Genitourinary; Diuretics; Fluid & Electrolyte Treatments Flashcards
relax smooth muscle bladder; inhibits/blocks effects of acetylcholine (blocks PNS - affects ANS: decreases urination)
Actions: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
Bladder spasm, overactive bladder - urinating at times not want to
Indications: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
Oral
Route/dose: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
exacerbate effects - GI obstruction, obstructive urinary tract problems (BPH), myasthenia gravis
Contraindications: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
Multiple! Check drug reference prior to admin.; any other drug with anticholinergic effects: diphenhydramine; exacerbate AE
Drug/Drug: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
related to blocking PSNS receptors in many places (anticholinergic effects - systemic AE) - Drowsiness, dizziness, blurred vision, tachycardia, dry mouth, nausea, urinary hesitancy, constipation, decreased sweating
AE: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
Assess urinary patterns - is drug being effective, AE
Nursing: - Urinary Tract Antispasmodics/Anticholinergics: Prototype: Oxybutynin
Maintenance of volume and composition of body fluids
Blood pressure control
Regulation of red blood cell production
Regulation acid-base
Electrolyte stability
Review renal funcs
Sodium regulation
Done through use of Na - water follows
Try to increase amount fluid volume excreted through kidneys - increase urination
Maintenance of volume and composition of body fluids
RAAS
Stimulation of RAAS sys
First line treatment HTN: thiazide diuretic: lower BP
Blood pressure control
Erythropoietin
Regulation of red blood cell production
Glomerulus - first part; checks and balances along way then get to end where sent down ureters and sent to bladder
Thiazides
Loop
Osmotic
Potassium-sparing
Matters where work - signifies potency of diuretic and understand diff actions of diuretic
Diuretics: sites of action
Hydrochlorothiazide
Distal tubules
Thiazides
Furosemide
Ascending loop of Henle
Loop
Mannitol
Proximal tubule
Osmotic
Spironolactone
Collecting duct
Potassium-sparing
Act on kidneys to increase urine output - end result/goal
Mechanism of Action: - Diuretics: gen overview
Hypertension (reduce/decrease intravascular volume; getting more fluid off) - hydrochlorothiazide
Fluid overload/edema apparent (heart failure, pulmonary edema, kidney/liver failure [ascites; peripheral edema])
Hyperkalemia (remove excess K) - treat high K levels because have K loss with admin
Indications for diuretics (see slides for specifics): - Diuretics: gen overview
GI effects (n/v/d)
Hypotension - acting on kidneys to get rid extra fluid and done too much get rid too much fluid on any diuretics this can occur
Dehydration (fluid volume deficit) - get rid too much fluid will get dehydrated
Fluid and electrolyte disturbances - hypo/hyper vary with diuretics: Sodium and potassium (mainly messed with)
Fluid rebound
Diuretics: gen AE
Occurs with patients on diuretics do not take in adequate water
Have too much fluid but if not enough fluid with therapy plasma more concentrated because less water in bloodstream so changes osmolarity blood to make more concentrated
Decrease fluid intake to decrease trips to bathroom
Results in concentrated plasma of smaller volume
Decreased volume is sensed by nephrons/kidneys, which activate RAAS cycle - need no more blood flow so activate RAAS: increase BP and intravascular volume - which body not need; when activated - ADH released - exacerbate prob; body hold onto more fluid exacerbating prob of fluid overload
Still have drink adequate amounts water even if on diuretics
Concentrated blood is sensed by osmotic center in brain, ADH is released to hold water and dilute the blood - hormones cause hang onto more water
Not want drink as much water then not pee as much but make prob worse; but actually make probs worse
Result in “rebound” edema as fluid is retained
2-3 L/day; prob when quit drinking
Fluid rebound explained
Pregnancy/lactation - gen avoided/contraindicated in this scenario
Severe renal failure - some diuretics not work appropriately if not have functioning kidneys; do not give diuretics because not work as well and can worsen kidney disease
Hypotension - AE
Dehydration - AE
Diuretics: gen contraindications
Digoxin: Increased potassium (K+) loss may occur - K-wasting (lose K); monitor K closely
Anticoagulants, antidiabetic drugs: reduced effectiveness
Lithium: Increased risk of toxicity because way works and impacts Na
Drug-Drug - Diuretics: gen contraindications
inhibits reabsorption of NaCl in distal tubule kidneys - inhibiting reabsorption of Na not get into bloodstream which means keep more water in tubule so more water excrete; remains in tubule for excretion (water follows Na); happening later in renal tubule where less Na exchange so so more gentler/milder diuretic
MoA: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
First line treatment for HTN - milder diuretic which need for someone who has HTN; not want pull off lots fluid; need little impact on volume
Indications: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
oral
Route/dose: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
Allergy to sulfa drugs - chem properties to sulfa and how formulated
Contraindications: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
SEE GENERAL; photosensitivity; hypokalemia - some exchanges electrolytes and diff pumps so as causing keep more Na in renal tubules + electric charge so is K - keep electric charges sim so increase excretion of K - so charges = so can lose K: risk is lower risk
AE: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
SEE GENERAL; use sunscreen
Nursing: - Thiazide Diuretics: Prototype: Hydrochlorothiazide (HCTZ)
inhibits reabsorption of NaCl in loop of Henle which causes a greater degree of diuresis than other diuretics (water follows Na) - typ more Na exchange in body so by using in this location more potent effect; inhibit reabsorption of NaCl so more Na and water in renal tubule so more excreted in urine so get more fluid off; secondary effects: vasodilation reducing preload and BP
MoA: - Loop Diuretics: Prototype: Furosemide (Lasix)
Conditions of/for fluid overload: HF, liver failure, kidney probs: not able do job effectively to help maintain fluid balance to make up for work of kidneys that other nephrons cannot do since died out; hyperkalemia - sig K loss: lower blood K and if on it automatically K replacements to correct
Indications: - Loop Diuretics: Prototype: Furosemide (Lasix)
oral; IVP (slow IV push rate: 20 mg/min); may be given IM or as IV gtt
Route/dose: - Loop Diuretics: Prototype: Furosemide (Lasix)
See general; ototoxic drugs; sulfa allergy
Contraindications: - Loop Diuretics: Prototype: Furosemide (Lasix)
See general; hypokalemia - dump out lot K with diuretic; CNS effects: paresthesia, ototoxicity (IVP slowly to prevent - more likely occur with IV)
AE: - Loop Diuretics: Prototype: Furosemide (Lasix)
See general; potassium supplements; IV fall risk - given IVP med works quickly (10-20 min) need go badly - figure out how go bathroom safely so not risking fall, think ahead so have things available so not fall; PO will have go but not as potent when PO and not go as quickly and as much of fall risk
Nursing: - Loop Diuretics: Prototype: Furosemide (Lasix)
aldosterone antagonist (norm action: reabsorp Na into bloodstream so lose K); blocks action of aldosterone in the distal tubule: loss of Na (leave more in renal tubule) & increased retention of K - K exchanged so have the potential for hyperkalemia
MoA: - Potassium-Sparing Diuretic: Prototype: Spironolactone
Conditions of fluid overload (CHF and liver disease)
Indications: - Potassium-Sparing Diuretic: Prototype: Spironolactone
Oral
Route/dose: - Potassium-Sparing Diuretic: Prototype: Spironolactone
See general
Contraindications: - Potassium-Sparing Diuretic: Prototype: Spironolactone
hyperkalemia (weakness, cardiac arrhythmias, n/v/d); photosensitivity; androgen effects - blocks androgen like hormones - secondary effect of blocking those: impotence, hirsutism, irregular menses, gynecomastia
AE: - Potassium-Sparing Diuretic: Prototype: Spironolactone
see general; EXCEPTIONS: monitor for high K - not low; Teach: avoid high K foods, use sunscreen
Nursing: - Potassium-Sparing Diuretic: Prototype: Spironolactone
increases osmolarity of glomerular filtrate (mannitol: sugar molecule - filtered into bowman’s gapsule and renal tubule which pulls more water into renal tubule to dilute out renal tubule - all sugar pulls water to dilute out all sugar); inhibits reabsorption of water and electrolytes and increases urinary output; Profound and rapid diuresis; effect all along the way; increases osmolarity of blood - wants bring to baseline so moves water from cells into bloodstream
MoA: - Osmotic Diuretics: Prototype: Mannitol
reduce intracranial pressure of cerebral edema because large fluid shifts and rapid initial diuresis; swelling neurons - move fluid from brain tissues into vascular space then fluid moved out through kidneys; shifting lot fluids in quick way and if shift lot fluids in cellular spaces into vascular spaces in CHF - give more fluid deal with because exacerbates prob; cannot deal with fluid shifts
Indications: - Osmotic Diuretics: Prototype: Mannitol
IV only - into bloodstream
Route/dose: - Osmotic Diuretics: Prototype: Mannitol
Can worsen edema; used with caution; pul. edema, renal failure, CHF, stroke…exacerbated by the large shifts in fluid
Contraindications: - Osmotic Diuretics: Prototype: Mannitol
hypovolemia - potent diuretic so can lose lot volume: not want do too much (hypotension, light-headedness, confusion, headache, electrolyte imbalance….cardiac decompensation and shock)
Adverse effects: - Osmotic Diuretics: Prototype: Mannitol
see general; monitor VS closely
Nursing: - Osmotic Diuretics: Prototype: Mannitol
Which assessment should the nurse prioritize prior to the administration of a diuretic?
A.Blood pressure
B.Weight
C.Lung sounds
D.Renal function
Answer: A
Potential cause most harm fastest
Check BP before give diuretic; because if not adequate cont go down; most harm quickly
Monitor weight - esp if CHF - track effectiveness of diuretic
Lung sounds - listen to esp if for pulm edema/CHF; altered with conditions of fluid overload
Renal func - imp can affect the kidneys; Want look at kidney func - look over long-term
Most sig to avoid AE is BP
Rationale: The nurse must take a blood pressure prior to administering any diuretic! Excessive fluid loss may result in hypotension. See notes for more.
H&P; allergies, contraindications; monitor kidney function - can give if have kidney impairment but can cause kidney injury - see if therapy appropriate; pats with CHF not perfused kidneys as well; end up with CKD
Focused assessments: depends on diuretics; depends on why giving meds
VS (hypotension = poor perfusion = symptomatic; make sure stable because not want drop too much); Rapid weight gain or loss (fluid balance - weight gain: acute CHF, weight daily to ensure losing the fluid)
I&O (fluid overload/dehydration) - tracking output imp for those on diuretic; make sure therapy effective - not see increase not having desired effect because trying get off excess fluid
Labs:
Nursing: assess and monitor
Decreased potassium (except K-sparing: increase K)
Decreased sodium - all except really with mannitol; lot less likely than K issues with diuretics
Increased serum uric acid (decreased excretion - higher risk for development gout - imp if already high risk or lot episodes of it)
Increased blood glucose levels (long-term use - not monitor routinely) - change in K keeps glucose out of cells; look at if one for years
Decreased kidney function - some DC if renal issues
Labs:
Weigh daily on same scale, same clothes, and at same time each day - esp imp for CHF - not gaining fluid too quickly
Monitor blood pressure (hypotension) - esp if outpat; get BP before admin med inpat
Potassium supplements as ordered (OR avoid potassium) - K loss predictable and almost have it; good tell why - understand imp on it
Maintain fluid intake to prevent fluid rebound or dehydration
Take diuretics in AM if possible so not going all night long
Change position slowly - can experience orthostatic hypotension - not fall
Adverse effects and when to notify PCP: hypotension, abnormal K level CM
Nursing: teaching
Teach aggravating factors fluid loss (diarrhea, vomiting, or excessive heat and sweating) - imp; adequate intake
S&S of fluid deficit/electrolyte imbalance or other AE to report - careful when may have extra fluid loss; fluid rebound, lower BP; ill, excessive sweating - may need to be held
Maintain fluid intake to prevent fluid rebound or dehydration
Which diuretics may cause hypokalemia? Select all that apply.
A.Mannitol
B.Spironolactone
C.Furosemide
D.Hydrochlorothiazide
Answer: A, C, D
Some K loss with mannital and HCTZ - less severe than loop diuretics; not always see HCTZ on K replacement like loop diuretics: loss is milder; mannitol: lose K and Na
Spironolactone - K-sparing
Rationale: Spironolactone works by blocking aldosterone, thus causing an increase in serum potassium.
The medical-surgical nurse is planning care for a client taking furosemide who was admitted with acute congestive heart failure. The nurse should plan for which expected outcome?
A.The client’s potassium level will decrease to 3.2 mEq/L.
B.The client’s weight will decrease by 9 pounds in 2 days.
C.The client’s urinary output will be 500 mL per day.
D.The client’s blood pressure will be 95/65 mmHg.
Answer: B
CHF and taking furosemide; which expected outcome: what want to happen with admin: goal for pat: get fluid off; weight down quickly cause getting extra fluid off
3.2 is an AE - might happen: goal for pat is not hypokalemia
Urinary output: want to increase; not enough
BP: 95/65: lower end: not planning for someone to become hypotensive
Rationale: the client needs to excrete excess fluid to decrease the workload on the heart. Weight loss will occur with fluid loss which is one way to assess effectiveness of the medication.
Adult total body water 50%-60% of body weight
Continuous exchange across semipermeable membranes (SPM) between intracellular and extracellular compartments
Can manipulate movement of water - IVF
Intracellular fluid (ICF) 70%
Extracellular fluid (30%)
Compartments of fluid in the body
Intravascular - plasma
Interstitial fluids
Extracellular fluid (30%)
measure of solute concentration “Pulling power”
In body fluids, 3 solutes determine osmolarity: Sodium, glucose, urea
Normal osmolality is 275–295 mOsm/kg
Greatest contributor is sodium: Sodium controlled by hormone aldosterone
Osmolarity
ability of solution to cause change in water movement across membrane due to osmosis
Tonicity of plasma used as a reference point: Plasma is isotonic; remains in intravascular space
Depends on Na composition
Tonicity
same concentration of particles as plasma
Stays in intravascular space
IV fluid same concentration as plasma
Not cause movement of water
Not change osmolarity of blood
Isotonic—
greater concentration than plasma
Water will move out of cells into solution (shrink)
Greater tonicity than osmolarity of the blood
Hypertonic—
lesser concentration than plasma
Fluid moves from extracellular compartments into cells (swell)
IV fluid lower tonicity than osmolarity of the blood
Causes shift of water
Hypotonic—
Increase: fluid volume deficit (dehydration)
Decrease: fluid overload (dilution); massive blood loss
Hemoglobin and Hematocrit - Diagnostics: lab studies for fluid imbalance
Increase: dehydration or impaired renal function
Decrease: fluid overload
BUN (blood urea nitrogen) (8-20 mg/dl) - Diagnostics: lab studies for fluid imbalance
Increase: renal failure
Creatinine (0.6-1.2mg/dl) - Diagnostics: lab studies for fluid imbalance
Increases: dehydration
Decreases: fluid overload
measure concentration of urine
Specific gravity: (1.010-1.025) - Diagnostics: lab studies for fluid imbalance
IV solutions with electrolytes; given IV - given into bloodstream; increase vascular volume - put fluid into vein increasing vascular fluid; causes shift of fluid
Used to replace fluids and promote urine output
Capable of leaving vascular space and moving to interstitial spaces and intracellular fluid
Infusions increase total fluid volume but compartment most expanded depends on solute (sodium) concentration
IV fluids: crystalloids
Isotonic: Normal saline (0.9% (NaCl))
Hypertonic: 10% Dextrose (D10W); 3 % NaCl
Hypotonic: 0.45% NaCl (1/2 strength saline/NS)
Infusions increase total fluid volume but compartment most expanded depends on solute (sodium) concentration
Expands vascular fluid volume with no shifts in compartments
No shift/movement of water
Not change osmolarity of blood
Uses:
AE: fluid overload
HTN - staying in vascular space and given too much
Examples:
Isotonic IV fluids
Isotonic fluid volume deficient (hydration)
Expands volume (ECF) to correct hypotension
Uses: - Isotonic IV fluids
Normal saline (0.9% NaCl): Sometimes abbreviated NS
Lactated ringers (LR)
5% dextrose in water (D5W)
Examples: - Isotonic IV fluids
Concentrate blood with more Na: water moves from cells and tissues into bloodstream to dilute it out; bring osmolarity back to baseline by taking water from cells and tissues
Expands plasma volume by drawing water away from cells and tissues
Helps dilute out all Na to get osmolarity backt to norm to get back to vascular space
Uses:
AE: excessive expansion of intravascular compartment (plasma); fluid overload and hypertension; overload vascular space: HTN, other signs of fluid overload
Examples:
Hypertonic IV fluids
Hyponatremia
Cerebral edema - common use
Uses: - Hypertonic IV fluids
3% Normal saline/NaCl (3% NS) - saltier; more concentrated than blood
Examples: - Hypertonic IV fluids
Lower osmolality than the blood; water moves from blood into cells; lower concentration - get osmolarity back to baseline
Water moves out of vascular space to cells (ICF)
Use: hypernatremia and cellular dehydration
AE: depletion of intravascular compartment and consequential hypotension
AE: too much expansion of intracellular compartment (peripheral edema) - low BP; expanding cells too much
Example:
Hypotonic IV fluids
0.45% NaCl (1/2 NS)
Less concentrated with Na
Give this IV fluid and already diluted and put in bloodstream diluting bloodstream - take water from bloodstream to get osmolarity back to baseline so water moves from vascular space to cells to get rid excess water because want certain osmolarity
Example: - Hypotonic IV fluids
Molecules too large to easily cross capillary membrane - not leave vascular space and draws water into vascular space
Draw water from intracellular fluid and interstitial spaces into plasma
Examples:
IV therapy: colloids
Stay in intravascular space & rapidly expand plasma volume
Molecules too large to easily cross capillary membrane - not leave vascular space and draws water into vascular space
5% Albumin - responsible for holding fluid in vascular space
Trauma (major blood loss)
Ascites (cirrhosis of liver - liver disease; not synthesizing albumin - replace what not have to help draw fluid from periphery back to vascular space; never synthesize albumin not correct underlying prob so short fix for pats)
Examples:
Transmission of nerve impulses, cardiac contraction, renal function, intracellular ion maintenance
Action: - Electrolyte replacement: Prototype: Potassium chloride
Prevention and treatment of hypokalemia; replace K
Indication: - Electrolyte replacement: Prototype: Potassium chloride
PO, IV
Route: - Electrolyte replacement: Prototype: Potassium chloride
Hyperkalemia (too much K): n/v/d, GI cramping, bradycardia, cardiac arrest
Adverse effects: - Electrolyte replacement: Prototype: Potassium chloride
Utilize electrolyte replacement protocol - admitted and ordered if pat admitted; in place - not have call for orders
Throughout administration monitor for:
Teach patient:
K chloride: nursing considerations - Electrolyte replacement: Prototype: Potassium chloride
Oral administration preferred
Follow dosing and lab draw times
Utilize electrolyte replacement protocol - admitted and ordered if pat admitted; in place - not have call for orders - K chloride: nursing considerations
Cardiac abnormalities (tele not required) - potential; hyperkalemia is a potential
Vein phlebitis (if intravenous) - burning at IV site; caustic to veins: slow down rate; can give through peripheral IV - use central line if can
Throughout administration monitor for: - K chloride: nursing considerations
Increase intake of high K+ foods if suffering from hypokalemia
Do NOT break, crush or chew ER caps or enteric capsules - PO - must take whole because could die
Report burning sensation at IV site
Teach patient: - K chloride: nursing considerations
Do NOT break, crush or chew ER caps or enteric capsules
With or after meals with full glass water
Dissolve effervescent tabs in 8 oz. cold water
Oral - K admin
Central line preferred: Caustic to veins
Admin rate (infusion):
Not exceed 10 mEq/hour for most pats; can give slightly faster: 20mEq/hr if necessary: ER/extrodinary circumstances - require tele because risk for hyperkalemia more sig
Slower through PIV if needed
Tele not required*
Monitor IV site (phlebitis)
Do NOT admin SQ or IM
IV infusion - K admin
H&P
Monitor:
Fluid intake and output
Daily weights (gain and loss)
Laboratory studies
Nursing: fluid and electrolytes
Fluid volume (overload or dehydration); HR, BP; heart, lungs
Monitor: - Nursing: fluid and electrolytes
Should be balanced; urine 30 mL/hr
Fluid intake and output - Nursing: fluid and electrolytes
Best way to determine fluid status
Edema not apparent until 5-10# excess fluid
Rapid gain or loss of 1 kg (2.2#)=1 L of fluid
Daily weights (gain and loss) - Nursing: fluid and electrolytes
As appropriate to administration
Laboratory studies - Nursing: fluid and electrolytes
