hey everyone it's sarah red sterner sorry and calm and today we're going to talk about Luke diuretics and as always when you get done watching 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 going through this pharmacology series we have been remembering the word nurse which helps us determine those important concepts that we need to know about these drugs that we are studying and again in stands for name because this tells us how the drug works on the body what family of drugs is a part of you tells us what it is used for what is it tree are tells us the responsibilities of the nurse and this is where a lot of test questions will come from to determine if you know how to care for a patient who is taking this drug S stands for side effects and then e stands for the education pieces for the patient about this medication so let's start with a name we are dealing with loop diuretics loop tells us that this medication is going to influence how the loop of Henle works within this nephron and specifically loop diuretics effect the thick ascending limb of the loop of Henle diuretics tells us that this medication is going to somehow increase the urinary output by affecting how sodium is reabsorbed back into the blood it's actually going to inhibit that process from occurring so you have more sodium within this nephron and if you have more sodium you're going to keep water within that nephron instead of it going back into the blood so these medications can help remove extra fluid volume from a patient who's like in fluid volume overload now loop diuretics are the most powerful of all the diuretics and will be also talking about thiazide x' and potassium sparing diuretics and our next videos and to help you recognize if you're dealing with a loop diuretic or a thiazide or a potassium sparing diuretic always look at the end of the generic name loop diuretics tend in ni de or my m ID and some examples are like you met an AI furosemide and tore some ID with exception of ethic rinic acid which doesn't end in night or mine so what loop diuretics do again is they effect this thick ascending limb of the loop of Henle and particularly what it's going to do is it's going to inhibit a special protein coat transporter from doing its job and this cotransporter is the sodium potassium chloride transporter and what it does just like its name says it does is it's going to help transport some specific ions from the filtrate to go back into the interstitium into the blood and those ions will be one sodium one potassium and two chloride and then we'll take that from the filtrate and in a sense push it back to go back into the interstitium which will go into the blood however if we inhibit this ion transport specifically the transport of sodium we're going to alter some things because it's going to change the tone isset II of this medulla inner stitch them because this area is very hyper tonic so if we decrease its tone isset II it's going to alter how specific parts of this nephron are able to reabsorb water back into the body instead more water will stay in this filtrate and hence will be urinated out which hits our goal of increasing urinary output however to truly understand this whole process we've got to go back and we have to review the anatomy and physiology of this nephron here on the right we have an illustration of a nephron and if we took one and we stretched it out it would look something similar to this and how its structures are set up and here on the Left we have how that nephron actually sets within the kidney and you want to take note of this because some parts of the nephron are found in the cortex which is like an isotonic environment compared to some of them being found in the medulla which is a hypertonic environment and this helps you understand how these nephrons work with the way that they will tweak the water and the ions so these nephrons are structures within the kidneys that allow them to function and without them actually working properly the kidneys won't be able to do their job and there are millions of these nephron units in each kidney and they function to manage the water ions and waste that will be reabsorbed by the body or excreted as urine and the nephron can be divided into several parts each part of the nephron has its own unique role for tweaking the filtrate that is created by the glomerulus until it's just what the body needs and what it doesn't need it will be excreted as urine and these parts include the afferent arteriole and the efferent arteriole and the afferent arteriole is going to take blood via the renal artery and deliver it to the nephron so it can be filtered and the every arteriole will take that blood that's been filtered and send it back to the body so blood enters into the nephron via the afferent arteriole and it's going to be filtered by the glomerulus and the glomerulus will create the filtrate which will eventually exit the body as urine and in this filtrate or ions which are like electrolytes like potassium sodium magnesium etc water and waste and this will drip down into Bowman's capsule now it's going to encounter its first to be aware the tweaking of what will be needed by the body or excreted by the body via the urine is going to occur so it goes through the proximal convoluted tubule and remember that this area so far is setting in that renal cortex which is an isotonic environment then that filtrate is going to go down into the descending loop of Henle so this is like that first structure of the loop of Henle and this is found in the medulla and again it's hypertonic so it's very salty compared to the isotonic and in the cortex where the salt content was equal on the inside of the nephron compared to the outside but here in the medulla that is different so really salty on the outside which is going to play a role in the way that water is reabsorbed so the filtrate goes down this ascending lute limb of the loop of Henle and what I want you to remember about this descending limb is that it is permeable to water but it's not permeable to ions which means water can leave this land that ions cannot so because it's so salty here hypertonic water is going to leave this descending limb which is going to concentrate that filtrate and make it really concentrated with sodium and all those other ions then the filtrate is going to go up through the ascending limb of the loop of Henle and it's going to hit the thick ascending limb and this is where loop diuretics work remember they block that co-transporter the sodium potassium chloride co-transporter and I thought filtrate hits this thick ascending limb it's really concentrated so normally those ions are going to be transported specifically that sodium that'll help keep that renal medulla hypertonic however whenever we're throwing in a loop diuretic that's not gonna work very well so then the filtrate will go up through the distal convoluted tubule it has left that hypertonic environment now it's back in the cortex where it's isotonic again it's going to be tweaked depending on what the body needs and then the filtrate is gonna go down through the collecting duct and some of this area enters again into the medulla where you're gonna have some more water reabsorption by the body and then the filtrate will go through the renal pelvis and then eventually will be urinated out so we've just seen how filtrate is created by this nephron and how it flows through the nephron and event exits the body as urine however since we're talking about loop diuretics we have to dive a little bit deeper into this loop of Henle and how loop diuretics affect the loop of Henle to cause diuresis to increase urinary output and one thing it's going to do it's going to affect how the body is going to reabsorb sodium so keep that in mind because if we're not reabsorbing sodium it's staying in the nephron that means water is gonna stay in there and it's going to exit the body hence increasing our urination so we said that in the proximal convoluted tubule the filtrate is there it's in that nice isotonic environment but then once it goes down into the loop of Henle it's gonna go into the medulla which is hypertonic it's really salty and there's two parts of that loop of Henle we have the descending limb in the ACE ending limb and they're really different and what they're permeable to what they allow to leave the nephron and go back into the interstitium and into the blood so filtrate comes down from the proximal convoluted tubule hits this descending limb of the loop of Henle and remember that was permeable only to water not ions and since its hit this really salty environment the waters like hey we're leaving we like salt so the water leaves the filtrate and this loop of Henle is actually responsible for about 15 to 20 percent of water reabsorption so it reabsorbs a lot of water so now waters left and the filtrate is really concentrated with these ions which is great because once it hits this ascending limb the ascending limb deals with that because remember this thick part of this sending limb is permeable to ions those electrolytes but not water so hits this ending limb and you have all these little Co transporters simipour channels that are going to help allow ions to leave this filtrate go through the cell hit the inter stitch and go to the blood and they're all working together beautiful to do their job and one of those code transporters was the sodium potassium chloride co-transporter so it takes one sodium one potassium two chloride takes it puts it back into the blood now the cool thing about the loop of Henle it's responsible for about 25 percent of the sodium reabsorption which it's gonna play a role in keeping this renal medulla hypertonic keeps it salty so we can play a role with reabsorbing water because also you're collecting doug's once it hits this hypertonic environment water is going to be removed right before it leaves so if we throw in something like a loop diuretic that's going to inhibit this co-transporter from transporting especially the sodium the potassium and chloride we're going to alter the tone isset ii of this environment which is going to decrease how much water is able to be reabsorbed through the collecting duct and from this loop of Henle so if the water is not leaving this nephron it's staying in there because we have lots of sodium still in here and remember sodium water love each other the water is going to stay in this nephron it's not going to be reabsorbed through the body so it's gonna leave the body as urine and we've hit our goal we have increased urinary output now let's talk about what loop diuretics are used for what do they treat well we've already established with how luke diuretics effect this nephron is that they're gonna increase a patient's ability to urinate so they're gonna be putting out a lot more urine well if you're putting out a lot more urine that's dropping your fluid volume in your blood now why would we want to draw up a patient's fluid volume well patients who are in fluid volume overload where they have way too much fluid hanging out in the blood and this can occur in patients who have heart failure where the heart is just so weak it just can't pump blood forward and you have different types like systolic dysfunction or diastolic dysfunction but the blood can backflow go into the lungs leading to pulmonary edema literally it's like the patient is drowning in their own fluid and the fluid can leak and go into the lower extremities where you have swelling there as edema so we throw on this loop diuretic that is going to tell the blood once it's being filtered by this nephron hey we're not going to be sending too much water back to you because we're going to tell this nephron not to reabsorb this water because we're going to alter the sodium content in our nephron and around in this medulla we're not gonna make it as hypertonic so guess what you're not gonna have some fluid coming back to the body instead this patients going to urinate it out also patients who have liver impairment where they get the side effect of ascites where they have a lot of swelling in the abdomen that can help with that patient the pulmonary edema as we just talked about and hypertension leave diuretics aren't as helpful with hypertension compared to like thiazide but sometimes they're prescribed for that to help lower the blood pressure and that would come from lowering the fluid volume which will lower the pressure same concept you lower the amount of water that's going through a water hose you're gonna lower the pressure and it also treats hypercalcemia which is where you have a high calcium level in the blood but how can loop diuretics treat a high calcium level in the blood well we've learned that loop diuretics really manipulate how ions are going to be transported back into the blood from this filtrate because we're inhibiting this sodium potassium chloride transporter and that will throw things off so normally the filtrate will flow down through here remember once it passes this distal limb it's going to be really concentrated in ions so we're not only talking about like sodium potassium chloride we're also talking about calcium and magnesium they're positively charged so they're going to go up in this thick ascending limb where we're having normally if we don't have a loop diuretic we will have sodium one sodium one potassium and two chloride being transported over also working as well doing its ion exchanges like the sodium potassium pump you can have potassium chloride symporters and calcium channels and all of this together is creating this like positive potential this concentrate electrical gradient that can normally take this calcium and this magnesium and force it out of this filtrate to go back into the interstitium and be reabsorbed into the blood but if we inhibit this co-transporter that's going to throw those things off and we'll lose that positive potential so the calcium and the magnesium will stay in the filtrate will not go and be reabsorbed and that can lower our calcium levels and our magnesium levels more so our calcium levels so that's why we can use this to treat high calcium levels and I'll talk about the responsibilities of the nurse and the side effects associated with Luke diuretics we're going to mesh the two so with patients taking loop diuretics thread a huge risk for dehydration so we want to monitor their fluid status and make sure they're not becoming dehydrated how can we do that well we can look at their vital signs and see where's their blood pressure is that systolic less than 90 we've probably diurese them a little bit too much how's their heart rate are they tachycardic where it's above a hundred that can be signs of dehydration along with excessive thirst being lethargic and we want to make sure we are strictly measuring their intake and output because we don't want the patient just consuming all this fluid and it's really undermining the effectiveness of this drug or we don't want them to be just putting out so much where they have this major negative loss of fluid compared to how much they've been taking in so for me and you want to make sure that you give them a urinal and you measure it every time you into that urinal and women that you put the tool that height in the toilet so you can collect the urine and if they have the Foley you can just look and see how much urine was put out of the Foley plus we want to make sure that they're putting out enough here and and that we're not sending them into like renal failure and we're going to be collecting the weights daily at the same time using the same scale and we're looking and seeing how much their weight is fluctuating because Wayne a patient is a great indicator of their fluid volume status and how much weight they're losing because if they're gaining 3 pounds in like a 24-hour period that's not good that means they're retaining too much fluid so we will look at that and compare that and we want to monitor their labs patients who are going to be on live directs especially there's IV forms they're gonna be getting daily basic metabolic panels where we can look at their electrolytes and the renal status so one thing you're really going to look at is the potassium if you can't remember anything else about live diuretics remember that loop diuretics can lower the potassium level it can cause hypokalemia a normal potassium level is 3 point 5 to 5 milli equivalents per liter and it's very common if your patients on long term loop diuretics or those IV routes they're going to be receiving some type of potassium supplementation to help replace that potassium level and I want to point out this with digoxin this is the big thing you need to know we cover this in the digoxin video that we went over in this pharmacology series but if your patient is on digoxin and they're taking a loop diuretic you always always want to look at that potassium level before you minister their next dose of digoxin because it can increase digoxin toxicity so they're on digoxin taking a loop what are you gonna look at there potassium level we don't want them to have hypokalemia now why can they have a low potassium level well what's happening is that remember we're not having these ions being transported across so they're going back into the blood so one ion that's really gonna be concentrated in this filtrate will be sodium so once the filtrate goes up it's gonna hit the distal convoluted tubule and in this tube you'll especially the distal part it uses a transporter that is influenced by aldosterone to reabsorb sodium and one thing that we have learned about aldosterone in our lectures is that it will cause the body to keep sodium but excrete potassium so we have a high amount of sodium here it's influenced by this aldosterone so it's really going to enhance how the aldosterone is gonna work so you'll be keeping reabsorbing the sodium but you're going to be excreting potassium now only are you going to excrete potassium which is going to lower the level you're going to excrete hydrogen ions so the patient can also have metabolic alkalosis as well with these loop diuretics so that is another side effect so it can also draw up your magnesium level which we talked about over here with how it's affecting how calcium magnesium are being reabsorbed and of course it can drop your sodium level because we're keeping sodium in the snare on and excreting it out another thing that I want you to remember is that loop diuretics can increase uric acid levels so watch out for signs and symptoms of gout and why is it increasing uric acid levels well the proximal convoluted tubule is being affected with how is dealing with urea and urate is a waste and what this medication can do unfortunately is cause the body to increase its absorption of urate which in turn will increase uric acid levels so that's another thing you have to watch out for and another thing I want you to remember is that loop diuretics can cause inner ear damage with a condition called odo toxicity and as a nurse how can you prevent this from happening one way is slowly and ministry IV routes of loop diuretics so when a patient is ordered like IV lasix or all some I'd you want to give it slowly because we don't want to cause inner ear damage and as a nurse you're going to be looking at the effectiveness of this drug you're going to be looking at their weights are they losing weight meaning they're losing fluid you're gonna see how much urine they're putting out look at their eyes and O's you're gonna listen to their lungs do they sound clear or you hear crackles where there's still fluid in there and look at their edema they're swelling has their legs swelling went down they they're not pitting as much and even the patient's starting to feel better a lot of patients will report wow I feel so much better since I've had this fluid removed and one thing you want to keep in mind as the nurse is when to give this loop diuretic because as I pointed out they're very powerful and they work pretty fast so if you if the dose is order dry before bedtime that's probably not the best time to give it to the patient because they're gonna be up throughout the night urinating which is going to affect their sleep and if they're trying to get to the bathroom in the dark that can increase the risk of falling Plus let's say a dose is due but they have to go for a procedure you want to make sure that you call that department and make sure that patient is going to have access to the bathroom because they will have to urinate after taking this medication now let's wrap up this lecture and let's talk about the education pieces for the patient so we definitely want to teach them to watch out for signs and symptoms of dehydration because they're going to be urinating a lot we don't want to deplete their fluid volume so you want to teach them to watch out for excessive thirst where they're not urinating at all or they're really tired and to monitor their blood pressure and heart rate at home if there are really hypotensive where that systolic is less than 90 and all that together they'll want to report to their physician and teaching them about following a healthy diet and eating foods that are rich in potassium because we're wasting potassium and foods that are rich from potassium are like potatoes avocados bananas spinach etc so they definitely don't want to restrict that and they want to change positions slowly when they're getting up from a sitting or lying down position because we're changing the fluid volume status in the patient they can have orthostatic hypotension and we don't want to get up and fall so encourage that and to weigh themselves daily and to record it because as a nurse that's performer nursing interventions we are weighing them we want to see their fluid status so they need to do that as well and to monitor their weights and make sure that they're not gaining like no more than 3 pounds per day because that could be a sign that they're retaining fluid okay so that wraps up this review over loop diuretics thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos