4.3 Applying the Nursing Process to ANS Medications

Assessment

Many classes of medications stimulate or inhibit specific ANS receptors to create desired effects. By understanding these common effects, it becomes easier for the nurse to recognize common side effects from a variety of medication classes 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 anticipates monitoring the client’s blood pressure, heart rate, and lung sounds carefully for expected therapeutic effects and side effects. Medications classified as anticholinergics cause muscle relaxation and the nurse anticipates monitoring for the side effects of urinary retention, constipation, and dry mouth.

Planning

Common goals related to administering medications that affect the ANS include the following:

• Client will adhere to the drug regimen.
• Client’s vital signs will be within the desired range.
• Client will be able to verbalize the action of the medication, as well as side effects, to report to the health care provider.

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 provider. For example, when no parameters are provided, blood pressure medications should not be administered if the client’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 essential for nurses to know the reason why a medication is ordered for a specific client 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.