this is Professor Hoffman and this is a continuation of the material for topic six uh on cardiovascular drugs this is topic 6B we're going to be looking at diuretics uh specifically so as you're looking at your uh reading guide and learning objectives we're looking at items 3 through five so specific specifically we're looking at Loop Diuretics thide diuretics and uh aldosterone inhibiting diuretics so just as a real quick review or establishing sort of a baseline diuretics are used to increase urine output and they work primarily through the increased excretion of sodium uh it's tied into an increased excretion of chloride as well and the chloride and sodium travel together but sodium is our main electrolyte for water uh movement in the body so as we lose sodium through the kidneys water will follow so that's the diuretic effect our indications for diuretic use is going to be hypertension again we have too much fluid within our pipes in our pump pipe um uh model and as a result we're going to have increased pressure on the arterial walls the heart is going to have to work harder again we're going to build up hypertension or high blood pressure when when we have too much fluid built up in the vascular space we're going to have the hydrostatic pressure that you talked about in anatomy and physiology and in pathophysiology that's going to result in edema that edema could be out in the periphery of the body and the extremities can also be in the lungs in which case we'd be looking at pulmonary edema so again we have this increase of fluid within the pump and the pipes and it's going to be causing some problems we need to get rid of it so our classes again again we're going to look at our Loop Diuretics thide and th thide likes diuretics and the ostrin inhibitor or potassium sparing diuretics so we'll look first at Loop Diuretics that are going to give us the most immediate response our example drugs are pomide or Lasix and banide or bumex also Demodex or torside Loop Diuretics as their name indicates they work in the kidneys and the loop of hen so if you need to go back and review your anatomy and physiology again that's the functional part of the nefron in the kidneys and this is where excretion reabsorption of water and electrolytes happens Loop diuretics are going to encourage the excretion of sod of chloride and sodium with sodium we have a increased excretion of water but it also encourages the excretion of potassium and calcium so our purpose is if we have edema either peripheral or pulmonary chronic or a cute we're going to get a fairly quick response and it's also going to be helpful with hypertension again a fairly quick response with the furos with the Loop Diuretics such as fosite and bux or beide so our reactions we want to watch for is that water loss out of the vascular space causes a Cascade effect if you'll remember from anatomy and physiology and pathophysiology that as the water leaves the vascular space and leaves the body it's going to start drawing water from other sources eventually we have water leaving the cells we have cellular dehydration so an effective Loop Diuretics continued use is cellular dehydration if we're not replacing water adequately we're concerned about electrolyte depletion again we assume we're going to lose sodium and are generally okay with that because that's what's taking the water out but we're particularly concerned that we're also losing potassium and in this case also calcium potassium is a high-risk electrolyte for cardiac function so that becomes comes a key one that we want to watch there is a situation with Loop Diuretics such as a furosemide mide that if we give that too quickly um through the IV route we can cause ototoxicity so we'll get symptoms of ringing in the ear or tenus again as you're doing your check offs but also as you're in practice into clinical sites it's really important to watch for this if they develop any issues with oo toxicity so that ringing in the ears any changes in hearing it is probably a result of us administering the drug improperly usually it's going to be a temporary issue it can become permanent so again High caution with administering Loop Diuretics through IV route make sure you it's given over the prescribed time uh kidney impairment again with severe kidney impairment none of these drugs are going to work effectively because they require um they work within the functional part of the kidneys uh Loop Diuretics however are still useful with mild renal impairment and that makes is one of their benefits our nursing consideration as we lose that fluid we should see a drop in blood pressure so we want to monitor that we want to monitor electrolytes and particularly pottassium um as well as calcium but particularly potassium because the cardiac response if the patient's going to be on Loop Diuretics as a for a longer term is sort of a maintenance type drug they need to make sure they're working eating a potassium rich diet to replace that loss pottassium or they might need to take potassium supplements uh we want to be aware of renal function and again we're going to watch for signs of dehydration make sure intake is adequate to replace the loss water at levels that will meet our basic needs and we're going to monitor the weight with any of the diuretics but particularly with the loop and the thide keep in in mind that water a liter of water is equivalent to a kilogram of weight or a pint of water is equal to a pound of water so we can assess the effectiveness of Loop Diuretics by monitoring weight loss if a patient loses a kilogram we should see if it's related to the diuretic uh uh liter loss of fluid during that time period we should be able to equate uh the weight movement to the water movement in Di esis with the thide and the thide like diuretics they're going to often end in their generic names with the term thide they're going to function at a different part of the kidneys at the distal Tu tubule at this area we can still excrete chloride we can still excrete sodium we can still excrete water and potassium so we're getting that diuretic effect by excreting more sodium the water will follow but we're also losing potassium so we we have to keep that in mind however at the distal tubu calcium is retained so we don't have calcium loss in this case so again our uses are going to be hypertension and edema so similar uses but again it's not quite as quick of a response so our reactions again electrolyte depletion particularly sodium and potassium we are going to be watching for calcium retention though uh we have that same water movement out of the vascular space with a Cascade effect to the cell so chance of dehydration we want to watch for that blood pressure is going to drop again kidney function is extremely important with thide diuretics to work so we have impaired renal function we cannot expect the thide DI to be effective or as effective and in some cases um some individuals may have a hyper sensitivity response to it so we'll just have to be aware of that potential our nursing consideration again it's not going to be for immediate diur diuretic you might think of as sort of a Kinder gentler diuretic so when we look at primary hypertension uh without um the emergent issues of Edema we're going to see aide diuretics as being the the diuretic of choice and that'll come up in our hypertension discussion um again we have potassium loss we want make sure that it's being supplemented kidney function again and again the same other considerations as we talked about with Loop Diuretics the third class of diuretic drugs are the aldosterone Inhibitors more commonly known as the potassium sparing diuretics uh spironolactone or aldactone is um sort of the poster child for this class they are not working with the issue of chloride and sodium directly like the other two were this case it's working on aldosterone aldosterone is released through that renin renin angot testin and aldosterone system as part of our normal body functioning when aldosterone is released it's released in response to perceived low volume so adrone goes to the distal tubule and it tells um the kidneys that the distal tub hold on to sodium so we hold on to water so this drug class then blocks that action so an aldosterone inhibitor is going to go to the distal tubu and tell the distal tubul to go ahead and lose sodium and it's really focused on the sodium itself as the sodium leaves then we have water following the sodium the important thing to realize with this remember is that pottassium is retained it's not affected by the action of aldosterone it's not excreted at a higher rate so we're going to retain potassium so it's not going to be as potent potent or as strong as the thide and Loop Diuretics so it's going to be a little bit of a lower key type response it's usually going to be using this adjunct it's going to be really important when we're dealing with cardiac patients where it's important to maintain potassium levels so we're going to be looking at um again potassium levels staying more normal as a result of but we're still going to get some fluid loss so again our use will be hypertension and edema again generally tied in with use of a thite or Loop diuretic and it's going to be extremely helpful in heart failure so that we maintain the appropriate level of potassium in circulation to keep the heart and that should be heart failure not heat failure um as effective as possible so our reactions um again we're losing sodium but we're maintaining potassium so we're looking at hyper calmia at this point with Loop Diuretics and thigh diuretics we're looking at hypokalemia as a major side effect or adverse reaction um with the Loop Diuretics remember we were looking at hypokalemia hypocalcemia as well as loss of sodium with a thide diuretic we were looking at hypokalemia hyponatremia but hyper calcemia because the calcium wasn't being excreted in this casee we're really focusing on hyper calmia with the aerone inhibiting diuretics so it's really important that we're aware of what's going in through their IVs or other drugs if they happen to be put on a potassium supplement as well as being started on aldosterone inhibitor we are going to greatly increase that chance for hyperkalemia again it is a diuretic so we're going to see the cellular dehydration as a potential risk the hypotension kidneys have to be functioning for this to work effectively to be responsive to the drug um potential for some hypers sensitivity responses as well in rare rare situations so again a lot of the same considerations uh with our electrolytes were really focused heavily on the potassium and in this case we're watching for hyper calmia so that is uh the overview of the diuretics um and in the next uh slide will'll move into another area of cardiovascular drugs