module - 3 Diuretics

Potassium-Sparing Diuretics - indications

Adjuncts with *thiazide or loop diuretics* Patients who are at *risk for hypokalemia*

Osmotic Diuretics - actions

used for *emergency situation* Pull water into the renal tubule *without sodium loss* Used a lot in drug overdoses and in the ICU

Potassium-Sparing Diuretics

Caution - Pregnancy and lactation Adverse Effects - *Hyperkalemia*

Loop Diuretics - Indications

*Acute CHF* *Acute pulmonary edema* Edema associated with CHF Edema associated with renal or liver disease Hypertension

Loop Diuretics

*Furosemide (Lasix)* body fluids out 20pound a day. - *Most commonly used*; less powerful than new drugs; larger margin of *safety for home use* Bumetanide (Bumex) and Torsemide (Demadex) - New drugs; more powerful than Lasix Ethacrynic acid (Edecrin) - First loop diuretic introduced, used less frequently in the clinical setting Tend to be the most potent diuretic and it causes patients to pee a lot Can lose 20 IB in a day if you have severe diuretic Pg. 889 If they have *renal failure* then loop diuretics *don't work*

Osmotic Diuretics - indications

*Increased cranial pressure* or *acute renal failure due to shock*, *drug overdose*, or trauma

Diastolic dysfunction

*Left sided heart failure* Ventricle unable to fill with blood Symptoms: pulmonary congestion, pulmonary edema

Indications for Diuretic Use

*Liver disease* (including cirrhosis<간경변>) *Renal disease* Hypertension Conditions that cause *hyperkalemia*

Systolic dysfunction

*Right Sided heart failure* Heart lacks force to pump all the blood needed Symptoms: decreased exercise tolerance, poor peripheral tissue perfusion

A patient has been placed on a loop diuretic to reduce the fluid that has been accumulating in the lungs. Which statement made by the patient indicates a need for further teaching about the medication by the nurse? "I'll be sure to take my medication with supper." "I'll have a banana with my breakfast every morning." "I'll weigh myself each day before breakfast." "If my shortness of breath returns, I'll contact my physician."

A

What is the action of thiazide diuretics? Select all that apply: A. Blocks the chloride pump B. Blocks the sodium pump C. Blocks the potassium pump D. Blocks the carbonic anhydrase pump

A

F -because of the potential for adverse effects on fluid and electrolyte changes in the fetus and the baby.

A breast-feeding mother who needs a diuretic may continue to breast-feed with taking the thiazide diuretic chlorothiazide (Diuril).

Carbonic Anhydrase Inhibitors - Indications

Adjuncts to other diuretics *Glaucoma*

Loop Diuretics - Contraindications

Allergy Electrolyte depletion *Anuria*(not peeing at all) *Severe renal failure* Hepatic coma(coma that can occur in severe cases of liver disease) Pregnancy and lactation

Potassium-Sparing Diuretics - Contraindications

Allergy Hyperkalemia, renal disease, or anuria Patients taking amiloride or triamterene *The diuretic effect decreases if taken with salicylates*

Thiazide and Thiazide-Like Diuretics - Contraindications

Allergy to thiazides or *sulfonamides* Fluid and electrolyte imbalances, and renal and liver disease *Bipolar disorders* : Because it is a drug-drug interactions with bipolar drugs Pregnancy and lactation

Carbonic Anhydrase Inhibitors -Contraindications

Allergy—to drug or *sulfa* drugs Angle closure glaucoma

A patient has presented to the emergency department reporting feeling short of breath. What other symptom alerts the nurse that the patient may be in heart failure? Lungs clear to auscultation 2+ ankle edema BP 118/74 mm Hg Stable weight

B

The use of diuretics in the treatment of heart failure may lead to what condition? Fluid retention Hypotension Hyperglycemia Diarrhea

B

Loop Diuretics - Actions

Block the *chloride pump* in the *ascending loop of Henle* This causes a decrease in reabsorption of sodium and chloride

Carbonic Anhydrase Inhibitors - Actions

Block the effects of carbonic anhydrase; *slow down* the movement of *hydrogen ions* *More sodium* and *bicarbonate* are *lost* in the urine

Pathogenesis(병의 발생) of Heart Failure

Body compensates for inadequate cardiac output - Releases epinephrine and norepinephrine - RAAS(renin-angiotensin-aldosterone system) stimulates renal distal tubule to retain sodium and water - Increases production of vasopressin(Antidiuretic hormone) - Kidneys increase sodium reabsorption, increasing blood volume, causing increased pressure within capillaries, resulting in edema formation RAAS Helps regulate long term blood volume and BP in the body

A patient has been recently diagnosed with heart failure due to systolic dysfunction. She asks the nurse to explain the disease process to family members. The best explanation is: "The heart rate is failing to keep up with the body's needs." "The patient has developed dysrhythmias that have failed to respond to medication." "The heart does not have adequate force to pump all needed blood." "The left ventricle fails to relax enough between beats to fill with blood."

C

Potassium-Sparing Diuretics - action

Cause a loss of sodium while retaining potassium *Block* the actions of *aldosterone* in the *distal tubule*

Heart Failure

Cluster of signs/symptoms that arise when the ventricles (left, right, or both) lose ability to pump enough blood to meet body's needs

How do carbonic anhydrase inhibitors work? A. Slow down the reabsorption of sodium B. Speeds up creation of sodium bicarbonate C. Balances acidic and alkaline solutes in urine D. Slows down the movement of hydrogen ions

D

Which is a common finding with combination diuretic products? They are a part of the initial diuretic therapy. They increase the risk of hypokalemia. Little follow-up is needed after the initial treatment. They increase the risk of hyperkalemia and hyponatremia.

D

Function of Diuretic Agents

Edema associated with congestive heart failure Acute pulmonary edema

Nursing Assessment for Hydration Status

Evaluate for dehydration: skin turgor, oral mucous membranes Monitor laboratory values for changes Evaluate location of edema, signs of reduction Obtain daily weights - *Include this in discharge teaching* Measure *intake and output* - Should tell the nurse if they are *gaining more than 2 pounds in 2 days*

The loop diuretics cause the body to excrete a copious amount of potassium-rich urine.

False

F -decrease their fluid intake in order to decrease the number of trips to the bathroom. The result is a rebound of water retention after the diuretic effect.

Fluid rebound occurs when patients taking diuretics increase their fluid intake in response to an increased thirst sensation.

Osmotic Diuretics - Pharmacokinetics

Freely filtered at the renal glomerulus, poorly reabsorbed by the renal tubule Not secreted by the tubule Resistant to metabolism

Thiazide and Thiazide-Like Diuretics - Caution

Gout(a painful inflammation of the big toe and foot caused by defects in uric acid metabolism resulting in deposits of the acid and its salts in the blood and joints) Systemic lupus(any of several forms of ulcerative skin disease) Diabetes—May need to *increase their insulin dose* *Hyperparathyroidism*

Thiazide and Thiazide-Like Diuretics - Actions

Helps to decrease blood pressure : 1. Used when lifestyle changes do not help 2. *Begin* hypertension therapy with *Thiazide diuretic* Keeps *chloride* and the *sodium* in the tubule to be *excreted in the urine*, thus preventing the reabsorption of both in the vascular system

Loop Diuretics - Caution

SLE(Systemic lupus erythematosus) , gout, and diabetes mellitus

Carbonic Anhydrase Inhibitors -Caution

Lactation Fluid or electrolyte imbalances Renal or hepatic disease *Adrenocortical insufficiency* *Respiratory acidosis* *COPD*

T - acute HF, acute pulmonary edema, edema associated with HF or with renal or liver disease, and hypertension.

Loop diuretics, like furosemide (Lasix), are the drugs of choice for treating patients with pulmonary edema.

Nursing Process Implementation(while in the hospital)

Measure and record *intake and output* Restricted *sodium diet* Potassium intake depends on type of diuretic prescribed Keep urinal or bedpan available

Loop Diuretics - Pharmacokinetics

Metabolized and excreted primarily through the urine

T - block the chloride pump and excrete sodium in urine

Patients receiving loop diuretics should have regular blood work to monitor sodium levels.

Carbonic Anhydrase Inhibitors - Pharmacokinetics

Rapidly absorbed and widely distributed Excreted in the urine

Carbonic Anhydrase Inhibitors - Adverse Effects

Related to disturbances in acid and base balance and electrolyte balances *Metabolic acidosis* Hypokalemia Paresthesias of extremities, *confusion*, *drowsiness*

Thiazide and Thiazide-Like Diuretics - Adverse Effects

Related to interference with the normal regulatory mechanisms of the nephron *Hypokalemia* : *check the BP and potassium level* Lithium *Decreased calcium excretion* Altered blood *glucose levels* Urine will be slightly *alkalinized*

Osmotic Diuretics - Adverse Effects

Related to sudden drop in fluid levels Nausea, vomiting, *hypotension, light-headedness*(멍함), confusion, and headache

Loop Diuretics - Adverse Effects

Related to the imbalance in electrolytes and fluid *Hypokalemia* *Alkalosis*—can cause muscle cramping/weakness Decreased acid, too much base *Hypocalcemia*

Osmotic Diuretics - Contraindications

Renal disease and anuria *Pulmonary congestion* *Intracranial bleeding*, *dehydration* CHF

True

Spironolactone's (Aldactone's) potassium-sparing action makes it the drug of choice for treating hyperaldosteronism.

Classes of Diuretics

Thiazide and Thiazide-like Diuretics Loop Diuretics Carbonic Anhydrase Inhibitors Potassium-Sparing Diuretics Osmotic Diuretics

Thiazide and Thiazide-like Diuretics - Indications

Treatment of edema associated with *CHF, liver, or renal disease* Monotherapy or adjuncts(부속물) for the treatment of hypertension

Thiazide and Thiazide-Like Diuretics - Pharmacokinetics

Well absorbed for the GI tract, metabolized in the liver and excreted in the urine.

Potassium-Sparing Diuretics - Pharmacokinetics

Well absorbed, protein bound, and widely distributed Metabolized in the liver and excreted in the urine