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Chapter 28 Diuretic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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1 Chapter 28 Diuretic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2  Drugs that accelerate the rate of urine formation  Result in the removal of sodium and water  Used in the treatment of hypertension, heart failure, and renal failure Diuretic Drugs 2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3  In the nephron, where sodium goes, water follows  60% to 70% of sodium and water is returned to bloodstream by the proximal tubule  20% to 25% of all sodium is reabsorbed into the bloodstream in the ascending loop of Henle  5% to 10% is reabsorbed in the distal tubules  3% is reabsorbed in collecting ducts  If water is not absorbed, it is excreted as urine Sodium 3Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

4 The Nephron and Diuretic Sites of Action 4Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5 Classroom Response Question Which location is the area where the highest percentage of sodium and water are resorbed back into the bloodstream? A.Glomerulus B.Proximal tubule C.Ascending loop of Henle D.Distal tubule 5Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6  Carbonic anhydrase inhibitors  Loop diuretics  Osmotic diuretics  Potassium-sparing diuretics  Thiazide and thiazide-like diuretics Types of Diuretic Drugs 6Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

7  acetazolamide (Diamox)  Most commonly used CAI Carbonic Anhydrase Inhibitors (CAIs) 7Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8  The enzyme carbonic anhydrase helps to make H + ions available for exchange with sodium and water in the proximal tubules  CAIs block the action of carbonic anhydrase, thus preventing the exchange of H + ions with sodium and water Carbonic Anhydrase Inhibitors: Mechanism of Action 8Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9  Inhibition of carbonic anhydrase reduces H + ion concentration in renal tubules  As a result, there is increased excretion of bicarbonate, sodium, water, and potassium  Resorption of water is decreased, and urine volume is increased Carbonic Anhydrase Inhibitors: Mechanism of Action (cont’d) 9Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10  Adjunct drugs in the long-term management of open-angle glaucoma  Used with miotics to lower intraocular pressure before ocular surgery in certain cases  Also useful in the treatment of:  Edema  High-altitude sickness Carbonic Anhydrase Inhibitors: Indications 10Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

11  Acetazolamide (Diamox) is used in the management of edema secondary heart failure (HF) when other diuretics are not effective  CAIs are less potent diuretics than loop diuretics or thiazides—the metabolic acidosis they induce reduces their diuretic effect in 2 to 4 days Carbonic Anhydrase Inhibitors: Indications (cont’d) 11Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

12 Carbonic Anhydrase Inhibitors: Adverse Effects  Metabolic acidosis  Anorexia  Hematuria  Photosensitivity  Melena  Hypokalemia  Drowsiness  Paresthesias  Urticaria  Glycosuria in diabetic patients 12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13  bumetanide (Bumex)  ethacrynic acid (Edecrin)  furosemide (Lasix)  torsemide (Demadex) Loop Diuretics 13Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14  Possess renal, cardiovascular, and metabolic effects  Act directly on the ascending limb of the loop of Henle to inhibit chloride and sodium resorption  Increase renal prostaglandins, resulting in the dilation of blood vessels and reduced peripheral vascular resistance  Useful in treatment of edema Loop Diuretics: Mechanism of Action 14Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15  Potent diuresis and subsequent loss of fluid  Decreased fluid volume causes a reduction in:  Blood pressure  Pulmonary vascular resistance  Systemic vascular resistance  Central venous pressure  Left ventricular end-diastolic pressure  Potassium and sodium depletion Loop Diuretics: Drug Effects 15Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16  Edema associated with HF or hepatic or renal disease  To control hypertension  To increase renal excretion of calcium in patients with hypercalcemia  In cases of HF resulting from diastolic dysfunction Loop Diuretics: Indications 16Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17 Loop Diuretics: Adverse Effects Body SystemAdverse Effects Central nervous system (CNS)Dizziness, headache, tinnitus, blurred vision Gastrointestinal (GI)Nausea, vomiting, diarrhea IntegumentaryStevens-Johnson syndrome (torsemide) 17Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18 Body SystemAdverse Effects HematologicAgranulocytosis, neutropenia, thrombocytopenia MetabolicHypokalemia, hyperglycemia, hyperuricemia Loop Diuretics: Adverse Effects (cont’d) 18Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19 Classroom Response Question When administering a loop diuretic to a patient, it is most important for the nurse to determine if the patient is also taking which drug? A.lithium (Eskalith) B.acetaminophen (Tylenol) C.penicillin D.theophylline 19Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20  mannitol (Osmitrol)  Most used osmotic diuretic  Urea  Organic acids  Glucose Osmotic Diuretics 20Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

21  Work mostly in the proximal tubule  Nonabsorbable, producing an osmotic effect  Pull water into the renal tubules from the surrounding tissues  Inhibit tubular resorption of water and solutes, thus producing rapid diuresis Osmotic Diuretics: Mechanism of Action 21Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

22  Increases glomerular filtration rate and renal plasma flow—helps to prevent kidney damage during acute renal failure  Reduces intracranial pressure or cerebral edema associated with head trauma  Reduces excessive intraocular pressure Osmotic Diuretics: Drug Effects 22Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

23  Treatment of patients in the early, oliguric phase of acute renal failure (ARF)  To promote excretion of toxic substances  To reduce intracranial pressure  Treatment of cerebral edema  NOT indicated for peripheral edema Osmotic Diuretics: Indications 23Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

24  Convulsions  Thrombophlebitis  Pulmonary congestion  Also headaches, chest pains, tachycardia, blurred vision, chills, and fever Osmotic Diuretics: Adverse Effects 24Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

25  Intravenous infusion only  May crystallize when exposed to low temperatures  Use of a filter is required Osmotic Diuretics: Mannitol (Osmitrol) 25Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

26 Classroom Response Question While preparing an infusion of mannitol (Osmitrol), the nurse notices small crystals in the IV tubing. The most appropriate action by the nurse is to A.administer the infusion slowly. B.discard the solution and obtain another bag of medication. C.obtain a filter, and then infuse the solution. D.return the fluid to the IV bag to dissolve the crystals. 26Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

27  amiloride (Midamor)  spironolactone (Aldactone)  triamterene (Dyrenium) Also known as aldosterone-inhibiting diuretics Potassium-Sparing Diuretics 27Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

28  Work in collecting ducts and distal convoluted tubules  Interfere with sodium-potassium exchange  Competitively bind to aldosterone receptors  Block resorption of sodium and water usually induced by aldosterone Potassium-Sparing Diuretics: Mechanism of Action 28Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

29  Prevent potassium from being pumped into the tubule, thus preventing its secretion  Competitively block aldosterone receptors and inhibit their action  Promote the excretion of sodium and water Potassium-Sparing Diuretics: Drug Effects 29Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

30  spironolactone and triamterene  Hyperaldosteronism  Hypertension  Reversing potassium loss caused by potassium- losing drugs  Certain cases of HF  amiloride  Treatment of HF Potassium-Sparing Diuretics: Indications 30Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

31 Body SystemAdverse Effects CNSDizziness, headache GI Cramps, nausea, vomiting, diarrhea OtherUrinary frequency, weakness, hyperkalemia Potassium-Sparing Diuretics: Adverse Effects 31Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

32 spironolactone (Aldactone)  Gynecomastia  Amenorrhea  Irregular menses  Postmenopausal bleeding Potassium-Sparing Diuretics: Adverse Effects (cont’d) 32Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

33  Thiazide diuretics  hydrochlorothiazide (Esidrix, HydroDIURIL)  chlorothiazide (Diuril)  Thiazide-like diuretics  metolazone (Mykrox, Zaroxolyn)  chlorthalidone (Hydone, Thalitone)  indapamide (Lozol) Thiazide and Thiazide-like Diuretics 33Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

34  Inhibit tubular resorption of sodium, chloride, and potassium ions  Action primarily in the distal convoluted tubule  Result: water, sodium, and chloride are excreted  Potassium is also excreted to a lesser extent  Dilate the arterioles by direct relaxation Thiazide and Thiazide-like Diuretics: Mechanism of Action 34Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

35  Lowered peripheral vascular resistance  Depletion of sodium and water (and potassium) Thiazide and Thiazide-like Diuretics: Drug Effects 35Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

36  Thiazides should not be used if creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min)  Metolazone remains effective to a creatinine clearance of 10 mL/min Thiazide and Thiazide-like Diuretics (cont’d) 36Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

37  Hypertension (one of the most prescribed group of drugs for this)  Edematous states  Idiopathic hypercalciuria  Diabetes insipidus  Heart failure due to diastolic dysfunction  Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, or corticosteroid or estrogen therapy Thiazide and Thiazide-like Diuretics: Indications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.37

38 Body SystemAdverse Effects CNSDizziness, headache, blurred vision GIAnorexia, nausea, vomiting, diarrhea GUImpotence HematologicJaundice, leukopenia Thiazide and Thiazide-like Diuretics: Adverse Effects 38Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

39 Body SystemAdverse Effects IntegumentaryUrticaria, photosensitivity MetabolicHypokalemia, hyperglycemia, hyperuricemia, hypochloremic alkalosis Thiazide and Thiazide-like Diuretics: Adverse Effects (cont’d) 39Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

40  Perform a thorough patient history and physical examination  Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs—especially postural BPs  Assess for disorders that may contraindicate or necessitate cautious use of these drugs Nursing Implications 40Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

41  Instruct patients to take the medication in the morning if possible to avoid interference with sleep patterns  Monitor serum potassium levels during therapy Nursing Implications (cont’d) 41Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

42  Teach patients to maintain proper nutritional and fluid volume status  Teach patients to eat more potassium-rich foods when taking any but the potassium-sparing drugs  Foods high in potassium include bananas, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, meats, fish, and legumes Nursing Implications (cont’d) 42Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

43  Patients taking diuretics along with a digitalis preparation should be taught to monitor for digitalis toxicity  Patients with diabetes mellitus who are taking thiazide and/or loop diuretics should be told to monitor blood glucose and watch for elevated levels Nursing Implications (cont’d) 43Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

44  Teach patients to change positions slowly and to rise slowly after sitting or lying to prevent dizziness and fainting related to orthostatic hypotension  Encourage patients to keep a log of their daily weight  Remind patients to return for follow-up visits and lab work Nursing Implications (cont’d) 44Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

45  Patients who have been ill with nausea, vomiting, and/or diarrhea should notify their primary care provider because fluid and electrolyte imbalances can result  Signs and symptoms of hypokalemia include muscle weakness, constipation, irregular pulse rate, and overall feeling of lethargy Nursing Implications (cont’d) 45Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

46  Instruct patients to notify their primary care provider immediately if they experience rapid heart rates or syncope (reflects hypotension or fluid loss)  Excessive consumption of licorice can lead to additive hypokalemia in patients taking thiazides Nursing Implications (cont’d) 46Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

47  Monitor for adverse effects  Metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness  Monitor for hyperkalemia with potassium-sparing diuretics Nursing Implications (cont’d) 47Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

48  Monitor for therapeutic effects  Reduction of edema  Reduction of fluid volume overload  Improvement in manifestations of heart failure  Reduction of hypertension  Return to normal intraocular pressures Nursing Implications (cont’d) 48Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

49 Case Study A patient with a creatinine clearance of 20 mL/min is admitted to the medical surgical unit. The patient is in need of rapid diuresis. Which class of diuretic does the nurse anticipate administering? A.Potassium-sparing B.Thiazide C.Osmotic D.Loop 49Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

50 Case Study (cont’d) The patient is ordered furosemide (Lasix). Before administering furosemide, it is most important for the nurse to assess the patient for allergies to which drug class? A.Aminoglycosides B.Sulfonamides C.Macrolides D.Penicillins 50Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

51 Case Study (cont’d) Two days after admission, the nurse is reviewing laboratory results of the patient. Which is the most common electrolyte finding resulting from the administration of furosemide (Lasix)? A.Hypocalcemia B.Hypophosphatemia C.Hypokalemia D.Hypomagnesemia 51Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

52 Case Study (cont’d) The patient is being discharged home with furosemide (Lasix). When providing discharge teaching, which instruction will the nurse include? A.Avoid prolonged exposure to the sun. B.Avoid foods high in potassium content. C.Stop taking the medication if you feel dizzy. D.Weigh yourself once a week and report a gain or loss of more than 1 pound. 52Copyright © 2014 by Mosby, an imprint of Elsevier Inc.


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