CHAPTER 30

Adrenergic Agonists
LEARNING OBJECTIVES:
• Describe two ways that sympathomimetic drugs act to produce effects at adrenergic
receptors.
• Describe the therapeutic actions, indications, pharmacokinetics, contraindications, most
common adverse reactions, and important drug–drug interactions associated with
adrenergic agonists.
• Discuss the use of adrenergic agents across the lifespan.
• Compare and contrast the prototype drugs dopamine, phenylephrine, and isoproterenol
with other adrenergic agonists.
• Outline the nursing considerations, including important teaching points, for patients
receiving an adrenergic agent.

1. Ms. Cruz is an 80-year-old in the critical care unit receiving treatment for shock. She is
currently receiving Dopamine at 10 mcg/kg/min and Dobutamine at 10 mcg/kg/min with a
stable blood pressure and heart rate. Currently, she is not able to interact with family or the
health care team. Her medical history includes mild heart failure and mild hypertension, which
are treated with oral medications. She has many family members with her, including a son who
is using the Internet to gather information on her medications.
a. The son asks why his mother is on dopamine and dobutamine “when they are the same
medication.” How do you answer his question?
- Dopamine-dobutamine integration or combination raised mean arterial pressure (p less
than 0.05), maintained normal inspiratory pressure and avoided hypertension or shock
worsening.

b. If the dopamine and dobutamine reach the maximum therapeutic range, what
medication would you anticipate adding to help maintain blood pressure, heart rate, and tissue
perfusion?
- After the maximal levels of dopamine and dobutamine have been achieved, another drug called
norepinephrine can be utilized. This is a favored vasoactive, especially for shock patients.
-
2. Mr. Cruz has been prescribed phenylephrine drops for his glaucoma. He calls the clinic very
upset that the drops burn his eyes. After careful questioning, Mr. Jones admits that he was not
willing to pay for prescription eye drops and decided to use the over-the-counter nasal drops
because “they are the same drug.”

a. What patient teaching is essential in the situation?

- Mr. Jones should be educated on the importance of sticking to a physician's prescriptions and
medication adherence. Mr. Jones' treatment adherence is primarily reliant on following
prescriptions and taking prescribed medicines.
 CHAPTER 30
b. Explain the differences in how phenylephrine is used to treat
glaucoma and shock.
- In the treatment of shock, phenylephrine acts as a vasopressor by reducing the mean heart
rate. Phenylephrine treats glaucoma by constricting blood vessels, particularly those in the
eyes, causing the pupils to dilate. When used to treat glaucoma, phenylephrine works as a
decongestant, shrinking the blood vessels in the eye. When used to treat shock, phenylephrine
has a high affinity for binding to blood vessels, reducing the amount of hypertension that might
induce shock.

3. A child has been prescribed the adrenergic agonist Albuterol be taken at home.
What teaching is essential to provide to the parents who may seek over-the-counter allergy and
cold preparations for their child?

- I believe that drug adherence and consultation with a physician are crucial services to give to
parents. The parents of this child should be well informed on how to take the appropriate
medication at the appropriate dose. Drug adherence is a critical component in choosing the
proper medication. As a result, parents should always obtain medical advice before
administering any over-the-counter medication to their children. This will be useful in resolving
issues such as medication side effects.
 CHAPTER 31
Adrenergic Antagonists
LEARNING OBJECTIVES
• Describe the effects of adrenergic blocking agents on adrenergic receptors, correlating
these effects with their clinical effects.
• Describe the therapeutic actions, indications, pharmacokinetics, contraindications and
cautions, most common adverse reactions, and important drug–drug interactions
associated with adrenergic blocking agents.
• Discuss the use of adrenergic blocking agents across the lifespan.
• Compare and contrast the prototype drugs labetalol, phentolamine, doxazosin,
propranolol, and atenolol with other adrenergic blocking agents.
• Outline the nursing considerations, including important teaching points, for patients
receiving an adrenergic blocking agent.

1. Mr. Cruz is a 50-year-old male with diabetes. He has been

diagnosed with hypertension and congestive heart failure and is
prescribed carvedilol (Coreg) 6.25 mg orally b.i.d.

a. What are the key teaching points for Mr. Rodriguez about carvedilol?
Teach him the possible contraindications in taking this medication. This includes a history of
severe hypersensitivity reactions to this medication or other medications containing carvedilol,
such as Stevens-Johnson syndrome, anaphylactic reaction, or angioedema, Bronchial asthma, and
bronchospasm.
- Treatment is required for chronic obstructive pulmonary disease (COPD), 2°/3° AV block, sick
sinus syndrome without a permanent pacemaker, cardiogenic shock, severe bradycardia,
decompensated heart failure requiring IV inotrope medicine, and severe hepaticimpairment.

b. Explain why carvedilol is the preferred drug to treat Mr. Cruz for his combined hypertension
and congestive heart failure.
- Carvedilol works by stopping natural chemicals in your body, such as epinephrine, from acting on
your heart and blood arteries, making it useful in the treatment of hypertension and heart disease.
As a result of this impact, your heart rate, blood pressure, and cardiac strain are lowered.
Approximately 90% of the peak drop in BP is noted at the time of the second dosage. Furthermore,
clinical investigations have demonstrated that carvedilol 25 mg once day decreases arterial blood
pressure in people with moderate and severe hypertension better than the standard beta-blocker
atenolol. Carvedilol can be used alone or in combination with other drugs to treat hypertension.
Because of high blood pressure, the heart and arteries must work harder.
 CHAPTER 31
2. Mr. Cruz has been taking betaxolol 20 mg orally daily to treat his hypertension. He arrives for
a routine follow-up and expresses dissatisfaction because he feels “weak, dizzy, and tired when
taking the drug.”

a. What adjustments can be made to help Mr. Cruz deal with the adverse effects of betaxolol?
- Mr. Caraglione should be instructed to gently rise from a sitting or reclining position to lessen
the possibility of experiencing lightheadedness and dizziness. Because this drug may limit
blood flow to the hands and feet, causing them to feel chilly, Mr. Caraglione should also be
clothed warmly. This impact may be exacerbated by smoking, thus he should refrain from
using tobacco entirely. He should avoid driving, using machinery, or engaging in any activity
that needs attentiveness while taking the drug. At all costs, sedatives and alcoholic beverages
should be avoided. Also, keep a watch on how much Mr. Caraglione's blood pressure has
decreased after starting Betaxolol, so you might perhaps reduce the dose.

b. Further investigation has determined that Mr. Cruz’s symptoms have increased since he
started taking ginseng. What are the drug–drug interactions for patients taking ginseng and
betaxolol?
- Ginseng is the most often utilized herbal medicine for immune system activation and as an
adjunct to pharmaceutical drugs due to its various pharmacologic actions. It is critical to
research the therapeutic benefits of ginseng as well as its interactions with medications. The
ginseng supplement has a substantial effect on the heart rate and diastolic blood pressure
during activity, as well as the systolic blood pressure at rest and during exercise. This suggests
that ginseng enhances exercise-induced heart rate and blood pressure, as well as cardiac
output and blood circulation, which boosts oxygen supply to active muscles. It is also critical
to be aware of any potential interactions between herbs and prescription medications.
Because practically all HMPs, even single-herb preparations, include combinations of
pharmacologically active ingredients, herb-drug interactions are more frequent than drug-
drug interactions.
 CHAPTER 32
Cholinergic Agonists
LEARNING OBJECTIVES
• Describe the effects of cholinergic receptors, correlating these effects with the clinical
effects of cholinergic agonists.
• Describe the therapeutic actions, indications, pharmacokinetics, contraindications and
cautions, most common adverse reactions, and important drug–drug interactions
associated with the direct- and indirect-acting cholinergic agonists.
• Discuss the use of cholinergic agonists across the lifespan.
• Compare and contrast the prototype drugs bethanechol, donepezil, and pyridostigmine
with other cholinergic agonists.
• Outline the nursing considerations, including important teaching points, for patients
receiving a cholinergic agonist.

James is 10 years old with a history of spina bifida. He has been performing self-catheterizations
for the last 2 years. During his last clinic visit, he was started on bethanechol for neurogenic
bladder.

a. How does bethanechol treat neurogenic bladder?

- Patients with incomplete motor paralytic bladder with coordinated sphincter, sensory
paralytic bladder with decompensation, the recovery phase of spinal shock when the
periurethral striated muscle has recovered and is under voluntary control, and the early phase
of coordinated reflex neurogenic bladder and sphincter when there is incomplete bladder
emptying due to feeble or unstained detrusor contractions can all benefit from bethanechol.

b. What are the adverse effects of bethanechol and other direct-acting cholinergic agonists?
- Bethanechol and other direct-acting cholinergic agonists produce cardiovascular side effects such
as bradycardia, heart block, hypotension, and cardiac collapse. Nausea, vomiting, cramping,
diarrhea, increased salivation, urine urgency, flushing, and increased perspiration are all possible
side effects.
 CHAPTER 32
Cholinergic Agonists
2. Ms. Cruz has myasthenia gravis and will be switching from neostigmine to pyridostigmine to
help with compliance. She is concerned about missing doses and taking the medication
correctly.

a. What are some dosing concerns with pyridostigmine, and what are the key teaching
points?
- Dosing concerns with pyridostigmine include extreme muscular weakness, loss of mobility in
any area of your body, shallow or weak breathing, slurred speech, visual difficulties, and
worsening or no improvement in myasthenia gravis symptoms. The essential takeaway is to
take the drug (pyridostigmine) even if you feel OK. Swallow the extended-release pills
completely. Take pyridostigmine precisely as prescribed by your doctor, and do not take more
or less of it.

b. Ms. Cruz is scheduled for a follow-up diagnostic exam using edrophonium. Explain how
edrophonium is used in diagnosingmyasthenia gravis.
- A Tensilon test can be used to identify myasthenia gravis, a neuromuscular disorder
characterized by muscle weakness. Following a Tensilon (edrophonium) injection, your
muscular strength is evaluated to establish whether myasthenia gravis is to blame for your
weakness.
 CHAPTER 33
Anticholinergic Agents

LEARNING OBJECTIVES
• Define anticholinergic agents.
• Describe the therapeutic actions, indications, pharmacokinetics, contraindications and
cautions, most common adverse reactions, and important drug–drug interactions of
anticholinergic agents.
• Discuss the use of anticholinergic agents across the lifespan.
• Compare and contrast the prototype drug atropine with other anticholinergic agents.
• Outline the nursing considerations, including important teaching points, for patients
receiving anticholinergic agents.

1. Mr. Cruz will undergo eye surgery for a torn retina. The ophthalmologist has ordered
ophthalmicatropine drops for mydriasis prior to the procedure.

a. What are the key nursing considerations when administering mydriatics to patients with
dark-pigmented eyes?
- To achieve appropriate dilatation, dark-pigmented eyes may require much longer time and
mydriatic drops.

b. What teaching will Mr. Cruz need related to postoperativemydriasis?

- Appropriate mydriasis and inflammatory management are critical for successful intraocular
lens (IOL) exchange surgery. To achieve these goals, a variety of topical and/or intracameral
medications have been utilized to dilate the pupil and treat postoperative discomfort and
inflammation.

2. Ms. Cruz is planning a vacation cruise and is concerned about motion sickness. She has been
prescribed a scopolamine patch.

a. Explain the proper method for applying a transdermal patch.

- Scopolamine transdermal patches are used to treat nausea and vomiting caused by surgery,
narcotic pain relievers, or anesthesia. It is also used to alleviate nausea and vomiting caused by
motion sickness. When administering a new patch, always remove the existing one before
applying the new one. To avoid medication contamination, gloves should always be worn when
removing and putting a Fentanyl patch. If the patient sweats a lot, has oily skin, or the patch is
put in a high-friction location, you may need to tape or apply tegaderm to keep it from sliding
off.

b. What are the potential adverse effects of a scopolaminetransdermal patch?

- You may experience enlarged pupils and impaired vision while your body adjusts to the
medicine. Mild itching or redness at the application site, tiredness, dizziness, diarrhea, and dry
mouth are also possible side effects.

Reference: Karch, A. M. (2019). Focus on Nursing Pharmacology (8th Edition). Wolters Kluwer Health.