Lopez, Gabrielle B.

1. Make a drug study on the individual drugs discussed in this course unit ANS
AGENTS. Type in Word, Times new Roman, Font 12, 1.5 spacing and
submit here in canvas.
2. Search for 2 new drugs for each classification of ANS drugs not discussed
in this course unit and include them in the drug study.

Drug study:

DRUG

DOSAGE

THERAPEUTIC ACTION

ADVERSE EFFECTS

CONTRAINDICATION

NURSING CONSIDERATION

ALPHA-and-BETA ADRENERGIC AGONISTS

Epinephrine

DRUG - adrenaline

DOSAGE - Adults and children weighing 30 kg (66 lb) or more. 0.3 to 0.5 mg,

THERAPEUTIC ACTION - alpha blockers such as phentolamine, antihypertensives, diuretics,

ergot

alkaloids, phenothiazine antipsychotics, vasodilators such as nitrates: Antagonized pressor

effects of epinephrine antidepressants of the imipramine and triptyline types, MAO inhibitors:
Increased risk of severe, prolonged hypertension.

ADVERSE EFFECTS - CNS: Anxiety, apprehensiveness, chills, CVA, disorientation, dizziness,

drowsiness, excitability, fever, hallucinations, headache, impaired memory, insomnia, light-
headedness, nervousness, panic, psychomotor agitation, restlessness, seizures, sleepiness,
temporary worsening of Parkinson’s disease, tingling, tremor, weakness.
CONTRAINDICATION - Cerebral arteriosclerosis, coronary insufficiency, dilated
cardiomyopathy,general anesthesia with halogenated hydrocarbons or cyclopropane,
hypersensitivity to epinephrine or its components, labor, angle-closure glaucoma, organic brain
damage, shock (nonanaphylactic).

NURSING CONSIDERATIONS –

 Use epinephrine with extreme caution in patients with

angina, arrhythmias, asthma, degenerative heart disease, or
emphysema. Epinephrine’s inotropic effect equals that of
dopamine and dobutamine; its chronotropic effect exceeds
that of both.
 Use drug cautiously in elderly patients and those with
cardiovascular disease (other than listed above), diabetes
mellitus, hypertension, hyperthyroidism, prostatic
hypertrophy, and psychoneurologic disorders.
 Know that if the Adrenalin brand of epinephrine is used
during intraocular surgery to induce and maintain
mydriasis, the 30-ml multiple-dose vial of the drug should
not be used because it contains chlorobutanol, which may
be harmful to the corneal endothelium. Also, be aware
that the Adrenalin 1-ml single-use vial must be diluted
before intraocular use.

Dopamine

DRUG- adrenergic

DOSAGE - Adults. Initial: 2 to 5 mcg/kg/min

THERAPEUTIC ACTION- alpha blockers: Antagonized peripheral vasoconstriction with

high doses of

Dopamine beta blockers: Antagonized beta receptor–mediated inotropic effects of

Dopamine cyclopropane, halogenated hydrocarbon anesthetics: Increased cardiac

autonomic irritability with possible increased risk of hypertension and ventricular arrhythmias.

ADVERSE EFFECTS- CNS: Anxiety, headache

CV: Angina, atrial fibrillation, bradycardia, cardiac conduction

abnormalities, ectopic beats, hypertension, hypotension, palpitations,

peripheral vasoconstriction, sinus tachycardia, ventricular arrhythmias,

widened QRS complex

GI: Nausea, vomiting

GU: Azotemia

RESP: Dyspnea

SKIN: Extravasation with tissue necrosis, piloerection

CONTRAINDICATION- Hypersensitivity to dopamine or its components, pheochromocytoma,

uncorrected ventricular fibrillation, ventricular tachycardia, and other tachyarrhythmias.

NURSING CONSIDERATIONS-

 Avoid, if possible, giving dopamine to patients with occlusive vascular

disease, such as
atherosclerosis, Buerger’s disease, diabetic endarteritis, or Raynaud’s disease,
because of risk of
 decreased peripheral circulation. Also, be aware that high doses of dopamine
given for a prolonged period of time increase the risk of decreased peripheral
circulation and could lead to gangrene in the patient’s extremities.
 Use drug cautiously in patients with cardiac disease, particularly coronary artery
disease, because dopamine increases myocardial oxygen demand. Also use drug
cautiously in patients allergic to sulfites, which are contained in some forms of
dopamine.
 Inspect parenteral solution for particles and discoloration before administration

Norepinephrine

DRUG- levophed

DOSAGE- Adults. Initial average dose: 8 to 12 mcg/min of base.

THERAPEUTIC ACTION- cyclopropane and halothane anesthetics: Increased cardiac

autonomic

irritability, sensitizing the myocardium to the action of norepinephrine MAO inhibitors of the
imipramine or triptyline types: May cause prolonged, severe hypertension

ADVERSE EFFECTS - CNS: Anxiety, dizziness, headache, insomnia, nervousness, tremor,

weakness
CV: Angina, bradycardia, ECG changes, edema, hypertension, hypotension,

palpitations, peripheral vascular insufficiency (including gangrene), PVCs, sinus

tachycardia

GI: Nausea, vomiting

GU: Decreased renal perfusion

RESP: Apnea, dyspnea

SKIN: Pallor

Other: Infusion-site sloughing and tissue necrosis, metabolic acidosis

CONTRAINDICATION- Concurrent use of cyclopropane and hydrocarbon inhalation

anesthetics,

hypersensitivity to norepinephrine or its components, hypovolemia (except as an emergency

measure), mesenteric or peripheral vascular thrombosis (except as an emergency measure),
profound hypercarbia or hypoxia

NURSING CONSIDERATIONS

 Dilute norepinephrine concentrate for infusion by adding a 4 ml ampule (contains

4 mg) of drug to 1,000 ml of a 5% dextrose-containing solution. Each ml of this
dilution contains 4 mcg of the base of the drug.
 Make sure solution contains no particles and isn’t discolored before
administering.
 Give drug with a flow-control device.
 Check blood pressure every 2 to 3 minutes, preferably by direct intra-arterial
monitoring, until stabilized and then every 5 minutes.

Phenylephrine

DRUG- vazculep

DOSAGE- 10 mg/mL

THERAPEUTIC ACTION- a class of medications called nasal decongestants. It works by

reducing swelling of the blood vessels in the nasal passages.

ADVERSE EFFECTS- Mild upset stomach, trouble sleeping, dizziness, lightheadedness,

headache, nervousness, shaking, or fast heartbeat may occur. If any of these effects persist or
worsen, tell your doctor or pharmacist promptly. This product may reduce blood flow to your
hands or feet, causing them to feel cold.

CONTRAINDICATION- overactive thyroid gland acidosis, a high level of acid in the blood

high blood pressure significant uncontrolled high blood pressure a heart attack coronary artery
disease partial heart block rapid ventricular heartbeat slow heartbeat chronic heart failure

severe hardening of the arteries a blood clot in an artery acute inflammation of the liver

acute inflammation of the pancreas enlarged prostate decreased oxygen in the tissues or blood

NURSING CONSIDERATIONS- Monitor signs of peripheral vasoconstriction, such as extreme

coldness in the hands and feet, cyanosis, and muscle cramping. Notify physician of severe or
prolonged signs of vasoconstriction. Assess symptoms of respiratory distress including dyspnea,
shortness of breath, and cyanosis.

Midrodrine

DRUG- proamatine

DOSAGE- 2.5 mg, 5mg and 10 mg

THERAPEUTIC ACTION- used to treat orthostatic hypotension (sudden fall in blood

pressure that occurs when a person assumes a standing position). Midodrine is in a class of
medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten,
which increases blood pressure.

ADVERSE EFFECTS- numbness and tingling scalp itching,

goose bumps, Chills, frequent urination. urgent need to urinate, difficulty urinating

CONTRAINDICATION- contraindicated in patients with severe organic heart disease, acute

renal disease, urinary retention, pheochromocytoma or thyrotoxicosis. Midodrine hydrochloride
should not be used in patients with persistent and excessive supine hypertension.

NURSING CONSIDERATIONS-

 Monitor supine and sitting BP prior to and during therapy.

 Assess pattern of urinary output prior to and during treatment for incontinence.
 Lab Test Considerations: Monitor renal and hepatic function prior to
and periodically during therapy.

Clonidine

DRUG- catapres-tts
DOSAGE- Adults. Initial: 0.1 mg twice daily

THERAPEUTIC ACTION- barbiturates, other CNS depressants: Increased depressant effects of

these drugs beta blockers, calcium channel blockers, digoxin: Additive effects, such as
bradycardia and AV block; increased risk of worsened hypertensive response when clonidine is
withdrawn (beta blockers only)

ADVERSE EFFECTS-

CNS: Agitation, delusional perception, depression, dizziness, drowsiness,

fatigue, hallucinations, headache, malaise, nervousness, paresthesia, sedation,

syncope, weakness, tremor

CV: Arrhythmias, AV block, bradycardia (severe), chest pain,

congestive heart failure, orthostatic hypotension, Raynaud’s

phenomenon

EENT: Accommodation disorder, blurred vision, burning eyes, decreased

lacrimation, dry eyes and mouth, salivary gland pain

GI: Constipation, hepatitis, mildly elevated liver enzymes, nausea, vomiting

GU: Decreased libido, erectile dysfunction, nocturia

HEME: Thrombocytopenia

SKIN: Pruritus, rash, urticaria

Other: Angioedema, weight gain, withdrawal symptoms

CONTRAINDICATION- Anticoagulant therapy (epidural infusion); bleeding diathesis; (epidural

infusion); hypersensitivity to clonidine or its components, including adhesive used in transdermal

patch; injection-site infection (epidural infusion)

NURSING CONSIDERATIONS-

 Be aware that clonidine should not be used in most patients with severe cardiovascular
disease or in those who are not hemodynamically stable because of the potential for
severe hypotension.
 Use clonidine cautiously in elderly patients, who may be more sensitive to its
hypotensive effect.
  Monitor blood pressure and heart rate often during clonidine therapy because clonidine
may worsen AV block and sinus node dysfunction, especially if patient is taking
another sympatholytic drug. If severe bradycardia occurs, be prepared to administer IV
atropine or isoproterenol and assist with insertion of temporary cardiac pacing.
 Be aware that extended-release tablets are not interchangeable with immediate-release
tablets.

Methyldopa

DRUG-

DOSAGE- s. Initial: 250 mg twice daily or three times daily for first 48 hr

THERAPEUTIC ACTION- anesthetics: Possiibly enhanced effect requiring reduced dosage of

anesthetics

antihypertensives: Increased hypotension CNS depressants: Possibly increased CNS depression

ferrous gluconate, ferrous sulfate: Decreased bioavailability of methyldopa lithium: Increased
risk of lithium toxicity MAO inhibitors: Possibly hallucinations, headaches, hyperexcitability,
and severe hypertension

ADVERSE EFFECTS-

CNS: Decreased concentration, depression, dizziness, drowsiness, fever,

headache, involuntary motor activity, memory loss (transient), nightmares,

paresthesia, Parkinsonism, sedation, vertigo, weakness

CV: Angina, bradycardia, edema, heart failure, myocarditis, orthostatic

hypotension

EENT: Black or sore tongue, dry mouth, nasal

congestion ENDO: Gynecomastia

GI: Constipation, diarrhea, flatulence, hepatic necrosis, hepatitis, jaundice,

nausea, pancreatitis, vomiting

GU: Decreased libido, impotence

HEME: Agranulocytosis, hemolytic anemia, leukopenia, positive Coombs’

test, positive tests for ANA and rheumatoid factor, thrombocytopenia

SKIN: Eczema, rash, urticaria

Other: Weight gain

CONTRAINDICATION- Active hepatic disease, hypersensitivity to methyldopa or its

components,

impaired hepatic function from previous methyldopa therapy, use within 14 days of MAO
inhibitor

NURSING CONSIDERATIONS-

 For I.V. infusion, add methyldopate to 100 ml of D5W and administer over 30
to 60 minutes.
 Expect to monitor CBC and differential results before and periodically
during methyldopa therapy.
 Monitor blood pressure regularly during therapy.
 Monitor results of Coombs’ test; a positive result after several months of treatment
indicates that patient has hemolytic anemia. Expect to discontinue drug.
 Assess for edema and weight gain. If they develop, give a diuretic, as prescribed.
 Notify prescriber if patient has signs of heart failure (dyspnea, edema, hypertension) or
involuntary,rapid, jerky movements.
 Be aware that hypertension may return within 48 hours after stopping drug

BETA-SPECIFIC ADRENERGIC AGONISTS

Isoproterenol

DRUG- Isuprel

DOSAGE- 0.2mg/mL

THERAPEUTIC ACTION- a beta-1 and beta-2 adrenergic receptor agonist resulting in the
following: Increased heart rate. Increased heart contractility. Relaxation of bronchial,
gastrointestinal, and uterine smooth muscle
ADVERSE EFFECTS- headache, dizziness, nervousness Nausea blurred vision tremors; or
sweating, flushing (sudden warmth, redness, or tingly feeling).

CONTRAINDICATION- contraindicated in patients with tachyarrhythmias; tachycardia or

heart block caused by digitalis intoxication; ventricular arrhythmias which require inotropic
therapy; and angina pectoris. Use with caution in patients with hyperthyroidism or diabetes.

NURSING CONSIDERATIONS- Assess heart rate, ECG, and heart sounds, especially during
exercise (See Appendices G, H). Immediately report any rhythm disturbances or symptoms of
increased arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and
fatigue/weakness.

Albuterol

DRUG

DOSAGE- Adult and Pediatric Dosage Forms and Strengths

Aerosol metered-dose albuterol inhaler

90mcg (base)/actuation (equivalent to 108mcg albuterol sulfate)

Powder metered-dose albuterol inhaler

90mcg (base)/actuation (equivalent to 108mcg albuterol sulfate); ProAir RespiClick

Tablet

2 mg

4 mg

Tablet, extended release 4

mg 8 mg

Nebulizer solution

0.083%
0.5%

1.25mg/3mL

0.63mg/3mL

Syrup

2 mg/5 mL

THERAPEUTIC ACTION- to relax the bronchial smooth muscle. It also inhibits the release
of immediate hypersensitivity mediators from cells, especially mast cells. Although albuterol
also affects beta-1 adrenergic receptors, this is minimal and has little effect on the heart rate.

ADVERSE EFFECTS- nervousness or shakiness, headache, throat or nasal irritation, and muscle
aches. More-serious though less common side effects include a rapid heart rate (tachycardia) or
feelings of fluttering or a pounding heart (palpitations).

CONTRAINDICATION- overactive thyroid gland, diabetes. a metabolic condition where the

body cannot adequately use sugars called ketoacidosis, excess body acid, low amount of
potassium in the blood, high blood pressure, diminished blood flow through arteries of the heart,
a low supply of oxygen rich blood to the heart.

NURSING CONSIDERATIONS- commonly used to treat asthma and chronic obstructive

pulmonary disease (COPD). Nursing Considerations: Monitor respiratory rate, oxygen
saturation, and lungs sounds before and after administration. If more than one inhalation is
ordered, wait at least 2 minutes between inhalations.

Arformoterol

DRUG- brovana

DOSAGE- inhalation solution

THERAPEUTIC ACTION- a bronchodilator. It works by relaxing muscles in the airways to

improve breathing. Arformoterol inhalation is used to prevent bronchoconstriction in people with
chronic obstructive pulmonary disease, including chronic bronchitis and emphysema
ADVERSE EFFECTS- shakiness (tremor),nausea, vomiting,

diarrhea, headache, nervousness, weakness, dizziness,

CONTRAINDICATION- thyrotoxicosis, diabetes, low amount of potassium in the blood.

high blood pressure, diminished blood flow through arteries of the heart, prolonged QT interval
on EKG, abnormal EKG with QT changes from birth, asthma attack.

NURSING CONSIDERATIONS- Assess lung sounds, pulse, and BP before administration and
periodically during therapy. Monitor pulmonary function tests before initiating therapy and
periodically during therapy to determine effectiveness of medication.

Indacaterol

DRUG- arcapta neohaler

DOSAGE- 75 mcg inhaled orally qDay

THERAPEUTIC ACTION- stimulating adrenergic beta-2 receptors in the smooth muscle of the
airways. This causes relaxation of the muscle, thereby increasing the diameter of the airways,
which become constricted in asthma and COPD.

ADVERSE EFFECTS- cough, sore throat, runny nose, headache.

Nausea, shaking of a part of the body that you cannot control, nervousness

difficulty falling asleep or staying asleep.

CONTRAINDICATION- thyrotoxicosis, diabetes, low amount of potassium in the blood.

high blood pressure, diminished blood flow through arteries of the heart, prolonged QT interval
on EKG, abnormal heart rhythm, abnormal EKG with QT changes from birth.

NURSING CONSIDERATIONS- It is used to treat COPD (chronic obstructive pulmonary

disease).

This medicine is not to be used to treat intense flare-ups of shortness of breath. Use a rescue
inhaler. Talk with the doctor.
Dobutamine

DRUG- dobutamine

DOSAGE- infusion solution, in D5W

100mg/100mL

200mg/100mL

400mg/100mL

injectable solution

12.5mg/mL

THERAPEUTIC ACTION- stimulates heart muscle and improves blood flow by helping the
heart pump better. Dobutamine is used short-term to treat cardiac decompensation due to
weakened heart muscle. Dobutamine is usually given after other heart medicines have been tried
without success.

ADVERSE EFFECTS- increased heart rate and increased blood pressure ,ventricular ectopic
activity,

Nervousness ,headache ,nausea, vomiting, palpitations, low platelet counts (thrombocytopenia),

CONTRAINDICATION- contraindicated in patients with acute myocardial infarction, unstable

angina, left main stem disease, severe hypertension, arrhythmias, acute myocarditis or
pericarditis, hypokalemia and idiopathic hypertrophic sub-aortic stenosis

NURSING CONSIDERATIONS-

 Observe IV site closely and avoid extravasation. Dobutamine can cause

inflammatory response and tissue ischaemia.

 Monitor for adverse reactions.

 Continuous blood pressure monitoring.

  Continuous cardiorespiratory monitoring.

 Document vital signs hourly and PRN.

 Monitor fluid balance.

Terbutaline

Drug - Brethaire, Brethine, Bricanyl, Bricanyl Turbuhaler

Dose-Adults and adolescents age 15 and over. 2.5 to 5 mg three times a day at 6-hr

intervals while awake. Maximum: 15 mg daily.

Children ages 12 to 15. 2.5 mg three times a day at 6-hr intervals while awake.

Maximum: 7.5 mg daily.

Children ages 6 to 11. 50 to 75 mcg/kg three times a day at 6-hr intervals while

awake. Maximum: 150 mcg/kg/dose or 5 mg daily.

Therapeutic Action- to prevent and treat wheezing, shortness of breath, and chest tightness
caused by asthma, chronic bronchitis, and emphysema. Terbutaline is in a class of medications
called beta agonists. It works by relaxing and opening the airways, making it easier to breathe.

Adverse effect

CNS: Anxiety, dizziness, drowsiness, headache, insomnia, light-headedness,

nervousness, restlessness, tremor, weakness

CV: Chest pain, irregular heartbeat, palpitations, tachycardia

EENT: Dry mouth, taste perversion

ENDO: Hyperglycemia

GI: Heartburn, nausea, vomiting

MS: Muscle spasms

RESP: Dyspnea

SKIN: Diaphoresis, flushing, rash

Contraindication- Hypersensitivity to terbutaline, other sympathomimetic amines, or their

components.

Nursing consideration-

 Use terbutaline cautiously in patients with cardiovascular disease because drug can
adversely affect cardiovascular function. Monitor patient’s heart rate and rhythm
and blood pressure, and assess for chest pain.
 For subcutaneous use, inject into lateral deltoid area.
 Assess patient’s respiratory rate, depth, and quality; oxygen saturation; and activity
tolerance at regular intervals because continuous use of beta2-agonists for 12 months or
longer accelerates the decline in pulmonary function.

Isoxsuprine

Drug- vasodilan

Dose- oral tablet (10 mg; 20 mg)

Therapeutic Action- causes direct relaxation of uterine and vascular smooth muscle. Its
vasodilating actions are greater on the arteries supplying skeletal muscle than on those supplying
skin. It is used in the treatment of peripheral vascular disease and in premature labor.

Adverse effect- weakness, dizziness, flushing (feeling of warmth),upset stomach, vomiting.

stomach pain.

Contraindication- It is contraindicated in patients who have cardiovascular disease (especially

arrhythmias), hyperthyroidism, chorioamnionitis, bleeding, and eclampsia or severe pre-
eclampsia

Nursing consideration-
  Monitor for therapeutic effectiveness: Response to treatment of peripheral
vascular disorders may take several weeks. Evaluate clinical manifestations of
arterial insufficiency.
 Monitor BP and pulse; may cause hypotension and tachycardia. Supervise ambulation.
 Observe both mother and baby for hypotension and irregular and rapid heartbeat if
isoxsuprine is used to delay premature labor. Hypocalcemia, hypoglycemia, and
ileus have been observed in babies born of mothers taking isoxsuprine.

DIRECT-ACTING CHOLINERGIC AGONISTS

Bethanechol

Drug- duvoid, urecholie

Dose- Adults. 10 to 50 mg three times daily or four times daily. To determine minimum

effective dose: 5 to 10 mg repeated every hour until response is obtained or maximum of 50 mg

is reached.

Therapeutic action-acts principally by producing the effects of stimulation of the

parasympathetic nervous system. It increases the tone of the detrusor urinae muscle, usually
producing a contraction sufficiently strong to initiate micturition and empty the bladder.

Adverse effect-

CNS: Headache, malaise

CV: Hypotension with reflex tachycardia, vasomotor

response EENT: Excessive salivation, lacrimation, miosis

GI: Abdominal cramps, colicky pain, diarrhea, eructation, nausea, vomiting

GU: Urinary urgency

RESP: Asthma attack, bronchoconstriction

Contraindication- Acute inflammatory lesions of GI tract, bronchial asthma, coronary artery

disease, epilepsy, hypersensitivity to bethanechol or its components, hyperthyroidism, marked

vagotonia, mechanical obstruction of GI or GU tract, Parkinson’s disease, peptic ulcer disease,
peritonitis, pronounced bradycardia or hypotension, questionable integrity of GI or GU mucosa,
spastic GI disorders, vasomotor instability

Nursing consideration-

 Assess urine elimination before starting bethanechol therapy.

 Give oral bethanechol 1 hour before or 2 hours after meals to reduce risk of nausea and
vomiting.

Cevimeline

Drug- evoxac

Dose- 30mg

Therapeutic action- a cholinergic agonist which binds to muscarinic receptors. Muscarinic

agonists in sufficient dosage can increase secretion of exocrine glands, such as salivary and
sweat glands and increase tone of the smooth muscle in the gastrointestinal and urinary tracts.

Adverse effect- Sweating, nausea, runny nose, flushing, frequent urge to urinate, dizziness,
weakness, diarrhea, and blurred vision may occur. If any of these effects persist or worsen, tell
your doctor or pharmacist promptly. This medication may cause an increase in tears. This can be
helpful if you have dry eyes.

Contraindication- inflammation of the iris - the colored part of the eyeball, closed angle
glaucoma, decreased vision at night, a decrease in sharpness of vision called reduced visual
acuity, a heart attack, non-Q wave heart attack, angina, a type of chest pain, abnormal heart
rhythm.

Nursing consideration- Instruct patient to take cevimeline as directed. May cause visual
disturbances, especially at night, that could impair ability to drive safely. Advise patient to drink
extra water if sweating excessively. May cause dehydration.
INDIRECT-ACTING CHOLINERGIC AGONISTS ( AGENTS for MYASTHENIA
GRAVIS )

Pyridostigmine

Drug- mestinon

Dose- 60 mg

Therapeutic action- used to improve muscle strength in patients with a certain muscle disease
(myasthenia gravis). It works by preventing the breakdown of a certain natural substance
(acetylcholine) in your body. Acetylcholine is needed for normal muscle function.

Adverse effect- stomach pain, nausea, vomiting, diarrhea, muscle cramps, twitching;

sweating, increased salivation, cough with mucus, rash, or blurred vision.

Contraindication- General Information, Bromide hypersensitivity, Bladder obstruction, GI

obstruction, ileus, urinary tract obstruction, Cholinesterase inhibitor toxicity, Asthma,
bradycardia, cardiac arrhythmias, chronic obstructive pulmonary disease (COPD), glaucoma,
hypertension, Neonates, Renal disease.

Nursing consideration-

 Report increasing muscular weakness, cramps, or fasciculations. Failure of patient to

show improvement may reflect either underdosage or overdosage.
 Observe patient closely if atropine is used to abolish GI adverse effects or other
muscarinic adverse effects because it may mask signs of overdosage (cholinergic
crisis): Increasing muscle weakness, which through involvement of respiratory muscles
can lead to death.
 Monitor vital signs frequently, especially respiratory rate.
 Observe for signs of cholinergic reactions (see Appendix F), particularly when
drug is administered IV.
 Observe neonates of myasthenic mothers, who have received pyridostigmine, closely for
difficulty in breathing, swallowing, or sucking.
 Observe patient continuously when used as muscle relaxant antagonist. Airway and
respiratory assistance must be maintained until full recovery of voluntary respiration and
neuromuscular transmission is assured. Complete recovery usually occurs within 30
min.
Neostigmine

Drug- prostigmin

Dose- 15 mg

Therapeutic Action- Allows intensified and prolonged effect of acetylcholine at cholinergic

synapses (basis for use in myasthenia gravis). Also produces generalized cholinergic response
including miosis, increased tonus of intestinal and skeletal muscles, constriction of bronchi and
ureters, slower pulse rate, and stimulation of salivary and sweat glands.

Adverse Effect- salivation, increased mucus, muscle twitching, bowel or abdominal cramps,

nausea, vomiting, diarrhea, decreased pupil size

Contraindication- Hypersensitivity to neostigmine, cholinergics, or bromides; bradycardia,

hypotension; mechanical obstruction of intestinal or urinary tract; peritonitis; administration with
other cholinergic drugs; pregnancy (category C), lactation.

Nursing consideration-

 Check pulse before giving drug to bradycardic patients. If below 60/min or other
established parameter, consult physician. Atropine will be ordered to restore
heart rate.
 Monitor pulse, respiration, and BP during period of dosage adjustment in treatment
of myasthenia gravis.
 Report promptly and record accurately the onset of myasthenic symptoms and drug
adverse effects in relation to last dose in order to assist physician in determining
lowest effective dosage schedule.
 Reduce possible GI (muscarinic) side effects, which occur especially during early
therapy, by giving drug with milk or food. Physician may prescribe atropine or
other anticholinergic agent to suppress side effects (note: these drugs may mask
toxic symptoms of neostigmine).
 Note time of muscular weakness onset carefully in myasthenic patients. It may indicate
whether patient is in cholinergic or myasthenic crisis: Weakness that appears
approximately 1 h after drug administration suggests cholinergic crisis (overdose) and
is treated by prompt withdrawal of neostigmine and immediate administration of
atropine. Weakness that occurs 3 h or more after drug administration is more likely due
to myasthenic crisis (underdose or drug resistance) and is treated by more intensive
anticholinesterase therapy.
  Record drug effect and duration of action. S&S of myasthenia gravis relieved by
neostigmine include lid ptosis; diplopia; drooping facies; difficulty in chewing,
swallowing, breathing, or coughing; and weakness of neck, limbs, and trunk muscles.
 Manifestations of neostigmine overdosage often appear first in muscles of neck and those
involved in chewing and swallowing, with muscles of shoulder girdle and upper
extremities affected next.
 Monitor respiration, maintain airway or assisted ventilation, and give oxygen as
indicated, when used as antidote for tubocurarine or other nondepolarizing
neuromuscular blocking agents (usually preceded by atropine). Respiratory assistance is
continued until recovery of respiration and neuromuscular transmission is assured.
 Report to physician if patient does not urinate within 1 h after first dose when used to
relieve urinary retention.

AGENTS for ALZHEIMER’S DISEASE

Donepezil

Drug- aricept

Dose-5 mg, 10 mg tablets and orally disintegrating tablets

Therapeutic Action- Aricept, a cholesterase inhibitor, presumably elevates

acetylcholine concentration in the cerebral cortex by slowing degradation of
acetylcholine released by remaining intact neurons

Adverse Effect- nausea, vomiting, diarrhea, loss of appetite, weight loss.

frequent urination, difficulty controlling urination, muscle cramps.

Contraindication- Hypersensitivity to donepezil or tracine; pregnancy (category C), lactation;

children; GI bleeding, jaundice.

Nursing consideration-

 Monitor therapeutic effectiveness: Improvement as noted on the Alzheimer's

Disease Assessment Scale.
 Monitor closely for S&S of GI ulceration and bleeding, especially with concurrent use
of NSAIDS.
 Monitor carefully patients with a history of asthma or obstructive pulmonary disease.
 Monitor cardiovascular status; drug may have vagotonic effect on the heart,
causing bradycardia, especially in presence of conduction abnormalities.
Rivastigmine

Drug- exelon

Dose- 2 mg/mL solution

Therapeutic Action- The G1 form of acetylcholinesterase is found in higher levels in the brains
of patients with Alzheimer's disease. Rivastigmine inhibits acetylcholinesterase more specifically
in the brain (hippocampus and cortex) than the heart or skeletal muscle.

Adverse Effect- nausea, vomiting, loss of appetite, heartburn or indigestion, stomach pain.

weight loss, diarrhea, constipation.

Contraindication- Hypersensitivity to rivastigmine or carbamate derivatives; lactation.

Nursing consideration-

 Monitor cognitive function and ability to perform ADLs.

 Monitor for and report S&S of GI distress: Anorexia, weight loss, nausea and vomiting.
 Lab tests: Periodic ECG, serum electrolytes, Hgb & Hct, urinalysis, blood glucose
HbA1C, especially with long-term therapy.
 Monitor ambulation as dizziness is a common adverse effect.
 Monitor diabetics for loss of glycemic control

2.Search for 2 new drugs for each classification of ANS drugs not discussed in this course
unit and include them in the drug study.

Beta 2

Hexoprenaline

Drug-

Dose - 100-200 mcg up to 6 times/day by aerosol inhalation.

Therapeutic action- is a stimulant of beta 2 adrenergic receptors. It is used as a

bronchodilator, antiasthmatic, and tocolytic agent.

Adverse effects- Occasionally, tachycardia. Palpitation and skeletal muscle tremor (on high
and cumulative doses)
 Contraindication- Heavy genital haemorrhage, premature separation of the placenta, intra-
uterine infections, severe myocardial insufficiency.

Nursing consideration-

Pseudoephedrine

Drug- Sudafed, Nexafed, Zephrex-D

Dose- 30 mg, 60 mg tablets; 120 mg, 240 mg sustained release tablets; 15 mg/5 mL, 30 mg/5
mL liquid; 7.5 mg/0.8 mL drops

Therapeutic action- Effective as a nasal decongestant.

Adverse effects- Nausea, vomiting, trouble sleeping, dizziness, headache, or nervousness may
occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Stop
taking this medication and tell your doctor promptly if you have dizziness, nervousness, or
trouble sleeping.

Contraindication- Hypersensitivity to sympathomimetic amines; severe hypertension; coronary

artery disease; use within 14 d of MAOIs; glaucoma; hyperthyroidism; prostatic hypertrophy.
Safety during pregnancy (category C), lactation, or in children <6 y is not established.

Nursing consideration-

 Monitor HR and BP, especially in those with a history of cardiac

disease. Report tachycardia or hypertension.

DIRECT-ACTING CHOLINERGIC AGONISTS

Methacholine

Drug- provocholine

Dose – 25 mg

Therapeutic action- non-specific cholinergic agonist (parasympathomimetic) that acts

through muscarinic receptors in the lungs to induce bronchoconstriction, which is more
significant in patients with asthma than those without

Adverse effects- Headache, sore throat, lightheadedness, nausea, vomiting, or dizziness may
occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.
Remember that your doctor has prescribed this medication because he or she has judged that
the benefit to you is greater than the risk of side effects

Contraindication- Absolute contraindications include FEV1 less than 1.5 L in adults, less
than 1 L in children, recent severe acute asthma, myocardial infarction or cerebral vascular
accident within 3 months, and arterial aneurysm

Nursing consideration- Besides monitoring the patient's vital signs and oxygenation, the
nurse should document the test; when it started, what was injected, and when the test was
terminated. Also, the respiratory status of the patient during and after the test requires full
documentation by the nurse.

Acetylcholine

Drug- miochol e

Dose – 20 mg

Therapeutic action- It has a role as a vasodilator agent, a muscarinic agonist, a hormone, a

human metabolite, a mouse metabolite and a neurotransmitter. It is an acetate ester and an
acylcholine. Acetylcholine is a Cholinergic Receptor Agonist. The mechanism of action
of acetylcholine is as a Cholinergic Agonist.

Adverse effects- slow heart rate, flushing, low blood pressure (hypotension)

breathing difficulty, sweating.

Contraindication- contraindicated in any patient with a known hypersensitivity to

acetylcholine or any of the product components. Acetylcholine use should be avoided in
patients with acute iritis and acute inflammatory disease of the anterior chamber

Nursing consideration-

Anticholinergic Agents /

Parasympatholytics Oxybutynin

Drug- ditropan

Dose - 5 mg tablets; 5 mg, 10 mg sustained-release tablets; 5 mg/5 mL syrup; 3.9 mg/d

transdermal patch

Therapeutic action- Prominent antispasmodic activity

Adverse effects- dry mouth, blurred vision, dry eyes, nose, or skin,stomach pain
Constipation, diarrhea, nausea, heartburn, gas, change in ability to taste food, headache,
dizziness, weakness, confusion, sleepiness, difficulty falling asleep or staying asleep,
nervousness, flushing, swelling of the hands, arms, feet, ankles, or lower legs

back or joint pain

Contraindication - Hypersensitivity of oxybutynin; narrow angle glaucoma, myasthenia

gravis, partial or complete GI obstruction, gastric retention, paralytic ileus, intestinal atony
(especially older adult or debilitated patients), megacolon, severe colitis, GU obstruction,
urinary retention, unstable cardiovascular status.

Nursing consideration-

 Periodic interruptions of therapy are recommended to determine patient's need for

continued treatment. Tolerance has occurred in some patients.
 Keep physician informed of expected responses to drug therapy (e.g., effect on
urinary frequency, urgency, urge incontinence, nocturia, completeness of
bladder emptying).
 Monitor patients with colostomy or ileostomy closely; abdominal distension and the
onset of diarrhea in these patients may be early signs of intestinal obstruction or of toxic
megacolon

Orphenadrine

Drug- norflex

Dose - 100 mg tablets; Relaxes tense skeletal muscles indirectly, possibly by analgesic action
or by atropinelike central action. Has some local anesthetic and antihistaminic activity but
less than that of diphenhydramine. Also produces slight euphoria. 100 mg sustained-release
tablets; 30 mg/mL injection

Therapeutic action-

Adverse effects- dry mouth, drowsiness, dizziness or lightheadedness, upset stomach

Vomiting, constipation, difficulty urinating, blurred vision, headache

Contraindication- Narrow-angle glaucoma; pyloric or duodenal obstruction, stenosing peptic

ulcers; prostatic hypertrophy or bladder neck obstruction; myasthenia gravis; cardiospasm
(megaloesophagus). Safe use during pregnancy (category C), lactation, or in the pediatric age
group is not established.

Nursing consideration-

 Lab tests: Periodic blood, urine, and liver function studies with prolonged therapy.
 Report complaints of mouth dryness, urinary hesitancy or retention, headache, tremors,
GI problems, palpitation, or rapid pulse to physician. Dosage reduction or drug
withdrawal is indicated.
 Monitor elimination patterns. Older adults are particularly sensitive to
anticholinergic effects (urinary hesitancy, constipation); closely observe.
 Monitor therapeutic drug effect. In the patient with parkinsonism, orphenadrine reduces
muscular rigidity but has little effect on tremors. Some reduction in excessive
salivation and perspiration may occur, and patient may appear mildly euphoric.