Republic of the Philippines

Bulacan State University

City of Malolos

NCM 106 - Pharmacology

Drugs acting on the ANS

Prepared by:

Carmina O. Fabonan, RN

Marly Molina, MAN

Christopher E. Olipas, Ph.D.

A.Y. 2020-2021- 1 Semester

st
Introduction

Do you feel your heart beating? How about the movement of air in and out of your
lungs? How amazing that your body is working without exerting any effort to command
every time the heart pumps blood or the lungs inhale and exhale air. This process is
regulated by the autonomic nervous system (ANS). As the name implies it is the
regulation of the involuntary physiologic process of the body. The system works
automatically without a conscious effort untiringly. This will be your focus in this module,
drugs that affect the ANS. The autonomic nervous system controls your daily lives, into
two major ways sympathetic and parasympathetic responses that maintain the
homeostatic of the body. There are four types of drugs used to treat disorders of the ANS
that will be discussed in depth in each lesson of this module. These are the drug of choice
in any situation that arises altering the balance of the body.

This particular module is divided into 4 lessons:

Lesson 5.1 Adrenergic agents
Lesson 5.2 Adrenergic Blocking agents
Lesson 5.3 Cholinergic agents
Lesson 5.4 Cholinergic Blocking agents

You need to have an understanding of how this medication affects the most
important system in the body. This agent may alter signals that promote balance and if
given without proper knowledge can lead to serious effect including the death of your
patient. The module includes a pre-test, self-check exercises, and post-test, that helps
you assess and evaluate your understanding of each lesson. You are encouraged to take
time in answering the question. It will also help you to build your study style along the
way.

Objectives/Competencies
Upon completion of this module, you are expected to:
1. Explain the importance of the different drugs based on their classification, its
identified therapeutic actions, side effects, and adverse effects.
2. Apply the nursing process in drug therapy and patient safety.
3. Formulate a health teaching plan.
Pre Test
Compare and contrast the following idea or term related to Autonomic Nervous System
that will give you an idea for your preceding lessons:
Symphatetic Response

______________________ ______________________
______________________ ______________________
______________________ ______________________

Parasymphatetic Response
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
Agonist

______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________

Antagonist
Title of the Lesson: Adrenergic agents

Duration: 2 hours
By this time, I know you have already an idea of how sympathetic and
parasympathetic response works from your previous subjects. Adrenergic agents are also
called sympathomimetic drugs because they act in the same way with the sympathetic
nervous system. They respond like the chemical messengers of the body, the
epinephrine, and norepinephrine or by stimulating their release.
Adrenergic drugs are classified accordingly to a receptor that they stimulate: Alpha-
agonists that stimulate alpha-receptor and beta-agonists that stimulate beta-receptors.
See the table below that summarized these adrenergic agents
Table 5.1 Adrenergic agents

Alpha- and Beta- Generic Name

Adrenergic Dobutamine Dopamine Ephedrine
Epinephrine Norepinephrine
Agonists

Actions Stimulate the adrenergic receptor in target organs.

(Pharmacodynamics)
Indicated for the treatment of hypotensive states or shock, bronchospasm,
and some types of asthma

Pharmacokinetics Given IV or through mucous membranes

Metabolized in the liver
Excreted in the urine.

Contraindication/ Contraindication
Caution  Contraindicated in the presence of known allergy to any component
of the drug.
 Patient with tachyarrhythmias or ventricular fibrillation, halogenated
hydrocarbon general anesthetics, hypovolemia
Caution
 Pregnancy and lactating woman
 Patient with peripheral vascular disease

Adverse Effect Arrhythmias, hypertension, palpitations, angina, and dyspnea,

Hypokalemia, headache, sweating, feelings of tension or anxiety, and
piloerection
GI effect
nausea, vomiting, and constipation

Drug-Drug Increased effects of tricyclic antidepressants and monoamine oxidase

Interaction inhibitors
Lose effectiveness if combined with any adrenergic antagonist.
Increased risk of hypertension if alpha and beta-adrenergic agonists are
given with any other drugs that cause hypertension
Alpha-Specific Generic Name
Adrenergic Clonidine
Midodrine
Agonists Phenylephrine

Actions Stimulation of alpha-receptors within the Sympathetic nervous system

(Pharmacodynamics)
Clonidine is used for the treatment of hypertension
Midodrine treatment of orthostatic hypotension
Phenylephrine treatment for cold and allergy

Pharmacokinetics Metabolized in the liver

Excreted in the urine

Contraindication/ Contraindication
Caution  Contraindicated in the presence of known allergy to any drug
component
 Pregnancy and lactating woman
Caution
 Patients with CV disease or vasomotor spasm, thyrotoxicosis or
diabetes, hepatic or renal impairment.

Adverse Effect Feelings of anxiety, restlessness, depression, fatigue, strange dreams, and
personality changes. Blurred vision and sensitivity to light

Sudden withdrawal can lead to tachycardia, hypertension, arrhythmias,

flushing, and even death

Drug-Drug Severe hypertension, headache, and hyperpyrexia with Phenylephrine and

Interaction maois. Increased sympathetic effect with phenylephrine and TCA
Decreased antihypertensive effect with clonidine and TCA
Increased drug effects of digoxin, beta-blockers, and many antipsychotics
with Midodrine

Beta-Specific Generic Name

Adrenergic Albuterol Arformoterol Formoterol Indacaterol
Levalbuterol Metaproterenol Olodaterol Salmeterol
Agonists Terbutaline Isoproterenol

Actions Stimulation of all beta-adrenergic receptors.

(Pharmacodynamics) Used to manage and treat bronchial spasm, asthma, and other obstructive
pulmonary conditions.

Pharmacokinetics Metabolized in the liver

Excreted in the urine
 Contraindication/ Contraindication
Caution  Contraindicated in the presence of known allergy to any drug
component
 Patient with pulmonary hypertension
 Pregnancy and lactating woman

Caution
 Patient with diabetes, thyroid disease, vasomotor problems,
degenerative heart disease, or history of stroke

Adverse Effect Restlessness, anxiety, fear, tremor, fatigue, and headache, difficulty
breathing, coughing, and bronchospasm to severe pulmonary edema.

Self-Check 5.1

1. Lola Anita was rush to the emergency department with a chief complaint of
severe headache, nausea, and vomiting with a blood pressure of 160/100 mm/hg.
The doctor ordered for clonidine 150 mcg twice a day. The nurse notes that
clonidine was prescribed to treat which of the following?

a) Treatment of hypertension
b) Prevent thrombus formation
c) Prevent hyperthermia
d) Prevent nausea and vomiting

2. Fill in the table below based on the case scenario given in the above question.

Patient Name: Diagnosis:

Drug Name: (generic) (brand name)

Drug Classification Action:

Nursing Process

Pre-Administration Post Administration Nursing Consideration/Health

Assessment Evaluation Teaching

Great! Hope you answered the question correctly. For further reading you can check
Chapter 30 of the book entitled “Focus on nursing pharmacology” (7th ed.). by Karch,
A. M., (2013) or other references. You can also watch the video about Pharmacology
- Adrenergic Receptors and Agonist https://www.youtube.com/watch?v=KtmV-
yMDYPI&vl=en for a quick review.
Title of the Lesson: Adrenergic Blocking agents

Duration: 2 hours
Adrenergic blocking agents are also called sympatholytic drugs because they
prevent the typical manifestations of Sympathetic Nervous System activation. These
effects include interrupting the action of adrenergic drugs, reducing available
norepinephrine, and preventing the action of cholinergic drugs.
Adrenergic blocking agents are classified according to their site of action: alpha-
adrenergic blockers also known as alpha-blockers, and beta-adrenergic blockers also
called beta-blocker. Some Adrenergic blocking agents are nonselective receptors.

Nonselective adrenergic
blocking agents
Amiodarone
Carvedilol
Non selective alpha-
Labetalol adrenergic blocking
agents
Phentolamine

Alpha-blockers
Alpha1-selective
adrenergic blocking
Adrenergic blocking agents
agents Alfuzosin, Doxazosin,
Prazosin, Tamsulosin,
Terazosin

Non selective beta-

adrenergic blocking
agents
carteolol, metipranolol,
nadolol, nebivolol,
propranolol, sotalol, timolol
Beta-blockers
drugs that end with -"olol'
Beta1-selective
adrenergic blocking
agents
acebutolol, atenolol,
betaxolol, bisoprolol,
esmolol, metoprolol

Nonselective Adrenergic Blocking Agents are used to treat cardiac-related condition like
hypertension, or in combination with diuretics. They block the effects of norepinephrine
at alpha-and beta-receptors
Phentolamine a nonselective alpha-adrenergic blocker is indicated to prevent and treat
dermal necrosis and sloughing associated with IV extravasation of norepinephrine or
dopamine. Alpha-selective adrenergic blocking agents are used in treating hypertension
and for treating BPH from the effects of relaxing the bladder and prostate.
A drug interaction occurs with alpha-adrenergic blockers include when Prazosin taken
with diuretics, propranolol, or other beta-adrenergic blockers results in increased
frequency of syncope with loss of consciousness. Doxazosin or terazosin, given with
clonidine results in decreased clonidine effects. Terazosin taken with antihypertensive
may cause excessive hypotension.

The adverse effect includes orthostatic hypotension or severe hypertension, bradycardia

or tachycardia, edema, difficulty breathing, light-headedness, flushing, arrhythmias,
angina or heart attack, spasm of the blood vessels in the brain or a shock like state.
Beta-blockers are used to treat hypertension, stage fright,
migraines, angina, and essential tremors. Non-selective beta-
blockers, block all beta-receptors resulting in loss of the reflex
bronchodilation. They are primarily used for allergic or
seasonal rhinitis, asthma, or COPD. Beta1-selective
adrenergic blocking agents are indicated in treating
hypertension and angina while extended-release forms are
used to treat heart failure.
Careful administration with beta-blockers because serious
effects of drug-drug interactions include cardiac depression,
arrhythmias, respiratory depression, severe bronchospasm,
and severe hypotension that can lead to vascular collapse.
Figure 5.1 Beta blocker site of action
Beta-adrenergic blockers increased the effects or toxicity to
digoxin, calcium channel blockers, and cimetidine. Decreased
effects with antacids, calcium salts, barbiturates, anti-inflammatories, and rifampin.
Insulin and oral antidiabetic drugs is altered. Potential lidocaine toxicity can occur.
Impaired theophylline ability to with beta-adrenergic blockers. Clonidine taken with a
nonselective beta-adrenergic blocker can result in life-threatening hypertension during
clonidine withdrawal. Sympathomimetics and nonselective beta-adrenergic blockers can
cause hypertension and reflex bradycardia.

Adverse reaction to beta-blockers include hypotension, bradycardia, peripheral vascular

insufficiency, AV block, heart failure, bronchospasm, diarrhea or constipation, nausea,
vomiting, abdominal discomfort, anorexia, flatulence, rash, fever with a sore throat, spasm
of the larynx, and respiratory distress
Self-Check 5.2
1. Patient Ana is taking metoprolol 100 mg once a day for hypertensive maintenance
medication Metoprolol belongs to the class Beta1-selective adrenergic blocking agents.
Which of the following statement made by Patient Ana needs further understanding?
 a. “Metoprolol helps to keep my blood pressure under control”
b. “This drug may cause dizziness. If affected, I will not drive or take part in
any activity in which I need to be alert.”
c. “I can take indomethacin if I feel pain while on metoprolol”
d. “I will inform my doctor if I feel a severely slow heartbeat and abnormal heart
rhythm.”
2. Complete the diagram below summarizing the mechanism of action of the Adrenergic
blocking agent including nursing responsibilities in administering the medication.

Adrenergic blocking agent

Alpha blocker Beta blocker

_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Take a break for a while. If you need further reading you can check Chapter 31 of the
book entitled “Focus on nursing pharmacology” (7th ed.). by Karch, A. M., (2013) or other
references. You can also watch the video about Pharmacology - Alpha and Beta Blockers
https://www.youtube.com/watch?v=41Xloc_vvX8
Title of the Lesson: Cholinergic agents

Duration: 2 hours
Cholinergic drugs accelerate the action of the neurotransmitter acetylcholine that
contracts smooth muscles, dilates blood vessels, increases bodily secretions, and slows
the heart rate. It is also called parasympathomimetic, because it has the same action
during the parasympathetic response.
Cholinergic drugs are subdivided accordingly how they act with acetylcholine receptors.
Direct-acting cholinergic drugs react with the acetylcholine receptor sites to cause
cholinergic stimulation. While indirect-acting cholinergic drugs are
acetylcholinesterase inhibitors. They block acetylcholinesterase to prevent it from
breaking down acetylcholine in the synaptic cleft. See the table below for Cholinergic
agents and their properties.
Table 5.2 Cholinergic agents

Direct-acting Generic Name

cholinergic drugs Bethanechol Carbachol Cevimeline Pilocarpine

Indirect-Acting Agents for Myasthenia Gravis Agents for Alzheimer’s Disease

Cholinergic Edrophonium Donepezil
Neostigmine Galantamine
Agonists Pyridostigmine Rivastigmine

Actions Slowing the heart rate and decreased myocardial contractility, vasodilation,
(Pharmacodynamics) bronchoconstriction, and increased bronchial mucus secretion, increased GI
activity and secretions, increased bladder tone, relaxation of GI and bladder
sphincters, and pupil constriction.

Cholinergic agonists are used to:

• treat atonic (weak) bladder conditions and postoperative and postpartum
urinary retention
• treat GI disorders, such as postoperative abdominal distention and GI
atony
• reduce eye pressure in patients with glaucoma and during eye surgery
• treat salivary gland hypofunction caused by radiation therapy and
Sjögren’s syndrome.

Pharmacokinetics The metabolism and excretion of these drugs are not known

Contraindication/ Contraindication
Caution  Contraindicated in a patient with hypersensitivity to any component
of the drug
Caution
 Pregnancy and lactating woman
 Adverse Effect nausea and vomiting, cramps and diarrhea, blurred vision, decreased heart
rate and low blood pressure, shortness of breath, urinary frequency, and
increased salivation and sweating.

Drug-drug Quinidine reduces the effectiveness of cholinergic agonists

Interaction Increased risk of GI bleeding if these drugs are used with nonsteroidal anti-
inflammatory drugs (NSAIDs)

Self-Check 5.3
Case Scenario:
Lola Anita an 88-year-old woman without any significant medical history, visit your
hospital for complaint of memory loss and confusion most of the time. She noticed of
forgetting the names of her children including her way home. She was diagnosed with
Alzheimer’s disease after the doctor's evaluation. The doctor prescribed Galantamine 4
mg twice a day for 4 weeks by mouth. Formulate a Drug study and health teaching plan
for Lola Anita.
Drug Study

Date Route of
ordered/ Administration/Dosag Mechanis Contraindicati Clients Nursing
Medication Indication
Given/ e/ m of Action on Response Responsibilities
Taken Frequency

Generic Date Dosage: Before:

Name: ordered:

Brand Name: Date

Route; During:
given:

Classifications
: Date
Taken: Frequency: After:

Health Teaching Plan

Learning Objectives Learning Content Strategies Time Allotment Resources Evaluation

If you need further reading you can check Chapter 32 of the book entitled “Focus on
nursing pharmacology” (7th ed.). by Karch, A. M., (2013) or other references. You can
also watch the video about Pharmacology - Cholinergic Drugs
https://www.youtube.com/watch?v=r-gJaMoMon0
Title of the Lesson: Cholinergic Blocking agents

Duration: 2 hours
Anticholinergic drugs, also called parasympatholytic drugs, block the effects of
acetylcholine at cholinergic receptor sites, thus blocking the effects of the
parasympathetic nervous system. This class of drugs is less commonly used nowadays
because new drug development which is more specific and less systemically toxic drugs
are available.

Table 5.3 Cholinergic Blocking agents

Anticholinergics Generic Name

Aclidinium Atropine Darifenacin Dicyclomine
Fesoterodine Flavoxate Glycopyrrolate Hyoscyamine
Ipratropium Meclizine Methscopolamine Propantheline
Scopolamine Solifenacin Tiotropium Toliterodine
Trospium

Actions  Competitively block the acetylcholine receptors at the muscarinic

(Pharmacodynamics) cholinergic receptor sites that are responsible for mediating the
effects of parasympathetic postganglionic impulses
 All anticholinergic drugs are used to treat spastic or hyperactive
conditions of the GI and urinary tracts because they relax muscles
and decrease GI secretions.
 Anticholinergic drugs are given by injection before some diagnostic
procedures, such as endoscopy or sigmoidoscopy, to relax the GI
smooth muscle.
 Atropine is also used as a pre-operative medication to reduce oral,
gastric, and respiratory secretions and prevent a drop in heart rate
caused by vagal nerve stimulation during anesthesia and to relive
symptomatic sinus bradycardia

Contraindication/ Contraindication
Caution  Contraindicated in a patient with hypersensitivity to any component
of the drug
 Patient with myasthenia gravis or any disorder that any condition
that exacerbated the blockade of the parasympathetic nervous
system
Caution
 Pregnancy and lactating woman

Adverse Effect Blurred vision, pupil dilation, and resultant photophobia, cycloplegia, and
increased intraocular pressure.

Drug-drug effectiveness of phenothiazines decrease if they are combined with

Interaction anticholinergic drugs and the risk of paralytic ileus increases
 Nursing Assessment
Process Assess for conditions in which anticholinergic drugs would be used, such as
bradycardia, heart block diarrhea, and peptic ulcer disease.
Assess for conditions that are contraindicated with the use of anticholinergic drugs
glaucoma, myasthenia gravis, prostatic hyperplasia, reflux esophagitis, or GI obstructive
disease.

Nursing Diagnosis (Possible)

 Urinary retention related to adverse effects on the bladder
 Constipation related to adverse effects on the GI tract
 Risk for injury related to adverse drug effects

Planning
 The patient will experience relief of symptoms.
 The patient will remain free from adverse reactions.

Implementation
 Follow dosage recommendations. Some drugs should be given with meals.
 Monitor vital signs, cardiac rhythm, urine output, and vision for potential drug
toxicity.
 Monitor for adverse reactions, such as dry mouth, increased heart rate, and
blurred vision.
 Have emergency equipment available to treat new cardiac arrhythmias.
 Help alleviate symptoms if adverse effects occur. For example, provide
lozenges and frequent mouth care for patients experiencing dry mouth.

Evaluation
 The patient’s underlying condition improves, maintains a normal heart rate,
normal voiding pattern, normal bowel patterns.
 Patients and family or caregivers demonstrate an understanding of drug
therapy.

Self-Check 5.4
1. Lola Anita was diagnosed with Irritable bowel syndrome characterized by abdominal
pain and changes in bowel movement. The doctor prescribed atropine 0.6 mg at bedtime
as a single dose by mouth. The nurse is giving health teaching to Lola Anita. Which of
the following statement made by Lola Anita indicate further teaching is needed.
a. “Atropine may cause giddiness, unsteadiness, and visual disturbances. If
affected, I will not drive or take part in any activity in which I need to be alert
or need to see clearly.”
b. “Dry mouth is a common side effect of this medicine. If I experience severe
dry mouth, I will take some sweets, mints, or chewing gum to help reduce
discomfort.”
c. “I can drink alcohol while on atropine therapy”
d. “I will inform the doctor if I experience any increased pressure in my eye”
2. You are preparing a take-home instruction to Lola Anita about the atropine. Fill in the
table below to guide Lola Anita in taking the medication.

Patient Name: Diagnosis:

Drug Name: (generic) (brand name)

Drug Classification Action:

Health Teaching

If you need further reading you can check Chapter 33 of the book entitled “Focus on
nursing pharmacology” (7th ed.). by Karch, A. M., (2013) or other references. You can
also watch the video about Pharmacology - Cholinergic Blocking agents
https://www.youtube.com/watch?v=cp_CZpCBVpk
Post-test
1. Patient Ana has a new prescription for Timolol. The nurse determines that the client
has misunderstood instructions given about the medication if the client states the need
to:
a. Change position slowly
b. Report shortness of breath to the physician.
c. Taper or discontinue the medication when the client feels well.
d. Have enough medication on hand to last through weekends and vacations.
2. A client has been prescribed a clonidine patch (Catapress-TTS), and the nurse has
instructed the client regarding the use of patch. The nurse determines that further
instruction is needed if the nurse noted that the client:
a. Intended to change the patch every 7 days.
b. Trimmed the patch because one edge was loose.
c. Selected a hairless site on the torso for application
d. Planned to leave the patch in place during bathing or showering.
3. A client who has episodes of bronchospasm and a history of tachydysrhthias is
admitted to the hospital. The nurse reviews the physician to verify which medication, if it
has been prescribed/
a. Albuterol (Proventil)
b. Metaproterenol (Alupent)
c. Epinephrine ( Primatene Mist)
d. Salmeterol/fluticasone (Advair)
4. A client has begun medication therapy with betaxolol (kedone). The nurse determines
the client is experiencing the intended effect of therapy if which of the following is noted?
a. Edema present +3
b. weight loss of 2 kilos
c. Pulse rate increased from 58 to 74 bpm
d. Blood pressure decreased from 142/ 94 mmhg to 128/82 mmhg.
5. A medication nurse is supervising a newly hired nurse who is administering
pyridostigmine (Mestinon) orally to a client with myasthenia gravis. Which observation by
the medication nurse indicates safe practice by the newly hired nurse before
administering this medication?
a. Asking the client to take sips of water.
b. Asking the client to lie down on her right side.
c. Asking the client to look up at the ceiling for 30 seconds
 d. Instructing the client to void before taking the medication.
6. A nurse reviews the client’s health care record and notes that the client is taking
donepezil hydrochloride ( Aricept). Understanding the purpose of this medication, the
nurse suspects this client has:
a. Dementia
b. Seizure disorder
c. History of schizophrenia
d. Obsessive-compulsive behavior.
7. A client is taking albuterol sulfate (Ventolin Diskus) by inhalation but cannot cough up
secretions. The nurse teaches the client to do which of the following to best help clear the
bronchial secretions?
a. Get more exercise each day.
b. Use a dehumidifier in the home.
c. Administer an extra dose before bedtime.
d. Increase the amount of fluids consumed every day.
8. A nurse administer a dose of scopolamine to a preoperative client. The nurse monitors
the client for which common side effect of the medication?
a. Dry mouth
b. Diaphoresis
c. Excessive urination
d. Pupillary constriction.
9. A client has been prescribed metoprolol (Lopressor) for hypertension. The nurse
monitors client compliance carefully because of which common side effect of the
medication?
a. Impotence
b. Mood swings
c. Increased appetite
d. Complete atrioventricular (A-V) block
10. A client with myasthenia gravis is admitted to the hospital, and the nursing history
reveals that the client is taking pyridostigmine (Mestinon). The nurse assesses the client
for side effects of the medication and asks the client about the presence of:
a. Mouth ulcer
b. Muscle cramps
c. Feelings of depression
d. Unexplained weight gain.
Final Requirement:
Case Scenario:
Lola Anita an 88-year-old woman without any significant medical history, visit your
hospital for complaint of memory loss and confusion most of the time. She noticed of
forgetting the names of her children including her way home. Vital signs as follows BP:
120/80, RR: 20 PR: 100. She was diagnosed with Alzheimer’s disease after the doctor's
evaluation. The doctor prescribed Rivastigmine 3 mg twice a day for 4 weeks by mouth.
Formulate a Drug study and health teaching plan for Lola Anita.
Drug Study

Date
Route of
ordered Mechanis Nursing
Administration/Dosag Indicatio Contraindicatio Clients
Medication / m of Responsibilitie
e/ n n Response
Given/ Action s
Frequency
Taken

Generic Date Dosage: Before:

Name: ordered
:

Brand Name:
Route; During:
Date
given:

Classifications
:
Date Frequency: After:
Taken:

Health Teaching Plan

Learning Objectives Learning Content Strategies Time Allotment Resources Evaluation