Pharm 236 Ch 53 Diuretics

Front 1

Diuretics are drugs that increase renal excretion of water, sodium, and other electrolytes, thereby increasing urine formation and ___________

Back 1

output

Front 2

The primary function of the kidneys is to regulate the volume, _____________, and pH of body fluids.

Back 2

Composition

Front 3

Each nephron is composed of a _____________ and a tubule.

Back 3

Glomerus

Front 4

The glomerulus is a network of __________ that receives blood from the renal artery.

Back 4

Capillaries

Front 5

__________ __________ is a thin walled structure that surrounds the glomerulus then narrows and continues as the tubule.

Back 5

Bowman's capsule

Front 6

act at the distal tubule to decrease sodium re-absorption and potassium excretion.

Back 6

Potassium sparing diuretics

Front 7

Produce rapid diuresis by increasing the solute load (osmotic pressure) of the glomerular filtrate

Back 7

Osmotic agents

Front 8

Synthetic drugs that are chemically related to the sulfonamides.

Back 8

Thiazide Diuretics

Front 9

Used to prevent potassium imbalances.

Back 9

Diuretic combinations

Front 10

Diuretics that inhibit sodium and chloride re-absorption in the ascending limb of the loop of Henle

Back 10

Loop diuretics

Front 11

Explain how convoluted tubules enhance renal function.

Back 11

The tubules are often called convoluted tubules because of their many twists and turns. The convolutions provide a large surface area that brings the blood flowing through the peritubular capillaries and the glomerular filtrate flowing through the tubular lumen into close proximity.

Front 12

Describe the process of glomerular filtration.

Back 12

The nephron functions by three processes: glomerular filtration, tubular re absorption, and tubular secretion. These processes normally maintain the fluid volume, electrolyte concentration, and pH of body fluids with in a relatively narrow range. They also remove waste products of cellular metabolism. A minimum daily urine output of aproximately 400mL is required to remove normal amounts of metabolic end products.

Front 13

What happens to the fluid processed during glomerular filtration?

Back 13

The glomerular filtration rate (GFR) is about 180L per day or 125mL per minute. Most of this fluid is reabsorbed as the glomerular filtrate travels through the tubules. The end product is about 2L of urine daily. Because filtration is a non-selective process the re absorption and secretion processes determine the composition of the urine. After it is formed urine flows into collecting tubules which carry it to the renal pelvis, then through the ureters bladder and urethra for elimination from the body.

Front 14

What happens to blood that does not become part of the glomerular filtrate?

Back 14

Blood that does not become part of the glomerular filtrate leaves the glomerulus through the efferent arteriole. The efferent arteriole branches into the peritubular capillaries that eventually empty into veins, which return the blood to systemic circulation.

Front 15

Mrs. Watson, age 75, is diagnosed with atrial fibrillation and chronic congestive heart failure. The physician orders a combination of digoxin and diuretics to treat her diseases. recent laboratory results indicate that the clients potassium level is 2mEq/L. The patient is at risk for which of the following?

a. Exacerbation of the atrial fibrillation

b. Subtherapeutic levels of serum digoxin.

c. Digoxin toxicity

d. Congestive heart failure.

Back 15

c

Rationale: When digoxin and diuretics are given concomitantly, the risk of digoxin toxicity is increased due to diuretic induced hypokalemia.

Front 16

Mr. Bingham presents to the emergency room with shortness of breath, dizziness, and confusion. He is diagnosed with severe congestive heart failure. The physician orders high dose furosemide continuous IV infusions. You would expect that the rate of dosage would be which of the following to decrease adverse effect?

a. 4mg/min or less

b. 5mg/min or less

c. 6mg/min or less

d. 8mg/min or less

Back 16

a

Rationale: High dose furosemide continuous IV infusions should be given at a rate of 4mg/min or less to decrease or avoid risks of adverse effects including ototoxicity.

Front 17

Mrs. Carter is diagnosed with chronic congestive heart failure and hypertension. You would expect the physician to order which of the following types of diuretics?

a. Hydrochlorothiazide

b. Furosemide

c. Bumetanide

d. Torsemide

Back 17

a

Rationale: Thiazides and related diuretics are the drugs of choice for most patients who require diuretic therapy, especially for long term management of the heart failure and hypertension.

Front 18

There is a known cross sensitivity of some sulfonamide allergic patients to which of the following sulfonamide non antibiotics?

a. Hydrochlorothiazide

b. Furosemide

c. Bumetanide

d. Torsemide

Back 18

a

Rationale: There is a known cross sensitivity of some sulfonamide allergic patients to sulfonamide non antibiotics such as thiazides.

Front 19

Mr. Hackmore is prescribed potassium sparing diuretics to treat his disease process. During his annual visit to the physician he complains that he is experiencing muscle weakness and tingling in his fingers. Which of the following conditions do you suspect?

a. Hypokalemia

b. Hyperkalemia

c. Hypocalcemia

d. Hypercalcemia

Back 19

b

Rationale: Potassium sparing diuretics are contraindicated in patients with renal impairment because of the high risk of hypekalemia.

Front 20

Mrs. Kingman is diagnosed with hyponatremia. Which of the following diuretics would most likely promote this symptom?

a. Osmotic

b. Thiazide

c. Potassium sparing

d. Loop

Back 20

d

Rationale: Loop diuretics have a sodium losing effect up to 10times greater than that of thiazide diuretics.

Front 21

Mr. Tabor is excited because it is football season. he has season tickets and attends most games with his friends. At his latest appointment, Mr. Tabors blood pressure is elevated. Which of the following do you suspect is the cause?

a. He is anxious about his team.

b. He is consuming excessive salty foods at the games.

c. He is developing comorbidities.

d. He has become a vegetarian until his team wins the championship.

Back 21

b

Rationale: Excessive table salt and salty foods may aggravate edema or hypertension.

Front 22

A body weight change of _________ lbs or _________ kg may indicate a gain or loss of 1000mL of fluid.

Back 22

2.2lbs or 1kg

Front 23

Diuretic drugs act on the kidneys to decrease ___________ of sodium, chloride, water, and other substances.

Back 23

Re-absorption

Front 24

Diuretics are often taken in the home setting. The home care nurse may need to assist patients and caregivers by doing which of the following tasks? (select all that apply)

a. Monitoring patient responses

b. Assessing use of over the counter medications that may aggravate the patients condition.

c. Weighing the patient daily

d. Appropriation all sodium rich foods in the home.

Back 24

a,b

Rationale: Diuretics are often taken in the home setting. The home care nurse may need to assist patients and caregivers in using the drugs safely and effectively; monitor patients responses (ex. with each home visit, assess nutritional status, blood pressure, weight, use of over the counter medications that may aggravate edema or hypertension); and provide information as indicated.

Front 25

Mr. Gardner is critically ill with a diagnosis of congestive heart failure exacerbated by a myocardial infraction. Which of the following fast acting diuretics would be appropriate for the physician to order? (select all that apply)

a. Furosemide

b. Diazide

c. Hydrochlorothiazide

d. Bumetanide

Back 25

a,d


Rationale: Fast acting potent diuretics such as furosemide and bumetanide ae the most likely diuretics to be used in critically ill patients (ex. those with pulmonary edema)

Front 26

Which of the following methods of administration of fast acting diuretics would be most effective and least likely to produce adverse effects in a critically ill client with pulmonary edema?

a. IV bolus doses

b. Continuous intravenous infusion

c. Subcutaneous doses

d. Intramuscular doses

Back 26

b

Rationale: Although IV bolus doses of drugs are often given to critically ill clients continuous IV infusions may be more effective and less likely to produce adverse effects in critically ill patients.

Front 27

Although they are needed to reduce ascites in clients with hepatic impairment, diuretics may precipitate which of the following conditions?

a. Ammonia absorption

b. Sub-therapeutic drug levels

c. Hepatic encephalopathy

d. Hepatomegaly

Back 27

c

Rationale: Diuretics are often used to manage edema and ascites in patients with hepatic impairment. These drugs must be used with caution, because diuretic induced fluid and electrolyte imbalances may precipitate or worsen hepatic encephalopathy and coma.

Front 28

To prevent metabolic alkalosis or hypokalemia, which of the following drugs may be administered to patients with cirrhosis in addition to diuretic therapy?

a. Spironolactone

b. Diazide

c. Hydrochlorothiazide

d. Bumetanide

Back 28

a

Rationale: Patients with cirrhosis, diuretic therapy should be initiated in a hospital setting, with small doses an careful monitoring. To prevent hypokalemia and metabolic alkalosis supplemental potassium or spironolactone may be needed.

Front 29

Potassium sparing diuretics are contraindicated in patients with renal impairment because of he high risk of hyperkalemia. If they are used at all which of the following would be a priority?

a. Administration of concurrent potassium.

b. Monitoring of serum electrolytes, creatinine, and BUN

c. Administration of a thiazide diuretic

d. Monitoring of CBC and serum albumin

Back 29

b

Rationale: Potassium sparing diuretics are contraindicated in patients with a renal impairment because of the high risk of hyperkalemia. If they are used at all frequent monitoring of serum electrolytes, creatinine, and BUN is needed.

Front 30

To prevent accelerated degradation of furosemide which of the following IV solutions should be used to mix the drug?

a. D5W

b. D 51/2 NS

c. Lactated ringers solution

d. D 51/4 NS

Back 30

c

Rationale: For continuous infusion furosemide should be mixed with NS or lactated ringers solution

Front 31

Mr. Andrews age 71 is hospitalized with pulmonary edema; he is discharged with a prescription for a loop diuretic. He presents to the physicians office 1 wk later with symptoms indicating excessive diuresis. This patient is also at risk for which of the following?

a. Rebound hypertension

b. Hypervolemia

c. Embolism

d. Gastric ulcer disease

Back 31

c

Rationale: With loop diuretics older adults are at greater risk of excessive diuresis, hypotension, fluid volume deficit, and possibly thrombosis or embolism.

Front 32

The physician orders hydrochlorothiazide for Mr. Bunting. He has multiple comorbidities, and the physician chooses the smallest effective dose of the drug. You expect the physician to order a daily dose in which of the following ranges?

a. 0.25 to 0.50mg

b. 0.50 to 0.75mg

c. 8 to 12mg

d. 12.5 to 25mg

Back 32

d

Rationale: The smallest effective dose to treat elder adults in need of diuresis is recommended usually a daily dose of 12.5 to 25 mg of hydrochlorothiazide or equivalent doses of other thiazides and related drugs.

Front 33

Thiazide drugs become ineffective when the GFR is less than which of the following levels?

a. 30mL/min

b. 40mL/min

c. 50mL/min

d. 60mL/m

Back 33

a

Rationale: Thiazides may be useful in managing edema caused by renal disorders such as nephrotic syndrome and acute glomerulonephritis. However, their effectiveness decreases as the GFR decreases, and the drugs become ineffective when the GFR is less than 30mL/min.

Front 34

The physician orders furosemide for your pediatric client. The established dose of the drug should not exceed how many milligrams per kilogram of body weight per day?

a. 4

b. 6

c. 8

d. 10

Back 34

b

Rationale: Furosemide is a loop diuretic used most often in children. Oral therapy is preferred when feasible, as doses greater than 6mg/kg of body weight per day are not recommended.

Front 35

What is BUN and its normal range?

Back 35

Blood Urea Nitrogen (BUN)
Normal range 8 - 20mg/DL

Front 36

If the BUN is increased what does it mean?

Back 36

increased in: Renal failure (acute or chronic), urinary tract obstruction, dehydration, shock, burns, CHF, gastrointestinal bleeding. Drugs with renal toxicity, eg, gentamicin.

Front 37

If BUN is decreased what does this mean?

Back 37

Decreased in: Hepatic failure, nephrotic syndrome, cachexia (low-protein and high-carbohydrate diets).

Front 38

If you have an increase in Phosphorous what does it mean and what are the normal ranges?

Back 38

Normal Range: 2.5-4.5 mg/dL

increased in can indicate renal failure, massive blood transfusion, sarcoidosis, neoplasms, adrenal insufficiency, acromegaly, hypoparathyroidism, hypervitaminosis D, phosphate infusions or enemas, osteolytic metastases to bone, leukemia, milk-alkali syndrome, healing bone fractures, pseudohypoparathyroidism, diabetes mellitus with ketosis, malignant hyperpyrexia, cirrhosis, lactic acidosis, respiratory acidosis. Drugs: eg, anabolic steroids, ergocalciferol, furosemide, hydrochlorothiazide and others.

Front 39

If you have a decrease in phosphorous what does this mean?

Back 39

Decreased in: Hyperparathyroidism, hypovitaminosis D (rickets, osteomalacia), malabsorption (steatorrhea); malnutrition, starvation or cachexia; GH deficiency, chronic alcoholism, severe diarrhea, vomiting, nasogastric suction, severe hypercalcemia (any cause), acute gout, osteoblastic metatases to bone, severe burns (diuretic phase), respiratory alkalosis, hyperalimentation with inadequate phosphate repletion, carbohydrate administration (intravenous), renal tubular acidosis and other renal tubular defects, diabetic ketoacidosis (during recovery), acid-base disturbances, hypokalemia, pregnancy, hypothyroidism; prolonged use of thiazides, glucose infusion, salicylates (toxicity). Drugs: eg, phosphate-binding antacids, anticonvulsants, estrogens, isoniazid, oral contraceptives.

Front 40

___________ diuretic are synthetic drugs that are chemically related to sulfonamides and differ mainly in their duration of action. They are frequently prescribed in the long term management of heart failure and hypertension. They act to decrease re-absorption of sodium, water, chloride, and bicarbonate in the distal convoluted tubule. They work best only when urine flow is adequate.

Back 40

Thiazides

Front 41

____________ diuretics may be given orally or IV. They inhibit sodium and chloride re-absorption in the ascending limb of the loop of Henle and their effects are rapid occurring within 30 to 60mins. It is the diretics of choice for treatment of pulmonary edema. Contraindicated during pregnancy unless absolutely necessary.

Back 41

Loop Diuretics

Front 42

What are the thiazide diuretics?

Back 42

1. Chlopothiazide
2. Chlorthalidone
3. Hydrochlorothiazide
4. Indapamide
5. Metolazone

Front 43

What are the Loop diuretics?

Back 43

1. Bumetanide
2. Ethacrynic acid
3. Furosemide
4. Torsemide

Front 44

What are the potassium sparing diuretics?

Back 44

1. Amiloride
2. Spironolactone
3. Triamterene

Front 45

What are the Osmotic agents?

Back 45

1. Glycerin
2. Mannitol