Week 5: Parasympathetic Division: 10 q Flashcards
Autonomic division control
Generally works how?
Generally: Opposition (two divisions compete)
Sympathetic
E activities
Mydriasis?
Exercise
Excitement
Emergency
Embarrassment
blood flow to organs is reduced, flow to muscles is increased
Its activity is illustrated by a person who is threatened
◦Heart rate increases, and breathing is rapid and deep
The skin is cold and sweaty, and the pupils dilate
Mydriasis- “Wide Eyed with Fright”
Parasympathetic
D activities
digestion
defecation
diuresis
Concerned with keeping energy use low in the body
Its activity is illustrated in a person who relaxes after a meal
◦Blood pressure, heart rate, and respiratory rates are low
◦Gastrointestinal tract activity is high
◦The skin is warm, and the pupils are constricted
◦Miosis
What key controls Parasympathetic/Cholinergic Division?
Acetylcholine (ACh)(KEY)
What key controls
Sympathetic /Adrenergic Division?
Other sympathetic neurotransmitters?
Adrenaline (Epinephrine)
Adrenaline (KEY)= Adrenergic Division. (LOCK)
Other sympathetic neurotransmitters are norepinephrine and Dopamine
Cholinergic Receptors
Parasympathetic Division Receptors
Nicotinic Neuromuscular Junction (NMJ) control what?
These receptors are essential for SKELETAL MUSCLE control (skeletal, diaphragm)
Cholinergic Receptors
Parasympathetic Division Receptors
Muscarinic control what?
These receptors are essential for SMOOTH MUSCLE control and work on various organs
Examples of smooth muscle include Lung bronchioles, GI Tract, and Bladder
CHOLINERGIC CRISIS:
SLUDGE (M) and the Killer B’s
MUSCARINIC RESPONSE
Salivation/Secretions (mouth, GI tract, lungs)
Lacrimation (tear production)
Urination (voiding)
Defecation/Diarrhea
GI Motility and Gastric Acid production, can lead to abdominal cramping
Emesis (vomiting)
Miosis (pinpoint pupils, constrict)
Bradycardia
Bronchospasm
Bronchorrhea
blood pressure drop
Nicotinic receptors will cause what?
Nicotinic receptors will cause paralysis and patients cannot use their diaphragm muscles to breathe (need breathing support)
Parasympathic list of drugs to know
Direct acting?
Indirect acting?
Direct Acting: Bethanechol, Pilocarpine
Indirect Acting: Pyridostigmine
parasympathetics activity is illustrated in a person who relaxes after a meal
3 things
Blood pressure, heart rate, and respiratory rates are?
Gastrointestinal tract activity?
The skin is and the pupils are?
Blood pressure, heart rate, and respiratory rates are low
Gastrointestinal tract activity is high
The skin is warm and the pupils are constricted (miosis)
Parasympathetic drugs
Direct Acting Agents work where? agonists at?
Indirect Acting Agents work where?
Work DIRECTLY at a RECEPTOR
Produce effects that mimic Acetylcholine (ACh)
Are typically agonists at MUSCARINIC receptors
Do NOT work at RECEPTORs
Instead, they inhibit acetylcholinesterase, an enzyme that breaks down acetylcholine
Direct Acting- cholinergic agents
BETHanechol
used to treat?
NOTE: Most cholinergic drugs target?
(beth cant go to the bathroom)
Urinary retention
The goal is to reverse the retention and allow someone to void!
**GI TRACT
**BLADDER
◦Eyes
◦Heart (smaller percentage)
Bethanechol
Mechanism of action
BOTH DRUG AND KEY WILL BIND TO? FOCUSE ON?
Directly stimulate the parasympathetic division (muscarinic receptors) mainly located in the BLADDER
BOTH DRUG AND KEY WILL BIND TO SAME RECEPTOR (MUSCARINIC)
focused on the BLADDER
Bethanechol adverse affects
contraindication?
Exacerbation of asthma = contra-indication
In the Rest and Digest state- the (airways are narrow) lungs are constricted
This drug enhances PARAsympathetic- Decreased BP or HR
What happens if a patient overdoses on BETHanechol?
(SLUDE M) and
Killer Bs
Bethanechol
What is the intended use of the drug?
Goal?
Given how?
What’s contraindicated for this drug?
Antidote for Bethanechol??
(generally to get people to void after a procedure/surgery!)
GOAL: Increase Urine Output! (>30 ml/hr!)
GI concern- give 1 hour before or 2 hours after a meal
Asthma? CONTRAINDICATED!
ATROPINE
Direct Acting- cholinergic agents
Pilocarpine
Oral is used to treat?
Eye drops?
Higher pressure?
Lower pressure?
ORAL: Systemic doses are for Xerostomia (dry mouth)
Xerostomia can be caused by radiation or Sjögrens Syndrome
Eye drops: for Glaucoma
Higher pressure= worsens glaucoma (puts pressure on ocular nerve=blind)
Lower pressure= treats glaucoma
Pilocarpine
Mechanism of action
Agonist of cholinergic (muscarinic ) receptors
Causes increased secretions (sweating, salivation, GI tract)
EYE= Causes miosis, this decreases intraocular pressure
If someone overdoses on pilocarpine
what’s the antidote?
SLUDGE M and killer Bs
paralysis
Patients may need to be put on a ventilator
ATROPINE
Indirect Acting Cholinergic Agents/ Acetylcholinesterase Inhibitors:
Pyridostigmine
Used to treat?
can be used for what?
pre treatment for?
MYASTHENIA GRAVIS (important)
Can be used for Alzheimer’s Disease
Reverse Anticholinergic Effects
Reverse effects of Neuromuscular Blocking Agents
Pre-treatment for exposure to nerve gas (military)
indirect acting agents do what?
Pyridostigmine
Mechanism of action
Inhibits acetylcholinesterase, thereby increasing acetylcholine’s activity in the parasympathetic system
Pyridostigmine adverse affects
Vital signs?
Minor SLUDGE (M)
Vital Signs (drop in BP and/or HR)
Cholinergic Crisis!
Pyridostigmine
nursing considerations
What are our intended outcomes?
What are unintended outcomes?
Myasthenia Gravis- recovery of muscle strength!!!!!!!
Alzheimer’s Disease- maintain cognition
Reversal of NMB- Improve breathing status/respiratory function
Unintended:
Watch excessive activation (think SLUDGE)
Watch out for Cholinergic Crisis- concern is respiratory blockade
Organophosphates/Carbamates
POISONINGS (2)
MOA?
Can cause what?
- Insecticides (malathion)
- Nerve Gas (V agents like VX, Sarin)
acetylcholinesterase inhibitors, potentially irreversible
Can cause: Cholinergic Crisis
CHOLINERGIC CRISIS
symptoms?
Antidote?
SLUDGE m and Killer Bs
antidote!!! atropine
(treatment?)
Anticholinergics:
List of Drugs to Know
4
Atropine*SPECIAL
Oxybutynin, Solifenacin, Tolterodine
ANTIDOTE to Poisoning by Cholinergic Drugs/Agents?
Antidote to “Cholinergic Crisis”?
treats what?
ATROPINE
Reduce salivation and secretions (mucus)
-Anti-SLUDGE and the Killer B’s
-Used in the OR (to reduce secretions)
-Palliative Care, “Death Rattle”
Symptomatic Bradycardia (pale, irregular. breathing)
Why do hospitals stockpile atropine?
ACLS (reverse bradycardia)
Antidote (treat cholinergic crisis)
Atropine MOA
is it an antagonist or agonist?
ANTAGONISTS at various muscarinic receptors in the parasympathetic division of the body
Atropine adverse effects
ANTICHOLINERGIC (anti sludge m)
Can’t See
Can’t Pee
Can’t Spit
Can’t Shit
Cant Schvitz (sweat)
(ANTI SLUDGE M)
Superficial blood vessels will dilate to help with heat loss since patient can’t sweat appropriately (can result in flushing, red skin, dilated pupils, confused, hyperthermia
Atropine contraindication
2
Glaucoma
◦Why? because increases eye pressure
Benign Prostatic Hyperplasia/ Urinary retention/hesitancy
◦Why? because this doesn’t let you pee
ATROPINE CAUSES…
Can’t See (mydriasis)?
Can’t Pee (Urinary retention/hesitation)
Can’t Spit (Xerostomia)?
Can’t Shit (constipation)?
Can’t Schvitz/Sweat (Hypohydrosis)?
what to do?
Can’t See (mydriasis)
◦Blurred vision, dry eyes, increased IOP (bad for glaucoma!)
◦Mydriasis- allow light in at night
◦Protect the eyes with sunglasses
Can’t Pee (Urinary retention/hesitation)
◦Report a DISTENDED BLADDER!!!!!
◦Do not give in patients with enlarged prostate (BPH)
Can’t Spit (Xerostomia)
◦Sugar Free Gum/Candy (avoid sugar, if possible, to reduce risk of cavities)
◦Avoid Alcohol based mouthwash (use artificial saliva)
Can’t shit (constipation)
◦Increase Fiber, Fluid intake! Exercise!
Can’t Schvitz/Sweat (Hypohydrosis)
◦Patients may overheat and develop hyperthermia!
◦Be careful in hot heat/outdoors
◦Can experience Heat Related Illness (Heat stroke/exhaustion)
Confusion! (Benadryl like state!)
Atropine NURSING CONSIDERATIONS?
Atropine- Many uses!
Lifespan considerations:
Geriatric patients are very susceptible to developing adverse effects of anticholinergics
Anticholinergic Agents
Oxybutynin, Solifenacin, Tolterodine used to treat
All three are used for?
Symptoms? 4
All three are for Overactive Bladder (OAB)
Patient symptoms:
◦Urinary urgency
◦Urinary frequency
◦Urinary incontinence (some people refer to this as constant dribbling)
Constantly waking in the night to pee (nocturia)
Oxybutynin, Solifenacin, Tolterodine
Mnemonic
SOFT Bladder
Solifenacin
Oxybutynin
Finally…..
Tolterodine
Oxybutynin, Solifenacin, Tolterodine
adverse effects
Contraindicated in
Avoid in?
Can’t See
Can’t Pee
Cant Spit
Cant Shit
Can’t Schvitz
Contraindicated in Glaucoma and BPH
Avoid in urinary retention/hesitation!
Oxybutynin, Solifenacin, Tolterodine nursing considerations
patients should have?
Overactive Bladder (OAB)- patients should have decrease in urinary urgency/frequency, nocturia
Lifespan considerations:
Geriatric patients are very susceptible to developing adverse effects of anticholinergics!
