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of renal fxn due to damage to kidneys resulting in retention of nitrogenous waste (urea and Creatinine) and non-nitrogenous waste products that are norm excreted to the kidneys • Incidence and Mortality • Prevention • Precipitating factors o Prerenal(causes in the blood supply): • Hypovolemia (decreased blood volume), usually from shock or dehydration and fluid loss or excessive diuretics use. • • hepatorenal syndrome in which renal perfusion is compromised in liver failure vascular problems, such as atheroembolic disease and renal vein thrombosis (which can occur as a complication of the nephrotic syndrome) • infection usually sepsis, systemic inflammation due to infection o Intrarenal(damage to the kidney itself): • toxins or medication (e.g. some NSAIDs, aminoglycoside antibiotics, iodinated contrast, lithium)
Activates the reninJuxtaglomerular angiotensin system by cells producing angiotensin I of angiotensinogen
Extraglomerular Stimulate erythrocyte Erythropoietin (EPO) mesangial cells production Active form of vitamin D3 Calcitriol (1,25dihydroxyvitamin D3) Increase absorption of calcium and phosphate from gastrointestinal tract and kidneys inhibit release of PTH stimulates megakaryocytes to produce platelets
rhabdomyolysis (breakdown of muscle tissue) - the resultant release of myoglobin in the blood affects the kidney; it can be caused by injury (especially crush injury and extensive blunt trauma), statins, stimulants and some other drugs
nephritis with systemic lupus erythematosus o Post renal(obstructive causes in the urinary tract) due to: • • • • Medication interfering with normal bladder emptying. Benign prostatic hypertrophy or prostate cancer. Kidney stones. Due to abdominal malignancy (e.g. ovarian cancer, colorectal cancer). • • Obstructed urinary catheter. Pathophysiology o Prerenal conditions o Intrarenal conditions o Post renal conditions Clinical manifestations- Metabolic Acidosis and Hyperkalemia most serious biochemical manifestations DX: o BUN, Creatinine o UA o CBC Medical Mgmt o Diuretics o Correct electrolyte imbalances
hemolysis (breakdown of red blood cells) - the hemoglobin damages the tubules; it may be caused by various conditions such as sickle-cell disease, and lupus erythematosus
multiple myeloma, either due to hypercalcemia or "cast nephropathy" (multiple myeloma can also cause chronic renal failure by a different mechanism)
acute glomerulonephritis which may be due to a variety of causes, such as anti glomerular basement membrane disease/Goodpasture's syndrome, Wegener's granulomatosis or acute lupus
o Dialysis o Fluid restriction o diet Nsg Dx: o Tissue perfusion o Alteration in elimination Nsg Interventions: o Pt assessment o VS o UOP o Labs o QD weights o Nutrition o Prevent systemic infection o Prevent comps of immobility o Skin and mucous membrane care o Assess for GI bleed o Assist with hemodialysis o Assure pt safety o Provide psychosocial support o Pt. teaching
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Chronic Renal Failure • Incidence and Mortality • Prevention • Precipitating factors o Tubulointerstitial disease o Glomerulonephropathies o Nephritic syndrome
o Renal vascular disorders o Renal CA Pathophysiology o Diminished renal reserve o Renal insufficiency o End stage renal disease o Uremic syndrome Manifestations DX Med/Surg mgmt o Diet o Fluid restriction o Pharmacology o Blood product transfusion o Dialysis o Nephrostomy tubes/ nephrectomy o Renal transplantation Nsg Dx: o Excess fluid vol o Alteration in nutrition Nsg. Interventions o Pt assessment o VS o LAB o I/O o QD weight o Cardio pulmonary assessment o Adequate nutrition
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Good skin and mucous membrane care Assess for bone and joint comps Assess for seizure activity Signs of bleeding Prevent systemic infections Prepare hemodialysis Assist with CAPD Psychosocial support Pt teaching
Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney.
Dialysis• Primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure. • Dialysis may be used for very sick patients who have suddenly but temporarily, lost their kidney function (acute renal failure) or for quite stable patients who have permanently lost their kidney function (stage 5 chronic kidney disease). • When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate) and the kidneys remove from the blood the daily metabolic load of fixed hydrogen ions. The kidneys also function as a part of the endocrine system producing erythropoietin and 1,25-dihydroxycholecalciferol (Calcitriol). • Dialysis treatments imperfectly replace some of these functions through the diffusion (waste removal) and convection (fluid removal).
Thermal Burn Injury • Incidence • Etiology • Prevention • Classification of thermal burn injury • Calculation of extent of burn o Rule of nines o Lund-Browder o Pt’s hand = 1% TBSA • Degree of Burn injury o Superficial thickness/ minor o Partial thickness/ moderate o Full thickness/ major • Phases of burn injury o Emergent o Acute o Rehabilitation • Nsg. Dx o Skin integrity o Altered CO • Medical Mgmt o Emergent Phase O2 Circulatory mgmt Respiratory
Acid-base balance Pharmacology GI mgmt Renal Nutritional o Acute o Rehabilitation Cell Injury and Inflammation • The norm cell o Cytoplasm o Nucleus • Cellular Fxns • Cell injury o Hypertrophy o Hyperplasia o Atrophy o Metaplasia o Dysplasia o Anaplasia • Defense Against Injury o Mononuclear phagocyte system o Inflammatory response o Vascular response o Cellular response o Chemical response Altered Immune Response • Norm response
o Components of the immune system o Lymphocyte production o Cell-mediated immunity o Effects of aging on the immune system • Altered immune response- Hypersensitivity o Type I- Anaphylactoid o Type II- Cytotoxic & Cytolytic Hemolytic transfusion reactions o Immune-Complex reactions o Type IV- Delayed Hypersensitivity reactions Transplant rejection Human Immunodeficiency Virus (HIV) • Significance • Transmission • Pathophysiology • Spectrum of HIV infection o Acute retroviral syndrome o Early infection o Early Symptomatic Disease o AIDS • DX • Therapeutic Mgmt o Pharmacology o Nutrition o Nursing mgmt • Pretest and post test counseling Opportunistic Infections in AIDS • Illnesses/Organisms
• • Cancer
o Pneumocystis Carinii o Kaposi’s Sarcoma o Cytomegalovirus o Candida Albicans o Mycobacterium Avium o Mycobacterium tuberculosis o Herpes Simplex Type I or II o AIDS Dementia Coplex Medical Mgmt Nsg Mgmt Significance Biology of Ca o Proliferation o Cellular differentiation o Iniatation o Promotion o Progression The role of the immune system Classification of CA TX o Radiation therapy o Chemo o Biological response modifiers Nutritional Mgmt Mgmt of Oncological Emergencies o Obstructive Emergencies o Metabolic Emergencies
o Infiltrative Emergencies Mgmt of Oncological Complications
Management of the pt with Liver CA • Pathophysiology • Comparison to cirrhosis • Nsg Dx • Nsg Care plan
Secreted hormone Abbreviation From cells Effect
Insulin-like growth factor (or IGF somatomedin) (Primarily)
insulin-like effects Hepatocytes regulate cell growth and development vasoconstriction Release of
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Angiotensinogen and angiotensin
Hepatocytes aldosterone from adrenal cortex dipsogen.
stimulates Hepatocytes megakaryocytes to produce platelets
Liver Failure- ability to regenerate.
Secreted hormone From cells Effect
Pancreatitis • Acute vs. Chronic • Cancer of Pancreas o Whipple procedure
The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply. These arteries run through the head of the pancreas, so that both organs must be removed. If only the head of the pancreas was removed it would compromise blood flow to the duodenum.
Intake of glucose, glycogneogensis and glycolysis in liver and muscle from blood Insulin (Primarily) ß Islet cells intake of lipids and synthesis of triglycerides in adipocytes Other anabolic effects glycogenolysis and gluconeogenesis in liver increases blood glucose level Inhibit release of insulin  Somatostatin d Islet cells Inhibit release of glucagon  Suppress the exocrine secretory action of pancreas. Pancreatic PP cells Unknown •
Glucagon (Also a Islet Primarily) cells
The most common technique of a pancreaticoduodenectomy consists of the en bloc removal of the distal segment (antrum) of the stomach; the first and second portions of the duodenum; the head of the pancreas; the common bile duct; and the gallbladder.
It consists of removal of the distal half of the stomach (antrectomy), the gall bladder (cholecystectomy), the distal portion of the common bile duct (choledochectomy), the head of the pancreas, duodenum, proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum (pancreaticojejunostomy) and attaching the common bile duct to the jejunum (choledochojejunostomy) to allow digestive juices and bile to flow into the gastrointestinal tract and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through.
Communication alternatives NG Potential for tracheostomy Wound drainage devices Dressings and bandaging Pain control Surgical intervention • Radical neck dissection
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Radical Neck Dissection • CA of the mouth, throat and neck • RF’s • Prevention • Symptomatology • DX • Pre-op teaching needs
Pharmacology Anti-inflammatory • Corticosteroids • NSAIDS • Capsaicin, a naturally occurring ingredient in chili peppers. Studies have shown some success in the control of pain and inflammation when capsaicin is applied topically Antifungal • Polyene antifungals
and so they are much less susceptible. (Note: as polyene's hydrophobic chain is reduced, its sterol binding activity is increased. Therefore, increased reduction of the hydrophobic chain may result in it binding to cholesterol, making it toxic to animals.)
Natamycin -- 33 Carbons, binds well to ergosterol Rimocidin Filipin -- 35 Carbons, binds to cholesterol (toxic) Nystatin Amphotericin B Candicin
Imidazole and triazole antifungals The imidazole and triazole antifungal drugs inhibit the enzyme cytochrome P450 14α-demethylase. This enzyme converts lanosterol to ergosterol, and is required in fungal cell membrane synthesis. These drugs also block steroid synthesis in humans.
A Polyene is a circular molecule consisting of a hydrophobic and hydrophilic region. This makes Polyene an amphoteric molecule. The Polyene antimycotics bind with sterols in the fungal cell membrane, principally ergosterol. This changes the transition temperature (Tg) of the cell membrane, thereby placing the membrane in a less fluid, more crystalline state. As a result, the cell's contents leak out (usually the hydrophilic contents) and the cell dies. Animal cells contain cholesterol instead of ergosterol
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Imidazoles: Miconazole (Miconazole nitrate) Ketoconazole
Clotrimazole - marketed as Lotrimin or Lotrimin AF (and Canesten in the UK) Econazole Bifonazole Butoconazole Fenticonazole Isoconazole Oxiconazole Sertaconazole - marketed as Ertaczo in North America Sulconazole Tioconazole The triazoles are newer, and are less toxic and more effective: Fluconazole Itraconazole Isavuconazole Ravuconazole Posaconazole
Voriconazole Terconazole Allylamines Allylamines inhibit the enzyme squalene epoxidase, another enzyme required for ergosterol synthesis: Terbinafine - marketed as "Lamisil" in North America, Australia and the UK Amorolfine Naftifine - marketed as "Naftin" in North America Butenafine - marketed as Lotrimin Ultra Echinocandins Echinocandins inhibit the synthesis of glucan in the cell wall, probably via the enzyme 1,3-β glucan synthase: Anidulafungin Caspofungin Micafungin Others Others: Benzoic Acid has antifungal properties but must be combined with a keratolytic agent 
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Ciclopirox is a fungicidal. Its real name is ciclopirox olamine. Flucytosine, or 5-fluorocytosine, is an antimetabolite. Griseofulvin binds to polymerized microtubules and inhibits fungal mitosis. Gentian Violet Haloprogin Tolnaftate is fungicidal, marketed as Tinactin, Desenex, Aftate, as well as other names Undecylenic acid is fungistatic Alternatives: Tea tree oil -- ISO 4730 ("Oil of Melaleuca, Terpinen-4ol type") Citronella oil lemon grass orange oil palmarosa oil patchouli lemon myrtle Neem Seed Oil Coconut Oil -- medium chain triglycerides in the oil have antifungal activities
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Zinc dietary supplements or natural food sources, including pumpkin seeds and chick peas Selenium dietary supplements or natural food sources, particularly Brazil nuts  Dandruff shampoos Antifungal drugs are often found in dandruff shampoos. Among the most common are pyrithione zinc,selenium sulfide and ketoconazole (Nizoral).
Antiviral Immunologic Agents Antineoplastic Agents and BRM • Health Effects/Occupational Exposure • The adverse health effects associated with antineoplastic agents (cancer chemotherapy drugs, cytotoxic drugs) in cancer patients and some noncancer patients treated with these drugs are welldocumented. The very nature of antineoplastic agents makes them harmful to healthy constantly dividing cells and tissues, as well as the cancerous cells. For cancer patients with a life-threatening disease, there is a great benefit to treatment with these agents. However, for the
healthcare workers that are exposed to antineoplastic agents as part of their work practice, precautions should be taken to eliminate or reduce exposure as much as possible. Pharmacists that prepare these drugs or nurses that may prepare and/or administer them are the two occupational groups with the highest potential exposure to antineoplastic agents. In addition, physicians and operating room personnel may also be exposed through the treatment of patients. Hospital staff, such as shipping and receiving personnel, custodial workers, laundry workers, and waste handlers, all have potential exposure to these drugs during the course of their work. The increased use of antineoplastic agents in veterinary oncology also puts these workers at risk for exposure to these drugs. • • • • • Modes of action There are many classes of antineoplastics: Alkylating agents Antimetabolites Antimitotics: bind to tubulin and inhibit spindle dynamics and thus block cell division
Inhibition of topoisomerase II, thereby stopping DNA from being unwound, which is required for both DNA replication and RNA/protein synthesis.
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Generating free radicals. They are products of various strains of the soil bacteria Streptomyces. Examples actinomycin (L01DA01). The most important immunosuppressant from this group is dactinomycin, which is used to in kidney transplantations.
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anthracyclines doxorubicin (L01DB01) daunorubicin (L01DB02) epirubicin (L01DB03), which also inhibit topoisomerase II) other cytotoxic antibiotics bleomycin (L01DC01). Bleomycin acts in unique way through oxidation of a DNA-bleomycin-Fe(II) complex and forming free radicals, which induce damage and chromosomal aberrations.
Diuretics Drugs used in tx of Burns
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