1. Autonomic Nervous System Chapter 16, 17, 18, 19, 20 Clinical Drug Therapy

2. Nervous System Two main divisions  Central Nervous System or CNS  Peripheral Nervous System or PNS

3. 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.

4. Peripheral Nervous System or PNS Includes all the neurons and ganglia found outside the CNS  Afferent (sensory): modify motor output  Efferent:

5. Afferent Neurons Afferent neurons carry sensory input from the periphery to the CNS and modify motor output through the reflex arc.

6. Efferent Neurons Efferent neurons carry motor signals from the CNS to the peripheral areas of the body.

7. ANS / SNS Autonomic nervous system controls involuntary activities of smooth muscle, secretory glands and the visceral organs of the body such as the heart (involuntary activities of smooth muscle) Somatic nervous system innervates the skeletal muscles and controls voluntary movement

8. Autonomic Nervous System Sympathetic Nervous System Para sympathetic System Enteric System

9. The Race Horse and the Cow Sympathetic Nervous System

10. Sympathetic System Fight or Flight – stimulated by physical or emotional stress (exercise or work), pain, hemorrhage, intense emotions, temperature extremes

11. Sympathetic Nervous System Protective mechanisms designed to help person cope with the stress or get away from it.

12. Neurotransmitters  Acetylcholine: skeletal muscle  Norepinepherine: stress response

13. 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 systemic arteries and veins. Epinephrine is a constant in regulating heart rate, vasoconstriction in systemic arteries and veins and vasodilation of muscles and liver.

14. Dopamine Adrenergic neurotransmitter – essential for normal brain function.  Studies focus on connection between dopamine malfunction in schizophrenia and Parkinson’s Disease.  Role of dopamine in drug addition to drugs: stimulants and depressants.

15. Protective Mechanisms  Intensity of response depends on Norepinephrine and epinephrine  Fight or flight

16. Body Responses Increase in blood pressure and cardiac output. 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, mental activity, muscle strength, blood coagulation, respiratory rate, pupil dilation to aid vision, and increase in sweating.

17. 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.

18. Parasympathetic Nervous System Rest and Digest Save energy Decreased heart rate

19. Adrenergic Receptors Norepinephrine and epinephrine interact with two adrenergic receptors  Alpha and beta Alpha 1 Alpha 2 Beta 1 Beta 2

20. Alpha 1 Alpha 1 receptors allows calcium ions to move into the cell and produce muscle contraction.

21. 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

22. 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

23. Beta 1 Location Heart Kidneys Effects of stimulation Increase heart rate, force of contraction, automaticity and rate of atrial-ventricular function Increased renin release

24. 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

25. Dopamine Location Blood vessels of kidney, heart, and other viscera Effects of stimulation Vasodilation

26. Parasympathetic Nervous System Functions stimulated by PNS: Resting, reparative, or vegetative function

27. 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

28. Neurotransmitter Acetylcholine Two types of cholinergic receptors  Nicotinic: located in motor nerves and skeletal muscles  Muscarinic: located in internal organs, cardiovascular, respiratory, GI and GU

29. Autonomic Drugs Drugs used due to their ability to stimulate or block activity of the sympathetic or parasympathetic nervous system.

30. 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.

31. 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 tissues – side effects.

32. Simulation of SNS Stimulation of sympathetic nervous system can be divided into drug classifications:  Adrenergic  Sympathomimetic  Alpha and beta adrenergic agonists

33. Agonist In pharmacology an agonist is a substance that binds to a specific receptor and triggers a response in the cell.

34. Blockage of SNS Drugs that inhibit sympathetic nervous system are classified as  Antiadrenergic  Sympatholytic anticholinergic

35. Stimulation of PNS Parasympathetic nervous system stimulation drug classifications  Cholinergic  Parasympathomimenic  Cholinomimetic

36. Blocking of PNS Drugs that inhibit parasympathetic stimulation are classified as:  Anticholinergic  Parasympatholytic  Cholenergic blocking drugs

37. Classifications: SNS Sympathetic nervous system drug classifications  Adrenergic - stimulating  Antiadrenergic - blocking

38. Classifications: PNS Parasympathetic nervous system drugs  Cholinergic  Anticholinergic

39. Adrenergic Drugs Chapter 17

40. Adrenergic Drugs What do they do? Stimulation of the sympathetic nervous system.

41. Mechanism of Action Three mechanisms:  Directly with alpha 1 or beta-adrenergic receptors on surface membrane.  Indirect effects of postsynaptic adrenergic receptors.  Mixed action – combination of action on direct and indirect receptor.

42. Heart Direct stimulation of receptors  Alpha 1 - Vasoconstriction of blood vessels which increases blood pressure – pressor or vasopressor effect.  Beta 2 - increased force of myocardial contraction - Increased speed of electrical conduction in the heart.

43. Lungs Asthma and COPD (Chronic Obstructive Pulmonary Disease): Beta 2 drugs or bronchodilators are used to relieve broncho- constriction and broncho-spasm.

44. Pregnancy Adrenergic drugs used to relax uterine muscles in preterm labor.

45. OTC Adrenergic Drugs Common cold: anti-histamines Allergy: nasal or oral to relieve nasal congestion

46. Adrenergic Drugs Epinephrine Pseudoephedrine – Sudafed Isoproterenol (Isuprel) Phenylephrine (Neo-Synephrine) Clonidine (antihypertensive)

47. How does one choose a drug? How emergent is the situation PO or IM or IV

48. Allergic Response Runny nose, itchy eyes, cough Asthma: Cough with bronchospasms, difficulty breathing or SOB (shortness of breath) Anaphylactic shock – edema of airway

49. Allergy Response Nasal congestion, itchy eyes, non-productive cough Seasonal response to environmental causes Commonly mixed with other drugs in cold medications

50. Pseudoephedrine Therapeutic classification: allergy, cold, and cough remedies, nasal drying, and decongestants. Indications: symptomatic management of nasal congestion associated with acute viral upper respiratory tract infection. Most often used in combination with other drugs. Action: stimulates Alpha and beta-adrenergic receptors – vasoconstriction in respiratory tract mucosa – possible bronchodilation Therapeutic effects: reduction of nasal congestion, and swelling of nasal passages.

52. 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

53. Contraindications Severe Hypertension Severe CAD / coronary artery disease Use with caution in pregnancy, breast feeding and renal failure

54. Use with caution! Mild or moderate hypertension, hyperglycemia, hyperthyroidism, and cardiac disease.

55. Side Effects Dizziness, nervousness, restlessness, insomnia and arrhythmias Seizures Cardiovascular collapse

56. Additional Information OTC used in combination with anti- histamines Primarily excreted renally – adjust in patients with renal impairment May cause false-positive for amphetamines – athletes Currently need to ask pharmacist for Sudafed – OTC has been limited due to abuse

57. Nursing Implications Assess for congestion Monitor pulse and blood pressure before beginning therapy Assess lung sound for signs of bronchial secretions

58. 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 the glottis or epiglottis – this can result in closure of the airway.

59. How Do You Treat It? Epinephrine would be the drug of choice Classification: adrenergic Action: affects both the beta (cardiac) and beta (pulmonary) receptors – produces bronchodilation – inhibits hypersensitivity reaction of mast cells.

60. Epinephrine Therapeutic Effects:  Bronchodilation  Maintenance of heart rate and blood pressure Adverse Side Effects:  Nervousness, restlessness, tremors, angina, arrhythmias, hypertension, tachycardia

61. How it is given? Sub-Q or IV or inhaled The subcutaneous or intramuscular administration will help it to get into the blood stream quicker – epi-pen is given to clients with severe allergy reactions Not given by mouth because drug is inactivated by gastric juices Can be inhaled in asthma attack

64. CAUTION! Check dose, concentration, and route of administration – fatalities have occurred from medication errors – us TB syringe for subcutaneous administration Inhaled provided as metered dose inhaler 160 to 250 mcg – broncho-constriction is asthma IV would be 0.1 to 0.25 mg (cardiopulmonary resuscitation)

65. 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

66. 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.

67. Vasopressor / Inotropic Drugs Used extensively along with Dopamine to maintain myocardial and cerebral perfusion post cardiac arrest. Administered in small, consistent amounts intravenous.

68. Antiadrenergic Drugs Chapter 18 Clinical Drug Therapy

69. Antiadrenergic Drugs Blocks the effects of the sympathetic nerve stimulation, endogenous catecholamine and adrenergic drugs.

70. Mechanism of Action Act on alpha or beta receptors Receptors are blocked by adrenergic antagonists or pre-synaptic alpha 2 receptors are stimulated.

71. When Used? To manage hypertension and a number of cardiovascular disorders.

72. Anti – hypertensive Medication Clonidine: Catapres, Catapres TTS, Dixarit, Duracion Pharmacologic classification: adrenergic (centrally acting) Therapeutic classification: antihypertensive

73. Clonidine Action: Stimulates the alpha-adrenergic receptors in the CNS which results in decreased sympathetic outflow inhibiting cardioacceleration and vasoconstriction centers. Prevents pain signal transmission to the CNS by stimulating alpha-adrenergic receptors in the spinal cord. Therapeutic Effects: decreased blood pressure. Decreased pain.

74. Cholinergic Drugs Chapter 19 Clinical Drug Therapy

75. Cholinergic Drugs Cholinergic drugs stimulate the parasympathetic nervous system.

76. Mechanism of Action Direct acting cholinergic drugs are synthetic derivative of choline. Effects of drug  Decrease heart rate, vasodilation, and changes in BP  Increase tone and contractibility of smooth muscle  Increase tone and contractibility of bronchial smooth muscles  Increased respiratory secretions

77. Indications for Use Urinary retention without obstruction Postoperative abdominal distention due to paralytic ileus Myasthenia gravis – muscle weakness During surgery to reverse the effects of muscle relaxants used during surgery

78. 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

79. 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

80. 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.

81. Nursing Assessment: Alzheimer Signs and symptoms: loss of memory, cognitive function and decreased self-care Signs medication is working: increase memory and cognitive function and increase interest in activities of daily living

82. Use in Older Adults May be used in myasthenia gravis or Alzheimer’s disease

83. Contraindications Renal obstruction Liver disease

84. Anticholinergic Drugs Chapter 20 Clinical Drug Therapy

85. Anticholinergic Drugs Anticholinergics are a class of medications that inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells.

86. Mechanism of Action Drugs act by occupying receptor sites on target 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.

87. 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 patients with glaucoma

88. Uses GI disorders – peptic ulcer disease, gastritis, increased gastric acid secretion – relax gastric smooth muscle (replaced by newer drugs) Genitourinary – anti-spasmodic – urgency Excessive secretions Ophthalmology – relax eye for exam Respiratory disorder – asthma or bronchitis – inhaled form only Cardiac disorders – bradycardia or heart block Parkinson’s disease

89. Side Effects Hyperthermia, hot, dry flushed skin, dry mouth, tachycardia, delirium, paralytic ileus and urinary retention

90. Atropine Pharmacological classification: anticholinergic Therapeutic classification: antiarrhythmic Action: Inhibits the action of acetylcholine at postganglionic sites located in the smooth muscle, secretory glands, CNS. Low doses decrease: sweating, salivation and respiratory secretions.

91. Atropine Therapeutic effects:  Increased heart rate  Decreased GI and respiratory secretions  Reversal of muscarinic effects  May have spasmodic action on the biliary and genitourinary tracts.

92. Atropine Side effects: drowsiness, blurred vision, tachycardia, dry mouth, urinary hesitancy.

93. Atropine Prototype of anticholineric drugs – atropine sulfate Therapeutic Previously used in preoperative patients to reduce secretions – other newer drugs have replaced