6.9 Diuretics
Diuretics are used to decrease blood pressure and to decrease symptoms of fluid overload such as edema. There are many classifications of diuretics. We will discuss loop, thiazide, and potassium-sparing diuretics. Other diuretics, such as osmotic diuretics, are used to decrease fluid from cerebrospinal fluid and the brain.
Diuretics cause diuresis (increased urine flow) by inhibiting sodium and water reabsorption from the kidney tubules. By eliminating excess water, blood volume and blood pressure, as well as preload, are decreased. Diuretic medications can have a significant impact on renal function; therefore, laboratory monitoring of renal function tests may be required. Common tests that are ordered to assess side effects of diuretic medications include blood urea nitrogen (BUN), creatinine, and creatinine clearance. Clients with abnormal BUN and creatinine levels may require a lower dosage of diuretics or a different medication regimen. Creatinine clearance is then calculated based on the amount of creatinine in the urine and the blood, as well as the client‘s age, gender, and weight. The results of the test can help health care providers monitor kidney function in clients who are taking diuretics, as well as adjust dosages or medications if necessary to prevent further kidney damage.
Diuretics are often used in combination with other antihypertensive agents to reduce a client’s blood pressure. Cients on diuretics often require dietary medications. Clients should follow a low-sodium diet to prevent fluid retention and hypertension. However, some clients may substitute salt with high-potassium salt substitutes, which can increase potassium levels and cause hyperkalemia. Health care providers should educate clients regarding the risks of using salt substitutes and provide guidance on dietary recommendations.
Furosemide
Mechanism of Action: Loop diuretics inhibit absorption of sodium and chloride in the loop of Henle and proximal and distal tubules, thus causing fluid loss, along with sodium, potassium, calcium, and magnesium losses. Loop diuretics are very potent diuretics and are used when a client has an exacerbation of fluid overload.
Indications: Furosemide is used to treat clients with edema and is also used to treat hypertension. IV furosemide is used to urgently treat pulmonary edema in conditions such as congestive heart failure.
Nursing Considerations: The onset of diuresis following oral administration is within 1 hour. The peak effect occurs within the first or second hour. The duration of diuretic effect is 6 to 8 hours. When possible, loop diuretics should be administered in the morning, and evening doses should be avoided (unless urgent) so that sleep is not disturbed.
Nurses should continually monitor for dehydration and electrolyte imbalances that can occur with excessive diuresis, such as dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps, muscular fatigue, hypotension, oliguria, tachycardia, arrhythmia, or gastrointestinal disturbances such as nausea and vomiting.
Use cautiously in the geriatric population who have decreased renal function. Kidney function should be monitored closely for all clients because this is a potent medication that works within the kidney tubules.
Monitor the client closely for hypokalemia if furosemide is used concomitantly with digoxin. Hypokalemia may increase the risk of digoxin toxicity.
Side Effects/Adverse Effects: Adverse effects include dehydration, hypotension, and electrolyte imbalances such as hypokalemia. Health care providers may add potassium to a client’s scheduled medication list to decrease risk of hypokalemia. If using IV route, the administration must be given slowly to reduce the risk of the client developing ototoxicity.[1]
Health Teaching & Health Promotion: Advise clients to change position slowly as they may experience orthostatic changes. Clients should also report weight gain of more than three pounds in a day to their health care provider. Clients should also be encouraged to enjoy potassium-rich foods during loop diuretic drug therapy.[2]
Now let’s take a closer look at the medication grid for furosemide in Table 6.9a.[3]
Table 6.9a Furosemide Medication Grid
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Loop Diuretic | furosemide | Assess blood pressure
Monitor electrolytes (potassium) Promote potassium-rich diet Assess renal function Assess for dehydration and intake and output Monitor daily weight |
Based on indication; decreased blood pressure or edema | Dehydration
Electrolyte depletion (especially potassium) Ototoxicity with rapid IV infusion Renal impairment |
Critical Thinking Activity 6.9
Mrs. Smith is a 79-year-old widow who has lived alone for the past five years. Three years ago, she was hospitalized for an MI, which resulted in heart failure. She is compliant with her medications, which include digoxin (Lanoxin) 0.125 mg daily, furosemide (Lasix) 40 mg daily, and potassium (K-Dur) 20 mEq daily.
Recently, Mrs. Smith ran out of her potassium and thought that because it was “just a supplement,” it would be OK to go without it until the next time she went to town to fill the prescription. She has not taken her potassium for a week.
Today she comes into the clinic with generalized weakness, fatigue, nausea, and diarrhea. Her BP is 104/62, pulse 98 bpm and slightly irregular, RR 20, and temp 97.2 F. Blood is drawn and shows serum sodium level of 150 mEq/L, digoxin level of 2.6ng/mL and potassium level of 3.2 mEq/L.
- What assessments should a nurse do before and after administering a diuretic?
- What are the signs and symptoms of digoxin toxicity? What can happen to a client who has toxic levels of digoxin?
- What is the normal range for serum potassium level?
- What classification of medication is furosemide?
- Is dehydration a risk for clients on furosemide? Why or why not?
- How would you assess for dehydration?
- What electrolyte imbalance(s) can occur in clients taking furosemide?
- What relationship exists between this client’s furosemide, digoxin, and potassium levels?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
Hydrochlorothiazide
Mechanism of Action: Thiazide diuretics work near the distal tubule to promote the excretion of sodium and water, thus causing diuresis. They are not effective for immediate diuresis.
Indications: Hydrochlorothiazide diuretics are used to manage hypertension and edema.
Nursing Considerations: Thiazide diuretics are contraindicated for clients who have anuria or hypersensitivity.
After oral use, diuresis begins within 2 hours, peaks in about 4 hours, and lasts about 6 to 12 hours.
Use with caution in severe renal disease.
Side Effects/Adverse Effects: Clients who are taking thiazide diuretics should be monitored for electrolyte depletion, dehydration, weakness, hypotension, renal impairment, and hypersensitivities.[4]
Health Teaching & Health Promotion: Clients should be instructed to take these medications at the same time each day and notify their health care provider if they experience significant changes in weight. Thiazide diuretics may cause orthostatic changes so individuals should change positions slowly. Additionally, some clients may note increased photosensitivity so protective measures should be taken. Clients should monitor their blood pressure and comply with interventions to reduce hypertension. Hydrochlorothiazide (HCTZ) can interact with licorice to increase potassium levels. Clients on HCTZ should avoid consuming large amounts of licorice or licorice-containing products to prevent hyperkalemia.[5]
Now let’s take a closer look at the medication grid for hydrochlorothiazide in Table 6.9b.[6]
Table 6.9b Hydrochlorothiazide Medication Grid
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Thiazide Diuretic | hydrochlorothiazide | Assess blood pressure
Monitor electrolytes (potassium) Promote potassium-rich diet Assess renal function Assess for dehydration and intake and output Monitor weight |
Decrease blood pressure
Decrease edema |
Electrolyte depletion
Dehydration and weakness Hypotension Renal impairment Hypersensitivity (vasculitis, respiratory distress, photosensitivity, rash) |
Spironolactone
Spironolactone is a potassium-sparing diuretic that is used as a mild diuretic or in combination with another diuretic.
Mechanism of Action: Spironolactone acts primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule. Spironolactone causes increased amounts of sodium and water to be excreted, while potassium is retained.
Indications: Spironolactone is used to treat hypertension and to control edema for clients with heart failure or liver dysfunction.
Nursing Considerations: This medication may cause hyperkalemia. Monitor urine output and report if less than 30 mL/hour. Use cautiously with clients who have renal impairment due to increased risk for hyperkalemia. Use cautiously in clients with liver impairment. Administer in the morning to avoid nocturia.
Side Effects/Adverse Effects: Spironolactone can increase the chances of hyperkalemia, hyperglycemia, hyperuricemia, dehydration, hypotension, renal impairment, hypersensitivity, and gynecomastia. This medication may increase risk for lithium toxicity.[7]
Health Teaching & Health Promotion: Clients should be instructed to take these medications at the same time each day and notify their health care provider if they experience significant changes in weight. Diuretics may cause orthostatic changes so individuals should change positions slowly. Clients should be advised to avoid salt substitutes and foods that contain high levels of potassium.[8]
Now let’s take a closer look at the medication grid for spironolactone in Table 6.9c.[9]
Table 6.9c Spironolactone Medication Grid
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Potassium-Sparing Diuretic | spironolactone | Assess blood pressure
Monitor electrolytes (potassium) Assess renal function Assess for dehydration and intake and output Monitor weight |
Decrease blood pressure
Decrease edema |
Hyperkalemia, hyperglycemia, and hyperuricemia
Dehydration Hypotension Renal impairment Hypersensitivity (vasculitis, fever, anaphylactic reactions, rash) Gynecomastia |
Mannitol
Mannitol is an osmotic diuretic that works by increasing the osmotic pressure of the glomerular filtrate.
Mechanism of Action: Mannitol inhibits the reabsorption of water and electrolytes and promotes the excretion of water and electrolytes in the urine.
Indications for Use: Mannitol is used for the prevention and treatment of acute renal failure, cerebral edema, and intraocular pressure. It is also used to promote the excretion of toxic substances, such as certain drugs and poisons.
Nursing Considerations: Mannitol is administered intravenously, and the dose and rate of administration should be carefully monitored. Clients receiving mannitol should be closely monitored for fluid and electrolyte imbalances, dehydration, and kidney function. Mannitol should be used cautiously in clients with heart failure or pulmonary edema.
Side Effects/Adverse Effects: Adverse effects of mannitol include dehydration, electrolyte imbalances, and kidney dysfunction. Other potential adverse effects include headaches, nausea, vomiting, and allergic reactions.
Health Teaching & Health Promotion: Clients should be advised to report any adverse effects or changes in symptoms to their health care provider. Clients should also be encouraged to maintain adequate hydration and follow any dietary recommendations provided by their health care provider.
Now let’s take a closer look at the medication grid for mannitol in Table 6.9d.
Table 6.9d Mannitol Medication Grid
| Class/Subclass | Prototype/Generic | Nursing Considerations | Therapeutic Effects | Side/Adverse Effects |
|---|---|---|---|---|
| Osmotic Diuretic | Mannitol | Dose and rate of administration should be carefully monitored
Clients receiving mannitol should be closely monitored for fluid and electrolyte imbalances, dehydration, and kidney function Mannitol should be used cautiously in clients with heart failure or pulmonary edema |
Promotes the excretion of water and electrolytes in the urine | Dehydration
Electrolyte imbalances Kidney dysfunction Other potential adverse effects include headaches, nausea, vomiting, and allergic reactions |
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
- This work is a derivative of DailyMed by U.S. National Library of Medicine in the Public Domain. ↵