Chapter 13 Drugs Affecting Adrenergic Function

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Introduction
The nervous system is divided into two main branches: Central Nervous System Brain and the Spinal Cord

Peripheral Nervous System.

Somatic Controls voluntary Autonomic Sympathetic Parasympathetic

movements

(Adrenergic)

(Cholinergic)

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Autonomic Nervous System

The ANS has been identified as an involuntary system responsible for the control of smooth muscle. The actual connection between neurons and effector organs or tissues relies on neurotransmitters and synaptic transmission. The neurotransmitters in the ANS include acetylcholine (ACh), norepinephrine (NE), and epinephrine (Epi). Synaptic transmission initially involves the synthesis of neurotransmitters in the nerve terminal. In the SNS, preganglionic transmission is mediated by ACh, whereas postganglionic transmission is mediated by NE.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Important Point!

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Important Point!
To effect an action, the neurotransmitter needs to bind with an appropriate receptor site on the effector organ or tissue A neuro-pharmacologic drug works by increasing or decreasing receptor activation in the Autonomic Nervous System

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

SNS and PSNS Effects on the Body

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adrenergic Receptors SNS

Types of adrenergic receptors: alpha-adrenergic beta-adrenergic

dopaminergic (dopamine is the precursor to NE).

Alpha and beta receptors are located throughout the body. Alpha-1 and beta-1 receptors respond to : epinephrine, norepinephrine, and dopamine. Alpha-2 receptors respond to epinephrine and NE. Beta-2 receptors respond only to epinephrine.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pathophysiology
The therapeutic uses of sympathetic drugs are related to providing: extra-adrenergic stimulation blockade of normal ANS functioning.

One of the most frequent indications for adrenergic agonist drugs is Shock.
Shock is the result of : inadequate tissue perfusion cells without oxygen and nutrients

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adrenergic Agonists
Drugs that:
mimic the action of the SNS.( sympathomimetic) exert their effects by direct or indirect stimulation of adrenergic receptors Divided into two groups: catecholamines - ( similar chemical structure) short duration of action cannot be given orally do not cross the blood brain barrier non-catecholamines- ( do the opposite of above) Both alpha and beta adrenergic agonists are classified also as catecholamines orCopyright non-catecholamines 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adrenergic Agonists
Adrenergic agonists ( sympathomimetics) are drugs that: mimic the action of the SNS. They exert their effects by direct or indirect stimulation of adrenergic receptors.

These drugs are generally divided into two groups: catecholamines and noncatecholamines.
Adrenergic agonists are also classified according to their selectivity.

Nonselective adrenergic agonists stimulate both alpha and beta receptors.

Prototype drug: nonselective adrenergic agonist: epinephrine.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Core Drug Knowledge

Pharmacotherapeutics Wide variety of indications: asthma, shock Pharmacokinetics Administered: parenterally, topically, or by inhalation. Metabolism: liver. Absorption: into the tissues.

Excreted: kidneys.
Pharmacodynamics

Duration: 1-4 hours.

It stimulates all adrenergic receptors Profound effects in the cardiovascular system and CNS. Acts directly on the postsynaptic adrenergic receptors
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Core Drug Knowledge

Contraindications and precautions: hypersensitivity, sulfite sensitivity, closed-angle glaucoma patients with severe cardiac disease Adverse effects

Severe: hypertensive crisis, angina, cerebral hemorrhage, and cardiac arrhythmias

Main adverse effects: tremors, palpitations, apprehension Increase in blood glucose Drug interactions Tricyclic antidepressants, oxytocics, halogenated anesthetics, and beta blockers.
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Core Patient Variables

Health status Document preadministration vital signs. Review health history.

Life span and gender

Pregnancy risk category C. Lifestyle, diet, and habits Document the patients occupation and daily activities. Environment IV administration only by trained personnel.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Nursing Diagnoses and Outcomes

Imbalanced Nutrition: Less Than Body Requirements related to druginduced anorexia or nausea Desired outcome: the patient will maintain adequate nutrition. Desired outcome: the patient will learn about and practice sleep hygiene. Desired outcome: the patient will notify the provider if vision changes occur. Disturbed Sleep Pattern, Insomnia, related to CNS excitation

Disturbed Sensory Perception related to impaired vision

Ineffective Tissue Perfusion (Cardiopulmonary) related to cardiovascular effects of epinephrine Desired outcome: the patient will notify the provider if tachycardia, chest pain, or palpitations occur.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Planning & Interventions

Maximizing therapeutic effects Requires close monitoring of vital signs and careful monitoring for adverse effects. Take as prescribed. Minimizing adverse effects When treating anaphylactic shock, monitor blood pressure.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epinephrine: Teaching, Assessment & Evaluations

Patient and family education Acute illness: Teaching should be brief, simple, and supportive.

Explain how to administer drug properly.

Ongoing assessment and evaluation Assess the patient for resolution of the presenting problem.

Important to remember that epinephrine is a nonselective adrenergic agonist.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Which of the following receptors is (are) stimulated by epinephrine? A. Alpha 1

B. Alpha 2
C. Beta 1 D. Beta 2

E. All of the above

Answer: E
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Alpha-1 Adrenergic Agonists

The alpha-1 adrenergic agonists are drugs that stimulate the alpha-1 receptor directly. Prototype drug: phenylephrine (Neo-Synephrine).

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine: Core Drug Knowledge

Pharmacotherapeutics Used parenterally for vascular failure in shock. Used topically for relief of nasal mucosal congestion.

Pharmacokinetics
Administered: parenterally or topically. Metabolism: liver. Excreted: urine. Onset: 15 to 20 minutes. Duration: 1-2 hours.

Pharmacodynamics Is structurally similar to epinephrine and is a powerful alpha-1 adrenergic agonist ( depends on the route )
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine: Core Drug Knowledge

Contraindications and precautions Hypersensitivity, sulfite sensitivity, severe hypertension, ventricular tachycardia, and closed-angle glaucoma Adverse effects Headache, restlessness, excitability, and reflex bradycardia Drug interactions

Monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, and oxytocics

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine: Core Patient Variables

Health status Assess medical history and obtain baseline assessment Life span and gender

Used in pregnancy only if absolutely necessary

Lifestyle, diet, and habits Document the patients occupation and activities of daily living

Environment
Closely monitor during administration in acute care setting

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine : Nursing Diagnoses and Outcomes

Impaired Gas Exchange related to bronchoconstriction Desired outcome: gas exchange will remain unimpaired. Imbalanced Nutrition: Less Than Body Requirements related to anorexia or nausea Desired outcome: the patient will take sufficient nourishment. Disturbed Sleep Pattern, Insomnia, related to CNS excitation secondary to phenylephrine use

Desired outcome: the patient will maintain normal sleep patterns.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine: Planning & Interventions

Maximizing therapeutic effects Corrected any blood losses prior to administration.
To produce optimal mydriasis, instill the ophthalmic form into the conjunctival cul-de-sac.

Minimizing adverse effects

IV administration is through a large vein. Avoid driving at night because blurred vision can be hazardous.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phenylephrine : Teaching, Assessment & Evaluations

Patient and family education Stress the hazards associated with driving and operating heavy machinery.

Teach the patient about drug interactions.

Ongoing assessment and evaluation Completing a detailed and thorough history and physical examination is essential for any patient anticipating long-term adrenergic drug therapy.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Alpha-Adrenergic Antagonists
Alpha-adrenergic antagonists block the stimulation of alpha receptors. Alpha-1a receptors mediate human prostatic smooth muscle contraction. Alpha-1b and alpha-1d receptors are involved in vascular smooth muscle contraction. Prototype drug: prazosin (Minipress).

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Core Drug Knowledge

Pharmacotherapeutics Used to treat:

congestive heart failure , hypertension, prostatic outflow obstruction

Metabolism: liver.

Pharmacokinetics Administered: oral. Excreted: bile, feces, and urine. Onset: 1 hour. Duration: 10 hours. Pharmacodynamics

Blocks postsynaptic alpha-1 adrenergic receptors: lowers supine and standing blood pressure.
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Core Drug Knowledge

Contraindications and precautions Hypersensitivity; use caution with angina because hypotension may worsen the condition

Adverse effects
Light-headedness, dizziness, headache, drowsiness, weakness, lethargy, nausea, and palpitations Serious : first dose syncope Drug interactions Other antihypertensive medications
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Core Patient Variables

Health status Past medical history and physical assessment Life span and gender

Pregnancy category C
Lifestyle, diet, and habits Document the occupation and daily activities

Environment
Assess environment where drug will be given

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Nursing Diagnoses and Outcomes

Ineffective Tissue Perfusion related to prazosin-induced hypotension Desired outcome: the patient will maintain adequate tissue perfusion. Imbalanced Nutrition: Less Than Body Requirements related to nausea secondary to prazosin use Desired outcome: the patient will receive adequate nourishment by practicing appropriate dietary management. Risk for Injury related to orthostatic hypotension Desired outcome: the patient will remain free of injury.
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Planning & Interventions

Maximizing therapeutic effects Take as prescribed. Refraining from OTC medication usage. Minimizing adverse effects Take the first dose just before bedtime. Monitor weight and check for edema.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prazosin: Teaching, Assessment & Evaluations

Patient and family education Take drug as prescribed. Adverse effects, including symptoms, to report to doctor Ongoing assessment and evaluation Monitor blood pressure, heart and lung sounds, and edema. Identify potential drug interactions.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Beta-Adrenergic Antagonists : Beta Blockers

Grouped according to their specificity of action at the beta-1 and beta-2 receptors. Stimulation of beta-1 only (tachycardia, increased lipolysis, inotropy). Stimulation of both beta-1 and beta-2 receptors (vasodilation, decreased peripheral resistance, bronchodilation).

Prototype drug: Propranolol (Inderal).

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Core Drug Knowledge

Pharmacotherapeutics

Treatment of hypertension, angina, irregular cardiac rhythms, pheochromocytoma, and migraine.

Pharmacokinetics Administered: parenterally and orally. Metabolism: liver. Excreted: urine. Onset & duration: varies with route of administration.

Pharmacodynamics
Decreased cardiac output and blood pressure. Slowing of atrioventricular conduction and suppression of automaticity. Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Core Drug Knowledge

Contraindications and precautions Severe bradycardia, complete heart block, reactive airway disease and use of antidepressant drugs Adverse effects Cognitive dysfunction, hypoglycemia in patients with type 1 diabetes, diarrhea, and weight gain Drug interactions

Several drug interactions

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Core Patient Variables

Health status Past medical and physical assessment Life span and gender

Pregnancy category C
Lifestyle, diet, and habits Document occupation and daily activities

Environment
Assess environment where drug will be given

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Nursing Diagnoses and Outcomes

Sexual Dysfunction related to decreased libido or erectile dysfunction secondary to beta blockade Desired outcome: the patient will adapt to altered sexual functioning. Desired outcome: the patient will not sustain injury.

Risk for Injury related to dizziness secondary to beta blockade Disturbed Sleep Pattern, Insomnia and Drowsiness, secondary to beta blockade Desired outcome: the patient will sleep normally and awaken rested.

Activity Intolerance related to lethargy and weakness secondary to beta blockade Desired outcome: the patient will maintain a satisfactory activity level.
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Planning & Interventions

Maximizing therapeutic effects Do not abruptly stop medication. Minimizing adverse effects Check the apical and peripheral pulses prior to administration Monitor: blood pressure cardiac rhythm conduction.
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Propranolol: Teaching, Assessment & Evaluations

Patient and family education
Do not abruptly stop medication. Adverse effects, including symptoms, to report to doctor.

Ongoing assessment and evaluation

When evaluating the success of nursing management, anticipate the absence of signs and symptoms for the condition being treated. Monitor cardiovascular system: BP, heart rate, edema.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins