Urinary medication

Urinary Medications

• Medications are filtered from the blood by the kidneys
• Renal disease, urine pH changes, and age can affect medication effectiveness
• Patients with renal disease often receive reduced doses to prevent further damage or toxicity.
• Changes in urinary pH affect the absorption rate of some medications.

Diuretics

Carbonic Anhydrase Inhibitors

• Inhibit carbonic anhydrase enzyme
• Increase excretion of sodium, potassium, bicarbonate, and water
• Used to treat glaucoma, altitude sickness, seizures, and heart failure
• Decreases aqueous humor production in the eye, lowering intraocular pressure.
• Adverse reactions include rare serious blood disorders, nausea, vomiting, electrolyte imbalances, glucose disturbances, flu-like symptoms, and paresthesia.
• Seek immediate medical attention if eye pain doesn't improve or worsens.

Loop Diuretics

• Increase sodium and chloride excretion
• Work in the loop of Henle
• Used with nephrotic syndrome, heart failure, and pulmonary edema
• Adverse effects include dehydration, hyponatremia, hypochloremia, hypokalemia, hypocalcemia, hypomagnesemia, hypotension, ototoxicity, and hyperglycemia.

Loop Diuretics: Interactions

• Digitalis toxicity can occur with hypokalemia
• Potassium supplements should be given as needed
• Concurrent use with antihypertensives is possible
• Lithium levels can rise to toxic levels with hyponatremia.
• NSAIDs decrease kidney blood flow and diuretic effectiveness
• Avoid use in pregnancy unless necessary
• Caution with patients with existing cardiovascular disease, diabetes, dehydration, electrolyte imbalances, and gout.
• Avoid use with clients taking digoxin, lithium, ototoxic medications, NSAIDs, or antihypertensives.

Thiazides and Related Diuretics

• Manage systemic edema and mild/moderate hypertension
• Aid calcium reabsorption in postmenopausal osteoporosis
• Adverse effects include electrolyte imbalances, dehydration, hyperglycemia, hyperuricemia, and joint pain
• Use cautiously in patients with liver disease, diabetes, lupus erythematosus, or diarrhea
• Contraindicated in pregnancy and those with kidney impairment
• Interactions similar to loop diuretics, but do not increase hearing loss.

Potassium-Sparing Diuretics

• Used for hypertension, edema, and heart failure by blocking aldosterone.
• Adverse effects include hyperkalemia, endocrine effects in men (deepened voice, impotence), menstrual irregularities in women, drowsiness, and metabolic acidosis.
• Interactions with ACE inhibitors, angiotensin II receptor blockers, and direct renin inhibitors may increase risk of hyperkalemia
• Contraindicated in those with hyperkalemia, anuria, or severe kidney failure. Not recommended for children
• Avoid potassium-rich foods and potassium-containing salt substitutes

Osmotic Diuretics (Mannitol)

• Increase plasma osmotic pressure, redistribute fluids towards blood vessels, lower intraocular pressure, manage cerebral edema, and improve renal function in acute kidney failure
• Contraindicated with active intracranial bleeding, anuria, severe pulmonary edema, severe dehydration, or kidney failure.
• Adverse effects include heart failure, pulmonary edema, rebound increase in intracranial pressure (ICP), fluid and electrolyte imbalances, and metabolic acidosis.
• Interactions increase lithium excretion and hypokalemia with cardiac glycosides (digoxin)

Osmotic Diuretics: Interactions

• Increase lithium excretion with cardiac glycosides (digoxin) leading to hypokalemia
• Patients with increased intracranial pressure require monitoring of weight, urine output, blood pressure, pulse, and respiratory rate.
• Neurologic assessments should be routine, especially in intervals, and watch for signs and symptoms indicating decreasing intracranial pressure.

Nursing Process: Assessment

Pre-administration Assessment

• Take baseline vital signs and weight
• Review pertinent laboratory results (electrolytes, BUN/Creatinine, urinalysis (U/A))
• Assess for peripheral edema (non-pitting vs. pitting)

Ongoing Assessment

• Measure and record fluid intake and output
• Avoid administering diuretics late in the day
• Report significant decreases in daily output to the health care provider
• Daily patient weight
• Watch for signs of hypokalemia or hypovolemia (lightheadness, dizziness, GI distress, or weakness).
• Assess for tinnitus or hearing loss
• Assess blood pressure (BP) and adjust patient positioning slowly
• Dietary advice (increased potassium if needed)
• Monitor glucose and electrolytes
• Medication education about the importance of taking all medication as prescribed.

Nursing Process: Implementation

Indications of Effectiveness

• Adequate kidney function (urine output ≥30 mL/hr)
• Normal creatinine levels (0.6-1.3 mg/dL)
• Normal BUN levels (10-20 mg/dL)
• Weight loss
• Decreased intracranial and intraocular pressures

Patient with Renal Compromise

• Monitor renal function regularly
• Monitor serum uric acid and glucose levels

####Educating the client and family

• Advise about treatment completion
• Explain importance of taking medications as prescribed
• Avoid reducing fluids to decrease urination
• Explain the importance of taking medication with food or milk
• Caution about alcohol and non-prescription drugs
• Emphasize caution while driving or performing hazardous tasks
• Explain necessary interventions (sitting up slowly if dizziness or weakness occurs)
• Monitor weight weekly or as recommended
• Teach daily BP and weight monitoring
• Importance of avoiding sunlight or ultraviolet light exposure (sunburn and photosensitivity)
• For those with diabetes, report increased blood glucose results

Nursing Interventions

• Monitor for fluid overload (changes in pulse, respirations, lung sounds)
• Daily weight monitoring
• Monitor I&O
• Monitor vital signs (VS) until stabilized
• Reinforce positions changes and possible adverse effects reporting
• Monitor BUN, electrolytes, and urine.
• Avoid excessive sodium.
• Avoid foods high in Potassium (baked potatoes, bananas, apricots, navel oranges, dates, tomatoes, tomato juice, sweet potatoes, kale, raisins etc..)

Medication Lists:

Loop Diuretics

• Bumetanide (Bumex)
• Furosemide (Lasix)
• Torsemide (Demadex)

Thiazides and Related Diuretics

• Chlorothiazide (Diuril)
• Hydrochlorothiazide (Microzide)
• Indapamide (Lozol)
• Metolazone (Zaroxolyn)

Potassium-Sparing Diuretics

• Amiloride HCl (Midamor)
• Spironolactone (Aldactone)

Osmotic Diuretics

• Osmitrol (Mannitol)

Carbonic Anhydrase Inhibitors

• Acetazolamide (Diamox)

Anti-Infectives

• Amoxicillin (Amoxil)
• Nitrofurantoin (Macrobid, Macrodantin)
• Trimethoprim and Sulfamethoxazole (Bactrim, Bactrim DS)
• Others (details in the slides referenced).

Anti-infective list: Additional details

• Used for treating UTIs caused by susceptible bacteria
• Rapid excretion in the urine
• High urine concentration interferes with bacterial reproduction.

Antispasmodics

• List of drugs, actions, interactions and more details found within slides

Other Urinary Medications

• Finasteride (Proscar)
• Tamsulosin (Flomax)
• Bethanechol Chloride (Urecholine)
• Nortriptyline (Pamelor)
• Other drugs (details are in the slides)