hey everyone in cereth register nurse RN calm and today we're going to talk about thiazide diuretics and as always after you watch this youtube video you can access the free quiz that will test you on this medication so let's get started as we've been reviewing these medications in this pharmacology series we have been remembering the word nurse because each letter of that word helps us remember those important concepts we need to know for exams so first we're going to talk about the name specifically the family name of the drug because this tells us how the drug works on the body and we're dealing with the thiazide family specifically those thiazide diuretics well thiazide tells us that this medication works in the early part of the distal convoluted tubule that's found within this nephron and what this drug is going to do it's going to affect a co transporter that's found within this early part of the dct and this transporter is called the sodium chloride co-transporter and it is considered a cyanide sensitive transporter so hence why this drug works so well and what it's going to do is it's going to prevent this transporter from being able to do its job and just as its name says is that this transporter transports sodium and chloride from the filtrate to go back into the blood to be reabsorbed by the body well for stopping this process of this sodium chloride going back into the body that means it's gonna stay in this filtrate which eventually turns into urine when it exits the body so if we have sodium chloride stained in this filtrate it's going to result in increased sodium in the filtrate which is going to draw water to it because water loves sodium so more water will stay in this filtrate will not be reabsorbed back into the body less of it will be and this is going to cause the person to have increased urination because we have more fluid in the urine so we're getting those diuretic effects that this drug does and this will help slightly decrease our blood volume you because we're moving it now thiazide diuretics are not as potent or as powerful as loot diuretics like furosemide and the reason for that is because each type of diuretic that you have is going to affect different structures within this nephron which is going to alter how sodium is reabsorbed back into the body because if we keep it in the filtrate that means water is going to stay there and that's going to help provide that diuresis effect so for example loop diuretics we learn work in the loop of Henle and specifically this thick ascending line' and this thick ascending limb is responsible for about 25 percent of sodium reabsorption so we throw on a lube diuretic we're not going to be reabsorbing all that said he was going to stay in the filtrate that's a high percentage of sodium so it's going to have a stronger effect by keeping water in it compared to this distal convoluted tubule where it only accounts for about five to seven percent of sodium reabsorption so you can see the percentage differences and while loop diuretics are a lot more effective than a thiazide diuretic but the thiazide diuretic does provide a nice diuresis effect not as strong as a loop diuretic and another thing about thiazide is that they're less effective in patients who have a compromised GFR a go merrill ER filtration rate meaning that this glomerulus of this nephron is not very effective in filtering the blood and with loop diuretics they are good in patients who have this compromised GFR like they have renal failure let's say you have a patient with renal failure who has fluid volume overload well we can give them a loop diuretic and that can help remove that fluid but with a thigh we wouldn't want to do that because their GFR is compromised in some examples of thiazide diuretics are like hydrochlorothiazide in DAP amide clora thiazide Mottola zone and chlorothalonil unfortunately we can't go by their ending like with some of the other drugs generic names but some do in in thiazide now let's talk about how these thiazide diuretics work on this nephron to cause diuresis but to do that let's review the basic anatomy and physiology of this nephron here's an illustration of a nephron if we took a nephron and stretched it out it would look something similar to this also you can see how the nephron sets within the kidneys and these structures work within the kidneys to allow them to function and without them working properly the kidney fails to do its job and there are millions of these little nephron structures within each kidney and they function to filter the blood and manage the amount of water ions and waste in the blood and either it's going to cause some ions and water to be reabsorbed back into the blood so you can use them or it's going to make it where the ions and specifically waste and water will stay in the filtrate so it'll be excreted as urine so these little structures are always tweaking this filtrate that's created by the glomerulus until it's where your body needs it to be and if it's not you excrete it as urine and the nephron is divided into several parts and each part has its own unique role for tweaking this filtrate which is why certain diuretics work on certain areas of the nephron and the parts of the nephron include the afferent and efferent arteriole the afferent arteriole delivers blood via the renal artery to the nephron so it can be filtered the afferent arteriole takes blood away from the nephron after it has been filtered so when the nephron receives blood through the afferent arteriole it's going to go through the glomerulus and this is going to filter the blood and create the filtrate which will eventually exit the body as urine and the filtrate is going to contain ions which are like electrolytes water and waste and it's gonna drip down into Bowman's capsule which will collect the filtrate as it drips down from that mara less then the filtrate is going to start its journey of being tweaked and by the other parts of the nephron to the point where the body is satisfied with it and what it doesn't want it's going to be excreted as urine so the first stop is the proximal convoluted tubule and this area is going to reabsorb water ions etc and the parts that we've talked about up to this point hang out in the renal cortex of the kidney and this provides like an isotonic environment where the sodium concentration is equal in the inside hence the nephron and that filtrate compared to the outside however as this filtrate starts progressing going down into the loop of Henle it's going to enter into a hypertonic environment because it's in the renal medulla and this is very necessary for water re-absorption by that descending limb of the loop of Henle and the collecting duct so once it leaves the proximal convoluted tubule it's going to go down into the loop of Henle and then loop of Henle has the descending and a sending limb so it's tweaked there as well and remember I talked about how that thick ascending limb is responsible for about 25% of sodium reabsorption so the filtrate is going to go up and again it's going to enter back into the isotonic environment and it's going to go into the distal convoluted tubule and this is the structure that we care about for this lecture for the thiazide because this is where the thiazide diuretics works specifically in that early part and some functions of this distal convoluted tubule is to of course reabsorb sodium and chloride but it also plays a role in reabsorbing calcium and i want you to remember that because one of the side effects of thiazide diuretics is that it can increase calcium levels and also it plays a role with secretion of potassium into the filtrate then it leaves the DCT and it's making its journey to the collecting ducts and this is the last part of the nephron where the filtrate is finally tweaked ions and water will be it reabsorbed and the last part of the collecting duct is found in that renal medulla and this will play one last role with that water reabsorption then it will exit the body through the renal pelvis and you will have urine which will go to the ureters and be urinated out now let's go a little bit more in depth to how these thighs I diuretics work in this distal convoluted tubule and tie it in with why we're gonna see these certain electrolyte imbalances for these patients and these are some important concepts you want to remember for your exams because it'll tie in with your nursing interventions and your patient teaching so we've already established that the distal convoluted tubule is going to play a role in us reabsorbing sodium and chloride and calcium and the secretion of potassium ions as well into the back into this filtrate so the distal convoluted tubule when we throw a thiazide and it's going to affect this code transport the sodium chloride co-transporter it's going to prevent it from allowing these sodium and chloride ions from leaving the filtrate and going back into the blood and hanging out in the blood and keeping those levels nice and stable so because we're not going to be receiving that sodium we are going to potentially lower the sodium levels in the blood leading to hyponatremia so that's one electrolyte imbalance you want to watch out for now because we're inhibiting this co-transporter it's going to alter how these other channels and transporters can work within this distal convoluted tubule to deal with other ions to be reabsorbed and one ion reabsorption that's going to be affected will be calcium because it is affected by a particular channel known as the t RP v v channel and because we inhibit this sodium chloride coat transporter it's actually going to inhale how this channel works so it helps the body reabsorb calcium back into the blood well for enhancing how this channel works we're going to be reabsorbing more calcium in the blood which can lead to hypercalcemia increasing our calcium levels in the blood a normal calcium level is about eight point five to ten point five milligrams per deciliter now this can actually be beneficial and we're going into a little bit for what this drug is used for but patients who have recurrent renal stones that are composed of calcium can actually benefit from this because if we are increasing calcium reabsorption from the filtrate to go back into the blood that's leaving less calcium and that filtrate which leaves less calcium that can help create a renal stone also patients who have low calcium levels we can possibly throw in a thiazide to help increase the reabsorption of calcium in the blood which can hopefully help increase their bone density so it can be beneficial in some instances but as a nurse you want to watch that calcium level also thiazide diuretics can cause hypokalemia and that was similar to our loop diuretics they also can lower the potassium level so they share that and why is that same like with loop diuretics as this filtrate travels through this distal convoluted tubule here we in the early part we prevented that sodium from being reabsorbed so more is hanging out in the filtrate well it's journeying down through rest of this to be oh well it's high in sodium and these channels are influenced by aldosterone and we've learned that aldosterone causes the body to keep water and sodium in exchange for potassium so if we have a lot of sodium in the filtrate traveling down through these aldosterone influence channels that's really going to cause the body to secrete potassium into that filtrate which is going to lower our potassium levels and also going with that potassium hydrogen ions so we can lower our potassium levels in normal potassium levels about 3.5 to 5 milli equivalents per liter and the patient could possibly experience metabolic alkalosis due to the loss of those hydrogen ions so remember that and patients may have to take potassium supplements you'll want to be watching that potassium level for sure especially if they're on other medications which we'll talk about here in a moment and educate them about foods that are rich in potassium and they want to definitely keep those in their diet those are diuretics can also alter the blood sugar and this is important to know for your patients who are diabetic thiazide diuretics can increase the blood glucose level the reason for why they do that is not truly understood but we want to educate our patients to monitor their glucose glucose level closely because their insulin or their oral diabetic medications may have to be tweaked based on if they're getting this hyperglycemia and thiazide diuretics can increase uric acid levels which can lead to gout attacks and the reason for this is that these drugs alter how the proximal convoluted tubule deals with your ate and it actually increases how urate is reabsorbed which can increase your gas levels and lead to gaol attacks so you may need to monitor those uric acid levels and high uric acid levels for a male tends to be anywhere anything greater than seven and four females greater than six so if you see a uric acid level of 15 that is not good that means that they have high uric acid levels so what if eyes I diabetics use four which is the second part of our word of nurse well they can be used to treat hypertension high blood pressure and they're usually about the first line for helping a patient treat their high blood pressure and what it's going to do it's going to decrease that sodium and water out of the blood which can help lower the blood pressure in addition they can be ordered for patients who have heart failure this is where the heart is weak to pump blood it becomes overwhelmed and blood starts backing up into the lungs and to the body and the patient is really just miserable so what these medications can do is they can be prescribed a lot of times with ACE inhibitors and we talked all about ACE inhibitors and this can help actually increase the function of the heart and help the patient feel better also as we've talked about thiazide diuretics can be used in the treatment of renal calculi which are those renal stones that are composed of calcium now let's wrap up this review and let's talk about nursing responsibilities the side effects and education pieces for the patient who may be taking a thigh-high diuretic so whenever you have a patient taking a thiazide you really want to be watching out for signs and symptoms of dehydration because we're increasing your their urination and how much fluid is being removed from their blood volumes so some things as a nurse you can watch out for is you can look at their vital signs how is their blood pressure if it's hypotensive low that's the salts less than 90 that probably means that we've removed a little bit too much fluid volume from their blood also the heart rate will be increased as well we're tachycardic from where the heart's trying to compensate for that loss of fluid volume then we can also look at their eyes and O's you want to make sure you are strictly measuring that and the patient can help you with that they're alert and oriented and whenever they go to use the bathroom to urinate you definitely want to make sure you were measuring that because you want to look to see how much they're taking in versus how much they're putting out they're really not putting out anything at all the renal function could be compromised so we want to make sure that we are digressing them but not too much and we can look at their daily weights where we weigh them every day at the same time using the same scale this tells us their fluids status and really tells us how effective this medication is working because if they're gaining weight instead of losing weight we made not very effective with this diuretic they may need something else anyone to teach the patient to weigh themselves a lot of patients with heart failure may be on these medications and we want to teach them to weigh themselves every day and to write it down to keep track because if they've gained more than like three pounds in one day that could mean that they're retaining fluid and they may be having heart failure exacerbation and will need to go to their doctor to get treatment also as a nurse we want to monitor their labs because as we've learned these drugs cause electrolyte imbalances so the physician will order the labs we will get those results and we will look at them you always want to look into results especially before you give their medications because electrolyte imbalances can induce like toxicity of other drugs so we've learned that the I sides cause a lot of hypo a lot of hyper conditions so let's talk about the hypo we know that it can lower the calcium and potassium levels causing hypokalemia and if your patient is on digoxin and their potassium level goes too low it can increase the risk of digoxin toxicity so always look at that potassium level and be educating your patient to be consuming foods that are rich in potassium like bananas avocados strawberries potatoes etc because that will help keep that level high in a normal digital I just want to throw this in there is about 0.5 to 2 nanograms per milliliter the other hypo condition you can cost is hyponatremia where that sodium level is too low and that was another thing that lube diuretics did as well it can lower it too low so if you had a patient who's taking lithium that's not good because when sodium levels drop if a patient's taking lithium it can increase the risk of lithium toxicity so a normal lithium level is about 0.5 to 1.2 millimoles per liter so remember these two drugs if we go into these hypo conditions either hyponatremia or hypokalemia with those it can cause toxicity those are some important concepts no exams love to ask about the hyper conditions that these drugs can cause our hyper hyper Cal C Mia the high calcium level hyperuricemia the high uric acid level and hyperglycemia again teach your diabetic patients to monitor their blood glucose really closely while taking a thigh and some other little miscellaneous things you want to remember is that whenever you give a patient any type of diuretic they can get up and use the bathroom on their own you need to make sure they have easy access to it because you don't want them to fall and get hurt and avoid giving doses of diuretics at night because we want our patients to sleep at night we don't want them up using the bathroom all the time so make sure you're not doing that and orthostatic hypotension this is where the when the patients maybe they've been sitting or lying down they get up they can fall they become dizzy you want to teach them to change position slowly because we're altering the fluid status in their body and as a nurse you want to make sure that this medication is being effective is it doing its job how do their lungs sound is their blood pressure coming down maybe they're getting this drug for hypertension how is their weights are they gaining weight or losing weight so we play a huge role with that as well okay so that wraps up this review over thighs I diuretics thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos