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Slide 1

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Diabetes Mellitus
Pamela Krupilis RN MSN CNS
Joseph F. McCloskey School of
Nursing

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Joseph F. McCloskey School of Nursing

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Slide 2

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Joseph F. McCloskey School of Nursing

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Slide 3

Diabetes Mellitus
Pancreas - Large fish-shaped organ behind the stomach.

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Islets of Langerhans - Cells located thru-out the pancreas.


Produce Alpha ( ) and Beta ( )

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Joseph F. McCloskey School of Nursing

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Slide 4

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Beta Cells - Synthesize insulin (a hormone) -- lowers blood
sugar.

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Insulin is the key that unlocks the cell to allow glucose to move from the
blood stream into the cell.

Alpha Cells - Synthesize glucagon (also a hormone) -- raises


blood sugar

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Glucagon promotes conversion of glycogen (glucose stored in the liver) to


glucose.

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Joseph F. McCloskey School of Nursing

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Slide 5

Vocabulary
Gluconeogenesis - Production of new glucose from amino
acids.
Glycogenolysis - Glycogen breakdown in the liver through the
action of glucagon

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Joseph F. McCloskey School of Nursing

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Slide 6

Functions of Insulin
1. Promotes the transport of glucose from the bloodstream
across the cell membrane.
Receptor sites on cells necessary for this to happen.
In DM
Too few receptor sites (insulin resistance)
Too little insulin
No insulin

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Joseph F. McCloskey School of Nursing

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Slide 7

Functions of Insulin
2. Glycogen breakdown in the liver through the action of
glucagon

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CHO

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PROTEIN
FAT

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Joseph F. McCloskey School of Nursing

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Slide 8

Functions of Insulin
3. Promotes storage of excess glucose in the liver (glycogen).

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Joseph F. McCloskey School of Nursing

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Slide 9

Counterregulatory Hormones

Glucagon
Epinephrine
Growth Hormone
Cortisol

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Joseph F. McCloskey School of Nursing

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Slide 10

Diabetes Mellitus
According to CDC (2011):
26 million people have diabetes and another 7 million dont
know they have it.

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79 million people have pre-diabetes.


7th leading cause of death in US

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Joseph F. McCloskey School of Nursing

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Slide 11

Diabetes
Defined as: A chronic disease of metabolism
caused by an imbalance between insulin supply
and demand
Characterized by:
Hyperglycemia
Abnormal metabolism of CHO, fat, and
protein.

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Joseph F. McCloskey School of Nursing

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Slide 12

Types of Diabetes
Type I -- Insulin Dependent
Type II -- Non-Insulin
Dependent
Secondary (Medical condition and/or medications)

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Gestational (GDM)

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Joseph F. McCloskey School of Nursing

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Slide 13

Pre-diabetes
79 million people have it.

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BS > 100 but < 126 when fasting


Will usually develop Type II within 10 years.

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Can greatly reduce risk by weight loss and diet


Some PCP prescribe oral diabetic meds.

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Joseph F. McCloskey School of Nursing

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Slide 14

Type I (IDDM)
10% of all diabetics

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40 years old

thin
incidence peaks at age 12 (40% of children with diabetes are less than 2
years old).
highest among people of European origin.

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Joseph F. McCloskey School of Nursing

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Slide 15

Type I (IDDM)
Genetic predisposition.

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However, most (90%) type I diabetics do not have a firstdegree relative with DM.

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Joseph F. McCloskey School of Nursing

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Slide 16

Type I (IDDM)
1. Genetic predisposition HLA markers
2. Environmental triggers spring and fall viral?

3. Active autoimmunity development of islet cell


antibodies (ICA) and insulin antibodies.

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4. Progressive beta cell destruction (usually takes


80 90% destroyed before DM occurs.
5. Overt DM depend upon exogenous source of
insulin.

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Joseph F. McCloskey School of Nursing

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Slide 17

Type I (IDDM)
Manifestations
Polyuria, Polydipsia, & Polyphagia
Weakness & fatigue
Weight loss
Ketoacidosis
Ketonuria
Glycosuria

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Joseph F. McCloskey School of Nursing

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Slide 18

Type 2 (NIDDM)
90% of diabetics are type II
40 years old

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dramatic increase over past 40 years


especially among Blacks, Hispanics, and Native Americans

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Obese
In 2001, epidemic among those in their 30s

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Joseph F. McCloskey School of Nursing

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Slide 19

Type 2 (NIDDM)
Manifestations
Often nonspecific/asymptomatic
Polydipsia, Polyphagia, Polyuria
Fatigue, skin infections, recurrent candidal infection
Prolonged healing, visual changes
Pruritis

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Joseph F. McCloskey School of Nursing

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Slide 20

Four Metabolic Abnormalities

1. Insulin Resistance
2. The inability of pancreas to produce insulin
3. Decrease production of glucose by the liver
4. Altered production of hormones & cytokines by adipose
tissue

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Joseph F. McCloskey School of Nursing

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Slide 21

Metabolic Syndrome
Cluster of abnormalities that greatly increased risk for the
development of type 2 DM.
Increased risk for type 2 DM
Characterized by: insulin resistance, elevated insulin levels,
high levels of triglycerides, decreased HDL, increased LDL &
HTN.
Risk factors: obesity, sedentary, ethnicities

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Joseph F. McCloskey School of Nursing

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Slide 22

Gestational Diabetes

Occurs during pregnancy


Increase risk to develop type 2DM in 5-10 years after delivery.
Nutritional therapy first line of treatment
May need to add insulin therapy.

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Joseph F. McCloskey School of Nursing

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Slide 23

Secondary (other) Diabetes


Secondary to other medical condition
Medications
Diabetes risk test available at
www.diabetes.org/risk-test.jsp

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Joseph F. McCloskey School of Nursing

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Slide 24

Diagnostic Studies

Glycosylated Hemoglobin A1C 6.5%


Fasting plasma glucose (FPG) level 126 mg/dL
2 hour Oral Glucose Tolerance Test (OGTT) 200 mg/dL
Classic symptoms of hyperglycemia and a random plasma
glucose level 200 mg/dL

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Joseph F. McCloskey School of Nursing

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Slide 25

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Estimated Blood Glucose
Estimated Blood Glucose (eAG) =
28.7 X A1C 46.7

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A1C 7.5% = eAG of 169 mg/dL

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http://professional.diabetes.org/glucosecalculato
r.aspx

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Joseph F. McCloskey School of Nursing

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Slide 26

OGTT

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Joseph F. McCloskey School of Nursing

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Slide 27

Diabetes Management
Education

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Diet
Exercise

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BGM

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Medication

Joseph F. McCloskey School of Nursing

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Slide 28

Diet

Food pyramid Healthy American Diet


Approximately 30% Type II controlled by diet
Standard size servings for adults:
Beef: 3 ounce serving (approximately size of 3 middle fingers)
Pork: approximately size of 3 middle fingers and part of palm.
Fish: 3 middle fingers and all of palm
Vegetables: small fruit bowl.

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Joseph F. McCloskey School of Nursing

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Slide 29

Diet
Daily amt
Carbs

Min 130g/day

Sugars, starches & fiber

Fats

Sat <7%
Chol <200mg/d

Carries fat-soluble vits &


provides essential fatty
acids

Protein

15%-20%

High protein diets are not


recommended for ppl
with DM

Fiber

14g/1000kcal

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Joseph F. McCloskey School of Nursing

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Slide 30

Diet
CHO Count
Exchange Diet

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Read Food Labels.

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Joseph F. McCloskey School of Nursing

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Slide 31

Diet

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Alcohol
Can cause hypoglycemia depends upon severity of diabetes and
glycemic control.
Need to consult with physician / nurse.

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Joseph F. McCloskey School of Nursing

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Slide 32

Diet

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Sugar Substitutes
Safe for use
Sucrose, fructose, honey, corn syrup, molasses, fruit juice,
maltose, dextrose.
If 20 calories, considered Free
Sorbitol and other sugar alcohols have laxative effect.
Non-nutritive sweeteners have no calories aspartame,
saccharin.

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Joseph F. McCloskey School of Nursing

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Slide 33

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Exercise

Regular exercise program reduces insulin requirements by as much as 10%.

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Increased insulin uptake by muscle cells can lead to hypoglycemia.

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Joseph F. McCloskey School of Nursing

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Slide 34

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Blood Glucose Monitoring
Glycosylated Hemoglobin (HbA1C) 90 to 120 day
average
Good metabolic control:

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HbA1C < 7%

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Joseph F. McCloskey School of Nursing

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Slide 35

Blood Glucose Monitoring (FSBS)

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QID, AC, & HS


Q 6 hours if NPO (surgery) or on continuous
parenteral nutrition or tube feedings.
Diabetic Control and Complication Trial (DCCT)
Intensive therapy

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2 4x/day (pre-meal, 2 hr pc, 3 am)


4 8x/day for intensive management

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Joseph F. McCloskey School of Nursing

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Slide 36

Pancreas Transplantation
Type 1 DM
ESRD who plan to have a kidney transplant
Kidney & Pancreas transplants are performed
together

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Joseph F. McCloskey School of Nursing

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Slide 37

Stress & Surgery


Emotional & physical stress
May need extra insulin
Acute illness, injury, and surgery

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Joseph F. McCloskey School of Nursing

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Slide 38

Medications

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Insulin

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Oral Hypoglycemics

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Oral antihyperglycemics

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Joseph F. McCloskey School of Nursing

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Slide 39

Insulin - Inspection
Clear
Humulin R
Lispro (Humalog)
Lantus (Glargine)
No clumps or discoloration
Check expiration date!

Cloudy
All other Insulins mixed with protamine zinc

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Joseph F. McCloskey School of Nursing

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Slide 40

Insulin Regimen

Intensive Insulin Therapy


Goal 80-120mg/dL before meals
Mealtime Insulin (Bolus)
Basal Insulin
Review Table 49-4

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Joseph F. McCloskey School of Nursing

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Slide 41

Insulin - Storage
Refrigerate

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Stable at room temperature


Open vial good for 1 month

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Keep out of direct light and heat


Always have a spare vial on hand

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Joseph F. McCloskey School of Nursing

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Slide 42

Insulin - Needles
Available in 28-31 gauge with 1/2 and 5/16
needle

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Not recommended to re-use


Cleansing with alcohol will remove silicone
coating
risk of infection with re-use, especially if poor
hygiene / sanitation

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Joseph F. McCloskey School of Nursing

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Slide 43

Insulin - Needles

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New needle

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Needle after 2 uses
Joseph F. McCloskey School of Nursing

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Slide 44

Insulin - Syringes
Available in 0.3 ml, 0.5 ml, and 1ml

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Joseph F. McCloskey School of Nursing

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Slide 45

Pre-filled Syringes
Stable in frig for up to 3 weeks

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Store needle up

Gently roll to distribute insulin in suspension

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Joseph F. McCloskey School of Nursing

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Slide 46

Site Selection
Rate of absorption

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Abdomen
Arms
Legs
Rotate site in same area an inch apart
Variable absorption rates
Exercises involving arms / legs may absorption
hypoglycemia

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Joseph F. McCloskey School of Nursing

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Slide 47

Sources of Insulin
Beef (Bovine) -- NOT AVAILABLE in US

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Pork (Porcine) -- NOT AVAILABLE IN US


Human recombinant DNA

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Joseph F. McCloskey School of Nursing

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Slide 48

Type of Insulin Rapid Acting


lispro (Humalog), aspart (Novolog), glulisine (Apidra)

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Faster acting than Regular

immediate onset, peaks 0.5 to 1.5 hours, duration 2 to 4 hours


Give immediately before eating !!

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not approved for IV use


used when PEAK action more important than duration

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Joseph F. McCloskey School of Nursing

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Slide 49

Types of Insulin Short Acting


Regular (Humulin R, Novolin R)

onset 15 to 1 hour, peak 2 - 4 hours, duration 3


- 6 hours
Give 30 to 60 minutes AC
Only Insulin approved for IV use

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may be given IM if IV not available

sticks to IV bag and tubing

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Joseph F. McCloskey School of Nursing

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Slide 50

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Types of Insulin Intermediate
Acting
Humulin N

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NPH (Natural Protamine Hagedorn)


peak 4 - 6 hours, duration 10 - 16 hours

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Lente- peak 6 8 hours

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Joseph F. McCloskey School of Nursing

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Slide 51

Types of Insulin Long Acting


Humulin U

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Ultralente peak 18 hrs

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Joseph F. McCloskey School of Nursing

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Slide 52

Types of Insulin Long Acting


Lantus (glargine)

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Genetically designed rDNA


24 hour glucose-lowering effect

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Very acid -- therefore


cannot be mixed with other insulin
causes burning with injection
Do not give in same injection site

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Joseph F. McCloskey School of Nursing

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Slide 53

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Insulin Type

Start

Peak

Duration

Less than
15 min

0.5 1.5 hr

2 6 hrs

Rapid Acting
Humalog (Lispro)

Novolog (Aspart)

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Same as rapid

Exubera (Inhaled Insulin)

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Short Acting
Humilin R / Novolin R

- 1 hr

2 3 hrs

3 10 hrs

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Joseph F. McCloskey School of Nursing

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Slide 54

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Intermediate Acting
Humulin N / Humulin L (Lente)

2 - 4 hrs

4 10 hrs

10 18 hrs

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Novolin N

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Joseph F. McCloskey School of Nursing

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Slide 55

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Long Acting
Humulin U (Ultralente)

6 10 hrs

8 20 hrs
(variable)

18 24 hrs

Lantus (Glargine)

4 8 hrs *

Little Peak *

24 hrs

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ATI Med Surg Review, version 7.0 (2007), p. 586


* these times are NOT noted in the ATI med-surg review book.

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Premixed Insulins
Humulin 70/30 70% N + 30% R
Humulin 50/50 50% N + 50% R
Humalog 75/25 75% N + 25% Humalog

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Joseph F. McCloskey School of Nursing

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Slide 56

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Joseph F. McCloskey School of Nursing

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Slide 57

Insulin Pens

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Joseph F. McCloskey School of Nursing

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Slide 58

Insulin Pens

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Joseph F. McCloskey School of Nursing

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Slide 59

Somogyi Effect
Rebound hyperglycemia.

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Caused by too much insulin which results in


hypoglycemia.
Hypoglycemia triggers the release of counter
regulatory hormones (glucagon) which causes
early morning hyperglycemia.

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Problem is that patient may take even more insulin


to cover the rebound hyperglycemia.

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Joseph F. McCloskey School of Nursing

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Slide 60

Dawn Phenomenon
Hyperglycemia upon awakening in the morning
Possible R/T cortisol & GH
Affects majority of DM patients.

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Joseph F. McCloskey School of Nursing

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Slide 61

Oral Hypoglycemic Agents


Primary Site

Action

Pancreas

stimulates pancreas to increase insulin


production

Liver

suppresses glucose production in the


liver

Muscle

works at receptor site on muscle cells to


improve effectiveness of insulin

Bowel

inhibits glucose absorption

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Joseph F. McCloskey School of Nursing

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Slide 62

Sulfonylureas

glipizide (Glucotrol, Glucortol XL); glyburide (Micronase, DiaBeta,


Glynase); glimepiride (Amaryl)
Action: Stimulates release of insulin form the pancreas, decreases hepatic
production of glucose, & increases cellular sensitivity to insulin
Side Effects: renal or hepatic insufficiency, GI effects, weight gain,
Hyponatremia & SIADH, hypoglycemia,

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Joseph F. McCloskey School of Nursing

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Slide 63

Meglitinides
repaglinide (Prandin) & nateglinide (Starlix)
Action: Increase production of insulin from the pancreas
Side Effects: weight gain, hypoglycemia

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Joseph F. McCloskey School of Nursing

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Slide 64

Biguanide
metformin (Glucophage, Glucophage XL, Riomet,
Fortamet, Glumetza)
Action: decreases hepatic glucose production,
increases insulin sensitivity in adipose & skeletal tissue,
& decreases intestinal absorption of glucose. It also
lowers triglyceride levels & LDL, & promotes weight
loss.
Side Effects: GI disturbances, aplastic anemia, vitamin B
12 def, agranulocytosis, thrombocytopenia & Lactic
Acidosis
Contraindications: heart failure, hepatic & renal
function impairment

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Joseph F. McCloskey School of Nursing

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Slide 65

-Glucosidase Inhibitors
acarbose (Precose) & miglitol (Glyset)
Known as Starch Blocker
Action: slow down the absorption of
carbohydrates in the small intestine.
Side Effects: flatulence, abd pain, diarrhea
Contraindicated: IBD, colonic ulceration, hx of
bowel obstruction, liver & renal impairment

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Joseph F. McCloskey School of Nursing

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Slide 66

Thiazolidinediones
pioglitazone (Actos) & rosiglitazone (Avandia)
Referred as insulin sensitizers
Action: decreases endogenous glucose
production & increases insulin sensitivity,
transport, utilization at target tissues.
Side Effects: weight gain, edema, increased
risk for CV events such as MI or CVA
Do not use in patients with symptomatic HF or
with active Liver Disease

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Joseph F. McCloskey School of Nursing

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Slide 67

Dipeptidyl Peptidase-4(DPP-4)
Inhibitor
sitagliptin (Januvia) & saxagliptin (Onglyza)
Action: Enhances the incretin system,
stimulates release of insulin, & decreases
hepatic glucose production
Newest class of oral hypoglycemic
medications
Side Effects: URI, sore throat, headache, UTI,
diarrhea, abd pain, nausea, & peripheral
edema
Drug Interaction: Digoxin

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Joseph F. McCloskey School of Nursing

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Slide 68

Combination Therapy

Gluvance (metformin & glyburide)


Avandamet (Avandia & metformin)
Metaglip (metformin & glipizide)
Duetact (Actos & Amaryl)
Actoplus Met (metformin & Actos)
Janumet ( metformin & Januvia)
Prandimet (metformin & Prandin)
Avandaryl (Avandia & Amaryl)

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Joseph F. McCloskey School of Nursing

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Slide 69

Incretin Mimic
exenatide (Byetta) & liraglutide (Victoza)
Action: stimulates release of insulin; decreases
glucagon secretion; improves satiety;
decreases gastric emptying
Side Effects: nausea, vomiting, hypoglycemia,
diarrhea, headache, pancreatitis, & renal
failure

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Joseph F. McCloskey School of Nursing

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Slide 70

Amylin Analog
pramlinitide (Symlin)
Action: gastric emptying; glucagon
secretion; glucose production from the liver;
satiety
Indicated for type 1 & type 2 DM
Administered subcutaneously in thigh or
abdomen.
Can cause severe hypoglycemia when
administered with insulin
Side Effects: hypoglycemia, nausea, vomiting,
decreased appetite, & headache

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Joseph F. McCloskey School of Nursing

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Slide 71

Glucose Elevating Agents


Glucagon (GlucaGen)
Action: stimulates glycogenolysis, exerts
positive inotropic & chronontropic effect, &
relaxes GI smooth muscle
Administered IM, IV, or subcutaneous,
Side Effects: hypotension, respiratory distress,
N&V, hypokalemia in overdosage, urticaria
Drug Interactions: Oral anticoagulants

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Joseph F. McCloskey School of Nursing

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Slide 72

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Hypoglycemia
Defined as BS < 70.

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BS = stress.

Glucagon and epinephrine


released.

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Called counter-regulatory
hormones released to counter
effects of low BS.

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Joseph F. McCloskey School of Nursing

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Slide 73

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Hypoglycemia

Glucagon stimulates
breakdown of stored
glucose (glycogenolysis) in
the liver.

Epinephrine responsible for


s / s of mild hypoglycemia
(early warning system).

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Joseph F. McCloskey School of Nursing

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Slide 74

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Hypoglycemia

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Epinephrine necessary for


s / s of hypoglycemia.
This protective mechanism
lost in 25% of all diabetics
(4-6 cups coffee/day help?).

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Lost in 50% of all who have


had DM > 20 years.

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Joseph F. McCloskey School of Nursing

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Slide 75

Clinical Manifestations
Mild Symptoms
Caused by release of Epinephrine

Shakiness
Irritability
Nervousness

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Hunger
Tachycardia, maybe some palpitations

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Joseph F. McCloskey School of Nursing

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Slide 76

Clinical Manifestations
Moderate Symptoms
Diaphoresis

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Pallor

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Paresthesia

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Joseph F. McCloskey School of Nursing

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Slide 77

Clinical Manifestations

Neuroglycopenic Symptoms

Caused by decreased glucose getting


to the brain

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Headache
Inability to concentrate
Slurred speech
Unsteady gait / maybe a staggering gait

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Double / blurred vision

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Joseph F. McCloskey School of Nursing

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Slide 78

Clinical Manifestations
Neuroglycopenic Severe Symptoms

Confusion
Irrational behavior / appears as a mental
illness
Combativeness
Lethargy
Loss of consciousness
Coma
Seizure
Death

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Joseph F. McCloskey School of Nursing

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Slide 79

Procedure to follow
for
Treatment of
Hypoglycemia

When symptoms
recognized
*BGM, then

For mild to moderate


Non-neuroglycopenic
hypoglycemia

Give fast CHO


Repeat BGM in 15
minutes and give
another fast CHO if <
70

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Joseph F. McCloskey School of Nursing

if no BGM available,
safer to presume
hypoglycemia and
treat !
in many hospitals
and patient care
settings, BGM is not
available!

Slide 80

Procedure to follow
for
Treatment of
Hypoglycemia

Night-time
Hypoglycemia

or if meal longer than


an hour away
Give fast CHO followed
by
A longer acting CHO +
protein (such as milk)

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Joseph F. McCloskey School of Nursing

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Slide 81
Treatment for
Hypoglycemia

Mild Hypoglycemia

Fast CHO
Like burning newspaper
15 20 Gm

orange juice 4-6 oz


soda 4-6 oz
Low-fat milk 8 oz
candy 6 8 life savers
2 graham crackers
cake icing 2 oz tube (convenient for
travel)
Glucose tablets

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Slide 82
Treatment for
Hypoglycemia

Best!
milk and toast
lactose = quick source
protein = longer lasting source

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Mild Hypoglycemia

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Slide 83

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Treatment for
Hypoglycemia

Slow CHO
Like burning a log

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Peanut butter
Cheese

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Slide 84

20 30 Gm Fast CHO or

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Treatment for
Hypoglycemia

Glucagon, 1 mg sc or IM

Moderate
Hypoglycemia

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Slide 85

Dextrose 50% IV
Treatment for
Hypoglycemia

Glucagon, 1 mg IM or IV
Vomiting occurs frequently following injection
of
Glucagon -- Protective positioning !

Severe Hypoglycemia

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Slide 86

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Hyperglycemia

BS > 150
Factors that BS

Warm, dry skin


Flushed appearance
Nausea

Clinical Manifestations

Treatment

Usually treated with


Fast Acting or Rapid
Acting Insulin on a
sliding scale for BS
> 150.

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Slide 87

Complications
Diabetic Ketoacidosis

Most often seen in Type


1 DM, but may be seen in
Type 2 DM.
Precipitating factors:
illness, infection,
undiagnosed Type 1 DM,
inadequate insulin
dosage, & noncompliance

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Slide 88

Complications
Hyperosmolar
Hyperglycemic
Syndrome (HHS)

Occurs with type 2 DM


Precipitating factors:
UTI, pneumonia, sepsis,
acute illness, & newly
dx type 2 DM.

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Slide 89

Complications
Cerebrovascular
Stroke

Cardiovascular
HTN
CAD
Ischemic heart
disease
Myocardial Infarction

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Slide 90

Complications
Diabetic Retinopathy

Visual deficit
Periods of blurred vision
Cataracts
Glaucoma

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Slide 91

Complications
Diabetic Retinopathy

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Slide 92

Complications
Diabetic Retinopathy

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Slide 93

Complications
Peripheral Neuropathy

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Slide 94

Peripheral Neuropathy Treatment


Elavil

(amitriptyline)

Neurontin

(gabapentin)

Cymbalta

(duloxetine)

Lyrica

(pregabalin)

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Slide 95

Amputation

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Slide 96

Complications
Autonomic Neuropathy

Anhydrosis
Absence of / or excessive sweating of feet

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Gastroparesis -- 2 damage to
vagus nerve

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Nausea / vomiting
GERD, bloating
Constipation
Diabetic diarrhea (d/t fermentation of
intestinal contents caused by
peristalsis 2 vagal nerve damage)

Loss of cardiac reflexes


automatic adjustment of heart rate
and BP to activity and position

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Slide 97

Complications

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Diabetic Nephropathy

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Frequent UTI
BUN / Creatinine
Nephropathy
Proteinuria

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Slide 98

Complications
Nephropathy

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Slide 99

Complications
Hematology

Decreased blood
components d/t
inadequate protein
metabolism 2 insulin
deficiency
Hgb and Hct
albumin
leukocytes

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Slide 100

Complications
Integumentary

Atrophic skin -- shiny,


thin, hairless, perhaps
even transparent 2 loss
of subcutaneous tissue
(circulation)
Toenails thick and yellow
(fungus)
Great toe pointing inward
toward other toes,
positioned over
Joseph F. McCloskeyperhaps
School of Nursing
2nd toe (hallux valgus
flexor stronger)

Lack of hair on
extremities (circulation)
Yeast infection in
perineal area / beneath
skin folds.

Slide 101

Complications
Charcot Foot

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Slide 102

Complications
Charcot Foot

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Slide 103

Complications
Hallux Vulgus

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Slide 104

Complications
Hallux Vulgus

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Slide 105

Complications
Fungus

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Slide 106

Complications
Toe Ulcer

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Slide 107

Complications

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Slide 108

Complications

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Slide 109

Complications

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Slide 110

Complications
Charcot foot
with neuropathic pressure
ulcer

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Slide 111

Complications
Venous
ulcer

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Slide 112

Complications

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Venous
ulcer

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Slide 113

Complications
Neuropathic
Ulcers

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Slide 114

Complications
Mental illness

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Slide 115

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