Nursing Consideration Patients receiving mannitol

should be closely monitored

OSMOTIC DIURETICS for fluid and electrolyte
Pull water into the renal tubule without sodium loss. imbalance.
Currently, only one osmotic diuretic is available; Assessment:
> Assess for contraindication
Mannitol (Osmitrol) or cautions: any known
Allergies to thiazides or
> 50–100 g IV for oliguria; 1.5–2 g/kg IV to reduce sulfonamides.
intracranial pressure; dose not established for children >Perform a physical
<12 y assessment.
Diuretics of choice in cases of increased cranial > Inspect the skin carefully
pressure or acute renal failure due to shock, drug over- for signs and symptoms of
dose or trauma. edema; note the extent and
Site of action Glomerulus, Tubule degree of edema, including
Therapeutic Action Acts to pull large amounts of evidence of pitting.
fluid into the urine due to the > Assess cardiopulmonary
osmotic pull exerted by the status, including blood
large sugar molecule. pressure and pulse, and
Because the tubule is not auscultate heart and lung
able to reabsorb all of the sounds for abnormalities.
sugar pulled into it, large > Obtain an accurate body
amounts of fluid are lost in weight.
the urine. > Monitor intake and output
Indications Used intravenously to and assess voiding patterns.
increase the volume of fluid > Monitor the results of
produced by the kidneys. laboratory tests, including
serum
Used in acute situations when electrolyte levels, especially
it is necessary to decrease potassium and calcium,
IOP before eye surgery or uric acid, and glucose levels.
during acute attacks of
glaucoma. Implementation:
Contraindication Contraindicated in patients > Administer oral drug with
with renal disease and Anuria food or milk.
from severe renal disease, > Administer intravenous
Pulmonary congestion, diuretics slowly.
Intracranial bleeding, >Continuously monitor
Dehydration, and Heart urinary output, cardiac
failure, Routine use during response, and heart rhythm
pregnancy is not appropriate, of patients receiving
only if the benefit to the intravenous diuretics.
mother clearly outweighs the > Administer oral form early
risk to the fetus. in the day.
> Monitor the dose carefully
Adverse Effects The most common and
and reduce the dose
potentially dangerous
of one or both drugs if given
adverse effect related to an
with antihypertensive agents.
osmotic diuretic is the sudden
>Monitor the patient response
drop in fluid levels. Nausea,
to the drug (e.g., blood
Vomiting, Hypotension, Light-
pressure, urinary output,
headedness, Confusion, and
weight, serum electrolytes,
Headache can be
hydration, periodic blood
accompanied by cardiac
glucose monitoring).
decompensation and even
> Assess weight daily to
shock.
evaluate fluid balance.
 > Check skin turgor
> Provide comfort measures,
including skin care and
nutrition consultation.
> Provide potassium-rich or
low-potassium diet as
Appropriate.
> Provide thorough patient
teaching, including the
name of the drug and dosage
prescribed.
Evaluation:
> Monitor patient response to
the drug (weight, urinary
output, edema changes,
blood pressure).
>Monitor for adverse effects
(electrolyte imbalance,
orthostatic hypotension,
rebound edema,
hyperglycemia, increased uric
acid levels, acid–base
disturbances, dizziness).
>Monitor the effectiveness of
comfort measures and
compliance with the regimen.
>Evaluate the effectiveness
of the teaching plan (patient
can name drug, dosage,
adverse effects to watch for,
and specific measures to
avoid them).
CARBONIC ANHYDRASE INHIBITORS
Relatively mild diuretics
Used in combination with other diuretics when a stronger
diuresis is needed
Available agents include;
Acetazolamide (Diamox)
> 500 mg IV repeated in 2–4 h, then 250 mg–1 g/d in
divided doses q6–8h for glaucoma; 8–30 mg/kg/d in
divided doses for epilepsy
250 mg–1 g/d PO given in divided doses four times per
day or once or twice a day if using sustained-release
formulation
Methazolamide (generic)
> 50–100 mg PO b.i.d. to t.i.d.
Site of action Proximal tubule
Therapeutic Action Catalyst for the formation of
sodium bicarbonate, which is
stored
Indications These drugs are used as
adjuncts to other diuretics
when a more intense diuresis
is needed. Most often, used to
treat glaucoma.
Contraindication Allergy to the drug or to
antibacterial sulfonamides or
thiazides to prevent
hypersensitivity reactions, or in
patients w/ chronic
noncongestive angle-closure
glaucoma, which would not be
effectively treated by these
drugs. Routine use during
pregnancy is not appropriate,
only if the benefit to the mother
clearly outweighs the risk to
the fetus.
Adverse Effects Related to the disturbances in
acid-base and electrolyte
balances. Metabolic acidosis,
Hypokalemia, Paresthesias
(tingling) of the extremities,
Confusion, Drowsiness.
Nursing Consideration Acetazolamide (Diamox)
Assessment:
>. Acetazolamide tablets may
be crushed and suspended in
cherry, chocolate, raspberry or
other sweet syrup. Do not use
vehicles containing glycerin or
alcohol. As an alternative, 1
tablet may be submerged in 1
mL of hot water and added to
10 mL of honey or syrup.
> Tolerance after prolonged
use may necessitate dosage
increase.
> Do not administer the
sustained-release dosage form
as an anticonvulsant; it should
be used only for glaucoma and
acute mountain sickness
Implementation:
> Taking drug with food may
decrease GI upset/irritation.
> Assess drug effects before
undertaking tasks that require
mental alertness.
> Increases voiding frequency,
take early to avoid interrupting
sleep.
> Increase fluid intake to
prevent urine crystals/stone
formation.

Evaluation:
> Report if nausea, dizziness,
rapid weight gain, muscle
weakness, cramps, or any
changes in the
color/consistency of stools
occur.
Methazolamide (generic)
Assessment:
> Assess patient's ability to
perform ADL since drug may
cause fatigue and lethargy.
Implementation:
> Supervise ambulation in
older adult, since drug may
cause vertigo.
> Lab tests: Obtain periodic
serum electrolytes, especially
in older adults. Monitor lithium
levels with concurrent
administration of lithium and
methazolamide.
Evaluation:
>. Be aware that drug may
cause drowsiness. Advise
caution with hazardous
activities until response to drug
is known.
Do not breast feed while taking
this drug without consulting
physician.
POTASSIUM SPARING DIURETICS
Not as powerful as the loop diuretics, but they retain
potassium instead of wasting it.
Mild diuretics
Drugs include;
Amiloride (Midamor)
>15–20 mg/d PO with monitoring of electrolytes
Spironolactone (Aldactone)
> 100–200 mg/d PO for edema; 100–400 mg/d PO
for hyperaldosteronism; 50–100 mg/d PO for
hypertension
Pediatric: 3.3 mg/kg/d PO
Triamterene (Dyrenium)
> 100 mg/d PO b.i.d.
Spironolactone, the most frequently prescribed of these
drugs, is the drug of choice for treating
hyperaldosteronism.
Site of action Distal tubule and collecting
duct
Therapeutic Action Cause a loss sodium while
promoting the retention of
potassium
Indications Used for patients who are at
high risk for hypokalemia
associated with diuretic use
(e.g., patients receiving
digitalis or patients with
cardiac arrhythmias.
Contraindication Contraindicated for use in
patients with allergy to the
drug to prevent
hypersensitivity reactions,
Hyperkalemia, Renal disease,
or Anuria. Routine use during
pregnancy is not appropriate,
only if the benefit to the mother
clearly outweighs the risk to
the fetus.
Adverse Effects Most common adverse effect
is Hyperkalemia, which can
cause lethargy, confusion,
ataxia, muscle cramps, and
cardiac arrhythmias.
Nursing Consideration Patients taking these drugs
need to be evaluated regularly
for signs of increased
potassium and informed about
the signs and symptoms to
watch for.
They also should be advised
to avoid foods that are high in
potassium.
Patients must be careful not to
become hyperkalemic while
taking these drugs.
Amiloride (Midamor)
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Assessment:
> Assess for the mentioned
cautions and contraindications
(e.g., drug allergies, fluid and
electrolyte disturbances,
hepatorenal diseases, glucose
tolerance abnormalities, etc.)
to prevent any untoward
complications.
> Perform a thorough physical
assessment to establish
baseline data before drug
therapy begins, to determine
effectiveness of therapy, and
to evaluate for occurrence of
any adverse effects associated
with drug therapy.
> Inspect skin (note presence
of edema and status of skin
turgor) to determine hydration
status and have a baseline
data for effectiveness of drug
therapy.
> Assess cardiopulmonary
status (blood pressure, pulse
rate, heart and lung sounds,
etc.) to evaluate fluid
movement and state of
hydration. It is also to monitor
the effects on the heart and
lungs.
> Obtain an accurate body
weight to provide baseline to
monitor fluid balance.
> Monitor intake and output
and voiding patterns to
evaluate fluid balance and
renal function.
> Evaluate liver status to
determine potential problems
in drug metabolism.
> Monitor the results of
laboratory tests (e.g. serum
electrolyte levels especially
potassium and calcium, uric
acid and glucose levels, etc.)
to determine drug’s effect.
> Monitor liver and renal
function tests to identify need
for possible dose adjustment
and toxic effects.
Implementation:
> Administer drug with food or
milk if GI upset is a problem to
buffer drug effect on the
stomach lining.
>Administer intravenous
diuretics slowly to prevent
severe changes in fluid and
electrolytes.
> Administer oral form early in
the day to prevent increased
urination during sleep hours.
> Monitor patient response to
drugs through vital signs,
weight, serum electrolytes and
hydration to evaluate
effectiveness of drug therapy.
>Assess skin condition to
determine presence of fluid
volume Provide comfort
measures (e.g., skin care,
nutrition referral, etc.) to help
patient tolerate drug effects.
deficit or retention.
> Provide comfort measures
(e.g., skin care, nutrition
referral, etc.) to help patient
tolerate drug effects.
> Provide safety measures
(e.g., adequate lighting, raised
side rails, etc.) to prevent
injuries.
>Educate client on drug
therapy to promote
compliance.
Evaluation:
>. Monitor patient response to
therapy (e.g., weight, urinary
output, edema changes, blood
pressure).
>Monitor for adverse effects
(e.g., electrolyte imbalance,
hyperglycemia, hyperuricemia,
acid-base disturbances, etc.).
>Evaluate patient
understanding on drug therapy
by asking patient to name the
drug, its indication, and
adverse effects to watch for.
>Monitor patient compliance to
drug therapy.
ANTI-HEPATITIS B AGENTS
Hepatitis B is a serious-to-potentially fatal viral infection
of the liver. The hepatitis B virus can be spread by blood
or blood products, sexual contact, or contaminated
needles or instruments. Health care workers are at
especially high risk for contracting hepatitis B due to
needle sticks.
Drugs Include:
 Adefovir (Hepsera)
> Adult: 10 mg/d PO
Renal impairment:
CrCl 20–40 mL/min: 10 mg PO q48h
CrCl 10–19 mL/min: 10 mg PO q72h
Entecavir (Baraclude)
> Adults and children (≥16 y): 0.5 mg/d;
also receiving lamivudine: 1 mg/d
Reduce dose with renal impairment
Telbivudine (Tyzeka)
> Adults and children >16 y: 600 mg/d PO;
reduce dose with renal impairment.
Therapeutic Action All three of these antiviral
drugs are indicated for the
treatment of adults with
chronic hepatitis B who have
evidence of active viral
replication and either evidence
of persistent elevations in
serum aminotransferases or
histologically active disease.
The drugs inhibit reverse
transcriptase in the hepatitis B
virus and cause DNA chain
termination, leading to blocked
viral replication and decreased
viral load.
Indications Adefovir (Hepsera)
> Treatment of hepatitis B with
evidence of active viral
replication and persistent
elevations in liver enzymes.
Entecavir (Baraclude)
> Treatment of chronic
hepatitis B in adults with
evidence of active viral
replication and persistent liver
enzyme elevations.
Telbivudine (Tyzeka)
> Treatment of chronic
hepatitis B in patients >16 y
with
evidence of viral replication
and persistent liver enzyme
elevations
Contraindication These drugs are
contraindicated with any
known
allergy to the drugs to prevent
hypersensitivity reactions and
with lactation because of
potential toxicity to
the infant.
Adverse Effects The adverse effects most
frequently seen with these
drugs are headache,
dizziness, nausea, diarrhea,
and elevated
Liver enzymes. Severe
hepatomegaly with steatosis,
sometimes fatal, has been
reported with adefovir and
telbivudine use. Lactic acidosis
and renal impairment have
been reported with entecavir
and adefovir.
Nursing Consideration Assessment:
> Assess for contraindications
or cautions: any history of
allergy to adefovir, entecavir or
telbivudine
>Perform a physical
assessment to establish
baseline data
> Assess body temperature to
monitor underlying
disease.
>Assess level of orientation
and reflexes to assess for
central nervous system (CNS)
changes.
>Evaluate renal and liver
function tests.
Implementation:
> Monitor renal and hepatic
function prior to and
periodically during therapy.
> Withdraw the drug and
monitor the patient if he or
she develops signs of lactic
acidosis or hepatotoxicity.
> Caution patient to not run
out of this drug but to take it
continually.
>Advise women of
childbearing age to use barrier
contraceptives.
>Advise women who are
breast-feeding to find another
method of feeding the baby
while using the drug.
>Advise patients that these
drugs do not cure the disease
and there is still a risk of
transferring the disease.
> Instruct the patient about the
drug prescribed.
> Provide the following patient
teaching.
Evaluation:
 > Monitor patient response to
the drug (decreased viral
load of hepatitis B).
>Monitor for adverse effects
(liver or renal dysfunction,
headache, nausea, diarrhea).
>Evaluate the effectiveness of
the teaching plan (patient can
name the drug, dosage,
possible adverse effects to
watch for, and specific
measures to avoid adverse
effects).
>Monitor the effectiveness of
comfort and safety measures
and compliance with the drug
regimen.
ANTI-HEPATITIS C AGENTS
two new drugs were approved for the treatment of
hepatitis C, boceprevir (Victrelis) and telaprevir
(Incivek). Most liver transplants performed in the United
States are due to progressive liver disease caused by
hepatitis C virus (HCV) infection.
Drugs include:
Boceprevir (Victrelis)
> Adult: 800 mg PO t.i.d. at 7–9 h intervals
Telaprevir (Incivek)
> Adult: 750 mg PO t.i.d. at 7–9 h intervals
with food
Therapeutic Action
Indications Boceprevir (Victrelis)
> Treatment of hepatitis C in
adults with compensated liver
disease, must be given with
peginterferon and ribavirin
Telaprevir (Incivek)
> Treatment of hepatitis C in
adults with compensated liver
disease; must be given with
peginterferon and ribavirin
Contraindication Anti-hepatitis C: pregnancy,
hepatitis B, and HIV infections,
as safety is not established.
Adverse Effects The most common adverse
effects are headache, fatigue,
nausea and diarrhea. Bone
marrow suppression and
severe skin reactions can
occur.
Nursing Consideration Assessment:
> Assess for the mentioned
cautions and contraindications
(e.g., drug allergies,
hepatorenal impairment,
pregnancy and lactation, etc.)
to prevent any untoward
complications.
>Perform a thorough physical
assessment (other
medications taken, orientation
and reflexes, vital signs, etc.)
to establish baseline data
before drug therapy begins, to
determine effectiveness of
therapy, and to evaluate for
occurrence of any adverse
effects associated with drug
therapy.
>Evaluate hepatic and renal
function tests to determine
baseline function of the
kidneys and liver.
Implementation:
> Monitor renal and hepatic
function before and during
therapy to detect changes
requiring dose adjustments or
additional treatment as
needed.
>Withdraw the drug and
monitor the patient if he or she
develops signs of lactic
acidosis or hepatotoxicity
because these adverse effects
can be life threatening.
> Provide the following patient
teachings:
-Have regular blood tests and
medical follow-up.
-Realize that GI upset, with
nausea and diarrhea, is
common with this drug.
-Report severe weakness,
muscle pain, palpitations,
yellowing of the eyes or skin,
and trouble breathing.
>Educate client on drug
therapy to promote
understanding and
compliance.
Evaluation:
>Monitor patient response to
therapy (decreased viral load).
>Monitor for adverse effects
(e.g., liver or renal dysfunction,
headache, nausea, diarrhea,
etc.).
>Evaluate patient
understanding on drug therapy
by asking patient to name the
drug, its indication, and
adverse effects to watch for.
>Monitor patient compliance to
drug therapy.