Carbonic anhydrase inhibitors
loopdiuretics
osmotics
potassium spraring
thiazides and related

all but osmotics cause sun sensitivity

1. sulfanamides that do not kill bacteria
2.  inhibits the enzyme carbonic anhydrase action in kidney tubules resulting in excretion of NA, K, bicarbonate and water.
3. Used to treat glaucoma, lowers eye fluid and IOP
4.  acetazolamide (Diamox) and methazolamide
5. Also  used to treat certain types of seizures\

In general, loops increase secretion of sodium and/or chloride, bringing along water. 

1. furosemide and ethacrynic acid increases secretion of sodium and chloride by inhibiting their reabsorption in the distal and proximal tubules and in loop of Henle. B/C act on three sites, their effectiveness as diuretics is decreased
2. torsemide does the same, but primarily at ascending loop of Henle.
3. bumetanide primarily increased excretion of chloride, some sodium acting primarily on proximal tubule of the nephron.
4. Can increase blood sugar or cause sugar in urine (glycosuria) - contact PCP if this happens
5. Use with caution in liver disease, diabetes, lupus (esacerbate or activate) or diarrhea
6. Cross sensitivity with sulfanamides

increases density of the filtrate in the glomerulus preventing selective reabsorption of water, allowing it to be excreted, along with sodium and chloride

in other words

holds more water in glomerulus not allowing reabsorptin into body

decreases K excretion in 2 ways:

1. triamterene and amiloride depress Na reapsorption in tubules, increaseing Na and water excretion; depresses excretion of potassium
2. spironolactone antagonizes aldosterone (made at adrenal cortex and enhances reabsorption of Na at distal covoluted tubules) leading to more excretion of Na and not K, along with water.

Inhibits reabsorption of Na and Cl ions in ascending loop of Henle and early distal tubule of nephron, resulting in excretion of Na, Cl and water.

Can cause elevated blood sugars or sugar in urine (glycosuria) - contact PCP if happens

Mayh cuase a gout attack, contact PCP if sudden joint pain occurs

Use cautiously with liver disease, diabetes, lupus (can exacerbate or bring on) or diarrhea

Cross sensitivity with sulfanamides

Some contain trazine a yellow food dye that may cause allergic reaction or bronchial asthma

1.  For edema assoc with HF, corticosteroid and estrogen therapy and liver cirrhosis
2. Hypertension
3. Renal disease
4. Cerebral edema
5.  Acute glaucoma and increased IOP before and after surgery
6.  ethacrynic acid also used for mgmt of ascites caused by cancer, lymphadema

1. Neuromuscular - dizziness, lightheadnedness, headache, weakness, fatigue
2. CV - orthostatic hypotension, syncope, electrolyte imbalances, glycosuria
3.   GI - anorexia, N/V, cramping, gastritis, diarrhea, constipation
4.  Other - rash, photosensitivity; numbness/tingling or flaccid muscle indicate HYPOKLEMIA. HYPERKLEMIA, serious, may happen with K sparing, most likely to occur in dehydrated pts, those with diabetes or renal disease, elderly and severely ill.
5. GYNOCOMASTIA can occur and usually reversible
6.   ERECTILE DYSFUNCTION and reduced libido
7.  Hyperglycemia
8.   Hematologic changes Fluid imbalances

a.        Known hypersensitivity

b.       Electrolyte imbalances

c.        Severe kidney or liver dysfnx

d.       ANURIA

e.        Mannitol contra. pts active intracranial bleed

f.         K-sparing contra in pts with hyperk

g.       Not recommended for kids

a.        Pts with renal dysfnx

b.       Preg Cat B or C, lactation also

c.        Thiazides and loops cautiously with liver disease, diabetes, lupus (can exacerbate or even activate the disease) or diarrhea

d.       Thiazides with sulfanamides may have cross-sensitivity reaction

e.        Some thiazides contain trazine (yellow food dye) which may cause an allergic rxn or bronchial asthma

f.         Those sensitive to sulfanamides may also show sensitivity to  loop diuretics

g.       K-sparing used cautiously in liver disease, diabetes or gout

with primidone (seizures) decreases effectiveness (of what?)

• most nontoxic but ineffective or no more than caffeine.  
• Includes celery, chicory, sassafrass, juniper berries, St. John’s, foxglove, horsetail, licorice, dandelion, digitalis purpurea, ephedra, hibiscus, parsley and elderberry.  J
• uniper berries and shave grass or horsetail are contraindicated b/c juniper associated with renal damage and horsetail contains severely toxic compounds.  
• Hypertensives should avoid tea with ephedra.

                                                               i.      take vitals and weigh pt.  Lab tests, esp. serum electrolytes carefully reviewed

                                                              ii.      pts with reanal dysfunction should have BUN and creat clear monitored also

                                                            iii.      If has peripheral edema, inspect areas and record degree and extent

                                                            iv.      If receiving carbonic anhydrase inhibitor for IOP, get pts description of pain; also get vital and weight

                                                             v.      Review chart for description of seizures and frequency

                                                            vi.      If osmotic, focus on pts disease and sxs treated

                                                          vii.      Always weigh and take vitals

                                                               i.      Observe for therapeutic effect

                                                              ii.      Measure and record fluid intake and output and report marked decrease in output

                                                            iii.      Weigh pt same time daily making sure wearing same amount or type of clothing

a.        Impaired Urinary Elimination r/t action of diuretic causing increased frequency

b.       Risk for deficient fluid volume related to excessive diuresis secondary to admin or diuretic

c.        Risk for injury rt lighheadedness, dizziness or cardiac arrythmias.

1. weigh daily to monitor fluid loss; weight of 2 lbs per day ideal to prevent dehydration and electrolyte imbalances
2.   measure record in and out q 8 hrs
3.  Critically ill or pt with renal disease may req more frequent measurements of output
4. Monitor vitals q 4 hours or as ordered; acutely ill may req more freq of vitals
5.  Examine areas of edema daily to evaluate drug and record
6. examine general appearance and condition daily or more if acutely ill

1. teach how to monitor blood pressure and pulse
2.  If pt critically ill or excessive hypertension more freq assess of vitals

1. for carbonic anhydrase inhibitors evaluate response to drug by relief of eye pain q 2 hrs
2.    If ambulatory and vision problems, help with ambulations and self-care
3.   If eye pain no improve after 4 hours or increased pain 3-4 hrs after first dose of diuretic, report immediately.
4. If pt has acute closed-angle glaucoma, check pupil of affected eye 2 hr for dilateion and response to light

1.        carbonic anhydrase inhibitor given for absense or nonlocalized epileptic seizures

2.        assess pt frequently for freq of seizures and record time of onset and duration; be very accurate of pattern and number for PCP

1. Mannitol is given via IV
2. Inspect solution for crystals that may form in cold temp
3. If see crystals, withhold, return to pharmacy and get another dose
4. Monitor urine output hourly b/c rate of admin is adjusted to maintain a urine flow of at lease 30-50mL/hr

    

1.        Thiazides are admined

2.        Renal fnx monitored periodically

3.        These drugs precipitate azotemia (nitro. Waste in blood);

4.        If NonProtein Nitrogen (NPN) or BUN increases, report

5.        Serum uric acid monitored during tx bc may precipitate gout attach

6.        Also monitor for joint pain/discomfort

7.        Hyperglycemia may occur, so insulin and oral antidiabetics may need altered doses; serum glucose monitored periodically

1.  Pts who have arrythmias or who are being digitalized (digoxin therapy) may be more suseptable to K loss resulting in hypoK; so will take the K-sparing
2. Therefore nurse monitors for hyperK bc at increased risk
3. Monitor K levels frequently, esp. during initial tx
4. If pt experiences hyperK symptoms, or K is above 5.3mEq/mL, discontinue and PCP notified immediately
5. To treat hyperK toxic levels, IV bicarbonate (if acidotic) or oral/parenteral glucose with rapid acting insulin
6. Persistant hyperK may req dialysis

Thirst

Poor skin turgor

Dry mucous membranes

Weakness

Dizziness

Fever

Low Urine

Cold, clammy skin

Decreased skin turgor

Confusion

Hypotension

Irritability

Tachycardia

Leg and foot cramps

Hypertension

Tachycardia

Neuromuscular irritability

Tremor

Hyperactive deep tendon reflexes

Confusion

Hallucinations, visual or auditory

Paresthesias

Anorexia

N/V

Depression

Confusion

Arrythmias

Imparied though processes

Drowsiness

hypoklemia is slowing vs hyperklemia is more stimulating

1. before admin, explain purpose to remove fluid, when diuresis expected and how  long will last (diff drugs/routes have diff onset/durations)
2. Admin early to prevent sleep disturbance
3.   Reduce anxiety by explaining purpose and effects and explain that frequent urges will probably decrease
4. if on bed rest, make sure has call light and easy reach of bedpan, urinal 
5. Inform pt that give in morning and why
6. Some diuretics last long and may cause nighttime urgency/freq, especially early in therapy

1.        Esp. early in therapy, fluid and electrolyte imbalances most common adv rxns

2.        Fluid loss varies amongt pts

3.        Most common are loss of K and water.  Mag, NA, and Cl also.

4.        HypoKlemia can cx more serious arrythmias in those with arrythmias or taking digitalis

5.        HypoKlemia treated with potassium supp and foods high in K or by changing to K sparing

6.        Those taking loop diuretics prone to mag defic

7.        Dehydration can be serious too, esp. for elderly

8.        Very helpful to drink more water and eat well; if uncontrollable this way, may need electrolyte replacement

9.        Eldrly esp. prone to fluid volume deficit and elec imbalances when taking diuretics.  Monitor carefully for hypoK (loops/thiazides) and hyperK (Ksparing)

10.     To prevent fluid volume deficit, encourage fluids frequently while awake.  Blanced diet helpful for electrolyte balance.  Encourage to eat and drink all served, and even bt meals

11.     Monitor In and Out and notify PCP is fails to drink enouth fluid, if low urine, concentrated urine, appears dehydrated, or sign sxs of elec imbalance are apparent

12.     Closely observe prs receiving K-sparing for sign of hyperK for serious and potentially fatal elec imblance

•  Best to take early in AM
•  Expalin onset and duration
•  Pt fam must know signs and symptoms of fluid and electrolyte imbalances
• Must know about adv reactions
•  Stress how diuretic will help disorder
• If GI upset, take with food/milk
• Excess urination should subside
• Do not reduce fluid to reduce urinationg, drink what PCP says
• Avoid alcohol and nonprescrip drus unless approved
• Hypertensives be careful to avoid drugs that increase bp, like OTC drugs for appetite suppression and cold sxs (pseudoephidrine, eg)
• If dizzi/weak, cautious with driving, etc and rise slow from sitting or lying and avoid standing for too long
• Weigh self as recommended and keep record and contact pcp if loss exceeds 3-5lb a week
• If K supp recommended, do not exceed recommended and follow directions
• After time, diuresis should decrease b/c excess fluid removed, but keep taking to prevent further accumulation of fluid
• thiazide or related, loops, K-sparing, carb anhydrase inhibitors or triameterene, avoid exposure to sunlight or UV, wear sunscreen and protective clothing until tolerance known
• For diabetics and taking loops or thiazides, known that blood results may be elevated sugar or urine may have sugar (glycosuria) – contact PCP in these cases
• For K-sparing, avoid K foods and salt subs containing K; Read food labels.  No K supps.
• Males on spironolactone may have gynocomasita, should go away after therapy (usually)
• For thiazides, may cuase gout attacks, contact PCP if significant or sudden joint pain occur
• For those taking carbonic anhydrase inhibitors (CAIs) for tx of glaucoma – contact PCP if eye pain not relieved or eincreases
• For those taking carbonic anhydrase inhibitors (CAIs)for epilepsy for seizures – family member should keep a record of all seizures witness and bring to PCP next visit. Contact PCP immediately if number of seizures increases.
• Teach about high K foods if risk for hypoK
• Notify PCP if the follwing occur

1.        muscle cramps/weakness

2.        dizziness

3.        n/v

4.        diarrhea

5.        restlessness

6.        excessive thirst

7.        general weakness

8.        rapid pulse/heart rate

9.        GI distress

• Most commonly affected structure of UTI is bladder = CYSTITIS resulting in urgency, frequency, pressure, burning, pain with urination and pain from spasm
• URETHRITIS inflame of urethra, PROSTATITIS (prostate) and PYELONEPHRITIS of kidney and renal pelvis

Many of this class of drugs do not schieve significant blood levels so do not treat systemic infections.  Primarily excreted by kidneys and only affect urinary tract

Other antiinfectives are used for UTIs but are in other chapters

anti-infectives

anti-infective combos

antispasmodics

analgesics

• amoxicillin
• fosfomycin
• methenamine (chronic)
• nalidixic (chronic and acute) DO NOT TAKE WITH FOOD
• nitrofurantoin (Mactrobid)
• trimethoprim (TMP)

• trimehoprim and sulfamethoxazole (TMP-SMZ) = Bactrim
• also used for shigellosis and acute otitis media

• phenazopyridine (Pyridium)

                                                               i.      Are rapidly excreted, causing high urine concentration and interfere with bacterial multiplication.

                                                              ii.      Nitrofurantoin may be BACTERIOSTATIC (slows or retards) or BACTERICIDAL depending on concentration in urine

                                                               i.      Are CHOLINERGIC BLOCKING drugs to inhibit contractions and urge

                                                              ii.      Relax DETRUSOR muscle (smooth muscle) via parasympathetic receptors

                                                            iii.      Flavoxate (Urispas) also for DYSURIA (painful/difficult), urgency and NOCTURIA (excess at night), suprapubic pain, frequency and urge incontinence

                                                            iv.      Antispasmodics also for bladder instability including leakage, incontinence etc caused by NEUROGENIC BLADDER (often caused from a spinal cord injury)

                                                             v.      phenazopyradine (Pyridium) is a dye with topical analgesia of lining of tract

                                                               i.      Mainly GI disturbances

1.       anorexia, N/V diarrhea ab pain and stomatitis

                                                              ii.      Can also cause

1.       drowsiness, dizziness, headache, blurred vision, weakness, peripheral neuropathy

2.       rash, pruritus, photosensitivity

3.       leg cramps

                                                            iii.      When given in large doses can cause burning with urination and bladder irritation.  DO NOT MISTAKE FOR A CONTINUED INFECTION

                                                            iv.      Nitrofurantoin can cause acute/chronic pulmonary reactions

                                                               i.      Similar to other anticholinergics, including

1.       dry mouth, drowsiness, C/D (constipation/diarrhea), decreases tear production, decreased sweating, GI disturbances, dim vision, urinary hesitancy

2.       Also N/V, nervousness, vertigo, headache, rash, mental confustion (esp. older adults)

                                                               i.      Contra known hypersensitivity

                                                              ii.      Conta in pregnancy (Preg cat C ) and during lactation; exception in nitrofurantoin is cat B so used with caution during pregnancy

                                                            iii.      Nalidixic (NegGram) not for pts with convulsive disorders and contra for pts with hypersensitivity to fosfomycin; this durg also used cautiously in pts taking metoclopramide (Reglan)

                                                            iv.      Anti-infectives used cautiously in renal/hepatic impairment

                                                             v.      Those allergic to tarazine (food dye) should not take methanamine (Hiprex); this drug also used cautiously in pts with gout b/c can cause urine crystals

                                                            vi.      Nalidixic and nitrofurantoin used cautiously in pts with cerebral arteriosclerosis, diabetes, or a glucose-6-phosphate dehydrogenase (G6PD) deficiency

                                                               i.      Naldixic and sulfamethoxazole

1.        with oral anticoagulants increase bleeding risk

                                                              ii.      nitrofurantoin

1.        with magnesium triscillcate or magaldrate (for GI upset) decreases absorption of anti-infective

2.        with anticholinergics for bladder spasm delays gastric emptying, increasing absorption of nitrofurantoin

                                                            iii.      fosfomycin

1.        with metoclopramide (Reglan) for GI upset lowers plasma concentration and urinary excretion of fosfomycin

                                                            iv.      methenamine

1.        with antacids containing sodium bicarn or sodium carbonate will increase urine pH, decreaseing effectiveness of methenamine

                                                               i.      With antibiotics/antifungals decreases effectiveness of anti-infective

                                                              ii.      With meperidine, flurazepam or phenothizines (preop sedation) increases effect of the antispasmodics

                                                            iii.      With tricyclics increases effect of antispasmodics

                                                            iv.      With haloperidol for antianxiety/antipsychotic decreases effect of antipsychotic

                                                             v.      With digoxin increases serum digoxin

                                                               i.      What are symptoms? Like pain, frequency, bladder distension, etc.  Document for baseline.

                                                              ii.      Color/appearance of urine

                                                            iii.      Take vitals

                                                               i.      In hospital (most are not treated in hospital if only problem) monitor vitals q 4 hours or as ordered.  Rise in temp reported to PCP bc may need something to reduce fever or other tests ordered

                                                              ii.      Monitor response to therapy daily

                                                            iii.      If several days and no improvement , notify PCP ASAP

                                                            iv.      Monitor for reduction in sxs identified in preadmin asessment

a.        Umpaired urinary elimination r/t discomfort of UTI

b.       Ineffective breathing pattern rt adv rxn to drug (nitrofurantoin)

                                                               i.      Give with food to prevent GI upset.  Especially nitrofurantoin bc extra irritating

                                                              ii.      Fosfomycin (Monurol) admined by dissolving and immediately giving

                                                            iii.      Nalidixic can cause visual disturbances, so note if happens.  Usually subside

                                                            iv.      Antispasmodic dose may decrease as pt sxs improve

                                                             v.      Phenazopyridine given after meals to prevent GI upset

                                                            vi.      Phenazopyradine (Pyridium) (just for pain) not given more than 2 days with used in combo with antibact to treat UTI.  If used longer, can mask a more serious disorder (KNOW THIS NURING ALERT)

1.  encourage > 2000mL fluid daily to dilute urine, decrease pain, assist in physical removal of bacteria;  offer fluid to pt regularly (hospital), prefereablly water.  If juice, give cramberry.  Notify PCP if fails to drink extra, if urine out low or urine is concentrated during daytime.  Usually at 2000mL urine is light and dilute
2.  Elderly have decrased thirst and must be encouraged to drink, esp. true if on antispasmodic (Why?)
3. Measure/record in/out for volume and frequency q 8 hours, esp. when there is an order for increased fluid or when kidney infection
4.  PCP may also order daily pH when methanamine or nitrofurantoin is given  These drugs work best in acidic urine, if urine not acidic may add as acidifier like ascorbic acid.

• Nitrofurantoin (Macrobid) can cause pulm rxns; dyspnea, chest pain, cough, fever, and chills.
• can occur within hours to 3 weeks after therapy.
• If this occurs, IMMEDIATELY tell PCP and withhold drug until seen.  
• Other signs are nonproductive cough or malaise indicating a more chronic pulmoanary reaction during prolonged therapy.

1. Anticholinergic effects of dryness, blurred vision, constipation are common.
2. Dry mouth, recommend suck on hard candy, and also perform frequent mouth care  This effect may reduce with continued use
3. Hospitalized pts with blurred vision may need help ambulating
4. For constipation fluids, high-fiber and provide time for movement is able.  PCP may prescribe a lax of softener
5. Inform pt that phenazopyradine may cause reddish-orange pee and will stain.  Also, the fluid that lubes eyes may change color, causing permanent discoloration of contact lenses.  Reassure that this is normal and will go away once drug dced. 

1. Stress importnance of extra water to at lease 2000mL/day (unless contraindicated) to help remove bacteria
2.  For infections, often takes only several days of therapy to get better, but keep taking anti-infective!
3. Take with food.  If still have GI upset, call PCP
4. If drowsy/dizzy, avoid driving etc
5. Avoid alcohol and take no nonprescrip[ts unless approved
6. Notify PCP is not better within 3 to 4 days
7. notrofurantoin (Macrobid) with food always to improve absorption (not just to prevent GI upset).  “continue therapy for at least 1 week of for 3 days after the urine shows no signs of infection.”
8. nitrofurantoin (Macrobid): notify PCP IMMEDIATELY and do not take next dose if fever, chills, cough, SOB, chest pain, painful breathing.
9. nitrofurantoin (Macrobid) may turn pee brown and this is normal
10. naladixic, avoid prolonged exposure to sun or UV (sensitivity can cause bad burn)
11. methenamine, avoid excessive intake of citris and milk (why?) (I know methenamine like acidic pee…)
12. fosfomycin, after mixing powder in not hot water, take immediately and take with food to prevent GI upset.

1.  For dry mouth suck on candy, etc and frequent mouth care
2.  May cause drowsiness/blurred vision, so do not drive, etc until know how affects you
3. for constipation fluids, fiber and exercise.  If persists, caontact PCP for lax/soft
4. flavoxate, take 3-4 times a day, is used for symptom relief, not underlying cause.
5. for oxybutynin can take with or without food. The extended release (Ditropan XL) may pass into stool, is fine.  If using transdermal form, apply to clean, dru area of hip, abdomen or buttocks.  Rotate patches q 7 days
6. Antispasmodics can cause heat prostration (fever and heat stroke caused by decreased sweating) in high temps.  If hot weather take precautions
7.   for phenazopyridine may cause red-orange urine and tears may stain fabrics, contact lenses. Normal.  Take this without food.  Do not take for more than 2 days if also on antibiotic for UTI (may mask problem)

1. Primary preventative for urinary infections is good handwashing, for nurses to prevent giving to patients as well!
2. Are others on list but discussed above
3. Drink fluids every hour
4. Show how to measure intake and output
5. Encourage fluids even after symptoms subside
6. Notify PCP if urine output is low, urine is dark or concentrated during daytime, or sxs no improve 3-4 days
7. Review adv rxns of drugs, and signs of new or worsening infection, verbally and in writing
8. Emphasize importance follow up visits to determine effectiveness of therapy

Diamox

carbonic anhydrase inhibitor diuretic

CHLOROTHIAZIDE

HYDROCHLOROTHIAZIDE

HYDROFLUMETHIAZIDE

                                                               i.      And cisplatin risk of ototoxicity

                                                              ii.      And aminoglysides risk of ototoxicity

                                                            iii.      And anticoagulants/thrombolytics increase risk of bleeding

                                                            iv.      And digitalis increases risk of arrythmias

                                                             v.      And Lithium increases risk of toxicity

                                                            vi.      And Hydantoins decreases diuretic effectiveness

                                                          vii.      And NSAIDS/salicylates decreases diuretic effectiveness

                                                               i.      and angiotensin-converting enzyme inhibitors increases risk of hyperK

                                                              ii.      and potassium supps increases risk of hyper K

                                                            iii.      and NSAIDS/salicylates decreases diuretic effectiveness

                                                               i.      And allopurinol increases risk of hypersensitivity to allopurinol

                                                              ii.      And anesthetics increases anesthetic effectiveness

                                                            iii.      And antineoplastics extended leucopenia

                                                            iv.      And antidiabetics hyperglycemia

Promotion of optimal response in pt with cerebral edema who is given certain diuretics

1. Diuretics given are mannitol or urea
2. Monitor BP, pulse, and RR q 30-60 min or as ordered
3. report increase in BP, decrease in pulse or RR, or any changes in neuro status
4. Perform neuro assessments at intervals ordered and records; hopefully to show a decrease in intracranial pressure

Normal potassium values 

3.5-5

1.    Meats including fish

2.    Fruits like spricots, avocado, banana, cantelope, dates, plums, prunes tomatos, oranges, etc

3.    Vegetable carrots, lima beans, potatoes, radishes, spinach, sweet potatos tomatos

4.    Coffee, ginersnaps, craham crackers, molasses, nuts, peanuts/butter, tea

used to treat acute UTIs

Mix in NOT hot water,take immediately and with food to prevent GI upset

used to treat chronic UTIs

Those allergic to tarazine (a food dye) should not take this

Hiprex

Use cautiously in pts with gout bc can cause urine crystals

avoid excess intake of citrus and milk (why?)

Methenamine works best with acidic urine

Can cause visual disturbances, so note if happens; usually subside

used to treat both chronic and acute UTIs

DO NOT TAKE WITH FOOD 

Not used for pts with convulsive disorders

Contraindicated for pts with hypersensitivity to fosfomycin

Use cautiously if pt taking metoclopramide (Reglan) and in pts with cerebral arteriosclerosis, diabetes, or a G6PD deficiency

Avoid sun exposure (sensitivity can cause burn)

Works best in acidic urine,so PCP may order pH tests and possible add an acidifier like ascorbic acid

Macrobid

Used to treat acute UTIs

Can cause acute and chronic respiratory distress

Always with food to improve absorption and to prevent GI upset bc extra irritating

Notify PCP immediately and d/c if fever, chills, cough, SOB chest pain painful breathing

May turn pee brown, normal

may be bacteriostatic or bacteriocidal depending on concentration in urine

For treatment of UTIs

Bactrim

is trimethoprim and sulfamethoxazole

Also used to treat shigellosis and acute otitis media

Enablex

bladder antispasmodic

for "urinary symptoms" caused by infections or other problmes

Does not treat cause

Detrol

bladder antispasmodic

Sanctura

DO NOT TAKE WITH FOOD

bladder antispasmodic

Pyridium

urinary tract analgesic; only treats symptoms and do not take more than 2 days bc may cover up serious problem

Contraindicated in pts with renal impairment and in undiagnosed urinary tract pain

May cause red-orange urine and tears that may stain fabric, contact lenses.  Normal.  

Take with food

a loop diuretic

Lasix

osmotic diuretic used for increased intracranial pressure; given by IV

Contraindicated in pts with an active intracranial bleed

If see crystals, withhold, return to pharm and get another

IV bicarbonate (if acidotic)

or

oral/parenteral glucose with a rapid acting insulin

1. muscle cramps/weakness
2. dizziness
3. N/V
4. diarrhea
5. erstlessness
6. escessive thirst
7. general weakness
8. rapid pulse
9. GI distress

Three places

1. distal tubules
2. proximal tubules
3. loop of Henle

sodium and chloride and water

ascending loop of Henle

Sodium and Chloride excreted (along with water)

primarily enhances chloride excretion in proximal tubule of nephron (some sodium also)

1. Hyperklemia most likely to occur in patients with inadequate fluid intake, urine output, diabetics, renal disease, the elderly and those who are severely ill
2. Also patients at risk for hypoK and thus given a potassium sparing diuretic;therefore, pts with arrythmias or initiating digoxin (more susceptible to K loss) will be given a potassium-sparing
3. Also, pts taking a k sparing and taking angiotensin-converting enzyme inhibitors and potassium supplements have increased risk

Midamor

Potassium Sparing Diuretic

given for HF, hypertension, hypoklemia prevention and prevention of polyuria with lithium use

a.       K is monitored closely during initial treatment

b.      Drug d/ced andPCP notified immediately if pt experience hyperK symptoms or if serum K is above 5.3 mEq/mL

c.       Treatment of hyperklemia is IV bicarbonate (if pt is acidotic) or oral or parenteral glucose with rapid-acting insulin

d.      Persistent hyperklemia may require dialysis

                                                               i.      Angiotensin-converting enzyme inhibitors and potassium supplements

1.      causing increased risk of hyperklemia

SIGNS SYMPTOMS OF HYPERKLEMIA

KNOW THIS 

                                                               i.      Parasthesias

                                                             ii.      Muscular weakness

                                                            iii.      Fatigue

                                                           iv.      Flassid paralysis of extremities, bradycardia, shock, ECG abnormalities

                                                             v.      Irritability

                                                           vi.      Anxiety

                                                          vii.      Confusion

                                                        viii.      Nausea

                                                           ix.      Diarrhea

                                                             x.      Arrythmias

                                                           xi.      Abdominal distress

1. Glossitis
2. Stomatitis
3. Gastritis
4. Furry tongue
5. N/V
6. Diarrhea
7. Rash
8. Fever
9. Pain at injection site
10. Hypersensitivity reactions
11. Hematopoietic changes
12. Contraindicated in pregnancy
13. Use cautiously in renal/hepatic impairment

1. Headache
2. N/V
3. Fluid/electrolyte imbalance
4. Syncope

1. Naldixic is NegGram for acute/chronic UTIs
2. Do not take with food pg 492.  But pg 496 says do take with food to prevent upset…..
3. Anti-infectives in large doses can be irritating to ladder causing burning urination, don’t mistake for continues infarction
4. Contraindicated during pregnancy
5. Contraindicated in those with convulsive disorders and known hypersensitivities to fosfomycin
6. Not used during lactation either
7. Used cautiously in pt taking metoclopramide (Reglan)
8. Used cautiously in renal/hepatic impairment, cerebral arteriosclerosis, diabetes or a G6PD deficiency\
9. Naldixic with oral anticoagulants increases risk of bleeding
10. May cause visual disturbances, if so, note this, usually subsides after few days of therapy
11. Avoid prolonged sun can lead to burn

Nursing Interventions for Administration of Fosfomycin

1. For acuteUTI
2. Comes in dry form as a one-dose packet to be dissolved in 90-120 mL water (not hot).  Drink immediately after mixing and take with food.
3. With metoclopramide (Reglan) can lower plasma concentration and urinary tract excretion of fosfomycin

1. Macrobid for actuteUTI
2. Can be used cautiously in pregnancy
3. Use cautiously in cerebral arteriosclerosis, diabetes, or G6PD deficiency
4. With magnesium trisillicate or magaldrate decreases absorption of the antiinfective
5. With anticholinergics delays gastric emptying which increases nitro. Absorption
6. Can cause pulmonary reactions within hours to 3 weeks after initiation.  Signs are dypnea, chest pain, cough , fever, and chills.  Immediately notifyPCPand withhold drug. 
7. In patients on prolonged therapy may develop a non-productive cough and malaise indicating a more chronic resp. reaction
8. Works best in acidic urine, so PCPmay order pH and maybe urine acidifier like ascorbic acid

1. Urinary antispasmodics with digoxin can increase serum levels of digoxin, which can be toxic with cardiac implications
2. Loop diuretics with digitalis increases risk of arrythmias
3. Patients being digitized (treatment initiation) may be more susceptible to significant potassium loss resulting in hypoklemia when taking diuretics.  So, they will be given potassium sparing, but must watch for hyperklemia.

1. Thiazides work in ascending portion of loop of Henle and early distal tubule of nephron resulting in excretion of socium, choloride and water.
2. For renal compromise and thiazide, renal function is monitored regularly.  These drugs can precipitate azotemia (too much nitro waste in blood). 
3.  If NPN or BUN increases,PCPmay withhold or dc.  
4. Serum uric acid is also monitored with thiazides bc may cause attack of gout.  Monitor pt for joint pain/discomfort
5. Thiazides can cause hyperglycemia, so antidiabtic drugs may need alteration.  Glucose levels are periodically monitored
6. Give early in day to prevent nighttime disturbances
7. Thiazides with digitalis glycosides together require frequent monitoring of pulse and phytmh bc increase cardiac arrythmias; reposrt significant changes immediately

1. Elderly often have decreased thirst sensation, so must encourage to increase fluid.  Offer fluids often
2. This is all I could find…..

1. May stain clothes, even contacts
2. Discolors urine to reddish-brownish
3. Not taken more than 2 when given with an antibacterial forUTI.  May mask symptoms of more serious disorder
4. Food for GI upset
5. May need to stay out of sun

1. Urex/Hiprex for chronic UTIs
2. Avoid excessive intake of citrus products, milk and milk products
3. Works best in acidic urine and PCPmay order pH test and possibly an acidifier like ascorbic acid

1. Apply to clean, dry area of hip, abdomen or buttocks.  Remove old patch and rotate sites q 7 days

Patient education regarding bumetanide

KNOW THIS (Study guide)

1. A loop diuretic Bumex for edema due to HF, cirrhosis, renal disease, acute pulmonary edema
2. Photosensitivity concerns
3. Loops can cause increased blood sugar and contactPCPif happens
4. Teach adverse reactions

                                                               i.      Elec imbalnances

                                                             ii.      Hemotologic imbalances

                                                            iii.      Anorexia

                                                           iv.      N/V

                                                             v.      Dizziness

                                                           vi.      Reash, photosensitivity

                                                          vii.      Orthostatic hypotension

                                                        viii.      Glycosuria

                                                               i.      Know signs of fluid/electrolye imbalances

                                                             ii.      Take with food for GI upset

                                                            iii.      Take early in AM or as early as possible

                                                           iv.      Increase in urination; should subside

                                                             v.      Do not reduce fluid intake to control urination

                                                           vi.      Avoid alcohol and OTCs, epe hypertensives and OTCs that increase BP

                                                          vii.      NotifyPCP if weak, dizzy, N/V, diarrhea, restlessness, excessive thirst, general weakness, rapid pulse, increased heart rate or GI distress

                                                        viii.      Cautious with hazardous tasks; rise slowly

                                                           ix.      Weigh self weekly or as recommended and keep record and bring with to appt

                                                             x.      Follow dietary recommendations esp. re potassium, etc

                                                           xi.      After a time, diuretic effect will be minimal bc fluid will be removes, keep taking to prevent further fluid accumulation

                                                               i.      Preadmin

1.      take vitals and weigh pt

2.      Review test results esp. serum electrolytes including Bun and creatinine clearance

3.      Inspect edemic areas if able and record degree and extent

4.      Those receving an osmotic (mannitol eg) focus is on particular disorder

                                                             ii.      Ongoing

1.      Observe for effect of drug

2.      Measure/record in and out and report marked decrease in output

3.      Weigh pt same time daily with same clothing

1. Contraindicated during cranial bleed
2. Mannitol given via IV

                                                               i.      Carefully look for crystals, if find, return to pharm and get new dose

                                                             ii.      Rate of admin is individualized to pts in order to achieve urine output of about 30-50 per hour.

                                                            iii.      Nurse must monitor output hourly

3. Mannitol also given for cerebral edema (as is urea)

                                                               i.      Nurse monitors BP, pulse, rr q 30-60 minutes or as ordered

                                                             ii.      Report increases in BP, decrases in pulse, RR or any changes in neuro status

                                                            iii.      Nurse performs neurologic assessments at intervals ordered

                                                           iv.      Nurse evaluates/records patients response to drug by signs/sxs that may indicate a decrease in intracranial pressure

1. Cold, clammy skin
2. Decreased skin turgor
3. Confusion
4. Hypotension
5. Irritability
6. Tachycardia

1. known hypersensitivities
2. electrolyte imbalances
3. severe kidney/liver dysfunction
4. anuria
5. manntiol contraindicated in pts with active intracranial bleed except during a craniotomy
6. Potassium sparing contraindicated in patients with hyperklemia and not recommended for children

nitrofurantoin is cat B and used with caution during pregnancy

This is Macrobid, which can have respiratory adverse reactions

Galucoma

and

Certain seizures

All but the osmotics

CAIs

loops

k sparing

thiazides

How often should I/O be measured/recorded for pt taking diuretic (in general)?

Patients with

cerebral arteriosclerosis

diabetes

G6PD deficiency

When is naldixic contraindicated?

With what drug is it used cautiously?

NegGram contraindicated in pts with convulsive disorders, hypersensitive to fosfomycin

metoclopramide (Reglan)

When CAIs are given for glaucoma, how often should nurse asses pain? 

After how long of no decrease in pain should the nurse report to the PCP?

Check q 2 hours

Report after 4 hours of first dose

Hypoklemia

(so are given a potassium sparing)

Tell PCP immediately and withhold if

fever, chills, cough, SOB, chest pain, pain breathing

known hypersensitivities

glaucoma

gi blockage (bc anticholinergic effects)

abdomincal bleeding

myasthenia gravis

urniary tract blockage

GI infections

benign prostatic hypertrophy

urinary retention

hyperthyroidism

hep/renal disease

hypertension

pregnancy (cat C)

furthers leucopenia (decrease in white blood cells)

Is that a good or bad thing?  

sulfanamides

those sensitive to sulfanamide may also be sensitive to loops

nalidixic

I think there is another......

nalidixic and nitrofurantoin

are

NegGram and Macrobid

ETHACRYNIC ACID 

a loop diuretic

can cause visual disturbances

(are there others that can do this?)

Carbonic Anhydrase Inhibitors

They don't kill bactera