1. Case Study: Which diuretic is best choice? A patient who sustained a head injury is admitted to the critical care unit with increased intracranial pressure (ICP). The healthcare provider says that a diuretic will be used to lower the patient’s ICP. The nurse anticipates that which diuretic will be ordered, and why? A: The nurse anticipates that mannitol, an osmotic diuretic, will be ordered. Intracranial pressure (ICP) that has been elevated by cerebral edema can be reduced with mannitol. The drug lowers ICP because its presence in the blood vessels of the brain creates an osmotic force that draws edematous fluid from the brain into the blood. There is no risk of increasing cerebral edema because mannitol cannot exit the capillary beds of the brain. 1

2. Case Study: which diuretic, slide 2 Mannitol IV has been ordered for the patient. When the IV solution of mannitol arrives from the pharmacy, the nurse notes crystals in the fluid. What is the most appropriate action by the nurse? Answer: Most likely, the in-house pharmacy takes care of this issue. However, if you worked in a rural, under-resourced setting, then it might be good to know that: mannitol may crystallize out of solution if exposed to a low temperature. Accordingly, preparations should be observed for crystals before use. Preparations that contain crystals should be warmed (to redissolve the mannitol) and then cooled to body temperature for administration. 2

3. Case Study: which diuretic, slide 3 Are there any other steps the nurse should take regarding IV administration of mannitol? Answer: Along with following all the appropriate safety precautions for medication administration, the nurse should use a filter needle to withdraw mannitol from the vial, as well as an in-line filter for IV infusion, to prevent crystals from entering the circulation. 3

4. Patient Case TR, slide 1 TR is a 62 YO WM who presents in clinic complaining of some difficulty breathing while lying down at night, and increased swelling in his feet and ankles. TR is a 62 YO WM who presents in clinic complaining of some difficulty breathing while lying down at night, and increased swelling in his feet and ankles. → these are CLASSIC signs of heart failure, shortness of breath will also develop → these are CLASSIC signs of heart failure, shortness of breath will also develop He is diagnosed with mild congestive heart failure secondary to ischemic heart disease, and is placed on hydrochlorothiazide 50mg PO QD. He is diagnosed with mild congestive heart failure secondary to ischemic heart disease, and is placed on hydrochlorothiazide 50mg PO QD.

5. Patient Case TR, slide 2 What do you think is probably causing this patient’s symptoms? What do you think is probably causing this patient’s symptoms? What parameters are important to monitor in this patient with respect to: What parameters are important to monitor in this patient with respect to: Therapeutic effect? Therapeutic effect? Adverse effects? Adverse effects? What instructions does this patient need to ensure appropriate therapy? What instructions does this patient need to ensure appropriate therapy?

6. When providing discharge teaching for a patient who has been prescribed furosemide [Lasix], it is most important for the nurse to include which dietary items to prevent adverse effects of furosemide [Lasix] therapy? A.Oranges, spinach, and potatoes B.Baked fish, chicken, and cauliflower C.Tomato juice, skim milk, and cottage cheese D.Oatmeal, cabbage, and bran flakes Question: furosemide and dietary intake 6

7. When providing discharge teaching for a patient who has been prescribed furosemide [Lasix], it is most important for the nurse to include which dietary items to prevent adverse effects of furosemide [Lasix] therapy? A.Oranges, spinach, and potatoes B.Baked fish, chicken, and cauliflower C.Tomato juice, skim milk, and cottage cheese D.Oatmeal, cabbage, and bran flakes Answer: A Answer: A Rationale: Furosemide may have the adverse effect of hypokalemia. Hypokalemia can be reduced by consuming foods that are high in potassium, such as nuts, dried fruits, spinach, citrus fruits, potatoes, and bananas. Rationale: Furosemide may have the adverse effect of hypokalemia. Hypokalemia can be reduced by consuming foods that are high in potassium, such as nuts, dried fruits, spinach, citrus fruits, potatoes, and bananas. Question: furosemide and dietary intake 7

8. A patient is prescribed spironolactone [Aldactone] for treatment of hypertension. Which foods should the nurse teach the patient to avoid? A.Baked fish B.Low-fat milk C.Salt substitutes D.Green beans Question: spironolactone and dietary intake 8

9. A patient is prescribed spironolactone [Aldactone] for treatment of hypertension. Which foods should the nurse teach the patient to avoid? A.Baked fish B.Low-fat milk C.Salt substitutes D.Green beans Answer: C Answer: C Rationale: Spironolactone is a potassium-sparing diuretic. Medications that are potassium sparing, potassium supplements, and salt substitutes should be avoided. High-potassium foods should also be avoided. Rationale: Spironolactone is a potassium-sparing diuretic. Medications that are potassium sparing, potassium supplements, and salt substitutes should be avoided. High-potassium foods should also be avoided. SALT SUBSTITUTES that use POTASSIUM CAN BE (are) VERY HAZARDOUS! SALT SUBSTITUTES that use POTASSIUM CAN BE (are) VERY HAZARDOUS! Question: spironolactone and dietary intake 9

10. Question: bumetanide is a potent loop diuretic The nurse cares for a patient who is prescribed oral bumetanide twice daily. It is most important for the nurse to take which action? A.Monitor the patient for signs and symptoms of hyperkalemia. B.Insert a urinary catheter and assess the hourly urine output. C.Weigh the patient before administering each dose. D.Schedule the medication to be given at 0800 and 1400. 10

11. Question: bumetanide is a potent loop diuretic The nurse cares for a patient who is prescribed oral bumetanide twice daily. It is most important for the nurse to take which action? A.Monitor the patient for signs and symptoms of hyperkalemia. B.Insert a urinary catheter and assess the hourly urine output. C.Weigh the patient before administering each dose. D.Schedule the medication to be given at 0800 and 1400. Answer: D Answer: D Rationale: The nurse should administer oral bumetanide with twice-a-day dosing at 0800 and 1400 to minimize nocturia. Daily weights should be obtained in the morning before eating. Patients receiving IV bumetanide are more likely to need hourly monitoring of urine output with a urinary catheter. Bumetanide may cause hypokalemia; signs and symptoms of hypokalemia include irregular heartbeat, muscle weakness, cramping, flaccid paralysis, leg discomfort, extreme thirst, and confusion. Rationale: The nurse should administer oral bumetanide with twice-a-day dosing at 0800 and 1400 to minimize nocturia. Daily weights should be obtained in the morning before eating. Patients receiving IV bumetanide are more likely to need hourly monitoring of urine output with a urinary catheter. Bumetanide may cause hypokalemia; signs and symptoms of hypokalemia include irregular heartbeat, muscle weakness, cramping, flaccid paralysis, leg discomfort, extreme thirst, and confusion. 11

12. Question: furosemide and drug interactions A patient with heart failure who takes furosemide [Lasix] is diagnosed with bacterial pneumonia. Which medication, if ordered by the physician, should the nurse question? A.Ciprofloxacin [Cipro] B.Gentamicin [Garamycin] C.Amoxicillin [Amoxcil] D.Erythromycin [E-Mycin] 12

13. Question: furosemide and drug interactions A patient with heart failure who takes furosemide [Lasix] is diagnosed with bacterial pneumonia. Which medication, if ordered by the physician, should the nurse question? A.Ciprofloxacin [Cipro] B.Gentamicin [Garamycin] C.Amoxicillin [Amoxcil] D.Erythromycin [E-Mycin] Answer: B Answer: B Rationale: High-ceiling loop diuretics may cause hearing impairment; furosemide may result in deafness that is transient. Because of the risk of hearing loss, caution is needed when high-ceiling diuretics are used in combination with other ototoxic drugs (for example, aminoglycoside antibiotics). Gentamicin is an aminoglycoside. The other antibiotics are safe to administer with furosemide. Rationale: High-ceiling loop diuretics may cause hearing impairment; furosemide may result in deafness that is transient. Because of the risk of hearing loss, caution is needed when high-ceiling diuretics are used in combination with other ototoxic drugs (for example, aminoglycoside antibiotics). Gentamicin is an aminoglycoside. The other antibiotics are safe to administer with furosemide. 13

14. Patient Case NK, slide 1 NK is a 74 YO WM, POD 6 from CABG surgery. He is on 3L O2, with bilateral crackles in the bases. Weight is 104.4kg (preop 98kg). His renal function is mildly impaired, with a creatinine of 1.9 mg/dl. NK is a 74 YO WM, POD 6 from CABG surgery. He is on 3L O2, with bilateral crackles in the bases. Weight is 104.4kg (preop 98kg). His renal function is mildly impaired, with a creatinine of 1.9 mg/dl. What diuretic would be appropriate for this patient? What diuretic would be appropriate for this patient? Furosemide, orally (draw off the extra fluid, minimize risk of pneumonia, assure optimal recovery) Furosemide, orally (draw off the extra fluid, minimize risk of pneumonia, assure optimal recovery)

15. What monitoring parameters should be followed? What monitoring parameters should be followed? What are some options if the patient doesn’t respond? What are some options if the patient doesn’t respond? Patient Case NK, slide 2

16. Best diuretic for pulmonary edema? A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? A. Furosemide [Lasix] B. Hydrochlorothiazide [HydroDIURIL] C. Mannitol [Osmitrol] D. Spironolactone [Aldactone]

17. Best diuretic for pulmonary edema? A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? A. Furosemide [Lasix] CORRECT B. Hydrochlorothiazide [HydroDIURIL] C. Mannitol [Osmitrol] D. Spironolactone [Aldactone]

18. Edematous state with hyperkalemia A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? A. Bumetanide [Bumex] B. Furosemide [Lasix] C. Spironolactone [Aldactone] D. Hydrochlorothiazide [HydroDIURIL]

19. Edematous state with hyperkalemia A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? A. Bumetanide [Bumex] B. Furosemide [Lasix] C. Spironolactone [Aldactone] CORRECT D. Hydrochlorothiazide [HydroDIURIL]