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Nursing 220: Pharmacology Module II: Renal System Drugs


Renal corpuscle (glomerulus, Bowman capsule) Proximal convoluted tubule. Loop of Henle ... Renal Corpuscle. Proximal Convoluted. Tubule. Loop of Henle. Distal ... – PowerPoint PPT presentation

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Title: Nursing 220: Pharmacology Module II: Renal System Drugs

Nursing 220 PharmacologyModule II Renal
System Drugs
  • Presented by
  • Ronda M. Overdiek, MSN, CCRN, RNC

Overview Renal System Drugs
  • Chapter 39
  • Anatomy
  • Physiology
  • Drugs Affecting Renal System
  • Diuretics
  • High ceiling (loop) diuretics
  • Thiazide diuretics
  • Osmotic diuretics
  • Potassium sparing diuretics

Review Nephron
  • Nephron
  • Functional unit of the kidney
  • Function is to form a filtrate of protein-free
    plasma (process called Ultrafiltration)
  • Approximately 1.2 million are present
  • Tubular structure that contains
  • Renal corpuscle (glomerulus, Bowman capsule)
  • Proximal convoluted tubule
  • Loop of Henle
  • Distal convoluted tubule
  • Collecting duct

Review Nephron
  • Renal Corpuscle
  • Proximal Convoluted
  • Tubule
  • Loop of Henle
  • Distal Convoluted
  • Tubule
  • Collecting Duct

Process of Urine Formation
  • Process of urine formation depends on
  • 1. Glomerular Filtration formation of a
    filtrate of protein-free plasma
  • 2. Tubular reabsorption Movement of fluids and
    solutes from the tubular lumen to the peritubular
    capillary plasma.
  • 3. Tubular secretion Transfer of substances
    from the plasma of the peritubular capillary to
    the tubular lumen.

Review Nephron
Drugs of the Renal SystemDiuretics
Drugs of the Renal SystemDiuretics
  • Mechanism of Action
  • Blockade of sodium and chloride reabsorption
  • Create osmotic pressure within the nephron that
    prevents the passive reabsorption of water.
  • Increase in urine flow that a diuretic produces
    is directly related to the amount of
    sodium/chloride reabsorption that it blocks.
  • Diuretics that block reabsorption early in the
    nephron produce the greatest diuresis.
  • 1 of solute reabsorption that is blocked, urine
    output will increase 1.8 L

Drugs of the Renal SystemDiuretics
  • Classifications of Diuretics
  • High-Ceiling (loop) Diuretics
  • Thiazide Diuretics
  • Potassium-sparing Diuretics
  • Osmotic Diuretics

Diuretic ActionHigh Ceiling (Loop) Diuretics
High-Ceiling (Loop) Diuretics
  • Most effective diuretics available
  • Produce more loss of fluid/electrolytes than any
    other diuretics
  • Site of Action Loop of Henle
  • Prototype Furosemide (Lasix)
  • Acts of thick segment of the ascending limb of
    Henles loop to block reabsorption of sodium and
    chloride (normally 20 of filtered NaCl is

High-Ceiling (Loop) DiureticsFurosemide
  • Pharmacokinetics
  • Administered orally, IV, IM.
  • Oral Begins 60 minutes-persists for 8 hours
  • IV Begins 5 minutes persists for 2 hours
  • Undergoes hepatic metabolism and renal excretion

High-Ceiling (Loop) DiureticsFurosemide
  • Why do we care when onset of action is?

High-Ceiling (Loop) DiureticsFurosemide
  • Therapeutic Uses
  • Utilized by patients requiring rapid or massive
    mobilization of fluid
  • Pulmonary edema
  • Congestive heart failure (CHF)
  • Edema of hepatic, cardiac, or renal origin that
    has been unresponsive to less efficacious
  • Hypertension uncontrolled with other diuretics
  • Severe renal impairment

High-Ceiling (Loop) DiureticsFurosemide
  • Adverse Effects
  • Hyponatremia
  • Hypochloremia
  • Dehydration
  • Hypotension
  • Hypokalemia
  • Ototoxicity
  • Hyperglycemia (diabetic patients)
  • Hyperuricemia (gout patients)

Question 1
  • Duncan McKeough is admitted to the
    medical-surgical unit with symptoms of shortness
    of breath and peripheral edema. Mr. McKeough is
    52 years old and has a history of recurrent
    congestive heart failure. An IV is started and
    he is to receive furosemide 40 mg IV. Furosemide
    is supplied in 10mg/ml. How much will you give
    Mr. McKeough?
  • D/H X C DD

Question 2
  • The physician orders a maintenance dose of Lasix
    for Mr. McKeough. The nurse will check
    laboratory values and monitor for
  • Hyperchloremia
  • Hypermagnesemia
  • Hypophosphatemia
  • Hyponatremia

Question 3
  • Mr. McKeough is getting ready to go home. The
    physician writes for a discharge order to
    continue Furosemide 20 mg daily after discharge.
    The nurse will teach Mr. McKeough to
  • Take the food on an empty stomach
  • Eat foods high in calcium
  • Weigh daily and report rapid changes
  • Take medication in the evening

Diuretic ActionThiazides
Thiazides (Benzothiadiazides)
  • Increase renal excretion of sodium, chloride,
    potassium, and water.
  • Elevate plasma levels of uric acid and glucose
  • Diuresis less than loop diuretics
  • Loop diuretics effective in renal impairment,
    thiazides are not.

Thiazides (Benzothiadiazides)
  • Prototype Hydrochlorothiazide (HydroDIURIL)
  • Mechanism of Action
  • Blocks reabsorption of sodium/chloride in the
    early segment of the distal convoluted tubule.
    (10 of sodium and chloride reabsorbed at this
  • Dependent on adequate kidney function
    ineffective when glomerular filtration rate (GFR)
    is low.
  • Pharmacokinetics
  • Onset 2 hours after oral administration-peaks
    4-6 hours, persist up to 12 hours.

Thiazides (Benzothiadiazides)
  • Therapeutic Uses
  • Hypertension
  • Edema (mild/moderate CHF)
  • Adverse Effects
  • Hyponatremia
  • Hypochloremia
  • Dehydration
  • Hypokalemia
  • Hyperglycemia (diabetics)
  • Hyperuricemia (gout patients)

Question 1
  • Sam Weiss is being treated as an outpatient for
    mild hypertension. He is a 60 year old with a
    history of adult onset diabetes mellitus. Mr.
    Weiss is to begin treatment with chlorothiazide
    (Diuril) 500 mg PO daily. The nurse will note
    the following as important assessment data prior
    to administration
  • Thyroid levels
  • Gastric pH level
  • Creatinine clearance
  • Blood gas analysis

Question 2
  • Five days after starting diuretic therapy, Mr.
    Weiss calls to tell the nurse that he is having
    palpitations and skipped heart beats. The
    nurse informs the physician and is aware that
    these symptoms may relate to
  • Hypermagnesemia
  • Hyperglycemia
  • Hyponatremia
  • Hypokalemia

Diuretic ActionPotassium Sparing Diuretics
Potassium Sparing Diuretics
  • Two useful responses
  • Produce a modest increase in urine production
  • Produce a substantial decrease in potassium
  • Used in conjunction with loop and thiazide
  • Two Subcategories
  • Aldosterone antagonists
  • Nonaldosterone antagonists

Aldosterone AntagonistSpironolactone (Aldactone)
  • Spironolactone (Aldactone)
  • Blocks the actions of Aldosterone in the distal
  • Opposite effect retention of potassium and
    excretion of sodium
  • Onset 48 hours
  • Therapeutic Uses
  • Hypertension
  • Edema
  • Heart failure
  • Hyperaldosteronism
  • Used in combination w/loop or thiazide diuretics
  • Counteract potassium wasting

Aldosterone AntagonistSpironolactone (Aldactone)
  • Adverse Effects
  • Hyperkalemia
  • Tumors
  • Endocrine Effects

Nonaldosterone AntagonistsTriamterene/Amiloride
  • Mechanism of Action
  • Inhibit potassium loss by direct blockade of
    sodium/potassium exchange in the distal nephron
  • Produce only modest diuresis
  • Used with other diuretics for potassium sparing
    effects (thiazides/loop)
  • Adverse Effects
  • Hyperkalemia

Diuretic ActionOsmotic Diuretics
Osmotic Diuretics
  • Four Compounds
  • Mannitol
  • Urea
  • Glycerin
  • Isosorbide
  • Most common Mannitol

Osmotic Diuretics
  • Mannitol (Osmitrol)
  • Free filtered in the glomerulus
  • Undergoes minimal reabsorption
  • Not metabolized to a significant degree
  • It is pharmacologically inert
  • Mechanism of Action
  • Creates osmotic force within the lumen of the
    nephron, inhibiting passive reabsorption of
    water, increasing urine flow.
  • No significant effect on the excretion of
    potassium and other electrolytes.

Osmotic DiureticsMannitol
  • Pharmacokinetics
  • Must be given IV.
  • Distributes into extracellular water
  • Diuresis begins 30-60 minutes, persists for 6-8
  • Therapeutic Uses
  • Prophylaxis of renal failure
  • Reduction of ICP
  • Reduction of IOP

  • Margaret Roberts, aged 47 years, is recovering
    from a craniotomy. The nurse monitors the
    intracranial pressure (ICP) and reports an
    elevated reading. Mannitol is administered as
    ordered. Which of the following outcomes BEST
    represents therapeutic effects of mannitol
    therapy for Ms. Roberts?
  • Increased ICP
  • Decreased peripheral edema
  • Improved neurologic status
  • Enhanced creatinine clearance

Utilizing the Nursing Process
  • Assessment
  • Why does this patient need a diuretic?
  • Assess medication history of drugs currently
    taken, including nonprescription drugs
  • Baseline physical assessment
  • Weight, blood pressure, pulse, respiration,
    electrolytes, record site/extent of edema
  • Identify high risk patients
  • Cardiovascular disease, renal impairment,
    diabetes, gout, pregnant.

Utilizing the Nursing Process
  • Nursing Diagnosis
  • Knowledge deficit
  • Fluid volume excess
  • Fluid volume deficit
  • Electrolyte Disturbances
  • Planning
  • Determine nursing goals derived from nursing
  • Plan of care is individualized to patient

Utilizing the Nursing Process
  • Implementation
  • Administration Seven rights
  • Promote Compliance
  • Forewarn patients that treatment will increase
    urine volume and frequency

Utilizing the Nursing Process
  • Evaluation
  • Monitor intake/output, blood pressure, pulse
    rate, weight patient daily, evaluate for
    decreasing edema.
  • Minimize adverse effects
  • Electrolyte imbalances, dehydration, hypotension,
    hyperglycemia, hyperuricemia.
  • Drug interactions