Neuropharmacology:

Autonomic System
Prepared by: Alarzar, RN, CNN, MAN
1/12/2018

At the end of the discussion, the nurses will be able

to:
1. Briefly describe the human autonomic nervous
system
2. Identify functions of the sympathetic and

Objectives parasympathetic drugs

3. Compare and contrast indications and side
effects of sympathetic and parasympathetic
drugs
4. Apply nursing process for patients taking
sympathetic and parasympathetic drugs
ALARZAR
1/12/2018

NERVOUS SYSTEM

Anatomy and
Physiology
Review CENTRAL PERIPHERAL

ALARZAR
1/12/2018

CENTRAL NERVOUS SYSTEM

Anatomy and
Physiology
Review BRAIN SPINAL CORD

ALARZAR
1/12/2018

PERIPHERAL NERVOUS SYSTEM

AFFERENT/ SENSORY EFFERENT/ MOTOR

Anatomy and
Physiology AUTONOMIC NERVOUS
SYSTEM
SOMATIC NERVOUS SYSTEM

Review

SYMPATHETIC/ PARASYMPATHETIC/
ADRENERGIC CHOLINERGIC

ALARZAR
1/12/2018

§ NEURONS
1. AFFERENT – sends impulses to the CNS
2. EFFERENT – receives impulses, transmits
through the spinal cord to effector organ
Anatomy and cells
Physiology
Review
Efferent
(Motor) Afferent
(Sensory)

ALARZAR
1/12/2018

AUTONOMIC NS/ VISCERAL SYSTEM

qInvoluntary
qControls and regulates the heart, GI,
Anatomy and respiratory system, bladder, eyes and
Physiology glands
Review SOMATIC NS
qVoluntary
qInnervates the skeletal muscles

ALARZAR
2 NEURON CHAIN: REVIEW
1/12/2018

NEUROTRANSMITTERS: REVIEW
ALARZAR
1/12/2018

Synaptic
Transmission
ALARZAR
1/12/2018

Synaptic
Transmission

ALARZAR
1/12/2018

ALARZAR
1/12/2018

FIGHT OR FLIGHT
RESPONSE

ALARZAR
1/12/2018

§ Sympathetic NS
§ Terminal Neurotransmitter: Norepinephrine
§ Receptor organ cells: alpha, beta

Anatomy and
Physiology
Review

ALARZAR
1/12/2018

REST AND DIGEST

ALARZAR
1/12/2018
§ Parasympathetic NS
§ Terminal Neurotransmitter: Acetylcholine
§ Receptor organ cells: nicotinic, muscarinic
§ Acetylcholinesterase: inactivates
acetylcholine before reaching organ cells

Anatomy and
Physiology
Review

ALARZAR
1/12/2018

SYMPA PARASYMPA
Dilates pupils Constricts pupils
Dilates bronchioles Constricts bronchioles,
increase secretions
Anatomy and Increases heart rate Decreases heart rate
Physiology Constricts blood vessels Dilates blood vessels
Review Relaxes smooth muscles Increases peristalsis
of the GI
Relaxes uterine muscles
Increases salivation

ALARZAR
1/12/2018

SYMPA
OR
PARASYMPA

ALARZAR
1/12/2018

SYMPA OR
PARASYMPA

ALARZAR
1/12/2018

SYMPA OR
PARASYMPA

ALARZAR
1/12/2018

SYMPA OR
PARASYMPA

ALARZAR
1/12/2018

SYMPA OR
PARASYMPA

ALARZAR
1/12/2018

SYMPA OR
PARASYMPA

ALARZAR
1/12/2018

SO, HOW DO THE DRUGS WORK?

ALARZAR
1/12/2018

Receptor Theory
l Drugs act through
receptors by binding to
the receptors to initiate a
response or prevent a
response.
l It is similar to the fit of the
right key in a lock.

ALARZAR
1/12/2018

Agonist & Antagonist

l Agonist – drugs that

produces a response
l Antagonist – drugs that
blocks a response
l Effects are determined by
the inhibitory action of the
drug.

ALARZAR
 1/12/2018

ADRENERGIC ADRENERGIC CHOLINERGIC CHOLINERGIC

AGONIST ANTAGONIST AGONIST ANTAGONIST

STIMULATE THE SNS INHIBIT THE SNS STIMULATE THE PNS INHIBIT THE PNS

SYMPATHOMIMETIC SYMPATHOLYTIC PARA- PARA-

SYMPATHOMIMETIC SYMPATHOLYTIC

ANS Drugs
ALARZAR
1/12/2018

PHARMACOLOGIC
EFFECT
When Autonomic drugs are given, the goal
is not to treat an autonomic disorder, it is to
correct disorders of target organs through
autonomic nerves

ALARZAR
 1/12/2018

SYMPATHETIC NERVOUS SYSTEM

ADRENERGIC AGONISTS & ADRENERGIC BLOCKERS

ALARZAR
1/12/2018

RECEPTORS:
ALPHA 1

ALARZAR
1/12/2018

RECEPTORS:
ALPHA 2

ALARZAR
1/12/2018

RECEPTORS

ALARZAR
1/12/2018

RECEPTORS

ALARZAR
1/12/2018

ADRENERGIC AGONISTS

ALARZAR
1/12/2018

SYMPATHOMIMETICS/ ADRENERGIC AGONISTS

§ Stimulate adrenergic receptors

§ CATEGORY BASED ON MECHANISMS OF ACTION:

ALARZAR
1/12/2018

CATECHOLAMINES
- Has a catechol ring and
CATEGORY amines
BASED ON
CHEMICAL
STRUCTURE
NONCATECHOLAMINES – has
no catechol ring

ALARZAR
1/12/2018

BEING SELECTIVE

SELECTIVE - NON-
influences one SELECTIVE –
type of influences all
receptor receptors
ALARZAR
1/12/2018

RECEPTOR TREATMENT
Alpha 1 Hypotension, nasal
congestion, dilation of pupils

THERAPEUTIC Alpha 2 Hypertension

USES: Beta 1 Heart failure, cardiac arrest,
shock
Beta 2 Asthma, premature labors of
contraction

ALARZAR
 1/12/2018

ADRENERGIC AGONISTS
DRUG RECEPTOR THERAPEUTIC USE
Epinephrine A1, A2, B1,B2 Cardiac arrest; asthma
Pseudoephedrine; A1, B2 Nasal decongestant
phenylephrine
Isoproterenol B1, B2 Increase heart rate, force of
contraction and conduction

Dobutamine B1 Increases heart rate, force of

contraction in heart failure, shock

Albuterol B2 Asthma/ COPD ALARZAR

1/12/2018

§ THERAPEUTIC CLASS: Vasopressor

§ PHARMACOLOGIC CLASS: Adrenergic
§ INDICATIONS: anaphylaxis, asthma,
cardiac stimulation, indiction and
maintenance of mydriasis during
EPINEPHRINE intraocular surgery

ROUTE ONSET PEAK DURATION

IV Immediate 5 mins Short
IM Variable unknown 1-4 hours
SQ 5-15 mins 30 mins 1-4 hours
Intraocular unknown unknown unknown
ALARZAR
1/12/2018

Tissue necrosis – check IV sites frequently

Tachycardia, palpitations, tremors, dizziness,

increased blood pressure
SIDE EFFECTS OF
Urinary retention r/t high doses
ADRENERGIC
AGONISTS
Nausea and vomiting – offer food

ANTIDOTE: phentolamine Mesylate (Regitine) for

extravasation of norepinephrine and dopamine

ALARZAR
1/12/2018

ASSSESMENT
V/S, drug history, health history for
contraindications , CBG
NURSING
PROCESS DIAGNOSIS
q Disturbed sleep pattern
q Deficient knowledge

ALARZAR
1/12/2018

Monitor ECG, BP, U/O, F&E

PRE-ADM:
• correct hypovolemia
• give cardiac glycosides if ordered first
NURSING • Adm using large peripheral vein or CVC
PROCESS: •
•
Dilute as ordered
Don’t adm catecholamines in the same IV line as
CATECHOLAMINES other drugs

EVALUATION

• Adequate Cardiac output

• No injury from adverse reactions
• Understanding of drug therapy
ALARZAR
1/12/2018

§ Obtain baseline respiratory status and

pulse rate

NURSING § If adm using inhalation, wait 2 minutes

between doses
PROCESS: NON-
CATECHOLAMINES § Give injections using lateral deltoid area
§ Teach patient to use aerosols 15 mins
before exercise

ALARZAR
1/12/2018

ADRENERGIC BLOCKERS

ALARZAR
1/12/2018

ADRENERGIC BLOCKERS

Mechanism:

> Direct blocking by occupying

Blocks alpha and beta receptors
receptor blockers
> Indirect blocking by inhibiting
release of neurotransmitters

ALARZAR
1/12/2018

§ Causes:
§ Relaxation of smooth muscles
§ Vasodilation: hypertension and PVDs
§ Reduces contraction of smooth muscle in
ALPHA bladder and prostate
BLOCKERS § Includes:
§ Terazosin
§ Doxazosin
§ Prazosin

ALARZAR
1/12/2018

§Dizziness
Watch out for: §Orthostatic hypotension
§Headache, nasal congestion

ALARZAR
1/12/2018

§ A decrease of 20 mm Hg or more in SBP, a

decrease of 10 mm Hg or more in DBP, and/or
§ An increase in the HR of 20 beats/minute or
ORTHOSTATIC more from supine to standing indicates
HYPOTENSION orthostatic hypotension
– Lewis

ALARZAR
1/12/2018

§ Decrease heart rate

§ Decreases blood pressure
§ Useful for treating mild to moderate
hypertension, angina pectoris and
myocardial infarction
BETA BLOCKERS § Includes:
§ Atenolol
§ Propanolol
§ Pindolol
§ Timolol
§ Metoprolol
ALARZAR
 ADRENERGIC ANTAGONISTS
1/12/2018

DRUG RECEPTOR THERAPEUTIC USE

Phentolamine, A1, A2 Hypertension
Phenoxybenzamine
Prazosin, Terazosin A1 Hypertension
Tamsulosin, A1 BPH- urinary relief
Alfuzosin
Propanolol (1st gen) B1, B2 Hypertension, Angina, Migraine

Timolol (1st gen) B1, B2 Glaucoma, decrease intraocular pressure

Atenolol, Metoprolol B1 Hypertension (2nd gen- cardioselective)
Carvedilol, Labetalol B1 B2 Hypertension – with vasodilation

ALARZAR
Pindolol B1, B2 Decrease CO, HR for patients with heart block
1/12/2018

§ THERAPEUTIC CLASS: Anti-hypertensive

§ PHARMACOLOGIC CLASS: Alpha Blocker
PRAZOSIN § INDICATION: mild to moderate hypertension

ROUTE ONSET PEAK DURATION

PO 30-90 mins 2-4 hours 7-10 hours

ALARZAR
1/12/2018

§ ASSESSMENT
§ Health and drug history, V/S,
ECG
§ DIAGNOSES
NURSING § Decreased cardiac output
PROCESS § Risk for falls
§ Fatigue
§ Sexual dysfunction
§ Noncompliance
ALARZAR
1/12/2018

§ Assess BP, cardiac and respiratory status

(Beta blockers)
§ Check apical pulse (<60 bpm alert!)
§ Watch out for hypoglycemia, fluid
retention
NURSING
§ Give with meals
PROCESS
§ Health teaching:
§ Do not stop taking the drug suddenly
§ Do not take herbal medicines without
prescription
§ Avoid performing hazardous activities until
CNS effects are confirmed ALARZAR
1/12/2018

CHOLINERGIC AGONISTS

ALARZAR
1/12/2018

SYMPATHETIC NERVOUS SYSTEM

CHOLINERGIC AGONISTS AND CHOLINERGIC BLOCKERS

ALARZAR
1/12/2018

MUSCARINIC 5 receptors, stimulate smooth

muscle and slows HR

M1 (GU) and M3 (lungs, glands) –

may increase calcium activity

M2 (heart) – may increase

potassium and decrease heart rate
RECEPTORS NICOTINIC 2 receptors, affect skeletal muscles

1. Nm – muscle contraction

2. Nn – transmission of cholinergic
signals

ALARZAR
1/12/2018

ALARZAR
1/12/2018

§ Mimic the parasympathetic

neurotransmitter acetylcholine

CHOLINERGIC
AGONISTS

ALARZAR
1/12/2018

DRUG, THERAPEUTIC USE

Acetylcholine Non-specific cholinergic effect,
decreases CO, HR, BP, increase GI
activity
Carbachol Not as susceptible to AChE, used
Direct Acting locally to constrict pupil and
decrease IOP
Pilocarpine Constricts pupil, decrease IOP for
acute glaucoma
Bethanechol Increase muscle tone in bladder
ang GIT

ALARZAR
1/12/2018

§ THERAPEUTIC CLASS: Urinary Stimulants

§ PHARMACOLOGIC CLASS: Cholinergic Agonists
§ INDICATIONS: acute post-operative and postpartum

BETHANECOL nonobstructive urine retention, neurogenic atony of

urinary bladder with urine retention

ROUTE ONSET PEAK DURATION

PO 30-90 mins 1 hour 6 hours

ALARZAR
1/12/2018

DRUG DURATIO THERAPEUTIC

N USE
Edrophonium 10-20 mins Diagnosis of MG
Physostigmine 30mins-2 Overdose of
INDIRECT hours atropine
ACTING Neostigmine, 20-30 mins Symptoms of MG,
Pyridostigmine reverse effects of
REVERSIBLE anesthesia
Donepezil, unknown Alzheimer’s disease
Rivastigmine, to improve
Galantamne cognitive function

ALARZAR
1/12/2018

§ Famous for military use as nerve

INDIRECT gases
ACTING § Clinical use: Echothiophate –
IRREVERSIBLE treatment of open glaucoma

ALARZAR
1/12/2018

D - Diarrhea
U - Urination
M – Miosis and Muscle Weakness
ADVERSE B - Bronchorrhea
REACTIONS B - Bradycardia
E - Emesis
L - Lacrimation
S – Salivation/ Sweating

ALARZAR
1/12/2018

§ Caused by overdose of cholinergic

agonists
§ S/Sx:
CHOLINERGIC § Extreme muscle weakness
CRISIS § Paralysis of muscles for respiration
§ Bradycardia, constricted pupils, skin
flushing, increase secretions
§ NEOSTIGMINE (Tensilon) Test –
increased weakness

ALARZAR
1/12/2018

ASSESSMENT
1. Assess for bladder and bowel function

NURSING 2. Assess for respiratory adequacy

PROCESS DIAGNOSES
1. Impaired gas exchange
2. Ineffective airway clearance
3. Impaired urinary elimination

ALARZAR
1/12/2018

1. Take on empty stomach to lessen nausea and

vomiting and increase drug absorption

2. Supervise ambulation

NURSING 3. Teach patient not to take OTC drugs without

consultation
PROCESS 4. Monitor for effects of cholinergic drugs
5. Assist patient in establishing drug administration
schedule

ALARZAR
1/12/2018

ANTI-CHOLINERGIC AGENTS

ALARZAR
1/12/2018

Anticholinergic
Drugs

Anti-muscarinics Anti-nicotinics

Natural Synthetic Ganglion Neuromuscular

Alkaloids Substitutes Blockers Blockers
ALARZAR
1/12/2018

DRUGS THERAPEUTIC USE

Atropine Mydriasis, Psychoplegia prior to an eye
surgery or exam
Blocks M3 – redcues GI motility
Blocks M2 – SA and AV node, tachycardia in
high doses
Cyclopentolate, Same as atropine but with less duration of
ANTI- Tropicamide action

MUSCARINIC Scopolamine Motion sickness, Post Op Nausea and Vomiting

as patches
AGENTS Ipratropium COPD, rhinorrhea as inhalation to brochodilate
and decrease secretion
Oxybutynin Bladder function
Benztropine Parkinson’s like disorders

ALARZAR
1/12/2018

§ THERAPEUTIC CLASS: Anti-arrhythmics

§ PHARMACOLOGIC CLASS: Anti-cholinergic
belladonna alkaloids
§ INDICATIONS: Bradycardia, anti-
cholinesterase poisoning, preoperatively to
ATROPINE diminish secretions and block cardiac vagal
reflexes, antimuscarinic
ROUTE ONSET PEAK DURATION
IV Immediate 2-4 mins 4 hours
IM 5-40 mins 20-60 mins 4 hours
SQ Unknown Unknown Unknown
ALARZAR
1/12/2018

A – Agitation
B – Blurred vision
ADVERSE
EFFECT C- Constipation, Confusion
D –Dry mouth
S – Stasis of urine and Sweating

ALARZAR
1/12/2018

§ NICOTINE
§ Stimulate and block cholinergic function
§ Increase production of neurotransmitters
GANGLIONIC § Increase BP, HR but may also decrease BP
BLOCKERS – non-selective effect
§ CNS Stimulation – causes addiction
§ Not useful in clinical practice

ALARZAR
1/12/2018

NON-DEPOLARIZING
NEURO- AGENTS

MUSCULAR NM BLOCKERS

BLOCKERS DEPOLARIZING
AGENTS

ALARZAR
1/12/2018

§ Binds to ACh receptors but do not induce ion

channel opening
§ Facilitates mechanical ventilator and tracheal
intubation
NON- § Given as IV as it is not absorbed in the GI
DEPOLARIZING § Rapid effect in less than 2 mins, will paralyze
AGENTS small muscles
§ Includes
§ Cisatracurium, Pancuronium – 90 mins for MSOF
§ Rocuronium, Vecuronium – 40 mins
ALARZAR
1/12/2018

§ Succinylcholine
§ Causes sodium channels to open for
prolonged depolarization

DEPOLARIZING § PHASE I block

AGENTS § PHASE II block
§ For rapid sequence tracheal intubation
§ Facilitates ECT
§ Duration – 1 to 10 mins

ALARZAR
1/12/2018

§Prolong Apnea
ADVERSE
EFFECTS §Hyperkalemia
§Malignant Hyperthermia

ALARZAR
1/12/2018

ASSESSMENT
1. Assess for urine retention and
bladder distension
2. Assess for paralytic ileus
NURSING
PROCESS 3. Assess for respiratory adequacy
DIAGNOSES
1. Urinary retention
2. Constipation
3. Risk for injury ALARZAR
1/12/2018

§ Follow dosage recommendations

§ Monitor V/S, HR, U/O, vision
NURSING § Have emergency equipment
PROCESS
ready

ALARZAR
1/12/2018

Sympathomimetic
Parasympathomimetic

DRUG
INTERACTIONS
Sympatholytic
Parasympatholytic

ALARZAR
1/12/2018

Sympathomimetic Parasympatholytic

DRUG
INTERACTIONS
Sympatholytic Parasympathomimetic

ALARZAR
1/12/2018

1. Kee, J., Hayes, E., McCuistion, L. Pharmacology – A Patient-Centered

Nursing Process Approach. 8th Edition. 2015. Elsevier Saunders.

2. Lehne, R. Pharmacology for Nursing Care. 7th Edition. 2010. Elsevier

Saunders.

3. McCann, J. Nursing Pharmacology made Incredibly Easy. 3rd

RESOURCES: Edittion. Wolters Kluwer.

4. UERM Slides. Pharmacology The Nervous System

5. CrashCourse. 2015.04.11. Autonomic Nervous System: Crash
Course A&P #13. Retrieved from
https://www.youtube.com/watch?v=71pCilo8k4M&t=303s.

ALARZAR