Week 9: Chapter 51 Diuretic Agents

Indications for Diuretic Use

-Edema associated with congestive heart failure -Acute pulmonary edema -Liver disease (including cirrhosis) -Renal disease -Hypertension -Cirrhosis -Used sometimes to decrease fluid pressure in the eye (glaucoma) -Conditions that cause hyperkalemia

Pharmacokinetics of Osmotic Diuretics

-IV meds -freely filtered at the renal glomerulus, not secreted by the tubule, resistant to metabolism

Prototype Potassium-Sparing Diuretic: Spironactolone

-used for primary hyperaldosteronism, edema w/ HF esp as an adjunct, hypokalemia, nephrotic syndrome, hepatic cirrhosis, essential HTN -blocking the effects of aldosterone in renal tubule, causes a loss of sodium and water and retention of potassium -Adverse effects: dizziness, drowsiness, H/A, diarrhea, hyperkalemia, hirsutism, gynecomastia, deepening of voice, irregular menses -slow onset of action (1-2 days)

Indications for Osmotic Diuretics

-used in emergency situations -indicated for increased cranial pressure, acute renal failure due to shock, drug overdose or trauma

Your patient is prescribed hydrochlorothiazide. The patient's potassium level is 2 mEq/L. What medication below should the nurse hold and notify the physician for further orders? A. Dilantin B. Digoxin C. Warfarin D. Lithium

B. Digoxin

What conditions below are potassium-sparing diuretics ordered to treat? Select all that apply: A. Edema due to renal failure B. Hyperaldosteronism C. Hypertension D. Hypokalemia secondary to loop or thiazide diuretic usage

B. Hyperaldosteronism C. Hypertension D. Hypokalemia secondary to loop or thiazide diuretic usage

What electrolyte imbalances would the nurse monitor for in the patient who is taking a loop diuretic? Select all that apply: A. Hyperkalemia B. Hypocalcemia C. Hypernatremia D. Hypokalemia E. Hypomagnesemia

B. Hypocalcemia D. Hypokalemia E. Hypomagnesemia

Your patient will be started on a thiazide diuretic to help manage blood pressure. Select all the medications below that are considered a type of thiazide diuretic: A. Furosemide B. Indapamine C. Hydrochlorothiazide D. Spironolactone E. Metolazone F. Chlorothiazide

B. Indapamine C. Hydrochlorothiazide E. Metolazone F. Chlorothiazide

You're developing a plan of care for a patient with heart failure that will be prescribed a thiazide diuretic. What nursing interventions will you include in this patient's plan of care? Select all that apply: A. Encourage the patient to limit the consumption of bananas, avocadoes, spinach, strawberries, and potatoes. B. Measure the patient's intake and output daily. C. Weigh the patient daily using a bedside scale. D. Assess lab results for electrolyte imbalances like hypercalcemia and hyperkalemia.

B. Measure the patient's intake and output daily. C. Weigh the patient daily using a bedside scale.

A patient with heart failure is prescribed Digoxin and a loop diuretic. The nurse knows that what finding below would increase a patient's risk of developing Digoxin toxicity? A. Magnesium level 1.8 mg/dL B. Potassium 2 mEq/L C. BUN 15 D. Albumin 5 g/dL

B. Potassium 2 mEq/L

Your patient is ordered a loop diuretic at 1000. Which finding below would require you to hold the dose and notify the physician for further orders? A. Calcium level 9 mg/L B. Potassium level 1.5 mEq/L C. Blood pressure 102/78 D. Sodium level 144

B. Potassium level 1.5 mEq/L

A patient is scheduled to take a dose of Lithium at 1000. The patient is also prescribed a thiazide diuretic. What lab result below requires the nurse to hold the dose of Lithium and notify the physician for further orders? A. Potassium 3.2 mEq/L B. Sodium 115 mEq/L C. Calcium 10.5 mg/L D. Magnesium 2 mg/dL

B. Sodium 115 mEq/L

Which potassium-sparing diuretic can cause antiandrogenic effects in a patient, such as menstrual irregularities, gynecomastia, and decreased sex drive? A. Triamterene B. Spironolactone C. Amiloride D. Eplerenone

B. Spironolactone

Which potassium-sparing diuretics are known to antagonize aldosterone in order to cause diuresis? Select all that apply: A. Triamterene B. Spironolactone C. Amiloride D. Eplerenone

B. Spironolactone D. Eplerenone

The physician prescribes the patient a thiazide diuretic. The patient is experiencing increased urination. As the nurse you know that this medication causes this type of affect by how it affects the nephron. It does this by? A. inhibiting the sodium-potassium-chloride cotransporter in the distal convoluted tubule B. inhibiting the sodium-chloride cotransporter in the distal convoluted tubule C. inhibiting the water reabsorption in the distal convoluted tubule D. inhibiting the sodium-potassium transporter in the distal convoluted tubule

B. inhibiting the sodium-chloride cotransporter in the distal convoluted tubule

You're providing discharge teaching to a patient who will be taking a thiazide diuretic for the treatment of hypertension. You note that the patient has type I diabetes. What statement by the patient represents they misunderstood your teaching points about this medication and requires you reinforce some of the education pieces? A. "I must monitor my blood glucose closely while taking this medication." B." This medication can cause sudden and severe drops in my blood glucose." C. "I will try my best to eat a diet that includes foods rich in potassium." D. "I will report to my physician if I experience excessive thirst, little or no urination, and extreme fatigue."

B." This medication can cause sudden and severe drops in my blood glucose."

Carbonic anhydrase inhibitors, such as acetazolamide, increase sodium excretion by decreasing sodium-hydrogen ion exchange. They are used to treat

seizure disorders and open-angle glaucoma.

Select all the medications below that are considered loop diuretics: A. Chlorothiazide B. Bumetanide C. Triamterene D. Spironolactone E. Furosemide F. Torsemide G. Hydrochlorothiazide

B. Bumetanide E. Furosemide F. Torsemide

TRUE or FALSE: Potassium-sparing diuretics are the most effective type of diuretic and are often combined with loop or thiazide diuretics. True False

False

True or False: Thiazide diuretics are more potent than loop diuretics and provide immediate diuresis affects. True False

False

True or false: the loop diuretics cause the body to excrete a copious amount of potassium-rich urine.

False

Prototype Osmotic Diuretic: Mannitol

-IV med -indicated for oliguric phase of renal fiaure, reduce intracranial pressure, reduce intraocular pressure, excretion of toxic substances -elevates osmolarilty of glomerular filtrate -Adverse effects: fluid/electrolyte imbalance, diuresis, low bp, thirst, dry mouth, diuresis Nursing considerations: -history and physical exam -known allergies -inspect skin due to pitting edema, skin turgor for fluid status, can have weeping -Fluid/electrolyte disturbances, gout, glucose tolerance abnormalites, SLE -Hyperparathyroidism and bipolar -heart and lung sounds (crackles) -arrhythimias -baseline weight -I&O -liver status and appropriate lab values (potassium, calcium, sodium) -pt teaching: can be given w/ food or milk to prevent gi upset, give IV slowly, take pill early in day, report increase of 3 lbs in 1 day or 5 lbs in a week, make sure they are safe going to the bathroom, avoid hot environments

Prototype Loop Diuretic: Furosemide

-Indicated for edema and HTN -Inhibits the reabsorption of sodium/chloride loop of henle -Adverse effects: dizziness, orthostatic hypotension, gi, bladder spasm, glycosuria -Pt eduction: weigh daily, report loss/gain of 3 lbs or more in one day or 5 lbs or more in 1 week -Can be taken w/ food -Pts should maintain usual fluid intake and avoid excessive salt intake, eat foods high in potassium such as OJ, raisins, and bananas -Make sure there are safety precautions because they may feel faint, change positions slowly, easy access to bathroom, increase thirst (lozenges), frequent mouth care, report cramps, swelling, N/V, avoid OTC meds, take early in day so not up all night peeing

Prototype Thiazide Diuretic: Hydrochlorothiazide

-Indicated for edema, cirrhosis, corticosteroid or estrogen therapy and renal dysfunction, HTN -Stops the reabsorption of sodium and chloride in the tubules which increases the excretion of sodium chloride and water -Adverse effects: dizziness, vertigo, orthostatic hypotension, anorexia, N/V, diarrhea, dry mouth, nocturia, polyuria, muscle cramps or spasms

Pharmacokinetics of Loop Diuretics

-Metabolized and excreted primarily through the urine -PO (1-2 hrs) or IV (30 min or so)

Pharmacokinetics: Thiazide and Thiazide-Like Diuretics

-Metabolized in the liver -Excreted in the urine -Absorbed in the GI tract -Work at the level of the kidneys -Work w/in a few hours

Adverse effects of Osmotic Diuretics

-N/V -hypotension -lightheadedness -H/A -confusion -cardiac decompensation and further shock

Classes of Diuretics

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

Indications: Thiazide and Thiazide-Like Diuretics

-Treatment of edema associated with CHF, liver, or renal disease -HTN (as an adjunct) -Often first-line drugs to treat HTN

Drug-drug Interactions for Loop Diuretics

-aminoglycosides or cisplatine -anticoagulation (can increase effects), -indomethacin, -ibuprofen -salicylates -NSAIDs

Actions of Potassium-Sparing Diuretics

-block the actions of aldosterone in the distal tubule, retain potassium instead of wasting it, cause a loss of sodium -not as powerful as loop diuretics

Actions: Thiazide and Thiazide-Like Diuretics

-block the chloride pump, this keeps chloride and the sodium in the tubule to be excreted in the urine and that prevents the reabsorption of both in the vascular system -Thiazide-like means that they have a slightly different chemical structure but work in the same way as a thiazide diuretic

Contraindications for Loop Diuretics

-electrolyte depletion -anuria, -severe renal failure -hepatic coma -pregnancy and lactation Cautions: lupus, gout, diabetes

Pharmacokinetics of Carbonic Anhydrase Inhibitors

-given IV or oral -rapidly absorbed, widely distributed, excreted in urine

Adverse effects: Thiazide and Thiazide-Like Diuretics

-glucose tolerance abnormalities, can lead to high blood sugar -GI upset -fluid and electrolyte imbalance -low potassium and calcium -acidosis -hypotension -alkalized urine -can cause bladder infections in people at risk

Contraindications to Potassium-Sparing Diuretics

-high potassium -renal disease -anuria -pts taking amiloride or triamterene caution: pregnancy and lactation

Drug-drug interactions: Thiazide and Thiazide-Like Diuretics

-lithium -digoxin -antidiabetic agents -cholestyramine

Contraindications of Carbonic Anhydrase Inhibitors

-noncongestive angle-closure glaucoma -pregnancy or lactation -severe fluid-electrolyte imbalances -kidney or liver disease -adrenocortical insufficiency -respiratory acidosis -COPD -Caution: many acid/base, electrolyte related

Adverse effects of Carbonic Anhydrase Inhibitors

-r/t disturbance in acid/base balance -electrolyte imbalance -paresthesia of extremities -confusion -drowsiness, -low potassium

Adverse Effects of Loop Diuretics

-r/t to fluid and electrolyte imbalance -hypokalemia -alkalosis -hypocalcemia, -dizziness -low BP -high blood sugar and ototoxicity in long-term use

Contraindications for Osmotic Diuretics

-renal disease -anuria -pulmonary congestion -pregnancy -intracranial bleeding -dehydration -CHF

Prototype Carbonic Anhydrase Inhibitor: Acetazolamide

-used for open-angle or secondary glaucoma, acute mountain sickness, edema -inhibits carbonic anhydrase -Adverse effects: weakness, fatiguge, rash, bone marrow suppression, increased urine, weight loss

Indications for Carbonic Anhydrase Inhibitors

-used less often -used as adjuncts to other diuretics when more intense diuresis needed -mild on their own -glaucoma, HF, altitude sickness

Indications for Potassium-Sparing Diuretics

-useful for pts who are at risk for hypokalemia (heart arrhythmias) -adjunct w/ thiazide or loop diuretic

Pharmacokinetics of Potassium-Sparing Diuretics

-well absorbed, protein bound, and widely distributed -metabolized in liver and excrete in urine

Contraindications: Thiazide and Thiazide-Like Diuretics

-Allergy to thiazides or sulfonamides -Fluid and electrolyte imbalances -Renal and liver disease Caution: multiple medical history components that should be kept in mind (gout, lupus, liver disease, hyperparathyroidism, bipolar disorder), pregnancy and lactation, diabetes

Actions of Loop Diuretics

-Block the chloride pump in the ascending loop of henle (where 30% of all sodium that has been filtered in reabsorbed), this causes a decrease in the reabsorption of sodium and chloride and the production of sodium-rich urine -do the job of diuresis to a bigger degree than others, work quickly, strong, drug of choice when needing to diuresis quickly as long as the pt can perfuse the kidneys

You're educating a group of new nurse graduates about loop diuretics. One topic you discuss is ototoxicity. You ask the new nurses to explain how to prevent this adverse side effect in a patient prescribed a loop diuretic. Which response by one of the new nurses is correct? A. "Always administer intravenous loop diuretics slowly." B. "Monitor for signs and symptoms of low potassium levels because this increases the risk of inner ear damage while taking loop diuretics." C. "Administer the medication with meals." D. "Avoid administering loop diuretics with a tetracycline."

A. "Always administer intravenous loop diuretics slowly."

Which patients below may be prescribed a loop diuretic based on their diagnosis? Select all that apply: A. A 58-year-old male with congestive heart failure. B. A 69-year-old female with pulmonary edema. C. A 45-year-old male with hypercalcemia. D. A 50-year-old male experiencing a gout attack.

A. A 58-year-old male with congestive heart failure. B. A 69-year-old female with pulmonary edema. C. A 45-year-old male with hypercalcemia.

Your patient is prescribed to take Lisinopril and Triamterene. As the nurse you know that these medications increase a patient's risk for developing? A. Hyperkalemia B. Hypertension C. Hypernatremia D. Renal failure

A. Hyperkalemia

You're developing a plan of care for a patient with fluid volume overload related to heart failure exacerbation. The physician has prescribed an IV loop diuretic. What nursing interventions will you include in the patient's plan of care? Select all that apply: A. Perform and assess daily weights. B. Educate the patient about consuming a low potassium diet. C. Strict measuring of the patient's daily intake and output. D. Encourage the patient to drink 2 L of fluids per day. E. Assess lung sounds every shift.

A. Perform and assess daily weights. C. Strict measuring of the patient's daily intake and output. E. Assess lung sounds every shift.

You're providing discharge teaching to a patient who will be taking Amiloride. Which items below should the patient limit in their diet? Select all that apply: A. Salt-substitutes B. Spinach C. Bananas D. Rice E. Cheese

A. Salt-substitutes B. Spinach C. Bananas

Based on your nursing knowledge of how thiazide diuretics work, which patients below would benefit from these types of medications? Select all that apply: A. A patient with a glomerular filtration rate (GFR) of less than 30 cc/hr. B. A patient with a recurrent history of renal calcium calculi. C. A patient with primary hypertension. D. A patient with heart failure and frequent gout attacks. E. A patient with diabetes that has uncontrolled hyperglycemia.

B. A patient with a recurrent history of renal calcium calculi. C. A patient with primary hypertension.

A patient is currently taking a potassium-sparing diuretic. The patient is experiencing EKG changes with tall-peaked T-waves, nausea, diarrhea, and paresthesia. The patient's morning lab results are back and the nurse makes it priority to check what lab result? A. Calcium B. Potassium C. Magnesium D. Sodium

B. Potassium

Actions of Carbonic Anhydrase Inhibitors

Block effects of carbonic hydrase which slows movement of hydrogen ions, more sodium and bicarbonate are lost in urine

A 55-year-old-male with hypertension is prescribed a thiazide diuretic. The patient has a health history of diabetes type I and gout. What lab results below represent some known side effects of this medication and requires the nurse to report the lab results to the physician? Select all that apply: A. Potassium 5.2 mEq/L B. Calcium 9 mg/L C. Blood glucose 300 mg/dL D. Ammonia 20 mcg/dL E. Uric acid level 15 mg/dL F. Blood glucose 45 mg/dL

C. Blood glucose 300 mg/dL E. Uric acid level 15 mg/dL

Potassium-sparing diuretics alter how sodium is reabsorbed in what part of the nephron? Select all that apply: A. Loop of Henle B. Proximal Convoluted Tubule C. Distal Convoluted Tubule D. Collecting Duct E. Thick ascending limb of the loop of Henle

C. Distal Convoluted Tubule D. Collecting Duct

The physician prescribes the patient a potassium-sparing diuretic. Which statement below best describes how this medication works to cause diuresis? A. These medications work to inhibit the sodium-chloride cotransporter in the early part of the distal convoluted tubule. B. These medications work to inhibit the sodium-potassium-chloride cotransporter in the thick ascending limb of the loop of Henle. C. These medications work to inhibit the sodium and potassium exchange within the sodium channels in the distal tubule and collecting duct. D. These medications work to inhibit the sodium channels within the proximal convoluted tubule by decreasing sodium reabsorption.

C. These medications work to inhibit the sodium and potassium exchange within the sodium channels in the distal tubule and collecting duct.

Loop diuretics are effective with inhibiting sodium reabsorption within the nephron because it inhibits? A. the sodium-chloride transporter B. the effects of aldosterone on the distal convoluted tubule C. the sodium-potassium-chloride cotransporter D. the transport of bicarbonate by the proximal convoluted tubule

C. the sodium-potassium-chloride cotransporter

Actions of Osmotic Diuretics

pull water in renal tubule w/out sodium loss

You're providing discharge instructions to a patient who will be taking a loop diuretic at home. Which statement by the patient demonstrates they did NOT understand the teaching material and requires that you reinforce some of the teaching points? A. "I will eat a diet rich in potatoes, bananas, avocadoes, strawberries, and spinach." B. "I will weight myself daily and report to my physician if I gain more than 3 lbs in 1 day." C. "I will change position slowly because I can become dizzy easily while taking this medication." D. "This medication can cause dehydration, so I will stay hydrated by consuming at least 2 L or more of fluid per day."

D. "This medication can cause dehydration, so I will stay hydrated by consuming at least 2 L or more of fluid per day."

The physician prescribes the patient a loop diuretic. As the nurse you know that this type of diuretic causes diuresis by MAINLY affecting what structure in the nephron? A. Distal convoluted tubule B. Descending limb of the loop of Henle C. Proximal convoluted tubule D. Ascending limb of the loop of Henle

D. Ascending limb of the loop of Henle

A patient has a dose of Spironolactone due at 1000. Which finding below would require the nurse to hold the dose and notify the physician for further orders? A. Magnesium 1.5 mg/dL B. BUN 18 C. Sodium 140 mEq/L D. Potassium 7 mEq/L

D. Potassium 7 mEq/L

Drug-drug interactions for Potassium-Sparing Diuretics

salicylates

Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema? a. Furosemide b. Chlorothiazide c. Spironolactone d. Acetazolamide

a. Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium; is available for IV administration; and is more effective than chlorothiazide, spironolactone, and acetazolamide.

Which principle explains how loop diuretics promote diuresis? a. Osmosis b. Filtration c. Diffusion d. Active transport

a. Osmosis Loop diuretics inhibit the reabsorption of sodium and water in the ascending loop of Henle. The increased sodium load in the distal tubule causes the passive transfer of water from the glomerular filtrate to urine through the process of osmosis.

Indications for Loop Diuretics

acute CHF, edema, HTN

Which medication would the nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? a. Chlorothiazide b. Acetazolamide c. Methazolamide d. Aclidinium bromide

b. Acetazolamide Acetazolamide is a carbonic anhydride inhibitor that decreases inflow of aqueous humor and controls intraocular pressure in acute angle-closure glaucoma attack.

A child is prescribed IV mannitol. The nurse understands mannitol belongs to which classification of diuretics? a. Loop b. Osmotic c. Potassium sparing d. Carbonic anhydrase inhibitor

b. Osmotic Osmotic diuretics, such as mannitol, increase the osmotic pressure of glomerular filtrate and thus decrease absorption of sodium; they are used to treat cerebral edema and increased intraocular pressure.

Which assessment would the nurse perform specific to the safe administration of IV mannitol? a. Body weight daily b. Urine output hourly c. Vital signs every 2 hours d. Level of consciousness every 8 hours

b. Urine output daily Mannitol, an osmotic diuretic, increases the intravascular volume that must be excreted by kidneys. The client's urine output should be monitored hourly to determine the client's response to therapy.

Which adverse medication effect will a nurse monitor for in a client with cirrhosis of the liver who develops ascites and is prescribed spironolactone? a. Bruising b. Tachycardia c. Hyperkalemia d. Hypoglycemia

c. Hyperkalemia Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse would monitor the client for signs and symptoms of hyperkalemia.

Which mechanism of action explains how diuretics reduce blood pressure? a. They facilitate vasodilation. b. They promote smooth muscle relaxation. c. They reduce the circulating blood volume. d. They block the sympathetic nervous system.

c. They reduce the circulating blood volume. Diuretics decrease blood volume by blocking sodium reabsorption in the renal tubules, thus promoting fluid loss and reducing arterial pressure.

Potassium-sparing diuretics, such as spironolactone, interfere with sodium resorption in the distal tubules, thus decreasing potassium excretion; they are used to treat

cirrhotic ascites and pulmonary edema.

Which food would a nurse instruct the client to include in the diet when being prescribed furosemide? a. Liver b. Apples c. Cabbage d. Bananas

d. Bananas Furosemide is a loop diuretic that increases potassium secretion by preventing renal absorption. Bananas have a significant amount of potassium.

Acetazolamide is used in the treatment of ________ to lower intraocular pressure.

glaucoma

Loop diuretics, such as furosemide, inhibit reabsorption of sodium and potassium in the loop of Henle; they are used for

heart failure and pulmonary edema.

Adverse effects of Potassium-Sparing Diuretics

hyperkalemia (lethargy, confusion, heart arrhythmia, ataxia, muscle cramps), listen to apical pulse

Drug-drug interactions for Carbonic Anhydrase Inhibitors

lithium, salicylates

Nursing considerations for Osmotic Diuretics

monitor fluid and electrolyte closely