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Chapter 22 Drugs Used for Diuresis Diuresis means the increased formation and excretion of urine Diuretic: a drug that promotes the formation and excretion of urine Diuretics increase the flow of urine Purpose is to increase the loss of water from the body, the do this by increasing the excretion of sodium Used in treatment of hypertension and heart failure Used to treat cerebral edema, glaucoma and liver disease Ascites: abnormal accumulation of fluid in the peritoneal cavity (fig 22-1) Peritoneum is a 2 layer membrane that lines the abdomen, the peritoneal cavity is the space between them SEE BOX 22-1 (pg. 284) for a review of urinary system Delegation Guidelines Drugs Used for Diuresis: Some drugs used for diuresis are given parenterally- by intramuscular or intravenous injection. Because you do NOT give parenteral dose forms, they are NOT included in this chapter. Should a nurse delegate the administration of such to you, you must: - remember that parenteral dosages are often very different from dosages other routes -Refuse the delegation. Make sure to explain why. Do NOT just ignore the request. Make sure the nurse knows that you cannot give drug and why Loop Diuretics: Loop of Henle is u-shaped part of renal tubule (fig 22-3) has thin descending limb and a thick ascending limb loop diuretics inhibit the re-absorption of sodium and chloride from the ascending loop of Henle goals of therapy: ◦ promote diuresis ◦ reduce edema ◦ improve symptoms related to excess fluid in tissues drugs used for diuresis bumetanide (Bumax): ◦ strong diuretic ◦ inhibits sodium and chloride re-absorption in the ascending loop of Henle ◦ increases blood flow to the glomeruli ◦ diuretic activity begins in 30-60 minutes after administration, peaks within 1-2 hours and lasts 4-6 hours ◦ drug is used to treat edema from heart failure and kidney disease Assisting With the Nursing Process bumetanide (Bumex) ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea, measure blood glucose if person has diabetes PLANNING: oral dose form: 0.5, 1, and 2mg tablets IMPLEMENTATION: initial adult dose is 0.5 to 2mg given as a single, daily dose. additional doses may be given at 4-5 hour intervals. max daily dose is 10mg. Give drug with food/milk. Give before mid-afternoon, prevents nocturnia EVALUATION: report and record: - oral irritation, dry mouth: give oral hygiene as directed by the nurse/care plan, if nurse allows give hard candy or ice chips - orthostatic hypotension, dizziness, weakness, fainting: BP is measured daily (supine/standing), provide for safety - stomach irritation, abdominal pain: give drug with food/milk - changes in alertness and orientation to person, time, place.. - confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) drugs used for diuresis cont… ethacrynic acid (Edecrin): ◦ inhibits sodium and chloride re-absorption in the ascending loop of Henle ◦ diuretic activity begins in 30 minutes ◦ peaks in 2 hours and lasts 6-8 hours ◦ used: to treat edema from heart failure, liver disease, kidney disease and cancer Assisting With the Nursing Process ethacrynic acid (Edecrin) ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea, measure blood glucose if person has diabetes PLANNING: oral dose form: 25 and 50mg tablets IMPLEMENTATION: initial adult dose is 50-100mg, followed by 50200mg daily. Max daily dose is 400mg/day. give with food or milk, give before mid-afternoon to prevent nocturia EVALUATION: report and record: orthostatic hypotension, dizziness, weakness, fainting: BP is measured daily (supine/standing), provide for safety - changes in alertness and orientation to person, time, place.. - confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) - “coffee ground” vomitus: dark tarry stools: signal GI bleeding - changes in hearing/balance, deafness, tinnitus: person with impaired kidney function may have these symptoms - diarrhea: may become severe: dehydration and electrolyte imbalance are risks - hyperglycemia: may occur with person who has or is at risk for diabetes drugs used for diuresis cont… furosemide(Lasix): ◦ acts on ascending loop of Henle to prevent sodium and chloride re-absorption ◦ acts on proximal and distal portions of the tubule to prevent sodium and chloride re-absorption ◦ maximum effect from oral dose forms occurs in 12 hours, lasts 4-6 hours ◦ this drug is one of the strongest and most effective diuretics currently available ◦ the drug is used to treat edema from heart failure and liver and kidney diseases, hypertension ◦ used alone or with other anti-hypertensives Assisting With the Nursing Process furosemide (Lasix): ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea, measure blood glucose if person has diabetes, observe for signs of hearing loss PLANNING: oral dose form: 20, 40, 80mg tablets, 10mg/mL and 40mg/5mL oral solution IMPLEMENTATION: persons allergic to sulfonamides (ch. 34) may also be allergic to furosemide. Adult dose is 20-80mg given as single dose. If 2nd dose needed it is given 6-8 hours later. Dose is increased 20-40mg per day, usually given in morning. Give drug with food/milk EVALUATION: report and record: - oral irritation, dry mouth. Give oral hygiene as directed by nurse/care plan. Nurse may allow for hard candy or ice chips orthostatic hypotension, dizziness, weakness, fainting: BP is measured daily (supine/standing), provide for safety - changes in alertness and orientation to person, time, place. - confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) - hyperglycemia: may occur with person who has or is at risk for diabetes - hives, rash, itching: may signal allergic reaction, tell nurse at once. Do not give next dose unless approved by nurse drugs used for diuresis cont… torsemide (Demadex): ◦ acts on ascending loop of Henle to prevent sodium and chloride re-absorption ◦ maximum effect from oral dose forms occurs in 1 -2 hours, lasts for 6-8 hours. ◦ drug is used to treat edema from heart failure and liver and kidney diseases, and hypertension ◦ used alone or with other anti-hypertensive agents Assisting With the Nursing Process torsemide (Demadex): ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea, measure blood glucose if person has diabetes, observe for signs of hearing loss PLANNING: oral dose form: 5, 10, 20, 100mg tablets IMPLEMENTATION: persons allergic to sulfonamides (ch. 34) may also be allergic to torsemide (Demadex). Adult dose is 5-20mg once/day. Dose may be doubled until the desired response is achieved. EVALUATION: report and record: oral irritation, dry mouth. Give oral hygiene as directed by nurse/care plan. Nurse may allow for hard candy or ice chips orthostatic hypotension, dizziness, weakness, fainting: BP is measured daily (supine/standing), provide for safety changes in alertness and orientation to person, time, place. confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) hyperglycemia: may occur with person who has or is at risk for diabetes hives, rash, itching: may signal allergic reaction, tell nurse at once. Do not give next dose unless approved by nurse drugs used for diuresis cont… Thiazide Diuretics: ◦ act on distal tubules to block the re-absorption of sodium and chloride ◦ sodium and chloride that are not re-absorbed take water with the, this results in diuresis ◦ used in treatment of edema from: heart failure kidney disease liver disease pregnancy obesity pre-menstrual syndrome administration of cortico-steroids (ch 28) ◦ thiazides also have anti-hypertensive effects, cause vaso-dialation of peripheral arterioles ◦ goal of therapy: promote diuresis reduce edema improve symptoms related to excess fluid in tissues reduce BP Assisting With the Nursing Process thiazides: ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea, measure blood glucose if person has diabetes, observe for signs of hearing loss PLANNING: see 22-1 and 22-2 (pg 288) for “Oral Dose Forms” IMPLEMENTATION: see 22-1 and 22-2 (pg 288) for “Adult Dosage Range”, give drug before mid-afternoon, prevents nocturia. For hypertension: most of the diuretics listed are given in divided doses. For edema: most listed are given in single daily doses EVALUATION: report and record: orthostatic hypotension, dizziness, weakness, fainting: BP is measured daily (supine/standing), provide for safety stomach irritation, nausea, vomiting, constipation: give drug with food/milk changes in alertness and orientation to person, time, place. confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) hyperglycemia: may occur with person who has or is at risk for diabetes hives, rash, itching: may signal allergic reaction, tell nurse at once. Do not give next dose unless approved by nurse drugs used for diuresis cont… Potassium-Sparing Diuretics: ◦ excrete sodium but retain potassium ◦ examples: amiloride (Midamor) spironolactone (Aldactone) triamterene (Dyrenium) drugs used for diuresis cont… amiloride (Midamor): ◦ acts on distal renal tubule to retain potassium and excrete sodium ◦ diuresis is mild ◦ drug has weak anti-hypertensive effects ◦ used with other diuretics to treat hypertension or heart failure ◦ goals of therapy: -reduce edema -improve symptoms related to excess fluid in tissues Assisting With the Nursing Process amiloride (Midamor) ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea PLANNING: Oral Dose Form is 5mg tablets IMPLEMENTATION: initial dose is 5mg daily, dosages may be increased by 5mg to achieve a max daily dose of 20mg, give drug with food/milk, give drug before mid-afternoon, this prevents nocturia EVALUATION: report and record: anorexia, nausea, vomiting, flatulence: should be mild if drug is given with food headache: measure BP changes in alertness and orientation to person, time, place. confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) drugs used for diuresis cont… spironolactone (Aldactone): ◦ blocks the sodium-retaining properties of aldosterone (ch. 19) ◦ it blocks potassium and magnesium excretion caused by aldosterone ◦ sodium and water are excreted ◦ drug is useful in relieving edema and ascites that do not respond to usual diuretics ◦ may be given with other diuretics ◦ goals of therapy: reduce edema improve symptoms related to excess fluid in tissues improve symptoms from heart failure Assisting With the Nursing Process spironolactone (Aldactone): ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea PLANNING: Oral Dose Forms are 25, 50, 100mg tablets IMPLEMENTATION: initial dose is 50-100mg daily, maintenance dose is 100- 200mg daily, some persons need up to 400mg daily. Give drug with food/milk. Give drug before mid-afternoon, prevents nocturia EVALUATION: report and record: confusion: provide for safety headache: measure BP diarrhea: note the number and consistency of stools changes in alertness and orientation to person, time, place, confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) breasts may enlarge in men: breast tenderness and menstrual irregularities in women. These reverse when therapy is discontinued drugs used for diuresis cont… triamterene (Dyrenium): ◦ mild diuretic ◦ blocks the exchange of potassium for sodium in the distal tubules ◦ potassium is retained ◦ sodium and water are excreted through urine ◦ goals of therapy: cause diuresis improve symptoms related to excess fluid in tissues Assisting With the Nursing Process triamterene (Dyrenium): ASSESSMENT: measure: vital signs, weight daily, intake/output, observe alertness and orientation to person, time and place, observe for : confusion, muscle strength, tremors, ask about muscle cramps, nausea PLANNING: Oral Dose Forms are 50 and100mg tablets IMPLEMENTATION: initial dose is 50-150mg daily, 2x/day EVALUATION: report and record: changes in alertness and orientation to person, time, place, confusion , nausea, muscle cramps: may signal dehydration or electrolyte imbalance (potassium, sodium and chloride) hives, rash, itching: may signal an allergic reaction. Tell nurse at once, do NOT give next dose unless approved by nurse drugs used for diuresis cont… Combination Diuretic Products: ◦ low potassium (hypokalemia) is a common problem with thiazide diuretics ◦ several products contain a potassium-sparing diuretic with a thiazide diuretic (table 22-3 p. 290) ◦ the goal is to promote diuresis and antihypertensive effects while maintaining normal potassium levels ◦ persons receiving a combination product are at risk for side effects from each of the drugs in product ◦ high potassium and low sodium levels have been reported