE case study
L.S. is a 55-year-old male patient who is seeing his family physician today. The patient’s wife, who is a nurse, believes L.S. has type 2 diabetes. When the physician questions the patient about his symptoms, the patient reports that his wife commented on how much water he was drinking and that he had to urinate frequently. He has had an 8-lb weight loss as well. L.S.’s wife performed fingerstick blood glucose levels on the patient, and the results were 160 mg/dL and 180 mg/dL on separate days. Today his blood sugar is 176 mg/dL. The physician prescribes glimepiride (Amaryl).

1.	The patient asks how a pill will lower his blood sugar. How will the nurse respond?

Answer: The nurse will tell the patient that glimepiride will stimulate cells in the pancreas to secrete more insulin, which will help lower the patient’s blood sugar.

Rationale: Glimepiride binds to specific receptors on beta cells in the pancreas to stimulate the release of insulin. In addition, sulfonylureas appear to secondarily decrease the secretion of glucagon. For this class of drugs to be effective, the patient must still have functioning beta cells in the pancreas.

2.	At the patient’s next visit, his A1C level is 6%. How will the nurse interpret this finding?

Answer: An A1C level of 6% is a normal result. This indicates that the patient has had good glycemic control over the past several months.

Rationale: The glycemic goal recommended by the American Diabetes Association for patients with diabetes is a hemoglobin A1C level of less than 7%. The A1C test measures the percentage of hemoglobin A that is irreversibly glycosylated. A1C is an indicator of glycemic control in a patient over the preceding 2 to 3 months (the average lifespan of a red blood cell) and is not affected by recent fluctuations in blood glucose levels.

in-class/ONLINE case study
1.	N.B., who has type 2 diabetes, is 26 weeks pregnant and placed on insulin therapy during pregnancy. She asks about why she is unable to take her oral medication as usual. What is the nurse’s best response?

Answer: Oral medications are not recommended for pregnant patients because of a lack of firm safety data. For this reason, insulin therapy is the only currently recommended drug therapy for pregnant women with diabetes.

Rationale: All antidiabetic drugs are classified as pregnancy category B or C drugs.

2.	N.B. is concerned about how her diabetes can affect her baby. What teaching points would the nurse provide?

Answer: Pregnant women who have diabetes require special care with regard to diabetes management and have increased risks for a number of things, including having babies with large birth weight, a higher risk of having low blood sugar after birth, birth defects, or being stillborn. However, the nurse will tell her, “We will do everything possible to help you have a healthy baby.”

Rationale: Even though insulin does not normally cross the placenta, effective glycemic control during pregnancy is essential because infants born to women with diabetes have a two- to threefold greater risk of congenital anomalies. In addition, the incidence of stillbirth is directly related to the degree of maternal hyperglycemia. Weight reduction is generally not advised for these women because it can jeopardize fetal nutritional status. Women with diabetes tend to have babies that weigh more, and these children may have low blood sugar in the postnatal period.

3.	N.B. asks why her insulin dose continues to increase after 20 weeks of gestation and is worried something is wrong. What information should be provided to N.B.?

Answer: It is expected that as pregnancy progresses (in the second and third trimesters) that insulin needs will go up. This is normal. The nurse will tell N.B., “We would be worried if your insulin needs did not increase.”

Rationale: The hormones of the placenta, human placental lactogen and prolactin, along with increased cortisol and glycogen levels cause a resistance to insulin and decreased glucose tolerance during the second half of pregnancy. It is expected for her insulin needs to increase two or three times than before pregnancy. She’s at risk for developing ketoacidosis because fats are more likely to be metabolized during a fasting state.

CHapter 32: Answer Key to Textbook Case Studies
Note: Answers to these questions can be found on the Evolve site. Click here.