ANATOMY AND PHYSIOLOGY - Released from postganglionic

Anatomy of the Autonomic Nervous neurons

System - Causes sympathetic stimulation
 Composed of systems by triggering the release of
- Sympathetic nervous system epinephrine and more
(adregenic system) norepinephrine
- Parasympathetic nervous system - Produces its effects by combining
(cholinergic system) with adrenergic receptors found
 Includes pathways that consist of 2 on effector organs
types of neurons which transmit
Adrenergic receptors are divided into
information to the effector organs
alpha and beta receptors.
 Preganglionic neuron – extends
from the CNS to a ganglion Alpha receptors include two
 Postganglionic neuron – subgroups:
extends from the ganglion to the
effector organ or gland o Stimulation of Alpha1 receptors
produces contractions of
FUNCTIONS of ANS smooth muscle walls and blood
Controls involuntary (automatic) vessels
body functions, glands, and organs, such as o Stimulation of Alpha2 receptors
cardiac muscle activity and the smooth produces the opposite effect by
muscle of blood vessels, eyes, stomach, inhibiting norepinephrine
and intestines. release from the sympathetic
nerve endings
 Sympathetic System
- Helps the body cope with external Beta receptors include 2 subgroups:
stimuli and functions during stress o Stimulation of beta1 receptors
- Flight or fight response causes the heart to beat faster
 Parasympathetic Nervous System and more forcefully
- Works to save energy o Stimulation of beta2 receptors
- Activates the GI system
dilates bronchi and relaxes
- Supports restorative, resting body
blood vessels
functions
CHOLINERGICS
ANS NEUROTRANSMITTERS
(PARASYMOATHOMIMETICS)
Acetylcholine
Cholinergic Agonists
- Helps neurons transmit impulses
 Mechanism of Action
in the CNS
- Directly stimulate cholinergic
- Released from the axons of pre-
receptors, mimicking the action of
ganglionic neurons in response to
acetylcholine
a stressful event
- Stimulates postganglionic Pharmacokinetics
neurons, causing the release of
epinephrine and norepinephrine o Absorption: varies widely
- Activates effector organs by o Distribution: widely distributed
combining with cholinergic o Metabolism: Metabolized by
receptors on effector organs cholinesterase’s in plasma and liver
- Inactivated by cholinesterase o Excretion: excreted in urine
Norepinephrine Drug examples
- Helps neurons transmit impulses  Bethanechol
in the CNS  Pilocarpine

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Indications
 Treat atonic bladder conditions and
postoperative and postpartum urine
retention
 Treat GI disorders
 Decrease eye pressure in patients with
glaucoma and during eye surgery
 Treat salivary gland hypofunction
caused by radiation therapy
Contraindications & Precautions
o Prostate enlargement
o Possible urinary or GI obstruction
o Hyperthyroidism
o Bradycardia or AV conduction
defects
o Asthma
o Coronary artery disease
Adverse Reactions
o Hypotension, headache, sweating,
increased salivation, abdominal
cramps, nausea, vomiting, diarrhea,
blurred vision, urinary frequency,
decreased heart rate, shortness of
breath
Nursing Responsibilities
 Assess urinary status
 Assess bowel sounds and abdomen
 Administer by mouth or SQ, never give
IV or IM
 Observe patient for 20 to 60 minutes
after subcutaneous administration
 Monitory for toxicity; administer atropine
as an antidote as prescribed
ACETYLCHOLINESTERASE INHIBITORS
 Mechanism of Action
- Inhibit acetylcholinesterase, the
enzyme that inactivates
acetylcholine; as acetylcholine
builds up, cholinergic receptors
are stimulated
Pharmacokinetics
o Absorption: Absorbed readily in the GI
tract, subcutaneous tissues, and
mucous membranes, except for
neostigmine which is absorbed poorly
if given orally
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o Distribution: Widely distributed
o Metabolism: metabolized in plasma
o Excreted: Excreted in urine
Drug Examples
 Ambenonium
 Edrophonium
 Neostigmine
 Physostigmine
 Pyridostigmine
Indications
 Myasthenia gravis
 Glaucoma
 Anticholinergic poisoning
 Paralytic ileus
Contraindications & Precautions
o Possible urinary or GI obstruction
Adverse Reactions
o Nausea, vomiting, diarrhea, dyspnea,
arrhythmias, headaches, anorexia,
seizures, insomnia, pruritus, urinary
frequency, and nocturia
Nursing Responsibilities
 Assess the patient’s neuromuscular
status before and during drug therapy
 Monitor for drug toxicity; administer
atropine as an antidote, as prescribed
 Monitor vital signs and breath sounds
every 4 hours
 Take seizure precautions
ALZHEIMER’S TREATMENT DRUGS
 Mechanism of Action
- Centrally act to inhibit
cholinesterase, leading to
elevated acetylcholine levels in
the cortex, thereby slowing the
neuronal degradation that occurs
in Alzheimer’s disease
Pharmacokinetics
o Absorption: absorbed orally
o Distribution: widely distributed
o Metabolism: metabolized in liver
o Excretion: excreted in urine
Drug Examples
  Donepezil o Metabolism: metabolized in the liver
 Galantamine o Excretion: excreted in the feces and
 Memantine urine
 Rivastigmine
Drug Examples
Indications
 Belladonna alkaloids: Atropine,
 Mild to moderate Alzheimer’s type Belladonna hyoscyamine,
dementia Scopolamine
 Moderate to severe Alzheimer’s type  Quaternary ammoniums:
dementia Glycopyrrolate, Methascopolamine,
Propantheline
Contraindications & Precautions  Tertiary amines: Benztropine,
o GI bleeding Dicyclomine, Oxybutynin,
Trihexyphenidyl
o Seizures
o Asthma Indications
o Severe hepatic and renal
impairment  Reduce oral, gastric, and respiratory
secretions
Adverse Reactions  Reverse heart block
 Paralyze ciliary muscles of the eye
o Insomnia, fatigue, dizziness,
 Treat symptomatic bradycardia
confusion, ataxia, depression,
(Atropine)
syncope, bradycardia, nausea,
 Prevent bradycardia caused by
vomiting, diarrhea, anorexia, and
abdominal pain vagal nerve stimulation during
o Hepatotoxicity (Donepezil) general anesthesia
 Treat biliary colic (Belladonna
o Hypertension (Memantine)
alkaloids)
Nursing Responsibilities  Antidote to cholinergic and
anticholinergic drugs (Atropine &
 Establish a functional baseline Hyoscyamine)
 Notify the surgeon about the use of  Prevent nausea and vomiting
Alzheimer’s treatment drugs if surgery resulting from motion sickness
is planned (Scopolamine)
 Teach the patient that these drugs
won’t cure Alzheimer’s, only slows its Contraindications & Precautions
progress o Angle-close glaucoma, uncontrolled
 Administer Donepezil daily at bedtime tachycardia, urinary or GI
ANTICHOLINERGICS obstruction, bladder neck
(PARASYMPATHOLYTICS) obstruction, COPD, severe
ulcerative colitis, myasthenia gravis,
 Mechanism of action acute or severe hemorrhage, and
- Interrupt parasympathetic nerve unstable cardiovascular status
impulses in the CNS and ANS o Breastfeeding women
and prevents acetylcholine from
stimulating cholinergic receptors Adverse Reactions
- Also referred to as o Commonly dose-related
CHOLINERGIC BLOCKERS
Nursing responsibilities
Pharmacokinetics
o Absorption: absorbed in the GI tract  Administer before meals
 Monitor adverse reactions
o Distribution: most are widely
distributed
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  Teach patient to consult the o With caution in patients with
practitioner before taking non- diabetes, atherosclerosis, Reynaud’s
prescription drugs disease, and cardiac insufficiency
 Advice the patient on how to reduce
dry mouth and constipation Adverse Reactions
 Monitor Intake and Output o Arrhythmias, tachycardia, angina
ADRENERGIC AGONISTS o Restlessness, anxiety, dizziness
o Headache, hypertension, stroke
Catecholamines (Sympathomimetics) o Increased blood glucose levels
 Mechanism of Action Nursing Responsibilities
- Stimulate nervous system by
combining with either alpha-  Monitor ECG, hemodynamic
adrenergic or beta-adrenergic parameters, vital signs, and urine
receptors output
 Correct hypovolemia
Pharmacokinetics  Administer through a large vein to
o Absorption: rapidly absorbed if given prevent extravasation. Always
administer with an infusion pump
sublingually, SQ, IV
o Distribution: widely distributed  Monitor for a sudden drop in blood
pressure after stopping the drug
o Metabolism: metabolized primarily in
the liver NONCATHECOLAMINES
o Excretion: Urine
 Mechanism of Action
Drug Examples - Stimulate sympathetic nervous
system by directly stimulating
 Dobutamine
alpha or beta2 receptors or
 Dopamine
indirectly affecting adrenergic
 Epinephrine
receptors
 Isoproterenol
 Norepinephrine Pharmacokinetics
Indications o Absorption: varies by drug
o Distribution: varies by drug
 Bradycardia, heart blocks, and
o Metabolism: metabolized in the liver
decreased cardiac output
o Excretion: Urine
 Acute hypertension and shock
 Acute drug-induced allergic reaction Drug Examples
 Treat mild renal failure caused by
decreased cardiac output (Dopamine  Albuterol
– which dilate renal arteries in low  Ephedrine
doses)  Isoetharine
 Stimulate the heart in cardiac arrest  Mephentermine
 Increase blood pressure through  Metaproterenol
vasoconstriction in acute  Phenylephrine
hypotension and shock  Terbutaline
 Increase myocardial force and Indications
cardiac output in patients with acute
heart failure and those undergoing  Hypotension and severe shock
cardiopulmonary bypass  Preterm labor
Contraindications & Precautions  Bronchodilation treatment
 Nasal congestion
o Acute MI or tachyarrhythmias
o During pregnancy Contraindications & Precautions

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 o Tachyarrhythmias, hypertension, o Orthostatic hypotension, tachycardia,
coronary artery disease, history of dizziness, arrythmias, ergotism
stroke, angle-closure glaucoma, and
thyrotoxicosis Nursing Responsibilities
o With caution in elderly patients and
 Monitor blood pressure for signs of
those with diabetes, hyperthyroidism, orthostatic hypotension, as
angina, or a history of seizures appropriate
Nursing Responsibilities  Instruct patient to change positions
slowly to minimize orthostatic
 If given via inhalation, administer the hypotension
bronchodilator inhaler, wait for 2 mins  Administer drug with milk or food
and administer the corticosteroid  If patient experiences a shock-like
inhaler state place in the Trendelenburg
 Monitor respiratory status position, notify practitioner, and begin
emergency resuscitation, as
ADRENERGIC BLOCKERS appropriate
Alpha-Adrenergic Blockers Beta-Adrenergic Blockers
 Mechanism of Action  Mechanism of Action
- Interrupt the action of epinephrine - Prevents stimulation of the
and norepinephrine at alpha sympathetic nervous system by
receptors inhibiting the action of
Pharmacokinetics catecholamines at the beta-
adrenergic receptors
o Absorption: erratic when administered
orally; more rapid and complete when Selective beta-adrenergic blockers block
administered sublingually beta1 receptors
o Distribution: unknown Nonselective beta-adrenergic blockers
o Metabolism: metabolized in liver block beta1 and beta2 receptors
o Excretion: excreted in urine
Pharmacokinetics
Drug Examples
o Absorption: absorbed rapidly and well
 Doxazosin from GI tract
 Ergotamine o Distribution: widely distributed
 Phenoxybenzamine o Metabolism: metabolized in liver
 Phentolamine o Excretion: excreted in feces and urine
 Prazosin
 Terazosin Drug Examples
Indications Selective
 Peripheral vascular disorders  Acebutolol
 Raynaud’s disease  Atenelol
 Vascular headaches  Betaxolol
 Adrenergic excess  Carteolol
 Esmolol
Contraindications & Precautions  Metoprolol
o MI Nonselective
o Coronary insufficiency
o Evidence of coronary artery disease  Carvediol
 Labetolol
o Pregnancy
 Levobunolol
Adverse Reactions  Nadalol
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  Penbutolol o Absorption: given parenterally
 Propanolol because of poor absorption after oral
 Sotalol administration; IV is the preferred
 Timolol route of administration
o Distribution: distributed rapidly
Indications
throughout the body
 Hypertension o Metabolism: partially metabolized in
 Angina liver
 Tachyarrhythmias o Excretion: most drugs excreted
 Migraines unchanged in urine
 MI
 Glaucoma Drug Examples
 Acute anxiety reaction
 Cisatracurium
 Mild to severe heart failure
 Pancuronium
 Left ventricular dysfunction after MI  Vecuronium
Contraindications & Precautions
Indications
o Bradyarrhythmias
o COPD  Prolonged or intermediate, muscle
o Heart block relaxation for surgery or ET
o Asthma intubation

Adverse Reactions Contraindications & Precautions

o Bradycardia, bronchospasm, nausea,
o Hypersensitivity
vomiting, diarrhea, hypertension
o Neonates
Nursing Responsibilities o Pregnancy
o Breastfeeding
 Assess pulse rate; withhold drug and
notify practitioner if rate is below 50 Adverse Reactions
bpm
 Advise patient receiving long-term o Apnea, hypotension, skin reactions,
therapy not to discontinue the drug
bronchospasm, excessive bronchial
suddenly because of the risk of MI or
or salivary excretions
arrhythmia
NEUROMUSCULAR BLOCKERS Nursing Responsibilities

Nondepolarizing Drugs  Monitor for adverse reactions

 Have oxygen and ET and suction
 Mechanism of Action
equipment available
- Complete with acetylcholine at the
 Monitor respirations frequently until
cholinergic receptor sites of the
skeletal muscle membrane, the patient is fully recovered
thereby blocking acetylcholine  Suction patient as needed
transmitter action and preventing  Frequently check the mechanical
muscle membranes from ventilator settings and functions to
depolarizing ensure proper functioning
- Also referred to as COMPETITIVE  Always administer with sedation or
or STABILIZING DRUGS general anesthesia

Pharmacokinetics DEPOLARIZING DRUGS

 Mechanism of Action
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 - Mimic the action of acetylcholine
but aren’t inactivated by
cholinesterase, causing persistent
depolarization and muscle
fasciculation, paralysis, and
flaccidity

Pharmacokinetics

o Absorption: IV is preferred; absorbed

poorly in the GI tract
o Distribution: unknown
o Metabolism: metabolized in the liver
and plasma
o Excretion: excreted in urine
Drug Examples
 Succinylcholine
Indications

 Skeletal muscle relaxation for

surgery or mechanical ventilation
Contraindications & Precautions
o Hypersensitivity
o History of malignant hyperthermia
o Acute angle-closure glaucoma
o Penetrating eye injuries

Adverse Reactions
o Prolonged apnea and cardiovascular
effects, hypotension, muscle pain,
increased intraocular pressure
Nursing Responsibilities

 Maintain airway patency

 Monitor closely; check respiratory rate
and pattern every 5 mins
 Keep oxygen and suction equipment
available
 Always administer with sedation or
general anesthesia

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