Drugs acting on Autonomic Nervous System

Autonomic nervous system controls involuntary activities of smooth muscle, secretory glands and the visceral organs of the body such as the heart (involuntary activities of smooth muscle). The autonomic system (ANS) regulates the everyday requirements of vital body functions without the conscious participation of the mind. Sympathetic System  Fight or Flight – stimulated by physical or emotional stress (exercise or work), pain, hemorrhage, intense emotions, temperature extremes Protective mechanisms designed to help person cope with the stress or get away from it. Activates and prepares the body for vigorous muscular activity, stress, and emergencies.

The two systems generally act in opposition to each other. For example, a stimulation by the sympathetic system on the heart would increase contractions, while a stimulation by the parasympathetic system would decrease heart contractions. Where dual control of an organ exists, both systems operate simultaneously although one may be operating at a higher level of activity than the other. The operation is similar to the operation of a car with both the accelerator and brake pedals depressed. The Autonomic drugs mimic, intensify, or block the effects of the parasympathetic and sympathetic divisions of the autonomic nervous system. They are divided into the following groups: I. Cholinergic Agonists II. Cholinergic Antagonists III. Adrenergic Agonists IV. Adrenergic Antagonists

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Parasympathetic System     Rest and Digest Save energy Decreased heart rate Lowers the activity, operates during normal situations, permits digestion, and conservation of energy.

I. Cholinergic Agents     Drugs that stimulate the parasympathetic nervous system (PSNS) The PSNS is the opposing system to the SNS Also known ascholinergic agonists or parasympathomimetics Mimic the effects of the PSNS neurotransmitter Acetylcholine (ACh)

In Summary : The somatic nervous system controls functions that are under conscious voluntary control such as skeletal muscles and sensory neurons of the skin. The autonomic nervous system, mostly motor nerves, controls functions of involuntary smooth muscles, cardiac muscles, and glands. The autonomic nervous system provides almost every organ with a double set of nerves - the sympathetic and parasympathetic. These systems generally but not always work in opposition to each other. The sympathetic system activates and prepares the body for vigorous muscular activity, stress, and emergencies. While the parasympathetic system lowers activity, operates during normal situations, permits digestion, and conservation of energy.

Drug Effects of Cholinergic Agents “SLUDGE” – Salivation, Lacrimation, Urinary incontinence, Diarrhea, Gastrointestinal cramps, Emesis           Stimulate intestine and bladder Stimulate pupil Increased salivation and sweating Cardiovascular effects Respiratory effects Cholinergic Agents:Therapeutic Uses Treatment of urinary retention and abdominal retention Miosis during ocular surgery Reduce intraocular pressure in open angle and narrow angle glaucoma Treat myasthenia gravis

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sweating. salivation. not for a cure. Monitor for side effects. presence of GI or GU obstructions.  When donepezil is prescribed for Alzheimer’s disease.  The doses should be spread evenly apart to optimize the effects of the medication. Patients should notify their physician if they experience muscle weakness. convulsions  Gastrointestinal: -Abdominal cramps.   Relaxes sphincters in bladder and GI tract. look for:    Increased bowel sounds Passage of flatus Occurrence of bowel movements In patients with urinary retention/hypotonic bladder. asthma. allowing them to empty Used in the treatment of mild to moderate Alzheimer’s disease. nausea. abdominal cramps. disorientation. bronchospasms  Other: Lacrimation. diarrhea.  Cardiovascular:             Increased respiratory Abdominal cramping secretions Bronchospasms Dysrhythmias Difficulty breathing Hypotension Nausea and vomiting Bradycardia Diarrhea Increased sweating Increase in frequency and urgency of voiding patterns Alleviated signs and symptoms of myasthenia gravis -Bradycardia. hypotension. including: Cholinergic Agents: Side Effects Side effects are a result of overstimulation of the PSNS. be honest with caregivers and patients that the drug is for management of symptoms. In postoperative patients with decreased GI peristalsis.  Assess for allergies. urination should occur within 60 minutes of bethanecol administration II. Helps to increase or maintain memory and learning capabilities   Atropine is the antidote for cholinergics. dizziness. or difficulty breathing. increased secretions.  Perform baseline assessment of VS and systems overview. Patients should not adjust the dosages unless directed by the physician.  Overdosing can cause life-threatening problems. miosis Cholinergic Agents: Nursing Implications  Keep in mind that these agents will stimulate the PSNS and mimic the action of ACh. conduction abnormalities (AV block and cardiac arrest)  CNS: -Headache. It should be available in the patient’s room for immediate use if needed.  Therapeutic effects of donepezil may not occur for up to 6 weeks. hallucinations  Gastrointestinal Relax smooth muscle tone of GI tract Decrease intestinal and gastric secretions Decrease motility and peristalsis  Eye 2 Cardiovascular Small doses: decrease heart rate Large doses: increase heart rate CNS Small doses: decrease muscle rigidity and .  Medications should be taken as ordered and not abruptly stopped. Cholinergic Antagonist Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS) Drug Effects of Cholinergic Blocking Agents   tremors Large doses: drowsiness. loss of binocular accommodation. or coronary artery disease. vomiting  Respiratory: Increased bronchial secretions.  Encourage patients with myasthenia gravis to take medication 30 minutes before eating to help improve chewing and swallowing. peptic ulcer disease.

Cholinergic Blocking Agents: Nursing Implications Anticholinergics may lead to higher risk for heat stroke due to effects on heat-regulating mechanisms. increased intraocular pressure Gastrointestinal Decreased salivation. and hard candy.Dilated pupils (mydriasis) Decreased accommodation due to paralysis of ciliary muscles (cycloplegia)  Genitourinary Relaxed detrusor muscle Increased constriction of internal sphincter Result: urinary retention  Glandular Decreased bronchial secretions. sweating  Respiratory Decreased bronchial secretions Dilated bronchial airways Cardiovascular dysrhythmias CNS irritability. CHF. restlessness. 3  . When giving ophthalmic solutions. including OTC medications. Results: Decreased secretions from nose. Blockade of PSNS results in: Decreased secretions Relaxation of smooth muscle Decreased GI motility and peristalsis  Genitourinary Relaxed detrusor muscles of the bladder Increased constriction of the internal sphincter Reflex neurogenic bladder Incontinence Cholinergic Blocking Agents: Side Effects Body System Side/Adverse Effects       Respiratory Cholinergic Blocking Agents: Nursing Implications   Keep in mind that these agents will block the action of ACh in the PSNS. hallucinations. apply pressure to the inner canthus to prevent systemic absorption. MI. Perform baseline assessment of VS and systems overview. Overdosing can cause life-threatening problems. can be handled by chewing gum. decreased visual accommodation. Cholinergic Blocking Agents: Nursing Implications Blurred vision may cause problems with driving or operating machinery. salivation. tachycardia. Medications should be taken exactly as prescribed to have the maximum therapeutic effect. presence of BPH. bronchi Relaxed smooth muscles in bronchi and bronchioles Decreased airway resistance. Increased heart rate. Patients may experience sensitivity to light and may want to wear dark glasses or sunglasses. decreased gastric secretions. hiatal hernia. pharynx. delirium Eye Dilated pupils. Assess for allergies. and GI or GU obstruction. frequent mouth care. Check with physician before taking any other medication. decreased motility Genitourinary Glandular Urinary retention Decreased sweating Decreased bronchial secretions Cholinergic Blocking Agents: Therapeutic Uses  CNS Decreased muscle rigidity and muscle tremors Parkinson’s disease Drug-induced extrapyramidal reactions  Cardiovascular Affect the heart’s conduction system Low doses: slow the heart rate High doses: block inhibitory vagal effects on the SA and AV node pacemaker cells Result: increased heart rate  Respiratory      Blocking the cholinergic stimulation of the PSNS allows unopposed action of the SNS. CNS excitation. Dry mouth may occur. Bronchodilation  Gastrointestinal PSNS controls gastric secretions and smooth muscles that produce gastric motility. glaucoma. mouth. ANTIDOTE for atropine is physostigmine salicylate (Antilirium). disorientation.

4 . vasoconstriction. hypertension or fluctuations in BP  Other: -anorexia. constipation. thus relieving conjunctival congestion.  Reduction of intraocular pressure and mydriasis (pupil dilation): treatment of open-angle glaucoma Examples: epinephrine and dipivefrin  Anorexiants: adjuncts to diet in the short-term management of obesity Examples: benzphetamine phentermine dextroamphetamine Dexedrine  Nasal decongestant: Intranasal (topical) application causes constriction of dilated arterioles and reduction of nasal blood flow. also called cardioselective sympathomimetics  Used to support the heart during cardiac failure or shock. mild tremors. inotropes). insomnia. Examples: epinephrine naphazoline phenylephrine tetrahydrozoline  Vasoactive sympathomimetics (pressors. taste changes (rare) Adrenergic Agents: Nursing Implications  Assess for allergies and history of hypertension. nervousness  Cardiovascular: -palpitations (dysrhythmias).   Teach patients to limit physical exertion. palpitations. and avoid high temperatures and strenuous exercise. restlessness. Emphasize the importance of adequate fluid and salt intake. vomiting. tachycardia. tremors. sedation or amnesia. thus decreasing congestion. or fever III. Examples: dobutamine dopamine ephedrine epinephrine fenoldopam isoproterenol methoxamine norepinephrine phenylephrine Adrenergic Agents: Side Effects  CNS: -headache. euphoria. Patients should report the following to their physician: urinary hesitancy and/or retention. cardiac dysrhythmias. stimulating alpha receptors on small arterioles. Adrenergic Agents Drugs that stimulate the sympathetic nervous system (SNS) Also known as adrenergic agonists or sympathomimetics Mimic the effects of the SNS neurotransmitters: norepinephrine (NE) and epinephrine (EPI) Drug effects of Adrenergic Agents on smooth muscles results in: Vasoconstriction of blood vessels Relaxation of GI smooth muscles Contraction of the uterus and bladder Male ejaculation Decreased insulin release Contraction of the ciliary muscles of the eye (dilated pupils) on the airways results in: Bronchodilation (relaxation of the bronchi) Uterine relaxation Glycogenolysis in the liver Adrenergic Agents: Therapeutic Uses Bronchodilators: treatment of asthma and bronchitis Agents that stimulate beta2-adrenergic receptors of bronchial smooth muscles causing relaxation Examples: albuterol ephedrine epinephrine isoetharine isoproterenol levalbuterol metaproterenol salmeterol terbutaline  These agents may also affect uterine and vascular smooth muscles. nausea. dry mouth. confusion. excitement. or other cardiovascular disease. excessive dry mouth (especially if they have chronic lung infections or disease). Examples: epinephrine ephedrine naphazoline phenylephrine tetrahydrozoline  Ophthalmic Topical application to the eye surface affects the vasculature of the eye.

cramps. Adrenergic-Blocking Agents Bind to adrenergic receptors. heart failure. Follow administration guidelines carefully.   Assess renal. heart block. Include postural blood pressure and pulse.Dizziness. Perform baseline assessment of vital signs. hypotension. temperature. Educate about proper dosing and equipment care. CHF. cardiac dysrhythmias.Impotence. fewer rales Increased air exchange Decreased cough Less dyspnea    . 5  Monitor for therapeutic effects (asthma):      Return to normal respiratory rate Improved breath sounds.AV block. Body System      * Salmeterol is indicated for PREVENTION of bronchospasms.   Improved blood gases Increased activity tolerance IV. and capillary refill. Avoid OTC or other medications because of possible interactions. ischemic colitis Other. Remember that alpha blockers may precipitate hypotension. Inform patients taking inhaled isoproterenol that their sputum or saliva may turn pink. lethargy. but inhibit or block stimulation of the sympathetic nervous system (SNS) Have the opposite effect of adrenergic agents Also known as adrenergic antagonists or sympatholytics Adrenergic-Blocking Agents: Therapeutic Uses          Acute Athma Treatment of open angle glaucoma Treatment of shock Treatment of congestive heart failure As a nasal decongestant Treatment supraventricular tachycardia Treatment of bronchospasm Used to treat hypertension Adrenergic-Blocking Agents: Side Effects Side/Adverse Effects IV administration:            Check IV site often for infiltration Use clear IV solutions Use an infusion device/IV pump Infuse agent slowly to avoid dangerous cardiovascular effects Monitor cardiac rhythm Monitor for therapeutic effects (cardiovascular uses): Decreased edema Increased urinary output Return to normal vital signs Improved skin color and temperature Increased LOC With chronic lung disease:     Instruct patients to avoid factors that exacerbate their condition. thrombocytopenia Cardiovascular. peripheral pulses. hallucinations Gastrointestina. alopecia. Blood. diarrhea. congestive. hypotension. Encourage fluid intake (up to 3000 mL per day) if permitted. not management of acute symptoms.Agranulocytosis. peripheral vascular. dry mouth. vomiting.Nausea. and cardiac function before treatment. mental depression. and bronchoconstriction. bronchospasms Adrenergic Blocking Agents: Nursing Implications  Assess for allergies and history of COPD. skin color. or other cardiovascular problems Any preexisting condition that might be exacerbated by the use of these agents might be a CONTRAINDICATION to their use. Encourage patients to take medications as prescribed. hepatic. bradycardia. Remember that beta blockers may precipitate bradycardia. bradycardia.    Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations. Administering two adrenergic agents together may precipitate severe cardiovascular effects such as tachycardia or hypertension. insufficiency CNS. CHF. rash.

dyspnea. dizziness and fainting may occur with increased activity. Notify the physician if these problems occur. Avoid caffeine (excessive irritability). Inform patients that they may notice a decrease in their tolerance for exercise. Monitor for therapeutic effects    Decreased chest pain in patients with angina Return to normal BP and P Other specific effects. Patients should notify their physician if palpitations. Report constipation or the development of any urinary hesitancy or bladder distention. Avoid OTC medications because of possible interactions. Avoid alcohol ingestion and hazardous activities until blood levels become stable. Patients should report the following to their physician:         Weight gain of more than 2 pounds (1 kg) within a week Edema of the feet or ankles Shortness of breath Excessive fatigue or weakness Syncope or dizziness Rebound hypertension or chest pain may occur if this medication is discontinued abruptly. Monitor for side effects. nausea.   These medications should never be stopped abruptly. depending on the use Possible drug interactions may occur with: o o o o o     Antacids (aluminum hydroxide type) Antimuscarinics/anticholinergics Diuretics and cardiovascular drugs Neuromuscular blocking agents Oral hypoglycemic agents Teach patients to change positions slowly to prevent or minimize postural hypotension. including: Hypotension Fatigue Lethargy Tachycardia (alpha blockers) Bradycardia Heart block CHF Depression Insomnia Vivid nightmares Increased airway resistance 6 . or vomiting occur. Patients should notify their physician if they become ill and unable to take medication.

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