Lemuel C.

Candelasa, MAN, RN
UC- Nursing Faculty
 University of Cebu
College of Nursing

Pharmacology

Module 5
Neuro Drugs
Lemuel C. Candelasa EdD (c), MAN, RN
UC- Nursing Faculty
 Learning Compass
Utilize essential concepts of nursing pharmacology to enable safe and appropriate use of medications.
Specifically, students will be able to:
·Compare and contrast the actions of the sympathetic and parasympathetic divisions of the autonomic
nervous system.
·Explain mechanisms by which drugs affect synaptic transmission.
·Describe the actions of acetylcholine at cholinergic synapses.
·Describe the actions of norepinephrine at adrenergic synapses.
·Compare the actions of the adrenal medulla with those of other sympathetic effector organs.
·Develop a health teaching plan for an individual who has cardiovascular diseases.
Engage
"DESCRIBE AND APPLY"
Explore
"BREAKOUT ROOMS"
 Explain
"PRESENTATION OF OUTPUTS"
 Review of Nervous System

 Autonomic Nervous System

Application to Nursing Pharmacology

Application to Nursing Pharmacology
Merging Pharmacology to Nursing Process
Presentation of Outputs
 Case Study
(Application)
GROUP A - CASE OF SOPHIA (EXPLORE)
GROUP B - CASE OF AMELIA (ELABORATE)
GROUP C - CASE OF NOAH (")
GROUP D - CASE OF ISABELLA (")
GROUP E - CASE OF ALEXANDER (")
Presenation of Outputs
Elaborate
"MENTAL MODELS"
 Evaluate
"FORMAL ASSESSMENT: MOODLE QUIZ"
Thank you!
DO YOU HAVE ANY QUESTIONS FOR ME?
 DRUGS ACTING ON
CARDIOVASCULAR SYSTEM
▪DRUGS AFFECTING BLOOD PRESSURE
▪CARDIOTONIC DRUGS
▪ANTIARRHYTHMIC DRUGS
▪LIPID LOWERING DRUGS
▪DRUGS AFFECTING BLOOD COAGULATION
▪DRUGS USED TO TREAT ANEMIA

DRUGS ACTING ON CARDIOVASCULAR SYSTEM

▪Antihypertensive Agents
▪Antihypotensive Agents

DRUGS AFFECTING BLOOD PRESSURE

▪Increase in BP
▪Essential hypertension – 90%
▪Secondary hypertension – 10%

HYPERTENSION
 REGULATORS OF BLOOD PRESSURE

▪Kidneys
▪Blood vessels
▪Hormones
 REGULATORS OF BLOOD PRESSURE

KIDNEYS
▪control fluid volume
▪Renin-Angiotensin-Aldosterone system (RAAS)
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
BARORECEPTORS
CATECHOLAMINES
▪increase BP through VASOCONSTRICTION
activity
▪Norepinephrine - released from the
sympathetic nerve terminals
▪Epinephrine – released from the adrenal
medulla

HORMONES
ANTIDIURETIC HORMONE
▪produced by the hypothalamus and is stored
and released by the posterior pituitary gland
▪stimulates the kidneys to conserve and retain
water when there is fluid volume deficit

HORMONES
HORMONES
BRAIN NATRIURETIC PEPTIDE
▪is a hormone secreted by
cardiomyocytes in the heart ventricles
in response to stretching ventricular
volume

HORMONES
 ACCORDING TO JNC
▪2 out of 3 patients with hypertension have
uncontrolled BP or not optimally treated…
▪CVD risks doubles with each increase of
20/10 mm Hg starting at 115/75
2017 GUIDELINES FOR HYPERTENSION
STEP 1:
• Lifestyle modification
STEP 2:
• continue step 1; add one agent (diuretic, Ca Channel
Blockers, ACE inhibitors, Beta-blockers)
STEP 3:
• continue Step 1;add or change another agent
(Adrenergic Blocking Agents)
STEP 4:
• continue step 1; add or change another agent (Direct
vasodilator)

STEPPED-CARE APPROACH FOR HYPERTENSION

▪exercise
▪reduction of stress
▪cessation of smoking
▪loss of excess weight
▪restriction of sodium
▪decrease in alcohol consumption

NONPHARMACOLOGICAL
CONTROL OF HYPERTENSION
1.Diuretics
2.Sympatholytics (Sympathetic depressants)
3.Direct-acting arteriolar vasodilators
4.ACE inhibitors
5.Angiotensin II Receptor Blockers (ARBs)
6.Calcium Channel Blockers

ANTIHYPERTENSIVES
▪Effective first line drugs for treating mild
hypertension
▪Promote sodium depletion, which
decreases ECF volume

DIURETICS
DIURETICS
ACTIONS:
• increase sodium and water excretion
• decrease cardiac output
• decrease peripheral vascular resistance
(PVR): a resistance to the flow of blood
determined by the tone of systemic vascular
musculature and the diameter of the blood
vessels.
CLASSIFICATIONS:
▪thiazide
▪loop diuretics
▪Potassium-sparing
▪*Carbonic anhydrase inhibitors
(acetazolamide)

DIURETICS
Actions:
• inhibit sodium and chloride reabsorption in the
distal tubule and lower peripheral vascular
resistance.
Major S/E:
▪ orthostatic hypotension
▪ electrolyte imbalance – Hypokalemia
▪ anorexia, N/V – due to electrolytes loss
▪ glucose intolerance – High glucose levels
▪ dry mouth, thirst

THIAZIDE AND THIAZIDE-LIKE AGENTS

Interactions:
• Decreased excretion of lithium – could cause
toxicity
• Increased dysrhythmias with DIGITALIS in the
presence of hypokalemia
• Increased potassium loss with corticosteroids
and some penicillin
• Orthostatic hypotension if taken with alcohol
or other hypotensive agents
• Hyponatremia and hyperglycemia which may
be caused by oral hypoglycemic and insulin

THIAZIDE AND THIAZIDE-LIKE AGENTS

• Nursing Implications
• Check for allergies to sulfonamides
• Monitor for glucose and potassium levels
• Monitor closely in the presence of renal or liver
dysfunction
• Common Drugs
• Chlorothiazide (Diuril)
• Hyrdorchlorothiazide (Esidrix, HydroDiuril)

THIAZIDE AND THIAZIDE-LIKE

AGENTS
LOOP DIURETICS
ACTIONS:
• Block the reabsorption of Na in the loop of
henle (the descending loop where the
greatest Na reabsorption normally occurs)

LOOP DIURETICS
MAJOR SIDE EFFECTS;
• Increased electrolyte depletion because of its
potency – hypokalemia
• Excessive diuresis which could lead to circulatory
collapse
• High doses: transient hearing loss, abdominal pain
• Leukopenia: abnormal decrease in WBC
(<5,000/mm3)
• Thrombocytopenia: reduction in platelets to
<150,000/mm3)
• Postural hypotension
 LOOP DIURETICS
INTERACTIONS:
• Hypotension with alcohol
• Toxicity with lithium
• GI bleeding with anticoagulants
• Toxicity with digitalis (cardiac glycoside)
• Hyponatremia with oral hypoglycemic
• Hypertension with NSAIDs
• NURSING IMPLICATIONS:
• Schedule the last dose early enough to prevent nocturia
• Assess allergies to sulfonamides – they are chemically
related
• Teach the client to do the following:
• Consume K+ rich foods
• Report muscle cramps, which are usually in calves of
the legs especially at night
• Assess for dehydration, especially in older adults
• Caution client about switching brands without
physician consent – this may change bioavailability
and the clinical effects.

LOOP DIURETICS
 LOOP DIURETICS

•Common Drugs:
• Furosemide (Lasix)
• Ethacrynate Na (Edecrin)
• Bumetanide (Bumex)
ACTIONS:
• Inhibit the pump system that normally exchanges
potassium for sodium in the distal convoluted
tubule.
• Spironolactone (Aldactone) – antagonizes
aldosterone, which mediates Na and K exchange.
This mechanism reduces Na reabsorption while
retaining K.
• Other drugs within this class produce the same
effects as spironolactone (aldactone) but do not
depend on aldosterone.

POTASSIUM-SPARING AGENTS
• MAJOR SIDE EFFECTS:
• Hyperkalemia if used with high-potassium diet
or supplements
• Hypotension
• GI upset: N/V, diarrhea, abdominal cramps
• Weakness, fatigue
• Paresthesia (numbness or tingling) of the
hands and feet
• Megaloblastic anemia

POTASSIUM SPARING AGENTS

 POTASSIUM SPARING AGENTS

• INTERACTIONS:
• Hyperkalemia with K supplements
• Toxicity with lithium
• Nephrotoxicity with Indocin
• NURSING IMPLICATIONS:
• Teach that high-potassium diet is contraindicated
• Monitor other medications for potassium sources
• Frequently monitor CBC (Complete Blood Count) –
anemia
• Teach the client the symptoms of hyperkalemia and to
report these as soon as noticed
• Keep tablets stored in a dark container
• Asses K levels closely if patient is receiving blood. Blood
can contain > 30mEq of K/Liter when stored.
• COMMON DRUGS:
• Spironolactone (Aldactone)
• Amiloride Hydrochloride (Midamor)
SYMPATHOLYTICS (SYMPATHETIC
DEPRESSANTS)
 ANTIHYPERTENSIVE

▪Beta adrenergic blockers / beta blockers

ACTIONS:
• Inhibit sympathetic stimulation, which lowers
heart rate and decreases cardiac output
and lower BP
• Often used in combination with a diuretic

BETA ADRENERGIC BLOCKERS (BETA BLOCKERS)

MAJOR SIDE EFFECTS:
▪CV: hypotension, bradycardia
▪Bronchospasm
▪Fatigue
▪Edema – gain weight
▪Beta blocker blues: decreased libido

BETA BLOCKERS
NURSING IMPLICATIONS:
• Monitor BP and pulse before, during,
and after therapy. If the apical pulse is
below 60 for a full minute, refer to the
physician.
• Assess other medications the client is
taking. Avoid administering at the same
time as antacids (wait 1 to 2 hours),
calcium blockers or cardiac glycosides
• Use cautiously in clients with Chronic
Airway Limitations
BETA ADRENERGIC BLOCKERS (BETA BLOCKERS)
Client teaching:
▪Do not abruptly withdraw the medication without
consulting the physician first – abrupt withdrawal
may result in angina
▪Take the medication at the same time each day
▪If a dose is forgotten, do not double dose
▪Report any side effects to the physician
▪Do not take hot baths, sit in hot tubs, or be
exposed to the hot sun for long periods
▪Monitor the pulse / CR at the same time daily –
count for 1 full minute
BETA BLOCKERS
• INTERACTIONS:
• Increased potential for bradycardia with concurrent use
of cardiac glycoside and calcium channel blockers and
an increased hypotensive effect with diuretics.
• COMMON DRUGS (these drugs end in “lol”)
• Propranolol hydrochloride (Inderal)
• Nadolol (Corgard)
• Metoprolol Tartrate (Lopressor)
• Atenolol (Tenormin)
• Pindolol (Viskin)
• Timolol Maleate (Blocarden)

BETA ADRENERGIC BLOCKERS (BETA

BLOCKERS)
• ACTIONS:
• Inhibit release of intracellular calcium, which
decreases the force of contraction and prevents
entry of calcium ions into smooth muscles – this
lowers arteriole constriction, thereby lowering PVR
and decreasing BP.
• USES: mild to moderate hypertension – alone or
in combination with diuretics

CALCIUM CHANNEL BLOCKERS

 CALCIUM CHANNEL BLOCKERS

• MAJOR SIDE EFFECTS:

• Hypotension
• Bradycardia
• Worsening CHF
• Dyspnea
• Wheezing
INTERACTIONS:
• Increased effects if taken with a beta blocker

NURSING IMPLICATIONS:
• Monitor BP, PR before during and after
administration.
• Watch out for bradycardia
• Administer these medications with meals
• Monitor renal status: urine output
CALCIUM CHANNEL BLOCKERS
 CALCIUM CHANNEL BLOCKERS

• COMMON DRUGS:
• Diltiazem hydrochloride (Cardizem)
• Felodipine (Plendil)
• Nicardipine HCl (Cardene)
• Nifedipine (Procardia)
• Verapamil HCl (Calan, Isoptin)
ACTIONS:
• Intrerrupt the renin-angiotensin-aldosterone
system
▪ Inhibit conversion of angiotensin I to angiotensin II
▪ Decrease aldosterone secretion
▪ Compete with angiotensin II to block its effect
(Angiotensin II Receptor Blockers)

• USES: mild to moderate hypertension

ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN

CONVERTING ENZYME INHIBITORS OR ACE INHIBITORS)
RENIN-ANGIOTENSIN-
ALDOSTERON SYSTEM
(RAAS)
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)
MAJOR SIDE EFFECTS:
• Chest pain
• Palpitations
• Hypotension
• Tachycardia
• Proteinuria: large quantities of protein in the urine
• Rash
• Neutropenia: abnormal decrease in the number of
neutrophils in the blood
• Agranulocytosis: reduction in the number of granulocytes
• Hyperkalemia: potassium > 5.0 mEq/L
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)

NURSING IMPLICATIONS:
• Monitor CBC and K levels
• Assess for signs of infection
• Check BP daily and keep a monthly log as needed
• Instruct client to:
▪ Inform any new physician about the medication taken
▪ Avoid excess intake of foods rich in potassium and
potassium supplements
▪ Do not abruptly stop taking the medication
▪ Avoid OTC drugs without the approval of the physician
▪ Take medication on an empty stomach
 ANGIOTENSIN ANTAGONISTS (ANGIOTENSIN CONVERTING
ENZYME INHIBITORS OR ACE INHIBITORS)

COMMON DRUGS (drugs usually ending in “ril”)

• Captopril (Capoten)
• Enalapril maleate (Vasotec)
• Ramipril (Altace)
• Benazepril hydrochloride (Lotensin)
• Losartan
• Candesartan
• Eprosartan
• Losartan
• Olmesartan
• Telmisartan
• Valsartan
Angiotensin II Blockers (angiotensin II
receptor blockers)
• GROUPS OF DRUGS WITHIN THIS CLASS
• CENTRALLY ACTING ADRENERGIC AGENTS
• GANGLIONIC BLOCKERS
• ALPHA ADRENERGIC BLOCKING AGENTS
• PERIPHERALLY ACTING ANTIADRENERGIC AGENTS

• ACTIONS: INHIBIT stimulation of the SYMPATHETIC NERVOUS

SYSTEM, which causes a DROP IN BP from peripheral
VASODILATION or DECREASED CARDIAC OUTPUT.

ADRENERGIC BLOCKING AGENTS

USES: moderate to severe essential hypertension
COMMON DRUGS:
• Centrally acting adrenergic agents
▪Methyldopa (aldomet)
▪Quanfacine (Tenex)
▪Guanabenz acetate (Wytensin)
▪Clonidine hydrochloride (catapres)
• Ganglionic blockers
▪Mecamylamine hydrochloride (Invesine)
▪Trimethaphan camsylate (Arfonad)

ADRENERGIC BLOCKING AGENTS

Ganglionic blockers - inhibits transmission
between preganglionic and postganglionic neurons in the Autonomic Nervous
System
• Prevents response to sympathetic stimulation to the blood vessels – vasodilation
ALPHA ADRENERGIC BLOCKERS
•PRAZOSIN hydrochloride (minipress)
•Phentolamine (regitine)
PERIPHERALLY ACTING ANTIADRENERGIC
AGENTS
•Reserpine (Serpalan)
•TERAZOSIN (Hytrin)
ADRENERGIC BLOCKING AGENTS
PRAZOSIN AND TERAZOSIN – BPH
MAJOR SIDE EFFECTS:
•Postural hypotension
•Bradycardia
NURSING IMPLICATIONS
•Monitor BP and HR
•Instruct client to change position slowly

ADRENERGIC BLOCKING AGENTS

• ACTIONS:
• RELAX ARTERIOLAR SMOOTH MUSCLE, DILATE
ARTERIES and DECREASE PERIPHERAL
VASCULAR RESISTANCE
• USES: moderate to severe hypertension and
hypertensive crisis

DIRECT VASODILATING AGENTS

MAJOR SIDE EFFECTS:
• Headache, N/V
• Sodium retention
• Rebound hypertension
• Increased workload of the heart:
tachycardia, palpitations.

DIRECT VASODILATING AGENTS

• NURSING IMPLICATIONS:
• Monitor VS q 5 to 15 minutes – do not leave
patient unmonitored
• Monitor I and O
• Do not mix with other drugs
• Since sodium nitroprusside (Nipride) must be
protected from light, wrap IV bag and
tubings with foil
• Use microdrip tubing
DIRECT VASODILATING AGENTS
• COMMON DRUGS:
• Sodium nitroprusside (Nipride)
• Hydralazine Hcl (Apresoline)
• Diazoxide (Hyperstat)
• Guanethidine Sulfate (Ismelin)

DIRECT VASODILATING AGENTS

• Monitor baseline BP and pulse before, during and
after therapy
• Monitor I and O, renal function
• Encourage lifestyle change
• Teach client to report edema, cough and weight
gain (> 2 lbs/week)
• Stress need to comply with taking the BP and
medication
• Stress the need to avoid all OTC products unless
physician has been consulted
GENERAL IMPLICATIONS FOR ANTIHYPERTENSIVES
Sympathetic Adrenergic Agonists – first choice in
treating SHOCK
• Drugs react with sympathetic adrenergic
receptors to cause the effects of a
sympathetic stress response: increased BP,
increased blood volume and increase
strength of muscle contraction
• Used to treat severe hypotension and shock

ANTIHYPOTENSIVE AGENTS
Common drugs
• Dobutamine
• Dopamine
• Epinephrine

ANTIHYPOTENSIVE AGENTS
• A drug used to treat orthostatic hypotension
• Activates ALPHA RECEPTORS in arteries and
veins to produce an INCREASE in
VASCULAR TONE and an INCREASE in
BLOOD PRESSURE.

MIDODRINE
 Contraindications:
• Pheochromocytoma • Urinary retention –
– could precipitate can be
hypertensive crisis exacerbated
• Acute renal disease because of
– interfere with sympathetic
excretion stimulation
• Thyrotoxicosis

MIDODRINE
 MIDODRINE

CAUTION
• Pregnancy and lactation
• Visual problems
• Renal and hepatic impairment
ADVERSE EFFECTS
• Piloerection
• Chills and rash
• Hypertension
• BRADYCARDIA
• Dizziness
• Vision changes
• Headache
• Problems in urination

MIDODRINE
 INTERACTIONS:

• Increased risk of toxicity of cardiac

glycosides, beta-blockers, alpha-
adrenergic agents, and corticosteroid if
taken with midodrine
NURSING IMPLICATIONS:
• Monitor BP, HR carefully
• Monitor patients with known visual problems
carefully
• Encourage patient to VOID before taking a
dose of the drug to decrease the risk of
urinary retention problems
MIDODRINE