THE SITUATION
E.K., a 64-year-old woman with a long history of heart disease, has suffered from repeated bouts of cystitis. The course of her most current infection was marked by severe pain, frequency, urgency, and even nocturnal enuresis. She was treated with an antibiotic deemed appropriate after a urine culture and sensitivity test, and she was given atropine to relax her bladder spasms and alleviate some of the unpleasant side effects that she was experiencing. Within the next few days, she plans to travel to a warm climate for the winter and wants any information that she should have before she goes.
Critical Thinking
E.K. presents many nursing care problems. What are the implications of giving an anticholinergic drug to a person with a long history of heart disease?
Repeated bouts of cystitis are not normal; what potential problems should be addressed in this area?
E.K. is about to leave for her winter home in the South; what teaching plans will be essential for her if she is taking atropine when she leaves?
What are the medical problems that can arise with people who live in different
areas at different times of the year?
Considering her age, what written information should E.K. take with her as she travels?
DISCUSSION
E.K. is doing well with her cardiac problems at the moment, but she could develop problems as a result of the anticholinergic drug that has been prescribed. The anticipated adverse effect of tachycardia could tip the balance in a compensated heart, leading to heart failure or oxygen delivery problems. She will need to be carefully evaluated for the status of her heart disease and potential problems.
E.K. should be further evaluated for the cause of her repeated bouts with cystitis.
Does she have a structural problem, a dietary problem, or a simple hygiene problem?
She should receive instruction on ways to avoid bladder infections, such as wiping only from front to back, voiding after sexual intercourse, avoiding baths, avoiding citrus juices and other alkaline ash foods that decrease the acidity of the urine and promote bacterial growth, and pushing fluids as much as possible.
E.K. also should be evaluated to establish a baseline for vision, reflexes, the possibility of glaucoma, GI problems, and so on. She should receive thorough teaching about her atropine, especially adverse effects to anticipate, safety measures to take if vision changes occur, and a bowel program that she can follow to avoid constipation.
Because E.K. is leaving a cold climate and traveling to a warm climate, she will need to be warned that atropine decreases sweating. This means that she may be susceptible to heat stroke in the warmer climate. She should be encouraged to take precautions to avoid these problems.
It will be difficult to monitor E.K. while she is away. It should be anticipated that patients such as E.K. might have two sets of health care providers who may not communicate with each other. It is important to give E.K. written information about her current diagnosis, including test results; details about her drugs, including dosages; information about the adverse effects she may experience and ways to deal with them; and ways to avoid cystitis in the future. It may be useful to include a telephone number that E.K. can use or can give to her southern health care provider to use if further testing or follow-up is indicated.
Nursing Care Guide for E.K.: Heart Disease Assessment: History and Examination
Assess for a history of allergy to anticholinergic drugs, chronic obstructive pulmonary disease (COPD), narrow-angle glaucoma, myasthenia gravis, bowel or urinary obstruction, tachycardia, and recent GI or urinary surgery
Focus the physical examination on the following:
CV: Blood pressure, pulse rate, peripheral perfusion, electrocardiogram (ECG) CNS: Orientation, affect, reflexes, vision
Skin: Color, lesions, texture, sweating GU: Urinary output, bladder tone GI: Abdominal exam
Respiratory: Respiratory rate, adventitious sounds
Nursing Diagnoses
Decreased cardiac output related to cardiovascular effects Constipation related to GI effects
Impaired urinary elimination related to bladder relaxation effects Risk for injury related to CNS effects
Risk for hyperthermia related to decrease in ability to sweat Deficient knowledge regarding drug therapy
Planning
The patient will receive the best therapeutic effect from the drug therapy.
The patient will have limited adverse effects to the drug therapy.
The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.
Implementation
Ensure safe and appropriate administration of drug.
Provide comfort and safety measures, including assistance/side rails; temperature control; dark glasses; small, frequent meals; artificial saliva, fluids; sugarless lozenges, mouth care; bowel program.
Provide support and reassurance to deal with drug effects, discomfort, and GI effects.
Provide patient teaching regarding drug name, dosage, adverse effects, precautions, and warnings to report.
Monitor blood pressure and pulse rate, and adjust dose as needed.
Evaluation
Evaluate drug effects: Pupil dilation, decrease in signs and symptoms being treated.
Monitor for adverse effects: CV effects—tachycardia, heart failure; CNS—
confusion, dreams; urinary retention; GI effects—constipation; visual blurring, photophobia.
Monitor for drug–drug interactions as indicated for each drug.
Evaluate effectiveness of patient-teaching program and comfort and safety measures.
Patient Teaching for E.K.
Anticholinergics are drugs that block or stop the actions of a group of nerves that are part of the parasympathetic nervous system. These drugs may decrease the activity of your GI tract, dilate your pupils, or speed up your heart.
Some of the following adverse effects may occur:
Dry mouth, difficulty swallowing: Frequent mouth care will help to remove dried secretions and keep the mouth fresh. Sucking on sugarless candies will help to keep the mouth moist. Taking lots of fluids with meals (unless you are on fluid restriction) will help swallowing.
Blurred vision, sensitivity to light: If your vision is blurred, avoid driving, operating hazardous machinery, or doing close work that requires attention to details until your vision returns to normal. Dark glasses will help to protect your eyes from the light.
Retention of urine: Take the drug just after you have emptied your bladder. Moderate your fluid intake while the drug’s effects are the highest; if possible, take the drug before bedtime, when this effect will not be a problem.
Constipation: Include fluid and roughage in your diet, and follow any bowel regimen that you may have. Monitor your bowel movements so that appropriate laxatives can be taken if necessary.
Flushing, intolerance to heat, decreased sweating: This drug blocks sweating, which is your body’s way of cooling off. This places you at increased risk for heat stroke. Avoid extremes of temperature, dress coolly on very warm days, and avoid exercise as much as possible.
Report any of the following to your health care provider: Eye pain, skin rash, fever, rapid heartbeat, chest pain, difficulty breathing, agitation or mood changes (a dose adjustment may help to alleviate this problem).
Avoid the use of over-the-counter medications, especially for sleep and nasal congestion; avoid antihistamines, diet pills, and cold capsules. These products may contain drugs that cause similar anticholinergic effects, which could cause a severe reaction. Consult with your health care provider if you feel that you need medication for symptomatic relief.
Tell any doctor, nurse, or other health care provider involved in your care that you are taking these drugs.
Keep this drug, and all medications, out of the reach of children. Do not share these drugs with other people.
KEY POINTS
Atropine is the most commonly used anticholinergic drug. It is indicated for a wide variety of conditions and is available in oral, parenteral, and topical forms.
Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing, constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of vision, and heat intolerance caused by a decrease in sweating.
SUMMARY
Anticholinergic drugs, also called parasympatholytic drugs, block the effects of acetylcholine at cholinergic receptor sites, thus blocking the effects of the parasympathetic nervous system.
Parasympathetic nervous system blockade causes an increase in heart rate, decrease in GI activity, decrease in urinary bladder tone and function, and pupil dilation and cycloplegia.
These drugs also block cholinergic receptors in the CNS and sympathetic postganglionic cholinergic receptors, including those that cause sweating.
Many systemic adverse effects associated with the use of anticholinergic drugs are due to the systemic cholinergic blocking effects that also produce the desired therapeutic effect.
Atropine is the most commonly used anticholinergic drug. It is indicated for a wide variety of conditions and is available in oral, parenteral, and topical forms.
Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing, constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of vision, and heat intolerance caused by a decrease in sweating.
Answers to the questions in this chapter can be found in Answers to Check Your Understanding
Questions on .
MULTIPLE CHOICE
Select the best answer to the following.
1. Anticholinergic drugs are used
a. to allow the sympathetic system to dominate.
b. to block the parasympathetic system, which is commonly hyperactive.
c. as the drugs of choice for treating ulcers.
d. to stimulate GI activity.
2. Atropine and scopolamine work by blocking a. nicotinic receptors only.
b. muscarinic and nicotinic receptors.
c. muscarinic receptors only.
d. adrenergic receptors to allow cholinergic receptors to dominate.
3. Which of the following suggestions would the nurse make to help a patient who is receiving an anticholinergic agent reduce the risks associated with decreased sweating?
a. Covering the head and using sunscreen b. Ensuring hydration and temperature control
c. Changing position slowly and protecting from the sun d. Monitoring for difficulty swallowing and breathing
4. Which of the following would the nurse be least likely to include when developing a teaching plan for a patient who is receiving an anticholinergic agent?
a. Encouraging the patient to void before dosing
b. Setting up a bowel program to deal with constipation
c. Encouraging the patient to use sugarless lozenges to combat dry mouth d. Performing exercises to increase the heart rate
MULTIPLE RESPONSES Select all that apply.
1. A nurse would expect atropine to be used for which of the following?
a. To depress salivation
b. To dry up bronchial secretions c. To increase the heart rate
d. To promote uterine contractions e. To treat myasthenia gravis f. To treat Alzheimer’s disease
2. Remembering that anticholinergics block the effects of the parasympathetic nervous system the nurse would question an order for an anticholinergic drug for patients with which of the following conditions?
a. Ulcerative colitis b. Asthma
c. Bradycardia
d. Inner ear imbalance e. Glaucoma
f. Prostatic hyperplasia
BIBLIOGRAPHY AND REFERENCES
Andrews, M., & Boyle, J. (2011). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Brunton, L., Chabner, B., & Knollman, B. (2011). Goodman and Gilman’s the pharmacological basis of therapeutics (12th ed.). New York: McGraw-Hill.
Facts and Comparisons. (2015). Drug facts and comparisons. St. Louis, MO: Author.
Karch, A. M. (2014). Lippincott’s nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins.
The Medical Letter. (2015). The medical letter on drugs and therapeutics. New Rochelle, NY: Author.
Porth, C. M. (2013). Pathophysiology: Concepts of altered health states (9th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.