Chapter 18: Medications Affecting Urinary Output

Nursing Administration for Osmotic Diuretics

-Ensure clients receive mannitol by continuous IV infusion -Monitor : -daily weights -I&O -serum electrolytes -Monitor for Manifestations of Dehydration and Edema -Obtain Baseline Data: -Orthostatic BP -Weight -Electrolytes -Location and extent of edema -If potassium level is below 3.5, notify HCP, potassium supplement may be needed -Clients should report: -lightheadedness -dizziness -GI distress -general weakness indicative of hypokalemia or hypovolemia -Monitor for increased ICP: -changes in LOC -changes in pupils -headache -nausea -vomiting -Monitor for Manifestations of Metabolic Acidosis -drowsiness -restlessness

Nursing Administration for Loop Diuretics

-Obtain Baseline Data -orthostatic BP -weight -electrolytes -location and extent of edema -Weigh clients at the same time each day with the same amount of clothing and bed linen (if using a bed scale) usually when they awaken -Avoid administering PO diuretics late in the day to avoid nocturia (excessive urination at night) *Usual dosing times are 0800-1400 (8am-2pm) -If Potassium levels drop below 3.5, monitor the ECG, and notify the HCP, client may require a potassium supplement -Instruct clients who are taking diuretics to manage hypertension to self-monitor blood pressure & weight and to keep a log -Client should report: -significant weight loss -lightheadedness -dizziness -GI distress -general weakness *indicative of hypokalemia or hypovolemia -Clients with Diabetes should monitor for elevated blood glucose (Normal 70-200) -Instruct clients to observe for Manifestations of Low Magnesium levels (Normal 1.7-2.2) -weakness -muscle twitching -tremors -Instruct clients to observe for Manifestations of low Calcium levels (Normal 8.5-10.3) -muscle twitching, muscle cramps, tingling in the hands or feet) -Instruct clients to report Manifestations of Ototoxicity: -tinnitus (ringing in the ears) -hearing loss

Nursing Administration for Potassium-sparring Diuretics

-Obtain Baseline data: -Orthostatic BP -Weight -Electrolytes -Location and Extent of Edema -Monitor ECG periodically -Instruct clients to avoid Salt Substitutes that contain Potassium and reduce their intake of Potassium-rich foods : (bananas, citrus fruits, nuts, potatoes, dried fruit, dates) -Instruct clients to self-monitor BP, keep a log of BP and Weight -Warn clients that triamterene can turn urine a bluish color -Client should report : -cramps -diarrhea -thirst -menstrual changes -or deepened voice -Clients should avoid activities that require alertness

Nursing Administration for Thiazide Diuretics

-With the exception of chlorothazide (IV and PO) thiazide diuretics are only for PO administration -Obtain baseline data: -orthostatic BP -weight -electrolytes -location and extent of edema -Instruct clients to take medication first thing in the morning ; for twice-a-day dosing, be sure clients take the second dose by 1400 (2PM) to prevent nocturia -If GI upset occurs, clients should take with or after meals -Alternate-day dosing can decrease the risk of electrolyte imbalances -If Potassium levels drop below 3.5, monitor the ECG, notify HCP as Potassium supplement may be needed -Instruct clients to manage Hypertension to self-monitor BP and weight and keep a log -Instruct clients to report: -dizziness -lightheadedness -significant weight loss -GI distress -general weakness can indicate hypokalemia or hypovolemia -Instruct clients who have Diabetes to monitor for hyperglycemia -Observe of Manifestations of low Magnesium levels (Normal 1.7-2.2) -weakness -muscle twitching -tremors

Medication Interactions associated with Potassium-sparring Diuretics (2)

1) Concurrent use of: -ACE Inhibitors -Angiotensin Receptor Blockers -Direct Renin Inhibitors increases the risk of Hyperkalemia Nursing Actions: -Monitor the client's Potassium levels, Notify the HCP if Potassium is above 5.0 mEq/L -Avoid concurrent use 2) Concurrent use of : -Potassium Supplements -Salt Substitues -Another Potassium-sparring Diuretic increases the risk of Hyperkalemia Nursing Action: Avoid concurrent use

Complications associated with Thiazide Diuretics (4)

1) Dehydration, Hyponatremia Nursing Actions: -Monitor for Manifestations of Dehydration: -dry mouth -excessive thrist -minimal urine output -weight loss -Monitor electrolytes and weight -Report urine output less than 30mL/hr. Withhold medication and notify HCP 2) Hypokalemia and Hypochloremia Nursing Actions: -Monitor Cardiac Status and Potassium levels, especially in clients taking digoxin -Report a decrease in Potassium levels (less than 3.5) Client Education: -Consume foods high in Potassium: -bananas -dried fruit -nuts -potatoes -citrus fruit -Report Manifestations of Hypokalemia : -nausea -vomiting -fatigue -leg cramps -general weakness 3) Hyperglycemia Nursing Actions: Monitor for increase in blood sugar (Normal 70-200mg/dL) 4) Hyperuricemia, Hypomagnesemia, increased LDL Nursing Action: -Monitor: -uric acid -magnesium -LDL & HDL levels Client Education: -Observe for Manifestations of Low Magnesium levels (Normal 1.7-2.2) : -weakness -muscle twitching -tremors

Medication Interactions with Loop Diuretics (4)

1) Digoxin Toxicity (Ventricular Dysrhythmias) can occur in the presence of Hypokalemia -providers sometimes prescribe Potassium-sparring diuretics concurrently with Loop Diuretics to reduce to risk Nursing Actions: -Monitor Cardiac Status and Potassium and Digoxin levels -Administer Potassium supplements when necessary 2) Concurrent use of Antihypertensives can have an additive Hypotensive effect Nursing Actions: -Monitor BP 3) Lithium carbonate levels can increase, which can lead to toxicity, if Hyponatremia occurs due to Loop Diuretics Nursing Actions: -Monitor Lithium levels -Adjustments in dosage may be necessary 4) NSAID's decrease blood flow to the kidneys, which reduces the diuretic effect Nursing Actions: -Watch for a decrease in the effectiveness of the diuretic, such as a decrease in urine output (less than 30mL/hr)

Contraindications and Precautions associated with Potassium-sparring Diuretics (3)

1) Do not administer to clients who have Hyperkalemia or are taking Potassium Supplements or another Potassium-sparring Diuretic 2) Do not administer to clients who have Severe Kidney Failure with Anuria (no urine output) 3) Clients who have kidney or liver disease, electrolyte imbalances, or metabolic acidosis require caution when taking

Contradictions, Precautions, and Medication Interactions associated with Thiazide Diuretics (4)

1) During Pregnancy, thiazide diuretics decrease maternal blood volume and decrease placental perfusion, causing a compromise in the fetal nutrient supply 2) Clients taking a thiazide diuretic should not breastfeed because the diuretic enters the milk and can harm the infant 3) Kidney Impairment is a contraindication 4) Clients who have : -Cardiovascular Disease -Diabetes Mellitus -Hypokalemia -Hyperlipidemia -Hypomagnesemia -Gout require caution as do clients taking: -digoxin -lithium -antihypertensives INTERACTIONS: -Medication and Food interactions are the same for Loop Diuretics -Thiazide Diuretics do not worsen the risk for hearing loss in clients also taking ototoxic medications

Complications associated with Osmotic Diuretics (3)

1) Heart Failure, Pulmonary Edema Nursing Actions: -If Manifestations of HF : -dyspnea -weakness -fatigue -distended neck veins -weight gain develop, withhold the medication immediately and notify the HCP 2) Rebound Increased ICP Nursing Actions: -Monitor for Increased ICP: -change in LOC -change in pupils -headache -nausea -vomiting 3) Fluid and Electrolyte Imbalances, Metabolic Acidosis Nursing Actions: -Monitor Lab Values -Monitor for Manifestations of Metabolic Acidosis : -drowsiness -restlessness

Complications associated with Potassium-sparring Diuretics (3)

1) Hyperkalemia -Ace Inhibitors -Angiotensin Receptor Blockers -Direct Renin Inhibitors require caution in combination because these medications can elevate Potassium levels Nursing Actions: -Monitor Potassium levels. Potassium levels greater than 5 require cardiac monitoring (Normal 3.5-5) -Monitor electrolytes and Manifestations of Hyperkalemia: -weakness -fatigue -dyspnea -dysrhythmias -Treat Hyperkalemia by withholding medication and notifying the HCP, and restricting Potassium in the diet -if necessary, administer a Potassium-Excreting Diuretic -the HCP may also prescribe Glucose and Insulin IV to drive Potassium back into the cell -Do not administer Potassium supplements or other Potassiump-sparring Diuretics in cojunction with Spironolactone (Aldactone) 2) Endocrine Effects Male: Deepened Voice, Impotence (inability to get an erection) Female: Menstrual Irregularities Client Education: Observe for Adverse Effects, notify the HCP if these responses occur 3) Drowsiness, Metabolic Acidosis (Metabolic Acidosis= pH < 7.35, HCO3 < 22) (Normal pH: 7.35-7.45) (Normal HCO3: 22-26) Nursing Actions: Monitor for Manifestations of Metabolic Acidosis : -drowsiness -restlessness Client Education: Avoid activities that require alertness until they know how these medications affect them

Indications for the use of Diuretics (3)

1) Management of Blood Pressure 2) Excretion of edematous fluid due to Heart Failure and/or Kidney/Liver Disease 3) Prevention of Kidney Injury Medications include: -Loop Diuretics -Thiazide Diuretics -Potassium sparing Diuretics -Osmotic Diuretics

Contraindications/Precautions associated with Loop Diuretics (4)

1) Unless absolutely necessary, clients who are Pregnant should NOT take Loop Diuretics 2) Anuria (no urine output) is a contraindication for taking Loop Diuretics 3) Clients who have: -Cardiovascular Disease -Diabetes Mellitus -Dehyrdation -Electrolyte Depletion -Gout (form of arthritis) require caution 4) Clients taking: -digoxin -lithium -ototoxic medications -NSAID's -antihypertensives require caution

Contraindications (5), Precautions (4), and Medication Interactions (2) with Osmotic Diuretics

CONTRAINDICATIONS: 1) Active Intracranial Bleeding 2) Anuria 3) Severe Pulmonary Edema 4) Severe Dehydration 5) Kidney Failure while taking mannitol PRECAUTIONS: 1) Heart Failure 2) Pregnancy or Breastfeeding 3) Kidney Insufficiency 4) Electrolyte Imbalances while taking mannitol MEDICATION INTERACTIONS: 1) Increases Lithium excretion through the kidneys Nursing Action: Monitor Lithium levels 2) Increases the risk of Hypokalemia with Cardiac Glycosides Nursing Actions: Monitor Potassium and ECG

Complications associated with Loop Diuretics (5)

Furosemide (Lasix) Ethacrynic (Edecrin) Bumetanide (Bumex) Torsemide (Demadex) 1) Dehydration, Hyponatremia, Hypochloremia Nursing Actions: -Monitor for Manifestations of Dehydration -dry mouth -increased thirst -minimal urine output -weight loss -Monitor electrolytes -Report urine output less than 30mL/hr and withhold the medication; notify HCP -If Headache or Chest, Calf, or Pelvic Pain occur, notify the HCP, indicative of Thrombosis or Embolism -Get daily weights to detect fluid gains/losses, *Initial low doses help minimize the risk for Dehydration 2) Hypotension Nursing Actions: Monitor BP Client Education: -Manifestations of Postural Hypotension include Headache & Dizziness -Avoid sudden changes in position and arise slowly from lying down or sitting -Elevate the HOB slowly before getting out of bed and walking 3) Ototoxicity (toxic to the ear) Transient (lasting a short time) with furosemide (Lasix) and irreversible with ethacrynic acid (Edecrin) Nursing Actions: Avoid concurrent use of other ototoxic medications, such as Amnioglycoside ABX (gentamycin) Client Education: Notify the HCP of tinnitus (ringing in the ears) indicative of Ototoxicity 4) Hypokalemia : Potassium levels less than 3.5 (Normal Range: 3.5-5.0) Nursing Actions: -Monitor Cardiac status and Potassium Levels -Report Potassium levels below 3.5 Client Education: -Consume high Potassium containing foods : -bananas -potatoes -dried fruits -nuts -spinach -citrus fruits -Manifestations of Hypokalemia: -nausea -vomiting -fatigue -leg cramps -general weakness 5) Other Adverse Effects -Hyperglycemia (Normal 70mg/dL-200mg/dL) -Hyperuricemia (Males: 3.4-7.0 mg/dL) (Females: 2.4-6.0 mg/dL) -Hypocalcemia (Normal 8.5-10.3mg/dL) -Hypomagnesemia (Normal 1.7-2.2mg/dL) -Increases in LDL ("bad cholesterol) levels (Normal less than 130mg/dL) -Decreases in HDL ("good" cholesterol) levels (Males: > 45mg/dL) (Females: > 55mg/dL) Nursing Actions: -Monitor: -Blood Glucose (Normal 70-200mg/dL) -Uric Acid (Males: 3.4-7.0 mg/dL) (Females: 2.4-6.0 mg/dL) -Calcium (Normal 8.5-10.3 mg/dL) -Magnesium (1.7-2.2 mg/dL) -Lipid Levels (HDL Females : greater than 55) (HDL Males : greater than 45) (LDL : less than 130mg/dL) Client Education: -Observe for Manifestations of Low Magnesium Levels : -weakness -muscle twitching -tremors

High Ceiling Loop Diuretics (4)

Furosemide (Lasix) Ethacrynic (Edecrin) Bumetanide (Bumex) Torsemide (Demadex) Routes of Administration: Oral, IV, IM work in the ascending limb of the loop of Henle -blocks reabsorption of sodium and chloride and prevent reabsorption of water -cause extensive diuresis even with severe kidney impairment Therapeutic Uses: -useful when there is an emergent need for rapid mobilization of fluid -Pulmonary Edema due to HF -Conditions that do not respond to other diuretics (edema due to liver, cardiac, or kidney disease, hypertension) Unlabled Use: Hypercalcemia Medication Effectiveness: Indications of effectiveness include the following: -decrease in pulmonary and peripheral edema -weight loss -decrease in blood pressure -increase in urine output -decrease in calcium level

Thiazide Diuretics

Hydrochlorothiazide Chlororthiazide Methyclothiazide Thiazide type Diuretics: -Indapamide -Chlorthaliadone -Metolazone work in the early distal convoluted tubule -blocks the reabsorption of sodium and chloride, and prevents the reabsorption of water at this site -promote diuresis when kidney function is adequate -Thiazide Diuretics are often the medication of First Choice for essential Hypertension -Treat : -Edema from Mild to Moderate Heart Failure and Liver and Kidney Disease -Thiazide Diuretics with Anithypertensives increase Blood Pressure Control -Reduce Urine Production in clients who have Diabetes Insipidus -Promote reabsorption of Calcium and reduce the risk for Postmenopausal Osteoporosis Medication Effectiveness: Indications of effectiveness include the following: -decrease in BP -decrease in edema -increase in urine output -reduced urine output with Diabetes Insipidus -preservation of bone integrity in women who are postmenopausal

Osmotic Diuretics

Mannitol -reduce the ICP and IOP by raising serum osmolality and drawing fluid back into the vascular and extravascular space -Prevents Kidney Failure in specific situations (Hypovolemic Shock, Severe Hypotension) because Mannitol does not undergo reabsorption. Mannitol remains in the nephron, drawing off water, thus preserving urine flow and preventing kidney failure -Decreases ICP due to Cerebral Edema by drawing off fluid from the brain into the bloodstream -Decreases IOP by drawing ocular fluid into the bloodstream -Promotes Sodium retention and water Excretion in clients who have Hyponatremia and Fluid Volume Excess (FVE) -Treats Oliguria (little to no amount of urine) phase in Acute Kidney Injury Medication Effectiveness Indications of effectiveness include the following: -Adequate kidney function: -Urine output at least 30mL/hr -Creatine levels: Males: 0.6-1.3 mg/dL Females: 0.5-1.1 mg/dL -BUN levels 10-20 mg/dL -Decrease in ICP -Decrease in IOP

Potassium-sparring Diuretics

Spironalactone (Aldactone) Triameterene Amiloride Route of Administration: Oral -block the action of Aldosterone (sodium and water retention) which results in potassium retention and the excretion of sodium and water -in combination with other diuretics (Loop, Thiazide) for Potassium-sparring effects treat Hypertension and Edema -Management of HF -Block the action of Aldosterone (sodium and water retention) in primary Hyperaldosteronism by retaining potassium and increasing sodium excretion, causing an opposite effect on the action of aldosterone in the distal nephrons -Therapeutic effects can take 12-48 hrs Medication Effectiveness: Indications of effectiveness include the following: -Potassium levels 3.5-5.0 mEq/L -Weight loss -Decreases in BP and edema