Diuretics PDF

Diuretics Medications - High-ceiling loop: - Furosemide, Ethacrynic acid, Bumetanide, Torsemide - Take extra potassium & sodium with these - Thiazide : - Hydrochlorothiazide (HCT2), chlorothiazide, methyclothiazide - Taken 2x daily...

Diuretics Medications - High-ceiling loop: - Furosemide, Ethacrynic acid, Bumetanide, Torsemide - Take extra potassium & sodium with these - Thiazide : - Hydrochlorothiazide (HCT2), chlorothiazide, methyclothiazide - Taken 2x daily - Potassium- sparing - Spironolactone, Triamterene, Amiloride - Don't use salt substitutes (Mrs. Dash seasoning) - Use for heart failure & hypertension - Osmotic: - Mannitol- drops everything, ICU med Differentiate diuretic type by disposition of electrolyte imbalance - High-ceiling loop - Blocks reabsorption of sodium and chloride and prevents reabsorption of water - Severe renal impairment - Thiazide - Promotes diuresis when renal function is not impaired - Potassium-sparing - Administered for heart failure - Combined with other diuretics Loop and thiazide for potassium-sparing effects to treat hypertension and edema - Osmotic - Osmotic diuretics lower pressure in the brain and eyes by making the blood thicker, which pulls extra fluid from tissues back into the bloodstream. Foods to eat/avoid based on diuretic type - High-ceiling loop - EAT: Foods high in potassium (dark leafy greens) & sodium - Thiazide - EAT: Foods high in potassium - LIMIT: spinach & tomatoes - Potassium- sparing - AVOID: Salt substitutes, - Osmotic Complications - High-ceiling loop - Dehydration  - Hypotension - Ototoxicity (damage to the ear, can cause tinnitus) - Hypokalemia: CONSUME bananas, potatoes, dried fruits and nuts, spinach, citrus fruits - Leg cramps** - Electrolyte imbalances: hypo-everything - Thiazide - Dehydration & hyponatremia - Hypokalemia & hypochloremia - Hypokalemia is big on leg cramps. (K+ less than 3.5 mEq/L) - s/sx of N/V/D/ fatigue - Potassium- sparing - “i feel off” - Hyperkalemia*** only one that is HYPERkalemia. - Dyspnea & dysrhythmias - No potassium substitutes, no salt - Amenorrhea - Gynecomastia - Impotence (erectile dysfunction) - Monitor potassium levels & EKG - tumors - Osmotic - Monitor potassium & ECG Client education - High-ceiling loop - Change positions slowly & monitor BP - If BP too low, skip dose & increase fluids - Eat high- potassium foods/ monitor I&O - Watch for leg cramps - Thiazide - Watch for leg cramps - Take first thing in the AM, no later than 2PM - Weigh self at same time everyday - Increase potassium rich foods & fluid intake - Potassium- sparing - No salt or potassium - Monitor BP & weight - Osmotic - Change positions slowly  - Monitor for hypovolemia: a condition that occurs when the body loses too much fluid, such as blood or water, and is characterized by low blood or fluid levels - Report weight loss, lightheadedness, dizziness, gi distress, generalized weakness ACE Inhibitors Medications - Captopril, enalapril, enalaprilat, fosinopril,Lisinopril, ramipril, moexipril, benazepril, quinapril, trandolapril, perindopril - Vasodilation (arteriole), makes flow easier in body - Worry about hypotension Client Education - Change positions slowly & monitor BP - Watch for dry cough - Avoid salt substitutes & potassium - Watch for tongue swelling; treat w epi (when on Ramipril) - Take captopril & moexipril 1 hr before meals - Watch for rash & altered taste (dysgeusia) Therapeutic Findings - Use for HYPERtension to bring BP down - Heart failure - MI - Diabetic nephropathy - Ramirpil; prevent MI, stroke, death Complications - Hypotension w/ 1st dose - Dry persistent cough = NOT GOOD - angioedema; allergic reaction ARB Medications - Losartan, Azilsartan, Valsartan - Block the action of angiotensin 2 - Vasodilation - Excretion of sodium and water - ARB’s do not cause hyperkalemia Client education - Avoid grapefruit juice** - Take BP before each dose - Take at same time every day - Use birth control  - Monitor for dizziness/lightheadedness - Nursing interventions - Monitor lithium levels - Check BP before each dose - Give at same time everyday Complications - Hypotension - dizziness & lightheadedness Calcium Channel Blockers Medications - Nifedipine, Verapamil, Diltiazem - Nausea, Vomiting, Diarrhea Complications - For Nifedipine - Reflex tachycardia - Acute toxicity - Orthostatic hypotension & peripheral edema - For Verapamil & Diltiazem - Orthostatic hypotension & peripheral edema - Constipation - Suppression of cardiac function - Dysrhythmias - Acute toxicity Client Education - Observe for swelling in lower extremities - Monitor for postural hypotension - Increase high fiber intake and oral fluids - Observe of cardiac function (slow pulse, activity intolerance) Interactions - ALWAYS GRAPEFRUIT JUICE*** - Nifedipine - Beta-blockers are used to treat reflex tachycardia (heart rate rapidly increases as a reflex response to a drop in blood pressure) - Cimetidine, famotidine, and grapefruit juice can lead to toxicity - Verapamil Diltiazem - Verapamil can increase digoxin levels which increases the risk of digoxin toxicity - Concurrent use of beta-blockers can lead to heart failure, AV block, and bradycardia - Consuming grapefruit juice while on these can lead to toxicity Centrally Acting Alpha2 Agonists Medications - Clonidine - Guanfacine** - Methyldopa** Complications - Drowsiness & sedation - Drowsiness will diminish as the use of medication continues - Dry mouth Nursing Complications - Avoid activities that require mental alertness - Be compliant with the medicine regimen - Resolves within 2-4 weeks - Chew gum/ hard candy, take small amounts of water or ice chips Beta Blockers Medications - Cardioselective: only affects the heart (A-M) - Metoprolol - Atenolol - Esmolol - Nonselective: affects both lungs & heart (N-Z) - Propranolol - Nadolol - Alpha & Beta-blockers - Carvedilol - Labetalol Precautions CARDIOSELECTIVE DRUGS: METOPROLOL NONSELECTIVE: PROPRANOLOL - Bradycardia - 50 bpm and below, hold med & notify the provider - DECREASED CARDIAC OUTPUT - Increase in skin temp, +3 pulse, urine output Client Education - Change positions slowly - Monitor blood sugar for HYPOglycemia - Monitor for excessive shortness of breath, edema, weight gain & fatigue - Nonselective beta blockers are contraindicated for ppl with asthma, bronchospasm & heart failure Medications for hypertensive crisis Medications - Nitroprusside - Nitroglycerin - Nicardipine Complications - Excessive HYPOtension - Administer slowly, monitor ECG, and BP continuously, and keep pt supine during admin - **Cyanide poisoning/thiocyanate toxicity** - Headache and drowsiness, and can lead to cardiac arrest - Nitroprusside only - Tylenol safe for headaches with this Cardiac Glycosides medications - Digoxin - Under 60 bpm hold & notify MD - Adults: 60 bpm and below - Children: 7-bpm and below - Infants: 90 bpm and below - Most recent potassium level*** Toxicity s/sx - Gi effects - anorexia, N/V, abdominal pain, vision changes - Loss of appetite: “Im not hungry” - CNS effects - Fatigue, weakness, vision changes (blurry vision & yellow-green or white halos around objects) - Assess pt. vitals , potassium levels & labs Management of digoxin toxicity - Stop digoxin and potassium-wasting diuretics immediately - Monitor potassium levels & if under 3.5 admin potassium IV or PO. do not give for levels over 5.0 or AV block is present - Treat dysrhythmias with phenytoin or lidocaine - Treat bradycardia with atropine - EXCESSIVE TOXICITY, treat with activated charcoal, cholestyramine, or digoxin immune fab can be used to bin digoxin and prevent absorption Administration - IV admin give slowly over 5 minutes but 10-15 minutes for ppl with pulmonary edema and monitor for dysrhythmias - Give at same time daily  - Assess HR - Adults: 60 bpm and below - Children: 70 bpm and below - Infants: 90 bpm and below - AVOID OTC meds to prevent adverse effects Client education - Monitor gi effects closely - Monitor HR & rhythm - Take med as prescribed, if a dose is missed DO NOT DOUBLE UP next dose Organic Nitrates Medications - Nitroglycerin (NTG) - All types of administration types available - Pt sent home with sublingual most of the time - IV contains micro dosing Complications - Headache - Orthostatic hypotension - Reflex tachycardia that can result from hypotension - tolerance ** - Only take this 3x - Wait 5 minutes then take another, when taken 2nd pill call 911 Client education - Use aspirin or acetaminophen for pain - Notify MD if headaches do not go away - Change positions slowly - Lie down with feet elevated to promote venous return and increase BP Nursing interventions - Monitor vitals - Give a beta-blocker (metoprolol) if needed or a calcium channel blocker (verapamil)which can prevent sympathetic cardiac stimulation that results in a decreased cardiac oxygen demand by direct supervision of heart *** Transdermal patch only 10-12 hours MAX ***SR tabs, take whole, do not crush or chew Treatment of anginal attack using sublingual tabs/spray - Stop activity - Immediately put tablet under the tongue, let it dissolve, rest for 5 minutes - If pain is not relieved by the first tablet, call 911 then take a 2nd tablet - After another 5 minutes, take 3rd tablet if the pain is still not relieved but do not take more than 3 sublingual tabs Statins: Medications - Atorvastatin, simvastatin, lovastatin, pravastatin, Rosuvastatin, fluvastatin, pitavastatin, - NO GRAPEFRUIT JUICE*** except pravastatin you can take it with - Simvastatin & Ezetimibe for cholesterol - Decrease LDL & VLDL cholesterol Pre-administration assessments - Monitor liver & creatinine levels beforehand - You can take them PO - Lovastatin must be taken with meals, others are okay without food, but evening dosing is better because cholesterol is synthesized during night Nursing interventions - Obtain liver function baseline - Obtain creatine levels before Client education - Monitor for liver dysfunction (anorexia, vomiting, nausea, jaundice) - No alcohol - Report muscle aches, pains, and tenderness - Report all meds currently taking - Complications - Hepatotoxicity - Obtain baseline liver function tests - Med can be discontinued if LFTs are above the expected reference range - Myopathy - Muscle pains/cramps - Vitamin B3, Niacin, decreases LDL & VLDL - Overdose: causes flushed look - Hypotension: headaches, dizziness, cough Interactions - Grapefruit juice suppresses CYP3A4 and can increase the levels of some statins Bile-Acid Sequestrants: Medications - Colesevelam, colestipol, cholestyramine Medication administration - Monitor liver functions before admin - Colesevelam is taken orally in tablet form, should be taken w food & 8oz water, with no other meds  - Colestipol is given as an oral tablet & cannot be crushed or chewed, given 30 mins before meals. Also supplied as a powder form separately Client education - Increase fluid & fiber intake - Take meds that interact with bile-acid sequestrants 1 hr before or 4 hours after Interactions - Bile acid sequestrants interfere with the absorption of many meds - They also form insoluble complexes with thiazide diuretics, digoxin, and warfarin Hepatotoxicity - Monitor liver function tests before admin They drop LDL hepatotoxicity= liver function tests Binds to LDL= pass it thru fecal matter, can cause constipation Anticoagulants: Medications - Heparin - INR & aPTT for test - PTT = 1.5-2 times baseline - Enoxaparin- no overdose, longer half-life, less dose - Fondaparinux- no overdose, longer half-life, less dose - antidote for warfarin is vitamin K Antidotes/reversal agents Labs (which tests are associated with which medication) Complications - Heparin - Hemorrhage secondary to heparin toxicity or other factors Interactions - Antiplatelet agents (aspirin, NSAIDs, other anticoags) can increase the risk for bleeding. Resveratrol and saw palmetto can also have antiplatelet effects Thrombolytics: Medications - Alteplase - Tenecteplase - Reteplase Precautions/ Contraindications - Prior intracranial hemorrhage - Known structural cerebral lesion - Active internal bleeding  - Ischemic stroke within the past 3 months other than the current episode (within prior 4.5 hrs) Interactions - Concurrent use of other meds that enhance bleeding (NSAIDS, heparin, warfarin, thrombolytics, antiplatelets) increases the risk of bleeding Nursing interventions - Limit venipuncture & injections - Apply pressure dressings to recent wounds - Monitor for changes in vital signs, changes in level of consciousness, weakness, and indications of intracranial bleeding, and indications of bleeding - Monitor aPTT and PT, Hgb, and Hct - May require blood product replacement - For severe bleeding, fibrinolysis following alteplase can be reversed by administration of aminocaproic acid IV Antiplatelets: Medications - Aspirin, abciximab, clopidogrel, cilostazol - Prevents platelets from clumping together Complications - Aspirin - Gi effects N/V/Dyspepsia - Hemorrhagic stroke - Prolonged bleeding time, gastric bleed, thrombocytopenia - Tinnitus, hearing loss - Abciximab - Hypotension and bradycardia - Prolonged bleeding time, gastric bleed, thrombocytopenia, bleeding from cardiac cath site - Clopidogrel - Bleeding - Gi effects (diarrhea, dyspepsia, and pain) Interactions - Aspirin - Feverfew, garlic, ginger, glucosamine, ginkgo biloba, resveratrol, saw palmetto can increase the risk of bleeding