Drugs affecting the renal system: iv solutions – fluid - Belong to a chemical class of drugs called

and electrolytes. sulfonamides.

Diuretics - Have different chemical structures but work in
- It is used in the management of glaucoma,
the same mechanism.
hypertension, and edema in heart failure, liver
- Most commonly used class of diuretics.
failure, and renal diseases.
- Therapeutic action
Edema
- Is the accumulation of fluids in the interstitial o active pumping out of chloride from

spaces. the cells lining the ascending limb of

- Edema in HF Loop of Henle and distal tubule by
o Caused by activation of the renin- blocking the chloride pump. Since
angiotensin system due to an sodium passively moves with chloride to
inefficient pumping activity of the maintain electrical neutrality, both
heart. sodium and chloride are excreted in the
- Cirrhosis and other liver diseases urine.
o Reduced plasma protein production
- Indication
leading to decreased oncotic pressure.
o Considered to be a milder form of
o Portal system obstruction due to
diuretics compared to loop diuretics.
hepatic vessel congestion.
o First-line drugs for management of
- Edema in renal diseases is because of a damaged
essential hypertension
basement membrane which makes it possible for
plasma proteins to be lost into urine. - Children

Hypertension o Has established pediatric dosing

- Can lead to multiple organ failure and severe guidelines; control of hypertension in
cardiovascular complications. children.
- Diuretic agents are used in the management of o Effect of diuretics may be abrupt in
hypertension to reduce blood pressure by children because of their rapid
decreasing circulating fluid volume and sodium. metabolism so caution is exercised by
Glaucoma
careful monitoring of serum electrolyte
- Is characterized by increased intraocular pressure
changes and for evidence of fluid
(IOP), which can damage the optic nerve and
volume changes.
cause irreversible blindness.
- Adults
- Diuretic agents
o Likely to use diuretics on long-term
o enhancing the osmotic pull to
effectively remove some fluid in the basis

eye, decreasing the IOP. o Should be educated on warning signs of

- Primarily increase the excretion of sodium. To fluid volume changes
some extent, they also increase the volume of o To influence fluid shifts in pregnant
urine produced by the kidneys. patients is not appropriate.
- By blocking the absorptive capacity of cells lining o Lactating women should switch to an
the renal tubules for sodium, intravascular volume alternative method.
and the eventual leaking of fluid from capillaries is - Older adults
reduced and prevented.
o possibility of having renal and hepatic
5 types of diuretics
impairments
o The lowest dose possible is started
initially and it is titrated slowly.
o Frequent monitoring of serum
electrolytes, activity level, and dietary
intake

- Pharmacokinetics

- Contraindications and cautions

1. Thiazide and thiazide-like diuretics
 o Allergy to loop diuretics. renal failure, electrolyte imbalances,
o Fluid and electrolyte imbalances. and nitrogen retention.
o Severe renal failure, anuria. - Children
o Systemic lupus erythematosus (SLE). o When a stronger diuretic is needed but
o Glucose tolerance abnormalities and dose should not be more than 6
diabetes mellitus. mg/kg/d
o Gout. o oral form in some situations but not
o Liver disease. in infants.
o Bipolar disorder. o Bumetanide is generally not
o Pregnancy, lactation. recommended for children but is
- Adverse effects indicated when the child is taking
o CNS: weakness other ototoxic drugs.
o CV: hypotension, arrhythmias - Adults
o GI: GI upset o Should be educated on warning signs of
o GU: hypokalemia (can precipitate fluid volume changes.
hyperglycemia), hypercalcemia, hyper - Pregnant women
uremia, slightly alkalinized urine (can o It should not be stopped if indicated
lead to bladder infections) for a specific medical cause provided
- Interactions that they are made aware of the
o Cholestyramine or colestipol: must be possible effects to the fetus.
taken separated for at least 2 hours. o Lactating women should switch to an
o Digoxin: because of changes in serum alternative method.
potassium levels - Older adults
o Quinidine: increased risk for quinidine o The possibility of older adult patients
toxicity having renal and hepatic impairments
o Decreased effectivity of antidiabetics o The lowest dose possible is started
o Lithium: increased risk for lithium initially and it is titrated slowly based
toxicity on patient’s response.
2. Loop diuretics o Frequent monitoring of serum
- Exerts its main effect on the loop of Henle. electrolytes, activity level, and dietary
Hence, so named. intake is a must.
- High-ceiling diuretics - are capable of causing - Pharmacokinetics
greater degree of diuresis
- Therapeutic action
o Blocks the action of chloride pump in
the ascending limb of the loop of
Henle, where 30% of sodium is
normally reabsorbed; This causes
decreased reabsorption of chloride and
sodium.
o Exerts the same effect on the - Interactions

descending limb of loop of Henle and o Aminoglycosides or cisplatin: increased

distal tubule causing sodium rich urine. ototoxicity effect of loop diuretics

- Indications o Anticoagulants: increased

o Indications anticoagulation effects

o acute HF, acute pulmonary edema, and o Indomethacin, ibuprofen, salicylates and

edema associated with HF or with o other NSAIDs: decreased

renal or liver disease, and hypertension. antihypertensive effects and loss of

o Drug of choice: rapid and extensive sodium.

diuresis, can produce a fluid loss up to - Contraindications and cautions

20 pounds per day. o Allergy to thiazides and sulfonamides.

o Proven to be effective even with the o Electrolyte depletion.

presence of acid base disturbances, o Severe renal failure, anuria.

o Systemic lupus erythematosus (SLE).
 o Glucose tolerance abnormalities and o Renal and hepatic impairments requires
diabetes mellitus. health care team to be cautious of the
o Gout. use of this drug.
o Hepatic coma o Lowest dose possible is started initially
o Pregnancy, lactation o Monitoring of serum electrolytes,
- Adverse effects activity level, and dietary intake is a
o CNS: dizziness must.
o CV: hypotension - Pharmacokinetics
o GI: GI upset
o GU: hypokalemia (can precipitate
hyperglycemia), increased bicarbonate
excretion (can lead to alkalosis),
hypocalcemia and tetany
o EENT: ototoxicity, reversible loss of
hearing
3. Carbonic anhydrase inhibitors
- Relatively mild diuretics
- Adverse effects
- Therapeutic action
o CNS: paresthesia, confusion, drowsiness
o Inhibits the action of the enzyme
o CV: hypotension
carbonic anhydrase, the catalyst for
o GU: hypokalemia (can precipitate
the formation of sodium bicarbonate
hyperglycemia), increased loss of
stored as an alkaline reserve in the
bicarbonate (can lead to metabolic
renal tubules and is important for the
acidosis)
excretion of hydrogen.
- Interactions
o It slows down the movement of
o Salicylate, lithium: increased excretion
hydrogen ions which leads to greater
of these drugs
amount of sodium and bicarbonate lost
- Contraindications and cautions
in the urine.
o Allergy to carbonic anhydrase inhibitors,
- Indications
thiazides, and anti-bacterial
o Most often used for the treatment of
sulfonamides.
glaucoma. Inhibition of carbonic
o Chronic non-congestive angle closure
anhydrase results in decreased secretion
glaucoma.
of aqueous humor of the eyes.
o Fluid and electrolyte imbalance, renal
o Also used as adjunct to other diuretics
or hepatic disease, adrenocortical
when more intense diuresis is needed.
insufficiency, respiratory acidosis,
- Children
chronic obstructive pulmonary disease
o Not indicated for children
(COPD).
- Adults
o Pregnancy, lactation.
o Are more likely to use diuretics on a
long-term basis and should be
4. Potassium-sparing diuretics
educated, weigh themselves daily to - Less powerful than loop diuretics but they retain
monitor for fluid retention or sudden potassium instead of wasting it.
fluid loss, may aggravate fluid loss like - Typically used for patients who have high risk for
vomiting, diarrhea, and profuse hypokalemia associated with diuretic use
sweating should be emphasized to - Therapeutic action
them because these may change the o This type of diuretics causes a loss of
need for diuretics. sodium while promoting the retention
- Pregnant women of potassium.
o Not appropriate. o Spironolactone acts as aldosterone
o Lactating women should switch to an antagonist which blocks the action of
alternative method of feeding. aldosterone in the distal tubule. On
- Older adults the other hand, amiloride and
 triamterene block potassium secretion - Contraindication
through the tubule. o Allergy to potassium-sparing diuretics.
- Indications - Prevent severe hypersensitivity
o This is often used as adjuncts with reactions.
thiazide or loop diuretics or in patients o Hyperkalemia, renal disease, anuria.
who are especially at risk if Exacerbated by the effects of the
hypokalemia develops. drug.
o Spironolactone is the drug of choice for o Pregnancy, lactation. Can cause
treating hyperaldosteronism typically potential adverse effects to the fetus
seen in patients with liver cirrhosis and and baby. Routine use of this drug in
nephrotic syndrome. pregnancy is not appropriate and
- Children should be used only when there is
o Spironolactone is the only potassium- underlying pathological conditions. For
sparing diuretic recommended for lactating women, an alternative
children. method of feeding should be
- Adults instituted.
o Instruct to avoid potassium-rich foods - Adverse effects
(e.g. avocados, bananas, broccoli, o CNS: lethargy, confusion, ataxia
tomatoes, and dried fruits) and to o CV: arrhythmias
have regular monitoring of serum o Musculoskeletal: muscle cramps
potassium levels. o GU: hyperkalemia, increased loss of
- Pregnant women bicarbonate (can lead to metabolic
o Use of diuretics to influence fluid acidosis)
shifts in pregnant patients is not o Associated with various androgen
appropriate. However, it should not be effects such as hirsutism,
stopped if indicated for a specific gynecomastia, deepening of the voice,
medical cause provided that they are and irregular menses.
made aware of the possible effects to - Interactions
the fetus. o Salicylates: decreased diuretic effect
o Lactating women should switch to an 5. Osmotic diuretics
- This type of diuretic exerts their therapeutic
alternative method of feeding as this
effect by pulling water into the renal tubule
drug may have potential effect to the
without loss of sodium.
baby.
- Only one osmotic diuretic is currently available,
mannitol (Osmitrol).
- Older adults
- Therapeutic actions
o Have medical conditions where thiazide
o Mannitol is a sugar that is not well
diuretics and thiazide-like diuretics are
reabsorbed by the tubules and it acts
usually indicated.
to pull large amounts of fluid into the
o The possibility of older adult patients
urine due to the osmotic pull exerted
having renal and hepatic impairments
by large sugar molecule.
requires health care team to be
o This also pulls fluid into the vascular
cautious of the use of this drug.
system from extravascular spaces like
o The lowest dose possible is started
aqueous humor.
initially and it is titrated slowly based
on patient’s response. Frequent
- Indications
monitoring of serum electrolytes,
o Mannitol is usually used in acute
activity level, and Sdietary intake is a
situations when it is necessary to
must.
decrease IOP before eye surgery or
- Pharmacokinetics
during acute attacks of glaucoma.
o Diuretic of choice in cases of increased
cranial pressure or acute renal failure
 due to shock, drug overdose, or - Adverse effects
trauma. o CNS: light-headedness, confusion,
o Also available as an irrigant in headache
transurethral prostatic resection and o CV: hypotension, cardiac
other transurethral procedures. decompensation, shock
- Children o GI: nausea, vomiting
o Not indicated for children o GU: fluid and electrolyte imbalance
- Adults o Most common and potentially
o Conditions that may aggravate fluid dangerous adverse effect related to an
loss like vomiting, diarrhea, and profuse osmotic diuretic is the sudden drop in
sweating. fluid levels.
- Pregnant woman
Nursing consideration for diuretic drug
o Is not appropriate. However, it should
- Assess for the mentioned cautions and
not be stopped if indicated for a
contraindications (e.g. drug allergies, fluid and
specific medical cause provided that
electrolyte disturbances
they are made aware of the possible
- Perform a thorough physical (note presence of
effects to the fetus.
edema and status of skin turgor)
o Lactating women should switch to an
- Assess cardiopulmonary status (blood pressure,
alternative method of feeding.
pulse rate, heart and lung sounds, etc.)
- Older adults
- Obtain an accurate body weight
o Where thiazide diuretics and thiazide-
- Monitor intake and output and voiding patterns
like diuretics are usually indicated.
to evaluate fluid balance and renal function.
o The possibility of older adult patients
Implementation
having renal and hepatic impairments
- Administer with food or milk if GI upset is a
requires health care team to be
- Administer intravenous diuretics slowly
cautious of the use of this drug.
- Administer oral form early in the day
o The lowest dose possible is started
- Monitor patient response to drugs through vital
initially and it is titrated slowly based
signs, weight, serum electrolytes and hydration
on patient’s response. Frequent
- Determine presence of fluid volume deficit or
monitoring of serum electrolytes,
retention.
activity level, and dietary intake is a
- Provide comfort measures (e.g. skin care,
must.
nutrition referral, etc.)
- Pharmacokinetics
- Provide safety measures (e.g. adequate lighting,
raised side rails, etc.) to prevent injuries.
- Educate client on drug therapy to promote
compliance.

- Contraindications and cautions

o Renal disease, anuria, pulmonary
congestion, intracranial bleeding,
dehydration,
o HF. Exacerbated by large shifts in fluid
related to drug use.
o Pregnancy, lactation. Can cause
potential adverse effects to the fetus
and baby. Routine use of this drug in
pregnancy is not appropriate and
should be used only when there is
underlying pathological conditions. For
lactating women, an alternative
method of feeding should be
instituted.
Fluids and electrolytes response to an increase in concentration of
- fluid and electrolyte balance is dynamic process sodium and other solutes in the intravascular
that is crucial for life and homeostasis fluids.
- Fluid occupies almost 60% of the weight of an
adult.
- Body fluid is located in two fluid compartments:
the intracellular space and the extracellular space.
- Electrolytes in body fluids are active chemicals or
cations that carry positive charges and anions
that carry negative charges.
- The major cations in the body fluid are sodium,
potassium, calcium, magnesium, and hydrogen
ions.
- The major anions are chloride, bicarbonate,
sulfate, and proteinate ions.
Negative and positive feedback - The RAA system. The RAA system controls fluid
- Feedback is the relaying of information about a volume, in which when the blood volume
given condition to the appropriate organ or decreases, blood flow to the renal juxtaglomerular
system. apparatus is reduced, thereby activating the RAA
- Negative feedback. Negative feedback occurs when system.
the body reverses an original stimulus for the
body to regain physiologic balance.
- Positive feedback. Positive feedback enhances or
intensifies the original stimulus.
•Examples. Blood pressure control and maintenance of normal
body temperature are examples of negative feedback while
blood clotting after an injury and a woman in labor are
examples of positive feedback.
System involved in feedback
- Nervous system
o regulates homeostasis by sensing
system deviations and sending nerve - Atrial natriuretic peptide. The heart also plays a
impulses to appropriate organs. role in correcting overload imbalances, by releasing
ANP from the right atrium.

- Endocrine system
o The endocrine system uses the release
and action of hormones to maintain
homeostasis.
Fluid regulation mechanisms
- The thirst centers. The thirst center in
hypothalamus stimulates or inhibits the desire for
a person to drink.

Overhydration and edema

- Overhydration. Overhydration is an excess of
water in the body.
- Edema. Edema is the excess accumulation of fluid
in interstitial tissue spaces, also called third-space
fluid.
- Cause of edema. Edema is caused by a disruption
of the filtration and osmotic forces of the body’s
circulating fluids.
- Treatment of edema. Diuretics are commonly
given for systemic edema.

- Antidiuretic hormone. ADH regulates the

Dehydration
amount of water the kidney tubules absorb and is
released in response to low blood volume or in
 - Dehydration. Dehydration is a deficiency of body molecules from an
water or excessive loss of water. area of higher
- External causes. External causes of dehydration concentration to an
include prolonged sun exposure and excessive area of lower
exercise, as well as diarrhea, vomiting, and burns. concentration.
- Treatment of dehydration. Supplemental fluids
and electrolytes are often administered.
Osmosis Osmosis is the
diffusion of a pure
Electrolytes
solvent, such as
- An electrolyte is a substance that will disassociate
water, across a
into ions when dissolved in water.
semipermeable
- Origins. Electrolytes are found in the form of
membrane in response
inorganic salts, acids, and bases.
to a concentration
- Active chemicals. Electrolyte concentrations
gradient in situations
measured according to their chemical activity and
where the molecules
expressed as milliequivalents.
of a higher
- Ions. Each chemical element has an electrical
concentration are non-
charge either positive or negative.
diffusible.
- Intracellular electrolytes. Important intracellular
Filtration. Filtration is the
electrolytes are potassium, magnesium, sulfate,
transport of water
and phosphate, and the most dominant cation is
and dissolved materials
potassium while the most dominant anion is
concentration already
phosphate.
exists in the cell
- Extracellular electrolytes. Important extracellular
- Active transport
electrolytes include sodium, chlorine, calcium, and
o Mechanisms
bicarbonate, and the most essential cation is
 Active transport mechanisms
sodium while chlorine is the most important
require specific enzymes and
anion.
an energy expenditure in the
form of adenosine
Fluid and electrolyte transport
triphosphate (ATP).
- The body cells. Nutrients and oxygen should enter
o Processes
body cells while waste products should exit the
 Active transport processes
body.
can move solutes “uphill”,
- The cell membrane. The cell membrane separates
against the normal rules of
the intracellular environment from the
concentration and pressure.
extracellular environment.
Fluid and electrolyte balance
- Permeability. The ability of a membrane to allow
- Fluid and electrolyte balance is vital for proper
molecules to pass through is known as
functioning of all body systems.
permeability.
- Water
- Osmolarity
Permeability of Membranes o This is the property of particles in a
- Freely permeable membranes. These membranes solution to dissociate into ions.
allow almost any food or waste substance to pass - Electroneutrality
through. o This is the balance of positive and
- Selectively permeable. The cell membrane is negative charges.
selectively permeable, meaning that each cell’s Acid-base balance
membrane allows only certain specific substances - Acid
to pass through. o An acid is one type of compound that
Passive transport. Passive transport contains the hydrogen ion
mechanisms - Base
include diffusion, o A base or alkali is a compound that
osmosis, and contains the hydroxyl ion.
filtration. - Salt
Diffusion Diffusion, or the o A salt is a combination of a base and
process of “being acid and is created when the positive
widely spread”, is the ions od a base replace the positive ions
random movement of of an acid
 - Important salts causing an elevation in blood pH.
o The body contains several important
salts like sodium chloride, potassium Classification: different fluid volume disturbances that may
chloride, calcium chloride, calcium affect and individual
carbonate, calcium phosphate, and
sodium phosphate. fluid volume deficit
Potential of hydrogen - hypovolemia occurs when loss of ECF volume
- pH exceeds the intake of fluid.
o the symbol of pH refers to the Fluid volume excess
potential or power of hydrogen ion - hypervolemia refers to an isotonic volume
concentration within the solution expansion of the ECF caused by the abnormal
- Low pH retention of water and sodium in approximately
o if the pH number is lower than 7, the the same proportions in which they normally exist
solution is an acid in the ECF.
- High pH Hyponatremia Refers to a serum sodium
o If the pH is greater than 7, a solution level that is less than 135
is basic or alkaline mEq/L
- Neutral pH Hypernatremia A serum sodium level
o If the pH is 7, then the solution is higher than 145 mEq/L.
neutral.
Hypokalemia usually indicates a deficit
Buffers
in total potassium stores.
- A buffer is a chemical system set up to resist
Hyperkalemia refers to a potassium level
changes, particularly in hydrogen ion levels.
greater than 5.0 mEq/L.
- Bicarbonate buffer system
Hypocalcemia Are serum levels below 8.6
o Sodium bicarbonate and carbonic acid
mg/dl
are the body’s major chemical buffers
Hypercalcemia is calcium level greater
- Carbon dioxide
than 10.2 mg/dl.
o The major compound controlled by the
Hypomagnesemia refers to a below-normal
lungs is CO2, and the respiratory
serum magnesium
system can very rapidly compensate for
concentration
too much acid and too little acid by
Hypermagnesemia are serum levels over 2.3
increasing or decreasing the respiratory
mg/dl.
rate, thereby altering the level of
Hypophosphatemia is indicated by a value
CO2.
below 2.5 mg/dl.
- Bicarbonate
Hyperphosphatemia is a serum phosphorus level
o Bicarbonate ions are basic components
that exceeds 4.5 mg/dl in
in the body, and the kidneys are key
adults
in regulating the amount of
bicarbonate in the body.
Pathophysiology
- Maintenance
Measurement of arterial blood gas (ABGs)
o The body expends a great deal of
- Respiratory acidosis
energy in maintaining the sodium and
o Respiratory acidosis occurs when
potassium concentrations through cell
breathing is inadequate and PaCO2
membrane pumps that exchange sodium
builds up.
and potassium ions.
- Respiratory alkalosis
- Osmosis
o Respiratory alkalosis occurs as a result
o When two different solutions are
of hyperventilation or excess aspirin
separated by a membrane that is
intake.
impermeable to the dissolved
- Metabolic acidosis
substances, fluid shifts from the region
o In metabolic acidosis, metabolism is
of low solute concentration to the high
impaired, causing a decrease in
solute concentration until the solutions
bicarbonates and a buildup of lactic
are of equal concentrations.
acid.
- Diffusion
- Metabolic alkalosis
o Diffusion is the natural tendency of a
o Metabolic alkalosis occurs when
substance to move in an area of higher
bicarbonate ion concentration increases,
 concentration to an area of lower dysrhythmias,
concentration. intestinal colic, cramps,
abdominal distention, and
anxiety
Hypocalcemia The signs and symptoms
are
numbness, tingling of
fingers, toes, and
circumoral
region, positive Trousseau’s
sign and Chvostek’s sign,
seizures, hyperactive deep
CLINICAL MANIFESTATION tendon reflexes,
Fluid volume deficit Clinical signs and symptoms
irritability, and
include acute weight loss,
bronchospasm.
decreased skin turgor,
Hypercalcemia The signs and symptoms
oliguria,
include muscle weakness,
concentrated urine,
constipation, anorexia,
orthostatic hypotension, a
nausea and vomiting,
weak, rapid
dehydration, hypoactive
heart rate, flattened neck
deep tendon reflexes
veins, increased
lethargy, calcium stones,
temperature,
flank pain, pathologic
thirst, decreased or
fractures, and deep bone
delayed capillary refill,
pain.
cool, clammy
Hypomagnesemia. Clinical manifestations
skin, muscle weakness, and
include neuromuscular
cramps.
irritability, positive
Fluid volume excess Clinical manifestations for
Trousseau’s and Chvostek’s
FVE include edema,
sign, insomnia, mood
distended neck veins, and
changes, anorexia,
crackles.
vomiting, and increased
Hyponatremia Signs and symptoms
deep tendon reflexes.
include anorexia, nausea
Hypermagnesemia Signs and symptoms are
and vomiting, headache,
flushing, hypotension,
lethargy,
muscle weakness,
dizziness, confusion, muscle
drowsiness, hypoactive
cramps and weakness,
reflexes, depressed
muscular twitching,
respirations, and
seizures, dry skin, and
diaphoresis.
edema.
Hypophosphatemia. Signs and symptoms
Hypernatremia. The signs and symptoms
include paresthesia muscle
are thirst, elevated body
weakness, bone pain and
temperature,
tenderness, chest pain,
hallucinations, lethargy,
confusion, seizures, tissue
restlessness, pulmonary
hypoxia, and nystagmus.
edema, twitching, increased
Hyperphosphatemia. Clinical manifestations are
BP and pulse
tetany, tachycardia,
Hypokalemia Clinical manifestations are
anorexia, nausea and
fatigue,
vomiting, muscle weakness,
anorexia, muscle weakness,
and hyperactive reflexes
polyuria, decreased bowel
motility, paresthesia, ileus,
Complications
abdominal distention, and
- Fluid and electrolyte imbalances could result in
hypoactive reflexes
complications if not treated promptly
Hyperkalemia. Signs and symptoms
- Dehydration
include muscle weakness,
tachycardia, paresthesia,
 o Fluid volume deficit could result in o These are new pharmacologic agents
dehydration of the body tissues. that treat hyponatremia by
stimulating free water excretion.
- Cardiac overload - Diuretics
o Fluid volume excess could result in o To decrease fluid volume in FVE,
cardiac overload if left untreated. diuretics are administered.
- SIADH - IV calcium gluconate
o Water is retained abnormally in SIADH. o If serum potassium levels are
- Cardiac arrest dangerously elevated, it may be
o Too much potassium administered could necessary to administer IV calcium
lead to cardiac arrest. gluconate.
- Calcitonin
Assessment and diagnostic findings o Calcitonin can be used to lower the

BUN may be decreased in FVE serum calcium level and is particularly

due to plasma dilution. useful for patients with heart disease

Hematocrit levels in FVD are greater or heart failure who cannot cannot

than normal because there tolerate large sodium loads.

is a decreased plasma Nursing assessment

volume. - I&O
o the nurse should monitor for fluid I&O
Physical examination Necessary to observe the
at least every 8 hours, or even hourly.
signs and symptoms of the
- Daily weight
imbalances.
o Assess the patient’s weight daily to
Serum electrolyte levels should be performed to
measure any gains or losses.
check for presence of an
- Vital signs
imbalance.
o Vital signs should be closely monitored.
ECG can also contribute to the
- Physical exam
diagnosis of fluid and
o Physical exam is needed to reinforce
electrolyte imbalance.
other data about a fluid or electrolyte
ABG analysis may reveal acid-base
imbalance.
imbalances.
Diagnosis
- Excess fluid volume related to excess fluid intake
Medical management
and sodium intake.
- Isotonic electrolyte solutions
- Deficient fluid volume related to active fluid loss
o These solutions are used to treat the
or failure of regulatory mechanisms.
hypotensive patient with FVD because
- Imbalanced nutrition: less than body requirements
they expand plasma volume.
related to inability to ingest food or absorb
- Accurate I&O
nutrients.
o Accurate and frequent assessments of
- Imbalanced nutrition: more than body
I&O should be performed when therapy
requirements related to excessive intake.
should be slowed or increased to
- Diarrhea related to adverse effects of
prevent volume deficit or overload
- medications or malabsorption.
- Dialysis
o Hemodialysis or peritoneal dialysis is
Nursing care planning and goals
performed to remove nitrogenous
- Maintenance of fluid volume at a functional level.
wastes and control potassium and acid-
- Display of normal laboratory values.
base balance, and to remove sodium
- Demonstration appropriate changes in lifestyle and
and fluid.
behaviors including eating patterns and food
- Nutritional therapy
quantity/quality.
o Treatment of fluid and electrolyte
- Reestablishment and maintenance of normal
imbalances should involve restrictions or
pattern and GI functioning.
enforcement of the concerned
Nursing interventions
electrolyte.
- There are specific nursing interventions for fluid
and electrolyte imbalances that can aid in
Pharmacologic therapy alleviating the patient’s condition.
- AVP receptor agonist - Monitor turgor
o Skin and tongue turgor are indicators
of the fluid status of the patient.
 - Urine concentration of cations and anions
o Obtain urine sample of the patient to Examples: 0.9 NaCl,
check for urine concentration. Ringer’s Solution, and
- Oral and parenteral fluids LRS.
o Administer oral or parenteral fluids as Alkalinising solutions. administered to treat
indicated to correct the deficit. metabolic acidosis
- Oral rehydration solutions Example: LRS.
- These solutions provide fluid, glucose, and Acidifying solutions. used to counteract
electrolytes in concentrations that are easily metabolic alkalosis.
absorbed. Example: D51/2NS, 0.9
- Central nervous system changes NaCl.
o The nurse must be alert for central Volume expanders. To increase the blood
nervous system changes such as volume after a severe
lethargy, seizures, confusion, and blood
muscle twitching. loss, or loss of plasma.
- Diet Example: dextran, human
o The nurse must encourage intake of albumin, and plasma.
electrolytes that are deficient or
restrict intake if the electrolyte levels ISOTONIC IVF
are excessive. - have the same concentration of solutes as blood
Iv solutions plasma.
- IVF or intravenous solutions - When infused, isotonic solutions expand both the
- are supplemental fluids used in intravenous intracellular fluid and extracellular fluid spaces,
therapy to restore or maintain normal fluid equally.
volume and electrolyte balance when the oral - Such fluids do not alter the osmolality of the
route is not possible vascular compartment.
- IV fluid therapy is efficient and effective way of - Are considered isotonic if the total electrolyte
supplying fluids directly into the intravascular content is approximately 310 mEq/L.
fluid compartment, in replacing electrolyte losses, - Have a total osmolality close to that of the ECF
and in administering medications and blood and do not cause red blood cells to shrink or
products. swell.
- Types of iv fluids - 0.9% NaCl (Normal Saline Solution, NSS.
o Classified based on tonicity- most
common way to categorize IV fluids.
- Crystalloids
o contain small molecules that flow easily
across semipermeable membranes.
o Categorized according to their relative
tonicity in relation to plasma.
- There are three types: isotonic, Shypotonic, and
hypertonic.

Nursing consideration for isotonic solutions

- Document baseline data.
o (signs, edema status, lung sounds, and
heart sounds. Continue monitoring
during and after the infusion.)
- Observe for signs of fluid overload. (signs of
hypervolemia such as hypertension, bounding
pulse, pulmonary crackles, dyspnea, shortness of
breath, peripheral edema, jugular venous
IV CLASSIIFCATION BASED ON THEIR distention, and extra heart sounds.}
PURPOSE - Monitor manifestations of continued hypovolemia.
Nutrient solution Contain dextrose, glucose,
(decreased urine output, poor skin turgor,
and levulose - the
tachycardia, weak pulse, and hypotension.
carbohydrate component –
- Prevent hypervolemia.
and water.
- Elevate the head of the bed at 35 to 45
Examples: D5W, D5NSS.
degrees.
Electrolyte solutions. Contains varying amounts
 - Elevate the patient’s legs. - Risk for increased intracranial pressure (IICP).
- Educate patients and families. Should not be given to patients with risk for IICP
- Close monitoring for patients with heart failure. (remember: hypotonic solutions make cells swell).
- Monitor for manifestations of fluid volume
COMPARISON OF IV SOLUTIONS deficit. S/S include confusion in older adults.
Instruct patients to inform the nurse if they feel
dizzy.
- Warning on excessive infusion. can lead to
intravascular fluid depletion, decreased blood
pressure, cellular edema, and cell damage.
- Do not administer along with blood products. can
cause hemolysis of RBC especially during rapid
infusion of the solution.

Hypertonic IVF solutions

- have a greater concentration of solutes (375
mEq/L and greater) sodium and chloride, than
plasma contain a higher concentration of normally
contained in plasma
Hypotonic IVF
- Cause fluids to move out of the and into the
- Have a lower osmolality and contain fewer solutes
ECF in order to normalize the concentration of
than plasma.
particles between two compartments.
- They cause fluid shifts from the ECF into the ICF
- This effect causes cells to shrink and may disrupt
to achieve homeostasis, therefore, causing cells to
their function.
swell and may even rupture.
- They are also known as volume expanders as they
- IV solutions are considered hypotonic if the total
draw water out of the intracellular space,
electrolyte content is less than 250 mEq/L.
increasing extracellular fluid volume
- Used to provide free water for excretion of body
wastes, treat cellular dehydration, and replace
the cellular fluid.

COMPARISON OF IV SOLUTIONS

Hypertonic IVF solutions: nursing considerations fro

hypertonic solutions
Hypotonic IVF: general nursing considerations - Document baseline data.
- Document baseline data. - Watch for signs of hypervolemia. signs of swelling
- Do not administer in contraindicated conditions. in arms, legs, face, shortness of breath, high
Hypotonic solutions may exacerbate existing blood pressure, and discomfort in the body (e.g.,
hypovolemia and hypotension causing cardiovascular headache, cramping.
collapse. Avoid use in patients with liver disease, - Monitor and observe the patient during
trauma, or burns. administration.
- Verify order. .
- Assess health history. kidney or heart disease,
dehydrated should not receive hypertonic IV
fluids.
- Prevent fluid overload.
- Do not administer peripherally. should be through
a central vascular access device inserted into a
central vein.
- Monitor blood glucose closely
Cardiovascular system: antilipemic and coagulation - Triglycerides make up the third component of
modifiers drug cholesterol and act as unused calories that are
Anti-lipemic drugs stored as fat in the blood.
- The lipid lowering agents are used to treat - Triglycerides make up the third component of
hypercholesterolemia and dyslipidemias/ cholesterol and act as unused calories that are
Hyperlipidemia. stored as fat in the blood.
- Triglycerides make up the third component of
Complications of atherosclerosis
cholesterol and act as unused calories that are
- Acute Myocardial Infarction
stored as fat in the blood.
- Cerebrovascular Ischemic Stroke
- lipids, such as cholesterol and triglycerides, are
- Peripheral Vascular Disease
insoluble in water.
4 general types
1. Bile Acid Resins Or Sequestrants
2. Fibrates
3. Statins
4. Cholesterol Absorption Inhibitor
o Ezetimibe
o Lomitapide
5. Others: vitamin b3 (nicotinic acid)
Antilipemic – table of commonly encountered
antihyperlipidemic drugs,
1. bile acid resins or sequestrants
- Are the oldest and safest lipid lowering agents,
but are less potent than other classes.
- The bile acid sequestrants are highly positively
charged molecules that bind to the negatively
charged bile acids in the intestine, inhibiting their
lipid solubilizing activity and thus blocking
cholesterol absorption.
- Used to be the primary means of lowering
cholesterol.
- Capable of producing 20% drop in LDL cholesterol

Lipidemia
- Your liver creates cholesterol to help you digest
food and make hormones.
- Eat cholesterol in foods from the meat and dairy
aisles. Since your liver can make as much
cholesterol as you need, the cholesterol in foods
you eat is extra.
- Too much cholesterol (200 to 239 mg/dL is
borderline high and 240 mg/dL is high)

- Therapeutic action
o exert their effect in the intestines by
binding into bile acids which contain a
high level of cholesterol.
o The resultant insoluble complex formed
by this combination is then excreted
through feces.
o As this happens, more LDL segments
from the circulation will be absorbed
Cholesterol by the intrahepatic circulation to make
- Two types more bile acids.
o High density lipoprotein (HDL) good - Pharmacokinetics
cholesterol o Not absorbed systemically and is
o Low density lipoprotein (LDL) bad excreted in the feces.
cholesterol
 fatsoluble vitamins can be
detrimental to fetus or
neonate.
Adverse effects
- The adverse effects of bile acid sequestrants
nurses need to watch out for are as follows:
o CNS: headache, anxiety, fatigue,
drowsiness
- Indications
o GI: GI upset, constipation, fecal
o used as the treatment for primary
impaction, nausea, aggravated
hypercholesterolemia (high cholesterol
hemorrhoids
and high LDL) as an adjunct to diet
o Hema: increased bleeding time,
and exercise.
decreased production of clotting factors
o Cholestyramine
o Musculoskeletal: muscle aches, muscle
 also used to treat pruritus
pains
associated with partial
o Other: rash, fat-soluble vitamin
biliary obstruction.
deficiencies
o Children/Familial hypercholesterolemia
 treatment in children is
Nursing considerations
limited to tight dietary
- Assess for the mentioned contraindications
restrictions of calorie and
- Conduct thorough physical assessment before
fats because lipids in
beginning drug therapy . Obtain baseline status
children are important for
for weight
the development of the
- Assess neurological status, Assess bowel
nervous system
elimination patterns.
o adults
- Assess closely patient’s heart rate and blood
 used in combination with
pressure
HMG-CoA reductase
- Inspect abdomen for distention and auscultate
inhibitors for patients whose
bowel sounds
lipid levels are challenging to
- Monitor results of laboratory tests
normalize with the use of
- Administer powdered agents already mixed with
HMG-CoA reductase
fluids.
inhibitors alone.
- Instruct client not to chew, crush, and cut
 For pregnant women, bile
tablets.
acid sequestrants are the
- Administer drug before meals
drug of choice in lowering
- Administer other drugs 1 hour before or 4-6
cholesterol and lipid levels.
hours after bile acid sequestrants
o Older adults
- Arrange for a bowel program
 In taking care of this age
- Instruct patient to increase oral fluid intake and
group, reinforcement of
dietary fiber intake
lifestyle changes is given
- Provide comfort measures (e.g. small frequent
focus.
meals for GI upset and instituting safety
 Older adults are instructed
measures for drowsiness and weaknesses
on drugs that can’t be cut,
- Educate patient on drug therapy.
crushed, and chewed.
- Contraindications and cautions
2. Fibrates
o Allergy to bile acid sequestrants.
- fibrates lower lipid levels is unknown, but they
 Prevent severe
may act through interactions with the hepatic
hypersensitivity reactions.
peroxisome proliferator activated receptors
o Complete biliary obstruction.
(PPARs) which regulate gene transcription of
 Prevent bile from being
enzymes involved in lipid synthesis and secretion.
secreted into the intestines.
- The fibrates bind specifically to a PPAR alpha
o Abnormal intestinal function.
isozyme, which is found largely in the liver and
 Aggravated by the presence
which regulates fatty acid oxidation, increasing
of bile acid sequestrants.
lipoprotein lipase levels which, in turn, enhances
o Pregnancy and lactation.
clearance of triglyceride rich lipoproteins.
 Potential decrease in
- Chemical formulas and structures
absorption of fat and
 - Most likely, due to the effect mediated by
PPAR-alpha, fibrates can reversibly increase serum
creatinine and levels.
- Patients can present with leg cramps, abdominal
pain, etc., as fibrates can cause a slightly
increased risk (less than 1.0%) of myopathy,
cholelithiasis, and venous thrombosis.
- Fibrates generally should be avoided in
combination with statins since they can inhibit
statin metabolism, causing an increased risk of
myopathy.
- Recommendations are to always to measure serum
creatinine levels and renal function before using
the two drugs simultaneously. Gemfibrozil has
proved to be unsafe for this interaction, whereas
clinicians can still use bezafibrate and fenofibrate.
Contraindications
- Known hypersensitivity to the drug class.
- Administration - Active liver disease, as fibrates are shown to be
o Before starting fibrate therapy, hepatotoxic if pre-existing liver inflammatory
patients should start on an adequate states exist.
lipid-lowering diet. It should be used - Active gall bladder disease as fibrates cause a
only as an adjunct to lipid-lowering PPAR-Alpha mediated downregulation in bile acid
diet and medication and not as a first- production, which, in turn, is responsible for an
line mode of therapy. increased tendency to form gall stones.
o Fibrates are administered orally, ideally - Severe renal dysfunction, including patients

as once a day tablets. According to receiving dialysis therapy.

Toxicity
the FDA, the dosing of fibrates in
- There is no known antidote to fibrate toxicity. If
adults adjusted for the patient profile
possible, eliminate any unabsorbed drug via emesis
Dosage and special precautions or gastric lavage, maintaining the necessary
- Primary hypercholesterolemia or mixed common precautions for airway protection.
dyslipidemia - If a patient happens to overdose on fibrates, do
o Start with 120 mg daily. not consider hemodialysis as fibrates are highly
- Severe hypertriglyceridemia plasma protein-bound drugs.
o The dose ranges from 40 mg to 120 Nursing responsibilities s
mg daily and is adjusted according to - Monitor
lipid levels. o Side effects, periodic lipid profile
- Renally impaired patients o Therapeutic response: decreased
o Initiate with 40 mg per day. Conduct triglycerides, increased HDLs
regular renal function tests and serum - Client education
cholesterol levels and up-titrate the o Purpose of medication: lower their
drug as required. triglycerides and increase HDL levels
- Geriatric patients o Take gemfibrozil twice each day, 30
o The dosing is per the renal function of minutes before breakfast and dinner
the patient. o Take fenofibrate once daily with food
- The above regime is for fenofibrate, which is o Increase their fluid intake while taking
available as 40 mg and 120 mg tablets. The their medication
patient's response to it must be measured every o Lifestyle modifications to reduce the
4 to 8 weeks, followed by adjusting the drug risk of cardiovascular events
dosage. o Can take up to three months to
Adverse effects determine efficacy
- The most common adverse effects of this drug o Side effects: upset stomach, diarrhea
class include reporting of deranged AST, ALT o Immediately report
levels, along with infrequent elevations in serum  Symptoms of
CPK (creatinine phosphokinase) levels during rhabdomyolysis; e.g.,
therapy. unexplained muscle pain,
weakness; brown urine
  Symptoms of gallstone - Conduct thorough physical assessment before
development; e.g., pain in beginning drug therapy
upper abdomen, between o to establish baseline status, determine
shoulder blades, or right effectivity of therapy, and evaluate
shoulder; nausea and potential adverse effects.
vomiting. - Obtain baseline status for weight
3. Statins – Hydroxymethylglutaryl-coenzyme o while noting recent manifestations that
a (HMG-COA) reductase inhibitors increases or decreases to determine
- Are the most potent, best tolerated and most patient’s fluid status.
widely used oral cholesterol lowering agents. - Assess neurological status
- This drug group increases the cell absorption of o with particular focus on consciousness,
LDL by blocking the enzyme (HMG-CoA reflexes, and affect.
reductase) regulating the rate-limiting step in - Assess closely patient’s heart rate and blood
the synthesis of cholesterol. With this alteration pressure
in fat metabolism, HDL increases slightly. o to identify cardiovascular changes that
Indications may warrant change in drug dose.
- Pravastatin, lovastatin, and simvastatin are - Assess bowel patterns
indicated for patients with documented CAD to o to determine possibility of developing
slow progression of the disease. constipation and resultant fecal
- Together with these three agents, atorvastatin is impaction.
used as prophylaxis for first myocardial infarction - Administer drug at bedtime
attack for patients with multiple risk factors for o to maximize effectiveness of the drug
CAD. because peak of cholesterol synthesis is
Contraindications and cautions from midnight to 5 AM. However,
- Allergy to HMG-CoA reductase inhibitors atorvastatin can be given at any hour
- Active liver disease of the day.
- Pregnancy, lactation. - Monitor serum cholesterol and LDL levels
- Impaired endocrine function. o to determine effectiveness of drug
- Renal impairment. therapy.
Interactions - Monitor results of liver functions
- Cyclosporine, erythromycin, gemfibrozil, niacin, o tests to determine possible liver
antifungal drugs: increased risk for rhabdomyolysis damage.
- Digoxin, warfarin: increased serum levels and - Ensure patient has initiated a 3-6 month diet
resultant toxicity of HMG-CoA reductase and exercise program
inhibitors o before initiating drug therapy to
- Oral contraceptives: increased serum estrogen ensure need for drug therapy.
- Grapefruit juice: increased serum levels and - Emphasize the importance of lifestyle changes
resultant toxicity o to the patient to decrease risk of CAD
Adverse effects and promote drug effectiveness.
- CNS: headache, dizziness, insomnia, fatigue, - Provide comfort and safety measures
blurred vision, cataract development o to help patient tolerate drug side
- CV: increased risk for cardiovascular effects with effects.
simvastatin started at 80 mg for new patients. - Educate patient on drug therapy
- GI: flatulence, nausea, vomiting, cramps, o including drug name, its indication, and
abdominal pain, constipation adverse effects to watch out for to
- Hepatobiliary: increase liver enzymes, acute liver enhance patient understanding on drug
failure with use of atorvastatin and Fluvastatin. therapy and thereby promote
Pharmacokinetics adherence to drug regimen.
4. Cholesterol absorption inhibitors
- Therapeutic action
o Acting on the brush border of
intestines, cholesterol absorption
inhibitors block the absorption of
Nursing considerations
dietary cholesterol. Consequently, less
- Assess for the mentioned contraindications to this
cholesterol goes to the liver and it
drug (e.g. hypersensitivity, acute liver disease,
increases the cholesterol clearance to
pregnancy etc.)
make up for the drop.
o to prevent potential adverse effects.
 o Cholesterol absorption inhibitors are Interactions
one of the new class of drugs approved - Assess the interaction of the drug with the
(2003) to lower serum cholesterol following:
levels. - Cholestyramine, fenofibrate, antacid, gemfibrozil:
elevated serum level of cholesterol absorption
inhibitors
- Cyclosporine: increased toxicity of cholesterol
absorption inhibitors
- Fibrates: increased risk for development of
cholelithiasis
- Warfarin: increased serum warfarin levels
Nursing assessment
Indications
- Assess for the mentioned contraindications to this
- Adjunct to diet and exercise as a monotherapy or
drug (e.g. hypersensitivity, acute liver disease,
in combination with HMG-CoA inhibitors or bile
pregnancy etc.).
acid sequestrants.
o To prevent potential adverse effects.
- Used in combination with statins to treat
- Conduct thorough physical assessment before
homozygous familial hypercholesterolemia.
beginning drug therapy.
Children
o To establish baseline status, determine
- Not indicated for this age group.
effectivity of therapy and evaluate
Adults
potential adverse effects.
- Used in combination with HMG-CoA inhibitors or
- Assess closely patient’s heart rate and blood
bile acid sequestrants.
pressure.
- The importance of lifestyle changes (e.g. dietary
- Assess bowel patterns
restrictions, regular exercise, and smoking
- Assess neurological status.
cessation) should be emphasized to this age
- Monitor laboratory test results of serum
group.
cholesterol, LDL, and liver function.
- Effect to fetuses and neonates is not known.
Implementation
Older adults
- Monitor serum cholesterol and LDL levels.
- Are more susceptible to drug toxicity because of
o To determine the effectiveness of drug
underlying conditions that would interfere with
therapy.
metabolism and excretion of drug.
- Monitor results of liver functions tests.
- Importance of mentioned lifestyle changes should
o To determine possible liver damage.
also be emphasized
- Ensure patient has initiated a 3- 6 month diet
Pharmacokinetics
and exercise program before initiating drug
therapy.
o To ensure the need for drug therapy.
- Emphasize the importance of lifestyle changes.
o To the patient to decrease the risk of
CAD and promote drug effectiveness.
- Provide comfort and safety measures.
o To help patient tolerate drug side
Contraindications and cautions effects.
- Allergy to cholesterol absorption inhibitors. - Educate patient on drug therapy
o Prevent severe hypersensitivity o Include in the teaching plan the drug
reactions. name, its indication, and adverse
- Liver disease, pregnancy, lactation: effects to watch out for to enhance
o not used if combined with statins patient understanding of drug therapy
because of the effects of statins to and thereby promote adherence to the
these health conditions. Effect of this drug regimen.
class to fetuses and neonates is not COAGULATION MODIFIERS DRUGS: ANTICOAGULANTS,
known. ANTIPLATELETS, THROMBOLYTICS
Adverse effects Classification Generic name Brand name
- CNS: headache, dizziness, fatigue Aspro clear,
Aspirin
- Respiratory: upper respiratory tract infection disprin
Antiplatelet
(URI) Cilostazol Pletal
agents
- GI: mild abdominal pain, diarrhea Dipyridamole Presantine
- Musculoskeletal: muscle aches and pains, back pain Tirofiban Aggrastat
 Warfarin Coumadin - This drug class exerts its action by decreasing the
Anticoagulants Dabigatran Pradaxa responsiveness of platelets to stimuli that cause
Rivaroxaban Xarelto it to clump or aggregate. Through this, formation
Thrombolytic of platelet plug is decreased.
Alteplase Activase
agents - Therapeutic actions
o By blocking receptor sites on the
Reteplase Retavase
platelet membrane, platelet adhesion
TNKase and aggregation is inhibited.
Tenecteplase
o Also, platelet-platelet interaction as
well as interaction of platelets to
Urokinase Abbokinase clotting chemicals are prevented.
Others Indications
Dalteparin Fragmin - Primarily indicated for cardiovascular diseases that
Low-molecular
Enoxaparin Lovenox have potential for development of vessel
weight heparins
Tinzaparin Innohep occlusion.

Lepirudin Refludan - Other indications include maintenance of arterial

Anticoagulant Protaminse and venous grafts, preventing cerebrovascular
adjunctive sulfate occlusion, and including them as adjunct to
therapy thrombolytic therapy for treatment of myocardial
Vitamin K
infarction.
Hemorheological - One drug, anagrelide, blocks the production of
Pentoxifylline trental
agent platelets in the bone marrow.
Children
Coagulation modifier drugs: blood thinners - these drugs alone require careful dose calculation.
- Antiplatelet (Only heparin and warfarin are indicated for
o Acetyl Salic cyclic (Aspirin) (NSAID) children)
o Clopidogrel (Plavix) Adults
o Anticoagulant - Caution is particularly important to prevent
- Anticoagulant injury (e.g. using electric razor and softbristled
o Heparin (Heparin) toothbrush).
o Warfarin (Coumadin) Pregnant women
- Thrombolytic - For pregnant women, it is not advisable unless
o Streptase (Streptokinase) the benefit to the mother would clearly outweigh
o Retevase ( Reteplase) the risk for the fetus. On the other hand, for
Hemorrhagic disorders lactating women, it is generally inadvisable.
- characterized by excessive bleeding. These are Older adults
treated by drugs that promote the clotting - Are more susceptible to drug toxicity and drug-
process. to-drug interactions.
- Hemophilia: - Careful monitoring of liver and kidney function is
o characterized by genetic lack of clotting important for this age group.
factors - Therapy is always started at the lowest level
- Liver disease possible and adjusted accordingly.
o characterized by non-production of Pharmacokinetics
proteins and clotting factors necessary
for clot formation
- Bone marrow disorders:
o characterized by insufficient quantity
of platelets rendering them ineffective.
Thromboembolic disorders
- Include medical conditions (e.g. CAD) which
involve overproduction of clots which result into
decreased blood flow and total vessel occlusion.
Contraindications and cautions
- Manifestations s include hypoxia, anoxia, and even
- Allergy to antiplatelet agents.
necrosis. These disorders are treated by drugs
- Known bleeding disorder.
that interfere with normal coagulation process to
- Closed head injuries.
prevent formation of clots.
- History of thrombocytopenia.
1. Antiplatelet agents
 - Pregnancy, lactation. Generally inadvisable because - Among the many indications for this drug class
of potential adverse effects to fetus or neonate include: stroke and systemic emboli risk reduction,
Adverse effects nonvalvular atrial fibrillation, and deep vein
- CNS: headache, dizziness, weakness thrombosis.
- GI: GI distress, nausea - Heparin is used for prevention of blood clots in
- Skin: skin rash blood samples, dialysis, and venous tubing. It also
- Hema: bleeding (oftenly occurs while brushing the does not enter breastmilk so it is the
teeth) anticoagulant of choice for lactating women.
Interactions - Antithrombin is a naturally occurring
- Increased risk of bleeding if combined with anticoagulant and is a natural safety feature in
another drug that affects blood clotting. the clotting system.
Nursing considerations Children
- Assess for the mentioned contraindications to this - Only heparin and warfarin are indicated for
drug (e.g. hypersensitivity, acute liver disease, children but these drugs alone require careful dose
pregnancy etc.) to prevent potential adverse calculation.
effects. Adults
- Conduct thorough physical assessment before - Caution is particularly important to prevent
beginning drug therapy to establish baseline injury
status, - It is also important that adults are educated on
- Obtain baseline status for complete blood count what to do should bleeding
and clotting studies to determine any potential - Other drugs taken should be documented because
adverse effects there are a lot of drug interactions with these
Implementation with rationale drug class
- Administer drug with meals to relieve GI upset. Pregnant women
- Provide comfort measures for headache - For pregnant women, it is not advisable
- Educate patient on ways to promote safety like Older adults
using electric razor, soft-bristled toothbrush, and - Careful monitoring of liver and kidney
cautious movement - Therapy is always started at the lowest level
- Educate patient on drug therapy including drug Pharmacokinetics
name, its indication, and adverse effects to watch
out for
2. anticoagulants
- By interfering with clotting cascade and thrombin
formation, anticoagulants are able to interfere
with the normal clotting process.
Therapeutic action
- Warfarin, an oral agent in this class, reduces
Contraindications and cautions
Vitamin K dependent clotting factors. As a
- Allergy thrombolytics
result, clotting process is prolonged.
o Prevent severe hypersensitivity
- Two new oral agents, dabigatran and rivaroxaban,
reactions.
directly inhibits thrombin (last step in clotting
- Known bleeding disorder, recent trauma/surgery,
process) and factor Xa, respectively.
acute liver disease, cerebrovascular accident within
- Heparin and antithrombin block formation of
2 months, GI ulcers.
thrombin from prothrombin.
o These conditions can affect normal
clotting factors and normal plasminogen
aPTT – how fast does the blood clot intrinsic
production.
PT - how fast does the blood clot extrinsic
- Pregnancy, lactation.
o Potential adverse effects to fetus or
neonate.
Adverse effects
- CV: cardiac arrhythmias, hypotension •Hema:
bleeding (most common)
- Hypersensitivity reaction
- (uncommon) is characterized by rash, flushing,
and bronchospasm
Interactions
Indications
 - Anticoagulant, antiplatelet: increased risk of - It is also important that adults are educated on
bleeding what to do should bleeding occurs.
Nursing considerations - It should also be emphasized that periodic blood
- Assess for the mentioned contraindications to this tests is expected to monitor the effect of
drug (e.g. hypersensitivity, acute liver disease, therapy
CVA within 2 months, etc.) Pregnant women
o to prevent potential adverse effects. - it is not advisable On the other hand, for
- Conduct thorough physical assessment before lactating women is inadvisable.
beginning drug Older adults
- Obtain baseline status for complete blood count, - Are more susceptible to drug toxicity and drug-
fecal occult blood test (FOBT), and clotting to-drug interactions’ Careful monitoring of liver
studies and kidney function.
o to determine any potential adverse Contraindications and cautions
effects. - Allergy to thrombolytics. Prevent severe
Implementation hypersensitivity reactions.
- Assess for signs signifying blood loss (e.g. - Known bleeding disorder, recent trauma/surgery,
petechiae, bruises, dark-colored stools, etc.) acute liver disease, cerebrovascular accident within
- Establish safety precautions (e.g. raising side rails, 2 months, GI ulcers. These conditions can affect
ensuring adequate room lighting, padding sides of normal clotting factors and normal plasminogen
bed, etc.) production.
- Evaluate effectiveness by monitoring coagulation - Pregnancy, lactation. Potential adverse effects to
studies fetus or neonate.
- Educate patient on drug therapy including drug Adverse effects
name, its indication, and adverse effects to watch - CV: cardiac arrhythmias, hypotension
out for to enhance patient understanding on drug - Hema: bleeding (most common)
therapy and thereby promote adherence to drug - Hypersensitivity reaction (uncommon) is
regimen. characterized by rash, flushing, and bronchospasm.
3. Thrombolytic agents Interactions
- Promote clot resolution, the process of activating - Anticoagulant, antiplatelet: increased risk of
the plasmin system to break down the thrombus bleeding
or clot that has been formed. Pharmacokinetics
How do thrombolytics dissolve clots?
- Thrombolytic agents are proteases that break
down clots formed through the body's normal
clotting cascade.
- Thrombolytics primarily work by activating a
substance known as plasminogen.
- Plasminogen is then converted to plasmin, an
enzyme that breaks down strands of a protein Nursing considerations
called fibrin. - Assess for the mentioned contraindications to this
Therapeutic action drug (e.g. hypersensitivity, acute liver disease,
- The conversion of plasminogen to plasmin is the CVA within 2 months, etc.)
body’s natural anticlotting system. Thrombolytic o to prevent potential adverse effects.
agents’ action to activate this promotes - Conduct thorough physical assessment
breakdown of fibrin threads and dissolution of o before beginning drug therapy to
formed clots. establish baseline status, determine
- It is necessary to prevent vessel occlusion and effectivity of therapy, and evaluate
therefore, to deliver adequate blood flow to body potential adverse effects.
systems. - Obtain baseline status for complete blood count,
Indications fecal occult blood test (FOBT), and clotting
- For treatment of acute MI, pulmonary embolism, studies to determine any potential adverse
and acute ischemic stroke. effects.
- Also for clearing of occluded intravenous catheters Implementation
and central venous access devices. - Assess for signs signifying blood loss (e.g.
Children petechiae, bruises, dark-colored stools, etc.)
- Not indicated for this age group. - Establish safety precautions (e.g. raising side rails,
Adults ensuring adequate room lighting, padding sides of
- Caution is particularly important to prevent bed, etc.)
- Evaluate effectiveness by monitoring coagulation
studies
- Educate patient on drug therapy including drug
name, its indication, and adverse effects