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Autonomic Nervous System
Chapter 16, 17, 18, 19, 20
Clinical Drug Therapy
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Nervous System
Two main divisions
Central Nervous System or CNS
Peripheral Nervous System or PNS
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Central Nervous System or CNS
Brain and spinal cord: receives and
processes incoming sensory information and
responds by sending out signals that initiate
or modify a process.
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Peripheral Nervous System or PNS
Includes all the neurons and ganglia found
outside the CNS
Afferent (sensory): modify motor output
Efferent:
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Afferent Neurons
Afferent neurons carry sensory input from the
periphery to the CNS and modify motor
output through the reflex arc.
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Efferent Neurons
Efferent neurons carry motor signals from the
CNS to the peripheral areas of the body.
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ANS / SNS
Autonomic nervous system controls
involuntary activities of smooth muscle,
secretory glands and the visceral organs of
the body such as the heart (involuntaryactivities of smooth muscle)
Somatic nervous system innervates the
skeletal muscles and controls voluntarymovement
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Autonomic Nervous System
Sympathetic Nervous System
Para sympathetic System
Enteric System
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The Race Horse and the Cow
Sympathetic Nervous System
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Sympathetic System
Fight or Flightstimulated by physical or
emotional stress (exercise or work), pain,
hemorrhage, intense emotions, temperature
extremes
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Sympathetic Nervous System
Protective mechanisms designed to help
person cope with the stress or get away from
it.
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Neurotransmitters
Neurotransmitters
Acetylcholine: skeletal muscle
Norepinepherine: stress response
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Norepinephrine and epinephrine
Both always present in the blood.
Norepinephrine varies according to the
amount of stress present and will cause
transient changes in heart rate and systemicarteries and veins.
Epinephrine is a constant in regulating heart
rate, vasoconstriction in systemic arteries andveins and vasodilation of muscles and liver.
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Dopamine
Adrenergic neurotransmitteressential for
normal brain function.
Studies focus on connection between dopamine
malfunction in schizophrenia and ParkinsonsDisease.
Role of dopamine in drug addition to drugs:
stimulants and depressants.
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Protective Mechanisms
Intensity of response depends on
Norepinephrine and epinephrine
Fight or flight
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Body Responses
Increase in blood pressure and cardiacoutput.
Increase blood flow to brain, heart and
skeletal muscles. Decrease blood flow to skin and organs not
needed for flight.
Increase in glycogen for energy, mentalactivity, muscle strength, blood coagulation,respiratory rate, pupil dilation to aid vision,and increase in sweating.
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Fight of Flight Response
Can be a problem if the body stay in the fight
or flight mode.
Type A personalities?
High stress environment?
Medications may be needed reduce the
physiologic body responses.
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Parasympathetic Nervous System
Rest and Digest
Save energy
Decreased heart rate
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Adrenergic Receptors
Norepinephrine and epinephrine interact with
two adrenergic receptors
Alpha and beta
Alpha 1 Alpha 2
Beta 1
Beta 2
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Alpha 1
Alpha 1 receptors allows calcium ions to
move into the cell and produce muscle
contraction.
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Alpha 1
Location
Blood vessels
Kidney
Intestinal smooth muscles
Genitourinary
Eyes = blinking
Pregnant uterus =
contractions
Male sexual organs =
sexual function
Effects of stimulation
Vasoconstriction
Release of renin (kidney)
Relaxation
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Alpha 2
Location
Nerve endings
Vascular smooth
muscles Pancreatic beta cells
Platelets
Effects of stimulation
Inhibits release of
Norepinephrine
Vasoconstriction Inhibit insulin secretion
Aggregation or clotting
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Beta 1
Location
Heart
Kidneys
Effects of stimulation
Increase heart rate,
force of contraction,
automaticity and rate ofatrial-ventricular
function
Increased renin release
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Beta 2
Location
Bronchioles
Blood vessels
Gastrointestinal tract Liver
Urinary bladder
Pregnant uterus
Effects of stimulation
Vasodilation
Decreased motility and
tone Glycogenolysis
Relaxed detrusor
muscle (bladder
muscle)
Relaxation of uterus
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Parasympathetic Nervous System
Functions stimulated by PNS: Resting,
reparative, or vegetative function
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Body Responses
Dilation of blood vessels in skin
Decrease heart rate (bradycardia)
Increase secretion of digestive enzymes
Constriction of smooth muscle of bronchi Increase in sweat glands
Contraction of smooth muscles of urinary
bladder Contraction of smooth muscle of skeletal
system
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Autonomic Drugs
Drugs used due to their ability to stimulate or
block activity of the sympathetic or
parasympathetic nervous system.
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Effect of Drugs
Drugs that act of ANS usually affect the entire
body.
Effects depend on whether you are trying to
stimulate or inhibit function.
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Receptor Activity
Drugs are developed to stimulate or inhibit
particular subtypes of receptors.
More selective on particular body tissues.
Decrease adverse effects on other body
tissuesside effects.
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Classifications: SNS
Sympathetic nervous system drug
classifications
Adrenergic - stimulating
Antiadrenergic - blocking
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Classifications: PNS
Parasympathetic
nervous system drugs
Cholinergic
Anticholinergic
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Adrenergic Drugs
Chapter 17
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Adrenergic Drugs
What do they do?
Stimulation of the sympathetic nervous
system.
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Mechanism of Action
Three mechanisms:
Directly with alpha 1 or beta-adrenergic receptors
on surface membrane.
Indirect effects of postsynaptic adrenergicreceptors.
Mixed actioncombination of action on direct and
indirect receptor.
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Heart
Direct stimulation of receptors
Alpha 1 - Vasoconstriction of blood vessels which
increases blood pressurepressor or
vasopressor effect. Beta 1 - increased force of myocardial contraction
- Increased speed of electrical conduction in the
heart.
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Lungs
Asthma and COPD (Chronic Obstructive
Pulmonary Disease): Beta 2 drugs or
bronchodilators are used to relieve broncho-
constriction and broncho-spasm.
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Pregnancy
Adrenergic drugs used to relax uterine
muscles in preterm labor.
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OTC Adrenergic Drugs
Common cold: anti-histamines
Allergy: nasal or oral to relieve nasal
congestion
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Adrenergic Drugs
Epinephrine
PseudoephedrineSudafed
Isoproterenol (Isuprel)
Phenylephrine (Neo-Synephrine)
Clonidine (antihypertensive)
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How does one choose a drug?
How emergent is the situation
PO or IM or IV
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Allergic Response
Runny nose, itchy eyes, cough
Asthma: Cough with bronchospasms,
difficulty breathing or SOB (shortness of
breath)
Anaphylactic shockedema of airway
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Pseudoephedrine
Therapeutic classification: allergy, cold, and coughremedies, nasal drying, and decongestants.
Indications: symptomatic management of nasal
congestion associated with acute viral upperrespiratory tract infection. Most often used incombination with other drugs.
Action: stimulates Alpha and beta-adrenergicreceptorsvasoconstriction in respiratory tract
mucosapossible bronchodilation Therapeutic effects: reduction of nasal congestion,
and swelling of nasal passages.
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Forms and Dosage
How supplied: tabs, chew tabs, extended
release tabs, liquid or drops
Dosing: 30 to 60 mg / dose q 6-8 hours PO
Maximum dose 240 mg/24 hours
Sustained release: 120 mg PO q 12 hours
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Contraindications
Severe Hypertension
Severe CAD / coronary artery disease
Use with caution in pregnancy, breast feeding
and renal failure
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Use with caution!
Mild or moderate hypertension,
hyperglycemia, hyperthyroidism, and cardiac
disease.
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Side Effects
Dizziness, nervousness, restlessness,
insomnia and arrhythmias
Seizures
Cardiovascular collapse
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Additional Information
OTC used in combination with anti-
histamines
Primarily excreted renallyadjust in patients
with renal impairment May cause false-positive for amphetamines
athletes
Currently need to ask pharmacist for SudafedOTC has been limited due to abuse
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Nursing Implications
Assess for congestion
Monitor pulse and blood pressure before
beginning therapy
Assess lung sound for signs of bronchialsecretions
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Severe Anaphylactic Shock
Usually involving the airways
Some thing as simple as food allergy can
trigger it
Peanuts, shell fish, legumes, bee sting,medications
Symptoms usually starts with numbness and
tingling of lips and leads to swelling of theglottis or epiglottisthis can result in closure
of the airway.
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How Do You Treat It?
Epinephrine would be the drug of choice
Classification: adrenergic
Action: affects both the beta (cardiac) and
beta (pulmonary) receptorsproduces
bronchodilationinhibits hypersensitivity
reaction of mast cells.
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Epinephrine
Therapeutic Effects:
Bronchodilation
Maintenance of heart rate and blood pressure
Adverse Side Effects:
Nervousness, restlessness, tremors, angina,
arrhythmias, hypertension, tachycardia
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How it is given?
Sub-Q or IV or inhaled
The subcutaneous or intramuscular
administration will help it to get into the blood
stream quickerepi-pen is given to clientswith severe allergy reactions
Not given by mouth because drug is
inactivated by gastric juices Can be inhaled in asthma attack
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P i i h
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Precautions with Use
Tachyarrhythmia's (fast irregular heart rate),
headache, nausea, and palpitations
Short acting so more definitive treatment
needs to be initiated Need cardio-respiratory monitoring
Pulse oximetry
Cardiac monitor
C di A
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Cardiac Arrest
Epinephrine is the best studied and most
widely administered adrenergic agonist used
for the treatment of cardiac arrest.
Used to jump start the heart.
V / I i D
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Vasopressor / Inotropic Drugs
Used extensively along with Dopamine to
maintain myocardial and cerebral perfusion
post cardiac arrest.
Administered in small, consistent amountsintravenous.
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Antiadrenergic Drugs
Chapter 18
Clinical Drug Therapy
A i d i D
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Antiadrenergic Drugs
Blocks the effects of the sympathetic nerve
stimulation, endogenous catecholamine and
adrenergic drugs.
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Wh U d?
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When Used?
To manage hypertension and a number of
cardiovascular disorders.
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Ch li i D
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Cholinergic Drugs
Cholinergic drugs stimulate the
parasympathetic nervous system.
M h i f A i
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Mechanism of Action
Direct acting cholinergic drugs are synthetic
derivative of choline.
Effects of drug
Decrease heart rate, vasodilation, and changes inBP
Increase tone and contractibility of smooth muscle
Increase tone and contractibility of bronchial
smooth muscles
Increased respiratory secretions
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N i A t i t ti
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Nursing Assessment: urine retention
Urinary retention
Bladder distention
Fluid intake
Time of last void
How do you know drug is working?
Fluid intake equal to urine output
Patient has voided within the last 8 hours
N i A t l ti il
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Nursing Assessment: paralytic ileus
Paralytic ileus
Hypo-peristalsis
Decreased bowel sounds
No gas or bowel movement
How do you know drug is working?
Bowel sounds heart in all four quadrants
Client states has passes gas Client states has had a bowel movement
Nursing Assessment: Myasthenia Gravis
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Nursing Assessment: Myasthenia Gravis
Signs and symptoms: muscle weakness,
ptosis (droopy eye lid), diplopia (double
vision), difficulty chewing and swallowing,
decreased activity intolerance. How do you know medication is working?
Increased muscle tone, no droopy eye lid or
double vision, increased activity tolerance.
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Use in Older Ad lts
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Use in Older Adults
May be used in myasthenia gravis orAlzheimers disease
Contraindications
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Contraindications
Renal obstruction
Liver disease
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Anticholinergic Drugs
Chapter 20
Clinical Drug Therapy
Anticholinergic Drugs
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Anticholinergic Drugs
Anticholinergics are a class of medicationsthat inhibit parasympathetic nerve impulses
by selectively blocking the binding of the
neurotransmitter acetylcholine to its receptorin nerve cells.
Mechanism of Action
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Mechanism of Action
Drugs act by occupying receptor sites ontarget organs innervated by parasympathetic
nervous system leaving fewer receptor sites
free to respond to acetylcholine. Parasympathetic response is absent or
decreased depending on number of receptors
blocked.
Effects of Anticholinergic Drugs
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Effects of Anticholinergic Drugs
CNS stimulation followed by depression Decreased cardiovascular response to
parasympathetic (vagal) stimulation that
slows heart rate Bronchodilation and decrease respiratory
secretions
Antispasmodic effects in GI system
Change in intra-ocular pressure in patientswith glaucoma
Uses
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Uses
GI disorderspeptic ulcer disease, gastritis,increased gastric acid secretionrelax gastricsmooth muscle (replaced by newer drugs)
Genitourinaryanti-spasmodicurgency
Excessive secretions Ophthalmologyrelax eye for exam
Respiratory disorderasthma or bronchitisinhaled form only
Cardiac disordersbradycardia or heart block
Parkinsons disease
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Atropine
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Atropine
Pharmacological classification:anticholinergic
Therapeutic classification: antiarrhythmic
Action: Inhibits the action of acetylcholine atpostganglionic sites located in the smooth
muscle, secretory glands, CNS. Low doses
decrease: sweating, salivation andrespiratory secretions.
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Atropine
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Atropine
Side effects: drowsiness, blurred vision,tachycardia, dry mouth, urinary hesitancy.
Atropine
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Atropine
Prototype of anticholineric drugsatropinesulfate
Therapeutic
Previously used in preoperative patients toreduce secretionsother newer drugs have
replaced