Autonomic Nervous System

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Autonomic Nervous System

• Chapter 17,18, 19, 20

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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

• Includes all the neurons and ganglia found
  outside the CNS
• Includes the
• Sympathetic receptors (adrenergic)
• Parasympathetic receptors (cholinergic)

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Sympathetic Nervous System

• Helps the body cope with external stimuli and
  functions during stress (triggers the flight or
  fight response)
• Vasoconstriction increase in blood pressure
• Increased heart rate
• Increased respiratory rate
• Cold, sweaty palms
• Pupil dilation

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Sympathetic Nervous System
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Parasympathetic Nervous System

• Works to save energy, aids in digestion, and
  supports restorative, resting body functions.
• Decrease in heart rate
• Increased gastro intestinal tract tone and
  peristalsis
• Urinary sphincter relaxation
• Vasodilation decrease in blood pressure

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The Race Horse and the Cow
Sympathetic Nervous System
Parasympathetic
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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 systemic arteries and veins.
• Epinephrine is a constant in regulating heart
  rate, vasoconstriction in systemic arteries and
  veins and vasodilation of muscles and liver.

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Adrenergic Receptors

• Norepinephrine produces its effects by combining
  with adrenergic receptors
• Alpha
• Beta

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Adrenergic Receptors

• Found in
• Cardiovascular
• Endocrine
• Gastrointestinal
• Genitourinary
• Respiratory
• Ocular

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Alpha Receptors

• Alpha 1 adrenergic receptors located on
  postsynaptic effector cells.
• Smooth muscles of blood vessels Constriction
• Bladder sphincter
• Penis
• Uterus
• Pupillary muscles of iris

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Adrenergic Receptor

• Alpha 1
• Therapeutic Uses
• Control topical superficial bleeding
• Treat nasal congestion
• Elevate blood pressure
• Delay absorption of local anesthesia
• Decrease intraocular pressure (pressure in eye)

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Alpha 2

• Same as the Alpha 1 but are located in the
  presynaptic nerve terminals.

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Adrenergic Receptor

• Beta 1
• Cardiovascular
• Cardiac muscle increased contractility
• Atrioventricular node (AV) increased heart rate
• Sinoatrial node increase (SA) in heart rate
• Endocrine
• Pancreas (insulin)

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Cardiac Conduction System
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Beta 1 Drugs

• Predominately works on vascular smooth muscle of
  the heart.

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Adrenergic Receptor

• Beta 2
• Cardiovascular
• Dilation of blood vessels
• Endocrine
• Uterine relaxation
• Respiratory dilation of bronchial muscles

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Beta 2 Drugs

• Used in Asthma to relieve bronchocontriction.
• Used to delay pre-term labor by relaxing the
  uterus.

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Dopamine

• Adrenergic neurotransmitter essential for
  normal brain function.
• Studies focus on connection between dopamine
  malfunction in schizophrenia and Parkinsons
  Disease.
• Role of dopamine stimulants and depressants.

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Body Responses fight or flight

• 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 fight.
• Increase in glycogen for energy, mental activity,
  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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Sympathetic Nervous System

• Protective mechanisms designed to help person
  cope with the stress or get away from it.

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Body Responses rest and digest

• Dilation of blood vessels in skin
• Decrease heart rate
• Increase secretion of digestive enzymes
• Constriction of smooth muscle of bronchi
• Increase in sweat glands - cooling
• Contraction of smooth muscles of urinary bladder
• Contraction of smooth muscle of skeletal system

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Adrenergic Drugs

• What do they do?
• Stimulation of the sympathetic nervous system.

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Indications

• Respiratory conditions
• Topical nasal congestion
• Ophthalmic conditions
• Cardiovascular

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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.
• Action dilation of bronchioles

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Asthma
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OTC Adrenergic Drugs

• Common cold anti-histamines
• Allergy nasal or oral to relieve nasal
  congestion

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Heart

• Direct stimulation of receptors
• Alpha 1
• Vasoconstriction of blood vessels which increases
  blood pressure
• Pressor or vasopressor effect to maintain blood
  pressure
• Beta 1
• Increased force of myocardial contraction
• Increased speed of electrical conduction in the
  heart.

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Heart SA Node
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Ophthalmic Conditions

• Used to reduce intraocular pressure in treatment
  of glaucoma.

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Glaucoma
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Contraindications

• Only contraindications to use of adrenergic drugs
  are
• Drug allergy
• Severe hypertension

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Adrenergic Drugs

• Epinephrine
• Pseudoephedrine Sudafed
• Isoproterenol (Isuprel)
• Phenylephrine (Neo-Synephrine)
• Clonidine (antihypertensive)

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pseudoephedrine

• Trade names Sudafed, Afrin nose spray
• Functional Classification Adrenergic
• Therapeutic classification allergy, cold and
  cough remedies, nasal drying agents /
  decongestants
• Action stimulates alpha and beta adrenergic
  receptors

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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 coronary artery disease (CAD)
• Use with caution in pregnancy, breast feeding and
  renal failure

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Side Effects

• Dizziness, nervousness, restlessness, insomnia
  and arrhythmias
• Seizures
• Cardiovascular collapse

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Additional Information

• 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

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Nursing Implications

• Assess for congestion
• Monitor pulse and blood pressure before beginning
  therapy
• Assess lung sound for signs of bronchial
  secretions

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Allergies
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Anaphylactic Shock
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Epinephrine

• Epinephrine would be the drug of choice
• Classification Adrenergic
• Action affects both the beta 1 (cardiac) and
  beta 2 (pulmonary) receptors
• produces bronchodilation
• inhibits 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
• 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

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CAUTION!

• Check dose, concentration, and route of
  administration
• fatalities have occurred from medication errors
• use TB syringe for subcutaneous administration
• Inhaled provided as metered dose inhaler 160 to
  250 mcg can have 3 treatments 5 minutes apart.
• IV would be 0.1 to 0.25 mg (cardiopulmonary
  resuscitation)

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Calculation

• The order is for 0.25 mg of epinephrine.
• How much would you need to draw up from the vial
  
• Epinephrine 1 mg / 1 ml

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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

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Vasopressive Drugs

• Pressor drugs or pressors or inotropes
• Used to support the cardiovascular system during
  cardiac failure or shock.
• Common vasopressors
• Dobutamine 1
• Dopamine 2
• Nor-epinephrine (in addition to 1 2)

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Dobutamine

• Functional classification Adrenergic direct
  acting B1 agonist, cardiac stimulant
• Uses management of heart failure caused by
  depressed contractibility of the heart
• Action stimulates beta 1 (myocardial) adrenergic
  receptors with relatively minor effect on heart
  rate or peripheral blood vessels.

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Dopomine

• Functional Classification adrenergic
• Uses to improve blood pressure, cardiac output,
  urine output treatment of shock
• Action stimulates Dopomine receptors and beta 1
  adrenergic receptors
• Effect increase BP, cardiac output and renal
  blood flow

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Adrenergic-blocking Drugs

• Chapter 18

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Antiadrenergic Drugs

• Blocks the effects of the sympathetic nerve
  stimulation, endogenous catecholamine and
  adrenergic drugs.

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Mechanism of Action

• Act on alpha or beta receptors
• Receptors are blocked by adrenergic antagonists
  or pre-synaptic alpha 2 receptors are stimulated.

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When Used?

• To manage hypertension and a number of
  cardiovascular disorders.
• Beta 1 blocking drugs acute myocardial
  infarction (heart attack) MI, angina (chest
  pain), hypertension
• Alpha1 blocking drugs heart failure, angina,
  hypertension

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When Used?

• Urinary retention to reduce smooth muscle
  contraction of the bladder neck
• Migraine headaches ergotamines to dilate blood
  vessels of the brain and carotid arteries.
• Uterine contractions ocytocics used to control
  post-partum bleeding

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Patient Teaching

• Teach about therapeutic and adverse effects.
• Take medications as prescribed and do not
  abruptly stop do not take more or less.
• Avoid caffeine and other CNS stimulants.
• Change positions slowly to avoid dizziness or
  syncope
• Hypotension
• Postural hypotension or orthostatic hypotension

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Patient Education

• Avoid alcohol
• Hot tubs and saunas
• Report constipation and urinary retention
• Report to health care providers
• Confusion
• Depression
• Hallucinations
• Nightmares
• Palpitations
• Dizziness

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Orthostatic Hypotension

• Abnormally low blood pressure that occurs when a
  person assumes a standing position from a sitting
  or lying position.

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Cholinergic Drugs Chapter 19

• Cholinergic drugs stimulate the parasympathetic
  nervous system.

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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 in
  BP
• Increase tone and contractibility of smooth
  muscle
• Increase tone and contractibility of bronchial
  smooth muscles
• Increased respiratory secretions

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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

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bethanechol

• Trade name Urecholine
• Functional classification urinary tract
  stimulant
• Chemical classification cholinergic
• Uses postoperative urinary retention
• Action stimulates cholinergic receptors

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Nursing Assessment urine retention

• Urinary retention
• Bladder distention
• Difficulty voiding
• How do you know drug is working?
• Fluid intake equal to urine output
• Patient has voided within the last 8 hours

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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

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Myasthenia Gravis

• Signs and symptoms muscle weakness, ptosis
  (droopy eye lid), diplopia (double vision),
  difficulty chewing and swallowing, decreased
  activity intolerance.

• Ho

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pyridostigmine

• Trade name Mestinon and Antillrium
• Functional classification antimyasthemics
• Chemical classification cholinergics
• Indications used to increase muscle strength in
  the symptomatic treatment of myasthenia gravis

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Evaluation of drug effectiveness

• How do you know medication is working?
• Increased muscle tone
• No droopy eye lid or double vision
• Increased activity tolerance.

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Alzheimer

• Signs and symptoms loss of memory, cognitive
  function and decreased self-care
• Clinical trials with Razadyne (drug is in test
  stage and there is not enough evidence to show
  that is works)
• Evaluation of medication effectiveness
• Increase memory and cognitive function
• Increase interest in activities of daily living.

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Cholinergic-Blocking Drugs

• Chapter 20

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Colinergic-Blocking 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.

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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.

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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 patients with
  glaucoma

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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
• Parkinsons disease

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Side Effects

• Hyperthermia, hot, dry flushed skin, dry mouth,
  tachycardia, delirium, paralytic ileus and
  urinary retention

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Atropine

• Chemical classification anticholinergic
• Functional 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.

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Atropine

• Therapeutic effects
• Increased heart rate
• Decreased GI and respiratory secretions
• May have spasmodic action on the biliary and
  genitourinary tracts.

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Atropine

• Side effects
• Drowsiness
• Blurred vision
• Tachycardia
• Dry mouth
• Urinary hesitancy