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Renal Pharmacology Drugs affecting the Kidney pinoynursing.webkotoh.com

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Drug classification The nursing process applied to pharmacology Pharmacokinetics Pharmacodynamics

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Outline of review <ul><li>Recall the anatomy of the urinary system </li></ul><ul><li>Recall the physiology of the urinary system </li></ul><ul><li>Review- drugs of the following categories: </li></ul><ul><ul><li>1. Diuretics </li></ul></ul><ul><ul><li>2. Drug for BPH </li></ul></ul>

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Diuretics <ul><li>Agents that increase the amount of urine produced by the kidneys </li></ul>

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Classes of Diuretics <ul><li>Five major classes </li></ul><ul><li>1. Thiazides and thiazide-like </li></ul><ul><li>2. Loop diuretics </li></ul><ul><li>3. Potassium-sparing </li></ul><ul><li>4. Carbonic anhydrase inhibitors </li></ul><ul><li>5. Osmotic diuretics </li></ul>

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General indications for the use of the diuretics <ul><li>Treatment of edema </li></ul><ul><ul><li>Urine output will increase and excess fluid is flushed out of the body </li></ul></ul>

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General indications for the use of the diuretics <ul><li>Treatment of CHF </li></ul><ul><ul><li>The sodium loss in the kidney is associated with water loss </li></ul></ul>

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General indications for the use of the diuretics <ul><li>Treatment of Hypertension </li></ul><ul><ul><li>Diuretics will decrease the blood volume and serum sodium </li></ul></ul>

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General indications for the use of the diuretics <ul><li>Treatment of Glaucoma </li></ul><ul><ul><li>Diuretics will provide osmotic pull to remove some of the fluid from the eye to decrease the IOP </li></ul></ul>

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time of administration of the diuretics <ul><li>Usually in the morning!! </li></ul>

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Diuretics Comparison Hypokalemia Ototoxicity Loop of Henle 3. Loop diuretics Hypovolemia & hypotension Glomerulus 5. Osmotic diuretic Hyperkalemia Distal tubule 4. Potassium sparing Hyperuricemia Hypokalemia Proximal tubule 2. Thiazide and thiazide like Acidosis Proximal tubule 1. Carbonic anhydrase inhibitor Special Side effect (s) Major site of action Diuretic class

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Diuretics Comparison Hypercalcemia 3. Loop diuretics Increased ICP LITHIUM TOXICITY 5. Osmotic diuretic CHF taking digoxin 4. Potassium sparing Nephrolithiasis due to calcium stones Hypocalcemia 2. Thiazide and thiazide like Mountain sickness Meniere’s disease 1. Carbonic anhydrase inhibitor Special Uses Diuretic class

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Thiazides <ul><li>Prototype: Hydrochloro thiazide </li></ul><ul><li>1. Bendroflume thiazide </li></ul><ul><li>2. Ben thiazide </li></ul><ul><li>3. Chloro thiazide (Diuril) </li></ul><ul><li>4. Hydroflume thiazide </li></ul><ul><li>5. Methylclo thiazide </li></ul><ul><li>6. Trichlorme thiazide </li></ul>

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Thiazide-like <ul><li>1. Indapamide </li></ul><ul><li>2. Quinethazone </li></ul><ul><li>3. Metolazone </li></ul><ul><li>4. Chlorthalidone </li></ul>

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Thiazides <ul><li>Pharmacodynamics </li></ul><ul><li>These drugs BLOCK the chloride pump </li></ul><ul><li>This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine </li></ul><ul><li>Potassium is also </li></ul><ul><li>flushed out!! </li></ul>

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Thiazide <ul><li>Special Pharmacodynamics: Side effects </li></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>DECREASED calcium excretion  hypercalcemia </li></ul></ul><ul><ul><li>DECREASED uric acid secretion  hyperuricemia </li></ul></ul><ul><ul><li>Hyperglycemia </li></ul></ul>

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Loop Diuretics <ul><li>Prototype: Furosemide </li></ul><ul><li>1. Bumetanide </li></ul><ul><li>2. Ethacrynic acid </li></ul><ul><li>3. Torsemide </li></ul>

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Loop Diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>High-ceiling diuretics </li></ul><ul><li>BLOCK the chloride pump in the ascending loop of Henle </li></ul><ul><li>SODIUM and CHLORIDE reabsorption is prevented </li></ul><ul><li>Potassium is also excreted together with Na and Cl </li></ul>

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Loop Diuretics

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Loop Diuretics <ul><li>Special Pharmacodynamics: side-effects </li></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Bicarbonate is lost in the urine </li></ul></ul><ul><ul><li>INCREASED calcium excretion  Hypocalcemia </li></ul></ul><ul><ul><li>Ototoxicity- due to the electrolyte imbalances </li></ul></ul>

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Potassium sparing diuretics <ul><li>Prototype: Spironolactone </li></ul><ul><li>1. Amiloride </li></ul><ul><li>2. Triamterene </li></ul>

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Potassium sparing diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>Spironolactone is an ALDOSTERONE antagonist </li></ul><ul><li>Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule </li></ul><ul><li>Diuretic effect is achieved by the sodium loss to offset potassium retention </li></ul>

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Potassium sparing diuretics

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Potassium sparing diuretics <ul><li>Pharmacokinetics: Side effects </li></ul><ul><ul><li>HYPERkalemia! </li></ul></ul><ul><ul><li>Avoid high potassium foods: </li></ul></ul><ul><ul><ul><li>Bananas </li></ul></ul></ul><ul><ul><ul><li>Potatoes </li></ul></ul></ul><ul><ul><ul><li>Spinach </li></ul></ul></ul><ul><ul><ul><li>Broccoli </li></ul></ul></ul><ul><ul><ul><li>Nuts </li></ul></ul></ul><ul><ul><ul><li>Prunes </li></ul></ul></ul><ul><ul><ul><li>Tomatoes </li></ul></ul></ul><ul><ul><ul><li>Oranges </li></ul></ul></ul><ul><ul><ul><li>Peaches </li></ul></ul></ul>

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Osmotic Diuretics <ul><li>Prototype: Mannitol </li></ul><ul><li>1. Glycerin </li></ul><ul><li>2. Isosorbide </li></ul><ul><li>3. Urea </li></ul>

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Osmotic Diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>Mannitol is a sugar not well absorbed in the nephron  osmotic pull of water  diuresis </li></ul>

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Osmotic Diuretics <ul><li>Pharmacokinetics: side effects </li></ul><ul><ul><li>Sudden hypovolemia </li></ul></ul><ul><li>Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle! </li></ul>

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Carbonic Anhydrase Inhibitors <ul><li>Prototype: Acetazolamide </li></ul><ul><li>1. Methazolamide </li></ul>

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Carbonic Anhydrase Inhibitors <ul><li>Pharmacodynamics </li></ul><ul><li>Carbonic Anhydrase forms sodium bicarbonate </li></ul><ul><li>BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules </li></ul><ul><li>plus sodium is lost in the urine </li></ul>

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Carbonic Anhydrase Inhibitors <ul><li>Pharmacokinetics: side effects </li></ul><ul><ul><li>Metabolic ACIDOSIS happens when bicarbonate is lost </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul>

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The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>Assess the REASON why the drug is given: </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul>

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The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>The nurse must elicit history of allergy to the drugs </li></ul><ul><ul><li>Allergy to sulfonamides may contraindicate the use of thiazides </li></ul></ul><ul><li>Assess fluid and electrolyte balance </li></ul><ul><li>Assess other conditions like gout, diabetes, pregnancy and lactation </li></ul>

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The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>Physical assessment </li></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>Special electrolyte and laboratory examination </li></ul></ul><ul><li>Assess symptom of body weakness which may indicate hypokalemia </li></ul>

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The Nursing Process and the diuretics <ul><li>Nursing Diagnosis </li></ul><ul><ul><li>Fluid volume deficit related to diuretic effect </li></ul></ul><ul><ul><li>Alteration in urinary pattern </li></ul></ul><ul><ul><li>Potential for injury (ototoxocity, hypotension) </li></ul></ul><ul><ul><li>Knowledge deficit </li></ul></ul>

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The Nursing Process and the diuretics <ul><li>IMPLEMENTATION </li></ul><ul><li>Administer IV drug slowly </li></ul><ul><li>Safety precaution for dizziness/hypotension </li></ul><ul><li>Provide potassium RICH foods for most diuretics, with the exception of spironolactone </li></ul><ul><li>Provide skin care, oral care and urinary care </li></ul>

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The Nursing Process and the diuretics <ul><li>IMPLEMENTATION </li></ul><ul><li>Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy </li></ul><ul><li>Monitor urine output, cardiac rhythm. Serum electrolytes </li></ul><ul><li>ADMINISTER in the MORNING! </li></ul><ul><li>Administer with FOOD! </li></ul>

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The Nursing Process and the diuretics <ul><li>EVALUATION: for effectiveness of therapy </li></ul><ul><li>Weight loss </li></ul><ul><li>Increased urine output </li></ul><ul><li>Resolution of edema </li></ul><ul><li>Decreased congestion </li></ul><ul><li>Normal BP </li></ul>