TEACH for Nurses for

28 Diuretic Drugs
OBJECTIVES
1. Describe the normal anatomy and physiology of the renal system.
2. Briefly discuss the impact of the renal system on blood pressure regulation.
3. Describe how diuretics work in the kidneys and how they lower blood pressure.
4. Distinguish among the different classes of diuretics with regard to mechanisms of action, indications,
dosages, routes of administration, adverse effects, toxicity, cautions, contraindications, and drug
interactions.
5. Develop a nursing care plan that includes all phases of the nursing process for patients receiving
diuretics.
1.
TEACHING FOCUS
 Begin this chapter with a review of kidney anatomy and function. Students will then be better able
to understand the effects of the various diuretics, classified in part by their sites of action.
 Emphasize that the diuretics are so potent, safe, and inexpensive that they are among the most
commonly prescribed drugs in the world and are the drug of choice in the treatment of many
conditions, particularly hypertension and heart failure.
 Students should be aware, however, of the diuretics’ dose-related metabolic adverse effects.

KEY TERMS
 Afferent arterioles, p. 452 
 Aldosterone, p. 452  Glomerular capsule, p. 452
 Ascites, p. 455  Glomerular filtration rate (GFR), p. 452
 Collecting duct, p. 452  Glomerulus, p. 452
 Distal convoluted tubule, p. 452  Loop of Henle, p. 452
 Diuretics, p. 452  Nephron, p. 452
 Efferent arterioles, p. 452  Open-angle glaucoma, p. 453
 Filtrate, p. 452  Proximal convoluted (twisted) tubule, p. 452
NURSING CURRICULUM STANDARDS
QSEN
 Patient-Centered Care
o Patient-Centered Care: Lifespan Considerations for the Pediatric Patient, p. 456
o Patient-Centered Care: Lifespan Considerations for the Older Adult Patient, Diuretic
Therapy, p. 460
o Patient-Centered Care: Patient Teaching, p. 462
 Evidence-Based Practice
o Potassium-Sparing Diuretics, p. 456
 Safety
o Overview, p. 452
o Patient-Centered Care: Lifespan Considerations for the Older Adult Patient, Diuretic
Therapy, p. 460
o Implementation, p. 461

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CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens JR: Concepts
in nursing practice, St Louis, 2013, Elsevier. The specific exemplars chosen and listed below for each
concept have been tailored specifically to correspond to the Lilley textbook.

THEME: Homeostasis and Regulation

 Concept: Fluid and Electrolyte Balance
o Exemplar: Overview, p. 452
o Exemplar: Pharmacology Overview, p. 462
o Exemplar: Loop Diuretics, p. 454
o Exemplar: Osmotic Diuretics, p. 455
o Exemplar: Potassium-Sparing Diuretics, p. 456
o Exemplar: Patient-Centered Care: Lifespan Considerations for the Pediatric Patient, p.
456
o Exemplar: Thiazides and Thiazide-Like Diuretics, p. 458
o Exemplar: Assessment, p. 459
o Exemplar: Patient-Centered Care: Lifespan Considerations for the Older Adult Patient, p.
460
o Exemplar: Nursing Diagnoses, p. 461
o Exemplar: Planning: Outcome Identification, p. 461
o Exemplar: Implementation, p. 461
o Exemplar: Evaluation, p. 461
o Exemplar: Patient-Centered Care: Patient Teaching, p. 462
 Concept: Nutrition
o Exemplar: Thiazides and Thiazide-Like Diuretics, p. 458
o Exemplar: Patient-Centered Care: Patient Teaching, p. 462
 Concept: Elimination
o Exemplar: Overview, p. 452
o Exemplar: Carbonic Anhydrase Inhibitors, p. 453
o Exemplar: Osmotic Diuretics, p. 455
o Exemplar: Potassium-Sparing Diuretics, p. 456
o Exemplar: Assessment, p. 459

THEME: Sexual/Reproductive
 Concept: Reproduction
o Exemplar: Carbonic Anhydrase Inhibitors, p. 453
o Exemplar: Loop Diuretics, p.454
o Exemplar: Osmotic Diuretics, p. 455
o Exemplar: Potassium-Sparing Diuretics, p. 456
o Exemplar: Thiazides and Thiazide-Like Diuretics, p.458
 Concept: Sexuality
o Exemplar: Thiazides and Thiazide-Like Diuretics, p. 458

THEME: Comfort
 Concept: Fatigue
o Exemplar: Carbonic Anhydrase Inhibitors, p. 453

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______________________________

Chapter 28| Diuretic Drugs 3

o Exemplar: Patient-Centered Care: Lifespan Considerations for the Pediatric Patient, p.
456
o Exemplar: Thiazides and Thiazide-Like Diuretics, p. 458
o Exemplar: Patient-Centered Care: Lifespan Considerations for the Older Adult Patient, p.
460
o Exemplar: Implementation, p. 461
o Exemplar: Evaluation, p. 461
o Exemplar: Patient-Centered Care: Patient Teaching, p. 462
 Concept: Nausea/Vomiting
o Exemplar: Carbonic Anhydrase Inhibitors, p. 453
o Exemplar: Thiazides and Thiazide-Like Diuretics, p. 458
o Exemplar: Implementation, p. 461
o Exemplar: Evaluation, p. 461
o Exemplar: Patient-Centered Care: Patient Teaching, p. 462
o Exemplar: Table 28-2: Loop Diuretics: Common Adverse Effects, p. 454
o Exemplar: Table 28-4: Potassium-Sparing Diuretics: Common Adverse Effects, p. 457
o Exemplar: Table 28-5: Thiazides and Thiazide-Like Diuretics: Potential Adverse Effects, p.
458

BSN ESSENTIALS
 Essential III: Scholarship for Evidence-Based Practice
o Potassium-Sparing Diuretics, p. 456

STUDENT CHAPTER RESOURCES

Chap. PREPARE FOR CLASS, CLINICAL, OR LABORATORY
28 READ – Textbook (pp. 451-463)

REVIEW – Evolve Resources

 Animations
o Diuretics
o Furosemide
 Key Points—Downloadable
 Textbook Case Studies Answer Key
 Textbook Critical Thinking and Prioritization Questions Answer Key

PREPARE FOR EXAMINATIONS

 Chapter 28 Review Questions—Preparation for NCLEX® Examination

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4 Chapter 28|Diuretic Drugs______________________________

INSTRUCTOR CHAPTER RESOURCES

TB TESTING RESOURCES – Test Bank
 Test Bank – Chapter 28
 To access the ExamView format, go to the Downloads section.

PPT TEACHING RESOURCES – Chapter 28: Diuretic Drugs

IC TEACHING RESOURCES – Image Collection

 Figure 28-1. The nephron and diuretic sites of action.

ETC. TEACHING RESOURCES – Chapter 28: Answer Keys—Critical Thinking and Prioritization
Questions (also available to students)

TEACHING RESOURCES – Chapter 28: Answer Keys—Textbook Case Studies (also available to
students)

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______________________________
Chapter 28| Diuretic Drugs 5
TEACHING STRATEGIES
CONTENT FOCUS CONTENT HIGHLIGHTS
OVERVIEW Review with students the flow of urine
through the nephron.
Emphasize the importance of the
glomerular filtration rate (GFR) and the
significance of the afferent and efferent
arterioles and what causes them to
vasodilate (prostaglandins) and
vasoconstrict (angiotensin II).
Review the site of action of each of the
diuretics within the nephron. Help
students understand that the site of
action affects the amount of diuresis.
PHARMACOLOGY The sites of action of the various
OVERVIEW diuretics are determined by the way in
which they affect the various solute
CARBONIC (electrolyte) and water transport
ANHYDRASE systems located along the nephron.
INHIBITORS
Carbonic anhydrase inhibitors (CAIs) are
Mechanism of Action chemical derivatives of sulfonamide
and Drug Effects antibiotics. CAIs inhibit the activity of
the enzyme carbonic anhydrase, which is
Indications found in the kidneys, eyes, and other
parts of the body. CAIs are used
Contraindications primarily for glaucoma.
Adverse Effects Loop diuretics have renal,
cardiovascular, and metabolic effects.
Interactions These drugs act primarily along the thick
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LEARNING ACTIVITIES
 Discussion: Using Figure 28-1 or
another diagram of the
nephron, have different
students point out the site of
action of the main types of
diuretic drugs. Cite examples of
each type of diuretic.
 Reflection: Have students
consider all the safety
implications for patients taking
diuretics. Write the list on the
board, and when the chapter
content is over, ask for
additional thoughts on safety
concerns.
 Medication Administration
Error Prevention: Emphasize
the potential confusion
between bumetanide (Bumex)
and buprenorphine (Buprenex).
Also similar names with
furosemide (Lasix) with
torsemide (Demadex).
 Small Group Activity: Have
students work together making
a concept map with potassium
as the central theme. They
could be given the following
subconcepts to include on the
concept map as they relate to
K+:
 Classes of diuretics
 S/S hypokalemia and
hyperkalemia including
cardiac rhythm
disturbances
 Food sources to be
encouraged or limited
 Relationship to sodium
 Relationships evident
Lilley
6 Chapter 28|Diuretic Drugs______________________________
ascending limb of the loop of Henle,
Dosages blocking chloride and, secondarily,
sodium resorption. They are also
Drug Profile thought to activate renal prostaglandins,
which results in dilatation of the blood
LOOP DIURETICS vessels of the kidneys, the lungs, and the
rest of the body (i.e., reduction in renal,
Mechanism of Action pulmonary, and systemic vascular
and Drug Effects resistance).
Indications Loop diuretics are particularly useful
when rapid diuresis is needed because
Contraindications of their rapid onset of action.
Adverse Effects Loop diuretics are used to manage the
edema associated with heart failure and
Toxicity and hepatic or renal disease, to control
Management of hypertension, and to increase the renal
Overdose excretion of calcium in patients with
hypercalcemia.
Interactions
Mannitol, an osmotic diuretic, works
Dosages along the entire nephron. Its major site
of action, however, is the proximal
Drug Profile tubule and descending limb of the loop
of Henle. Because it is nonabsorbable, it
OSMOTIC DIURETICS increases osmotic pressure in the
glomerular filtrate, which in turn pulls
Mechanism of Action fluid, primarily water, into the renal
and Drug Effects tubules from the surrounding tissues.
This process also inhibits the tubular
Indications resorption of water and solutes, which
produces a rapid diuresis. Ultimately,
Contraindications this reduces cellular edema and
increases urine production, causing
Adverse Effects diuresis. Mannitol can be used to treat
cerebral edema.
Interactions
The currently available potassium-
Dosages sparing diuretics are amiloride,
spironolactone, and triamterene.
Drug Profile Spironolactone and triamterene are
used to treat hyperaldosteronism and
POTASSIUM-SPARING hypertension and to reverse the
DIURETICS potassium loss caused by the potassium
wasting.
Mechanism of Action
and Drug Effects The thiazide diuretics include
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between all concepts using
arrows and a few words
written on the lines
demonstrating what the
connections are
 Teaching implications
 Prevent Medication Error:
Discuss with students the
dosage differences between the
two loop diuretics, furosemide
(Lasix) and bumetanide
(Bumex). (40 mg of Lasix = 1 mg
of Bumex.)
 Discussion: Lead a discussion
about potassium. Investigate its
role in the body and how it is
obtained and excreted. You may
even want to bring in a few
foods that are high in potassium
for emphasis (including salt
substitutes). Make sure to
compare the diuretics that
cause the body to lose
potassium and the potassium-
sparing diuretics. How do their
mechanisms of action differ?
 Discussion: Discuss the various
uses of the drugs acetazolamide
and mannitol. Point out the
various indications for these
drugs.
 Discussion: Be sure to
differentiate the signs and
symptoms of hyperkalemia and
hypokalemia. Have the class
note which classes of diuretics
can cause each condition.
 Discussion: Ask the class, “Why
is it dangerous to administer
both a potassium supplement
and drugs such as
spironolactone or an
angiotensin-converting enzyme
(ACE) inhibitor?”
(Spironolactone is a potassium-
sparing diuretic. If it is given
with a potassium supplement,
Lilley
______________________________

Chapter 28| Diuretic Drugs 7

chlorothiazide and hydrochlorothiazide. the patient could develop
Indications The thiazide and thiazide-like diuretics hyperkalemia, which could
are used in the treatment of edema of cause cardiac irregularities, and,
Contraindications various origins, idiopathic hypercalciuria, if potassium levels are severely
and diabetes insipidus, in addition to high, cardiac arrest could occur.
Adverse Effects hypertension. They are also used as The ACE Inhibitors block the
adjunct drugs in the management of release of aldosterone; Na and
Interactions heart failure and hepatic cirrhosis. water are therefore eliminated.
When Na++ goes, K+ stays.)
Dosages  Discussion: Ask the students to
explain why it could be a good
Drug Profiles treatment plan to have a
hypertensive older adult
THIAZIDES AND woman with osteoporosis on a
THIAZIDE-LIKE thiazide diuretic. (Causes
DIURETICS calcium retention.)
 Pose a question: Ask the
Mechanism of Action students their concerns about
and Drug Effects placing a patient with diabetes
on a thiazide diuretic. (Thiazides
Indications can increase blood sugar levels.)

Contraindications

Adverse Effects

Toxicity and
Management of
Overdose

Interactions

Dosages

Drug Profiles

NURSING PROCESS  Small Group Activity: Divide

the class into small groups and
Assessment have each develop and present
to the class a teaching plan for
Nursing Diagnoses the following patients:
 Mrs. S., age 82 years,
Planning: Outcome who takes furosemide daily
Identification as part of her treatment for
heart failure. She complains

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8 Chapter 28|Diuretic Drugs______________________________

Implementation of dizziness upon standing.

 Mrs. E., age 64 years,
Evaluation who has diabetes and is
now taking metolazone for
hypertension.
 Mr. K, who is taking
metolazone (Zaroxolyn) for
his essential hypertension.
He’s also taking digoxin and
allergic to trimethoprim–
sulfamethoxazole (Bactrim).
 Mrs. W., who is worried
about losing potassium
while taking bumetanide.
She asks you about ways to
increase her intake of
potassium and what signs to
look for if her potassium
“goes too low.”
 Mr. M, who has a
cerebral bleed: the
indications. safety
precautions (filter,
crystallization), and
expected outcome of
receiving mannitol.
Have students exchange case
studies and develop: (1) nursing
diagnoses, (2) goals, and (3)
outcome criteria for the mini
cases described above.

IN-CLASS/ONLINE CASE STUDY

S.W. is seeing her nurse practitioner today for a follow-up appointment. Two weeks ago, S.W. was seen
for complaints of occasional headaches. On that visit, S.W.’s blood pressure was 160/110 mm Hg. S.W.
has been monitoring her blood pressure for the past 2 weeks, and it has remained at 150/100 mm Hg or
higher. S.W. is not overweight, does not smoke, and walks for exercise at least three times per week. The
nurse practitioner decides to start S.W. on therapy with spironolactone (Aldactone) daily to control S.W.’s
hypertension.

1. What is the role of spironolactone in the treatment of hypertension?

Answer: Spironolactone is a potassium-sparing diuretic that competitively binds to aldosterone

receptors and therefore blocks the resorption of sodium and water that is induced by aldosterone
secretion. This reduces extracellular fluid volume, plasma volume, and cardiac output, which causes a
decrease in blood pressure.

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______________________________

Chapter 28| Diuretic Drugs 9

Rationale: It is important to understand the role a medication plays in the treatment of a disease or
disorder.

2. The patient asks the nurse what diet changes, if any, she will need to make. How will the nurse
respond?

Answer: The nurse will tell S.W. that she will need to limit her intake of potassium or keep her intake of
potassium consistent because this medication can cause a rise in serum potassium. Foods high in
potassium include bananas, oranges, apricots, dates, raisins, broccoli, green beans, potatoes, tomatoes,
meats, fish, wheat bread, and legumes. The nurse will also tell S.W. not to use a potassium-containing
salt substitute while she is taking spironolactone.

Rationale: With potassium-sparing diuretics, potassium is reabsorbed and not excreted, so hyperkalemia
may become problematic.

3. As the patient is leaving the office, the nurse overhears her talking on the phone. She says, “I’m
having terrible cramps. I can’t wait to get home and take some Tylenol.” Is any further patient
teaching necessary?

Answer: No, the patient may take acetaminophen (Tylenol) for pain relief without any drug interactions
with spironolactone. Concurrent use of nonsteroidal antiinflammatory drugs (NSAIDs), such as aspirin
and ibuprofen, will result in decreased diuretic effects and should be avoided.

Rationale: NSAIDs can inhibit renal prostaglandins, which decreases blood flow to the kidneys and
therefore decreases the delivery of diuretic drugs to this site of action. This in turn can lead to a
diminished diuretic response.

4. The patient calls into the clinic the following week and tells the nurse she is having lots of diarrhea,
and her legs are so weak that she is having trouble putting one foot in front of the other. She’s been
so irritable that her husband insisted she call in. What would the nurse suspect what occurring?

Answer: These are signs of hyperkalemia.

Rationale: Hyperkalemia can occur when taking a potassium-sparing diuretic such as spironolactone.

CHAPTER 28: ANSWER KEY TO TEXTBOOK CASE STUDIES

Note: Answers to these questions can be found on the Evolve site. Click here.

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