are anticholinergics, bc they block the parasymp NT ACh

another name is anticholinergics or cholinergic blockers

atropine

belladona

dicyclomine

glycopyyrolate

mepenzolate

methscopolamine

propantheline

scopolamine

trimethobenzamide

darfenacin (Enablex)

flavoxate

oxybutynin

solifenacin (Vesicare)

tolterodine (Detrol)

trospium  NOFOOD

Chloinergic Blocking Urinary Antispasmodics

benztropine mesylate

biperiden

procyclidine

trihexyphenidyl

Cholinergic Blocking Drugs for Parkinson's and drug induced extrapyramidal symptoms (EPS)

diphenhydramine is also one listed

ipatropium (Atrovent)

tiotropium

Cholinergic Blocking Drugs for acute respiratory relief

Inhibit ACh at parasymp nerve synapse to effector organ or structure

Are two types of receptors in parasymp (muscarinic and nicotinic); individual drugs target only one or can target both

1.       eg antispaspodics for overactive bladder inghibit muscarinic receptors, making detrussor muscle NOT contract - and does not affect nicotinic receptors (skeletal muscles)

2.       some inhibit both nicotinic and muscarinic - affect many parts of the body

pylorospasm and peptic ulcer

ureteral or biliary colic

bladder overactivity

vagal nerve-induced bradycardia

parkinsonism

preoperative reduction of oral secretions

control of nausea and vomiting

General Effects of Cholinergic Blockers

CNS

dreamless sleep

drowsiness

atropine can produce mild stimulation

Eyes

mydriasis (widening of pupils)

cyclopegia (inability to focus/accomodate eyes)

Respiratory

xerostoma (drying secretions in mouth)

drying of secretion resp tract

relaxation of smooth muscles of bronchi causing slight bronchodilation

CV

increase pulse rate (most pronounced with atropine)

      Urinary Tract

                       urinary retention

      GI

                       descreased GI motility

GI 

dry mouth

N/V

difficulty swallowing (less saliva)

heartburn (less protective mucus)

constipation (less water)

CNS

headache (hypotension from decreased blood volume?)

flushing 

nervousness

drowsiness, insomnia (odd paradoxical reaction)

weakness

nasal congestion 

fever

Visual

blurred vision

mydriasis (pupil dilation)

photophobia (from pupil dilation)

cycloplegia (can't accomodate/focus) (pupils open for far vision)

increased IOP (from pupil dilation)

Genitourinary System

Urinary hesitancey and retention (detrussor muscle is relaxed)

dysuria

CV

palpitations

bradycardia (low doses of atropine)

tachycardia (higher doses of atropine)

Other

urticaria

decreased sweat production

anaphylactic shock (hypotension from decreased blood volume?)

rash

the anticholinergics

It seems that by blocking parasyp, enhancing sympathetic, water is retained.  No pee, no saliva, etc.  Maybe water is being reserved for blood volume? Don't know, not taught it book or class.

Gerontology and anticholinergics

Elderly more sensitive.  Watch frequently for agitation, confusion, drowsiness, urinary retention, other adverse reactions.  can be seen with even small doses.  If happens, withhold next dose and contactPCP.  Ensure safety of pt while reactions occur

glaucoma

myasthenia gravis

tachyarrythmias

MI

HF (unless bradycardia is present)

trospoium (Sanctura) for overactive bladder NOFOOD

• different muslces
• when iris muscles contract, the pupil opens, under sympathetic control
• when cilliary muscles contract, under parasympathetic control, the pupil closes and pulls on the "angle" assisting in AH flow

Iris - In

Ciliary - Close

• GI infections
• benign prostate hypertrophy
• urinary retention
• hyperthyroidism
• hepatic or renal disease
• hypertension
• Atropine use cautiously with asthma
• Preg cat C, only use when benefits outweigh risk to fetus
• Elderly more sensitive

·         health hx

·         s/s of current problem

·         BP, pulse, RR

·         Depending on condition may also

o        check for blood in stool for peptic ulcer

o        determine visual acuity for glaucoma

o        assess for dehydration and weighing pt if prolonged diarrhea

·         close observation

·         VSs

·         adverse reactions

·         evaluate s/s of condition

·         report increases of sxs immediately

PaOR for pt receiving preop anticholinergic

·         Usually to dry up secretions to prevent aspiration

·         Instruct pt to void before surgery

·         inform that mouth will be very dry and is normal

·         do not drink fluid

·         raise bed rails and instruct to remain in bed once administered

·         NURSING ALERT – must admin at exact time prescribed in order to produce intended effect at the right time; MUST NOTIFY if given late. 

·         GERONTOLOGY – usually  not given in those over 60 bc effets on eyes andCNS

Re: admin of anticholinergic

“Impaired Comfort: Xerostomia”

·         Xerostomia is mouth dryness

·         can be severe and very uncomfortable, like cottonmouth

·         may impair swallowing

·         may impair speech

·         encourage sips water, candy, etc

·         Check mouth daily for soreness or ulcerations

Re: admin of anticholinergic

"Constipation rt slowing of peristalsis in GI tract from admin of anticholinergic

·         regular constipation teaching

·         Overactive bladder pts may not want to drink more – assure pt that anticholinergics will help urinary frequency and urgency.

Re: admin of anticholinergic

“Risk for Injury rt dizziness, drowsiness, mental confusion or heat prostration”

·         Drowsiness, dizziness, blurred vision, photophobia

·         visual effects are common, and degree is dose dependent

·         ambulation assist if needed, esp. older adults

·         GERONTOLOGY

o        inform of possible visual and mental effects (blurred vision, confusion, agitation)

o        Ensure safe environment to prevent falls (throw rugs, etc)

o        explain possibility of heat prostration and steps to avoid

§         decrease in sweating can lead to heat prostration

§         observe for s/s, especially elderly.

§          If suspected, withhold and contactPCP immediately

§         s/s are

·         fever

·         tachycardia

·         flushing

·         warm dry skin

·         confusion

o        pt is closely monitored first few days

o        Withhold and notifyPCP if mental changes occur, such as

§         excitement

§         agitation

§         confusion

§         drowsiness

o        Withhold and notify if other adverse reactions occur like urinary retention

o        ENSURE PT SAFETY WHILE ADVERSE REACTION OCCUR

Re: admin of anticholinergic

“Disturbed Sensory Perception: Visiual rt adverse drug reaction”

·         blurred vision and photophobia common with anticholinergics, especially elderly

·         May need shaded glasses

·         may keep rooms dim

·         Mydriasis (prolonged pupil dilation) and cycloplegia (ciliary paralysis resulting in blurred vision) may occur.  Sometime must be tolerated when drug is necessary.  

Re: admin of anticholinergic

“Ineffective Tissue perfusion rt impairmed heart pumping action”

·         Atropine for third degree heart block is placed on a cardiac monitor during and after admin

·         watch monitor for change in pulse rate or rhythm

·         Report immediately if tachydardic, arrhythmic, or drug fails to increase heart rate

Education anticholinergic

·         take even though symptoms relieved

·         advise to take caution with hazardous tasks requiring alertness and clear vision

·         for photophobia – keep lights low, sunglasses; Do outdoor activities before first dose taken

·         for dry mouth – regular stuff; good oral care necessary

·         for constipation

·         for heat prostration – avoid going outside on hot sunny days; use fans, sponge skin with cool water, wear loose fitting clothes; basically stay cool

·         for drowsniess – schedule tasks requiring alertness before first dose, eg early AM

·         for preop anticholinergics

o        tell which drugs given and why, when, why

o        give pt time to void before surgery

o        inform of dry mouth and drowsiness will occur about 20-30 min after admin

o        stress need to stay in bed and keep side rails up

·         for peptic ulcer pt

o        explain regimen which may also include dietary restrictions/changes

Regulates Cl- secretion

Cl- increases AH volume by osmosis

Carbonic anhydrase is an enzyme that, inside the eyes, acts to increase chloride ions which pulls in more fluid, increasing IOP

CA Inhibitors therefore decrease IOP

• Visual disturbances
• Confusion, agitation, excitement in elderly mostly
• Heat prostration - withhold and notify immediately if suspected
• Urinary retention

fever

tachycardia

flushing

warm dry skin

confusion

withhold anticholinergic and notify immediately