1. DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM 10/8/2015Winter 2013 11

2. 10/8/2015Winter 2013 2 Nicotinic - skeletal Muscarinic - organ

3. 10/8/2015Winter 2013 3

4. 4 Peripheral Nervous System Somatic: Voluntary Innervates skeletal muscles Controlled through conscious thought Neurotransmitter Acetylcholine 10/8/2015

5. Winter 2013 5 Autonomic Nervous System Autonomic or visceral division – not controlled by conscious Controls Blood pressure Heart rate Gastrointestinal activity Glandular secretions 10/8/2015

6. Winter 2013 6 SUBDIVISIONS OF THE AUTONOMIC NERVOUS SYSTEM Sympathetic nervous system Fight or Flight Useful in highly stressful or emergency situations Parasympathetic nervous system Maintains homeostasis Works in “opposition” of the Sympathetic nervous system “Rest and Digest” 10/8/2015

7. Winter 2013 7 VOCABULARY “SYNONYMOUS” TERMS SYMPATHETIC AKA ADRENERGIC SYMPATHOMEMETIC MIMICS THE SYMPATHETIC SYSTEM PARASYMPATHETIC AKA CHOLINERGIC PARASYMPATHOMEMETIC MIMICS THE PARASYMPATHETIC NERVOUS SYSTEM 10/8/2015

8. Winter 2013 8 Adrenergic/Sympathetic NEUROTRANSMITTERS (neurohormones) CATECHOLAMINES Epinephrine (prototype) – secreted by Adrenal gland, direct response at nerve ending Norepinephrine – secreted by Adrenal gland. Stored in the axon, direct response at the nerve ending RECEPTORS / RECEPTOR SITES ALPHA 1 ALPHA 2 BETA 1 BETA 2 10/8/2015

9. Winter 2013 9 10/8/2015

10. RECEPTOR Responses to Stimulation ALPHA I (located on the target cells) Blood vessels Constriction Pupils Dilation Penis Ejaculation Uterus Contraction Sphincters Constriction 10/8/2015 10

11. Winter 2013 11 Alpha-1 Adrenergic drugs Isuprel (isoproterenol) Used for shock Adrenalin (epinephrine) Cardiac arrest Anaphylactic shock Nasal decongestants (phenylephrine – Neo-Synephrine) Pseudoephedrine (Sudafed) 10/8/2015

12. RECEPTOR Responses to Stimulation ALPHA 2 (located on presynaptic terminal) Control the release of norepinephrine 10/8/2015Winter 2013 12

13. ALPHA 2 Adrenergic Drugs CLONIDINE (Catepres) Decrease blood pressure Management of Opioid withdrawal METHYLDOPA Decrease blood pressure 10/8/2015Winter 2013 13

14. RECEPTOR Responses to Stimulation DOPAMINE RECEPTORS Located in various tissues and organs Cause dilation of renal, mesenteric, coronary and cerebral arteries 10/8/2015Winter 2013 14

15. Winter 2013 15 Adrenergic drugs (Alpha 1) ADVERSE EFFECTS V. THERAPEUTIC EFFECTS Increased HR (tachycardia) Increased Blood pressure Decreased Gastric motility Restlessness, irritability, anxiety, pallor Increased Alertness 10/8/2015

16. Winter 2013 16 Adrenergic blocking drugs Alpha and BETA blocking drugs Uses (Beta 1 receptors are located primarily on cardiac tissues - cardioselective) Cardiac dysrhythmias Angina Hypertension Congestive heart failure Prostate hypertrophy (alpha blocker) 10/8/2015

17. Winter 2013 17

18. Adrenergic (beta-1) blocking drugs Beta-adrenergic blocking drugs Propranolol (Inderal) Nadolol (Corgard) Atenolol (Tenormin) Timolol (Timoptic) 10/8/2015Winter 2013 18

19. Winter 2013 19 ADRENERGIC BLOCKING DRUGS Adverse reactions Drowsiness, fatigue Bradycardia Hypotension Orthostatic hypotension Diarrhea 10/8/2015

20. Winter 2013 20 Adrenergic blocking drugs Nursing considerations Patient teaching Postural hypotension Signs and symptoms of Heart Failure Monitor blood pressure Taking their own pulse 10/8/2015

21. 21 Winter 2013

22. Parasympathetic (Cholinergic)Nervous System NEUROTRANSMITTER (neurohormone) Acetylcholine – Produced and stored in nerve endings Acetylcholine (ACh) binds to Cholinergic receptor sites and causes a response Stimulation results in “rest and digest’ 10/8/2015Winter 2013 22

23. Acetylcholinesterase (aka: cholinesterase) Breaks down Acetylcholine or limits response Maintains the balance between acetylcholine and dopamine 10/8/2015Winter 2013 23

24. Winter 2013 24 Uses – only four for cholinergic drugs: Drugs that increase Acetylcholine in the Synapse Glaucoma – Reduce intraocular pressure Myasthenia gravis – Disease caused by the lack of ACh at the synapse Relief of urinary retention Increase GI motility 10/8/2015

25. Indirect acting Cholinergic drugs Neostigmine (Prostigmine) (anticholinesterase) prototype Primarily used to treat Myasthenia Gravis Pyridostimine (Mestinon) Myasthenia Gravis Donepezil (Aricept) Works in the CNS to inhibit synthesis of Acetylcholinesterase Used to treat Alzheimer’s disease 10/8/2015Winter 2013 25

26. Winter 2013 26 Cholinergic drugs Direct acting Cholinergic drugs Directly stimulates the nerve ending to secrete acetylcholine Bethanechol (Urecholine) Used to treat urinary retention 10/8/2015

27. Winter 2013 27 ADVERSE REACTIONS CHOLINERGIC DRUGS Bradycardia Hypotension Headache, dizziness Increased secretions Abdominal cramping Increased respiratory secretions and possibly bronchospasms 10/8/2015

28. Winter 2013 28 Anticholinergic Medication Competitive antagonists Compete with ACh Inhibit nerve transmission Sites of action All systems except musculo-skeletal 10/8/2015

29. Winter 2013 29 Anticholinergic Medication EXAMPLES Bentyl (dicyclomine HCL) Antispasmotic used to decrease intestinal cramping in IBS Atropine (Prototype) Acetylcholine antagonist Antidysrhythmic Antispasmotic Antisecretory 10/8/2015

30. Winter 2013 30 Anticholinergic Medication USES Dry oral secretions Increase heart rate Treat ureteral colic Decrease GI motility Parkinson’s disease Decrease upper respiratory secretions 10/8/2015

31. Urinary antispasmodics AKA anticholinergics OXYBUTYNIN (DITROPAN) Synthetic antimuscarinic INCREASES BLADDER CAPACITY DECREASES FREQUENCY OF VOIDING TOLTERODINE (DETROL, DETROL LA) Synthetic antimuscarinic DELAYS THE URGE TO VOID INHIBITS BLADDER CONTRACTIONS 10/8/2015Winter 2013 31

32. Winter 2013 32 Anticholinergic Medication Adverse reactions / Side effects Dry mouth Blurred vision Photophobia Urinary retention Constipation Tachycardia Drowsiness 10/8/2015

33. Nursing Interventions Monitor for signs of anticholinergic crisis Report changes in heart rate, blood pressure, or development of dysrhythmias Provide comfort measures for dryness of mucous membranes Minimize exposure to heat or cold or strenuous exercise Monitor I&O Monitor patient for abdominal distension, and auscultate for bowel sounds 10/8/2015 33 Winter 2013

34. Anticholinergic Crisis 10/8/2015 34 Winter 2013