NURS 533 Exam 2 Study Guide PDF

**EXAM 2 Study Guide** **​​NURS 533 Exam 2 topics** **Total 40 questions, 60 minutes to take exam** **Adherence -- 3 questions** +-----------------------------------+-----------------------------------+ | **Factors that contribute to | Predictors of nonadherence | | patient adherence...

**EXAM 2 Study Guide** **​​NURS 533 Exam 2 topics** **Total 40 questions, 60 minutes to take exam** **Adherence -- 3 questions** +-----------------------------------+-----------------------------------+ | **Factors that contribute to | Predictors of nonadherence | | patient adherence or | | | non-adherence** | - - - - - - - - - | | | - - - | | | | | | **CAUSES of NONADHERENCE** | | | | | | - - - | | | | | | 3 basic pillars r/t med adherence | | | | | | - - - | | | | | | Unintentional nonadherence vs | | | intentional non adherence | | | | | | [Unintentional | | | nonadherence] | | | | | | Passive process | | | | | | - | | | | | | Cognitive Factors contributing | | | | | | - - - - - - - | | | | | | [Intentional | | | nonadherence] | | | | | | Active process | | | | | | - - - - | | | | | | Behavioral Factors and Beliefs | | | | | | - - - - - - - - - | | | | +===================================+===================================+ | **Evaluating for adherence and | **TOOLS + STRATEGIES FOR | | addressing patient inability to | ADDRESSING ADHERENCE ISSUES** | | adhere to a regimen** | | | | Cognitive Factors - Possible | | | Solutions | | | | | | - - - - - - - - | | | | | | Behavioral Factors and Beliefs- | | | Possible Solutions | | | | | | - - - - | | | | | | System and Health - Possible | | | Solutions | | | | | | - - - - - - | | | | | | "SIMPLE" explained | | | | | | **Simplifying regimen** | | | characteristics | | | | | | - - - | | | | | | **Imparting knowledge** | | | Discussion with physician, nurse, | | | or pharmacist | | | | | | - - | | | | | | **Modifying patient beliefs** | | | | | | - | | | | | | | | | | | | - | | | | | | **Provide communication and | | | trust.** Patient and family | | | communication Active listening | | | and providing clear, direct | | | messages | | | | | | - - - - | | | | | | **Leaving the bias** | | | | | | - | | | | | | **Evaluating adherence** | | | | | | - - | +-----------------------------------+-----------------------------------+ | **Techniques to demonstrate | BELOW in chart | | adherence** | | +-----------------------------------+-----------------------------------+ **Assessing/measuring adherence** **Direct Methods** **Advantages** **Disadvantages** ---------------------------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Directly observed therapy** **Accuracy** **Generally impractical in most situations; patients may hide medications in the mouth and later discard** **Measurement of drug or metabolite in the blood** **Objective means of assessing adherence** **Method is generally expensive; variations in patient metabolism may give a false impression of adherence; patients may regularly take a medication just prior to an appointment for a drug level thus also giving a false impression of adherence** **Measurement of a biologic marker** **Objective means of assessing adherence** **Expensive assays generally required** +-----------------------+-----------------------+-----------------------+ | **Indirect Methods** | **Advantages** | **Disadvantages** | +=======================+=======================+=======================+ | **Patient | **Simple and | **Pts may distort the | | questionnaires or | inexpensive** | results; probability | | self reports** | | of error increases | | | | with an increase in | | | | time between visits** | +-----------------------+-----------------------+-----------------------+ | **Pill counts** | **Quantifiable, | **Patients can dump | | | objective, easy to | pills** | | | perform** | | +-----------------------+-----------------------+-----------------------+ | **Prescription refill | **Data are easily | **Obtaining a refill | | rates** | obtainable, objective | does not equate to | | | means of assessing | actual ingestion of a | | | adherence** | medication; requires | | | | a closed pharmacy | | | | system** | +-----------------------+-----------------------+-----------------------+ | **Patient's clinical | **Simple and easy to | **Adherence is one of | | response** | perform in most | many factors that | | | cases** | could affect clinical | | | | response** | +-----------------------+-----------------------+-----------------------+ | **Electronic | **Precise means of | **Expensive; requires | | medication monitors** | tracking adherence | multiple visits to | | | patterns;** | the provider and | | | | downloading data from | | | **results easily | medication vials** | | | quantified** | | +-----------------------+-----------------------+-----------------------+ | **Measurement of | **Easy to perform in | **May be other | | physiologic markers | most cases** | factors that affect | | (i.e. BP and HR)** | | measurement of the | | | | marker** | +-----------------------+-----------------------+-----------------------+ | **Patient diaries** | **Helpful with poor | **Patients may easily | | | patient recall** | alter the data** | +-----------------------+-----------------------+-----------------------+ | **Questioning a | **Simple and | **Caregiver could | | caregiver** | objective** | distort the data** | +-----------------------+-----------------------+-----------------------+ **Medication reconciliation -- 3 questions** +-----------------------------------+-----------------------------------+ | **Med Reconciliation** | **[Med reconciliation | | | ]** | | | | | | Definition | | | | | | - | | | | | | Bring old meds to office - brown | | | bag review | | | | | | Integrating pharmacist into the | | | medication reconciliation process | | | is helpful | | | | | | Med rec initiatives stall bc | | | disagreements on crucial issues, | | | such as whose job it is to | | | perform the reconciliation | | | | | | Geriatric patients, including | | | those older than 65 years with | | | multiple chronic conditions, have | | | the highest rate of hospital | | | readmission | +-----------------------------------+-----------------------------------+ **Antibiotics** +-----------------------------------+-----------------------------------+ | **Streamlining -- 3 questions** | Antibiotic streamlining or de | | | escalation refers to the process | | | of converting patients from broad | | | spectrum to narrow spectrum | | | | | | - | | | | | | | | | | | | - | | | | | | Stages of infection | | | | | | STAGE 1 | | | | | | - - - - - - | | | | | | STAGE 2 | | | | | | - - - - - - | | | | | | STAGE 3 | | | | | | - - | | | | | | \*\*best opportunity for | | | antibiotic streamlining is in | | | stage 1 or early stage 2 | +===================================+===================================+ | **Stewardship -- 2 questions** | Penicillin allergy testing | | | supports effective antibiotic | | | stewardship and helps reduce | | | health care expenditure, | | | specifically excess hospital | | | days. | | | | | | - - - - - | +-----------------------------------+-----------------------------------+ | **Resistance -- 2 questions** | - - - | | | | | **Review risk factors for | - - - - - | | resistance** | | | | **Overuse of Antibiotics**: | | | Excessive prescribing of | | | antibiotics, particularly for | | | viral infections where they are | | | ineffective, can promote | | | resistance. | | | | | | **Incomplete Courses of | | | Treatment**: Patients not | | | completing their prescribed | | | antibiotic courses can lead to | | | the survival of resistant | | | bacteria. | | | | | | **Inappropriate Use**: Using | | | antibiotics for conditions that | | | do not require them, such as | | | common colds or mild infections. | | | | | | **Poor Infection Control**: | | | Inadequate hygiene and sanitation | | | in healthcare settings can | | | facilitate the spread of | | | resistant strains. | | | | | | **Global Travel**: Increased | | | travel can spread resistant | | | bacteria across regions and | | | countries. | | | | | | **Healthcare Exposure**: | | | Prolonged stays in hospitals or | | | frequent medical interventions | | | can increase the risk of exposure | | | to resistant organisms. | | | | | | **Underlying Health Conditions**: | | | Chronic illnesses or weakened | | | immune systems can make | | | individuals more susceptible to | | | infections caused by resistant | | | bacteria. | | | | | | **Lack of Vaccination**: | | | Inadequate vaccination rates can | | | lead to higher incidence of | | | infections, increasing the need | | | for antibiotics | +-----------------------------------+-----------------------------------+ **Gram stain and culture -- 2 questions** +-----------------------------------+-----------------------------------+ | **What does a gram stain and | Gram stain will differentiate a | | culture show you? How can you use | bacteria into two groups | | it?** | | | | - - | | | | | | | | | | | | - | | | | | | Culture | | | | | | - - - | +===================================+===================================+ | **Interpretation of gram stain** | | +-----------------------------------+-----------------------------------+ | **What does MIC mean? Need to | MIC→ minimum inhibitory | | know how to use it to choose | concentration | | antibiotic.** | | | | - - | +-----------------------------------+-----------------------------------+ **Choosing antibiotics/Specific types of infections** +-----------------------------------+-----------------------------------+ | **UTI -- 3 questions** | Urosepsis- Most common source of | | | gram negative bloodstream | | | infections | | | | | | Microbiology | | | | | | - - | | | | | | | | | | | | - | | | | | | \*Should not be treating if no | | | urinary symptoms | | | | | | - | | | | | | DX | | | | | | To have a UTI, must be | | | | | | 1. | | | | | | - - - - - - | | | | | | 2. | | | | | | - - | | | | | | Other findings supportive of UTI | | | | | | Urinalysis | | | | | | - - - - | | | | | | Asymptomatic bacteriuria | | | | | | Bacteriuria: literally, bacteria | | | in urine | | | | | | Asymptomatic bacteriuria: | | | Bacteria in urine, but no | | | symptoms and not a true infection | | | | | | **Treatment -- asymptomatic | | | bacteriuria** | | | | | | Bacteria present in urine but | | | patient asymptomatic | | | | | | - | | | | | | Treatment of asymptomatic | | | bacteruria is harmful! | | | | | | - - - - | | | | | | Treatment is only indicated if | | | patient: | | | | | | 1. 2. 3. | | | | | | **Definitions** | | | | | | Upper UTI/Pyelonephritis: | | | Infection of the kidney, discrete | | | surface abscesses and/or necrosis | | | | | | Lower UTI/Cystitis: Infection | | | localized to bladder | | | | | | **Complicated UTI vs. | | | uncomplicated UTI** | | | | | | **complicated UTI** | | | | | | - | | | | | | | | | | | | - | | | | | | **Selecting therapy** | | | | | | - - - | | | | | | **UTI: Oral Antimicrobial | | | Options** | | | | | | Sulfonamides | | | | | | - | | | | | | Beta-lactams | | | | | | - | | | | | | Tetracyclines (rarely) | | | | | | - | | | | | | Fluoroquinolones | | | | | | - | | | | | | Nitrofurantoin | | | | | | - | | | | | | Fosfomycin -- Enterococcus, E. | | | coli | | | | | | Linezolid | | | | | | **UTI: IV Antimicrobial Options** | | | | | | Aminoglycosides | | | | | | - | | | | | | Beta-lactams | | | | | | - | | | | | | Cephalosporins | | | | | | - | | | | | | Fluoroquinolones | | | | | | - | | | | | | Vancomcyin | | | | | | Daptomycin | | | | | | Linezolid | | | | | | FQ adverse effects Enhanced | | | warnings about the association of | | | fluoroquinolones with disabling | | | and potentially permanent side | | | effects involving tendons, | | | muscles, joints, nerves and the | | | central nervous system. | | | | | | **Treatment -- uncomplicated | | | cystitis in women** | | | | | | Nitrofurantoin 100 mg PO BID for | | | 5 days | | | | | | - | | | | | | Trimethoprim-sulfamethoxazole | | | (160/800 mg \[1 double strength | | | tablet\] BID for 3 days) | | | | | | - | | | | | | [Treatment | | | alternatives] | | | | | | Fluoroquinolones (levofloxacin) x | | | 3 days | | | | | | - | | | | | | Beta-Lactam agents, including | | | amoxicillin-clavulanate, | | | cephalexin and other oral | | | cephalosporins in 3--7-day | | | regimens | | | | | | - | | | | | | Fosfomycin | | | | | | - | | | | | | Treatment -- acute pyelonephritis | | | | | | Preferred empiric Tx: | | | | | | - | | | | | | Alternative empiric Tx: | | | | | | - - | | | | | | **Treatment -- catheter-related | | | UTI** | | | | | | - - - | | | | | | **Candida spp. in urine?** | | | | | | Not uncommon in catheterized | | | patients | | | | | | Consider: | | | | | | - - | | | | | | Treatment of asymptomatic or | | | minimally symptomatic candiduria | | | with fluconazole in catheterized | | | patients yields the same | | | recurrence rate at 2 weeks as | | | simply removing the catheter | | | | | | If treating, consider urine | | | penetration of antifungal | | | | | | **UTI in Pregnancy** | | | | | | Medications to Avoid | | | | | | - - - - | | | | | | **Recurrent infections** | | | | | | \< 3 infections per year -- treat | | | individually (3 day course) | | | | | | Treatment | | | | | | - - | | | | | | Single-dose prophylactic therapy | | | with SMX/TMP after intercourse to | | | reduce incidence of recurrence | | | | | | Continuous low-dose prophylaxis | | | | | | Consider resistance development | | | SMX/TMP SS 1 tab PO daily | | | Nitrofurantoin 50-100 mg daily | | | Relapses account for 20% of | | | recurrences In women, if | | | relapse after 2 weeks of therapy | | | -- treat another 2-4 weeks | | | | | | **UTI in MEN** | | | | | | Considered a complicated | | | infection | | | | | | Structural or functional | | | abnormality | | | | | | Prolonged treatment -- 10-14 days | | | | | | - | | | | | | **ABX PK considerations in UTI** | | | | | | Penetration -- Most commonly used | | | agents for UTI concentrate in the | | | urine and can eradicate sensitive | | | pathogens (FQ, beta-lactams) | | | | | | Renal failure may prevent the | | | kidney from being able to | | | concentrate the drug in the urine | | | | | | Typically beta-lactams and most | | | FQs concentrate adequately | | | despite severe renal dysfunction | | | | | | Nitrofurantoin should not be | | | used if CrCl \ | | | | | | - - | | | | | | Offer treatments instead of abx | | | | | | - - - - - | | | | | | \- **Initial Therapy:** | | | | | | \- **Amoxicillin-Clavulanate | | | (Augmentin)**: 500 mg/125 mg | | | orally three times daily or 875 | | | mg/125 mg twice daily for 5-7 | | | days | | | | | | \- **Alternatives for Penicillin | | | Allergy:** | | | | | | \- **Doxycycline**: 100 mg orally | | | twice daily | | | | | | \- **Levofloxacin**: 500 mg | | | orally once daily or | | | **Moxifloxacin**: 400 mg orally | | | once daily | | | | | | \- **Severe Infection Requiring | | | Hospitalization:** | | | | | | \- **Piperacillin-Tazobactam**: | | | 3.375 g IV every 6 hours | | | | | | \- **Ceftriaxone**: 1-2 g IV | | | every 24 hours or **Cefotaxime**: | | | 1-2 g IV every 8 hours | | | | | | \- **Meropenem**: 1 g IV every 8 | | | hours | | | | | | Acute bacterial exacerbations of | | | chronic bronchitis | | | | | | \- **First-Line Antibiotics:** | | | | | | \- **Amoxicillin-Clavulanate | | | (Augmentin)**: 500 mg/125 mg | | | orally three times daily or 875 | | | mg/125 mg twice daily | | | | | | \- **Doxycycline**: 100 mg orally | | | twice daily | | | | | | \- **Macrolides** (Azithromycin, | | | Clarithromycin): 500 mg orally on | | | day 1, then 250 mg daily | | | (Azithromycin) or 500 mg orally | | | twice daily (Clarithromycin) | | | | | | \- **For Frequent | | | Exacerbations:** | | | | | | \- **Levofloxacin**: 750 mg | | | orally once daily or | | | **Moxifloxacin**: 400 mg orally | | | once daily | | | | | | Pharyngitis - bacterial case | | | | | | - - - | | | | | | | | | | | | - - - - | +-----------------------------------+-----------------------------------+ | **Bloodstream infection -- 2 | **Central line associated | | questions** | bloodstream infections** | | | | | | Most commonly Bacterial | | | | | | Nosocomial: **Coagulase-negative | | | staphylococci** -- 16.4 percent | | | | | | S. aureus -- 13.2 percent | | | | | | Enterococci -- 15.2 percent | | | | | | - | | | | | | Rarely fungal | | | | | | (Weiner, et al., 2016) | | | | | | Cover Gram-positive: | | | **Vancomycin**, however with high | | | rates of MRSA with mic \2, best | | | to use Daptomycin. | | | | | | Depending on severity of | | | infection +hemodynamic | | | instability, cover for | | | gram-negative with **Cefepim**e | | | | | | - | | | | | | As soon as culture and | | | susceptibility come back, narrow | | | antibiotics as appropriate. | | | | | | (Mermel, et al., 2019). | +-----------------------------------+-----------------------------------+ | **Skin/soft tissue infections -- | **Skin and soft tissue infections | | 2 questions** | (SSTI)** | | | | | | - | | | | | | SSTI can generally be classified | | | as: | | | | | | - - - | | | | | | Infection sites are typically | | | erythematous, warm, and may be | | | painful Patients have positive | | | blood cultures ≤5% of the time | | | | | | **Diffuse, non-culturable | | | cellulitis with no defined | | | portal** | | | | | | Typically caused by Streptococcus | | | spp. (especially Group A | | | Streptococcus) | | | | | | - | | | | | | | | | | | | - - | | | | | | **Cellulitis associated with | | | abscesses (culturable) or entry | | | portal** | | | | | | - - - | | | | | | If antibiotics indicated | | | (previous slide): | | | | | | Mild/moderate: | | | | | | - - - | | | | | | Severe: | | | | | | - | | | | | | RCT of **TMP/SMX** vs **placebo | | | for uncomplicated abscess** | | | | | | - - - - - | | | | | | **Duration of therapy for SSTI** | | | | | | Based on resolution of most | | | erythema, fever, surgical | | | drainage, pain etc. | | | | | | - - | +-----------------------------------+-----------------------------------+ | **CAP -- 3 questions** | PNA | | | | | | - - | | | | | | Symptoms | | | | | | - - - - - - - - - | | | - | | | | | | MICRO eval | | | | | | Resp cultures | | | | | | Blood cultures | | | | | | - - | | | | | | Urine antigen | | | | | | - | | | | | | Resp viral panels | | | | | | PNA classifications | | | | | | - - | | | | | | CAP | | | | | | - - | | | | | | TX | | | | | | OUTPATIENT | | | | | | No comorbidities or risk factors | | | for MRSA/Pseudo | | | | | | - - | | | | | | Comorbidities present: chronic | | | heart, lung, liver or renal | | | disease; diabetes mellitus; | | | alcoholism; malignancies; | | | asplenia; | | | | | | - - | | | | | | INPATIENT | | | | | | Classification | | | | | | Minor criteria: - | | | | | | - - - - - - - - | | | | | | Major criteria: | | | | | | - - | | | | | |  | | | | | | \*\*why 2 antipneumococcal w | | | severe inpatient CAP | | | | | | - | | | | | | **Duration of therapy for | | | community-onset pneumonia** | | | | | | - - - | | | | | | To be eligible for treatment | | | discontinuation at day 5: | | | | | | - | | | | | | PROCALCITONIN to guide abx | | | therapy for PNA | | | | | | Keep in mind | | | | | | \*Viral infection suppress PCT | | | | | | \*Renal disease increase PCT | | | | | | **Prevention of bacterial CAP** | | | | | | - - | | | | | | HAP | | | | | | - - - | | | | | |  | | | | | | PATHOGEN DIRECTED THERAPY | +-----------------------------------+-----------------------------------+ | **VAP- 1 question** | VAP | | | | | | - - - - | | | | | | Best practices for preventing | | | VAP: | | | | | | - - - - - - - - | | | | | | Prevention of VAP | | | | | | - - | +-----------------------------------+-----------------------------------+ | **Otitis media- 1 question** | \- **First-Line Antibiotics:** | | | | | | \- **Amoxicillin**: High-dose 90 | | | mg/kg/day divided into two doses | | | for 5-7 days | | | | | | \- **Alternatives for Penicillin | | | Allergy:** | | | | | | \- **Cefdinir**: 14 mg/kg/day | | | divided into two doses | | | | | | \- **Cefuroxime**: 250-500 mg | | | orally twice daily | | | | | | \- **Clindamycin**: 30 mg/kg/day | | | divided into three doses (for | | | severe allergy or resistance) | | | | | | \- **Recurrent AOM:** | | | | | | \- Consider tympanostomy tubes if | | | multiple episodes | +-----------------------------------+-----------------------------------+ **Diabetes 8 questions** +-----------------------+-----------------------+-----------------------+ | | **hypoglycemia** | **hyperglycemia** | +=======================+=======================+=======================+ | **Symptoms** | - - - - - - | Increased thirst | | | - - - | (polydipsia) | | | | | | | | Frequent urination | | | | (polyuria) | | | | | | | | Fatigue | | | | | | | | Blurred vision | | | | | | | | Headaches | | | | | | | | Difficulty | | | | concentrating | | | | | | | | Dry mouth and skin | | | | | | | | Fruity-smelling | | | | breath (in severe | | | | cases) | +-----------------------+-----------------------+-----------------------+ | **Treatment** | \* | **Lifestyle | | | | Modifications:** | | | **Immediate Action:** | | | | | - - - | | | - | | | | | **Medications:** | | | **Follow-up:** | | | | | - - | | | - | | | | | **Emergency | | | **Long-term | Measures:** | | | Management:** | | | | | - - | | | - - | | | | | | | | **Emergency | | | | Measures:** | | | | | | | | - | | +-----------------------+-----------------------+-----------------------+ -- -- +-----------------------------------------------------------------------+ | **ADA ALGORITHM** | +=======================================================================+ |  | | | |  | +-----------------------------------------------------------------------+ **DIABETES MEDS** +-----------------------------------------------------------------------+ | **SGLT2i-** | +=======================================================================+ | MOA | | | | - - - | | | | \*stay hydrated | | | | Hx of ketoacidosis don\'t start on this medication | | | | **Adverse Effects** | | | | Increased urination (dehydration) | | | | Hypotension | | | | Genital myocytic infections and UTIs | | | | Ketoacidosis | | | | Foot amputations (canagliflozin) -- FDA black box warning | | | | Bone fractures (canagliflozin) | | | | Increase in LDL cholesterol | | | | Fournier's gangrene | | | | Jardiance is renal friendly | | | | \*\*SGLT2 or GLP1 no risk of hypoglycemia | | | | - | +-----------------------------------------------------------------------+ +-----------------+-----------------+-----------------+-----------------+ | **Brand** | **Generic** | **Dose** | **Renal dosing | | | | | (eGFR)** | +=================+=================+=================+=================+ | **Canagliflozin | **Invokana** | **100 mg once | **Renal cut off | | ** | | daily prior to | \ | | | | - | +-----------------------------------------------------------------------+ **Generic** **Brand** **Dose** **Comments** ------------------- ------------- ------------------- -------------------------- **Pioglitazone** **Actos** **15-45mg daily** **Would not use in CHF** **Rosiglitazone** **Avandia** **2-8mg daily** **Would not use in CHF** +-----------------------------------------------------------------------+ | **DPP4** | +=======================================================================+ | MOA | | | | - - - | | | | \*don\'t necessarily start on insulin until maxed on po / injectible | | treatment, Sort of a last option | | | | **Note on metformin** | | | | - - | +-----------------------------------------------------------------------+ +-----------------+-----------------+-----------------+-----------------+ | **Generic** | **Brand** | **Dose** | **Comments** | +=================+=================+=================+=================+ | **Sitagliptin** | **Januvia** | **100 mg QD** | **eGFR \ | | | | - | | | | | | | | - | +-----------------------------------------------------------------------+ **Generic** **Brand** **Initial Dose** **Max Dose** ------------------ ------------------ ------------------ -------------- **Glipizide** **Glucotrol** **2.5 mg** **40 mg** **Glipizide XL** **Glucotrol XL** **5 mg** **20 mg** **Glyburide** **Glynase** **1.25-5 mg** **20 mg** **Glimepiride** **Amaryl** **1-2 mg** **8 mg** **Basal Insulin** FBG goal→ 120 or less **Insulin** **Onset** **Peak** **Duration** **Titrate** ------------------------------------------------ ----------------- ------------------ ----------------- -------------- **Intermediate Acting Insulin** **NPH (Novolin N, Humulin N)** **2-4 hours** **6-10 hours** **10-16 hours** **3-5 days** **Regular (Humulin R U-500)** **\ | | | | - | | | | PreMixed insulin | | | | - - - - | | | | | | | | - - | | | | | | | | - - - | +-----------------------------------------------------------------------+ +-------------+-------------+-------------+-------------+-------------+ | **Insulin** | **Onset** | **Peak** | **Duration | **When to | | | | | of Action** | Take for | | | | | | CHO | | | | | | Coverage** | +=============+=============+=============+=============+=============+ | **Short | **0.5--1 | **2--3 | **3--6 | **30 | | Acting: | hour** | hours** | hours** | minutes | | Regular | | | | before | | (Novolin R, | | | | meal** | | Humulin | | | | | | R)** | | | | | +-------------+-------------+-------------+-------------+-------------+ | **Rapid | **\