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To induce sleepiness and amnesia and to relieve apprehension before anesthesia or before and during procedures order sildalist with american express. Infants and children ages 6 months to 5 years or less cooperative purchase sildalist online from canada, older children: 0 order sildalist canada. Additional doses to maintain desired level of sedation may be given by slow titration in increments of 25% of dose used to first reach the sedation end point. Additional doses to maintain desired level of sedation may be given by slow titration in increments of 25% of dose used to first reach the sedative end point. Contraindicated in patients hypersensitive to drug and in those with acute angle-closure glaucoma, shock, coma, or acute alcohol intoxication. Continuously monitor patient, including children taking syrup form, for life-threatening respiratory depression. Available forms: capsules - 10 mg, 25 mg and 50 mg; Injection - 25 mg/ml, and 50 mg/ml; Syrup - 10 mg/5 ml; and tablets - 10 mg, 25 mg, 50 mg, and 100 mg. Nursing Considerations: Anticholinergics may cause additive Anticholinergic effects. May cause false negative skin allergen tests by reducing or inhibiting the cutaneous response to histamine. Elderly patients may be more sensitive to adverse anticholinergic effects: monitor these 44 patients for dizziness, excessive sedation, confusion, hypotension, and syncope. Available in oral solution: 1 mg/ml (concentrate); orally disintegrating tablets: 0. Antiinfective drugs can be divided into those that are bacteriostatic, that is to arrest the multiplication and further development of the infectious agent, or bacteriocidal, which is to kill and thus eradicate all living microorganisms. Both lines of administration and length of therapy may be effective by this difference. Some antiinfectives halt the growth of or eradicate many different microorganisms and are termed broad spectrum antibiotics. Others affect only certain specific organisms and are narrow spectrum antibiotics. Penicillin’s cause more severe and more frequent hypersensitivity reactions than any other drug. Because of differences in susceptibility of infectious agents to antiinfectives, the sensitivity of the microorganism to the drug ordered should be determined before treatment is initiated. Certain antiinfective agents have marked side effects, some of the more serious of which are neurotoxicity, ototoxcicity, and nephrotoxicity. Care must be taken not to administer two antiinfectives with similar side effects concomitantly, or to administer these drugs to patients in whom side effects might be damaging (a nephrotoxic drug to a patient suffering from kidney disease). Inhibition of synthesis or activation of enzymes that disrupt bacterial cell walls leading to loss of viability and possibly cell lysis. Direct effect on the microbial cell membrane to affect permeability and leading to leakage of intracellular components. Effect on the function of bacterial ribosomes to cause a reversible inhibition of protein synthesis. Bind to the ribosomal subunit that alters protein synthesis and leads to cell death. Anti-metabolites that block specific metabolic steps essential to the life of 49 the microorganism. The choice of the antiinfectives depends on the nature of the illness to be treated, the sensitivity of the infecting agent, and the patient’s previous experience with the drug. Hypersensitivity and allergic reactions may preclude the use of the agent of choice. Side Effects The antibiotics and antiinfective agents have few direct toxic effects. Kidney and liver damage, deafness, and blood dyscrasias are occasionally observed. Suppression of the normal flora of the body, which in turn keeps certain pathogenic micro organisms such as Candida albicans, Proteus, or Pseudomonas, from causing infections. Incomplete eradication of an infectious organism, casual use of anti infectives favors the emergence of restraint strains insensitive to a particular drug. To minimize the chances for the development of restraint strains, anti infectives are usually given at specific doses for a prescribed length of time after acute symptoms has subsided. Hemodialysis may be used although its effectiveness is questionable, depending on the drug and the status of the patient (more effective in impaired renal function). Laboratory Test Consideration The bacteriologic sensitivity of the infectious organisms to the antiinfective (especially the antibiotic) should be tested by the lab before initiation of therapy and during treatment. Complete infusion (or as ordered) before the drug loses potency, check drug access. Document onset and characteristics of symptoms, location and source of infection (if known). Note any unusual reaction/sensitivity with any antiinfectives (usually penicillin). Assess for hives, rashes, or difficulty breathing, which may indicate a hypersensitivity or allergic response. Nephrotoxic drugs are usually contraindicated with renal dysfunction because toxic drug levels are rapidly attained. Verify orders when two or more antiinfectives are ordered for the same patient, especially if they have similar side effects such as nephrotoxicity and/or neurotoxicity. Assess for superinfections, particularly of fungal origin, characterized by black furry tongue, nausea, and/or diarrhea. Washing hands carefully before and after contact with the patient, providing/emphasizing good hygiene, washing hands carefully 51 before and after contact with the patient. Schedule administration throughout 24 - hour period to maintain therapy drug levels. Administration schedule is determined by the drug halflife, severity of infection, evidence or organ dysfunction, and patient’s need for sleep. Assess drug levels (peak and throph) to determine dosing and to assess adequacy of levels. This ensures that the organism is eradicated and diminishes the emergence of drug resistant bacterial strains. Incomplete therapy and indiscriminate use may render patient unresponsive to the antibiotic with the next infection. Report any unusual bleeding or bruising (bleeding gums, blood in stool, urine, or other secretions) signs and symptoms of allergic reactions including rash, fever, itching, hives, or super infections, such as pain, swelling, redness, drainage, perineal itching, diarrhea or a change in signs or symptoms. This is often accomplished by selective depression of hyperactive areas of the brain responsible for the convulsions.

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Try to identify if there was a story or emotion present just prior to the physical sensation cheap sildalist online. In the previous Ychapters you’ve discovered that: • You normally are not aware of many of your thoughts buy sildalist online. Having a good understanding of your own mind and stress-response is a great start order 120 mg sildalist visa, but there are many additional ways of trying to deal with stress. In this chapter, I’m going to outline the technique of mindfulness, which you can use to reduce your day-to-day stress. It’s an accepting, non-judgmental and compassionate awareness of what’s going on right at this moment in time. When practicing mindfulness, you bring your attention to the present moment without trying to change it. It’s an absolutely wonderful break for both your mind and your body to focus on the present moment in this way. You normally identify and react to the thoughts that come up in your conscious mind. You might grab onto a thought and expand it, resist it, or deny it, or simply let it pass by as a neutral sensation. Often, especially during times of stress, your thoughts are worries about the past as well as worries about what might happen in the future. This allows you to change the way you relate to your mental, emotional and physical experiences. By mentally creating a bit of breathing space, you don’t have to unconsciously react to whatever arises and you can experience the events in your life from a place of greater clarity and wisdom. By practicing the techniques of mindfulness, you’ll be better able to consciously respond to situations and you will not just automatically react to things in accordance with the long established patterns of your belief system. In this and subsequent chapters, you’ll learn to be present only to what’s happening in this very moment. You’ll be less powerless in the face of the chain of events that links thoughts, Mindfulness: A Technique to Deal with Stress • 43 to stories, to emotions, to body sensations, to reactions. The practice of mindfulness is a wonderfully liberating process that can free you from the tyranny of your own mind. There is inherent wisdom, peace, understanding, empathy and compassion that reside within the silence of awareness and acceptance. Think about whether you have ever personally experienced any of the following scenarios: • Have you ever reacted to a thought with a sudden, extreme, uncontrolled emotional response? These are the types of thought activity that you’ll experience without the clarity that mindfulness brings. Mindfulness and Awareness The first important step in the practice of mindfulness is to intentionally be aware (i. You’ve already been practicing a version of this in some of the previous exercises that I’ve asked you to try. Without this awareness, you’re not conscious of the multiple sensations that are driving your behaviour. You’re just swept along in the tidal wave of anger, sadness, judgment, happiness or whatever strong sensation arises. The problem is that you immediately identify with the thought, emotion, or physical sensation that arises. Mindfulness helps you to begin to recognize that you’re constantly being exposed to multiple sensations but are often unaware of them and how they may be influencing you. It’s an excellent alternative to allowing yourself to be absorbed in your own thoughts. You can bring awareness to what you’re thinking, what you’re feeling and what you’re physically experiencing in the present moment. The log moves according to the flow of the river, being pushed and pulled depending on the water flow. You can experience the flow of the river but you’re separate from it and you have the ability to control your movements as well. This next exercise will help you learn to become aware of what you’re experiencing on a continual basis. If a thought appears, the moment you recognize it, just say, “thinking” to yourself. Close your eyes, notice your sensations and as you do, name them as “thinking,” H “ feeling,” or “body sensation. This exercise is a way of cultivating your awareness but at the same time distancing yourself from the meaning that you would Mindfulness: A Technique to Deal with Stress • 45 normally attach to your thoughts and feelings. Just acknowledge this by saying, “thinking” and return to monitoring and labeling your experiences. What normally happens is that when an emotion such as anger, sadness, suffering, or joy arises, there is no awareness about what’s happening. You identify so strongly with the emotion that you become the emotional state itself, instead of recognizing that it’s just a state of mind that has arisen. For example, if you’re angry, this could actually reflect an underlying fear that you have, which is, in turn, based on previous experiences. This time, when a thought, feeling or physical sensation pops up, I want you to go a bit further with your labeling and actually try to name the experience. You’re trying to become more specific about each experience, rather than just generically noting the labels: “thinking,” “ feeling,” and “body sensation. Close your eyes, notice your sensations and label them specifically, H and then return to the text. Your mind was too busy noticing itself and your body to be engaged in the, often artificial, manufacture of stressful thoughts. Short Circuiting Judgments and Encouraging Acceptance With mindfulness, the goal is to take note of an experience for what it is without any further judgment and without the need to change what’s happening. Ideally there’s no layering over the experience with further, personal, biased perspectives. These biased perspectives lead to either a desire for, or a rejection of, what you’re currently experiencing. Remember that your normal response to an experience is to have an initial judgment of the event. Rather than just accepting this reaction, you tend to amplify it and judge yourself even further. When Mika’s on a diet and has some ice cream, she feels bad that she gave in to her cravings. Next, she makes the judgment that she’s always making these mistakes, and her pattern of thoughts leads right into her habitual story about how she’s hopeless and so fat that no one could ever love her.

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B When patient serum is available order discount sildalist on line, it will be Blood bank/Apply knowledge of laboratory crossmatched with donor cells order 120 mg sildalist. Patient serum might operations/Crossmatch/3 contain antibodies against antigens on donor cells 2 sildalist 120mgmg with visa. C A minor crossmatch consists of recipient red cells and explanation for these results? High-frequency alloantibody or a mixture of sample within 3 days of the scheduled transfusion; alloantibodies however, if the patient is pregnant or was transfused C. Donor plasma and donor red cells Blood bank/Apply knowledge of laboratory operations/ Crossmatch/1 140 4. Critical elements of the system have been Blood bank/Apply principles of basic laboratory validated on site procedures/Crossmatch/2 D. A technologist removed 4 units of blood from the blood bank refrigerator and placed them on the 7. B An O-negative individual has both anti-A and anti-B noticed that one of the units was leaking onto the and may receive only O-negative red cells. D Compatibility testing would not be affected if the procedures/Crossmatch/3 donor has anti-K in his or her serum. A donor was found to contain anti-K using pilot the major crossmatch uses recipient serum and not tubes from the collection procedure. Compatibility testing would not be affected would react with screening cells and most donor units. The negative autocontrol rules out Blood bank/Apply principles of basic laboratory autoantibodies. Anti-H and anti-S are cold antibodies procedures/Crossmatch/2 a and anti-Kp is a low-frequency alloantibody. Te unit may be labeled indicating it contains Blood bank/Evaluate laboratory data to make antibody and released into inventory identifications/Incompatible crossmatch/3 Blood bank/Apply knowledge of laboratory operations/ Hemotherapy/Blood components/1 14. Given a situation where screening cells, major recipient’s antibody screen is negative. Selected cell panel Blood bank/Evaluate laboratory data to make Blood bank/Apply principles of special procedures/ identifications/Incompatible crossmatch/3 Incompatible crossmatch/3 15. Antigen type the unit for high-frequency negative autocontrol rules out autoantibodies and antigens abnormal protein. Perform a panel on the incompatible unit coating the red cells, or the patient may have an alloantibody to a low-frequency antigen. An Blood bank/Apply principles of special procedures/ alloantibody to a high-frequency antigen would Incompatible crossmatch/3 agglutinate all units and screening cells. A The incompatible unit may have red cells coated autocontrol are positive in all phases. Cold and warm alloantibody mixture would cause antibody screen, crossmatch, and Blood bank/Evaluate laboratory data to make patient autocontrol to be positive. Alloantibodies identifications/Incompatible crossmatch/3 would not cause a positive patient autocontrol. What is the first step in a major confirms the antibody identification; antigen typing crossmatch? D The unit may be used in the general blood inventory, be crossmatched if it is properly labeled and only cellular elements C. An eluate Blood bank/Apply principles of special procedures/ would be helpful to remove the antibody, followed Incompatible crossmatch/2 by a cell panel in order to identify it. What corrective action should be taken when blood rouleaux causes positive test results? How long must a recipient sample be kept in the blood bank following compatibility testing? Perform a reverse grouping on donor plasma must be kept for 7 days following compatibility B. All of these options albeit in small amounts, in B-positive and O-positive Blood bank/Apply principles of basic laboratory units. B The abbreviated crossmatch usually consists of a type and screen and an immediate spin crossmatch. When a patient has not been transfused in the past 3 months Blood bank/Apply principles of basic laboratory procedures/Crossmatch/1 4. Check for a clerical error(s) biological characteristics/Transfusion reactions/1 C. B Over 90% of transfusion reactions are due to some Blood bank/Apply knowledge of standard operating type of clerical error. The most time-saving approach procedures/Transfusion reactions/2 would be to check all paperwork before performing any laboratory testing. What is the pathophysiological cause surrounding anaphylactic and anaphylactoid reactions? Antibody in patient serum is detected 3–7 days severe form of allergic transfusion reaction and are after transfusion, and is attached to donor red associated with deficient or absent IgA in the blood cells patients, allowing them the capability to form anti- B. These patients must be transfused with washed combine with allergens in patient plasma cellular products where the plasma has been C. B A transfusion reaction that occurs several days after a pregnancy transfusion of blood products is probably a delayed D. Patient is deficient in IgA and develops IgA immunologic reaction due to an antibody formed antibodies via sensitization from transfusion or against donor antigens. This is a classic example of a pregnancy reaction caused by an antibody such as anti-Jka. A patient has a hemolytic reaction to blood react with patient granulocytes and cause acute transfused 8 days ago. A 68-year-old female diagnosed with neutropenia 1% of all transfusions, results in a temperature and inflammation of the left hand was typed as A rise of 1°C or higher, is associated with blood positive, and received 1 packed red blood cell unit. Delayed hemolytic biological characteristics/Transfusion reactions/2 Blood bank/Correlation of laboratory and clinical 7. Two days later, he developed a Answers to Questions 5–9 fever and appeared jaundiced. Te donor cells were likely positive for the Jkb where the patient was most likely exposed to the antigen b Jk antigen at some point in his life, and upon D. Te recipient cells were likely positive for the Jkb re-exposure to the antigen, the antibody titer rose antigen to detectable levels. Panel on pre- and post-transfusion samples the urinalysis, microscopic red cells were also found. A febrile nonhemolytic reaction is highly consistent with both symptoms and post- transfusion test results. B negative and transfused 1 unit of packed red He had a 20-year history of head trauma and was blood cells, also B negative.

The nurse also periodically assesses the patient for increased tenderness and rigidity of the abdomen order 120mg sildalist amex. The nurse instructs the patient and family to report to the surgeon any change in the color of stools buy sildalist cheap online, because this may indicate complications purchase generic sildalist pills. Gastrointestinal symptoms, although not common, may occur with manipulation of the intestines during surgery. After laparoscopic cholecystectomy, the nurse assesses the patient for loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. These may indicate infection or disruption of the gastrointestinal tract and should be reported to the surgeon promptly. Because the patient is discharged soon after laparoscopic surgery, the patient and family are instructed verbally and in writing about the importance of reporting these symptoms promptly. Promoting Home and Community-Based Care Teaching Patients Self-Care The nurse instructs the patient about the medications that are prescribed (vitamins, anticholinergics, and antispasmodics) and their actions. It also is important to inform the patient and family about symptoms that should be reported to the physician, including jaundice, dark urine, pale-colored stools, pruritus, and signs of inflammation and infection, such as pain or fever. This is the result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months. If a patient is discharged from the hospital with a drainage tube still in place, the patient and family need instructions about its management. The nurse instructs them in proper care of the drainage tube and the importance of reporting to the surgeon 95 promptly any changes in the amount or characteristics of drainage. Managing Pain You may experience pain or discomfort in your right shoulder from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair, walking, or use of a heating pad may ease the discomfort. Managing Follow-Up Care Make an appointment with your surgeon for 7 to 10 days after discharge. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. In addition, fat breakdown occurs, resulting in an increased production of ketone bodies, which are the byproducts of fat breakdown. Type 2 Diabetes Mellitus • Accounts for 90% of patients with diabetes • Usually occurs in people over 40 years of age • 80-90% of patients are overweight Etiology and Pathophysiology • Pancreas continues to produce some endogenous insulin • Insulin produced is either insufficient or poorly utilized by the tissues • Insulin resistance –Body tissues do not respond to insulin –Results in hyperglycemia • Inappropriate glucose production by the liver –Not considered a primary factor in the development of type 2 diabetes Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises, and type 2 diabetes develops. One consequence of undetected diabetes is that long-term diabetes complications (eg, eye disease, peripheral neuropathy, peripheral vascular disease) may have developed before the actual diagnosis of diabetes is made Etiology (not well know) –Genetic factors –Increased weight. Secondary Diabetes • Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels –Cushing syndrome –Hyperthyroidism –Parenteral nutrition Clinical Manifestations Diabetes Mellitus • Polyuria • Polydipsia (excessive thirst) • Polyphagia • In Type I –Weight loss –Ketoacidosis Polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. Plasma glucose values are 10% to 15% higher than whole blood glucose 103 values, and it is crucial for patients with diabetes to know whether their monitor and strips provide whole blood or plasma results Assessing the Patient with Diabetes • History: Symptoms related to the diagnosis of diabetes: Symptoms of hyperglycemia Symptoms of hypoglycemia Frequency, timing, severity, and resolution Results of blood glucose monitoring Status, symptoms, and management of chronic complications of diabetes: Eye; kidney; nerve; genitourinary and sexual, bladder, and gastrointestinal Cardiac; peripheral vascular; foot complications associated with diabetes Adherence to/ability to follow prescribed dietary management plan Adherence to prescribed exercise regimen Adherence to/ability to follow prescribed pharmacologic treatment (insulin or oral antidiabetic agents) Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment Effects of diabetes or its complications on functional status (eg, mobility, vision) Physical examination Blood pressure (sitting and standing to detect orthostatic changes) Body mass index (height and weight) Fundoscopic examination and visual acuity Foot examination (lesions, signs of infection, pulses) Skin examination (lesions and insulin-injection sites) Neurologic examination Vibratory and sensory examination using monofilament Deep tendon reflexes Oral examination • Laboratory Examination • Need for Referrals 104 105 Diabetes Mellitus Collaborative Care • Goals of diabetes management: –Reduce symptoms –Promote well-being –Prevent acute complications –Delay onset and progression of long-term complications Nutritional Therapy –Overall objectives • Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control • Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease. Nutrition, meal planning, and weight control are the foundation of diabetes management. Alcohol may decrease the normal physiologic reactions in the body that produce glucose (gluconeogenesis). These effects are useful in diabetes in relation to losing weight, easing stress, and maintaining a feeling of well-being. Exercise also alters blood lipid concentrations, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels. Exercise/ Precautions • Don‘t exercise if blood glucose > 250 mg/dL or if there is ketone bodies in the urine. The liver then releases more glucose, and the result is an increase in the blood glucose level –Several small carbohydrate snacks can be taken to prevent hypoglycemia • Before exercising • At the end of the exercise with strenuous exercise • At the time with strenuous exercise • Deduce them from total daily calories –May need to reduce inlsulin dose The physiologic decrease in circulating insulin that normally occurs with exercise cannot occur in patients treated with insulin. Initially, patients who require insulin should be taught to eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex carbohydrates with a protein before engaging in moderate exercise, to prevent unexpected hypoglycemia. Drug Therapy: Insulin • Exogenous insulin: –Required for type 1 diabetes –Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means • Types of insulin –Human insulin • Most widely used type of insulin • Cost-effective ¯ Likelihood of allergic reaction Human insulin preparations have a shorter duration of action than insulin from animal sources because the presence of animal proteins triggers an immune response that results in the binding of animal insulin, which slows its availability. Names include Humulin N, Novolin N, Humulin L, Novolin L –Long-acting: Ultralente, Lantus Onset 6-8h, peak 12-16 h and lasts 20-30h. When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives). The treatment is desensitization, with small doses of insulin administered in gradually increasing amounts. Lipodystrophy refers to a localized reaction, in the form of either lipoatrophy or lipohypertrophy, occurring at the site of insulin injections. Lipoatrophy is loss of subcutaneous fat; it appears as slight dimpling or more serious pitting of subcutaneous fat. Resistance to Injected Insulin –Most patients have some degree of insulin resistance at one time or another. Simple pathophysiology –Basic definition of diabetes (having a high blood glucose level) –Normal blood glucose ranges –Effect of insulin and exercise (decrease glucose) –Effect of food and stress, including illness and infections (increase glucose) –Basic treatment approaches 2. Treatment modalities –Administration of medications –Meal planning (food groups, timing of meals) 116 –Monitoring of blood glucose and urine ketones 3. Recognition, treatment, and prevention of acute complications –Hypoglycemia –Hyperglycemia 4. Pragmatic information –Where to buy and store insulin, syringes, and glucose monitoring supplies –When and how to contact the physician Diabetes Mellitus Patient education • Planning In-Depth and Continuing Education –Foot care –Eye care –General hygiene (eg, skin care, oral hygiene) –Risk factor management (eg, control of blood pressure and blood lipid levels, normalizing blood glucose levels) Diabetes Mellitus Misconceptions Related to Insulin Treatment 1. Once insulin injections are started (for treatment of type 2 diabetes), they can never be discontinued 2. If increasing doses of insulin are needed to control the blood glucose, the diabetes must be getting ―worse‖ 3. There is extreme danger in injecting insulin if there are any air bubbles in the syringe 6. Conversely, patients who frequently have a glucose level in the low range of normal (eg, 80 to 100 mg/dL) may be asymptomatic when the blood glucose falls slowly to less than 50 mg/dL. Macrovascular Complications • Macrocirculation –Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. Therefore, diabetes itself is seen as an independent risk factor for accelerated atherosclerosis. Other potential factors that may play a role in diabetes-related atherosclerosis include platelet and clotting factor abnormalities, decreased flexibility of red blood cells, decreased oxygen release, changes in the arterial wall related to hyperglycemia, and possibly hyperinsulinemia. Management of Macrovascualr changes • Prevention and treatment of risk factors for atherosclerosis. A vitrectomy is a surgical procedure in which vitreous humor filled with blood or fibrous tissue is removed with a special drill-like instrument and replaced with saline or another liquid. As renal failure progresses, the catabolism (breakdown) of both exogenous and endogenous insulin decreases, and frequent hypoglycemic episodes may result.