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MODULE 13- PERIPHERAL NERVOUS
SYSTEM AGENTS
ACTIVITY 1
NSG124.13.01.01 SNS & PNS & CHOLINERGIC DRUGS
ACETYLCHOLINE
Transmitter released by all preganglionic neurons of the sympathetic nervous system, all preganglionic neurons of the parasympathetic nervous system, all postganglionic neurons of the parasympathetic nervous system, postganglionic neurons of the sympathetic nervous system that go to sweat glands, and all motor neurons. ACTIVATION OF ALPHA 1 RECEPTORS Contracts the radial muscle of the eye (causing mydriasis), constricts veins and arterioles, promotes ejaculation, and contracts smooth muscle in the prostatic capsule and bladder (trigone and sphincter). ACTIVATION OF BETA 1 RECEPTORS Increases heart rate, force of myocardial contraction, and conduction velocity through the atrioventricular node and promotes release of renin by the kidney. ACTIVATION OF BETA 2 RECEPTOS Dilates the bronchi, relaxes uterine smooth muscle, increases glycogenolysis, enhances contraction of skeletal muscle, and dilates arterioles (in the heart, lungs, and skeletal muscle). EPINEPHRINE Major transmitter released by the adrenal medulla. Activates alpha1, alpha2, beta1, and beta2 receptors. NOREPINEPHRINE Transmitter released by all postganglionic neurons of the sympathetic nervous system, except those that go to sweat glands. PNS TRANSMITTERS Acetylcholine, norepinephrine, and epinephrine ACTIVATION OF DOPAMINE RECEPTORS Dilates blood vessels in the kidney What does the nurse need to know to learn and understand peripheral nervous system drugs? Select all that apply. The nurse must make a decision to determine if the receptor activation is a positive or negative result for the patient Whether the drug increases or decreases receptor activation The normal responses to activation of those receptor Neurotransmitter life cycle The nurse must make a decision to determine if the receptor activation is a positive or negative result for the patient. Whether the drug increases or decreases receptor activation The normal responses to activation of those receptor The identity of the receptors at which that drug acts. ACTIVITY 2
NSG124.13.01.02 MUSCARINIC AGONISTS
Bethanechol [Urecholine] embodies the properties that typify all muscarinic agonists. The nurse knows which of the following are true regarding this drug? Select all that apply. Muscarinic activation relaxes the trigone and sphincter muscles and increases voiding pressure Drug of choice for patients with asthma Drugs bind reversibly to muscarinic cholinergic receptors to cause activation Also known as parasympathomimetic agents Muscarinic activation relaxes the trigone and sphincter muscles and increases voiding pressure Drugs bind reversibly to muscarinic cholinergic receptors to cause activation Also known as parasympathomimetic agents ACTIVITY 3 NSG124.13.01.03 MUSCARINIC ANTAGONISTS T/F: Based on Beers Criteria, anticholinergic drugs have been designated as potentially inappropriate for use in geriatric patients. True. T/F: Based on receptor action, the terms muscarinic antagonist and anticholinergic agent may be used interchangeably. True. Atropine [AtroPen] is a muscarinic antagonist. As the nurse prepares to administer this drug to a patient, the nurse knows which of the following are correct? Select all that apply. By preventing activation of muscarinic receptors on smooth muscle, atropine causes bronchospasm Causes effects through a competitive blockade at muscarinic receptors Effects result from prevention of receptor activation by endogenous acetylcholine or by drugs that act as muscarinic agonists Decreases secretion from salivary glands, bronchial glands, sweat glands, and the acid- secreting cells of the stomach Causes effects through a competitive blockade at muscarinic receptors Effects result from prevention of receptor activation by endogenous acetylcholine or by drugs that act as muscarinic agonists Decreases secretion from salivary glands, bronchial glands, sweat glands, and the acid- secreting cells of the stomach ACTIVITY 4 NSG124.13.01.04 MUSCARINIC NURSING CONSIDERATIONS CASE STUDY You are working with Mr. J, who is scheduled to have knee replacement surgery this morning. You can’t find his history and physical examination results on the chart. You read the preoperative orders, which consist of multiple drugs, including atropine sulfate. Shortly after you administer the atropine, Mr. J starts to hallucinate. He states that he must run away from the man chasing him. He is delirious, and his skin is hot, dry, and flushed. When you turn on the lights to assess him better, he complains that the light hurts his eyes.
Cholinesterase inhibitors used for management of myasthenia gravis Cholinesterase inhibitor toxicity can cause a life-threatening cholinergic crisis: Mnemonic 1: SLUDGE and the Killer Bs: Salivation, Lacrimation, Urination, Diaphoresis/Diarrhea, Gastrointestinal cramping, Emesis; Bradycardia, Bronchospasm, Bronchorrhea The nurse is caring for a patient diagnosed with myasthenia gravis. The patient is being treated with a cholinesterase inhibitor. Which of the following are true? Select all that apply. Common symptoms include ptosis, difficulty swallowing, and weakness of skeletal muscles. Patients with severe MG may have difficulty breathing owing to weakness of the muscles of respiration. Myasthenic crisis, is a state characterized by extreme muscle weakness caused by insufficient acetylcholine at the NMJ Medication drug doses cannot be adjusted by patient based on symptoms Patients with MG should be encouraged to wear a Medic Alert bracelet or some other form of identification to inform emergency medical personnel of their condition Common symptoms include ptosis, difficulty swallowing, and weakness of skeletal muscles. Patients with severe MG may have difficulty breathing owing to weakness of the muscles of respiration. Myasthenic crisis, is a state characterized by extreme muscle weakness caused by insufficient acetylcholine at the NMJ Patients with MG should be encouraged to wear a Medic Alert bracelet or some other form of identification to inform emergency medical personnel of their condition ACTIVITY 6 NSG124.13.02.02 CHOLINESTERASE INHIBITOR NURSING CONSIDERATIONS CASE STUDY Ms. A, a 42-year-old patient who lives alone, recently was diagnosed with myasthenia gravis. She tells you that she will be going home soon and that she is very worried about having to manage her disease. She asks you the following questions. What are your best responses to these questions? What medications will I have to take? ANSWER & RATIONALE Answer: Prostigmin (neostigmine bromide) is an anticholinesterase agent that is used to treat myasthenia gravis. Rationale: The major use of reversible cholinesterase inhibitors is treatment of myasthenia gravis. When will I be able to stop taking all these pills? Answer: You will need to take your medications for the rest of your life. Rationale: Myasthenia gravis is a disease that is not usually curable, and hence treatment may be lifelong. She should be encouraged to take her medications as prescribed. I'm concerned that they don't know how much medication to give me. How will they know when I have enough medication? Answer: You should tell Ms. A that usually patients need to monitor and record the times of drug administration; times at which fatigue occurs; the state of muscle strength,
ptosis, and ability to swallow; as well as excessive muscarinic stimulation. Based on these findings, her dosage will be increased or decreased. Rationale: The dosage in treating myasthenia gravis is individualized. Ms. A needs to know that she will play an important role in determining the most effective dosage for her needs. The nurse is preparing to administer a cholinesterase inhibitor. The nurse knows which of the following are correct? Select all that apply. Inform patients that MG is not usually curable, so treatment is lifelong. Encourage patients to take their medication as prescribed and to play an active role in dosage adjustment. Cholinesterase inhibitors are ineffective in treatment of myasthenia gravis (MG) Accumulation of acetylcholine at muscarinic receptors can cause profuse salivation, sweating, bronchoconstriction, and bradycardia Inform patients about signs of excessive muscarinic stimulation and advise them to notify the prescriber if these occur. Inform patients that MG is not usually curable, so treatment is lifelong. Encourage patients to take their medication as prescribed and to play an active role in dosage adjustment. Accumulation of acetylcholine at muscarinic receptors can cause profuse salivation, sweating, bronchoconstriction, and bradycardia Inform patients about signs of excessive muscarinic stimulation and advise them to notify the prescriber if these occur. ACTIVITY 7 NSG124.13.03.01 MUSCLE CONTROL, ADRENERGIC AGONiSTS & USE The nurse is reviewing the mechanisms of adrenergic agonists activation. The nurse knows which of the following are correct? Select all that apply. Inhibit MAO, increase the amount of NE available for release, and enhance receptor activation Direct mechanism of rreceptor activation through direct binding Receptor activation does not utilize nor imitate the actions of natural transmitters Inhibit NE reuptake, which causes NE to accumulate within the synaptic gap, and increase receptor activation Promotes NE release to cause indirect activation of adrenergic receptors. Inhibit MAO, increase the amount of NE available for release, and enhance receptor activation. Inhibit NE reuptake, which causes NE to accumulate within the synaptic gap, and increase receptor activation. T/F: To understand the actions of individual adrenergic agonists, a nurse needs to know their receptor specificity. True. ACTIVITY 8 NSG124.13.03.02 ADRENERGIC DRUGS T/F: The Institute for Safe Medication Practices (ISMP) includes all IV adrenergic agonists and adrenergic antagonists among its list of high-alert medications (similar to anticoagulants and insulin). True.
The nurse is preparing to administer an adrenergic agonist. The nurse knows which of the following are correct nursing implications? Select all that apply. Ensure you understand therapeutic goal and evaluate closely Perform a full assessment of cardiac, renal, and hemodynamic status for baseline data and continue to monitor closely Monitor cardiovascular effects closely, including dysrhythmias, angina, tachycardia, blood pressure Phentolamine is ineffective against extravasation Ensure you understand therapeutic goal and evaluate closely Perform a full assessment of cardiac, renal, and hemodynamic status for baseline data and continue to monitor closely Monitor cardiovascular effects closely, including dysrhythmias, angina, tachycardia, blood pressure ACTIVITY 10 NSG124.13.04.01 ADRENERGIC RECEPTORS & ADRENERGIC ANTAGONISTS The nurse is preparing to administer an adrenergic antagonist. The nurse knows which of the following are correct? Select all that apply. Beers Criteria specifically identifies several peripheral alpha1 blockers as potentially inappropriate for older adults because of the high incidence of orthostatic hypotension beta-adrenergic antagonists treat angina, hypertension, dysrhythmias Adverse effects of bradycardia and bronchoconstriction with beta-adrenergic antagonists Drug class of choice for older adult clients Beers Criteria specifically identifies several peripheral alpha1 blockers as potentially inappropriate for older adults because of the high incidence of orthostatic hypotension beta-adrenergic antagonists treat angina, hypertension, dysrhythmias Adverse effects of bradycardia and bronchoconstriction with beta-adrenergic antagonists ACTIVITY 11 NSG124.13.04.02 NSG124.13.04.02 ALPHA ADRENERGIC ANTAGONISTS NURSING CONSIDERATIONS CASE STUDY You are working as a nurse on the cardiac unit. Mr. D was recently prescribed propranolol (Inderal). You prepare his medications and start the discharge teaching plan. Your patient asks what the side effects of propranolol are. How would you respond? ANSWER & RATIONALE Answer: The most serious adverse effects of propranolol result from blockade of beta receptors in the heart and blockade of beta2 receptors in the lung. Rationale: Blockade of beta1 receptors in the heart puts the patient at risk for bradycardia. Your patient asks why he cannot stop the medication. How would you advise this patient? Answer: Use of propranolol should not be abruptly withdrawn. Rationale: Abrupt withdrawal can cause rebound cardiac excitation. What nursing interventions should be implemented prior to medication administration?
Answer: You should assess the heart rate before each dose. The drug can also cause AV heart block; therefore, the patient should be placed on a cardiac monitor. You should also assess for the early signs of heart failure, including shortness of breath, night coughs, and swelling of the extremities. Rationale: Use of propranolol can result in heart failure in patients with cardiac disease. The drug generally is contraindicated for patients with preexisting heart failure. The nurse is preparing to administer an adrenergic antagonist to a patient. The nurse knows which of the following are appropriate nursing implications? Select all that apply. Beta-adrenergic antagonists suppress myocardial contractility causing heart failure. Inform patients about early signs of heart failure (shortness of breath, night coughs, swelling of the extremities), and instruct them to notify the prescriber if these occur. Teach patient about desired therapeutic effect of drug, how to evaluate, and when to notify provider Beta-adrenergic antagonists are the drug of choice for patients with diabetes or asthma Warn patients against abrupt discontinuation of beta-adrenergic antagonist treatment. Beta-adrenergic antagonists suppress myocardial contractility causing heart failure. Inform patients about early signs of heart failure (shortness of breath, night coughs, swelling of the extremities), and instruct them to notify the prescriber if these occur. Teach patient about desired therapeutic effect of drug, how to evaluate, and when to notify provider Warn patients against abrupt discontinuation of beta-adrenergic antagonist treatment.
