Self Study

10 Gizmos and their Do Dads of Diabetics

Proceedure

Read the course materials and review the test.  Pay for the exam through the PayPal link Buy Now button and record the transaction number. Write your answers and your paypal transaction number in an email with self study in the subject line and send it to testanswers@afc-ce.com. The test answers will be graded and the results will be returned to you. A score of 70% or better is considered passing and a Certificate of Completion will be emailed to you for your records.

 
 

 

10 Gizmos and Their Required Do Dads of Diabetes

     Taking care of a diabetic resident is a bit more complicated than caring for your other residents. They come with confusing new gizmos that require various do dads. Let’s see if we can clarify some of confusion by discussing the basics of the more common machines, devices, and required supplies that you might encounter as a caregiver.

Diabetes Disease

    Diabetes is a disease where the body’s mechanics of the hormone insulin is broken. Either the patient doesn’t produce enough, or it’s just not as effective as it used to be. When insulin is messed up, then the use of glucose (our primary fuel source) and lipids (our primary source of body fat) are also messed up. That leads to all sorts of problems. Diabetes can cause blindness, amputations, kidney failure, obesity, heart and blood vessel problems, and death. While there is no cure, we can compensate for what is lost with a few man-made mechanics.

·        HBGM- Home blood glucose meters

·         Test strips

·         Testing solution

·         Batteries

·        Lancets devices

·         Lancets devices

·        Insulin delivery devices

·         Insulin needles

·         Insulin pens

·         Insulin pumps, with and without glucose meter

·        Home HbA1c tests

·        Home lipid tests.

·        Insulin carrying cases

·        Sharps containers

·        Journals

Diabetes, Glucose, Lipids, and Insulin

     Glucose is our preferred source of energy. Our muscles, brain, and just about every cell in our body depends on it to continue working. That means we need a lot of it floating around in the blood stream where it can reach where it’s needed. To meet the body’s demand, we are designed to convert a lot of what we eat into glucose.

     The irony is glucose is a very reactive molecule. It tends to attach itself to many other things in ways we don’t want it to if it hangs around too long. Water wants to hang around glucose, too.  Having too much glucose tends to disrupt its proper flow in our body’s systems.  What these and other occurrences means is that we need a constant supply of glucose, but we don’t want too much of it in our blood stream or have it hang around too long. So our bodies convert excess glucose into lipid molecules that are stored as body fat. The body fat can then be converted back into glucose when our supplies run low.

     If it sounds complicated, it is. Fortunately, we have hormone- based automatic systems that take care of it all for us. The main regulating hormone that controls the glucose/fat systems of our bodies is insulin.  Among other functions, it is the key that enables glucose to enter and be used by our cells. It also enables the lipid-processing systems.  If something does go wrong with our insulin control systems, then we are in a world of hurt. Glucose will start to back up in our blood, cells start to starve, fat starts to accumulate, and too much lipids float around. When that happens, bad symptoms start to occur and the doctor diagnoses the patient with diabetes.

      There is no cure for diabetes. We can’t fix what is going wrong with our body’s insulin. The best that we can do for now is to compensate by making the insulin that is there work better or give more artificial insulin. We can also help reduce the excessive amount of glucose and lipids in the blood through a controlled diet and proper exercise.  But we have to be careful not reduce the amount of glucose too far or we’ll die. A key component to both therapies (compensating for too much and too little) is knowing how much glucose is in the blood stream in the first place.    

    

HBGM- Home Blood Glucose Monitoring

     In the 1960s, Leland Clark and Champ Lyons at the Medical College of Alabama figured out how to measure the amount of glucose in a set amount of blood. Since then, the technology has improved to the point where we now have small handheld devices that we can use at home. Today, diabetics can more easily manage their disease by monitoring how much glucose is in their blood at any time. Without HBGM, they would suffer then die.

Gizmo 1 -Glucose Meters

     By 2011, there were more than five dozen different brands of glucose meters. Though they vary in size, cost, and features, all share the same basic components.  Test strips collect the patient’s blood, and the machine measures or “reads” how much glucose is in the sample of blood on the test strip. 

How do you use glucose meters?

     A drop of blood is collected. Usually it is obtained by pricking the skin with a sharp instrument called a lancet, but any blood source can be used. The blood is then place on a small band of specially prepared material called a test strip. The test strip is placed into the glucose meter, and the amount of glucose in the blood sample is measured. The measurement is then displayed by the machine. Once the concentration of blood glucose is known, therapy can be altered as needed.

How can I tell when the readings are good or bad?

     Meters display readings as mg/dl or mmol/l. Most doctors and care providers in the U.S. use mg/dl. As you can imagine, glucose readings are constantly changing. They normally go up after eating and down between meals or when we work our bodies harder.  Other events can naturally increase glucose in the blood, such as when we are sick or stressed.  Even with normal variations, we need to keep our glucose at a certain level or we start to get in trouble. An average normal reading is:

·        Fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dl

·        Two hours after eating is less than 140 mg/dl

     Determining a bad reading is a bit more complicated. It all depends on how long a patient stays at a certain level. The farther away from normal, the less time the patient should stay there. Generally speaking;

Too high (hyperglycemic)

·        Constantly over 200 mg/dl, contact the doctor.

·        300 to 400 mg/dl or higher is dangerous at any time. Call the doctor as soon as possible.

·        500 to 600 mg/dl is life threatening. Immediate action is required.

Too low (hypoglycemic)

·        Any reading that produces feeling shaky, sweaty, having one's heart pound, or other hypoglycemic symptoms.

·        Constantly at 50 to 60, contact the doctor.

·        Below 50 mg/dl, brain function is affected. Have the patient eat immediately. Call the doctor as soon as possible.

·        Below 40 mg/dl is life threatening.

     The above information is for general education purposes only. Individual patient reading guidelines should always be provided by the patient’s doctor and may differ from that above.

What are some other features of glucose meters?

     Each brand will have its own bells and whistles.  Their importance really depends on what the patient needs and how much money the patient has to spend. Some features that might be considered when selecting a meter:

·        Size. There always seem to be a trend to make technology smaller, but there comes a time when smaller makes it more difficult to use.

·        Read outs. Make sure you can read the screens. They even make versions that talk.

·        Volume of blood needed. This is important. The smaller the amount of blood needed, the easier and less painful testing becomes.

·        All in one. There are machines that integrate all aspects of HBGM into one device. With these meters, there is no need for obtaining and deposing of used separate lances and test strips.

·        Memory storage. Some meters are able to store in its memory a certain number of readings. It makes it a little easier to track how the patient is doing. The doctor can also download the readings to his computer.  Of course, you can do it the old-fashioned way and just write down the information. 

 

Glucometer Do Dad - Test Strips

     Test strips are small pieces of plastic or paper where the blood sample is placed. Depending upon the machine, they are placed in the meter before or after receiving the blood. The strips are coated with special chemicals that react with the glucose in the blood, enabling the meter to read how much glucose there is in the sample.

·        Coding/no coding of strips. Each batch of test strips is a little different than the next, which could affect the accuracy of the readings.  It will be required to enter into the meter a code that comes with each new batch of strips. Newer machines are trying to do away with the need to code.

·        Insurance coverage. Some insurance companies have special deals with certain manufacturers and reward the patient for using that brand. Some will even give the machine free of charge. But beware: The real cost is in the test strips. I know of several cases where it was actually cheaper to buy an inexpensive brand off insurance for cash than it was to pay the co-pay for the “preferred by the insurance” brand. Sure the inexpensive brand didn’t have all the latest features, but as I always say, “If you can’t afford a Cadillac, don’t drive one.”

 

Glucometer Do Dad - Batteries

     Glucometers are powered by batteries that come already installed. Eventually, they are going to run out of power, and you’ll have to replace them. Low battery power can give false readings. Most meters come with a low battery indicator that will tell you when to change them. If the machine has been around a while, you might want to double check the batteries if you start getting unusual readings. Glucometer batteries are watch batteries. Don’t go to the pharmacy to buy new ones. Most don’t stock them. Go to the watch counter instead. Bring the old batteries with you so can match up the numbers when you are trying to buy the right ones. Excessive heat drains batteries faster (and throws off glucometers). Store glucometers and supplies away from heat.

 

Glucometer Do Dad- Testing Solution

     All machines have a tendency to slip or wander from normal settings. From time to time they should be recalibrated for accuracy. Some machines come with testing solutions for this purpose. Testing solutions are small bottles of glucose solutions at a set concentration. You can use the solution as a standard to calibrate the machine according to procedures. Not all meters have testing solutions

 

Gizmo 2 - Lancet Devices

     Lancet devices are small pen-like apparatuses that are designed to house a blood lancet. They are used to prick the skin to obtain the required blood sample. Most come with an adjustable depth gauge that allows you to determine how far the lancet goes into the skin. The deeper the lancet goes, the easier it is to get the required amount of blood. But the deeper the lancet goes, the more painful it is. There are different types of lancet devices, ranging from disposable single-use ones to multi lancet devices.

     Many glucometer packages come complete with a separate lancet device. But since they are separate, they can get lost or broken. New lancet devices can be purchased by themselves. Make sure that the old lancets fit into the new device because they are not all interchangeable. 

Lancet Device Do Dad- Lancets

     Blood lancets, or just lancets, are small scalpel-like blades or pins that easily penetrate the skin to obtain blood. They are meant to be used once and thrown away. The more often a single lancet is used, the duller it gets and the more it hurts.  

How do you use a lancet?  

Step 1- Wash the blood sampling area. This is done for infection control and to remove any substances that might interfere with the glucose testing accuracy. Traditionally, alcohol pads are used for this purpose, but they are not required.

Step 2- Remove the cap off the lancet device and remove any old lancets.

Step 3- Insert a sterile new lancet. Place into the holder and push in firmly. Remove the protective disk or blade cover. Save the disk for safe disposable of the old lancet if required.

Step 4- Replace the lancet device cap.

Step 5- Adjust the depth gauge. Usually the larger the number, the deeper the blade goes.

Step 6- Cock the device. Most lancets are spring-loaded devices that need to be cocked before use. Push the cocking mechanism as directed by the manufacturer until the control button clicks.

Step 7- Place the lancet device against the sampling area and push the control button.

Where do I test from?

     A blood sample from anywhere on the body can be used. It is important to note that glucose readings can vary from one portion of the body to another. It would be wise to keep that in mind if you change sampling areas. The traditional area of sampling is the fingers. They are easier to reach and easier to obtain the right amount of blood. Unfortunately, the fingers have lots of nerve endings as well as easy-to-reach blood vessels. The process will be less painful if the sample is collected from the side of the finger. If the same area is used over and over again, skin scare tissue can build up, making it more difficult and painful to get a new blood sample.   New glucometers require less blood so other areas can be used that have fewer nerve endings, for example the forearm.

 

Insulin Use and Diabetes

     Type I diabetics have lost the ability to produce insulin and need to have regular injections. Additionally Type II diabetics often require the use of extra insulin in their therapy.  Insulin must be injected into the body. Pills and nasally inhaled versions are years off in development. That means caregivers must learn the “whats and hows” of insulin use.

How is insulin supplied?

     Insulin and insulin-like products are liquids. They are only good for so long at room temperature. Long-term storage requires refrigeration. Freezing also destroys insulin. Ask your pharmacist or manufacturer how long a particular insulin product is good for at normal temperatures. Insulin products come in multiuse vials and multiuse pen-like devices and are measured in units. Insulin is very potent so doses are rather small. Doses measure from a couple of units up to larger amounts. One-hundred units are about 1cc or ml.  The only way to get those doses into the patient is by injection, so sooner or later you are going to have to deal with needles.

Gizmo 3 - Insulin Syringes

     We are all familiar with what a syringe is. But just to be complete, its basic components are the plunger, barrel, needle hub or port, and the needle. The size of the syringe has three components: the barrel size, or how much liquid it holds and the needle length and thickness or gauge. Insulin is to be injected under the skin (subcutaneously or just sub-Q) but not into the muscle. That means insulin needles are short. 

·        Barrel size is measured in either cc/ml or units. Standard sizes are 1 cc or 100 units, ½ cc or 50 units, and 1/3 cc or 3o units. Barrels come with volume markings or graduations so that you can measure accurate doses. Only the 30unit syringe is graduated down to single- unit markings. Don’t get ccs and units mixed up or you’ll just sound dumb. If you ask for a 100 cc syringe you’re actually asking for a 10,000 unit elephant-size product.

·        Common needle lengths are measured in fractions of an inch: ½ inch regular and 5/16 inch shorts.

·        Needle thickness is measured in gauges. The bigger the gauge, the thinner the needle. Thinner needles hurt less when injected but some patients are afraid that they will snap off in their arm. Proper technique prevents that danger. Needles are also labeled as regular, fine, and ultrafine.

     Insulin syringes come in bags of 10 and boxes of 100. Boxes of 100 are the cheapest way to go. When ordering syringes, be sure to include all three measurement descriptions. For example, give me a box of Ultrafine, 30unit shorts or 31 gauge, 1/3cc, 5/16 inch needles

Gizmo 4 – Insulin Pens

   For patient convenience and dose accuracy, manufacturers have packaged insulin in pen-like devices simply called insulin pens. The basic components of a pen are the insulin-containing cartridge, the dose measurement dial, and the pen needle. Pens come in two different types:

1.      A multiuse pen that uses a replaceable insulin cartridge. When the insulin cartridge is empty, the empty cartridge is disposed of and a new one is inserted in the pen.

2.    A prefilled pen that is disposable.  The pen comes pre-filled with insulin. When the insulin reservoir is empty, the entire unit is thrown away.

Insulin Pens Do Dad- Pen Needles

     Insulin pens are really just fancy multiuse vials that require a new needle attached to it every time they are used. Pen needles are easy to replace. They just screw on and off like a regular cap. The thread is universal, so any brand will fit any pen. Needles sizes only have two measurements to worry about. Needle length and thickness.

·        Length is very short and is measured in mm or inches. Common sizes are 12.7 mm (1/2), 8 mm (5/16), 5 mm (3/16) short, 4 mm nano.

·        Thickness is in gauges again. Common gauges are 29, 30, 31, and 32 gauge.

  How do you use an insulin pen?

  •  Screw or click on a new pen needle.
  • If necessary, prime the pen to remove any air from the needle.
  • Turn the knob on the end of the pen (or "dial") to the number of units needed.
  • Insert the needle into a cleaned area of skin.
  • Press the button on the end of the pen to deliver the dose.
  • Count to five.
  • Remove.

 

Gizmo 5- Insulin Pump

     An insulin pump is exactly what the name says it is. It is a computerized pump that delivers insulin via an infusion set similar to an IV set seen in hospitals but much smaller. Its basic parts are the reservoir where the insulin supply goes, the pump, tubing, and the infusion set (the needle device that goes into the skin). The computer can be programmed to give a basal dose (the base rate where you want the insulin level to always be) and a bolus dose (a PRN dose to cover spikes like after a meal.)  An insulin pump makes things easier and more complicated at the same time. Be sure to get more training before you take care of a patient with one. Insulin pumps are complex machines that come with a whole set of their own do dads. It’s not very likely that care home providers will take care of many without having their own training, so that’s all I’ll write about that.

Other Supplies in Diabetic Care

     Diabetes affects every aspect of a patient’s life, so their care can be complicated. The above gizmos and do dads cover the basics, but there are other things that will be good for you to know about. 

Gizmo 6- Sharps Container

     A sharps container is a safety refuse bin where things that can poke or cut you go. You can buy specially designed and red ones.  I have seen all sorts of containers used instead, mainly empty milk jugs and the like. The essential idea is that everyone knows about the potentially harmful and sharp things inside and is kept safe from them. There are special rules about how to dispose of full sharps containers. You’ll get in trouble and possibly fined a hefty amount if you casually toss them in the trash. Consult with your local garbage collectors about sharps container disposal.

Sharps Do Dad- Safety Clipper

     Disposing of a sharps container is extra work and can be expensive. If you can make a sharps last longer, that’s all the better for you the caregiver. One popular way to make them last longer is to just use the sharps for needles and lancets only.  Once the sharp part of the object is removed, the rest can go in the regular trash (as long as there is no blood on it, of course).  I have seen people use a pair of pliers to grab onto and twist off the needle.  A safer way is to use a safety clipper. It’s basically a handy and safe needle-cutting device. 

Gizmo 7- Diabetic Carrying Case

     There are a lot of gizmos and do dads to keep track of in diabetes care. A handy way to keep things organized (especially when traveling) is to get a specially designed diabetic carrying case. They’re designed with all the right nooks and crannies and pockets and such for all your diabetic devices and supplies. Some even come with removable cold packs to keep the insulin cold.

Gizmos 8 and 9- OTC Tests

     The FDA has approved the over-the-counter sale (OTC) sale of two tests that are useful for diabetics. Home-testing products could never replace a doctor’s care and should be used for informational purposes only. You as a caregiver may never use them, but it’s good to know they are there.

·        HbA1C or just A1C.  Remember from the first part of this course I told you glucose tends to stick to other things in the body if the hang around too long. One of those things is the hemoglobin (Hb) in your red blood cells.  When a glucose molecule sticks to a Hb, it’s called a glycosylated hemoglobin molecule or HbA1C for short. It a good measure of the long-term effects of diabetes on a patient. The higher the A1C number, the worse off the patient is. The goal for a diabetic patient is to get under 7 percent. A doctor will regularly order a precise professional grade A1C test for their patients. If you want a good estimate of your A1C, you can buy the OTC-grade test.

·        Lipids are also affected by diabetes and are often forgotten about. High lipid concentrations in the blood also cause a lot of problems. If you wanted to keep a closer watch on your lipid levels, you could buy the OTC home cholesterol test. Lipids are comprised of several different molecules, and cholesterol is one of the more important ones.

    

Gizmo 10 – Diabetic Journals

     Diabetic journals are just a recording system. You could make your own easily. The commercial ones come preprinted with places for all the important information that a doctor (or caregiver, for that matter) might need. In my opinion, symptom journals are always worth the effort. Gathering and conveying information about your residents is an important part of a caregiver’s job.

 

The Government and Diabetic Gizmos and Do Dads

     Medicare and Medicaid cover diabetic equipment and supplies.  A lot of hoops and loops must be jumped through before they will pay. Aren’t you glad that you don’t have to worry about that? Your only concern is getting the right pharmacy to do it for you. If your regular pharmacy doesn’t want to deal with the hassle, you can always go “mail order” to get your supplies. Mail order requires at least planning two-three weeks ahead of time.  

     Because diabetic equipment deals with human blood, the government has made it illegal to return a meter to the pharmacy. The pharmacist can’t take it back, even if it was never opened or is defective. But you’re not out of luck. Remember, I told you the real money was in the strips. Many glucometer producing companies will mail you a new machine with little effort on your part. Just call the 1-800 number that comes with the meter’s instruction manual. They want to keep you buying their strips and many realize that giving away the meter is a good way to accomplish that. If the pharmacist who sold the meter is worth his or her salt, they’ll do the calling for you.   

One final note for you to remember. A lot of the information contained in this course is based on generalities. Specific patient instructions should come from the doctor, nurse, diabetic educator, or pharmacist. Product- specific information can be obtained from the manual or 1-800 number that comes with the product. The 1-800 operators are really quite good. If you get a stinker, just hang up and dial them up again for another operator.

 

Conclusion

     Diabetic caregiving is really not that hard. Involved caregiving for sure, but not that difficult. All the gizmos and do dads may seem daunting at first. But once you know how, you can manage them just fine. I hope this course has helped you to be better prepared for diabetic caregiving.

As always, good luck. Mark P.

 

References:

1. Blood Glucose Meters. American Diabetes AssociationAug 15 2013

 http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/blood-glucose-meters.html

2. Blood Glucose Meters 2013. Diabetes Forecast.Jan 2013

http://forecast.diabetes.org/meters-jan2013?loc=lwd-tc-bgmeters

3. Glucose Meter. Wikipedia The Free Encyclopedia

http://en.wikipedia.org/wiki/Glucose_meter

4. Guide to HbA1C. Diabetes.co.uk

http://www.diabetes.co.uk/what-is-hba1c.html

5. Lindsey Wahowiak, 2012 Blood Glucose Meters. Diabetes Forecast. Jan 2013

http://forecast.diabetes.org/meters-2012

6. Insulin Pumps 101. Diabetes Forecast. Jan 2013

http://forecast.diabetes.org/insulin-pumps

7. Micheal J Folwer, M.D. Diabetes Devices, Clinical Diabetes. Diabetes Journal.org. Online ISSN: 1945-4953

http://clinical.diabetesjournals.org/content/26/3/130.full

8. How do I use the OneTouch® Lancing Device?. One Touch. LifeScan

http://www.onetouch.com/support/products/use-device

9. Opportunities for Improving Outcomes with Insulin Injections . Pharmacy Times Oct 2013.

http://www.pharmacytimes.com/publications/issue/2013/October2013/R602_October2013?utm_source=Informz&utm_medium=Pharmacy+Times&utm_campaign=BD+P2P+eBlast+10%2D25%2D2013

10. Insulin pen. Wikipedis The Free Encyclopedia

http://en.wikipedia.org/wiki/Insulin_pen

11. What is an Insulin pump?. Diabetes Online Education University of California San Fransico

http://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/medications-and-therapies/type-1-insulin-pump-therapy/what-is-an-insulin-pump/

 

 

10 Gizmos and their required Do Dads of Diabetes

Exam

 

1.  When Insulin’s functioning is messed up, what else elements are messed up.

a. Salt

b. Glucose

c. Lipids

d. Both B and C

 

2. There is a cure for Diabetes

a. True

b. False

 

3. What can be converted into glucose when our supplies run low?

a. Insulin

b. Fat

c. Water

d. Blood

 

4. Diabetes can make cells starve and make fat accumulate

a. True

b. False

 

5. What does HBGM  stand for?

a. Hemoglobin

b. Hemoglobin generating molecule

c. Home Blood Glucose Monitoring

d. Home Blood Glucose Meters

 

6. Where does a glucose blood sample goes once it’s obtained

a. Glucometer

b. Lancet

c. Test strip

d. Control solution

 

7.  Two hours after eating, what would a normal blood glucose reading be?

a.  70

b.  140

c. 200

d. 300

 

8.  A blood glucose reading of 40 would be ______.

a. Life Threatening

b. Hyperglycemic

c. Hypoglycemic

d. Both a and c

 

9.  Generally speaking what does a smaller amount of blood sampling mean.

a. Less accurate readings

b. Harder to clean

c. Less painful

d. Older glucometer used.

 

10. Where is the most money spent in glucometer use.

a. Glucometers

b. Test Strips

c. Lancets

e. Sharps Container

 

11. Gulcometer batteries are _____?

a. usually obtained at the pharmacy

b. hearing aid batteries

c. watch batteries

d. both a and b

 

12. Are lancets interchangeable between lancet devices

a. Yes

b. No

 

 13.  Where does a blood sample come from?

a. Just the tips of the fingers.

b. From the sides of the fingers

c. From the fingers or arm

d. Anywhere on the body.

 

14. How is insulin supplied?

a. liquid form

b. nasal spray

c. pills

d. transdermal

 

15. A 50 unit insulin syring ______.

a. is 50 cc

b. is graduated down to single units

c. is ½ cc

d. is 50 ml

 

16.  Which gauge is a thicker needle?

a. 28

b. 29

c. 30

d. 31

 

17. Insulin Pen Needles ____?

a. Must be matching brands

b. Can be used on any insulin pen

c. Are made to be used multiple times

d. both b and c

 

18. What are insulin pumps similar to?

a. glucometers

b. lancet devices

c. IV sets

d. all of the above

 

19. What is the goal reading of HbA1C tests

a. 140

b. 70

c. 10

d. 7

 

20.  Can the pharmacy take back a defective glucometer?

a. With the doctor’s permission

b. With  government permission

c. With the manufacturer’s permission

d. No

Article Evaluation Questions

1.  The article was easy to read and comprehend.

A. Totally agree

B. Agree Some what

C. Disagree Some what

D. Totally Disagree

2. I found this article helpful in operating a care home.

A. Totally agree

B. Agree Some what

C. Disagree Some what

D. Totally Disagree

3. This article achieved all of its learning objectives.

A. Totally agree

B. Agree Some what

C. Disagree Some what

D. Totally Disagree

4.  The test was not too difficult.

A. Totally agree

B. Agree Some what

C. Disagree Some what

D. Totally Disagree

5. Rate this program on its effectiveness in meeting your educational needs?

A. Excellent

B. Very Good

C. Good

D. Fair

F. Poor

6.  Rate the overall quality of the article

A. Excellent

B. Very Good

C. Good

D. Fair

F. Poor

7.  What topics would you find useful in the future?

 

How to get a Certificate of Accomplishment

for this Self Study Article.

   Pay for the exam through the PayPal link Buy Now button and record the transaction number. Write your answers and your paypal transaction number in an email, with self study in the subject line, and send it to testanswers@afc-ce.com

 

This CE is $20.00