M.P. is an 83-year-old white female who began taking furosemide 20 mg PO twice daily approximately 2 weeks ago for peripheral edema. She is being admitted to a medical surgical floor following complaints of being exhausted and a physician diagnosis of dehydration. She has been getting up several times each night to use the bathroom. The swelling in her ankles has markedly improved; however, her laboratory values and assessment indicate the need for an admission for hydration and electrolyte balance. The physician has ordered furosemide 20 mg IV daily upon admission.
Keywords: furosemide, edema, diuretic, hypotension
Furosemide Management Plan
Furosemide is a “water pill used to reduce swelling of the body due to the accumulation of fluids in the cells caused by a wide variety of medical problems. Furosemide is commonly prescribed in patients with cardiovascular or hepatic diseases. It is a “management” drug, that is, it is not used to cure or treat a disease, only one of its symptoms (Alván, 1990, and Kee, 2012).
Furosemide Pharmacodynamics
Furosemide (C12H11ClN2O5S) is a benzoic-sulfanomide-furan loop diuretic used to manage patients with edema associated with congestive heart failure, liver cirrhosis, hepatic disease, and hypertension (Wakelkamp et al, 1999). This drug blocks the sodium-potassium-chloride cotransporter in the loop of Henle in the kidney , thus inhibiting the kidneys’ reabsorption of water (Hodgson, 2012). This makes the lumen more hypertonic and the intertitium less hypertonic altering the osmotic pressure in the nephrons (Hodgson, 2012).
Furosemide is excreted in the urine. When it action is strong, it causes the elimination of too much fluid, along with excess loss of electrolytes, especially potassium (Hodgson, 2012). Electrolyte imbalance may lead to kidney failure, thus furosemide therapy is generally supplemented with potassium chloride. Excess loss of fluid causes the patient to become dehydrated and lose weight, and become hypotensive, which may explain M.P.’s fatigue (Hodgson, 2012).
One of the side-effects of furosemide is ototoxicity; hearing is affected and the patient may become deaf (Wakelkamp et al, 1999). Other complications include weakness, dizziness, gastrointestinal problems, blurred vision, cognitive impairment, and muscle cramps (Hodgson, 2012).
Nursing Plan
The patient’s blood pressure and vital signs have to be monitored carefully. Her blood pressure should be monitored during diuresis and when determining the proper dose for the patient. The patient should be evaluated for any signs of electrolyte imbalance and should this occur it should be immediately reported to the attending physician (Alván, 1990, and Kee, 2012).
Blood count, and the levels of electrolytes in the serum and urine are to be measured often. S&S of hypokalemia should also be monitored carefully, as well as the ratio and pattern of I&O, any unusual variations in its level should be recorded and reported (Alván, 1990, and Kee, 2012).
The patient should be weighed frequently for signs of excessive loss of water which may lead to too much dehydration, hypotension, hypovolemia, and impairment of the circulatory system. Furosemide may elevate blood sugar levels, thus the levels of glucose in the blood and urine should be assessed frequently (Alván, 1990, and Kee, 2012).
Determine how much salt and fluids are allowed in M.P.’s diet.She is to avoid taking large amounts of water. It is not clear whether M.P. is receiving KCl therapy, but it is recommended that the patient’s diet be supplemented with foods that are rich in potassium, like certain fruits. Question the patient to determine the presence of any warning symptoms, like muscles cramps or increased weakness; if present, report these to her physician (Alván, 1990, and Kee, 2012).
Furosemide causes hypotension; therefore, care should be taken when handling M.P. Her position in bed is to be adjusted slowly to prevent dizziness or imbalance (Alván, 1990, and Kee, 2012).
Application of the 5-Plus-5 Rights of Drug Administration
The 5-plus-5 rights in pharmacology consist of (1) the right drug, (2) right patient, (3) right dose, (4) right route, and (5) right time.
M.P. was admitted into the hospital because she was suffering from dehydration due to furosemide medication. Nevertheless, her physician prescribed furosemide 20 mg IV daily upon admission, suggesting that M.P. may be suffering from congestive heart failure and that she may have pulmonary edema. The effect of furosemide is quick removal of excess water from the lungs to reduce pulmonary edema. Therefore, furosemide was the right drug and M.P. was the right patient. M.P. is elderly and at high risk of hypotension and dehydration. Therefore, once the excess water has been eliminated from the lungs, her furosemide dosage should be adjusted down to 10 mg IV (right route) daily (right time) at the hospital; and, upon her release from the hospital, down to 10 mg PO (right route) once daily (right time), the right doses for M.P. at the hospital and at home.
M.P. should monitor her weight at home for signs of dehydration. Should she experience a sudden drop in weight, she should forego furosemide medication until she regains weight (Wakelkamp et al, 1999).
References
Alván G., Helleday L., Lindholm A., Sanz E., & Villén T. (1990) Diuretic effect and
diuretic efficiency after intravenous dosage of frusemide. Br J Clin Pharmacol.
29(2):215-9.
Hodgson,B. & Kizior, R. (2012). Nursing drug handbook. St. Louis, MO:
Saunders/Elsevier Inc.
Kee, J.L., Hayes, E.R., & McCuistion, L.E. (2012). Pharmacology: A nursing process
approach (7th ed.). St. Louis, MO: Saunders/Elsevier.
Wakelkamp M., Blechert A., Eriksson M., Gjellan K., & Graffner C. (1999). The
influence of frusemide formulation on diuretic effect and efficiency. Br J Clin
Pharmacol. 48(3), 361-6.
