CHF Diuretics

Drug therapy- CHF and Diuretics

What patient might need a diuretic?

• “Alterations in fluid and electrolyte balance brought on by the inability of the kidneys to control the volume, composition, and pH of body fluids”

• HTN

• CHF

• Edema

DIURETICS –

• Loop

• Thiazide

• Potassium sparing

• Primary action is reduced fluid volume *(increased urine output)

ThiazideDyazide

(triamterene/hydrochlorothiazide)

• Adverse effects: ( less risk than loop)

• hypotension

• dehydration

• hypokalemia

• hyperglycemia-**especially in diabetics

• Increased uric acid levels

Thiazide

• Administering the medication

• Assessing for therapeutic effects

• Assessing for adverse effects

• Patient teaching

Loop diuretics –Lasix (furosemide)

• *Diuretic of choice to achieve rapid effects• Adverse effects:• dehydration• Orthostatic hypotension• hypokalemia• hyperglycemia especially in diabetics• **ototoxicity (slow IV push if ordered IV)• increased uric acid levels

Nursing Implications

• Administering this medication

• Assessing for therapeutic effects

• Assessing for adverse effects

• Patient teaching

High Potassium foods

• Apricot, banana, avocado, cantaloupe, raisins

• Potatoes, dark green vegetables, raw carrots

• Bran and bran products, milk, nut and seeds, peanut butter

• Processed foods, canned and frozen

Potassium sparing diureticsAldosterone antagonist

Aldactone (spiraldactone)

• Usually used in combination with other drugs• Produce only mild diuresis• Main risk: hyperkalemia• Adverse effects: dizziness, headache,

abdominal cramping, diarrhea

Nursing Implications

Administering the medication

Assessing for Adverse Effects

Patient teaching

If a drug causes a Decrease blood volume through diuresis

• monitor electrolytes ( related to specific type of diuretic)

• Many cause hyperglycemia so blood sugar must be controlled especially in diabetics

• Intake and out put

• Daily weights (what is a significant weight change?)

Osmotic Diuretics: mannitol (Osmitrol)

Mechanism of Action• Work in the proximal tubule

• Nonabsorbable, producing an osmotic effect

• Pull water into the blood vessels and nephrons from the surrounding tissues

Osmotic Diuretics: Indications

• Used in the treatment of patients in the early, oliguric phase of ARF

• To promote the excretion of toxic substances

• Reduction of intracranial pressure

• Treatment of cerebral edema

Osmotic Diuretics: Side Effects

• Primary concern: sudden drop in fluid levels

Nursing Implications for all diuretics

• Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs—especially postural BPs

Nursing Implications

• Instruct patients to take in the morning as much as possible to avoid interference with sleep patterns

• Monitor serum potassium levels during therapy

Nursing Implications

• Teach patients to maintain proper nutritional and fluid volume status

• Teach patients to eat more potassium-rich foods when taking any but the potassium-sparing agents

• Foods high in potassium include bananas, oranges, dates, raisins, plums, fresh vegetables, potatoes, meat, and fish

Nursing Implications

• Teach patients to change positions slowly, and to rise slowly after sitting or lying to prevent dizziness and possible fainting related to orthostatic hypotension

• Encourage patients to keep a log of their daily weight

• Encourage patients to return for follow-up visits and labwork

Nursing Implications

• Patients who have been ill with nausea, vomiting, and/or diarrhea should notify their physician because fluid loss may be dangerous

Nursing Implications

• Instruct patients to notify the physician immediately if they experience rapid heart rates or syncope (reflects hypotension or fluid loss)

• A weight gain of 2 or more pounds a day or 5 or more pounds a week should be reported immediately

Congestive heart failure

• Occurs when myocardium cannot pump adequately

• Right sided heart failure

• Left sided heart failure

• What are the symptoms of each?

Preload

• Affects cardiac output• Myocardial fibers

stretched prior to contraction

• Preload is affected by volume of blood return to the heart

• Venodilation decreases preload

• Affects cardiac output

• Pressure in aorta that must be overcome before blood is ejected from left ventricle

• Arterial dilation affects afterload by reducing pressure the heart pumps against

Afterload

• Affects cardiac output

• Strength of muscle contraction

Contractility

Drug therapy must :

1)Decrease work load

2)Increase contractility

3)Both

**Most often drugs are used in combination

Drugs for Heart Failure

Drug therapy

Diuretics• Reduce blood volume and

thus decrease cardiac workload

• Loop diuretic: Lasix (fuosemide)

Beta blockers• Decrease contraction force

• Decrease heart rate

• End result is decrease in work load

• Must not stop abruptly

• Drug to know: digoxin (Lanoxin)

• Primary action is to cause more forceful heartbeat, slower heart rate

• Perfect for heart failure since output increases but slowing pulse balances workload

Cardiac Glycosides

Adverse effects of Glycosides

• Main risk is dysrhythmias

• Electrolyte imbalance (especially k+) increases risk

• Nausea & vomiting

• Visual disturbance (yellow/green vision)

• Monitor potassium (K+)

• Monitor apical pulse for 1 minute

• Monitor Digoxin level (normal = 0.8-2.0 ng/mL)

• Evaluate for ventricular dysrhythmias

Nurse’s Role Cardiac Glycosides

• Monitor therapeutic levels with laboratory tests

• Know signs/symptoms of toxicity

• Monitor pulse rate

• Report weight gain

• Eat foods high in potassium/or potassium supplement if prescribed

Patient Teaching

• Reduce afterload by decreasing peripheral resistance and lowering blood volume

• This reduces cardiac work load and increases cardiac output

• Drug of choice for heart failure

• ARBs used if patient can not tolerate ACEs

Ace Inhibitors and ARBs

• The patient is prescribed digoxin (Lanoxin) for treatment of heart failure. Which of the following statements by the patient indicates the need for further teaching?– 1. “I may notice my heart rate decrease.”– 2. “I may feel tired when I begin taking this drug.”– 3. “This drug will help my heart muscle pump less

blood.”– 4. “My heart rate will speed up.”

Question 1

• The nurse reviews lab studies of a patient receiving digoxin (Lanoxin). Intervention by the nurse is required if the results include:– 1. serum digoxin level of 1.8 ng/mL– 2. serum potassium of 3.0 mEq/L– 3. hemoglobin of 14.4 g/dL– 4. serum sodium level of 140 mEq/L

Question 2

• The teaching plan for a patient receiving thiazide diuretics should include:– 1. taking the patient’s apical pulse– 2. the importance of including bananas,

melons, and veggies in their diet– 3. decreasing potassium-rich foods in their diet– 4. checking blood pressure 4 times a day

Question 3

• ACE inhibitors are part of the treatment regimen for a patient with heart failure. The nurse monitors the patient for the side effects of this classification of drugs which may include: CHOOSE ALL THAT APPLY– 1. Hyperkalemia– 2. Hypokalemia– 3. Cough– 4. Dizziness– 5. Headache

Question 4

• Therapeutic effects of positive inotropic agents given for heart failure include:– 1. the heart rate increases to normal allowing the

blood pressure to rise

– 2. edema is decreased because of the diuretic effects

– 3. the blood pressure returns to normal and urine output rises as the heart contracts more forcefully

– 4. the heart’s conduction system returns to a more regular pattern

Question 5