Pharmacologic Profile

General Use

Thiazide diuretics and loop diuretics are used alone or in combination in the treatment of hypertension or edema due to HF or other causes. Potassium-sparing diuretics have weak diuretic and antihypertensive properties and are used mainly to conserve potassium in patients receiving thiazide or loop diuretics. Osmotic diuretics are often used in the management of cerebral edema.

General Action and Information

Enhance the selective excretion of various electrolytes and water by affecting renal mechanisms for tubular secretion and reabsorption. Groups commonly used are thiazide diuretics and thiazide-like diuretics (chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, and metolazone), loop diuretics (bumetanide, furosemide, and torsemide), potassium-sparing diuretics (amiloride, spironolactone, and triamterene), and osmotic diuretics (mannitol). Mechanisms vary, depending on agent.

Contraindications

Hypersensitivity. Thiazide and loop diuretics may exhibit cross-sensitivity with other sulfonamides.

Precautions

Use with caution in patients with renal or hepatic disease. Safety in pregnancy and lactation not established.

Interactions

Additive hypokalemia with corticosteroids, amphotericin B, and piperacillin/tazobactam. Hypokalemia may ↑ the risk of digoxin toxicity. Potassium-losing diuretics ↓ lithium excretion and may cause toxicity. Additive hypotension with other antihypertensives or nitrates. Potassium-sparing diuretics may cause hyperkalemia when used with potassium supplements, ACE inhibitors, angiotensin II receptor antagonists, and aliskiren.

Nursing Implications

Assessment

• Assess fluid status throughout therapy. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes.
• Assess patient for anorexia, muscle weakness, numbness, tingling, paresthesia, confusion, and excessive thirst. Notify health care professional promptly if these signs of electrolyte imbalance occur.
• Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension.
• Monitor neurologic status and intracranial pressure readings in patients receiving osmotic diuretics to decrease cerebral edema.
• Monitor for persistent or increased eye pain or decreased visual acuity.
• Monitor electrolytes (especially potassium), blood glucose, BUN, and serum uric acid levels before and periodically throughout course of therapy.
• Thiazide and loop diuretics may cause ↑ serum cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride concentrations.

Potential Nursing Diagnoses

• Excess fluid volume (Indications)
• Deficient knowledge related to disease processes and medication regimen (Patient/Family Teaching)

Implementation

• Administer oral diuretics in the morning to prevent disruption of sleep cycle.
• Many diuretics are available in combination with other antihypertensives or potassium-sparing diuretics.

Patient/Family Teaching

• Instruct patient to take medication exactly as directed. Advise patients on antihypertensive regimen to continue taking medication, even if feeling better. Medication controls, but does not cure, hypertension.
• Caution patient to make position changes slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension.
• Instruct patient to consult health care professional regarding dietary potassium guidelines.
• Instruct patient to monitor weight weekly and report significant changes.
• Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
• Advise patient to consult health care professional before taking OTC medication concurrently with this therapy.
• Instruct patient to notify health care professional of medication regimen before treatment or surgery.
• Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, or numbness or tingling of extremities occurs.
• Emphasize the importance of routine follow-up.
• Reinforce the need to continue additional therapies for hypertension (weight loss, regular exercise, restricted sodium intake, stress reduction, moderation of alcohol consumption, and cessation of smoking).
• Instruct patients with hypertension in the correct technique for monitoring weekly BP.

Evaluation/Desired Outcomes

• Decreased BP.
• Increased urine output.
• Decreased edema.
• Reduced intracranial pressure.
• Prevention of hypokalemia in patients taking diuretics.
• Treatment of hyperaldosteronism.