Peak Development for ...

Medication Administration

Vol. 16 Issue 8
August 2015

Diuretic Agents: Potassium-Sparing Diuretics

Spironolactone
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Medication Administration are
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Assessment System for
Medication Administration
and may be reproduced for this
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The information contained in
Peak Development for
Medication Administration is
intended only as a guide for the
practice of licensed nursing
personnel who administer
medications. Every effort has
been made to verify the
accuracy of the information
herein. Because of rapid
changes in the field of drug
therapy, the reader is advised to
consult the package insert,
facility pharmacist or patients
physician for relevant
information. This is particularly
important for new or seldom
used drugs. Use of professional
judgment is required in all
patient care situations. It is the
readers responsibility to
understand and adhere to
policies and procedures set forth
by the employing institution.
The editor and publisher of this
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resulting from use or misuse of
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Copyright 2015

After completion the learner should be able to:

1. Identify appropriate indications for use of
potassium-sparing diuretics.
2. Relate general characteristics of potassiumsparing diuretics to specific patient situations.
3. Apply nursing process considerations for
potassium-sparing diuretics to specific patient
situations.
Kidney Function and Diuretics
The kidneys have several physiologic functions
including filtering of extracellular fluid, regulating
fluid/electrolyte and acid/base balance, regulating
blood pressure and assisting in red blood cell
formation. Diuretics affect the bodys fluid balance
by acting directly on the nephron units of the
kidney. The nephrons regulate extracellular fluid
(ECF) volume through three steps:
Filtration: This occurs in the renal glomerulus,
where small molecules are removed from the
blood stream to enter the renal tubules.
Substances removed include water,
electrolytes, amino acids, drugs, glucose, and
waste products.
Reabsorption: This causes movement of the
substances in the renal tubules back into the
blood stream. Nearly all of the amino acids and
glucose are reabsorbed and almost 80% of
water, sodium, potassium and other substances
are reabsorbed. In order of progression, 6070% of filtered substances are reabsorbed in
the proximal tubule, 20-25% in the loop of Henle
and 5-10% in the distal tubule. Most diuretic
drugs act by preventing reabsorption of some of
these substances. Additional water is then sent
out with the excreted substances, resulting in
diuresis. The strength of a diuretic drug is
directly related to the amount of reabsorption it
prevents. Drugs that prevent the most
reabsorption produce the greatest diuresis.
Different types of diuretics act on different parts
of the tubule. Because the majority of
substances are reabsorbed in the proximal
tubule and Loop of Henle, diuretics acting on
these sites, such as loop diuretics (furosemide),

tend to cause the greatest loss of sodium,

potassium and water.
Tubular secretion: Substances such as toxins,
drugs, and body wastes are moved from
surrounding capillaries into the renal tubules for
excretion. This occurs in the proximal and distal
tubules, and is important in maintenance of acid
-base balance.
Many pathologic conditions, such as cardiac,
liver and renal disease, can cause alterations in
renal function that may lead to sodium and water
retention, resulting in edema. Diuretics are given
to increase renal excretion of water, sodium and
other substances, thereby decreasing edema
associated with underlying disease processes.
These agents are commonly used in the
management of hypertension, to decrease fluid
volume and pressure on blood vessels. In patients
with heart failure, diuretics help the poorlyperfused kidneys to excrete excess fluid that tends
to accumulate in the lungs and peripheral tissues.
And, some types of diuretics may be used to pull
fluid from specific body sites, for example, to
decrease cerebral edema or to decrease eye fluid
in treating glaucoma.
Potassium-Sparing Diuretics
Because most diuretics act to reduce
reabsorption of substances earlier in the tubule,
they tend to cause excretion of significant
amounts of electrolytes, particularly potassium.
This is a potentially serious adverse effect, since
low potassium levels can result in muscle
weakness, respiratory failure, hypotension and
cardiac arrest. One group, the potassium-sparing
diuretics, acts from the late distal tubule to the
collecting tubes, and thus prevents excretion of
potassium. This group includes amiloride,
triamterene, spironolactone and eplerenone.
Because these drugs have a relatively weak
diuretic effect, they are often combined with
hydrochlorothiazide to promote diuresis while
preventing excessive potassium loss.
Spironolactone and eplerenone are the two
aldosterone antagonists in the group, and
spironolactone will be used as the prototype drug
for the purposes of this newsletter.

Indications
Spironolactone is approved for treatment of essential
hypertension, heart failure, nephrotic syndrome, primary
hyperaldosteronism, liver cirrhosis, and hypokalemia that is
unresponsive to other treatment.
Pharmacodynamics
Spironolactone acts as an antagonist of aldosterone, resulting
in excretion of water and sodium.
Pharmacokinetics
Absorption: Rapidly absorbed from the GI tract; food increases
absorption
Distribution: Highly protein-bound
Metabolism: Rapidly and extensively metabolized by the liver
Elimination: Via urine and bile
Major Interactions
ACE inhibitors, other aldosterone antagonists and heparin: May
cause severe hyperkalemia
Alcohol, barbiturates and opioids: Increased risk of postural
hypotension, dizziness and falls
NSAIDs: May reduce effectiveness of the diuretic and increases
the risk of hyperkalemia
Lithium: Should not be used with diuretics due to high risk of
lithium toxicity
Digoxin: Increased risk of digoxin toxicity
Adverse Effects/Toxicity
Spironolactone carries a black box warning due to
development of tumors in laboratory animals. May cause
drowsiness, dizziness, nausea/vomiting, diarrhea, leg cramps,
pruritis, confusion, sexual dysfunction, gynecomastia in males
and breast pain in females. Possible severe effects include
hyperkalemia, gastric bleeding, anaphylaxis, renal impairment
and bone marrow suppression.
Precautions/Contraindications
Use of spironolactone is contraindicated in patients having
hyperkalemia, Addisons disease, severe renal impairment or
anuria. It should be used cautiously in the elderly and in patients
with renal or liver impairment.
Nursing Process
Assessment
Determine baseline status: When using potassium-sparing
diuretics, baseline information is essential to evaluate therapeutic
effectiveness and monitor for adverse events. Physical
assessment should include weight, lying and standing blood
pressure, pulse, intake and output patterns, and skin turgor.
Serum electrolyte values are especially important to obtain prior
to beginning therapy.
Identify risk factors: Carefully review the patients current
medications for potential interactions, and medical history for
precautions and contraindications. Review all serum electrolytes
prior to administration to ensure they are within normal limits.
Evaluate other lab work related to renal function, such as serum
creatinine and blood urea nitrogen, to determine current renal
status.
Age-specific considerations: FDA pregnancy category C. Use

in breastfeeding women has not shown adverse effects on the

nursing infant. Safety and effectiveness in children have not
been established. Because the elderly are more likely to have
renal and liver impairment, close monitoring and regular
measurement of serum electrolytes are important.
Planning and Analysis
The goal of therapy with spironolactone is related to the
patients pathophysiology, and may be to decrease edema or
blood pressure, or to improve cardiac function in patients with
heart failure.
Intervention
Medication administration: Spironolactone is taken orally. It
should be administered in the morning, for single daily doses.
Additional doses should be given before 6pm to prevent nocturia.
Observe for therapeutic effects: Monitor intake and output and
daily weight, and observe for decreased edema. Based on initial
assessment and reason for use, therapeutic signs may include
increased urine output, decreased weight and blood pressure,
and improved breath sounds.
Observe for adverse effects: Watch for signs of dehydration
and fluid/electrolyte imbalance, including dry mouth, poor skin
turgor, excessive thirst and oliguria. Monitor serum electrolytes
and report any abnormalities promptly. Normal potassium levels
range from 3.55 mEq/L. For levels above this, or if signs of
hyperkalemia occur, hold the medication and notify the physician
promptly. Signs include nausea, weakness, irregular or slow
pulse, tingling/numbness, difficulty breathing and paralysis.
Monitor blood pressure for hypotension.
Patient/Family teaching: Teaching should focus on evaluation
of drug effectiveness, patient safety and early detection of
adverse effects:
Do not use potassium supplements or foods containing high
amounts of potassium, such as salt substitutes, without your
doctors guidance.
Take once-daily medication in the morning, and for multiple
daily doses, take the last one before 6pm to avoid nighttime
trips to the bathroom.
Weigh daily and maintain a weight chart. Notify your doctor if
sudden weight gain or loss occurs.
Move slowly from lying to sitting to standing positions to
prevent dizziness and possible falls.
Avoid use of alcohol, sedatives and narcotics, which may
increase risk of low blood pressure, dizziness and falls.
Do not drive or operate dangerous machinery until drug effects
are known.
Keep all doctors appointments for lab tests.
Notify the doctor of weakness, palpitations, tingling/numbness,
or other unusual symptoms.
Notify the doctor if vomiting or diarrhea occur repeatedly, as
dehydration may result.
Evaluation
Through careful administration and monitoring, the nurse can
promote the safe achievement of therapeutic benefits for the
patient receiving potassium-sparing diuretics.

Peak Development for Medication Administration

Diuretic Agents: Potassium-Sparing Diuretics - Spironolactone

Page 2

Peak Development for ...

Medication Administration
Competency Assessment Tool

Vol. 16 Issue 8
August 2015

Diuretic Agents: Potassium-Sparing Diuretics

Spironolactone
NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. In the kidneys, movement of sodium and water back into the blood stream occurs in which
of the following steps:
A. filtration
B. reabsorption
C. tubular secretion
D. diuresis
_____2. In the process of filtration, the renal glomerulus performs which of the following functions:
A. substances such as water, sodium and amino acids are removed from the blood
B. body waste is excreted
C. urine is formed and passes through the collecting tubules before moving to the ureters
D. substances in the renal tubules are moved back into the blood
_____3. Because potassium-sparing diuretics act on the late distal and collecting tubules, they have
a stronger diuretic effect than loop or thiazide diuretics.
A. True
B. False
_____4. Spironolactone is indicated for treatment of all of the following EXCEPT:
A. essential hypertension
B. liver cirrhosis
C. heart failure
D. Addisons disease
_____5. Severe hyperkalemia may occur if spironolactone is taken with:
A. alcohol
B. lithium
C. ACE inhibitors
D. digoxin

_____6. Spironolactone carries a black box warning regarding the risk of:
A. tumor development
B. GI bleeding
C. bone marrow suppression
D. gynecomastia
_____7. Which of the following patients should most clearly NOT receive spironolactone:
A. Mr. N, who is not producing urine
B. Mr. P, who is 82 years old
C. Mrs. R, who has type 2 diabetes
D. Mrs. Y, who has hypokalemia
_____8. Prior to administration of spironolactone, the nurse notes the patients potassium
level is 6.2 mEq/L. Which one of the following actions is most appropriate for the nurse to
take at this time:
A. give the dose as ordered
B. document this low potassium level
C. give the patient half of the dose and encourage fluids
D. hold the medication and notify the physician
_____9. Mr. Martin is taking spironolactone 50 mg PO daily with dinner. He calls the doctors office
complaining of lack of sleep, because he has to go to the bathroom 23 times/night.
Which one of the following responses by the nurse is most appropriate:
A. tell Mr. Martin to cut his dose in half for a few days each week, so he can sleep
B. instruct Mr. Martin to take his medication when he wakes up in the morning
C. have Mr. Martin discontinue the medication and come to the office today
D. tell Mr. Martin that this side effect should go away in several weeks
_____10. The nurse provides instruction to an elderly patient who is starting use of spironolactone.
Which of the following comments, made by the patient, shows that the teaching was
effective:
A. I should increase my intake of protein, like fish and beef.
B. I know to weigh myself at the beginning of each month.
C. If I urinate more than I usually do, I should stop the medicine and call the doctor.
D. I should change positions slowly.

Competency Assessment Tool

Diuretic Agents: Potassium-Sparing Diuretics - Spironolactone

Page 2

Month: August 2015

Issue:
Diuretic Agents: PotassiumSparing Diuretics
Spironolactone

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