508
P A R T 5
Drugs acting on the autonomic nervous system
CRITICAL THINKING SCENARIO
Anticholinergic drugs and heart disease
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 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 Queensland;
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 travelling
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 people such as E.K. might
have two sets of healthcare 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
plus 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 give to her northern
healthcare provider to use if further testing or follow-up
is indicated.
CARE GUIDE FOR E.K.: HEART DISEASE
Assessment: History and examination
Assess for a history of allergy to anticholinergic drugs,
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, ECG
CNS: orientation, affect, reflexes, vision
Skin: colour, lesions, texture, sweating
GU: urinary output, bladder tone
GI: abdominal exam
Respiratory: respiratory rate, adventitious sounds
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 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.
