Slide Deck for the 2014 School RN talk on Insulin Pump use by Stephen Ponder MD, FAAP CDE on June 21, 2014 in Austin, Texas at the TypeOneNation conference.
This document provides information on different types of insulin, including their onset, peak times and durations of action. It discusses using rapid-acting insulin to mimic the first phase insulin response and long-acting insulin to mimic the second phase. Formulas for calculating total daily insulin doses for patients with type 2 diabetes are presented. The importance of titrating insulin doses daily based on blood glucose results is emphasized to maintain good glucose control without hypoglycemia for hospitalized patients.
The document provides information about optimizing diabetes control through the use of an insulin pump. It discusses setting and testing basal rates to maintain stable blood glucose levels. It also covers using alternate and temporary basal rates for scheduled or unplanned changes in activity. Additionally, it explains optimizing bolus insulin through testing and adjusting the insulin-to-carb ratio and insulin sensitivity factor. Other topics include timing boluses, disconnecting from the pump, using a super bolus, and the importance of carb counting and blood glucose testing.
This presentation was authored by Meaghan Anderson MS RD LD CDE, Senior Diabetes Clinical Manager-Houston North - Medtronic Diabetes specially for the Advanced Diabetes Seminar at TLC on April 26, 2014.
Authored by Brant P. Foster, RN, a long time friend and contributor to the Texas Lions Camp. This seminar is for the Advanced Diabetes Seminar 2014 at TLC.
This 15-year-old male presented with polyuria, fatigue, and weight loss over the past month. His labs showed severely elevated blood glucose and ketones, along with an A1C of 13%. He was diagnosed with type 1 diabetes and started on basal and bolus insulin therapy. Type 1 diabetes results from beta cell destruction leading to insulin deficiency, whereas type 2 diabetes involves insulin resistance along with relative insulin deficiency. This patient's presentation with ketoacidosis and need for insulin therapy indicates he has type 1 rather than type 2 diabetes.
This document discusses insulin pump therapy and its goals of maintaining near-normal glycemia while avoiding crises and minimizing long-term complications. It describes how insulin pumps can more closely mimic physiological insulin secretion by providing basal insulin continuously and bolus doses at meals. Smart insulin pumps now include bolus calculators that help account for active insulin and minimize dosing errors, improving glycemic control for many patients with diabetes.
This document contains notes from a presentation on Sugar Surfing, which is described as a metaphor for "Dynamic Diabetes Self-Management" that goes beyond fixed dosing formulas. It involves learning to steer one's glucose responses in the moment using pattern management. Examples are provided of glucose readings from individuals of various ages who practice Sugar Surfing, demonstrating how it can be done regardless of insulin method or diet. Key concepts of Sugar Surfing like pivots, drops, shelves and following trends are defined and illustrated with graphs.
This document provides information on different types of insulin, including their onset, peak times and durations of action. It discusses using rapid-acting insulin to mimic the first phase insulin response and long-acting insulin to mimic the second phase. Formulas for calculating total daily insulin doses for patients with type 2 diabetes are presented. The importance of titrating insulin doses daily based on blood glucose results is emphasized to maintain good glucose control without hypoglycemia for hospitalized patients.
The document provides information about optimizing diabetes control through the use of an insulin pump. It discusses setting and testing basal rates to maintain stable blood glucose levels. It also covers using alternate and temporary basal rates for scheduled or unplanned changes in activity. Additionally, it explains optimizing bolus insulin through testing and adjusting the insulin-to-carb ratio and insulin sensitivity factor. Other topics include timing boluses, disconnecting from the pump, using a super bolus, and the importance of carb counting and blood glucose testing.
This presentation was authored by Meaghan Anderson MS RD LD CDE, Senior Diabetes Clinical Manager-Houston North - Medtronic Diabetes specially for the Advanced Diabetes Seminar at TLC on April 26, 2014.
Authored by Brant P. Foster, RN, a long time friend and contributor to the Texas Lions Camp. This seminar is for the Advanced Diabetes Seminar 2014 at TLC.
This 15-year-old male presented with polyuria, fatigue, and weight loss over the past month. His labs showed severely elevated blood glucose and ketones, along with an A1C of 13%. He was diagnosed with type 1 diabetes and started on basal and bolus insulin therapy. Type 1 diabetes results from beta cell destruction leading to insulin deficiency, whereas type 2 diabetes involves insulin resistance along with relative insulin deficiency. This patient's presentation with ketoacidosis and need for insulin therapy indicates he has type 1 rather than type 2 diabetes.
This document discusses insulin pump therapy and its goals of maintaining near-normal glycemia while avoiding crises and minimizing long-term complications. It describes how insulin pumps can more closely mimic physiological insulin secretion by providing basal insulin continuously and bolus doses at meals. Smart insulin pumps now include bolus calculators that help account for active insulin and minimize dosing errors, improving glycemic control for many patients with diabetes.
This document contains notes from a presentation on Sugar Surfing, which is described as a metaphor for "Dynamic Diabetes Self-Management" that goes beyond fixed dosing formulas. It involves learning to steer one's glucose responses in the moment using pattern management. Examples are provided of glucose readings from individuals of various ages who practice Sugar Surfing, demonstrating how it can be done regardless of insulin method or diet. Key concepts of Sugar Surfing like pivots, drops, shelves and following trends are defined and illustrated with graphs.
10 practical tips to make type 1 diabetes work for you tlc retreat 2013 ponderKevin McMahon
This document provides 10 practical tips to help manage type 1 diabetes. It begins with an overview of managing glucose flux and drift, understanding how diabetes tools like insulin, food, exercise, and monitors work and their limitations. It emphasizes recognizing trends versus randomness, making prudent changes, and treating diabetes management like a team sport. The document also covers common emergencies, how other factors like family impact management, and new developments in type 1 diabetes treatment. It aims to help readers better understand and control their condition through mastery of these diabetes management principles and tools.
This document provides information on dietary education tools for people with diabetes. It discusses the goals of dietary advice, which are to maintain health through appropriate food choices and achieve optimal health outcomes. The role of the dietician is described, which includes assessing individuals' specific needs and beliefs to develop a realistic eating plan. Dietary education tools are separated into two stages - stage one focuses on basic concepts like the food pyramid and plate model, while stage two covers more advanced topics such as food exchanges and carbohydrate counting. Carbohydrate counting is explained in detail as a key method for meal planning and insulin dosing.
The document discusses insulin pumps and their use for managing diabetes. It describes how insulin pumps work by continuously monitoring blood sugar levels and automatically delivering insulin to maintain safe blood sugar ranges. The document outlines important design considerations for insulin pumps, such as safety, reliability, and testing to validate the design and software. It also discusses potential hazards and failure modes that must be addressed.
The document provides a 3-step guide for interpreting iPro2 Professional CGM reports:
1. Overlay glucose data by meal to examine overnight, pre-prandial, and post-prandial periods.
2. Closely examine the 3 critical periods to identify causes of hypoglycemia or hyperglycemia.
3. Use daily summaries and patient logs to help identify relationships between behaviors, medications, and glucose levels.
This document discusses the differences between basal-bolus and sliding scale insulin regimens. It explains that basal insulin provides a constant background level, while bolus insulin covers mealtime needs. Sliding scale alone is reactive and can cause blood sugar fluctuations, while basal-bolus is proactive and mimics normal insulin delivery. During hospitalization, patients are best managed with basal-bolus rather than oral agents due to its flexibility and ability to be easily titrated.
Gestational diabetes develops due to increased insulin resistance during pregnancy. It can cause complications for both mother and fetus if uncontrolled. The standard treatment is insulin therapy, but oral hypoglycemic drugs like glyburide may be used. Glyburide does not cross the placenta and has not been shown to cause fetal anomalies. It can be started at a low dose of 2.5 mg once daily before meals and increased slowly as needed to control blood sugar levels while minimizing risks for the mother and fetus. Lifestyle changes like diet and exercise are also important for managing gestational diabetes.
Carbohydrate counting is an effective meal planning method that was used in the Diabetes Control and Complications Trial. It involves assessing a patient's needs, developing an optimal carbohydrate intake pattern based on lifestyle and schedule, and teaching patients how to achieve euglycemia through various carbohydrate intake patterns. Summarizing key points from the document, carbohydrate counting decreases A1C by 1-2% in people with diabetes, achieves and maintains target blood glucose and lipid levels, and prevents or slows chronic diabetes complications by modifying nutrient intake and lifestyle.
This document discusses the importance of exercise for managing diabetes. It notes that exercise can lower blood sugar, increase insulin sensitivity, reduce medication needs, and even potentially reverse diabetes symptoms. Structured aerobic and resistance exercise just three times per week can lower A1C by an average of 0.67% in three months. The document outlines barriers to exercise and provides seven strategies to overcome them, such as finding enjoyable activities and developing a reasonable exercise plan. It emphasizes setting specific, measurable, attainable, realistic, and time-bound goals to stay motivated.
The document discusses insulin therapy and glucose monitoring. It provides details on the different types of insulin including rapid, short, intermediate and long acting insulins. It describes insulin administration including sites, storage, precautions and complications. It also discusses glucose monitoring methods like fasting blood glucose, oral glucose tolerance test and self monitoring of blood glucose. The normal values and nursing considerations for these tests are outlined.
This document discusses diabetes, including its symptoms, effects, types, prediabetes, management, and tips for prevention. Diabetes is a metabolic disorder where the body does not properly produce or use insulin, resulting in high blood sugar. It discusses the main types of diabetes - type 1, type 2, and gestational diabetes - and their characteristics. Management of diabetes involves diet, exercise, oral medications, and possibly insulin therapy. Tips for prevention include monitoring blood sugar and weight, regular exercise and physical activity, and maintaining a high-fiber diet.
This document discusses basics of insulin therapy including:
- The discovery of insulin in the 1920s and types of insulin including basal, mealtime, premixed, and newer combinations.
- Insulin action profiles, indications for insulin use, administration techniques using vials, syringes and pens, and common insulin regimens for type 2 diabetes including once or twice daily basal insulin +/- mealtime insulin or premixed insulin.
- Proper storage, mixing, and injection of insulin as well as recommended sites for injection are also reviewed.
"The LEW.1WR1 rat is the only model so far that exhibits a low incidence of spontaneous diabetes that can be increased by perturbation. By far the most extensively studied of the models are the two BB rat strains, but all of them have provided interesting information. There are to date no rat models based on the insertion of transgenes, though genetic complementation has been used elegantly to identify the genetic defect in Komeda rats."
Diabetes mellitus is a chronic condition characterized by high blood glucose levels due to insufficient insulin production or resistance. There are four main types: type 1 caused by beta cell destruction; type 2 related to insulin resistance; gestational occurring during pregnancy; and other specific causes. Symptoms, causes, and management are described. Acute complications include diabetic ketoacidosis, hyperglycemic hyperosmolar state, diabetic coma, and hypoglycemia. Chronic complications involve damage to various organs over time if not properly managed.
Paracetamol (Bofalgan) is a non-opoid analgesic and antipyretic drug that is available over-the-counter or by prescription. It works by inhibiting prostaglandin synthesis and is effective at reducing pain and fever, and is sometimes used for cancer pain. The maximum recommended adult dose is 1 gram per dose and 4 grams per day. Overdosing on paracetamol can cause liver damage. It interacts with some drugs and its use is contraindicated in people with liver or kidney problems or a history of certain types of bleeding disorders.
This document contains a case study analysis for a patient named Mr. S who has been diagnosed with Crohn's disease. Key findings that support the Crohn's diagnosis include recent episodes of diarrhea and abdominal pain, weight loss, fever, and lactose intolerance. Laboratory results show decreased albumin and prealbumin levels indicating malnutrition. The patient was previously prescribed a low fiber diet following diagnosis to ease Crohn's symptoms. The document discusses potential nutritional consequences of Crohn's disease and recommendations for medical nutrition therapy if the patient develops short bowel syndrome, including energy and protein requirements during total parenteral nutrition and once solid foods are introduced.
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
sick day managment CAN SAFE LIFE FOR DM1AMER ALALI
This document discusses the importance of sick day management for diabetic patients and provides guidance on managing common illness scenarios. It emphasizes that failure to properly manage illness can lead to dangerous complications like DKA, cerebral edema, and death. The document outlines criteria for diagnosing DKA and provides a 5-step approach to prevent DKA during illness. It also discusses guidelines for different scenarios involving hypoglycemia, ketosis, and hyperglycemia during sickness. Overall, the document stresses that educating patients and caregivers on sick day management is critical for safely managing illness and avoiding life-threatening outcomes.
This document provides guidelines for initiating and adjusting insulin therapy for type 2 diabetes. It outlines a step-by-step regimen beginning with initiating either bedtime intermediate-acting insulin or bedtime or morning long-acting insulin. It instructs to monitor fasting blood glucose and increase the insulin dose until the target range is achieved. Additional injections of rapid-acting insulin are added before meals if blood glucose levels remain out of range. The regimen is monitored every 3 months by checking HbA1c and adjusting insulin doses up or down based on blood glucose levels and HbA1c targets.
Regular exercise has an important role in diabetes management by helping to control blood sugar levels, improve heart health, aid with weight control, and increase overall well-being. The document recommends aerobic exercise, strength training, and flexibility exercises at a low to moderate intensity for 20-60 minutes, 3-7 times per week depending on the type of diabetes. Guidelines include checking blood sugar levels before exercise, eating a snack beforehand for prolonged sessions, and exercising at the same time each day with consistent intensity levels.
Insulin pumps can help manage diabetes during pregnancy by more closely mimicking normal insulin physiology compared to multiple daily injections. Starting insulin pump settings during pregnancy typically involve dividing total daily insulin dose in half, with 50% for basal rates given continuously over 24 hours and 50% for bolus doses with meals. Basal and bolus rates often need adjustment throughout pregnancy as insulin resistance and needs increase. Close monitoring of blood sugars is important for optimizing pump settings to help prevent hyperglycemia and hypoglycemia. After delivery, insulin requirements usually decrease rapidly but may need to be adjusted based on breastfeeding and return of normal glucose levels.
This document provides an overview of the contents of a textbook on automobile chassis and body engineering. The textbook covers topics such as chassis frames, steering systems, braking systems, suspension systems, and more. It is intended for vocational and diploma students studying mechanical engineering. The document includes the table of contents which lists the chapters and subsections covered in the textbook.
10 practical tips to make type 1 diabetes work for you tlc retreat 2013 ponderKevin McMahon
This document provides 10 practical tips to help manage type 1 diabetes. It begins with an overview of managing glucose flux and drift, understanding how diabetes tools like insulin, food, exercise, and monitors work and their limitations. It emphasizes recognizing trends versus randomness, making prudent changes, and treating diabetes management like a team sport. The document also covers common emergencies, how other factors like family impact management, and new developments in type 1 diabetes treatment. It aims to help readers better understand and control their condition through mastery of these diabetes management principles and tools.
This document provides information on dietary education tools for people with diabetes. It discusses the goals of dietary advice, which are to maintain health through appropriate food choices and achieve optimal health outcomes. The role of the dietician is described, which includes assessing individuals' specific needs and beliefs to develop a realistic eating plan. Dietary education tools are separated into two stages - stage one focuses on basic concepts like the food pyramid and plate model, while stage two covers more advanced topics such as food exchanges and carbohydrate counting. Carbohydrate counting is explained in detail as a key method for meal planning and insulin dosing.
The document discusses insulin pumps and their use for managing diabetes. It describes how insulin pumps work by continuously monitoring blood sugar levels and automatically delivering insulin to maintain safe blood sugar ranges. The document outlines important design considerations for insulin pumps, such as safety, reliability, and testing to validate the design and software. It also discusses potential hazards and failure modes that must be addressed.
The document provides a 3-step guide for interpreting iPro2 Professional CGM reports:
1. Overlay glucose data by meal to examine overnight, pre-prandial, and post-prandial periods.
2. Closely examine the 3 critical periods to identify causes of hypoglycemia or hyperglycemia.
3. Use daily summaries and patient logs to help identify relationships between behaviors, medications, and glucose levels.
This document discusses the differences between basal-bolus and sliding scale insulin regimens. It explains that basal insulin provides a constant background level, while bolus insulin covers mealtime needs. Sliding scale alone is reactive and can cause blood sugar fluctuations, while basal-bolus is proactive and mimics normal insulin delivery. During hospitalization, patients are best managed with basal-bolus rather than oral agents due to its flexibility and ability to be easily titrated.
Gestational diabetes develops due to increased insulin resistance during pregnancy. It can cause complications for both mother and fetus if uncontrolled. The standard treatment is insulin therapy, but oral hypoglycemic drugs like glyburide may be used. Glyburide does not cross the placenta and has not been shown to cause fetal anomalies. It can be started at a low dose of 2.5 mg once daily before meals and increased slowly as needed to control blood sugar levels while minimizing risks for the mother and fetus. Lifestyle changes like diet and exercise are also important for managing gestational diabetes.
Carbohydrate counting is an effective meal planning method that was used in the Diabetes Control and Complications Trial. It involves assessing a patient's needs, developing an optimal carbohydrate intake pattern based on lifestyle and schedule, and teaching patients how to achieve euglycemia through various carbohydrate intake patterns. Summarizing key points from the document, carbohydrate counting decreases A1C by 1-2% in people with diabetes, achieves and maintains target blood glucose and lipid levels, and prevents or slows chronic diabetes complications by modifying nutrient intake and lifestyle.
This document discusses the importance of exercise for managing diabetes. It notes that exercise can lower blood sugar, increase insulin sensitivity, reduce medication needs, and even potentially reverse diabetes symptoms. Structured aerobic and resistance exercise just three times per week can lower A1C by an average of 0.67% in three months. The document outlines barriers to exercise and provides seven strategies to overcome them, such as finding enjoyable activities and developing a reasonable exercise plan. It emphasizes setting specific, measurable, attainable, realistic, and time-bound goals to stay motivated.
The document discusses insulin therapy and glucose monitoring. It provides details on the different types of insulin including rapid, short, intermediate and long acting insulins. It describes insulin administration including sites, storage, precautions and complications. It also discusses glucose monitoring methods like fasting blood glucose, oral glucose tolerance test and self monitoring of blood glucose. The normal values and nursing considerations for these tests are outlined.
This document discusses diabetes, including its symptoms, effects, types, prediabetes, management, and tips for prevention. Diabetes is a metabolic disorder where the body does not properly produce or use insulin, resulting in high blood sugar. It discusses the main types of diabetes - type 1, type 2, and gestational diabetes - and their characteristics. Management of diabetes involves diet, exercise, oral medications, and possibly insulin therapy. Tips for prevention include monitoring blood sugar and weight, regular exercise and physical activity, and maintaining a high-fiber diet.
This document discusses basics of insulin therapy including:
- The discovery of insulin in the 1920s and types of insulin including basal, mealtime, premixed, and newer combinations.
- Insulin action profiles, indications for insulin use, administration techniques using vials, syringes and pens, and common insulin regimens for type 2 diabetes including once or twice daily basal insulin +/- mealtime insulin or premixed insulin.
- Proper storage, mixing, and injection of insulin as well as recommended sites for injection are also reviewed.
"The LEW.1WR1 rat is the only model so far that exhibits a low incidence of spontaneous diabetes that can be increased by perturbation. By far the most extensively studied of the models are the two BB rat strains, but all of them have provided interesting information. There are to date no rat models based on the insertion of transgenes, though genetic complementation has been used elegantly to identify the genetic defect in Komeda rats."
Diabetes mellitus is a chronic condition characterized by high blood glucose levels due to insufficient insulin production or resistance. There are four main types: type 1 caused by beta cell destruction; type 2 related to insulin resistance; gestational occurring during pregnancy; and other specific causes. Symptoms, causes, and management are described. Acute complications include diabetic ketoacidosis, hyperglycemic hyperosmolar state, diabetic coma, and hypoglycemia. Chronic complications involve damage to various organs over time if not properly managed.
Paracetamol (Bofalgan) is a non-opoid analgesic and antipyretic drug that is available over-the-counter or by prescription. It works by inhibiting prostaglandin synthesis and is effective at reducing pain and fever, and is sometimes used for cancer pain. The maximum recommended adult dose is 1 gram per dose and 4 grams per day. Overdosing on paracetamol can cause liver damage. It interacts with some drugs and its use is contraindicated in people with liver or kidney problems or a history of certain types of bleeding disorders.
This document contains a case study analysis for a patient named Mr. S who has been diagnosed with Crohn's disease. Key findings that support the Crohn's diagnosis include recent episodes of diarrhea and abdominal pain, weight loss, fever, and lactose intolerance. Laboratory results show decreased albumin and prealbumin levels indicating malnutrition. The patient was previously prescribed a low fiber diet following diagnosis to ease Crohn's symptoms. The document discusses potential nutritional consequences of Crohn's disease and recommendations for medical nutrition therapy if the patient develops short bowel syndrome, including energy and protein requirements during total parenteral nutrition and once solid foods are introduced.
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
sick day managment CAN SAFE LIFE FOR DM1AMER ALALI
This document discusses the importance of sick day management for diabetic patients and provides guidance on managing common illness scenarios. It emphasizes that failure to properly manage illness can lead to dangerous complications like DKA, cerebral edema, and death. The document outlines criteria for diagnosing DKA and provides a 5-step approach to prevent DKA during illness. It also discusses guidelines for different scenarios involving hypoglycemia, ketosis, and hyperglycemia during sickness. Overall, the document stresses that educating patients and caregivers on sick day management is critical for safely managing illness and avoiding life-threatening outcomes.
This document provides guidelines for initiating and adjusting insulin therapy for type 2 diabetes. It outlines a step-by-step regimen beginning with initiating either bedtime intermediate-acting insulin or bedtime or morning long-acting insulin. It instructs to monitor fasting blood glucose and increase the insulin dose until the target range is achieved. Additional injections of rapid-acting insulin are added before meals if blood glucose levels remain out of range. The regimen is monitored every 3 months by checking HbA1c and adjusting insulin doses up or down based on blood glucose levels and HbA1c targets.
Regular exercise has an important role in diabetes management by helping to control blood sugar levels, improve heart health, aid with weight control, and increase overall well-being. The document recommends aerobic exercise, strength training, and flexibility exercises at a low to moderate intensity for 20-60 minutes, 3-7 times per week depending on the type of diabetes. Guidelines include checking blood sugar levels before exercise, eating a snack beforehand for prolonged sessions, and exercising at the same time each day with consistent intensity levels.
Insulin pumps can help manage diabetes during pregnancy by more closely mimicking normal insulin physiology compared to multiple daily injections. Starting insulin pump settings during pregnancy typically involve dividing total daily insulin dose in half, with 50% for basal rates given continuously over 24 hours and 50% for bolus doses with meals. Basal and bolus rates often need adjustment throughout pregnancy as insulin resistance and needs increase. Close monitoring of blood sugars is important for optimizing pump settings to help prevent hyperglycemia and hypoglycemia. After delivery, insulin requirements usually decrease rapidly but may need to be adjusted based on breastfeeding and return of normal glucose levels.
This document provides an overview of the contents of a textbook on automobile chassis and body engineering. The textbook covers topics such as chassis frames, steering systems, braking systems, suspension systems, and more. It is intended for vocational and diploma students studying mechanical engineering. The document includes the table of contents which lists the chapters and subsections covered in the textbook.
This document provides instructions for editing goals that have been set in an action plan. It states that if a goal in the action plan below the climbing frame grid needs to be edited, the user can click on that goal which will take them to the goal form to make the desired edits.
The document discusses analyzing network traffic using Wireshark. It describes how to use Wireshark to detect an ARP spoofing attack on a local network. The summary identifies that:
1) Wireshark detected a large amount of ARP traffic, indicating something suspicious was occurring.
2) Upon further examination, it was revealed that a machine on the network was sending fake ARP reply packets, associating the IP addresses of the server and router with its own MAC address. This allowed it to intercept all traffic between the router and server.
3) Wireshark provided the necessary information to identify the ARP spoofing attack and determine the source machine.
Dokumen tersebut membahas dua studi kasus wisata bahari, yaitu Wisata Bahari Lamongan dan Taman Impian Jaya Ancol. Kedua wisata bahari tersebut memiliki fasilitas rekreasi air dan wahana permainan serta memisahkan area rekreasi dengan fasilitas umum. Tampilan bangunan di kedua wisata bahari juga beragam dan disesuaikan dengan karakter masing-masing bangunan.
Cable television systems originated in the 1940s to provide broadcast signals to areas without reception. A cable television system uses coaxial cable to transmit signals from an antenna site to a headend facility where the signals are processed and distributed through a network of trunk and feeder cables to subscriber drops that connect to homes. Modern cable systems are two-way and provide additional services like high-speed internet, digital cable TV, and phone through a hybrid fiber-coaxial network.
JDRF TypeOneNation June 21 2014: Sugar surfing putting it all together by Ste...Stephen Ponder
This document discusses principles of "sugar surfing" or dynamic diabetes management. It emphasizes that diabetes care requires comprehending basic concepts, adjusting to changing conditions, and frequent reassessment. Effective management is like driving a car or surfing, requiring an understanding of how insulin, food, and activity impact blood sugar levels over time. The document provides tips on using continuous glucose monitors to track trends and patterns, calibrate sensors, test basal insulin needs, time insulin administration with meals, and experiment with micro-bolusing and corrections.
The document discusses the history and culture of Andalusia, Spain. It describes how Andalusia thrived under Moorish rule from the 10th to 15th centuries when cities like Cordoba and Granada were intellectual and economic centers. Andalusia experienced a decline after the empire ended and industrialization occurred elsewhere. However, Andalusian culture, including flamenco and bullfighting, has endured. The Kosmo People foundation community is based in Andalusia at Mi Casita to take advantage of Andalusian values like acceptance and love of life that were influenced by the region's long history under Moorish rule.
Keeping your child with diabetes out of the hospital prewebinar materialStephen Ponder
This slide deck is material for preparation for the August 19th 2014 Webinar by the same title to be presented at 7:30-9:00PM Central Standard Time in the USA. To register for the webinar go to
https://baylorscottandwhiteevent.webex.com/mw0307l/mywebex/default.do?siteurl=baylorscottandwhiteevent
Open education resources (OER) provide several benefits but also present some challenges. Some key benefits include that OER are free to access for anyone with an internet connection, many offer structured online courses, and there are peer-reviewed quality options available across several credible databases. However, challenges include determining the credibility of some free sources, understanding what can and cannot be done with the open licenses, and ensuring the author is not illegally posting copyrighted content. The lack of subject matter in some areas is also a limitation.
This document summarizes research findings about loneliness, sexual harassment, and feelings of safety among students at the University of Massachusetts. It also provides a hypothetical story about a student named Will who felt lonely in his residence hall. Some key points:
- 42% of students surveyed felt lonely occasionally or frequently, and 44% reported being sexually harassed in residence halls. Nearly 1/3 felt unsafe due to others' substance use.
- Will, an out-of-state student, spent most of his free time alone in his room studying or playing video games. His hallmates tried to include him but had trouble connecting with him.
- The document advocates cultivating compassionate residence halls through actively caring behaviors
Cracks in your walls aren't simply appalling; they can be cautioning signs for intense issues in your home. A few breaks are ordinary and originate from the common maturing procedure of a home.
Kelompok ini menggunakan teknik fotografi light painting dengan membuka shutter lama dan menggunakan berbagai sumber cahaya seperti LED dan senter untuk menciptakan foto abstrak. Mereka menawarkan jasa fotografi light painting untuk pasangan dan acara pre-wedding dengan paket harga Rp100.000-Rp300.000 yang mencakup jumlah foto dan cetakan tertentu.
How to Keep Your Child with Diabetes Out of the Hospital or ERStephen Ponder
No, it is generally not recommended to treat high blood sugars and ketones with an insulin pump alone. When a person has both high blood sugar and ketones, it means they require more insulin than their basal rates can provide. It is safer in this situation to treat with injections of rapid-acting insulin until blood sugar and ketones start to improve. The pump basal rates may need to be increased temporarily as well. Treating only with the pump risks not delivering enough insulin quickly enough to address the problem. Shots provide a larger, faster-acting dose that is more appropriate in this medical emergency situation.
The document introduces Kosmo People, a project developed by international women in Andalusia, Spain to offer solutions for a better world. Kosmo People will support men and women globally to participate in creating an alternative brand of ethical, sustainable, and fair services, products, and projects. The founders, called Kosmo Developers, aim to create a new socio-economic model based on creativity, generosity and human values over material values. They want to bring together 1% of conscious people in the world through their Read & Transform campaign, which challenges readers' ideas about issues that divide people. Revenue will support the development of these services and products to empower women and their families.
The document provides information on using temporary basal rates and advanced bolus options on insulin pumps. It discusses when to use temporary basal rate increases or decreases, such as for illness, exercise, or changes in activity level. It also reviews normal, extended, and dual/split bolus options and provides examples of when each would be appropriate. The document highlights tools like basal patterns, alarms, and pump suspensions that can help manage insulin needs and support forgetfulness. It concludes with tips for pump use and answers to common pump questions.
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014Stephen Ponder
1) Managing diabetes well requires comprehending changing glucose levels, adjusting to situations, and frequent assessments like surfing glucose levels with a CGM.
2) Effective CGM use involves wearing it often, checking trends, understanding sensor and insulin lag times, and being willing to experiment to improve skills over time.
3) "Sugar surfing" with a CGM means anticipating glucose level changes and giving small, frequent insulin doses or carbohydrate intake to keep levels in target range despite fluxes, rather than large reactive doses.
This document provides information about basic insulin pumping. It describes what an insulin pump is, potential benefits, and challenges. It discusses calculating basal rates, bolus doses, and correction factors. It provides guidance on pump maintenance like changing sites and settings. It addresses common questions around pump use, troubleshooting, and ensuring settings are optimized. The overall message is that pumps require diligent self-care and monitoring to achieve good blood sugar control.
This document provides information on using temporary basal rates and advanced bolus options on insulin pumps. It discusses when to increase or decrease temporary basal rates for situations like illness, exercise, or fasting labs. Examples are given of setting temporary basal rates for activities like basketball practice when blood sugar may run low. The document also covers normal, extended, and dual/extended bolus options and provides examples of when each would be best for different types of meals. The concept of a "super bolus" is introduced which delivers additional insulin by suspending part of the basal rate. Tools for reminders and multiple basal patterns are also mentioned.
The document discusses insulin pump therapy and technologies for managing diabetes. It provides information on:
1. Education needed before starting insulin pump therapy, including determining basal and bolus rates.
2. Safety measures to prevent hyperglycemic crises and inpatient considerations for insulin pump use.
3. Advanced pump features like temporary basal rates, prolonged boluses, and data downloads that can help fine-tune insulin delivery and management of blood glucose levels.
COPY AND PASTE THE WORKSHEET BELOW & ANSWER THE QUESTIONSSUBMIT AlleneMcclendon878
COPY AND PASTE THE WORKSHEET BELOW & ANSWER THE QUESTIONS
SUBMIT COMPLETED WORKSHEET IN THE SUBMISSION SECTION
Capstone for Chronic Diseases
Scenario : Billie
Billie is 16 years old and in generally good health. Her weight is normal for her height, and she watches her calorie intake to keep it that way. She participates in extracurricular activities in school, including chorus. Her main physical activity is a gym class once a week. She enjoys spending time with her friends, especially playing video games in her bedroom. She knows it’s not a great habit, but recently she has started smoking a few cigarettes each day. Both of her parents (aged 39 and 42) are also in good health. Her mother’s parents (aged 62 and 66) live nearby, and she spends a lot of time with them. They are also healthy and physically active, although her grandfather has started joking about how his wife seems to be “shrinking” and getting shorter every year. Her father’s dad is still living, but her father’s mom passed away recently after complications from hip surgery.
Billie is at risk for osteoporosis. Billie’s Daily Food Log and Intake vs Goals report is attached.
List 2 risk factors that Billie cannot change
List 2 lifestyle risk factors that she can change
2 dietary risk factors
2 foods or beverages that she can add to her regular diet to reduce her risk
Contraceptives Table
Type of Contraception
How does it work?
Side effects, risks, or contraindications
Benefits
Notes
Hormonal: Estrogen and Progesterone
1.) Combination Oral Contraceptive (pills)
2.) Transdermal Patch
3.) Vaginal Ring
(NuvaRing) disposable
(Annovera) re-usable
Hormonal: Progesterone only:
1.) Progestin only oral contraceptive pill (Mini-pill)
2.) Injection (Depo- Provera)
3.) Implant (Nexplanon)
4.) Progesterone IUD (Mirena, Skyla, Kyleena
1
Emergency Contraception:
1.) Plan B
2.) Copper IUD (ParaGard)
Barriers:
1.) Condom: (male and female)
2.) Diaphragm
3.) Cervical Cap
4.) Sponge
Behavioral: Fertility Awareness-Based Methods: 1.) Cervical mucous ovulation method
2.) Basal body temperature
3.) Symptothermal:
4,) Standard days
.
Permanent Sterilization: 1.) tubal ligation
2.) transcervical
3.) vasectomy
CW 4.21
11/27/21, 2:45 PM Clinical Assignment: Contraceptive Methods - NUR4545-01:Women & Newborn Health Nursing (2021 Fall Term 2)-14120 - Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=31365&grpid=0&isprv=0&bp=0&ou=16377 1/3
Contraceptive Methods Chart
Course: NUR4545-01:Women & Newborn Health Nursing (2021 Fall Term 2)-14120
Criteria
Level 2
1 point
Level 1
0 points
Criterion Score
Criterion 1: How does this
contraceptive method work?
Gives correct descriptions of
how contraceptive methods
...
This document provides a case study on a 41-year-old male patient with chronic kidney disease who is undergoing hemodialysis 3 times per week. It includes his medical history, social history, physical assessment, laboratory results, current diet, medication regimen, and recommendations for improving his diet. A registered dietitian provides an analysis of his current intake compared to goals, recommends an appropriate dietary pattern to meet his needs, and includes an ADIME note with interventions and monitoring plans.
Mr. S has been diagnosed with Crohn's disease based on his symptoms of diarrhea, fever, abdominal pain, weight loss, food intolerance, and anemia. He has undergone partial resection of his bowel and is recovering. Due to his unintended 15.7% weight loss and malnutrition, he requires increased calorie, protein, and fluid intake to aid his recovery. A low fiber diet is recommended initially to reduce abdominal pain. Close monitoring of his food intake and symptoms through a food diary will help evaluate his nutritional status and identify any foods that may trigger symptoms as he gradually resumes normal eating.
Det 120 estimating kcal, pro, fluid needs 02 13kbpennington
This document discusses methods for estimating an individual's calorie, protein, and fluid needs. It describes the gold standard method of indirect calorimetry for measuring calorie needs and notes more common predictive equation methods like Harris Benedict. Protein needs are typically estimated at 0.8-1.0g per kg body weight but may increase for stressed individuals. Fluid needs are also based on weight but can vary depending on factors like exercise, age, and medical conditions. The document provides examples for calculating daily calorie, protein, and fluid requirements.
Mrs. DM, a 35-year-old female, presented with type 1 diabetes, poorly controlled hypertension, and moderate albuminuria. Her lab results showed elevated fasting glucose, HbA1c, BUN, and urine albumin levels. She is currently taking medications for diabetes and hypertension. The patient was recommended a daily calorie intake of 1900 kcal, 53-67g of protein, and 1977mL of fluids. Dietary goals included reducing sodium intake to less than 2000mg per day through a DASH or Mediterranean diet, counting carbohydrates, and limiting protein to 53g due to diabetic nephropathy. The patient would receive diabetes education on understanding blood glucose numbers and carbohydrate counting. Self-
Mrs. Douglas, a 76-year-old female with type 2 diabetes, hypertension, and a history of heart failure and myocardial infarction, was admitted to the hospital for shortness of breath and swelling in her legs. Her lab values show elevated glucose, sodium, cholesterol, and triglycerides. A nutrition assessment found she consumes around 1800 calories daily but could benefit from following a cardiac diet lower in sodium, saturated fat and refined carbohydrates. A 1500 calorie diet is recommended for weight loss and heart health upon discharge.
A presentation for the April 26, 2014 Advanced Diabetes Seminar at Texas Lions Camp. Author is my friend and colleague Nelda Rodriguez-Caceres, RN, CDE -
ADA Outpatient Diabetes Program Coordinator
Diabetes Care Coordinator - Shoreline & CHRISTUS Spohn Hospital Corpus Christi.
This document provides information about diabetes, including:
- Type 1 diabetes is caused by a lack of insulin production while type 2 is caused by insulin resistance.
- Risk factors for type 2 diabetes include obesity, family history, age over 45, and certain ethnicities.
- Long-term complications of high blood glucose can include damage to nerves, eyes, kidneys, and heart.
- Proper diabetes management involves monitoring blood glucose, taking medication as prescribed, following a meal plan, getting regular exercise, and attending routine medical appointments.
Medical Nutrition Therapy (MNT) involves a four-step approach of assessing an individual's metabolic and lifestyle parameters, identifying nutrition goals, designing interventions to achieve those goals, and evaluating therapeutic outcomes. The assessment identifies eating habits and goals for things like weight loss, blood glucose and lipid control. Individualized treatment goals and meal plans are created, focusing on education, appropriate macronutrient distribution, fiber intake, and exercise. Progress is monitored and the nutrition care plan is reviewed and revised as needed.
- Correction insulin is preferable to sliding scale insulin for managing inpatient hyperglycemia as it treats current high blood sugars and prevents future highs through the use of basal, nutritional, and correctional insulin components.
- The case study patient should be started on correctional insulin therapy which includes initiation of basal insulin, nutritional insulin with meals, and additional correctional insulin for blood sugars over target.
- When initiating or adjusting insulin therapy in the hospital, consideration should be given to the patient's diabetes type and weight to determine the total daily insulin dose and regimen. Frequent monitoring and adjustments are important to achieve good glycemic control.
A blood glucose test measures the amount of glucose in a person's blood and is used to screen for and diagnose prediabetes and diabetes. There are several types of blood glucose tests, including fasting blood sugar tests, oral glucose tolerance tests, and A1c tests. Normal blood glucose levels are below 99 mg/dL when fasting, below 140 mg/dL two hours after eating, and below 6% for an A1c test. Nurses play an important role in properly conducting blood glucose tests and documenting the results.
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1 scoop myotein in 2 times feeding per day
Calories = 6(42kcal) x 6 + 2(30.1) = 1566.2 kcal/day
Protein = 6(1.7g) x 6 + 2(5g) = 72.4 g/day
Total CHO = 6(5.1g) x 6 = 183.6g/day
Total Fat = 6(1.6g) x 6 = 57.6g/day
3. Flush with 30ml of water
Gradually increase feeding amount based on tolerance.
Monitoring and Evaluation
1. Daily monitoring of:
- Intake and output
Similar to 2014 typeonenation pump talk for nurses Austin, Texas June 21 (20)
This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdfSachin Sharma
Here are some key objectives of communication with children:
Build Trust and Security:
Establish a safe and supportive environment where children feel comfortable expressing themselves.
Encourage Expression:
Enable children to articulate their thoughts, feelings, and experiences.
Promote Emotional Understanding:
Help children identify and understand their own emotions and the emotions of others.
Enhance Listening Skills:
Develop children’s ability to listen attentively and respond appropriately.
Foster Positive Relationships:
Strengthen the bond between children and caregivers, peers, and other adults.
Support Learning and Development:
Aid cognitive and language development through engaging and meaningful conversations.
Teach Social Skills:
Encourage polite, respectful, and empathetic interactions with others.
Resolve Conflicts:
Provide tools and guidance for children to handle disagreements constructively.
Encourage Independence:
Support children in making decisions and solving problems on their own.
Provide Reassurance and Comfort:
Offer comfort and understanding during times of distress or uncertainty.
Reinforce Positive Behavior:
Acknowledge and encourage positive actions and behaviors.
Guide and Educate:
Offer clear instructions and explanations to help children understand expectations and learn new concepts.
By focusing on these objectives, communication with children can be both effective and nurturing, supporting their overall growth and well-being.
Digital Health in India_Health Informatics Trained Manpower _DrDevTaneja_15.0...DrDevTaneja1
Digital India will need a big trained army of Health Informatics educated & trained manpower in India.
Presently, generalist IT manpower does most of the work in the healthcare industry in India. Academic Health Informatics education is not readily available at school & health university level or IT education institutions in India.
We look into the evolution of health informatics and its applications in the healthcare industry.
HIMMS TIGER resources are available to assist Health Informatics education.
Indian Health universities, IT Education institutions, and the healthcare industry must proactively collaborate to start health informatics courses on a big scale. An advocacy push from various stakeholders is also needed for this goal.
Health informatics has huge employment potential and provides a big business opportunity for the healthcare industry. A big pool of trained health informatics manpower can lead to product & service innovations on a global scale in India.
R3 Stem Cell Therapy: A New Hope for Women with Ovarian FailureR3 Stem Cell
Discover the groundbreaking advancements in stem cell therapy by R3 Stem Cell, offering new hope for women with ovarian failure. This innovative treatment aims to restore ovarian function, improve fertility, and enhance overall well-being, revolutionizing reproductive health for women worldwide.
Emotional and Behavioural Problems in Children - Counselling and Family Thera...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVedanta A
Air Ambulance Services In Rewa works in close coordination with ground-based emergency services, including local Emergency Medical Services, fire departments, and law enforcement agencies.
More@: https://tinyurl.com/2shrryhx
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At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
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This particular slides consist of- what is hypotension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is the summary of hypotension:
Hypotension, or low blood pressure, is when the pressure of blood circulating in the body is lower than normal or expected. It's only a problem if it negatively impacts the body and causes symptoms. Normal blood pressure is usually between 90/60 mmHg and 120/80 mmHg, but pressures below 90/60 are generally considered hypotensive.
Get Covid Testing at Fit to Fly PCR TestNX Healthcare
A Fit-to-Fly PCR Test is a crucial service for travelers needing to meet the entry requirements of various countries or airlines. This test involves a polymerase chain reaction (PCR) test for COVID-19, which is considered the gold standard for detecting active infections. At our travel clinic in Leeds, we offer fast and reliable Fit to Fly PCR testing, providing you with an official certificate verifying your negative COVID-19 status. Our process is designed for convenience and accuracy, with quick turnaround times to ensure you receive your results and certificate in time for your departure. Trust our professional and experienced medical team to help you travel safely and compliantly, giving you peace of mind for your journey.www.nxhealthcare.co.uk
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPTblessyjannu21
Prepared by Prof. BLESSY THOMAS, VICE PRINCIPAL, FNCON, SPN.
Emphysema is a disease condition of respiratory system.
Emphysema is an abnormal permanent enlargement of the air spaces distal to terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Emphysema of lung is defined as hyper inflation of the lung ais spaces due to obstruction of non respiratory bronchioles as due to loss of elasticity of alveoli.
It is a type of chronic obstructive
pulmonary disease.
It is a progressive disease of lungs.
Sectional dentures for microstomia patients.pptxSatvikaPrasad
Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
End-tidal carbon dioxide (ETCO2) is the level of carbon dioxide that is released at the end of an exhaled breath. ETCO2 levels reflect the adequacy with which carbon dioxide (CO2) is carried in the blood back to the lungs and exhaled.
Non-invasive methods for ETCO2 measurement include capnometry and capnography. Capnometry provides a numerical value for ETCO2. In contrast, capnography delivers a more comprehensive measurement that is displayed in both graphical (waveform) and numerical form.
Sidestream devices can monitor both intubated and non-intubated patients, while mainstream devices are most often limited to intubated patients.
2014 typeonenation pump talk for nurses Austin, Texas June 21
1. Advanced Insulin Pumping
(getting your pump to perform its best)
Stephen W. Ponder MD, FAAP, CDE
Professor
Texas Tech Health Sciences Center
2. Advanced pumping prerequisites
1. Advanced pumping without solid
pumping basics is like building a
mansion without a foundation!
2. Work towards mastering the art of
“glycemic load” combined with
your unique responses…know
your food!
3. You steer your own course
through the choppy waters of
tight blood sugar control…it’s all
about choices and process.
3. The “mother of all
pump settings” is the
total daily dose!
(TDD)
4. The 5 basic pump settings
1. Basal rate(s)
2. Insulin on board
3. Target BG(s)
4. Insulin to carb ratio
5. Correction factor
1 or more
2-8 hours (3-5)
1 or more (or a range)
1 or more
1 or more
REMEMBER: K.I.S.S.
5. Reviewing the rates and ratios
Insulin to Carb
(I:CHO)
Insulin Sensitivity
(correction) factor
Basal rate profile(s)
TDD⁄500
TDD⁄1800
12M – 3AM
3AM – 7AM
7AM – 12M
40-60% of TDD
0.7U/h
1.0U/h
0.85U/h
Example:
6. Doing an at home
pump “pit stop”
Check pump time
Download/review bolus
history (time?)
Download/review meter
and/or log book (time?)
Review basal rates
Check for bubbles
Inspect infusion site
7. Ponder’s Pumping Principles
I. A pump is no better or worse
than the human being attached to
it
II. Glycemic variability is the
NORM in diabetes: it’s a matter
of how much!
III. Age is not a limiting factor
IV. A good pump doc is more a
coach (educator) than a
prescriber
V. Simple is always a good start
8. Ponder’s Pumping Principles
VI. Quality diabetes self care is
more of a PROCESS than it
is an OUTCOME
VII. Hardware and software
change: people don’t
VIII. Consistency is a virtue
IX. Success is relative
X. Don’t ever be afraid to start
over
9. Common pump management errors
• Failure to recognize
need for changes
– Not reviewing BG, A1c
or pump history data
– Patient-related errors
– Update pump settings
• Failure to provide on-
going educational
support
10. Inaccurate carb counting
Missed boluses
Fear of hypoglycemia
No BG input from user
Lack of diabetes education
Outdated pump settings
The imprecision inherent in
pump settings
Weak links to good control with the
insulin pump
11. Know where the challenges are…
1. Overnights
2. Early mornings
3. Afternoons
4. Missed/skipped boluses
5. Over-bolusing
6. Adolescent “resistance”
7. Toddler hypersensitivity
8. Fix lows first
12. Know where the challenges are…
1. Overnights
2. Early mornings
3. Afternoons
4. Missed/skipped boluses
5. Over-bolusing
6. Adolescent “resistance”
7. Toddler hypersensitivity
8. Fix lows first
1. ↓ insulin need @ 2-4 AM
2. ↑ insulin need @ 6-9 AM
3. ↓ basal need mid-afternoon
4. More common in teens
5. More common in teens
6. Higher basal % in teen years
7. Lower basal % needed
8. Lows beget highs!
13. ~2AM to 4AM is the biologic low point for insulin need
~ 40% of hypoglycemia occurs during sleep! It’s often asymptomatic!
Breakfast
Lunch
Snack
Supper
Snack
2-4AM
Breakfast
6–9AM
Snack
15. Stop Lows First
Better control and more stability
• Mild lows cause followup
lows
• Small epinephrine release
makes muscles sensitive to
insulin
• Can lead to another low as
much as 36 hours after the first
• More carbs than usual are
needed
Severe lows cause highs
Higher stress hormone release
makes glucose rise for 6-10 hrs
Excess carb intake leads to highs
Boluses may be reduced/skipped
More insulin than usual needed
To stop lows, lower the TDD!!!
16. 10 advanced pumping tips
1. Basal and bolus self
review/checking
2. Extended boluses
3. Combination boluses
4. The “Sleep bolus”
5. Superbolusing
6. Temporary basal rates
7. Alternate basal profiles
8. Surgery and the pump
9. Bridging the gap
10.Do a pump “pitstop”
17. . . .
.
.
.
.
.
.
.
2 hours
150 mg/dl
80 mg/dl
135 mg/dl
glucose
0.75 U/hr B A S A L
timetime
94 mg/dl
Testing a basal segment
145 mg/dl
2 hours 2 hours
105 mg/dl
fasting
18. . . .
.
..
.
.
.
.
.
.
2 hours
155 mg/dl
95 mg/dl
125 mg/dl
glucose
0.75 U/hr B A S A L
timetime
60 mg/dl
Bolus for a measured
amount of carbs
Testing a bolus
145 mg/dl
215 mg/dl
19. 6
time
0.75 U/hr
Insulin to Carb [I : CHO] ratio
B A S A L I N S U L I N
. . .
.
..
.
.
.
.
.
.
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl 150mg/dl
Example: 1 to 10
60 grams CHO / 10
60 / 10 = 6
6
“Acceptable” = “target” +/- 30 mg/dl
glucose
bolusCHO
20. 5
time
0.75 U/hr
“Correction” dose
B A S A L I N S U L I N
. . .
.
..
.
.
.
.
.
.
2 hours
time
180 mg/dl
80 mg/dl
250 mg/dl
110 mg/dl
Example: 1 to 25
Actual – target / 25
250 – 125 / 25 = 5
5
“Acceptable” = “target” +/- 30 mg/dl
glucose
bolus
21. Two week pumper log sheet
(complete the open spots)
Influenced
by basal
Influenced
by boluses
Checks
overnight
basal(s)
22. 0.75 U/hr
“Extended” bolus
8 Units
60 minutes
B A S A L
timetime
Best used for grazing-like
feeding (e.g., long banquets,
receptions, salads, etc…)
23. Which of the following foods IS NOT a good reason for
considering use of the extended/combo bolus feature?
A. Cheese and Pepperoni pizza
B. Cheese enchilada plate
C. Pasta al dente
D. Salad bar
E. Baked potato
24. 0.75 U/hr
Combination bolus
2 hours
4 Units
6 Units
B A S A L
Ideal for patients with
gastroparesis (delayed
stomach emptying)
Also, excellent for foods
high in fat and protein
(pizza, mexican food,
pastas)
timetime
25. time
0.75 U/hr
The “Sleep bolus”
B A S A L I N S U L I N
. . .
.
.
.
.
.
.
.
.
6 hours
time
180 mg/dl
80 mg/dl
Bedtime (10PM) BG: 251 mg/dl
Fasting (7AM) BG: 120mg/dl
5.5 units
glucose
bolus
A modified extended bolus
For treating a high bedtime BG
Calculate correction dose
Deliver it over 5-6 hours
Reduces risk of low BG @ 3AM
26. 6
time
1.00 U/hr
Effect of high GI food
B A S A L I N S U L I N
. . .
.
..
.
.
.
.
.
.
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl
110mg/dl
Example: 1 to 10
60 grams high GI CHO
60 / 10 = 6
6
Blood sugar “spike”
glucose
bolusCHO
300 mg/dl
5-6 hours
27. Superbolusing: (i.e., Robbing Peter to pay Paul)
• Taking from basal to
add to bolus insulin
• Useful for
• high GI foods
• large carb loads
• faster correction of a
high BG
28. 0.00 U/hr
9
time
1.00 U/hr
“Superbolus”
B A S A L I N S U L I N
. . .
.
..
.
.
.
.
.
.
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl
Example: 1 to 10
60 grams high GI CHO
60 / 10 = 6 + 3 =
9
Normal BG change
glucose
bolusCHO
140 mg/dl
9
0.00 U/hr
30. . . .
.
..
.
.
.
.
.
.
2 hours
180 mg/dl
80 mg/dl
125 mg/dl
glucose
0.75 U/hr B A S A L
timetime
60 mg/dl
Exercise or other
strenuous activity
Temp basal rates
31. .
0.95 U/hr
timetime
Alternate basal rate profile examples
W E E K D A Y B A S A L P R O F I L E 1
0.95 U/hr W E E K E N D B A S A L P R O F I L E 2
6 AM 11 AM
1.35 U/hr
P R E M E N S T R UA L B A S A L P R O F I L E 3
32. Surgery and the Pump
If possible, wear the pump. It’s
the best way to control blood
sugar during the operation,
especially for minor procedures
(e.g., dental)
If infusion site is in the operating
field, simply relocate the site the
day before
The anesthesiologist can
monitor blood sugar and adjust
IV sugar as needed to keep
sugar levels under control.
D5
0.45
NS
33. Peak activity
Duration
NPH (0.3 - 0.4 U/kg)
Aspart or lispro (0.1U/kg)
RULE: insulin action via a pump is
short-lived. Rapid-acting injected
insulin can serve as a “bridge” while
longer acting insulin provides
“basal” insulin coverage.
Basal rate
Option 1
2 hours
34. Duration
Glargine (~basal dose)
Aspart or lispro (0.1 U/kg)
RULE: insulin action via a pump is
short-lived. Rapid-acting injected
insulin can serve as a “bridge” while
longer acting insulin provides
“basal” insulin coverage.
Basal rate
Option 2
2 hours