Week 4

Chapter 13 Adrenergic Drugs Affecting the

Autonomic Nervous System

Learning Outcomes
1. Compare and contrast the types of responses that occur when
drugs activate alpha1-, alpha2-, beta1-, beta2- or beta3-adrenergic
receptors.
2. Discuss the classification and naming of adrenergic drugs.
3. Describe the nurse’s role in the pharmacologic management of
patients receiving drugs affecting the sympathetic nervous
system
Sympathetic nervous system responses prepare the
body to react to a potential threat. Adrenergic drugs
are adrenalin-like and mimic involuntary bodily
functions in essentially the same way as the
sympathetic nervous system. Cardiovascular, renal,
respiratory, gastrointestinal, reproductive, and
ophthalmic targets are all affected. Adrenergic
agonists and antagonists treat disorders throughout
the body including abnormalities in blood pressure,
heart rate and rhythm, shock, pulmonary disorders,
glaucoma, and nasal congestion.
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13.1 Norepinephrine and Adrenergic Transmission
1. In the sympathetic nervous system, norepinephrine (NE) is the
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 neurotransmitter released from postganglionic nerve terminals.
2. The exception is sweat glands, in which Ach is the
neurotransmitter, and there is no ganglion.
3. NE belongs to a class of agents called catecholamines, all of
which are involved in neurotransmission. 
4. Natural catecholamines are NE, epinephrine (adrenalin), and
dopamine. 
5. Synthetic catecholamines are isoproterenol and dobutamine. 
6. Noncatecholamine drugs are structurally different and include
ephedrine, phenylephrine, and terbutaline.
7. All of these drugs bind to the same target tissues as adrenalin.
Thus,receptors located on target organs are
called adrenergic because when they are activated, adrenalin-
like responses result.

Adrenergic Drugs (Sympathomimetics)

 The adrenergic drugs, also known as adrenergic agonists or
sympathomimetics, stimulate the sympathetic nervous system
and induce symptoms characteristic of the fight-or-flight
response.

 These drugs have clinical applications in the treatment of shock

and hypotension.

13.2 Clinical Applications of Adrenergic Drugs

1. Sympathomimetics produce many of the same responses as the
anticholinergics*.
2. Sympathomimetics may be described chemically
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 as catecholamines or noncatecholamines. 
*Anticholinergics are drugs that block the action of
acetylcholine . Acetylcholine is a neurotransmitter, or a
chemical messenger. It transfers signals between certain cells to
affect how your body functions

3. They must be administered parenterally. The

noncatecholamines can be taken orally and have longer
durations of action 
4. Sympathomimetics act either directly or indirectly. Most
sympathomimetics act directly by binding to and activating
adrenergic receptors.
5. Examples include the three endogenous catecholamines:
epinephrine, norepinephrine, and dopamine.
6. Other medications in this class act indirectly by causing the
release of NE from its vesicles within the presynaptic terminal or
by inhibiting the reuptake or destruction of NE.
7. Those that act by indirect mechanisms, such as amphetamine or
cocaine, are used for their central effects in the brain rather than
their autonomic effects.
8. A few drugs, such as ephedrine, act by both direct and indirect
mechanisms.
9. Most effects of sympathomimetics are predictable based on their
autonomic actions, dependent on which adrenergic receptor
subtypes are stimulated.
10.Because the receptor responses are so different, the student will
need to memorize the specific subclass(es) of receptors activated
by each sympathomimetic. Specific subclasses of receptors and
therapeutic applications are as follows:

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  Alpha1 receptor. Treatment of nasal congestion or
hypotension; causes dilation of the pupil (mydriasis) during
ophthalmic examinations.
 Alpha2 receptor. Treatment of hypertension through a
centrally acting mechanism. Autonomic alpha2 receptors
are also located on presynaptic membranes of
postganglionic neurons; when activated, they reduce the
release of NE within the axon terminal.
 Beta1 receptor. Treatment of cardiac arrest, heart failure,
and shock.
 Beta2 receptor. Treatment of asthma and premature labor
contractions.
 Beta3 receptor. Treatment of overactive bladder
11. Some sympathomimetics are nonselective, stimulating more
than one type of adrenergic receptor. For example, epinephrine
stimulates all five types of adrenergic receptors and is used for
cardiac arrest and asthma.
12.Pseudoephedrine (Sudafed and others) stimulates both
alpha1 and beta2 receptors and is used as a nasal decongestant.
13. Isoproterenol (Isuprel) stimulates both beta1 and beta2 receptors
and is used to increase the rate, force, and conduction speed of
the heart and, occasionally, for asthma.
14.The nonselective drugs generally cause more autonomic-related
side effects than the selective drugs.
15.The side effects of the sympathomimetics are mostly extensions
of their autonomic actions. Cardiovascular effects such as
tachycardia, hypertension, and dysrhythmias are particularly
troublesome and may limit therapy. Large doses can induce CNS
excitement and seizures. Other sympathomimetic responses
that may occur are dry mouth, nausea, and vomiting. Some of
these drugs cause anorexia, which has led to their historical use
as appetite suppressants. However, because of prominent

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 cardiovascular side effects, sympathomimetics are now rarely
used for this purpose.

Adrenergic-Blocking Drugs
Adrenergic-blocking drugs or antagonists inhibit the sympathetic
nervous system and produce many of the same rest-and-digest
symptoms as the parasympathomimetics.
They have wide therapeutic application in the treatment of
hypertension.
13.3 Clinical Applications of Adrenergic-Blocking Drugs

1. Adrenergic antagonists are drugs that act by directly blocking

adrenergic receptors.

2. A less used description of these drugs is sympatholytics. 

3. The actions of these drugs are specific to either alpha or beta

blockade.

4. Alpha-adrenergic antagonists, or simply alpha blockers, are used

for their effects on vascular smooth muscle. By relaxing vascular
smooth muscle in small arteries, alpha1 blockers such as
doxazosin (Cardura) cause vasodilation, decreasing blood
pressure. They may be used either alone or in combination with
other drugs in the treatment of hypertension (see chapter 26).

5. A second use is in the treatment of BPH, due to their ability to

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 increase urine flow by relaxing smooth muscle in the bladder
neck, prostate, and urethra

6. The most common adverse effect of alpha blockers is orthostatic

hypotension, which occurs when a patient abruptly changes
from a recumbent to an upright position. Reflex tachycardia,
nasal congestion, and impotence are other important side effects
that may occur as a consequence of increased parasympathetic
activity.

7. Phentolamine (Regitine) is used as an aid in the diagnosis of

pheochromocytoma. Pheochromocytoma is a rare,
catecholamine-secreting tumor on the adrenal gland that may
precipitate life-threatening hypertension.

8. Sudden and marked reduction in blood pressure following

parenteral administration of phentolamine is brought about by
the nonspecific blockade of alpha receptors.

9. Other indications for phentolamine are hypertensive crises

caused by methoxamine and phenylephrine treatment, or excess
plasma levels of catecholamines in patients taking MAOIs.
Phentolamine is a specific antidote for catecholamine
overdose and is injected intradermally for catecholamine
extravasation.
10.Beta-adrenergic antagonists may block either beta1 receptors, or
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 beta2 receptors, or both types of receptors.
11. Regardless of their receptor specificity, all beta blockers are used
therapeutically for their effects on the cardiovascular system.
12.Beta blockers decrease the rate and force of contraction of the
heart and slow electrical conduction through the
atrioventricular node.
13. Drugs that selectively block beta1 receptors, such as atenolol
(Tenormin), are called cardioselective drugs. Because they
have little effect on noncardiac tissue, they exert fewer side
effects than nonselective drugs such as propranolol (Inderal,
InnoPran XL).
14.The primary use of beta blockers is in the treatment of
hypertension. Although the exact mechanism by which beta
blockers reduce blood pressure is not completely understood, it
is thought that the reduction may be due to decreased cardiac
output or to suppression of renin release by the kidneys.

15.Adverse effects may occur with beta-adrenergic blockade. Beta

blockers may exacerbate heart failure in some patients with pre-
existing myocardial conditions. Increased risk of hypotension
and bradycardia may occur.

16.Adverse non-cardiac effects include significant bronchial

constriction, which may be harmful especially in patients with
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 respiratory conditions such as asthma or COPD.

17.Beta blockers may cause hypoglycemia or hyperglycemia

and mask the symptoms of hypoglycemia in diabetic
patients.

18.Other adverse effects are diarrhea, nausea, vomiting,

muscle cramps, rash, blurred vision, fatigue, depression,
and problems with erections in men.

19.Beta blockers should be discontinued gradually. Abrupt

discontinuation can bring on an acute resurgence of
symptoms.

20. Notable reactions in some patients are heart palpitations, a

rise in blood pressure, or recurrence of chest pain.

Table 13.4

Key Concepts
1. 13.1 Norepinephrine is the primary neurotransmitter released at adrenergic receptors,
which are divided into alpha and beta subtypes. Drugs can affect nervous transmission
across a synapse by preventing the synthesis, storage, or release of the neurotransmitter;
by preventing the destruction of the neurotransmitter; or by influencing the binding of
neurotransmitters to the receptors.
2. 13.2 Sympathomimetics act by directly activating adrenergic receptors, or indirectly by
increasing the release of norepinephrine from nerve terminals. They are used primarily
for their effects on the heart (hypertension, cardiac arrest), bronchial tree (asthma,
COPD), and nasal passages (nasal congestion).
3. 13.3 Adrenergic-blocking drugs are used primarily for treatment of hypertension (minor
use for BPH) and are the most widely prescribed class of autonomic drugs.

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Review Questions
1. Following administration of phenylephrine (Neo-Synephrine), the nurse would assess for
which of the following adverse drug effects?
1. Insomnia, nervousness, and hypertension
2. Nausea, vomiting, and hypotension
3. Dry mouth, drowsiness, and dyspnea
4. Increased bronchial secretions, hypotension, and bradycardia
2. A patient is started on atenolol (Tenormin). Which is the most important action to be
included in the plan of care for this patient related to this medication?
1. Monitor apical pulse and blood pressure
2. Elevate the head of the bed during meals
3. Take the medication after meals
4. Consume foods high in potassium
3. Propranolol (Inderal) has been ordered for a patient with hypertension. Because of
adverse effects related to this drug, the nurse would carefully monitor for which adverse
effect?
1. Bronchodilation
2. Tachycardia
3. Edema
4. Bradycardia
4. The health care provider prescribes epinephrine (adrenalin) for a patient who was stung
by several wasps 30 minutes ago and is experiencing an allergic reaction. The nurse
knows that the primary purpose of this medication for this patient is to:
1. Stop the systemic release of histamine produced by the mast cells.
2. Counteract the formation of antibodies in response to an invading antigen.
3. Increase the number of white blood cells produced to fight the primary invader.
4. Increase a declining blood pressure and dilate constricting bronchi associated with
anaphylaxis.
5. To avoid the first-dose phenomenon, the nurse knows that the initial dose of prazosin
(Minipress) should be:
1. Very low and given at bedtime.
2. Doubled and given before breakfast.
3. The usual dose and given before breakfast.
4. The usual dose and given immediately after breakfast.
6. A patient who is taking an adrenergic-blocker for hypertension reports being dizzy when
first getting out of bed in the morning. The nurse should advise the patient to:
1. Move slowly from the recumbent to the upright position.
2. Drink a full glass of water before rising to increase vascular circulatory volume.
3. Avoid sleeping in a prone position.
4. Stop taking the medication.

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Chapter 13 – Answers to Review Questions

1. Answer: 1
Rationale: Adrenergic agonists such as phenylephrine (Neo-Synephrine) stimulate the
sympathetic nervous system and produce symptoms including insomnia, nervousness, and
hypertension. Options 2, 3, and 4 are incorrect. Nausea, vomiting, and drowsiness are not adverse
effects known to occur with adrenergic agonists. Hypotension and bradycardia are potential
adverse reactions related to the use of adrenergic antagonists. Dry mouth may occur from
anticholinergics, and increased bronchial secretions are an effect of cholinergic agents. Dyspnea is
not an adverse reaction related to adrenergic agonists, and adrenergics may be ordered for
bronchodilation properties.
Cognitive Level: Applying.
Nursing Process: Assessment.
Client Need: Physiological Integrity.

2. Answer: 1
Rationale: With beta-adrenergic blockers such as propranolol, the most important action is to
monitor the patient for adverse effects associated with the cardiovascular system such as changes
in pulse and blood pressure. Options 2, 3, and 4 are incorrect. Elevation of the head of the bed is
not specifically required for this drug regimen. Atenolol (Tenormin) can be taken any- time
regardless of meals, and the therapeutic action of atenolol is not contingent on serum K+ levels.
Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Planning.

3. Answer: 4
Rationale: Because beta-adrenergic blockers such as propranolol (Inderal) slow electrical
conduction through the cardiac conduction system, they may cause bradycardia. Options 1, 2, and

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3 are incorrect. Bronchodilation, tachycardia, and edema are not adverse effects associated with
beta-adrenergic blockers.
Cognitive Level: Applying.
Nursing Process: Evaluation.
Client Need: Physiological Integrity.

4. Answer: 4
Rationale: Epinephrine is used during anaphylaxis to prevent hypotension and
bronchoconstriction. Options 1, 2, and 3 are incorrect because the administration of epinephrine
for anaphylaxis does not prevent the formation of histamine or the formation of antibodies in
response to an invading antigen, nor does it affect white blood cell function.
Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Evaluation.

5. Answer: 1
Rationale: Drugs that cause a “first-dose phenomenon” should have very low initial doses
administered at bedtime. The decline in blood pressure due to prazosin is often marked when
beginning pharmacotherapy and when increasing the dose. This “first- dose phenomenon” can
lead to syncope due to reduced blood flow to the brain. Options 2, 3, and 4 are incorrect. Doses of
antihypertensive medications should never be doubled, but should be gradually increased to
avoid hypotension, and the best time to give prazosin in the initial phases of therapy is at
bedtime.
Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Implementation.

6. Answer: 1
Rationale: The nurse should suspect that the patient is describing orthostatic hypotension
induced by the medication. Most patients find it helpful to move slowly from a recumbent
position to avoid dizziness and syncope. Options 2, 3, and 4 are incorrect. Although drinking a
full glass of water with the medication is a health promotion activity that the nurse might
suggest, this action does not eliminate orthostatic hypotension. Sleeping positions do not
influence the presence of orthostatic hypotension. The patient should never abruptly stop taking
antihypertensive medication. Such action could result in hypertensive crisis, stroke, or heart
attack.
Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Implementation.

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