Diuretics

Diuretic Therapy and Drugs

for Renal Failure
Diuretics, sometimes called water pills, help rid
your body of salt (sodium) and water. Most work
by making your kidneys release more sodium into
your urine. The sodium then takes water with it
from your blood. That decreases the amount of
fluid flowing through your blood vessels, which
reduces pressure on your vessel walls.

Lasix

Aldactone
 BRAND NAME Furosemide (fur-oh-se-mide)

GENERIC NAME: Lasix

CLASSIFICATIONS:
TIME/ACTION
Therapeutic: diuretics PROFILE (diuretic
Pharmacologic: loop diuretics
effect)
PREGNANCY CATERGORY:
ROUTE C

ONSET
INDICATIONS: Edema due to heart failure, hepatic impairment or renal
PEAK disease. Hypertension.

DURATION
ACTION: Inhibits the reabsorption of sodium and chloride from the
loop of Henle and distal renal tubule. Increases renal
PO
excretion of water, sodium, chloride, magnesium, po-
30 – 60 min tassium, and calcium. Effectiveness persists in impaired renal
function.
1 – 2 hr
THERAPEUTIC EFFECTS: Diuresis and subsequent mobilization of excess fluid (edema,
6 – 8 hr
pleural effusions). Decreased BP.
IM
PHARMACOKINETICS:
10 – 30 min

unknown Absorption: 60 – 67% absorbed after oral administration (pin acute HF

and in re-nal failure); also absorbed from IM sites.
4 – 8 hr

IV
Distribution: Crosses placenta, enters breast milk.
5 min

30 min
Protein Binding: 91 – 99%.
2 hr

Metabolism and Excretion: Minimally metabolized by liver, some nonhepatic

CONTRAINDICATIONS/PRECAUTIONS:
metabolism, some renal excretion as unchanged drug.

Contraindicated in: Hypersensitivity; Cross-sensitivity with thiazides and

Half-life: sulfonamides mayrenal
30 – 60 min (qin occur; Hepatic coma or anuria; Some
impairment).
liquid products may contain alco-hol, avoid in patients with
 Endo: hypercholesterolemia, hyperglycemia,
hypertriglyceridemia, hyperuricemia.
PO (Children 1 mo): 2 mg/kg as a single dose; may beqby 1 –
F and E:
2 mg/kg q 6dehydration, hypo-calcemia,
– 8 hr (maximum hypochloremia,
dose 6 mg/kg).
hypokalemia, hypomagnesemia, hyponatremia,
PO (Neonates): 1 – 4 mg/kg/dose
hypovole-mia, metabolic 1alkalosis.
– 2 times/day.

Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS,

hemolytic
IM, IV (Adults): 20anemia,
– 40 mg,leukopenia,
may repeatthrombocytopenia.
in 1 – 2 hr andqby 20
MS: muscle cramps.
mg every 1 – 2 hr until response is obtained, maintenance dose
may be given
Neuro: q 6 – 12 hr; Continuous infusion— Bolus 0.1
paresthesia.
mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum
ofMisc: fever.
0.4 mg/kg/hr.

IM, IV (Children): 1 – 2 mg/kg/dose q 6 – 12 hr Continuous

infusion— 0.05 mg/ kg/hr, titrate to clinical effect.
INTERACTIONS:
IM, IV (Neonates): 1 – 2 mg/kg/dose q 12 – 24 hr.
Drug-Drug: Rrisk of hypotension with antihypertensives, nitrates, or
acute in-gestion of alcohol.qrisk of hypokalemia with other
diuretics, amphotericin B, stimulant laxatives, and
Hypertension
corticosteroids. Hypokalemia mayqrisk of digoxin toxicity
PO (Adults):
and 40 twice daily
risk of arrhythmia initiallytaking
in patients (whendrugs
added to prolong
that
regimen,pdose of other
the QT interval. anti-hypertensives
plithium excretion, may by 50%);
cause adjust
lithium
further dosing based
toxicity.qrisk on response.
of ototoxicity with amino-glycosides or
cisplatin.qrisk of nephrotoxicity with cisplatin.
NSAIDSpeffects of furosemide. Mayqrisk of methotrexate
NURSING IMPLICATIONS: toxicity.peffects of furosemide when given at same time as
sucralfate, cholestyramine,or colestipol.qrisk of salicyl-ate
Assessment toxicity (with use of high-dose salicylate therapy).
Concurrent
Assess fluid status. Monitor daily weight, intake anduse with ratios,
output cyclo-sporine
amount mayqrisk of gouty
and lo-cation of edema,
arthritis.
lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry
mouth, lethargy, weakness, hypotension, or oliguria occurs.

Monitor BP and pulse before andEdema

ROUTE/DOSAGE: during administration. Monitor frequency of prescription refills to
determine compliance in patients treated for hypertension.
PO (Adults): 20 – 80 mg/day as a single dose initially, may
Geri: Diuretic use is associated with increased
repeat inrisk
6 –for falls
8 hr; in older
mayq doseadults.
by 20 Assess
– 40 mgfalls
q 6 risk and
– 8 hr until
implement fall prevention strategies. desired response. Maintenance doses may be given once or
twice daily
Assess patients receiving digoxin for anorexia, (doses
nausea, up to 2.5
vomiting, g/day cramps,
muscle have been used in patients
paresthesia, and
with HF or renal disease). Hypertension— 40 twice daily
confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-
initially
depleting effect of the diuretic. Potassium (when added
sup-plements to regimen,pdosediuretics
or potassium-sparing of other may be used
concurrently to prevent hy-pokalemia. antihypertensives by 50%); adjust further dosing based on

Assess patient for tinnitus and hearing loss. Audiometry is recommended for pa-tients receiving
  Assess for allergy to sulfonamides.
 Assess patient for skin rash frequently during therapy. Discontinue
Patient/Family Teaching
fu-rosemide at first sign of rash; may be life-threatening. Stevens-
Johnson syndrome, toxic epidermal necrolysis, or erythema
multiforme may de-velop. Treat symptomatically; may recur once
Instruct patient to take furosemide as directed. Take missed doses as soon as pos-sible; do not double doses.
treatment is stopped.
 Lab Test Considerations: Monitor electrolytes, renal and hepatic
function, se-rum glucose, and uric acid levels before and periodically
Caution patient to change positions slowly to therapy.
throughout minimizeCommonlypserum
orthostatic hypotension. Caution May
potassium. patient that the use
causepserum
of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic
sodium, calcium, and magne-sium concentrations. May also
hypotension.
causeqBUN, serum glucose, creatinine, and uric acid levels.

Potential Nursing Diagnoses

Instruct patient to consult health care professional regarding a diet high in potas-sium.
Excess fluid volume (Indications)
Deficient fluid volume (Side Effects)
Advise patient to contact health care professional of weight gain more than 3 lbs in 1 day.

Implementation
Instruct patient to notify health care professional of all Rx or OTC medications, vi-tamins, or herbal
products being taken and to consult health care professional be-fore taking any OTC medications
concurrently
Do not confusewithLasix
this therapy.
with Luvox.

If administering twice daily, give last dose no later than 5 pm to minimize disrup-tion of sleep cycle.

IV routepatient
Instruct is preferred overhealth
to notify IM route
carefor parenteral of
professional administration.
medication regimen before treatment or surgery.

PO: May be taken with food or milk to minimize gastric irritation. Tablets may be crushed if patient has
difficulty swallowing.
Caution patient to use sunscreen and protective clothing to prevent photosensitiv-ity reactions.
Do not administer discolored solution or tablets.

Advise patient to contact health care professional immediately if rash, muscle weakness, cramps,
nausea, IV Administration
dizziness, numbness, or tingling of extremities occurs.

 Direct IV: Diluent: Administer undiluted (larger doses may be diluted and
administered
Advise diabetic patients to monitor as intermittent
blood glucose closely; may infusion [see below]).
cause increased Concentration:
blood glucose levels.10
mg/mL. Rate: Administer at a rate of 20 mg/min. Pedi: Administer at a
maximum rate of 0.5 – 1 mg/kg/min (for doses 120 mg) with infusion not
exceeding 10 min.
Emphasize the importance ofroutine follow-upInfusion:
Intermittent examinations.
Diluent: Dilute larger doses in 50 mL of D5W,
D10W, D20W, D5/0.9% NaCl, D5/LR, 0.9% NaCl, 3% NaCl, or LR.
Infusion stable for 24 hr at room temperature. Do not refrigerate. Protect
fromcaregivers
Geri: Caution older patients or their light. Concentration:
about increased1 mg/mL.
risk forRate:
falls. Administer at a ratefor
Sug-gest strategies notfall
to
prevention.
 BRAND NAME: Spironolactone (speer-oh-no-lak-tone)
CONTRAINDICATIONS/PRECAUTIONS:

Contraindicated
GENERIC NAME: in: Hypersensitivity; Anuria; Acute renal insufficiency; Signifi-
Aldactone
cant renal impairment (CCr 30 mL/min); SCr 2.5 m g/dL (for
CLASSIFICATIONS: patients with heart failure); Hyperkalemia; Addison’s
disease; Concurrent use of eplerenone.

Therapeutic: diuretics, potassium-sparing diuretics

Use Cautiously in: Hepatic dysfunction; Geriatric or debilitated patients or
PREGNANCY CATERGORY: Cpatients with diabetes mellitus (qrisk of hyperkalemia); OB,
Lactation: May cause endocrine dysfunction in infants. Is
tumorigenic
INDICATIONS: Management of and should
primary not be given to nursing
hyperaldosteronism. mothers. of
Management
Alternative method of feeding should be used if
edema associated with HF, cirrhosis and nephrotic syndrome. Management of essential
spironolactone is essential.
hypertension. Treat-ment of hypokalemia (counteracts potassium loss caused by other
diuretics).
ADVERSE REACTIONS/SIDE EFFECTS:

ACTION: Causes loss of sodium bicarbonate and calcium while saving

CNS: and
potassium dizziness,
hydrogenclumsiness,
ions by headache, sedation.
antagonizing aldosterone.
CV: arrhythmias.
GI: GI irritation.
THERAPEUTIC EFFECTS: Increased survival in pa-tients with severe heart failure (New
GU: erectile dysfunction, dysuria.
YorkEndo:
Heartamenorrhea,
Associationgynecomastia
class II-IV).(in
Weak di-uretic and
males), breast
antihypertensive response
tenderness, when compared
deepening withgrowth
of voice,qhair other (in
diuretics.
Conserva-tion of potassium.
females), sexual dysfunc-tion.
F and E: hyperkalemia, hyponatremia, hyperchloremic
metabolic acidosis.
PHARMACOKINETICS: Hemat: agranulocytosis, thrombocytopenia.
Derm: DRUG RASH WITH EOSINOPHILIA
Absorption: 90% absorbed.
AND SYSTEMIC SYMPTOMS (DRESS),
STEVENS-JOHNSON SYNDROME, TOXIC
EPIDERMAL NECROLYSIS, alopecia, pruritis.
MS: muscle cramps.
Distribution: Crosses the placenta; enters breast milk.
Misc: allergic reactions.

INTERACTIONS:
Protein Binding: 90%.

Drug-Drug: Use with eplerenoneqrisk of hyperkalemia; concurrent use con-

traindicated. q hypotension with acute ingestion of alcohol, other
Metabolism and Excretion: Converted by agents,
anti-hypertensive the liver
or to its active
nitrates. Use diuretic
with ACEcom-pound
inhibitors,
(canrenone).
NSAIDs, potassium supplements, angiotensin II receptor
antagonists, potassium-sparing diu-retics, angiotensin converting
enzyme inhibitors, or cyclosporineqrisk of hyperkalemia.plithium
Half-life: 78 – excretion. Antihypertensive 13
84 min (spironolactone); and–diuretic effectiveness may bepby
24 hr (canrenone).
NSAIDs. Mayqthe effects of digoxin.phypoprothrombinemic effect
of oral anticoagulants. Cholestyramine mayqrisk of hyperkalemic
metabolic acidosis.
 ROUTE/DOSAGE: PO (Adults): 25 – 400 mg/day as a single dose or 2 divided
Potential Nursing Diagnoses doses. HF— 25 – 50 mg/ day.

Excess fluid volume (Indications)

PO (Children 1 mo): Diuretic, hypertension— 1.5 – 3.3
mg/kg/day (60 mg/m2/ day) as a single dose or 2 – 4 divided
doses. Diagnosis of primary aldosteronism— 100 – 400
Implementation mg/m2/day in 1 – 2 divided doses.

PO: Administer in AM to avoid interrupting

PO sleep pattern. 1 – 3 mg/kg/day divided q 12 – 24 hr.
(Neonates):
Administer with food or milk to minimize gastric irritation and to increase bio-availability.

NURSING IMPLICATIONS
Patient/Family Teaching
Assessment

Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take
Monitor intake
medication and
at the output
same timeratios
eachand
day.daily
Takeweight
missedduring
dosestherapy.
as soon as remembered unless almost time for
next dose. Do isnot
If medication double
given doses.
as an adjunct to antihypertensive therapy, BP should be evaluated before
administering.
Caution patient to avoid salt substitutes and foods that contain high levels of potas-sium unless prescribed
by healthresponse
Monitor care professional.
of signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias,
polyuria, polydipsia). Assess patient frequently for development of hyperkalemia (fatigue, muscle
 May cause dizziness. Caution patient to avoid driving or other activities
weakness, paresthesia, confusion, dyspnea, cardiac arrhythmias). Patients who have diabetes mellitus or
requiring alertness until response to medication is known.
kidney dis-ease and elderly patients are at increased risk of developing these symptoms.
 Instruct patient to notify health care professional of all Rx or OTC
Periodic ECGs may be recommended medications, vi-tamins,
in patients receivingor herbal products
prolonged therapy. being taken and to consult
health care professional be-fore taking any OTC medications concurrently
Assess patient for skin rash frequently
with this during therapy.
therapy, Discontinue
especially OTCdi-uretic at first sign
decongestants, of rash;
cough or may
cold
be life-threatening. Stevens-Johnson syn-drome or toxic epidermal necrolysis may develop.
preparations, or appetite suppressantsdue to poten-tial for increased BP. Treat
symptomati-cally; may recur once treatment
 Instruct patientistostopped.
notify health care professional of medication regimen
prior to treatment or surgery.
Lab Test Considerations: Evaluate serum potassium levels prior to and rou-tinely during therapy. Withhold
 Advise patient to notify health care professional if rash, muscle weak-
drug and notify health care professional if patient becomes hyperkalemic.
ness or cramps; fatigue; or severe nausea, vomiting, or diarrhea
Monitor BUN, serum creatinine, occurs.
and electrolytes prior to and periodically during therapy. May causeqserum
 Advise female patients
magnesium, uric acid, BUN, creatinine, potassium, plasma torenin
notifyactivity,
health and
careurinary
professional
calciumif excretion
pregnancy is
planned or suspected or if breast feeding.
levels. May also causepso-dium levels.
 Emphasize the need for follow-up exams to monitor progress.
Discontinue potassium-sparing diuretics 3 days prior
Hypertension: to a glucose
Reinforce needtolerance test because
to continue of risktherapies
additional of severe for
hyperkalemia. hypertension (weight loss, restricted sodium intake, stress reduction,
moderation of alcohol in-take, regular exercise, and cessation of smoking).
May cause falseqof plasma cortisol concentrations. Spironolactone should be withdrawn 4 – 7 days before
Medication helps control but does not cure hypertension.
test.
 Teach patient and family the correct technique for checking BP weekly.