Fluid/Lytes/Minerals/Renal

(General Key Points)

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Diuretics  fluid loss via urine output

 Major uses of diuretics include prevention of renal failure and

management of hypertension.

 Most diuretics work by blocking reabsorption of Na+ and Cl-; the more
ion absorption blocked, the more fluid that is lost.

 Potassium is necessary for nerve impulse conduction and regulation of

acid-base balance.

 Calcium is critical to normal metabolic processes of the heart, nerves,

muscles, bones, and coagulation.

 Mineral supplements tend to cause GI distress and should be administered

with a full glass of water or with meals.
High Ceiling Loop Diuretics

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: furosemide (Lasix) — Others: ethacrynic acid (Edcrin),
Expected Action: bumetanide (Bumex), Torsemide (Demadex)
 In  Loop of Henle to block reabsorption of Na+/Cl-/H2O  Extensive diuresis.
Therapeutic Uses:  Pulmonary edema d/t heart failure
 Works well with renal impairment  Hypercalcemia r/t stone formation
 Reserved for conditions unresponsive to other diuretics (e.g. edema d/t liver,
cardiac or renal disease; hypertension)
Adverse Effects:  Dehydration ( output < 30 mL/hr)  Hypotension
 Ototoxic – furosemide (temp); ethacrynic acid (permanent) -  other ototoxics
 Hypokalemia  Hyperglycemia, hyperuricemia,  [Ca2+], [Mg2+]
Contraindications/Precautions: ♀ (C)  Caution ĉ diabetes, gout
Interactions:  Digoxin toxicity r/t K+  NSAIDs blunt diuretic effect
 Antihypertensives – Additive hypotensive effect  [Li] d/t diuresis
Education:  Daily weights  Infuse slowly (20 mg/min)
 K+ foods (avocado, strawberry, banana, potato, spinach, tomato, meat, carrots)
  Mg2+ signs: muscle twitch and tremor
Thiazide Diuretics

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: hydrochlorothiazide (HydroDIURIL) — Others:
Expected Action: chlorothiazide (Diuril), indapamide
 In early DCT to block Na+/Cl-/H2O reabsorption – promote diuresis when renal
function is not impaired.
Therapeutic Uses:  1st choice essential hypertension
 Edema of mild-to-moderate heart failure and liver/kidney disease.
Adverse Effects:  Dehydration  Hypokalemia  Hyperglycemia
Contraindications/Precautions: ♀ (B)   breastfeeding
 Caution ĉ renal impairment – may not be effective
Interactions:  Digoxin toxicity d/t K+  Antihypertensives: Additive effect
  lithium levels  NSAIDs blunt diuretic effect
Education:  Alternate day dosing can  electrolyte imbalances
  K+ foods (avocado, strawberry, banana, potato, spinach, tomato, meat)
K+-Sparing Diuretics

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: spironolactone (Aldactone) — Others: triamterene
Expected Action: (Dyrenium), amiloride (Midamore)
 Block aldosterone action resulting in K retention and Na+/H2O excretion.
+

Therapeutic Uses:  Combined with other diuretics for K+-sparing effect

 Heart failure  Blocks aldosterone in hyperaldosteronism
Adverse Effects:  Hyperkalemia (insulin injection drives K+ back into cell)
 Endocrine effects: Irregular menses or impotence
Contraindications/Precautions: ♀ (_) 

Interactions:  ACE inhibitors (lisinopril)   hyperkalemia
 K+ supplements   hyperkalemia
Education:  Triamterene may color urine blue
Osmotic Diuretics

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: mannitol (Osmitrol) — Others: urea, glycerin, isosorbide
  blood osmolality thus attracting fluid (e.g. 3rd spacing, CSF, intraocular)
Therapeutic Uses:   ICP   intraocular pressure (IOP)
 Prevent renal failure in hypovolemic shock or severe hypotension.
 Promote Na+ retention and H2O excretion in hyponatremia and fluid V excess
Adverse Effects:  Heart failure / pulmonary edema
 Renal failure (urine < 30 mL/hr, creatinine > 1.2 mg/dL, BUN > 20 mg/dL
 Fluid and electrolyte imbalance
Contraindications/Precautions: ♀ (_) 
 Lasix complements through renal excretion of fluid drawn by osmotics.
Education:  Most effective given as a bolus  Use filter to prevent crystals
 Monitor serum osmolarity and every 6 hours / urine osmolarity daily
Phosphate Binders

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: aluminum hydroxide gel (Amphojel) — Others: calcium
Expected Action: carbonate (Tums, OsCal), aluminum carbonate gel (Basaljel)
 Bind intestinal phosphate that is excreted in the feces
Therapeutic Uses:  Antacid
  hyperphosphatemia (>4.5mg/dL) in end-stage renal disease
Adverse Effects:  Constipation  Hypophosphatemia (<3mg/dL)
Contraindications/Precautions: ♀ (_) 
 CI: hypophosphatemia / bowel obstruction / pregnant or breastfeeding
 Alter absorption of many medications. Do not administer other
Interactions:
medications concurrently with Amphojel.
Education:  Give with first bite of food to absorb phosphate in food
 Avoid  PO4 foods: (dairy, fish, pork, nuts, whole-grains)
Kayexalate

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: Sodium Polystyrene (Kayexalate)

 Promotes K+ excretion and Na+ absorption, primarily in large intestine

Therapeutic Uses:  Treat hyperkalemia

Adverse Effects:  Electrolyte (Ca2+, K+, Na+, Mg2+) imbalance

Contraindications/Precautions: ♀ (_) 
Interactions:  Ca - or Mg -containing antacids or laxatives may  efficacy
2+ 2+

 Digoxin and K+-sparing diuretics should undergo frequent K+ monitoring

Education:  Given orally or rectally  Mix with juice
 Retain enema for 30-60 minutes; irrigate ĉ non-Na+-containing solution
K+ Supplements

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: Potassium Chloride (K-Dur) — Others:
Expected Action: K+ gluconate, K+ phosphate, K+ bicarbonate
 K is essential for nerve conduction, muscle excitability, and acid/base balance
+

Therapeutic Uses:  Hypokalemia  K+-sparing diuretics

 K loss d/t excessive/prolonged diarrhea, vomiting, GI fistulas, drainage
+

Adverse Effects:  GI distress (take with water or meals)

 GI ulceration (do not dissolve / take with water or meals)
 Hyperkalemia (rare ĉ oral) – signs = bradycardia, hypotension, ECG Δ
Contraindications/Precautions: ♀ (_)  Severe renal disease
 Hypoaldosteronism creates risk for hyperkalemia
Interactions: 
 Concurrent use of K+-sparing diuretics (spironolactone) or ACE inhibitors
(lisinopril) increases risk of hyperkalemia.
Education:  Never give IV push  Use infusion pump
 Assess site for irritation, phlebitis, infiltration – d/c immediately if present
 Dilute to no more than 40 mEq/L || give no faster than 10 mEq/hr.
Mg2+ Sulfate

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: Mag. sulfate — Others: mag. gluconate, mag. hydroxide
 Mg activates many intracellular enzymes, helps regulate muscle contraction and
2+

blood coagulation
Therapeutic Uses:  Hypomagnesemia (< 1.3 mEq/L)
 Oral doses for mild cases / parenteral doses for severe cases.
Adverse Effects:  Neuromuscular blockade and respiratory depression (IV
 Diarrhea administration requires careful monitoring of patient.)
Contraindications/Precautions: ♀ (B) 
 Caution ĉ AV block, rectal bleeding, nausea/vomiting, abdominal pain, renal, and
cardiac disease.
Interactions:  MgSO4  absorption of tetracyclines
Education:  Monitor serum Ca2+, Mg2+, PO4-  Mg2+ WNL
 Assess for depressed or absent deep tendon reflex as a sign of  1.3-2.1
toxicity. Calcium gluconate is given for MgSO4 toxicity. mEq/L
Sodium Bicarbonate

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: Sodium Bicarbonate
 Systemic alkalinizer used to correct metabolic acidosis (pH < 7.35)
Therapeutic Uses:  Acidosis d/t diabetes, cardiac arrest, or vascular collapse
 Given orally as an antacid  Raise urinary pH to enhance renal excretion
 Raise urinary pH to enhance renal excretion in salicylate overdose
Adverse Effects:  Na+ overload (>145 mEq/L)  Renal calculi (> 1500 cc/day)
 Alkalosis (pH > 7.45) (tachycardia, irritability, twitching)
Contraindications/Precautions: ♀ (_)  Unsuitable as antacid b/c short-acting
 Caution ĉ hypertension, ♥ failure, kidney disease
Interactions:  Corticosteroids   K+,  Na+  Many IV incompatibilities
 Pseudoephedrine, quinidine   effects of these
 Lithium, salicylates, benzodiazepines   effects of these
Education:  Confirm acidosis by ABG
Calcium Supplements

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: Calcium citrate — Others: Ca2+ carbonate, Ca2+ acetate
 Required for normal musculoskeletal, neurological, and cardiovascular function
Therapeutic Uses: 
 Hypocalcemia or deficiencies of PTH, vitamin D, or dietary calcium
Adverse Effects: 
 Hypercalcemia – tachycardia,  BP, muscle weakness, constipation.
Contraindications/Precautions: ♀ (_) 
 CI: hypercalcemia, bone tumors, and hyperparathyroidism
Interactions:  Glucocorticoids  Ca2+absorption 
  absorption of Tetracyclines, thyroxine  Thiazides   hypercalcemia
 IV Ca2+ precipitates with phosphates, carbonates, sulfates, and tartrates
 Digoxin + IV Ca2+  severe bradycardia
Education:  IV injections at 0.5-2 mL/min  Ca2+ WNL = 9-10.5 mg/dL
Selective Estrogen Receptor
Modifiers

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: raloxifene (Evista)— Others: tamoxifen citrate (Nolvadex)

 Endogenous estrogen in bone, lipid metabolism, and blood coagulation

  osteoclast activity   bone resorption.   plasma cholesterol
 Antagonist to estrogen on breast and endometrial tissue
Therapeutic Uses:  Postmenopausal osteoporosis   risk of breast cancer
Adverse Effects:  Hot flashes   risk of PE and DVT  Keep active
Contraindications/Precautions: ♀ (X)  CI: Hx of venous thromboses
Interactions:  None
 Sufficient calcium / vitamin D to PTH release Ca2+ WNL
Education:
and   Ca2+ release from bones 9-10.5 mg/dL
Bisphosphonates

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 Proto: alendronate (Fosamax)
Expected Action: Others: ibandronate (Boniva), risedronate (Actonel)
  number and action of osteoclasts   bone resorption
Therapeutic Uses:  ♂/♀ osteoporosis 
 Paget’s disease and hypercalcemia of malignancy
Adverse Effects:  Esophagitis  full glass of H2O and upright for 30 min
  risk for hyperparathyroidism @  doses in Paget’s disease
Contraindications/Precautions: ♀ (C)  CI: Esophageal disorders, GERD
Interactions: 
 Ca2+supplements, antacids, OJ, & caffeine all  alendronate absorption
Education:  Take first thing in AM, with  H2O
 Sufficient Ca2+ / vitamin D to PTH release and   Ca2+ release from bones
 Encourage weight-bearing exercise (30-40 min/day)
Calcitonin – Salmon

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
Expected Action: Proto: calcitonin salmon (Fortical, Miacalcin)

  osteoclasts bone resorption   tubular resorption of calcium

Therapeutic Uses:  Postmenopausal osteoporosis and Paget’s disease
 Hypercalcemia due to hyperparathyroidism and cancer
Adverse Effects:  Intranasal: dryness and irritation
 IM/SC: site inflammatory response  Self-limiting nausea
Contraindications/Precautions: ♀ (C)  CI: Hypersensitivity to fish protein
Interactions:   serum lithium 
Education:  Keep container upright  Alternate nostrils daily
 Check for Chvostek’s or Trousseau’s signs for hypocalcemia
 Sufficient Ca2+ / vitamin D to PTH release and   Ca2+ release from bones
Normal Lab Values

N203
ATI (Unit 9)
Fluids/Lytes/Minerals/Renal -
 RBC=4.7-6.1 x 1012/L  WBC = 5-10 x 109/L  PLT = 150-400 x 109/L
 PO2=75-100 mm Hg  PCO2=34-45 mm Hg  pH = 7.35-7.45

 Hgb=14-18 g/dL  Hct=42-52%  PT=11-12.5 s  PTT=60-70 s

 Na+=135-145 mEq/L  Cl-=100-108 mEq/L  Ca2+=9-10.5 mg/dL

 K+=3.5-5 mEq/L  PO43-=3-4.5 mg/dL  Mg2+=1.6-2.6 mg/dL

  

 Prot=6-8 g/dL  Creatinine=0.6-1.5 mg/dL  BUN=3.6-7.1 mmol/L

Neu=55-70% Lym=20-40% Mon=2-8% Eos=1-4%
(2,500-8,000) (1,000-4,000) (100-700) (50-500)
