let's get ready for chapter three with the review coming up I'm going to give you a high level overview of each chapter and pay attention to the bolded areas or the underlying areas because those those key facts will help you um identify the important areas in each chapter so let's first talk about the kidneys they are used to maintain homeostasis regulate fluid volume electrolytes and acid base remember kidneys secrete renin for blood pressure regulation arthop Putin to stimulate blood cell production and calcitrol as an active form of vitamin D for bone homeostasis and overall health now here is the diagram of the flow of a urine through the kidney it's important to recognize the nephron is the functional unit of the kidney blood is entering through the nefron as it shows in the top left corner through the glomus to the Bowman's capsule then to the proximal tubule and then filtrates passing through the loop of Henley as you see the loop there and then leaving the distal tubule then uh filtrate will empty in the collecting ducts and leave the nefron as urine now reabsorption is is largely affected by the proteins um and filtrate that's able to go back and forth uh throughout the blood now this is important to know because glucose amino acids sodium chloride calcium and bicarbonate can be excuse me can be reabsorbed sodium is the biggest factor in reabsorption now with renal failure it's important to decrease uh to recognize excuse me that kidneys are decreasing in function um unfortunately maintaining electrolyte and fluid balance and excretion um is challenging there's multiple causes usually an underlying pathology a disorder in the body system so the primary goal of renal failure whether it be acute or chronic is to increase and maintain flow through the kidneys to allow adequate urine output it's important to assess a patient um for safety especially with nephrotoxic drugs in example ineds ACE inhibitors IV contrast D are very high risk for those so doses may be lowered if the drugs required because the kidneys are not able to process the full dose now diagnostic testing for functionality your analysis creatinin Imaging renal biopsy and GFR remember GFR is going to be your best marker for estimating renal function um and it measures the volume of water filtered per minute now renal failure I talk about this a minute ago acute versus chronic biggest thing with acute is finding the underlying cause that can be heart failure dysrhythmia Hemorrhage or dehydration chronic usually happens over years or months it's usually due to diabetes or chronic hypertension it may go undiagnosed for a long time and remember those nephrotoxic drugs are uh definitely uh high risk for the patient nursing Focus recognize and respond educate about nephrotoxic drugs and expect significant drug reductions or continuation in dosing it's important again to treat the cause of dysfunction to increase uh the functionality of the kidney now one goal is uh one youth excuse me to increase the function is to give a diuretic and that increases the urine output total now diuretics uh after the volume and composition of bi body fluids they are given for hypertension heart failure liver failure pulmonary edema they're used to increase the rate of urine flow to decrease the total blood volume now they're classified into different categories Loop Diuretics function on the loop of H they're the most effective however they have a lot of risk with them Associated as well Loop Diuretics again affect the loop of hinley they're still effective when renal and cardiac outputs diminished a great example is fosite or leix you should focus on potassium replacement asking the patient to replace potassium either through Foods or oral supplements and watch for hypotension now thyoides are affecting the distal tubule they are primarily used to treat hypertension usually given orally they're less aggressive than Loop Diuretics but have the same risk with sodium and potassium loss example is hydrochlorizide potassium sparing spare the potassium from leaving the body but allow for diuresis with sodium important to educate the patient that potassium will be spared so it's important not to take additional supplements and refrain from high potassium foods such as po uh potatoes excuse me bananas Tomatoes apricots Etc and these are also increased risk for potassium uh increase with ACE inhibitors now it's important with these medications uh that you educate the patient but overall usually we'll obtain lobs testing to see how the patient's doing and then you have your miscellaneous drugs I won't go over those but you do have them available on your drug cards body fluid compartments this is extremely important it's a continuous exchange of fluid across membranes water traveling freely however will follow sodium so I'm explain this briefly as greatest contributor is sodium it's causing the water to move from different compartments sodium is controlled by aldosterone so it's very important to recognize the fluid shift note the intracellular fluid volume is greater than the extra cellular fluid volume on a regular basis um the plasma volume is going to be your vascular space so think of this as your blood vessel and this is where you get your blood pressure from going to go over this briefly water moves from an area of low osmolality to a high osmolality again following the sodium hypertonic IV solution water moves from the inti IAL space to the plasma shifting to the vascular space isotonic fluid no fluid shift hypotonic fluid water will move from the plasma to the intertial space I want to give you a few examples hypertonic fluid is going to be a high sodium content like 3% sodium chloride isotonic will be LR 0.9% uh normal saline or sodium chloride hypo iic is going to be half uh normal saline 0.45 NAC it's important to recognize the difference between them and which directions they move so that you can recognize what you are treating regulation of fluid balance it's important to regulate the fluid intake uh recognize osmo receptors and the hypothalamus control The Thirst mechanism it's your primary way of of increasing your fluid volume intake now renin and Angiotensin aldosterone um mechanism and ADH is your primary regulation of your kidneys for output colloids again are going to be uh ways to increase the blood pressure and blood flow through increasing fluid volume these are going to draw the water from the intracellular fluid and inter icial spaces into the plasma to increase the overall blood pressure now I'm not going to review specifics of signs and cures um however I do want you to look over these and recognize these pottassium normal range 3.5 to 5 remember low potassium can be a an adverse effect of your Loop Diuretics because you losing potassium through the loop of Henley they can also be a symptom of strenuous muscle activity exercise and severe vomiting or diarrhea hyperemia greater than five is going to be a possible outcome of uh eating high potassium rich foods as we previously discussed or dietary supplements it's important that it's a risk with patients with potassium sparing diuretics or patients with renal disease causing uh nephrotoxicity with the drugs through decreased excretion so signs and cures again I'm not going to review that too much just for the fact I do want you to recall and remember you want to give oral pottassium with food to prevent GI distress now acid base balance again you must balance the acid and the base in the blood and the kidneys to be able to maintain um your acid and and base it's important that you recognize there a constant push pull their uh your normal functioning body is going to adjust to this however if you have any underlying disease processes you may not be able to function to alter your body uh normal without drug therapy acidosis is a pH less than 7.35 alkalosis is a pH of greater than 7.45 I do not want to review this too much in depth but please review this and recognize metabolic uh alkalosis can be caused through a variety of reasons but most importantly excessive sodium bicarbonate Administration or diuretics that can cause potassium depletion size and cures please review this on your own classification of hypertension it's important to know the ranges recognize that prehypertension starts with a a systolic of greater than 120 excuse me greater than or equal to 120 or a diastolic of greater than equal 80 also stage one hypertension starts with a systolic BP of 140 over 90 remember cardiac output is heart rate time stroke volume the higher the output the higher the pressure Prof uh excuse me peripheral resistance uh is a relaxation of the vessels a decreasing and your autonomic nervous system increasing in response so remember your sympathetic nervous system and your parasympathetic nervous system blood volume decrease will allow for lower blood pressure and it is recommended as your first line cause and effect uh primary is excuse me 90% % secondary identif identifiable causes excuse me your target organs uh most affected by hypertension would be heart brain kidneys and retinas it's important to recognize those especially for the retinas because you can have uh very quick visual impairments and even blindness from the increase in pressure directly to those tiny arterials in the eye management is going to be no drug therapy and focus on Lifestyle Changes I'm not going to review this too much but just recognize a healthy moderate diet limit alcohol limit sodium and increased activity also limit or decrease discontinu tobacco treating with ACE inhibitors and arbs want to focus on Angiotensin converting enzymes ACE inhibitors angot tensin one is converting to two in the lungs causing potent vasil constriction um it's very important to recognize uh they are causing vasil constriction vasil constriction so if you're blocking this with an Ace inhibitor you are lowering the peripheral resistance and decreasing blood volume treating with calcium channel blockers calcium channel blocker drugs block the calcium ion channels causing Vaso dilation and decreased blood pressure adverse effect most commonly dizziness hypotension headache and flushing some uh selectively Target calcium channels in their arterials however others affect affect cardiac muscle tone as well calcium channel blockers it's important to recognize a big um adverse effect would be hypotension as previously stated angioedema impotence and mood changes these drugs cannot be given with grapefruit juice and should not be discontinued suddenly you should not also take them um with dexin uh because they can increase your dexin level and it's important to not mix with alcohol now beta blockers or aeric antagonists beta uh these are firstline drugs for hypertension they end in LOL that would be the generic name only they decrease the heart rate should not be given if heart rate is less than 60 beats per minute prior to Administration you should use with caution with asmatics also please taper the dose if the patient's coming off of this drug to prevent rebound hypertension and Mi let's talk about preload a little bit affects the cardiac output it's important to recognize um the contractility is an inotropic effect if drugs affect preload contractility they're positive inotropics if they do not they are negative Tropics afterload is um the pressure and the aort that must be overcome before the blood's allowed to be ejected from the left ventricle into the body lowering the blood pressure causes a decrease in afterload and less work for the heart it's important to recognize that decreasing peripheral resistance lowers after load now if the body is not able to eject this blood into uh the peripheral vascular system from the left ventricle it can back up into the lungs causing shortness of breath nitrates are drugs that specifically relax both arterial and Venus smooth muscle they dilate the coronary arteries they are used short acting to terminate acute and gin episodes it's important to recognize they do lower myocardial oxygen demand and reduce heart work load allowing for decrease in pain and increased oxygenation now it's important to recognize that beta blockers reduce the cardiac workload by slowing the heart rate and that contractility they are the first line drug for prophylaxis of stable and Gina pain so the key word here is stable also calcium channel blockers can be used uh for this same uh workload when beta blockers are not affected now acute coronary syndrome and Mi it's important to recognize that uh Mi and ACS occur when the coronary artery becomes completely uded depriving the the body and the certain area in The myocardium of oxygen uh necrosis starts immediately the marker that's most focus is a troponin and that is done seriously uh serially excuse me for testing to determine if the patient um had an MI versus unstable andinus symptoms it's important to rep reperfuse excuse me oxygenate watch The Rhythm control pain and anticoagulate shock uh several types of shock including anaphylactic cardiogenic hypovolemic neurogenic remember septic shock has to do with um infection uh specifically of a specific organ in the excuse me organism in the blood excuse me I can't talk today and it's important to make sure that you uh identify the type of shock so that you can address with a certain type of medication or resuscitation now signs and symptoms I'm not going to go over this too much much but just recognize that the heart of brain are affected early it's important to reperfuse as quickly as possible because you will have low blood pressure and diminished cardiac output reperfusion meaning increasing the total fluid or blood volume gold of gold therapy again increase the normal fluid volume and composition with blood blood products colloids or crystalloids to um reach an adequate blood pressure pressure for anaphylaxis is important to stop that hypers sensitive inflammatory response with fluid resuscitation it's important to recognize uh different fluids will be used however most commonly isotonic fluids will be used in the resuscitation effort norepinephrine is used to increase the systemic blood pressure after IV fluids have been shown ineffective so you'll give the fluid boluses first this will be second line treatment inotropic drugs for shock you're going to be giving the different dose based on what you're needing so low dose is a dop dopin meric effect high dose would be a beta aeric effect it's important to treat uh hypovolemic shock and cardiogenic shock and monitor your heart rhythm for anaphylaxis is very important it's important for the goal of therapy to give these drugs and treatments immediately um to prevent possible death to the patient start with oxygen sympathic via epinephrine you're going to give the dose I IM for an allergy you can give it subq but it will um not absorb this absorb as quickly excuse me you want to give it IV only if the patient's dying or dead um it's important to recognize you're also going to give an antihistamine a Bronco dilator and a corticosteroid we're going to review is EPO and Alpha this drug uh functionally improves uh the production of red blood cells for cancer patients renal failure and anemia it's important to monitor for hypertension also increased R risk of VTE or clotting um it's important again to watch for clots and cardiovascular events the next drug of next prototype drug excuse me that we'll review is filgrastim or nupen this drug is going to help your body increase the production of nutrifil uh immature white blood cells also enhance the functioning existing nutrifil it's important um that you recognize it will shorten the length of time to create white blood cells and the dosage is based on the patient's need now adverse effects fatigue rash bloody noses neutropenic fever bone pain lucyisanerd destruction or inefficient erythrite synthesis excuse me anemia symptoms are listed below it's important to recognize if you're deficient um in any type of B vitamin you can become um a high risk for anemia as well this is specific to folate and b12 um if you are a folate deficiency you can have a high risk for neural birth defect so it's important to take um supplementation with vitamins as well as uh foods high in folate via leafy green vegetables now the last prototype drug I will review in this section is feros sulfate this is supplemental iron this is treatment of iron deficiency anemia important focus with this is it can cause constipation you should increase fiber and also uh liquid intakes Also may show the stools as dark even though there is no active blood present if there is blood present it's important to notify the provider but also early on in education educate the patient dark toools are expected for them however they should report any other abnormal symptoms it's important to recognize that iron is the leading cause of fatal poisoning in children as well nurse work with iron deficiencies again focus on uh stools being dark green or black in color this is very concerning for patients if you have gi disturbances uh nausea vomiting you should take this with food um it's important that that pregnant women uh or those with heavy menstrual flow have increased uh vitamin uh iron intake again take with food if you're giving a liquid vitamin you should drink it through a straw to prevent staining of the teeth now anti-platelet drugs plagal or Plavix it's important you understand it inhibits platelet action prevents thite growth it will cause a mild increase in bleeding it's important to recognize if the patient has significant bleeding or bruising they should report this immediately um and these drugs are often used postm anti-coagulants it's important to assess bleeding um risk internal or external bleeding also make sure that you do not give a concurrent anti-coagulant uh together or to pregnant patients the only um type of anti coordinate you can give to a pregnant patient is heprin or low molecular weight heprin um to a specific pregnant patient you should also limit the intake of vitamin K and vitamin K riched Foods because patients will increase clotting with these as well as IM uh limiting the intake of garlic for risk of bleeding failure can be left or right sided it's important you recognize left-sided symptoms would be blood backing up into the lung as previously stated uh signifying a symptom of cough and shortness of breath right sighted heart failure blood back up into the lungs usually into the peripheral vascular system causing peripheral edema