Elimination+GU+2.pdf

ELIMINATION Genitourinary Drugs – Diuretics C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Diuretic Drugs • Drugs that accelerate the rate of urine formation • Result in the removal of sodium and water • Used in the treatment of hypertension, heart failure...

ELIMINATION Genitourinary Drugs – Diuretics C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Diuretic Drugs • Drugs that accelerate the rate of urine formation • Result in the removal of sodium and water • Used in the treatment of hypertension, heart failure (HF), and renal failure ↓ Workload of 2 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Role of Loading… Kidneys 3 • Nephron is main structural unit of the kidney. • Diuretics exert their effect in the nephron. • Initial filtering of blood takes place in the glomerulus. • Glomerular filtration rate (GFR) • Afferent arterioles • Efferent arterioles COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D Kidney Structure 4 Kidney Structure (Cont.) COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D • Proximal convoluted tubule (proximal tubule) • Returns 60% to 70% of sodium and water from the filtered fluid back to the bloodstream • Passive reabsorption of chloride and water Loading… • Loop of Henle (ascending) • 20% to 25% of sodium is reabsorbed here through active chloride reabsorption. • Distal convoluted tubule (distal tubule) • Remaining 5% to 10% of sodium is reabsorbed here. • Regulated by aldosterone • Collecting duct • Final pathway 5 Audience Response System Question #1 Which location is the area where the highest percentage of sodium and water are resorbed back into the bloodstream? A. B. C. D. Glomerulus Proximal tubule Ascending loop of Henle Distal tubule NOTE: No input is required to proceed. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 6 Answer to System Question #1 ANS: B The proximal convoluted (twisted) tubule or, more simply, proximal tubule, anatomically follows the glomerulus and returns 60% to 70% of the sodium and water from the filtered fluid back into the bloodstream. Another 20% to 25% of sodium is resorbed into the bloodstream in the ascending loop of Henle. The remaining 5% to 10% of sodium resorption takes place in the distal convoluted tubule, often called simply the distal tubule, which anatomically follows the ascending loop of Henle. The glomerulus does not resorb sodium or water but instead is the point of initial filtration of the blood. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 7 Pharmacology Overview • Diuretics classified according to their sites of action within the nephron, their chemical structure, and diuretic potency Types of Diuretic Drugs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 8 •Bumetanide (Bumex) Loop Diuretics COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D •Ethacrynic acid (Edecrin) •Furosemide (Lasix) •Torsemide (Demadex) 9 Loop Diuretics: Mechanism of Action COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D • 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 10 11 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . HT Orthostatic Monifor 12 Lab Work Monitor - Potent Diuresis , loss Fluid for D electrical ↓ Loop Diuretics: Loading… Vas . Pulmonary Drug Systemic Effects K- Supplement charge volume · cause BP rest · . Vas · k + Na . rest Depletion of Loop Diuretics: Indications C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 12 Loop Diuretics: Adverse Effects Body system Adverse effects Central nervous system (CNS) Dizziness, headache, tinnitus, blurred vision Gastrointestinal (GI) Nausea, vomiting, diarrhea Integumentary Stevens-Johnson (torsemide) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 13 Loop Diuretics: Adverse Effects (Cont.) Body system Adverse effects Hematologic Agranulocytosis, neutropenia, thrombocytopenia Metabolic Hypokalemia, hyperglycemia, hyperuricemia COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 14 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Loop Diuretics: Interactions Neurotoxicity Nephrotoxic Increase serum levels of Uris cid glucose alanine aminotransferase and aspartame aminotransferase Thiazide metolazone: sequential nephron blacked NSAIDs 15 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Loop Diuretics: Furosemide (Lasix) 16 Most commonly used Uses pulmonary edema and the edema associated with HF liver D nephrotic syndrome ascites and HT Audience Response System Question #2 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. B. C. D. Lithium (Eskalith) Acetaminophen (Tylenol) Penicillin Theophylline NOTE: No input is required to proceed. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 17 Answer to System Question #2 ANS: A Use of loop diuretics with lithium can increase the risk of lithium toxicity. Drug interactions with loop diuretic therapy can occur with concurrent use of nonsteroidal antiinflammatory drugs (NSAIDs), and vancomycin can cause increased neuro- and ototoxicity when used with loop diuretics. There is no associated risk of drug interaction when taking acetaminophen, penicillin, or theophylline with loop diuretics. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 18 PotassiumSparing Diuretics Amiloride midamor ' ' Spironolctone ldactone Trimterene dyrenium Aka aldosterone-inhibiting diuretics C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 19 Work in: collecting ducts n distal convoluted tubules PotassiumSparing Diuretics: Mechanism of Action Interfere: with Na-K exchange Bind: competitively bind to lobster one receptors C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 20 Prevent K from being pumped, preventing secretion PotassiumSparing Diuretics: Drug Effects Block=binds lobster one receptions n inhibit action Promote excretion on Na and H2O Sparing = holds on to C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 21 PotassiumSparing Diuretics: Indications Spironolactone n triamterene -hyperaldosteronism -HT -reversing K loss caused by K-losing drugs -HF ——something with a C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 22 PotassiumSparing Diuretics: Adverse Effects Body system Adverse effects CNS Dizziness, headache GI Cramps, nausea, vomiting, diarrhea Other Urinary frequency, weakness, hyperkalemia C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 23 PotassiumSparing Diuretics: Adverse Effects (Cont.) COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D • Spironolactone (Aldactone) • Gynecomastia Male breast • Amenorrhea Lack of period • Irregular menses • Postmenopausal bleeding 24 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Lithium Ngiotensin-converting enzyme inhibitors PotassiumSparing Diuretics: Interactions K supp. NSAIDs 25 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Thiazide and ThiazideLike Diuretics • hydrochlorothiazide Chloro 26 Thiazide and Thiazide-Like Diuretics: Mechanism of Action Inhibit tubular resorption of Na, Cl, and K ions Action in distal convoluted tubes Result: H2O, Na, and cl are excreted K is also excreted to lesser extent C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 27 Thiazide and ThiazideLike Diuretics: Drug Effects Lower peripheral vaIscular resistance —lowers resistance so fluid can get back to the kidneys Depletion of Na and H20 (n K) Thiazides should not be used if creatinine clearance is less than 30-50 Metolazone remains effective to a creatinine clearance of 10 mL/min C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 28 Thiazide and Thiazide-Like Diuretics: Indications HT (one of the most prescribed group of drugs for this) Loading… C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 29 Thiazide Not as many neg effects, not as much monitoring Thiazide and ThiazideLike Diuretics: Adverse Effects Loop has the most monitoring Body system Adverse effects CNS Dizziness, headache, blurred vision GI Anorexia, nausea, vomiting, diarrhea Genitourinary Impotence Hematologic Jaundice, leukopenia C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . Less WBC 30 Thiazide and Thiazide-Like Diuretics: Adverse Effects (Cont.) Body system Adverse effects Integumentary Dizziness, headache, blurred vision Metabolic Hypokalemia, hyperglycemia, hyperuricemia, hypochloremic alkalosis C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 31 Preform: Hx and physical exam Assess: baseline fluid volume state, I+O, serum electrolytes Take in the AM—avoid sleep distrubance Nursing Implications Monitor serum K levels during therapy, except for sparking K All diuretics monitor K C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 32 C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 33 Maintain proper nutritional and fluid volume Eat more K rich foods but the K-sparing drugs Foods- bananas, oranges, dates, raisins, green beans Nursing Implications (Cont.) Diuretics with digitalis preparation should be taught to monitor for digitalis tox.. need apical HR Pt with diabetes taking thiazide or look. Should monitor blood sug and watch for elevated levels Hydrochlorithrizide- has sever interaction w/ digoxin —-toxic! Nursing Implications (Cont.) Change positions slowly and rise slowly Log daily weight F/u visits and lab work S/s hypok. Weakness, costipation, dizzy C O P Y R I G H T © 2 0 2 0 E L S E V I E R I N C . A L L R I G H T S R E S E RV E D . 34 Nursing Implications (Cont.) Excessive licorice can increase hypok. Rapid HR call doc Monitor for hyperK. W/ K sparing AD. Effects, metabolic as COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 35 COPYRIGH © 2020 ELSEVIER INC. ALL RIGHTS R E S E RV E D Nursing Implications (Cont.) • Monitor for therapeutic effects: • Reduction of edema • Reduction of fluid volume overload • Improvement in manifestations of HF • Reduction of hypertension • Return to normal intraocular pressures 36 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. 1. Which class of diuretic does the nurse anticipate administering? A. B. C. D. Potassium sparing Thiazide Osmotic Loop NOTE: No input is required to proceed. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 37 Answer to Case Study Question #1 ANS: D The loop diuretics provide rapid diuresis because of their rapid onset of action. Loop diuretics are effective for patients with reduced kidney function (creatinine clearance below 25 mL/min). COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 38 Case Study The patient is ordered furosemide (Lasix). 2. 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 NOTE: No input is required to proceed. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 39 Answer to Case Study Question #2 ANS: B The nurse should assess patients receiving furosemide (Lasix) for cross-sensitivity to sulfonamides. Although allergy to sulfonamide antibiotics is listed as a contraindication, analysis of the literature indicates that cross-reaction with the loop diuretics is unlikely to occur. Loop diuretics are commonly given to such patients in clinical practice. The nurse should closely monitor these patients. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 40 Case Study Two days after admission, the nurse is reviewing laboratory results of the patient. 3. Which is the most common electrolyte finding resulting from the administration of furosemide (Lasix)? A. B. C. D. Hypocalcemia Hypophosphatemia Hypokalemia Hypomagnesemia COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 41 Answer to Case Study Question #3 ANS: C Of all of the adverse effects of furosemide (Lasix) administration, hypokalemia is of serious clinical importance. To prevent hypokalemia, patients often receive potassium supplements along with furosemide. The other electrolyte disturbances listed do not occur as a result of furosemide (Lasix) therapy. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 42 Case Study The patient is being discharged home with furosemide (Lasix). 4. When providing discharge teaching, which instruction will the nurse include? A. B. C. D. Avoid prolonged exposure to the sun. Avoid foods high in potassium content. Stop taking the medication if you feel dizzy. Weigh yourself once a week and report a gain or loss of more than 1 lb. NOTE: No input is required to proceed. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 43 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 Answer to Case Study Question #4 ANS: A Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 lb. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44