Adams Pharm for Nurses : Ch 24 : Diuretic Therapy & Drugs for Kidney Failure

Which action by the nurse is most important when caring for a patient with chronic kidney disease who has an order for furosemide? -Assess urine output & renal lab values for signs of nephrotoxicity. -Check the specific gravity of the urine daily. -Eliminate potassium-rich foods from the diet. -Encourage the patient to void every 4 hours

-Assess urine output & renal lab values for signs of nephrotoxicity. Rationale: Because the kidneys excrete most drugs, patients with CKD may need a lower dosage of furosemide (Lasix) to prevent further damage to the kidneys. Options 2, 3, and 4 are incorrect. Urine specific gravity will not adequately assess renal status and may be altered by the diuresis secondary to the furosemide. Potassium should be increased when furosemide, a potent loop diuretic, is ordered and not eliminated. If diuresis is occurring, the patient may need to void more often than every 4 hours.

The nurse is providing teaching to a patient who has been prescribed furosemide (Lasix). Which of the following should the nurse teach the patient? 1. Avoid consuming large amounts of kale, cauliflower, or cabbage. 2. Rise slowly from a lying or sitting position to standing. 3. Count the pulse for one full minute before taking this medication. 4. Restrict fluid intake to no more than 1 L per 24-hour period.

2. Rise slowly from a lying or sitting position to standing. Rationale: Loop diuretics such as furosemide (Lasix) may dramatically reduce a patient's circulating blood volume from diuresis and may cause orthostatic hypotension. To minimize the chance for syncope and falls, the patient should be taught to rise slowly from a lying or sitting position to standing. Options 1, 3, and 4 are incorrect. Kale, cauliflower, and cabbage contain vitamin K, which does not need to be restricted during diuretic therapy. Monitoring the pulse along with the blood pressure to assess for reflex tachycardia is advised, but the pulse does not need to be taken for one full minute before taking the drug. Fluids should not be restricted during diuretic therapy unless ordered by the provider.

3. Which of the following clinical manifestations may indicate that the patient taking metolazone (Zaroxolyn) is experiencing hypokalemia? 1. Hypertension 2. Polydipsia 3. Cardiac dysrhythmias 4. Skin rash

3. Cardiac dysrhythmias Rationale: Metolazone (Zaroxolyn) is a thiazide diuretic and causes potassium loss. Signs of hypokalemia include cardiac dysrhythmias, hypotension, dizziness, and syncope. Options 1, 2, and 4 are incorrect. Polydipsia is not associated with hypokalemia. HTN is a clinical indication for the use of diuretics. Skin rashes are an adverse effect of metolazone but are not a symptom of hypokalemia.

The patient admitted for heart failure has been receiving hydrochlorothiazide (Microzide). Which laboratory levels should the nurse carefully monitor? (Select all that apply.) 1. Platelet count 2. White blood cell count 3. Potassium 4. Sodium 5. Uric acid

3. Potassium 4. Sodium 5. Uric acid Rationale: Thiazide diuretics such as hydrochlorothiazide (Microzide) cause loss of sodium and potassium and may cause hyperuricemia. Options 1 and 2 are incorrect. Hydrochlorothiazide does not have a direct effect on blood cells.

While planning for a patient's discharge from the hospital, which teaching points would be included for a patient going home with a prescription for chlorothiazide (Diuril)? 1. Increase fluid and salt intake to make up for the losses caused by the drug. 2. Increase intake of vitamin-C rich foods, such as grapefruit and oranges. 3. Report muscle cramping or weakness to the healthcare provider. 4. Take the drug at night because it may cause drowsiness.

3. Report muscle cramping or weakness to the healthcare provider. Rationale: Muscle cramping or weakness may indicate hypokalemia and should be reported to the healthcare provider. Options 1, 2, and 4 are incorrect. Patients on diuretic therapy are taught to monitor sodium (salt) and water intake to maintain adequate, but not excessive, amounts. Vitamin C-rich foods do not need to be increased while a patient is taking chlorothiazide. The drug should be taken early in the day to avoid nocturia. It does not cause drowsiness.

A patient with a history of heart failure will be started on spironolactone (Aldactone). Which drug group should not be used, or used with extreme caution in patients taking potassium-sparing diuretics? 1. Nonsteroidal anti-inflammatory drugs 2. Corticosteroids 3. Loop diuretics 4. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers

4. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers Rationale: ACE inhibitors and ARBs taken concurrently with potassium-sparing diuretics increase the risk of hyperkalemia. Options 1, 2, and 3 are incorrect. NSAIDs are used cautiously with all diuretics because they are excreted through the kidney. Corticosteroids and loop diuretics may cause hypokalemia and may be paired with a potassium-sparing diuretic to reduce the risk of hypokalemia developing if a diuretic is needed.

A 43-year-old man is diagnosed with HTN following an annual physical examination. The patient is thin and states that he engages in fairly regular exercise, but he describes his job as highly stressful. He also has a positive family history for HTN and stroke. The healthcare provider initiates therapy with hydrochlorothiazide (Microzide). The patient asks the nurse, "I have high blood pressure. Why do I need a 'water pill' to help my blood pressure?" How does hydrochlorothiazide reduce blood pressure?

Hydrochlorothiazide acts on the kidney tubule to decrease the reabsorption of Na+. When hydrochlorothiazide blocks this reabsorption, more Na+ is sent into the urine. When sodium moves across the tubule water flows with it; thus, blood volume decreases and blood pressure falls. Thiazide diuretics are often ordered as a drug of choice in the treatment of HTN.

A 54-year-old female patient has been treated with chlorothiazide (Diuril) for HTN. Due to increasing blood pressure, edema, and signs of early heart failure, the provider switches her to a low dose of furosemide (Lasix) and spironolactone (Aldactone). The patient wants to know why she now needs two diuretics and questions the nurse about whether this is a safe thing to do. How should the nurse respond?

Thiazide diuretics such as chlorothiazide are often used in the treatment of HTN. When the blood pressure is not adequately controlled or signs of heart failure, such as increasing edema or night-time cough indicating pulmonary congestion, develop, a more potent loop diuretic such as furosemide (Lasix) may be ordered to increase diuresis. Because furosemide increases the amount of potassium lost from the body, a K-sparing diuretic such as spironolactone (Aldactone) may be ordered. Giving spironolactone with furosemide enhances diuretic action while limiting potassium loss.

diuretic

agent that increases urine output