ST.

LUKE’S COLLEGE OF NURSING

1st Semester
School Year: 2021-2022

GENERAL DISCUSSION SCHEDULE

COURSE CODE : NCM 106

COURSE TITLE : Pharmacology
LESSON NUMBER : 03 – Autonomic Nervous System (ANS) Drugs
TIME ALLOTMENT : 3 Hours
PRESCRIBED FLO : Preferred: e-Learning (E1, E2)
Alternative: Modular (M2)

TOPIC LEARNING OUTCOMES:

After the end of the lesson, the student should be able to:

1. Review the anatomy and physiology of the autonomic nervous system

2. Discuss, distinguish, and identify the various nursing responsibilities and patient education on adrenergic and cholinergic drugs
3. Highlight protocols for nursing responsibilities of administering ANS medications for geriatric patients

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 Activities Strategies TA Remarks
1 ATTENTION Open the class with updates on school matters and today’s topic 5 minutes

2 OBJECTIVE Discussion of the learning objectives for the day 5 minutes

3 RECALL Ask the class on what medications they or any family members usually take. Ask on 5 minutes
what they know about the medications they mentioned.
4 STIMULUS Deliver a 2-hour lecture 120 minutes

5 GUIDANCE Open the discussion for any inquiries from the class 5 minutes

6 PERFORMANCE Conduct a 10-item post-test 10 minutes

7 FEEDBACK Rationalize post-test answers 10 minutes

8 ASSESSING Conduct an pre-test 10 minutes

9 RETENTION Summarize the lesson, highlighting the salient points. 10 minutes

LESSON/TOPIC DISCUSSION

Learning Resources:
1. eBook
o Pharmacology: A Patient-Centered Nursing Process Approach, 9e by Linda E. McCuistion, Saunders (2017), Edition: 9
o Pharmacology and the Nursing Process by Lilley, L., Collins, S. & Snyder, J. (2017). 8th ed. St. Louis, Missouri: Elsevier.
o Mosby's 2020 Nursing Drug Reference, 33rd ed. by Linda Skidmore-Roth, St. Louis, MO : Elsevier (2020), Edition: 33
o Introducing Pharmacology: For Nursing and Healthcare by Roger McFadden, Routledge (2019), Edition: 3
o Pathophysiology and Pharmacology in Nursing (Transforming Nursing Practice Series) by Sarah Ashelford, Learning Matters (2019), Edition:
Second
o Lippincott NCLEX-RN Pharmacology Review by Hill
2. Scanned Reference Books
o PHARMACOLOGICAL REVIEWS Vol. 59, No. 4. 2007 by The American Society for Pharmacology and Experimental Therapeutics 70102/3301314
o Pharmacol Rev 59:289 –359, 2007
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 3. Online Resources
o Philippine Drug Enforcement Agency. Laws and Regulations. https://pdea.gov.ph/laws-and-
regulations#:~:text=WHEREAS%2C%20by%20virtue%20of%20the,chemicals%20as%20provided%20in%20R.A.

LESSON 3 TOPICS:
A. The Autonomic Nervous System (ANS)
B. Adrenergic Agonists
C. Adrenergic Antagonists
D. Cholinergic Agonists
E. Cholinergic Antagonists

ACTIVITY 1: INTRODUCTION
• Open the class with updates on school matters and today’s topic

ACTIVITY 2: PRE-TEST

DIRECTIONS: Read each questions below and choose the letter that best describe the answer for each.

1. The use of atropine for treatment of symptomatic bradycardia is contraindicated for a client with which of the following conditions?
a. Urinary incontinence
b. Glaucoma
c. Increased intracranial pressure
d. Right sided heart failure

2. Drugs which may be used to terminate paroxysmal supraventricular tachycardia:

a. Adenosine
b. Calcium channel blockers
c. Esmolol
d. Methoxamine
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 3. Which group of drugs mimics parasympathetic activity?
a. Cholinergic agents
b. Anticholinergic agents
c. Adrenergic agents
d. Antiadrenergic agents

4. A client is ordered an anticholinergic agent, atropine, to be administered preoperatively. Which physiological effect should the nurse monitor for?
a. Elevate blood pressure
b. Dry secretions
c. Reduce heart rate
d. Enhance sedation

5. Cholinergics are contraindicated in:

a. Tachycardia
b. Hypothyroidism
c. Hypotension
d. Asthma

6. Nurse Angelia is administering an adrenergic agent, albuterol (Proventil), to a child with asthma. Which of the following assessments by the nurse
indicate the need for an adjustment of the medication?
a. Lethargy and fatigue
b. Edema is the lower extremities
c. Apical Pulse of 112
d. Temperature of 39 degrees Celsius

7. Following norepinephrine (Levophed) administration, it is essential to the nurse to assess:

a. electrolyte status
b. color and temperature of toes and fingers
c. capillary refill
d. ventricular arrhythmias

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 8. Norepinephrine (Levophed) is contraindicated in which of the following conditions?
a. Hypovolemic shock
b. Neurogenic shock
c. Blood pressures above 80-100 mmHg (systolic)
d. Decreased renal perfusion

9. When administering dopamine (Intropin), it is most important for the nurse to know that:
a. The drug’s action varies according to the dose.
b. The drug may be used instead of fluid replacement.
c. The drug cannot be directly mixed in solutions containing bicarbonate or aminophylline.
d. The lowest dose to produce the desired effect should be used.

10. Dobutamine (Dobutrex) improves cardiac output and is indicated for use in all of the following conditions except:
a. septic shock
b. congestive heart failure
c. arrhythmias
d. pulmonary congestion

ACTIVITY 3: AUTONOMIC NERVOUS SYSTEM (ANS) MEDICATIONS

A. The Autonomic Nervous System (ANS)

• Autonomic Nervous System

o Controls involuntary body functions, glands, and organs
o Cardiac muscles, smooth muscles of blood vessels, eyes, stomach and intestines
• Sympathetic Nervous System
o Adrenergic* System
• Parasympathetic Nervous System
o Cholinergic* System
• Functions of Sympathetic System
o Helps body cope with external stimuli and stress
o Triggers fight-or-flight response
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 o Works to save energy
o Activates GI system, (aids in digestion)
o Supports restorative body functions
• ANS Neurotransmitters - endogenous chemicals that transmit signals from one neuron (nerve cell) to another "target" neuron, muscle cell, or gland cell.
o Acetylcholine, Norepinephrine
• Acetylcholine
o Released from the axons of the preganglionic neurons in response to stress
o Stimulates postganglionic neurons, causing release of epinephrine and norepinephrine
• Norepinephrine
o Released from postganglionic neurons
o Caused sympathetic stimulation by triggering the release of epinephrine and more norepinephrine
o Produces its effect by combining with adrenergic receptors in effector organs
• Receptors
o Specialized target macromolecule that binds a drug and mediates its pharmacological action.
o Ex. enzymes, nucleic acids, or specialized membrane-bound proteins.
o The formation of the drug-receptor complex leads to a biological response.
• Types of Receptor Drugs
o Agonist
o Antagonist
o Selective
o Non-Selective
• Receptor Site – Proteins that are on the surface of each cell that act as receivers of chemical messenger molecules in the intercellular fluid surrounding
every cell.
• Agonists – activate receptors to produce the desired response; drugs that produce a similar response
• Antagonists – prevent receptor activation; drugs that block a response
• Remember! The drug agonist that has an exact fit with a receptor is a strong agonist and is more biologically active
• ANS Drug Pathway
1. Stress triggers ANS
2. ANS releases acetylcholine from preganglionic neuron
3. Acetylcholine triggers release of epinephrine and norepinephrine (as neurotransmitters) from postganglionic neuron
4. Epinephrine and norepinephrine goes to effector organs and activates receptor - creating a drug-receptor complex
5. Drug-receptor complex triggers a biologic response
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 • Neurotransmitter Inactivation – After neurotransmitters have performed their function, their action must be stopped to prevent prolonged effect.
o Drugs halt termination of neurotransmitter
▪ By inhibiting norepinephrine reuptake
▪ By inhibiting norepinephrine degradation
• Neurotransmitter Inactivation
o Reuptake of transmitter back to the neuron
o Enzymatic transformation or degradation: MAO and COMT
▪ Monoamine oxidase (MAO) inside the neuron
▪ Catechol-O-methyltransferase (COMT) outside the neuron
o Diffusion away from the transmitter
• Remember! Certain drugs halt termination of neurotransmitters (MAO inhibitors)

B. Adrenergic Agonists

• Adrenergic Agonists
o AKA sympathomimetic, catecholamines
o Drugs that stimulate the adrenergic receptors to mimic sympathetic effect
o Stimulation: Alpha Adrenergic Receptors
o Alpha1
▪ ↑ cardiac contractility, vasoconstriction
▪ Dilate pupils, ↓ salivary gland secretion
▪ ↑ bladder and prostate contraction
o Alpha2
▪ ↓ norepinephrine release: ↑ vasodilation
▪ ↓ GI motility and tone
o Stimulation: Beta Adrenergic Receptors
o Beta1
▪ ↑ cardiac contractility, ↑ HR
▪ ↑ renin secretion, ↑BP
o Beta2
▪ ↓ GI tone and motility
▪ Bronchodilation
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 ▪ ↑ blood flow in skeletal muscles
▪ ↓ uterine tone
▪ Activates liver glycogenolysis*: ↑ blood glucose
o Simulation: Dopamine Receptors - Vasodilation

• Indication:
o Bradycardia, heart blocks, and ↓CO
o Acute and chronic asthma
o Acute drug-induced allergic reaction
o Mild renal failure
o Stimulates heart in cardiac arrest
o Acute hypotension and shock
o Heart failure
• Drug interaction:
o +alpha adrenergic blockers = hypotension
o +epinephrine on DM = may need to increase dose
o +other adrenergics = ↑effect
o +trycyclic antidepressants* = hypertension
• Side Effects/Adverse Effects:
o Arrhythmias
o Tachycardia
o angina*
o restlessness
o anxiety
o dizziness
o headache
o HPN
o Stroke
o hyperglycemia

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 Table 3.1: Adrenergic Agonists:

Photo from: Pharmacology for Nurses, A Pathophysiological Approach, 4th Edition by Michael Adams

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 • Contraindication/Precaution:
o C: AMI, tachyarrhymias, pregnancy
o P: DM, artherosclerosis**, Reynaud’s disease***, cardiac insufficiency
• Nsx. Action:
o Monitor ECG, VS, and I/O
o Correct hypovolemia prior to administration
o Administer via large-bore needle to prevent extravasation*
o Antidote: Phentolamine (Regitine) and NSS
o Administer with infusion pump
o Monitor sudden hypotension post-administration
o Epinephrine reversal agent: phentolamine

C. Adrenergics Antagonists
• Adrenergics Antagonists
o AKA symphatolytics, adrenergic blockers
o Action: drugs that block effects of neurotransmitters in adrenergic receptor sites
o Directly: by occupying receptors
o Indirectly: by inhibiting release of neurotransmitters epinephrine and norepinephrine
o Depression: Alpha Adrenergic Receptors
▪ Alpha1
• Vasodilation, ↓BP, reflex tachycardia*
• Pupil constriction
• Suppresses ejaculation
• Reduces contraction of smooth muscles in bladder neck and prostate
o Depression: Beta Adrenergic Receptors
▪ Beta1
• ↓Cardiac contractility, ↓BP
• ↓HR
▪ Beta2
• Bronchoconstriction
• Contracts uterus
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 • Inhibits glycogenolysis
• Indication:
o Alpha Adrenergic Antagonists
▪ PVD, Reynauld’s disease, HPN, adrenergic excess (ex. Pheochromocytoma*)
▪ Vascular headache
o Beta Adrenergic Antagonists
▪ HPN, angina, tachyarrhythmia, open-angle glaucoma*, pheochromocytoma, hypertrophic cardiomyopathy**
▪ Mild to severe heart failure, left ventricular dysfunction after MI
▪ Prevent migraine headache, MI and acute anxiety reaction
• Side Effects/Adverse Reactions:
o Alpha Blockers
▪ Orthostatic hypotension
▪ Vertigo
▪ Palpitation
▪ sexual dysfunction
o Beta Blockers
▪ Bradycardia
▪ Hypotension
▪ Dysrhythmias
▪ Headaches
▪ Dizziness
▪ Fainting
▪ Fatigue
▪ Mental depression
▪ Nausea, vomiting
▪ Diarrhea
▪ Blood dyscrasias
▪ Hypoglycemia

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 Table 3.2: Adrenergic Antagonists

Photo from: Pharmacology for Nurses, A Pathophysiological Approach,

4th Edition by Michael Adams

• Drug Interaction:
o Alpha-Blockers:
▪ +AntiHPN drugs = ↑effect
▪ Prazosin*+diuretics, propranolol, or other beta-blockers = ↑syncope**
o Beta-blockers:
▪ +Digoxin, Ca channel blockers, cimetidine = ↑effect and toxicity
▪ +Antacid, Ca salts, barbiturates, anti-inflammatories, rifampin = ↓effect
▪ Non-selective Beta-blockers may ↓effect of theophylline as bronchodilator

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 ▪ Non-selective Beta-blockers + sympathomimetics = HPN and reflex bradycardia

• Nsx Action:
o Monitor BP for signs of orthostatic hypotension
o When taking ergotamine for vascular headache, client should lie down in a dark, quiet room

D. Cholinergic Agonists

• Cholinergic Agonists
o AKA parasympathomimetics, cholinomimetics, cholinergic stimulants
o Drugs that stimulate cholinergic receptors, mimicking the action of acetylcholine
• Stimulation: Cholinergic Receptors
o Muscarinic receptors - Affect smooth muscles
o Nicotinic receptors - Affect skeletal muscles
o Acetylcholinesterase - Breaks down ACh = acetic acid + choline
• Stimulation: Cholinergic Receptors
o CV:↓HR and BP, vasodilation, slows conduction of AV node
o GI:↑tone and motility, ↑peristalsis, relax sphincter muscles
o GU: Contract bladder, ↑ureter tone, relax sphincter muscles, stimulate urination
o Eyes: pupil constriction, increase accommodation
o Lungs: Bronchial constriction, increase secretions
o Glands: ↑salivation, perspiration, tears
o Striated muscle: ↑neuromuscular transmission
• Indications:
o Glaucoma
o Atonic bladder*
o Post-op and postpartum urine retention
o Abdominal distension and GI atony
o Salivary gland hypofunction

Table 3.3: Cholinergic Agonists

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 Photo from: Pharmacology for Nurses, A Pathophysiological Approach, 4th Edition by Michael Adams

• Side-effects/Adverse Effects:
o HPN
o headache
o sweating
o ↑salivation
o abdominal cramps
o nausea
o vomiting
o diarrhea
o blurred vision
o urinary frequency
o ↓HR
o SOB
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 • Contraindication/Precaution:
o Prostate enlargement
o Urinary / GI obstruction
o Hyperthyroidism
o Bradycardia or AV conduction defects
o Asthma
o CAD

• Drug Interactions:
o +anticholinergic drugs = ↓effect
o +anticholinesterase drugs = ↑effect and risk for toxicity
o +quinidine* =↓effect
• Nsx. Action:
o Monitor I/O
o Assess bowel sounds and abdomen for paralytic ileus*
o Give bethanechol PO and SQ only
o WOF drug toxicity: urinary urgency, excessive secretions, resp. depression or spasm, bradycardia, abd cramping and involuntary defecation
o Antidote: atropine

E. Cholinergic Antagonists

• Cholinergic Antagonists
o AKA parasympatholytics, anticholinergics, cholinergic blockers
o Action: Inhibit action of ACh by occupying ACh receptors
• Action:
o ↓ GI motility, ↓ salivation, mydriasis, ↑HR, urinary retention, decrease rigidity and tremors
o Antidote to organophosphate ingestion or cholinomimetics
• Indication:
o Reverse heart blocks
o Paralyzes ciliary muscles
o Parkinson’s disease, GI spasm, motion sickness, and enuresis
o Symptomatic bradycardia (atropine)
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 o Reduces oral, gastric and respiratory secretions
o Biliary colic*
o Antidote to cholinergic drugs
o Prevents nausea and vomiting from motion sickness (scopolamine)

• Drug Interactions:
o +Trycyclic antidepressants, antidyskinetics, antiemetics, antipsychotics, cyclobenzaprine, or orphenadrine = ↑risk for AE
o Cholinergic agonists / anticholinesterase drugs = ↑effects
o NTG patch ↓effect when taken with anticholinergics
• Side Effects/Adverse Effects:
o Mydriasis
o Photophobia
o blurred vision
o confusion
o dry mouth
o restlessness
o agitation
o dizziness
o N/V
o constipation
o tachycardia
o palpitation
o ↓secretions

Table 3.4: Cholinergic Antagonists

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 Photo from: Pharmacology for Nurses, A Pathophysiological Approach, 4th Edition by Michael Adams

• Contraindications/Precautions:
o C: Angle-closure glaucoma, uncontrolled tachycardia, urinary of GI tract obstructions, COPD, severe ulcerative colitis*, MG, acute or severe
hemorrhage, and unstable CV status
o P: breastfeeding women
• Nsx Action:
o Administer before meals
o Monitor I/O and for adverse reactions
o Measures for dry mouth and constipation
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ACTIVITY 4: DISCUSSION / EXERCISE

• Ask the class for any questions that they may have regarding the lecture.

ACTIVITY 5: POST TEST

DIRECTIONS: Read each questions below and choose the letter that best describe the answer for each.

1. Nurse Hanna is preparing a teaching plan for a client with migraine headaches who is receiving a beta blocker to help manage this disorder. What
instructions would be appropriate to relay to this client?
a. “Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.”
b. “Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.”
c. “This drug will relieve the pain during the aura phase soon after a headache has started.”
d. “This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.”

2. A client is receiving a drug that stimulates the sympathetic division of the autonomic nervous system. What effects on the heart should the nurse expect
from the administration of this medication?
a. Decreased heart rate, decreased force of contraction
b. Increased heart rate, increased force of contraction
c. Decreased heart rate, increased force of contraction
d. Increased heart rate, decreased force of contraction

3. Physiological consequences alpha-2 receptor activation:

a. contraction of arterial smooth muscle
b. increased vagal tone
c. decreased sympathetic outflow
d. decreased insulin release
e. contraction of venular smooth muscle

4. Which of the following cardiovascular effects of cholinomimetics:

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 a. negative chronotropic
b. vasoconstriction
c. decreased AV nodal conduction velocity
d. negative inotropism

5. Nurse Cara is caring for a client who is receiving a central-acting anti-adrenergic agent, methyldopa hydrochloride (Aldomet), intravenously. Which of the
following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?
a. Headache
b. Mood changes
c. Hyperkalemia
d. Palpitations

6. Which of the following are effects of muscarinic agonists on the gastrointestinal tract
a. reduced intestinal peristalsis
b. reduced smooth muscle tone
c. reduced contraction amplitude
d. all of the above
e. none of the above

7. Nurse Dan is caring for a child receiving an adrenergic agent, albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this
medication. Which explanation is correct?
a. Decrease the swelling in the airways.
b. Relax the smooth muscles in the airways.
c. Reduce the secretions blocking the airways.
d. Stimulate the respiratory center in the brain that control respirations.

8. Drugs that mimic sympathetic activity are known as:

a. Cholinergics
b. Anticholinergics
c. Adrenergics
d. Antiadrenergics

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 9. Adrenergic blockers are contraindicated in:
a. Hypertension
b. Pheochromocytoma
c. Migraines
d. Obstructive airway disease

10. To reverse the effects of Epinephrine, which of the following must be administered:
a. cocaine
b. imipramine
c. propranolol
d. phentolamine
e. dopamine

ACTIVITY 6: SYNTHESIS / EXERCISE

• Summarize the lesson, highlighting the salient points.

Prepared by: Reviewed by: Approved by:

Dr. Tristan Jourdan C. Dela Cruz, RN Dennis Luis D. Abellera, RN MAN Dr. John Michael O. Lorena, RN
Lecturer, Pharmacology Academic Head Dean

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