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)

Thiazide
Dyazide
(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 diuretics

Aldosterone 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 signsespecially
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

Afterload

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

Contractility
Affects cardiac output
Strength of muscle contraction

Drugs for Heart Failure

Drug therapy must :

1)Decrease work load
2)Increase contractility
3)Both
**Most often drugs are used in combination

Drug therapy
Diuretics

Beta blockers

Reduce blood volume and

thus decrease cardiac
workload
Loop diuretic: Lasix
(fuosemide)

Decrease contraction force

Decrease heart rate
End result is decrease in
work load
Must not stop abruptly

Cardiac Glycosides
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

Adverse effects of Glycosides

Main risk is dysrhythmias
Electrolyte imbalance (especially k+)
increases risk
Nausea & vomiting
Visual disturbance (yellow/green vision)

Nurses Role Cardiac Glycosides

Monitor potassium (K+)
Monitor apical pulse for 1 minute
Monitor Digoxin level (normal = 0.8-2.0
ng/mL)
Evaluate for ventricular dysrhythmias

Patient Teaching
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

Ace Inhibitors and ARBs

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

Question 1
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 2
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 3
The teaching plan for a patient receiving
thiazide diuretics should include:
1. taking the patients 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 4
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 5
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 hearts conduction system returns to a more
regular pattern