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Pharmacology Chapter 43 - Diuretics

front 1

Diuresis

back 1

Increased urine flow

front 2

Natriuresis

back 2

Sodium loss in the urine

front 3

Diuretics

back 3

Used to decrease hypertension and decrease edema in pts with HF and renal or liver disorders. Diuretics have an antihypertensive effect because they promote sodium and water loss by blocking sodium and chloride reabsorption causing a decrease in fluid volume, lowering BP.

front 4

What categories of diuretics are used to treat HTN and HF?

back 4

  • Thiazide
  • Loop
  • Potassium Sparing

front 5

Thiazide Diuretics

back 5

Promote sodium, chloride, and water excretion. Also can caouse loss of potassium and magnesium, but they promote calcium re-absorption. They are used for patients with NORMAL renal fx. They can be effective as antihypertensives.

front 6

Thiazide Diuretics

Side Effects/Adv. Rxn

back 6

  • Hypercalcemia
  • Hyperglycemia
  • Hypokalemia
  • Hypochloremia
  • Hypomagnesemia
  • Hyperuricemia (elevated uric acid level)
  • Hyperlipidemia (increase LDL, triglycerides)
  • Minimal Bicarbonate loss

Total Cholesterol: <200 mg/dL
LDL: <100mg/dL

front 7

Thiazide Diuretics

Contraindications/Drug Interactions

back 7

Contraindications:

  • Renal Failure
  • Elevated BUN, Creatinine

Drug Interactions:

  • Thiazides can cause hypokalemia which enhances action of Digoxin
  • Thiazides enhance action of lithium

front 8

Thiazide Diuretics

Hydrochlorothiazide (HCT) Prototype p. 623

back 8

All information from the group of Thiazide Diuretics apply to HCT.

HCT has a longer half life than loop diuretics, so it should be given in the morning to avoid nocturia.

Take with food to avoid GI upset

SE: dizziness, nausea, vomiting, constipation, photosensitivity, headache, weakness

front 9

Thiazide Diuretics

Info from Nsg. Process

back 9

  • Obtain drug history: interactions possible with digoxin, corticosteroids, antidiabetics, ginko, licorice
  • Monitor vitals, electrolytes: K, glucose, uric acid, cholesterol levels
  • Slowly change positions to avoid orthostatic hypotension
  • Eat foods rich in potassium. Potassium supplements may be ordered
  • Wear sunblock for photosensitivity

front 10

Loop (High Ceiling) Diuretics

back 10

Loop's promote the loss of Na, K, Ca, Mg, and H2O. They are more potent than thiazides. They are potassium wasting diuretics. Loop's are NOT effective as antihypertensives. Never combine 2 Loop diuretics.

Loop diuretics can be used for patients with decreased renal function.

front 11

Loop (High Ceiling) Diuretics

Side Effects/ Adv. Rxn

back 11

  • Most common are fluid and electrolyte imbalances: hypokalemia, hyponatremia, hypocalcemia, hypomagnesmia, hypochloremia
  • orthostatic hypotension

front 12

Loop (High Ceiling) Diuretics

Drug interactions

back 12

  • Digitalis

front 13

Loop (High Ceiling) Diuretics

furosemide (Lasix) Prototype p. 626

back 13

All information from the group of Loop Diuretics apply to Lasix.

Take early to avoid nocturia. Take with food to avoid GI upset.

Contraindicated: anuria, hypersensitivity to sulfonamides because it's a sulfonamide derivative.

Side Effects: nausea diarrhea, constipation, headache, weakness, photosensitivity, hyperglycemia, HEARING LOSS with too rapid IV administration.

front 14

Loop (High Ceiling) Diuretics

Info from Nsg. Process

back 14

  • Drugs that may interact: alcohol, animoglycosides, anticoagulants, corticosteroids, lithium, digitalis, Coumadin
  • Urinary output should be at least 30 mL/hr
  • Be alert for marked decrease in BP
  • Administer IV Lasix slowly; hearing loss may occur if rapidly injected.

front 15

S/S of Hypokalemia

back 15

  • Muscle weakness
  • ab distension
  • leg cramps
  • cardiac dysrhythmias

front 16

Carbonic Anhydrase Inhibitors

back 16

Used only for patients with open angle glaucoma. It decreases IOP.

This group blocks the action of the enzyme carbonic anhydrase, which is needed to maintain the body's acid base balance, causing increased Na, K, and bicarbonate excretion. With long term use, metabolic ACIDOSIS can occur.

EX:

  • acetazolamide (Diamox)
  • Methazolamide (Neptazane)

front 17

Osmotic Diurectics

back 17

Promote Na, Cl, K, and H2O excretion. Used to prevent kidney failure, to decrease ICP, and to decrease IOP.

Pulmonary edema can occur from rapid shift of fluids.

EX: Mannitol:

Mannitol must be given with extreme caution to pts with heart disease and HF.

front 18

Potassium Sparing Diuretics

back 18

These are weaker than thiazides and loop diuretics. They are used as mild diuretics, or in combo with another diuretic. No potassium supplements are needed. They promote Na and H2O excretion and K retention.

front 19

Potassium Sparing Diuretics

side effects/adv rxn

back 19

  • The main SE is hyperkalemia
  • If given with an ACE inhibitor, hyperkalemia could become severe or life threatening.

front 20

Potassium Sparing Diuretics

spironolactone (Aldactone)

Prototype p. 630

back 20

Action: Blocks the action of aldosterone and inhibits the sodium potassium pump (ie, K is retained and Na is excreted). As a result of the action, the heart rate is MORE REGULAR.

Should not be taken with: ACE inhibitors, ARBs

Can be used in combo with a potassium wasting diuretic to intensify the diuretic effect and prevent K loss.

Give in the morning

SE: nausea, vomiting, diarrhea, dizziness, headache, weakness

front 21

Potassium Sparing Diuretics

Info from Nsg Process

back 21

  • Observe for s/s of hyperkalemia
  • take with food to avoid GI upset
  • if K levels are high advise pt to avoid foods rich in K

front 22

S/S hyperkalemia

back 22

  • Nausea
  • Diarrhea
  • Ab cramping
  • numbness and tingling of the hands and feet
  • Leg cramps
  • Tachycardia and later bradycardia
  • Oliguria

front 23

A patient is taking furosemide (Lasix) 40 mg daily for heart failure and hypertension. It is most important for the nurse to assess the patient for the development of

A.low serum potassium, sodium, and magnesium, and elevated calcium.

B.low serum potassium and sodium and elevated magnesium and calcium.

C.low serum potassium, sodium, magnesium, and calcium.

D.low serum potassium and sodium, with magnesium and calcium remaining normal.

back 23

Answer: C

Rationale: Loop diuretics cause a loss of potassium, sodium, magnesium, and calcium.

front 24

Which statement will the nurse include when teaching a patient about loop (high-ceiling) diuretics?

A.Take the medication at bedtime.

B.Take the medication on an empty stomach.

C.Rise slowly from a lying or sitting to standing position to prevent dizziness.

D.Avoid fruit and vegetables in the diet.

back 24

Answer: C

Rationale: The medication should be taken in the morning, not at bedtime, to prevent sleep disturbances and nocturia; taking the medication at mealtime or with a snack, not on an empty stomach, can prevent nausea from developing, and patients receiving this medication should eat a diet high in fruits and vegetables to prevent hypokalemia.

front 25

A patient is admitted to the intensive care unit with increased intracranial pressure. The nurse would anticipate administering

A.furosemide (Lasix).

B.mannitol (Osmitrol).

C.triamterene (Dyrenium).

D.spironolactone (Aldactone).

back 25

Answer: B

Rationale: Osmotic diuretics such as mannitol (Osmitrol) increase the osmolality and sodium reabsorption in the proximal tubule and loop of Henle. Sodium, chloride, potassium, and water are excreted. This group of drugs is used to prevent kidney failure, to decrease intracranial pressure, and to decrease intraocular pressure. Mannitol is a potent osmotic potassium-wasting diuretic frequently used in emergency situations such as ICP and IOP.

front 26

A patient is receiving furosemide (Lasix). It is most important for the nurse to monitor the patient for the development of

A.hyperkalemia.

B.hypokalemia.

C.hyponatremia.

D.hypernatremia.

back 26

Answer: B

Rationale: Hypokalemia is the most common electrolyte balance associated with furosemide (Lasix) therapy.

front 27

A patient with congestive heart failure gains 5 pounds in 1 week. This most likely indicates a fluid weight gain of

A.½ L.

B.1 L.

C.2 L.

D.3 L.

back 27

Answer: C

Rationale: Weight gain of 2.2 pounds is equivalent to an excess liter of body fluids.

front 28

Before administering triamterene (Dyrenium), it is most important for the nurse to determine if the patient is also receiving

A.digoxin (Lanoxin).

B.potassium chloride (K-Dur).

C.acetaminophen (Tylenol).

D.doxazosin (Cardura).

back 28

Answer: B

Rationale: Triamterene (Dyrenium) is a potassium-sparing diuretic. Potassium supplementation is not indicated unless the patient’s serum potassium level is very low.

front 29

Which statement about aldosterone does the nurse identify as being true? Aldosterone

A.promotes sodium excretion.

B.is a mineralocorticoid hormone.

C.promotes potassium retention.

D.is secreted by the pancreas.

back 29

Answer: B

Rationale: Aldosterone is a mineralocorticoid hormone that promotes sodium retention

front 30

A patient with chronic glaucoma is most likely to receive which drug?

A.A thiazide diuretic

B.A loop diuretic

C.A potassium-sparing diuretic

D.A carbonic anhydrase inhibitor

back 30

Answer: D

Rationale: Carbonic anhydrase inhibitors are primarily used to decrease IOP in patients with open-angle (chronic) glaucoma. Thiazides and loop diuretics are used to treat hypertension and peripheral edema. Potassium-sparing diuretics are used as mild diuretics in combination with other diuretics.

front 31

Which laboratory value will the nurse report to the health care provider as a potential adverse response to hydrochlorothiazide?

  1. Sodium level of 140 mEq/L
  2. Fasting blood glucose level of 140 mg/dL
  3. Calcium level of 9 mg/dL
  4. Chloride level of 100 mEq/L

back 31

2

Hydrochlorothiazide can cause hyperglycemia. Normal calcium level is approximately 8.8-10.3 mg/dL; normal sodium level is 135-147 mEq/L; normal chloride level is 95-107 mEq/L, and normal fasting blood glucose should be 60-110 mg/dL.

front 32

What is the best information for the nurse to provide to the patient who is receiving spironolactone (Aldactone) and furosemide (Lasix) therapy?

  1. “Moderate doses of two different diuretics are more effective than a large dose of one.”
  2. “This combination promotes diuresis but decreases the risk of hypokalemia.”
  3. “This combination prevents dehydration and hypovolemia.”
  4. “Using two drugs increases the osmolality of plasma and the glomerular filtration rate.”

back 32

2

Spironolactone is a potassium-sparing diuretic; furosemide causes potassium loss. Giving these together minimizes electrolyte imbalance. It is not accurate to state that the drug combination prevents dehydration and hypovolemia or that it increases the osmolality of plasma and the glomerular filtration rate. Stating that giving two different diuretics is more effective is not specific enough information for the patient.

front 33

The nurse is assessing a patient who is taking furosemide (Lasix). The patient’s potassium level is 3.4 mEq/L; chloride is 90 mmol/L, and sodium is 140 mEq/L. Based on the nurse’s understanding of the laboratory results, what prescribed therapy can the nurse anticipate administering?

  1. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly.
  2. Administer sodium polystyrene sulfonate.
  3. Administer 2 mEq potassium chloride per kilogram per day IV.
  4. Administer calcium acetate, two tablets three times per day.

back 33

3

Furosemide is a potent loop diuretic, resulting in the loss of potassium as well as water, sodium, and chloride. The patient needs chloride replacement. Normal potassium level is 3.5 to 5.2 mEq/L; normal sodium level is 135 to 147 mEq/L, and normal chloride level is 95 to 107 mEq/L. Potassium is never given by rapid infusion.

front 34

A patient taking spironolactone (Aldactone) has been taught about the medication. Which menu selection indicates that the patient understands teaching related to this medication?

  1. Potatoes
  2. Lima beans
  3. Chicken
  4. Strawberries

back 34

3

Spironolactone is a potassium-sparing diuretic that could potentially cause hyperkalemia. Chicken is the only appropriate choice of the foods listed because it is lower in potassium. Potatoes, lima beans, and strawberries are all known to contain high levels of potassium.

front 35

Which patient would the nurse need to assess first if the patient is receiving mannitol (Osmitrol)?

  1. A 67-year-old patient with type 1 diabetes mellitus
  2. A 21-year-old patient with a head injury
  3. A 47-year-old patient with anuria
  4. A 55-year-old patient receiving cisplatin to treat ovarian cancer

back 35

3

Mannitol (Osmitrol) is not metabolized but excreted unchanged by the kidneys. Potential water intoxication could occur if mannitol is given to a patient with anuria. Mannitol is safe to use with diabetic patients and those with head injuries, and it may function as a nephroprotectant when cisplatin is being used.

front 36

A patient is prescribed chlorthalidone (Thalitone). What is the most important information the nurse will teach the patient?

  1. “Do not drink more than 10 ounces of fluid a day while on this medication.”
  2. “Take this medication on an empty stomach.”
  3. “Take this medication before bed each night.”
  4. “Wear protective clothing and sunscreen while taking this medication.”

back 36

4

Adverse effects associated with chlorthalidone include photosensitivity. The nurse should teach the patient to protect himself when out in the sun. There is no evidence that fluid should be restricted while taking the medication, that it should be taken on an empty stomach, or that it should only be taken at bedtime.

front 37

A patient with acute pulmonary edema is receiving furosemide (Lasix). What assessment finding indicates to the nurse that the intervention is working?

  1. Potassium level decreased from 4.5 to 3.5 mEq/L
  2. Improvement in mental status
  3. Lungs clear
  4. Output 30 mL/hr

back 37

3

Furosemide (Lasix) is a potent, rapid-acting diuretic that would be the drug of choice to treat acute pulmonary edema. Furosemide should not cause a drastic change in output or decrease in potassium level, and there is no evidence that it will create any change in mental status.

front 38

Which assessment indicates to the nurse a therapeutic effect of mannitol (Osmitrol) has been achieved?

  1. Decreased intracranial pressure
  2. Decreased potassium
  3. Increased urine osmolality
  4. Decreased serum osmolality

back 38

1

Mannitol (Osmitrol) is an osmotic diuretic that pulls fluid from extravascular spaces into the bloodstream to be excreted in urine. This will decrease intracranial pressure, increase excretion of medications, decrease urine osmolality, and increase serum osmolality

front 39

What intervention will the nurse perform when monitoring a patient receiving triamterene (Dyrenium)?

  1. Assess urinary output every other day.
  2. Monitor for side effect of hypoglycemia.
  3. Assess potassium levels.
  4. Monitor for hypernatremia.

back 39

3

Triamterene (Dyrenium) is a potassium-sparing diuretic. The nurse should monitor potassium for potential hyperkalemia.

front 40

A patient is ordered furosemide (Lasix) to be given via intravenous push. Which interventions will the nurse perform? (Select all that apply.)

  1. Administer at a rate no faster than 20 mg/min.
  2. Assess lung sounds before and after administration.
  3. Assess blood pressure before and after administration.
  4. Maintain accurate intake and output record.
  5. Monitor ECG continuously.
  6. Insert an arterial line for continuous blood pressure monitoring.

back 40

1 2 3 4

Furosemide (Lasix) can be infused via intravenous push at the rate of 20 mg/min. Furosemide is a diuretic and will decrease fluid in alveoli, and assessing lung sounds can help to determine therapeutic effect. Blood pressure should decrease with the administration of a diuretic. It is appropriate to monitor before and after administration. It is appropriate to monitor intake and output for a patient receiving a diuretic. There is no need to insert an arterial line to continuously monitor the blood pressure since it should not fluctuate that dramatically. Also, there is no need to continuously monitor ECG since the medication is not cardiotoxic.