4.3 Using the Nursing Process with ANS Medications

Assessment

Many types of medications stimulate or inhibit specific ANS receptors. By memorizing the effects, it becomes easy for the nurse to recognize side effects resulting from the stimulation or inhibition of ANS neuroreceptors. Medications that stimulate ANS receptors often impact the heart, lungs, and blood vessels, so the nurse must often monitor blood pressure, heart rate, and lung sounds carefully for expected therapeutic effects and side effects. Anticholinergics cause muscle relaxation and can cause urinary retention, constipation, and dry mouth. The nurse should anticipate and assess for these side effects, and manage them as needed for patient comfort.

Planning

Common goals include:

Patient will adhere to the drug regimen.

Patient’s vital signs will be within the desired range.

Implementation of Interventions

A nurse should be aware of parameters to administer or withhold medications affecting the autonomic nervous system. If the order parameters are unclear, the nurse should withhold the medication following safe administration guidelines, and notify the prescriber.  For example,  when no parameters are provided, blood pressure medications should not be administered if the patient’s apical heart rate is less than 60  beats per minute and/or the systolic blood pressure is less than 100 mmHg.

Report any marked vital signs changes or suspected adverse effects.

Implement fall precautions, when needed, based on anticipated side effects of ANS medications.

Evaluation

It is always important for nurses to know the reason why a medication is ordered for a specific patient, so evaluation of therapeutic effectiveness can be documented. For example, if the purpose of medication is to improve urine flow, then improvement should be seen and documented. Otherwise, the side effects may not warrant the use of the medication.