Furosemide Nursing Implications
Furosemide Nursing Pharmacology
Furosemide is a prescription drug that belongs to the loop diuretics class and works on the kidneys to remove extra fluid in the body. It allows too much salt to pass into the urine rather than being absorbed in the body.
Furosemide is used in both pediatric and adult patients safely and effectively.
Indications of Furosemide
- Edema. Furosemide is prescribed to treat edema, a condition in which excess fluid is retained in the tissues as a result of a variety of medical conditions. These include congestive heart failure, cirrhosis of the liver, and kidney disease. If a rapid onset of fluid excretion is required in cases of acute pulmonary edema, furosemide is administered intravenously as a part of the treatment.
- Hypertension. Furosemide is given to patients who have mild to moderate hypertension. Furosemide can be used in combination with other antihypertensive medications and other regimens for severe high blood pressure, such as a low salt diet, keeping an ideal body weight, regular exercise, and smoking and drinking alcohol cessation.
Mechanism of Action of Furosemide
Furosemide promotes fluid excretion by inhibiting sodium and chloride reabsorption in the distal and proximal tubules, as well as the thick ascending loop of Henle.
This diuretic effect is obtained by competitively inhibiting NKCC2 or sodium-potassium-chloride cotransporters, which are found along these tubules in the nephron, preventing sodium ion transport from the lumenal corner to the basolateral part for reabsorption.
This reduction influences the frequency of water excretion as well as the excretion of other substances such as sodium, chloride, magnesium, calcium, hydrogen, and potassium ions.
Furosemide has direct vasodilatory outcomes, which contribute to its response in patients with acute pulmonary edema.
Vasodilation decreases the ability to respond to vasoconstrictors like angiotensin II and noradrenaline, as well as the secretion of endogenous natriuretic hormones with vasoconstricting components. It also causes an increase in the supply of vasodilating prostaglandins.
Furosemide may also expand potassium channels in resistance arteries. Furosemide’s main mode of action is distinct from its carbonic anhydrase and aldosterone inhibition action.
Pharmacokinetics of Furosemide
- Absorption. Furosemide is absorbed from the gastrointestinal passageway after oral administration. Furosemide has a changeable bioavailability from oral route forms ranging from 10 to 90 percent. Furosemide’s oral solubility from oral forms, whether tablet or solution is approximately 64 percent and 60 percent, including both, of that from an intravenous infusion of the medication.
- The volume of distribution. The volume of distribution after intravenous infusion of 40 mg furosemide was 0.181 L/kg in healthy individuals and 0.140 L/kg in patients with heart failure.
- Protein binding. In healthy people, plasma concentrations ranging from 1 to 400 mcg/mL are about 91-99 percent stable. At therapeutic levels, the unbound fraction is approximately 2.3-4.1 percent. Furosemide primarily binds to serum albumin.
- Metabolism. Furosemide is primarily metabolized in the kidneys and, to a lesser degree, the liver. The kidneys are responsible for approximately 85 percent of the overall furosemide clearance, with nearly 40 percent involving biotransformation.
- Elimination. The kidneys work for 85 percent of total furosemide elimination, with about 43 percent of the drug excreted in the urine. A remarkably greater amount of furosemide is eliminated in urine after intravenous administration rather than a tablet or oral solution. Roughly half of the furosemide amount is eliminated consistently in the urine, with the remainder being metabolized in and out of glucuronide in the kidney.
- Half-life. The half-life of 40 mg furosemide was 4 hours after oral ingestion and 4.5 hours after intravenous infusion. Furosemide has a terminal half-life of about 2 hours after intravenous administration. In patients with chronic kidney failure, the terminal half-life can be accelerated to 24 hours.
- Clearance. After the intravenous injection of 400 mg furosemide, plasma clearance was 1.23 mL/kg/min among heart failure patients and 2.34 mL/kg/min in healthy individuals.
Side Effects of Furosemide
These side effects are minor, they should subside in a couple of days or weeks. Consult your doctor if they become more serious or do not go away. These symptoms are:
- abdominal cramps
- blurring of vision
- urinary frequency
Furosemide may dehydrate the patient and this could lead to electrolyte imbalances. If the patient experiences excess loss of water and electrolytes, contact the doctor immediately. Symptoms include:
- dry mouth
- feeling thirsty
- body weakness
- muscular pain or cramping
- decrease in the amount of urine
- severe nausea or vomiting
If the patient is experiencing symptoms of an allergic reaction to furosemide, seek immediate medical attention. The following are the symptoms:
- sore throat
- difficulty of breathing
- swelling of face
- red or purple skin rash that expands and may cause blistering and peeling of the skin
Adverse Reactions to Furosemide
- Gastrointestinal system: pancreatitis, jaundice, elevated liver enzymes, anorexia, stomach cramps, diarrhea, constipation, nausea, vomiting.
- Systemic hypersensitivity reactions: Severe anaphylactic reaction, vasculitis, nephritis, necrotizing angiitis.
- Nervous system: dizziness, headache, paresthesias, vertigo, blurring of vision, xanthopsia.
- Hematologic disorder: anemia, aplastic anemia, eosinophilia, thrombocytopenia, agranulocytosis, eosinophilia, hemolytic anemia.
- Dermatologic reactions: steven-johnsons syndrome, erythema multiforme, exfoliative dermatitis, bullous pemphigoid, pruritus, urticaria, photosensitivity, rashes.
- Cardiovascular system: orthostatic hypotension, hyperlipidemia.
- Renal disorder: acute kidney injury secondary to fluid loss
- Metabolic disorders: hyperglycemia, hyperuricemia, hypokalemia, hypomagnesemia.
Contraindications of Furosemide
- Furosemide is not recommended for patients who have a known allergy to furosemide or who have anuria.
- Furosemide can cause ototoxicity. Using a higher than the recommended dose of furosemide or infusing the drug at a rapid rate predisposes patients to an increased risk of reversible or irreversible hearing impairment.
- If furosemide is administered prior to contrast administration, high-risk patients for radiocontrast-induced nephropathy tend to have worsened kidney function than high-risk patients who receive mild hydration before administering contrast.
- A large amount of furosemide, decreased oral potassium intake in patients with hyperaldosteronism states (liver disorders or licorice ingestion), or concurrent usage of corticosteroids, ACTH, and laxatives all increase the risk of hypokalemia.
- At high doses, more than 80 mg per day, furosemide prevents the binding of thyroid hormone to thyroid binding protein, resulting in a temporary rise in the level of thyroid hormones and a slight reduction in total thyroid hormone.
Cautions on Furosemide
- Patients with a history of urinary retention, such as benign prostatic hyperplasia, neurogenic bladder with abnormal bladder evacuation, or urethral and ureteral constrictions, should be closely watched during the first few days of furosemide therapies. Following that, they must be monitored for exacerbations because too much diuresis and holding of urine can cause acute urinary retention, which can result in acute kidney injury.
- Oliguria, azotemia, and volume level should be constantly supervised in patients with advanced kidney impairment and fluid overload. Furosemide should be stopped if either oliguria or azotemia develops to avoid kidney damage.
- Patients with pre-existing liver disease, particularly chronic liver disease, should be treated with caution because sudden electrolyte imbalance caused by furosemide use can result in hepatic encephalopathy and hepatic coma. Furosemide should be avoided in patients with hepatic coma until the patient’s mental state gets better.
- Use furosemide with caution because it is a potent diuretic that can cause severe loss of water and electrolytes, leading to dehydration with electrolyte imbalance.
- To prevent possible adverse effects of causing hyponatremia by inciting or aggravating syndrome of inappropriate antidiuretic hormone secretion (SIADH), caution is required when giving diuretics to patients 65 years and older; therefore, constant supervision of serum sodium is recommended at the start or even during dose adjustment in older adults.
Interactions with Furosemide
- Albuterol. The combination of furosemide and albuterol may develop the risk of hypokalemia, or a low level of potassium in the blood. Hypokalemia can cause muscle weakness, paralysis, breathing and swallowing problems (because of muscle paralysis), and irregular heart rate in serious conditions.
- Beta-blockers. The combination of furosemide and beta-blocker may reduce blood pressure and decrease heart rate. This can cause dizziness or the feeling of passing out, as well as loss of strength, lightheadedness, rapid or infrequent heartbeats, and reduced blood glucose control.
- ACE Inhibitors. Although furosemide and ACE inhibitors are commonly combined, their risks of reducing blood pressure may be additive. To take both medications safely, the doctor may need to adjust the dose or the patient needs to undergo special tests.
- Antidiabetics. Combining furosemide with diabetes medications may lead to increasing its effects, potentially leading to lactic acidosis, a possibly fatal condition that causes weakness, increased sleepiness, a decline in heart rate, muscle aches, breathlessness, upset stomach, experiencing light-headed, and fainting.
- Proton pump inhibitors. Prolonged use of proton pump inhibitors can occasionally result in hypomagnesemia (low levels of magnesium in the blood), and the probability is increased when combined with other medicines that have this effect, such as furosemide. Hypomagnesemia can cause abnormal heart rhythm, irregular heartbeats, muscle spasms, tremors, and seizures in serious forms. An abnormal heart rhythm in children can cause fatigue, stomachache, drowsiness, and lightheadedness.
- Corticosteroids. Taking furosemide and corticosteroids together may induce muscle aches or cramps, lack of appetite, loss of strength, drowsiness, or confusion.
Nursing Considerations for Patients on Furosemide
- Before, during, and after furosemide administration, check the patient’s blood pressure and pulse rate and monitor closely. Notify the doctor if there are any signs of hypotension, an irregular heart rhythm, or a low heart rate.
- If the patient has high blood pressure, tell them to take this medication even if they feel fine.
- Record to track intermittent therapy. Give the medication as soon as possible so that increased urination does not disrupt sleep. To avoid gastrointestinal upset, take it with food or meals.
- Evaluate digoxin patients for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Because of the diuretic’s potassium-depleting effect, patients taking digoxin are at a higher risk of digoxin toxicity.
- Check for tinnitus and hearing loss in the patient. Audiometry is advised for patients receiving large-dose IV therapy for an extended period of time. Hearing loss is more common in patients with impaired kidney function or those taking other ototoxic medication after fast or high-dose IV administration.
- Throughout therapy, evaluate the patient for skin rashes on a regular basis. Stop furosemide at the first sign of a rash and inform the doctor immediately.
- If the patient is scheduled for surgery, advise them to inform the doctor that they are taking furosemide.
- If the patient forgets to take a dose, instruct them to take it as soon as they remember. If the next dose is approaching, skip the missed dose and continue with the regular dosing schedule. Do not double the dose to make up for a skipped one.
Nursing Care Plan for Patients on Furosemide
Possible Furosemide Nursing Diagnosis
- Risk for Deficient Fluid Volume related to the possible side effect of furosemide
- Risk for Impaired Bowel Elimination ( Diarrhea or Constipation) related to the possible side effect of furosemide
- Risk for Electrolyte Imbalance (Hypokalemia) related to the mechanism of action of furosemide
- Risk for Injury related to the possible central nervous system (CNS) side effects of furosemide
|Furosemide Nursing Interventions||Rationale|
|Assess the patient for signs and symptoms of edema and/or hypertension.||To confirm the indication for administering furosemide.|
|Assess if the patient has any of the following conditions: |
|Furosemide is generally contraindicated in patients in patients with the said conditions as furosemide may worsen them.|
|Check the patient’s allergy status.||Previous allergic reactions to furosemide may render the patient unable to take it. Alternatives to furosemide should therefore be considered in case of allergy.|
|Assess if the patient is pregnant or lactating.||Pregnant and lactating/ breastfeeeding women are not recommended to take furosemide as this drug is under pregnancy category C and may be harmful for both the mother and baby. However, furosemide may be prescribed by a doctor if the benefits outweigh the risks, such as in the case of chronic hypertension which is deemed detrimental to a pregnant woman’s condition. Lactating women may take furosemide but must be aware that the drug may cause a reduction in breastmilk production.|
|Assess the areas of the body where edema is present.||To confirm the indication for administering furosemide and to establish baseline information about the edematous area/s of the body. These observations can be used to check the effectiveness of furosemide therapy after a few days or so of treatment.|
|Assess the patient’s mucous membranes and his/her ability to swallow. If giving the drug intravenously, assess the venous access of the patient.||To check for any potential problems with administration, hydration, and absorption.|
To ensure that the right form of the drug is given.
|Assess the patient’s vital signs, particularly the blood pressure. Obtain a baseline weight prior to starting furosemide therapy.||Furosemide works by reducing blood pressure levels and edema. The goal of furosemide treatment is to control hypertension and/or to resolve weight gain due to edema or swelling.|
Nursing Planning and Intervention
|Furosemide Nursing Interventions||Rationale|
|Administer furosemide with or without meals, ideally at the same time each day during waking hours.||To ensure optimal absorption and therapeutic action of furosemide, as well as to reduce possible side effects. Taking furosemide with meals during nighttime may cause the patient to have more trips to the bathroom to urinate and disrupt his/her sleep.|
|Swallow the tablet whole. If unable to swallow, furosemide can be crushed and dispersed in water.||Furosemide can be crushed for patients with difficulty of swallowing known as dysphagia. Crushing the tablet will not affect its effectiveness or potency.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking furosemide. Instruct the patient on how to self-administer furosemide.||To inform the patient on the basic information on furosemide, as well as to empower him/her to safely self-administer the medication.|
|Instruct the patient to slowly get out of bed, keeping their feet on the floor for a few minutes prior to standing. Obtain both lying and standing blood pressure levels at least once a day.||It is important to let the patient know about the possibility of dizziness, lightheadedness, and fainting if they stand up too quickly from a lying position while taking furosemide, a condition known as orthostatic hypotension. This is more common when starting furosemide for the first time.|
|Advise the patient to minimize unnecessary sun exposure for a lengthy time and to wear protective clothing, sunglasses, and sun protection.||Furosemide may make the skin photosensitive.|
|Instruct the patient to keep this medication in the appropriate containers, firmly sealed, and away from the reach of children. Place it at room temperature and away from sources of extreme temperatures and moisture.||To promote patient and family safety, as well as to ensure proper storage of the drug to maintain its efficacy.|
|Furosemide Nursing Interventions||Rationale|
|Ask the patient to repeat the information about furosemide.||To evaluate the effectiveness of health teaching on furosemide.|
|Monitor the patient’s blood pressure level and weight.||To ensure that furosemide did not cause any hypotension and to check if the weight is in the ideal target range.|
|Evaluate the patient’s fluid status. Keep track of the daily weight, intake and output ratios, edema amount and location, lung sounds, skin turgor, and mucous membranes. Report any decreases or unexpected increases in output.||Too much diuresis can cause dehydration and hypovolemia, as well as hypoperfusion and hypotension. It is important to notify the doctor f the patient’s complaints of thirst, dry mouth, lethargy, and weakness.|
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Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
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