NUR 106 (UNIT 5) Cardiovascular Therapy: Diuretic Drugs
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palentan Plus on October 17, 2011
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NUR 106 Pharmacology
CCTC Fall 2011
Cheryl L DeGraw
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62 terms
Terms | Definitions |
|---|---|
 First Line Drug Classes for Hypertension: | Angiotensin converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium Channel blockers Beta-adrenergic antagonists Diuretics Tx generally starts c Diuretics |
| Second line (alternate) treatments for Hypertension: | Alpha1-adrenergic antagonists Alpha2-adrenergic antagonists Direct-acting vasodilators Ganglionic Blocker Renin Inhibitor |
| Diuretics are used to treat: | hypertension heart failure pulmonary edema renal disease liver cirrhosis/failure glaucoma hyperkalemia when you get rid of fluid, you also get rid of electrolytes |
| Classes of Diuretics | Thiazide and Thiazide-like Diuretics (fairly weak) Loop Diuretics (Lasix) (strong) Carbonic Anhydrase Inhibitors (moderate) Osmotic Diuretics (inter-cranial) Potassium-Sparing Diuretics |
| Site of Action of Diuretics |  |
| Thiazide & Thiazide-like Diuretics examples | hydrochlorothiazide (HydroDIURIL) bendroflumethiazide (Naturetin) chlorothiazide (Diuril) hydroflumethiazide (Diucardin, Saluron) methyclothiazide (Aquatensen, Enduron) chlorthalidone (Hygroton) indapamide (Lozol) metolazone (Mykrox, Zaroxolyn) |
| Thiazide Diuretics actions: | Keeps chloride and the sodium in the tubule to be excreted in the urine (wastes Na and Cl), thus preventing the reabsorption of both in the vascular system Blocks reabsorption of bicarbonate (urine will be more base) |
| Thiazide Diuretics Drug-Drug | cholestyramine or colestipol digoxin toxicity increases Decreases effectiveness antidiabetic agents (may need to adjust the dose) Increases quinine(malaria tx) toxicity & lithium(antipsychotic) toxicity |
| Thiazide Diuretics Contras | Allergy to thiazides or sulfonamides Fluid and electrolyte imbalances, and renal and liver disease Bipolar disorders |
| Thiazide Diuretics cautions | Gout Systemic lupus erythematosus Diabetes Hyperparathyroidism Pregnancy (B, C) and lactation |
| Thiazide and Thiazide-Like Diuretics Prototype: Hydrochlorothiazide: Indications | Adjunctive therapy for edema associated with CHF, cirrhosis, corticosteroid or estrogen therapy, and renal dysfunction; treatment of hypertension as monotherapy or in combination with other antihypertensives |
| Thiazide and Thiazide-Like Diuretics Prototype: Hydrochlorothiazide: Actions | Inhibits reabsorption of sodium and chloride in distal renal tubules, increasing the excretion of sodium, chloride, and water by the kidneys |
| Thiazide and Thiazide-Like Diuretics Prototype: Hydrochlorothiazide: PK: | Oral, 2 h, 4-6 h, 6-12 h HL: 5.6-14 hours, liver, urine |
| Thiazide and Thiazide-Like Diuretics Prototype: Hydrochlorothiazide: AE/SE | Dizziness, vertigo, orthostatic hypotension, nausea, anorexia, vomiting, dry mouth, diarrhea, polyuria, nocturia, muscle cramps or spasms (build up of Ca leads to muscle spasms), headaches, decreased calcium excretion, hypokalemia, increased blood glucose levels, urine slightly alkalinized (HCO3 loss), dysrhythmias (urine more alkaline -- increase risk of infection) |
| Theo is for REAL but don't give it to a BEAR | Theo = Thiazide Renal (physical) dysfunction Edema Adjunct to hypertension Liver Disease Bi-polar Electrolyte imbalance Allergy to sulfonimides/Thiazide Renal (chemical) Disease/Liver Disease |
| Loop Diuretics: furosemide (Lasix) | Most commonly used; less powerful than new drugs; larger margin of safety for home use |
| Loop Diuretics: bumetanide (Bumex) and torsemide (Demadex) | New drugs; more powerful than Lasix |
| Loop Diuretics: ethacrynic acid (Edecrin) | First loop diuretic introduced, used less frequently in the clinical setting |
| Loop Diuretics Actions | Block the chloride pump in the ascending loop of Henle Decreases reabsorption of sodium and chloride - rapid diuresis (causes quick urination) |
| Loop Diuretics Interactions | Aminoglycosides or cisplatine Anticoagulation Indomethacin, ibuprofen, salicylates, or NSAIDs Pregnancy Category C |
| Loop Diuretics Contras | Allergy Electrolyte depletion Anuria, Severe renal failure Hepatic coma (the liver needs to be functional to metabolize the diuretic to avoid toxicity) Pregnancy and lactation |
| Loop Diuretics Cautions | SLE, gout, and diabetes mellitus Safety < 18 years of age not established |
| Loop Diuretics Prototype: Furosemide: Indicaitons | Treatment of edema associated with CHF, acute pulmonary edema, hypertension |
| Loop Diuretics Prototype: Furosemide: Actions | Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a sodium-rich diuresis increase risk of hyponatremia |
| Loop Diuretics Prototype: Furosemide: PK: | Oral, 60 min, 60-120 min, 6-8 h IV/IM, 5 min, 30 min, 2 h HL: 120 min; liver, urine |
| Loop Diuretics Prototype: Furosemide: AE/SE | Dizziness, vertigo, paresthesias, blurred vision, orthostatic hypotension, thrombophlebitis, photosensitivity, rash, urticaria, nausea, anorexia, vomiting, constipation, glycosuria, urinary bladder spasm, leukopenia, anemia, thrombocytopenia, muscle cramps, and spasms, *hypokalemia, hypocalcemia, tachycardia, metabolic alkalosis, ototoxicity (8th cranial nerve damage -> tinnitus --> deafness)* |
| Bumetanide (Bumex) (memory) |  used to help alleviate fluid in the lungs from congestive heart failure |
| T/F? The loop diuretics cause the body to excrete a copious amount of potassium-rich urine. | False Rationale: The loop diuretics have a similar effect in the descending loop of Henle and in the distal convoluted tubule, resulting in the production of a copious amount of sodium-rich urine. |
| 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 (increases alkalinity of the urine) |
| Carbonic Anhydrase Inhibitors: Indications | Adjuncts to other diuretics Glaucoma - decreases fluid |
| Carbonic Anhydrase Inhibitors Drug-Drug | Salicylates, corticosteroids, tricyclic antidepressants |
| Carbonic Anhydrase Inhibitors Contras | Allergy Angle closure glaucoma (blocks fluid from draining out of the eye properly) |
| Carbonic Anhydrase Inhibitors Cautions | Lactation Fluid or electrolyte imbalances Renal or hepatic disease Adrenocortical insufficiency Respiratory acidosis COPD Pregnancy Category C |
| Carbonic Anhydrase Inhibitors Prototype: Acetazolamide: Indications | Adjunctive treatment of open-angle glaucoma, secondary glaucoma; preoperative use in acute angle-closure glaucoma when delay of surgery is indicated; edema caused by CHF, drug-induced edema; centrencephalic epilepsy; prophylaxis and treatment of acute altitude sickness |
| Carbonic Anhydrase Inhibitors Prototype: Acetazolamide: Actions | Inhibits carbonic anhydrase, which decreases aqueous humor formation in the eye, intraocular pressure, and hydrogen secretion by the renal tubules |
| Carbonic Anhydrase Inhibitors Prototype: Acetazolamide: PK: | Oral, 1 h, 2-4 h, 6-12 h Sustained-release oral, 2 h, 8-12 h, 18-24 h IV, 1-2 min, 15-18 min, 4-5 h HL: 5-6 hours; excreted unchanged in urine |
| Carbonic Anhydrase Inhibitors Prototype: Acetazolamide: AE/SE | Weakness, fatigue, rash, anorexia, nausea, urinary frequency, renal calculi, bone marrow suppression, weight loss *diarrhea, metabolic acidosis, hypokalemia, paresthesia, confusion, drowsiness* |
| Osmotic Diuretics Actions | Pull water into the renal tubule without sodium loss |
| Osmotic Diuretics Contras | Renal disease and anuria Pulmonary congestion, HF Intracranial bleeding, dehydration, shock Pregnancy Category C |
| Osmotic Diuretics Drug-Drug | Increases excretion of many drugs: salicylates, barbiturates, lithium, imipramine, & potassium supplements |
| Osmotic Diuretics Prototype: Mannitol: Indications | Prevention and treatment of oliguric phase of renal failure; reduction of intracranial pressure and treatment of cerebral edema; reduction of elevated intraocular pressure; promotion of urinary excretion of toxic substances; diagnostic use for measurement of glomerular filtration rate; irrigant in transurethral prostatic resection and other transurethral procedures. (irrigate prostate to prevent blood clot from forming) |
| Osmotic Diuretics Prototype: Mannitol: | Elevates the osmolarity of the glomerular filtrate, leading to a loss of water, sodium, and chloride; creates an osmotic gradient in the eye, reducing intraocular pressure; creates an osmotic effect that decreases swelling after transurethral surgery |
| Osmotic Diuretics Prototype: Mannitol: | IV, 30-60 min, 1 h, 6-8 h Irrigant, Rapid, Rapid, Short HL: 15-100 min; excreted unchanged in urine |
| Osmotic Diuretics Prototype: Mannitol: | Dizziness, headache, hypotension, rash, nausea, anorexia, dry mouth, thirst, diuresis, fluid and electrolyte imbalances *tachycardia, confusion, convulsions, shock* (risk of removing inter-cranial fluid too quickly) |
| Osmitrol (Mannitol) (memory) |  |
| Nursing Considerations - Potassium Wasting Diuretics | Measure BP, P before taking & regularly Monitor: daily weight (report 3 lb increase)(same scale, same time, same clothing), I & O, skin turgor, lung sounds, heart sounds Rise slowly Administer early in day, bathroom access Provide K+ diet Take with meals, milk to decrease GI upset Monitor electrolytes - K+, Ca +, glucose Adequate fluid intake - fluid rebound - page 816 Avoid extravasation if given IV |
| Potassium Rich Foods: | Avocados, Bananas, Broccoli, Cantaloupe, Dried fruits Grapefruit, Lima beans, Nuts, Navy beans , Oranges, Peaches, Potatoes, Prunes, Rhubarb, Sanka coffee, Sunflower seeds, Spinach, Tomatoes, Watermelon |
| Potassium-Sparing Diuretics Actions | Cause a loss of sodium while retaining potassium Block the actions of aldosterone in the distal tubule Highly protein bound (reduces effects of other protein bound drugs. can lead to lower protein bound drug toxicity die to increase in quantity in blood caused by displacement) |
| Potassium-Sparing Diuretics Indications | Adjuncts with thiazide or loop diuretics Patients who are at risk for hypokalemia |
| Potassium-Sparing Diuretics Contras | Allergy Hyperkalemia (can cause heart issues: cardiac arrest), renal disease, or anuria |
| Potassium-Sparing Diuretics Cautions | Pregnancy (Category B, C) and lactation |
| Potassium-Sparing Diuretics Drug-Drug | Salicylates digoxin Potassium supplements Ammonium chloride |
| Potassium-Sparing Diuretics Prototype: Spironolactone: Indications | Primary hyperaldosteronism, adjunctive therapy in the treatment of edema associated with CHF, nephritic syndrome, hepatic cirrhosis; treatment of hypokalemia or prevention of hypokalemia in patients at high risk if hypokalemia occurs; essential hypertension |
| Potassium-Sparing Diuretics Prototype: Spironolactone: | Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium |
| Potassium-Sparing Diuretics Prototype: Spironolactone: | Oral, 24-48 h, 48-72 h, 48-72 h HL: 20 hours; liver, urine |
| Potassium-Sparing Diuretics Prototype: Spironolactone: | Dizziness, headache, drowsiness, rash, cramping, diarrhea, hyperkalemia, hirsutism, gynecomastia, deepening of the voice, irregular menses, muscle weakness, paresthesis, bradycardia, decreased fertility, cardiac dysrhythmias |
| Nursing Considerations - Potassium-Sparing Diuretics | Measure BP, P before & at intervals Administer in AM with food or milk Daily weight (same clothes, time, scales) Assess for signs of fluid retention Teach to avoid salt substitutes or foods high in potassium and salt Monitor I&O Baseline & periodic electrolytes Discontinue 3 days before glucose tolerance test due to risk of severe hyperkalemia |
| Spironolactone (memory) |  |
| normal potassium levels: | 3.5 - 5 mg/dL |
| What is the most effective way for the nurse to evaluate effectiveness of diuretics? | pt's weight |
| John presents at the clinic with headaches due to stress. His blood pressure is 146/96 on two exams. The health care provider orders hydrochlorothiazide 25 mg daily. What instructions does the nurse give John regarding this medication? | weight daily (report more than 3lb gain to HCP) eat K rich foods bathroom accessible rise slowly (ortho-hypo) GI upset (take c food or milk) dry mouth headache |
| Fluid Rebound Explained: | Care must be taken when using diuretics to avoid fluid rebound, which is associated with fluid loss. If a patient stops taking inwater and takes the diuretic, the result will be a concentratedplasma of smaller volume. The decreased volume is sensed by the nephrons, which activate the renin-angiotensin cycle.When the concentrated blood is sensed by the osmotic center in the brain, antidiuretic hormone (ADH) is released to hold water and dilute the blood. The result can be a "rebound" edema as fluid is retained. Many patients who are taking a diuretic markedly decrease their fluid intake so as to decrease the number of trips to the bathroom. The result is a rebound of water retention after the diuretic effect. This effect can also be seen in many diets that promise "immediate results"; they frequently contain a key provision to increase fluid intake to 8 to 10 full glasses of water daily. The reflex result of diluting the system with so much water is a drop in ADH release and fluid loss. Some people can lose 5 lb in a few days by doing this.However, the body's reflexes soon kick in, causing rebound retention of fluid to re-establish fluid and electrolyte balance.Most people get frustrated at this point and give up the fad diet.It is important to be able to explain this effect. Teaching patients about balancing the desired diuretic effect with the actions of the normal reflexes is a clinical skill. |
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