Automonic Nervous System Agents

by: Mary Lloyd, MSN, RN, CNE

Part One:
• Adrenergic and
Adrenergic
Blockers
 The Nervous System:
A Quick Review
• The Central Nervous System:
– Brain
– Spinal Cord
• The Peripheral Nervous System:
(located outside Brain & Spinal Cord)
– The Somatic Nervous System (voluntary control)
– control of skeletal muscle
– The Autonomic Nervous System: (involuntary)
– sympathetic nervous system
– parasympathetic nervous system
Review of Nervous System
 Review:Autonomic Nervous System
• Known as: Visceral System (= Involuntary System):
-Involuntary responses (no control by human)
-Controls smooth muscle and glands
ex: heart, resp, GI, bladder, eyes, glands
• Utilizes two types of neurons:
– Afferent (sensory)- Sends input to CNS for
interpretation (sendors = messengers)
– Efferent (motor) – receive info (impulses) from
brain & transmit impulses via spinal cord to organ
cells (=receivers)
 Review:ANS
Sympathetic Nervous
System (SNS)
-known as adrenergic system
-once believed adrenaline was
neurotransmitter that acted
on smooth muscle
-Norepinephrine =is the
neurotransmitter released >
stimulates cell receptors > R
-have 4 adrenergic receptor
organ cells:
:alpha 1,alpha 2, beta 1,beta 2
Parasympathetic Nervous
System (PNS)
-called cholinergic system
-Acetylcholine=
neurotransmitter released >
stimulates cell receptors > R
-have cholinergic receptor
organ cells = nicotinic or
muscarinic
Sympathetic Response
-dilates pupils
-dilates bronchioles
-^ HR
-constricts blood vessels
-relaxes smooth GI muscles
-relaxes bladder muscle
-relaxes uterine muscle
= “ fight or flight ” response
ex: Adrenergic drug ^ HR
(=sympathomimetic)
Parasympathetic Response
-constricts pupils
- constricts bronchioles
- ^ lung secretions
- < HR
-dilates blood vessels
- ^ peristalis
-constricts bladder muscle
-
- ^ salivation
ex: Cholinergic drug < HR
(=parasympathomimetic)
 Sympathetic Nervous System (SNS)
(Adrenergic System)
• Drugs that stimulate the SNS:
– Adrenergics
– Adrenergic agonists
– Sympathomimetics
– Adrenomimetics
• WHY? >Mimic neurotransmitters:
-norepinephrine
-epinephrine
• Act on one or more adrenergic receptor sites, found
on cells of smooth muscles Ex: bronchiole walls,
heart, GI tract, urinary bladder, ciliary muscle of eye
• 4 main receptors: alpha 1,alpha 2, beta 1,beta 2
 Sympathetic Nervous System (SNS)
(Adrenergic System)
Adrenergic drugs:
- either stimulate a response (agonists)

- inhibit a response (antagonists)

 Effects of Alpha-Adrenergic Receptors
Location: vessels of smooth Location: postganglionic
muscles sympathetic nerve endings
Alpha1 Alpha2

vasoconstriction < GI motility & tone

^ BP <vasoconstriction
^ cardiac contractility < BP
mydriasis (pupil dilation)
salivary glands < secretions
bladder contraction
prostate gland contraction
 Effects of Alpha-Adrenergic Receptors
Location:smooth muscles of
Location: Heart, primarily lungs :arterioles of skeletal
muscles & uterine muscle
Beta1 Beta2
^ heart rate relax smooth muscles of lung>
> bronchodilation
^ force of contraction
^ blood flow skeletal muscle
^ myocardial contractility
relax of uterine muscles >
^conduction via AV node
< uterine contraction
^ renin secretion < GI tone & motility
^ angiotensin ^glycogenolysis >
> ^BP ^ BS
1) The alpha-adrenergic receptor, Beta 1, affects:
a) Bronchodilation
b) < GI motility
c) <Uterine contraction
d) > Heart rate.
 Effects of Another Alpha-Adrenergic
Receptor: Dopaminergic
Location: renal, mesenteric, coronary, &
cerebral arteries

Dopaminergic: can be activated by dopamine only!

When stimulated:
• vessels dilate
• blood flow increases.
• Ex: espec. activation of receptors in kidney >
renal blood vessels to dilate
 Med: dopamine (Intropin)[sympathomimetic agent]

Receptor Pharmacologic Action USE

Low-dose renal bld vessel dilation - shock
Dopamine - heart failure
Mod-dose renal bld vessel dilation “
Dopamine ^ HR
Beta 1 ^myocardial contractility
^rate of contraction via AV node
High-dose
Dopamine (same actions as Mod dose) “
Beta 1 [except can >vasoconstriction]
Alpha 1
 Med: dopamine (Intropin)
[sympathomimetic agent]
SE NSG Interven/Pt Teaching
Beta 1 > dysrhythmias - Continuous cardiac
- ^O2 demand > angina monitoring
- Monitor for change in HR,
dysrhythmias & chest pain

- Monitor IV site carefully

- Necrosis (skin dies & turns
black) can occur from - D/C infusion at first sign of
extravasation (leakage of irritation
medication to surrounding
tissue) of high doses of
dopamine
 Med: dobutamine (Dobutrex)
[Adrenergic beta-1 agonist ]
Receptor Pharmacologic Action USE
Beta 1 ^ HR heart failure
^myocardial contractility
^rate of contraction via AV node

SE NSG Interven/Pt Teaching

^ HR -Continuous cardiac monitoring
-Report VS changes to MD
 NSG Interven/Pt Ed:
dopamine & dobutamine (Adrenergics)
• Must admin via IV by continuous infusion
• Use IV pump to control infusion
• Dosage titrated (determine concentration of med) based on BP
response
• EX: ICU patients
• STOP IV @ 1ST sign of infiltration
• assess/monitor for chest pain & notify MD if occurs
• continuous ECG monitoring & notify MD if tachycardia or dysrhythmias
NSG EVAL of Med Effectiveness:
• Improved perfusion, AEB UR O > or = 30mL/hr (with normal renal
function); improved mental status, & systolic BP maintained @ > or =
90mmHg
 Classification of
Sympathomimetics/Adrenomimetics
Sympathomimetic drugs that stimulate adrenenrgic receptors:
-classified into 3 categories, as per their affect on organ cells:
1)direct-acting sympathomimetics
-directly stimulate adrenergic receptor (ex:Epi or Norepi)
2)indirect-acting sympathomimetics
-stimulate release of Norepi from terminal ending(ex:amphetam
3)mixed-acting sympathomimetics(direct & indirect acting)
- stimulate adrenergic receptor sites
- stimulate release of norepinephrine from terminal endings
 Mixed-acting Sympathomimetic Drug
Ephedrine
- acts indirectly by stimulating release of Norepi
from nerve terminals
- acts directly on alpha 1, beta 1,beta 2 receptors
-^ HR (beta 1) ^ BP (alpha 1 and beta 1)
-^ BP (not as potent a vasoconstrictor as epinephrine)
-dilates bronchial tubes (beta 2)
-use: treat idiopathic orthostatic hypotension
:treat hypotension from spinal anesthesia
:treat mild forms of bronchial asthma
 Adrenergic Drug
Generic name: epinephrine (think beta 2)*
Trade name: Adrenalin (think bronchodilation)*
class: sympathomometic
action:acts on alpha 1,beta 1, beta 2* adrenergic receptor
(nonselective to one receptor) effects:
> ^ BP (action: think cardiac stimulation)
> ^ HR (tachycardia)
> bronchodilation (action: think bronchodilation)
> pupil dilation
use:allergic*reaction,asthma,bronchospasm,anaphylaxis,arrest
 Epinephrine (Adrenaline)
SE NSG Interven/Pt Teaching
- vasoconstriction from - Continuous cardiac
Alpha 1 > HTN crisis monitoring
- Report VS changes to MD

- Beta 1 > dysrhythmias - Continuous cardiac

- ^O2 demand > angina monitoring
- Monitor for change in HR,
dysrhythmias & chest pain
(cont’d) epinephrine(Adrenalin)
Pharmacokinetics
routes: subQ, IM, IV, inhalation, topical
*Not given orally> WHY? > rapidly metabolized in
GI tract & liver; So inadequate serum levels occur
SE:anorexia, N/V, nervousness, tremors, agitation,
headache, pallor, insomnia, syncope, dizziness
Contraindications: cardiac dysrhythmias, pregnancy,
narrow-angle glaucoma, cardiogenic shock, cerebral
arteriosclerosis
Caution:hypertension, hyperthyroidism, pregnancy,
prostatic hypertrophy, diabetes mellitus
(cont’d) epinephrine(Adrenalin)
Adverse reactions:palpitations, tachycardia, dyspnea
Life-threatening:ventricular fibrillation,pulmonary ed
Drug-Lab-Interactions
Lab: ^ Blood glucose
^serum lactic acid
Drug: < epinephrine effect with methyldopa,
beta blockers & alpha-adrenergic blockers
ex: phentolamine
Doses: see prototype drug chart 17-1
Onset of action (fast): see prototype drug chart 17-1
2) Epinephrine (Adrenalin) is classified as a
sympathomimetic drug which causes:
a) Bronchoconstriction
b) Bronchodilation.
c) < BP
d) < HR
 Adrenergic Drug
Generic name: albuterol sulfate (think asthmatics)
Trade name: Proventil, Ventolin, Salbutamol,
Novo-salmol (action: relaxes bronchial smooth muscle)
Class: Beta 2 - adrenergic agonist
Action: selective for beta 2 adrenergic receptors
> bronchodilation (better for asthmatics)*
WHY?> primary action is on beta 2 receptors
Use:*asthma*,bronchospasm, bronchitis&otherCOPD
Side Effects: tremor, dizziness, nervousness,
restlessness
Contraindications: severe cardiac disease, HTN,
diabetes mellitus, hyperthyroidism, pregnancy
(cont’d) albuterol sulfate (Proventil)

Pharmacokinetics
routes: PO, SR, inhalation, nebulizer
med must be given during shorter intervals,as 3-4x
day
excreted: 75% in urine
SE:tremor, dizziness, nervousness, restlessness
Contraindications: (see caution)
Caution= severe cardiac disease,
hypertension, hyperthyroidism, diabetes mellitus,
pregnancy
(cont’d) albuterol sulfate (Proventil)
Adverse reactions:palpitations, reflex tachycardia,
hallucinations Life-threatening adverse reaction =
cardiac dysrhythmias
Drug-Lab-Interactions (see table 17-2)
Lab: may ^ Blood glucose slightly
: may < potassium level
Drug: < effect with methyldopa, beta blockers & alpha-
adrenergic blockers
ex: phentolamine
Doses: see prototype drug chart 17-2
Onset of action: see prototype drug chart 17-2
 Other Adrenergic Agents
Isoproterenol (Isuprel) (see bronchodil=B2)(^HR=B1)
– Activates Beta1 and Beta2
– With excessive use > severe tachycardia
clonodine(Catapres) and methyldopa(Aldomet)
– Selective alpha 2 receptor stimulants
– Primary use: hypertension (HTN)
– Action: regulate release of norepinephrine
by inhibiting its release
– : produce a cardiovascular depression by
stimulating alpha 2 receptors in CNS >a decrease
in blood pressure ( < BP )
NSG Process: Adrenergic Drugs
SE: HTN (from A1); (from B1) tachycardia,
palpitations, dysrhythmias,
• tremors, dizziness, urinary difficulty, N/V
Assess: record VS
• assess drug interactions(Beta-blockers < effect of Epi)
• assess health history (Contra: cardiac dysrhythmias,
narrow-angle glaucoma & cardiogenic shock)
• evaluate lab values & findings
NSG DX: Decreased cardiac output
• Risk for impaired tissue integrity
PLAN: Closely monitor VS*
 NSG Process: Adrenergic Drugs
NSG Interven: Report ^BP & ^P
ex: If pt gets alpha-adrenergic drug IV for shock,
check BP q3-5 min or as indicated to avoid severe HTN
• check UR O & blad distention(WHY? >UR retention
can be due to ^ drug dose of cont’d use of adrenergics
• monitor IV site often as* infiltration causes tissue
necrosis* ex: epinephrine bitarte (Levarterenol) or
ex:dopamine*(Intropin)alpha1,beta1 for <BP;sparesrenal func
(Antidote for these two drugs: Regitine)
• offer food to avoid N/V/check labs (may be ^ BS)
 Patient Teaching: Adrenergic Drugs
• Med Admin: cold meds=nasal spray: head upright
• Do Not use of nasal spray laying down WHY? >
use of spray laying down > systemic absorption!
• Coloration of nasal spray/drops>means deterioration
• Use of cont’d nasal spray/drops containing adrenergics > >
>> nasal congestion rebound
(inflamed & congested nasal tissue)
• Nursing moms should not take drugs that contain
sympathetic drugs while nursing infants
WHY? > these drugs pass into breast milk
• OTC Diet/Cold meds have sympathetic properties &
pts with DM, CAD or dysrhythmias should not take these
 (cont’d) Patient Teaching:
Adrenergic Drugs
• Avoid excessive use of bronchodilator sprays
WHY?>use of a non-selective adrenergic that affects
Beta 1 & Beta 2 > tachycardia
• Cultural Considerations: < language barriers via
decode language of health care environment for pts
with language difficulties & for those who do not
work in health care; i.e. put in simple terms
• Evaluation: evaluate pt’s response to adrenergics
Continue monitoring VS & report abnormalities
3) The adrenergic agents, clonodine (Catapres) and
methyldopa (Aldomet), are primarily used for:
a) Hypotension
b) Hypertension.
Function of Adrenergics
 Adrenergic Blockers (Antagonists)=known as:
• drugs that block the effects of norepinephrine:
– Sympatholytics
– Adrenergic blockers
– Adrenergic antagonists
– most block alpha or beta by blocking the effects of the
neurotransmitter either: directly by occupying alpha or
beta receptors -OR- : indirectly by inhibiting release
of the neurotransmitters epi or norepi
– three sympatholytic receptors are:alpha-1 & beta-1&-2
– Effects of Adrenergic Blockers@receptor sites:
– alpha-1:<BP,reflex tachy,miosis,suppresses ejaculation,
<contraction of smooth musc of prostate & bladder neck
– beta-1:<HR, <P,< force of contraction
– beta-2:constricts bronchioles, contracts uterus, inhibits
glycogenolysis, which < BS
Alpha-Adrenergic Blockers/Sympatholytics
Are drugs that block or inhibit a response @alpha-adrenergic
receptor site(also called alpha-blockers); 2 groups=
– Selective alpha blockers : block alpha 1
– Nonselective alpha blockers: block alpha 1 and 2
Functions: treatment of BP
Side effects :orthostatic hypotension & reflex tachycardia
are reasonsWHY> not prescribed as often as beta-blocker
Use: alpha blockers = < S&S of BPH
(benign prostatic hypertrophy)
: peripheral vascular disease (Raynaud’s Disease)
Beta-Adrenergic Blockers/Beta Blockers
• block Beta 1 <HR; so, <BP
• block Beta 2 > so, bronchoconstriction occurs

Selective beta - 1 blockers (block beta1) (<P <BP)

Nonselective beta blockers (block beta 1 & beta 2):

Ex: Propranolol HCl (Inderal)
-1st beta blocker: blocks beta-1 & beta -2
– use: angina, HTN & cardiac dysrhythmias
– Contra: asthma, 2nd & 3rd degree heart block and
CHF
– Usage: extreme caution in asthma or COPD
Generic name: atenolol
Trade name: Tenormin, Apo-Atenolol
Class: Beta -1 adrenergic blocker
Action: blocks beta-1<HR; so, <BP
Use: HTN, angina pectoris, MI
Side Effects: drowsiness, dizziness, fainting,
weakness, N/V, diarrhea, cool extremities, leg pain
Adverse: bradycardia, hypotension, heart failure,
masking of hypoglycemia
Life-threatening:agranulocytosis,laryngospasm, resp
distress, pulmonary edema, dysrhythmias
Contraindications:sinus bradycardia, first degree
heart block, cardiogenic shock, cardiac failure
 atenolol=Beta -1 adrenergic blocker
(cont’d)
Adverse reactions:palpitations, bradycardia,
hallucinations Life-threatening adverse reaction =
cardiac dysrhythmias
Drug-Lab-Interactions (see table 17-3)
Drug: < effect with methyldopa, beta blockers &
alpha-adrenergic blockers
ex: phentolamine
Doses: see prototype drug chart 17-3
Onset of action: see prototype drug chart 17-3
 Selective Adrenergic Blocker *
metoprolol tartate (Lopressor)
Beta-1 blocker
• Slows HR; decreases BP
• use: HTN,post MI,angina
• caution: bradycardia & ortho hypotension
• note: formulated so does not cause bronchial
constriction
• may use in asthmatics
• NSG: take VS
• SE: bradycardia & orthostatic hypotension *
 More Adrenergic Blockers
carvedilol (Coreg) alpha1, beta 1, beta 2
• use: HTN; mild to moderate heart failure
• Use: alone or with thiazide diuretic
labetalol ((Normodyne Trandate)alpha1, beta 1, beta 2
• Use: mild to severe HTN; angina pectoris;
• Use: during surgery to manage BP

soltalol (Betapace) beta-1, beta-2

• Use: life-threatening ventricular arrhythmias
• Use: chronic angina pectoris
 Beta Blockers:Patient
Teaching/Monitoring
• Do not stop taking abruptly!
• WHY? > occurrence of rebound HTN, rebound
tachycardia or angina attack
• Family to learn how to monitor HR & BP
• early warning signs of hypoglycemia(nervousness &
tachycardia) may be masked by beta blockers
• slowly rise from supine or sitting to standing WHY?
> to avoid orthostatic (postural) hypotension
• mood changes may occur
• may cause impotence or decrease in libido
4) Selective Beta-1 blockers cause:
a) < P
b) <BP
c) <P and < BP.