Drug Therapy Considerations Across the Lifespan

Drug Therapy for Pediatric Clients

Pediatric Drug Therapy

Approximately 75% of all prescription drugs in the U.S. lack full approval by the FDA because most drugs are not studied on children. Studying the effects of drugs in children is a problem.
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Classification of Pediatric Clients

< 1 month Neonate 1 month to < 2 years Infant 2 years to < 12 years Child 12 years to < 18 years Adolescent
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Absorption
Gastric acid (hydrochloric acid) secretion in infants- less acidity Decreased first pass effect Increased topical drug absorption IM injection sites Intravenous drug administration - produce the least variable response because the medication given completely bypass the absorption step
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 Dependent upon the amount of water and/or fat present in the child, as well as plasma affinity of the drug and proteinbinding activity
Water-soluble drugs more effectively utilized than fat soluble -Protein binding capacity is less (until age one year)

Distribution

Distribution
Drugs that binds to CHON are generally bound to a lesser degree in pediatrics client than in adult due to: 1) low CHON concentration in pediatric patient 2) decrease affinity of their proteins for drug molecules
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Metabolism
Difficult to predict Immature liver function

Excretion
Depends on Glomerular filtration, tubular secretion, tubular reabsorption Immature Kidney function
Glomerular filtration does not reach adult levels until two years of age

Excretion increases as the kidney matures

Drug toxicity decreases as the kidney matures
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Pediatric Drug Sensitivity

Central nervous system drugsnot fully mature until 8 months and blood-brain barrier more permeable during this time Barbiturates and morphine
Depressant effects are exaggerated

Lowering body temperature

Acetaminophen
Becomes toxic easily with large doses

Salicylates
Do not give to children under the age of 12.
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Pediatric Dosages
Based on body weight Body Surface Area Determined by using a nomogram
Nomograms are generally accurate after the attainment of mature liver and kidney function. Pg 406 Pickar Text
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West Nomogram

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Pediatric Dosage Calculation

Clarks rule
* Child Dose = [Wt of child (lbs) x adult dose] Adult dose

Youngs rule (1 yr to 12 yrs.)

* Child Dose = [(Age in years) x (adult dose)] (Age + 12)

Frieds Rule (up to 1-2 yrs.)

* Child Dose = (Age in months x adult dose) 150
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Accurate way to Determine BSA

Metric BSA
m
2=

by 3,600 Then take the square root

ht (cm) X wt (kg) divided

Household BSA
m2 = ht (in) X wt divided by 3,131 Then take square root
Math exercise time

(lb)
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Calculating Safe Dosages Based on Weight

First step convert pounds to kilograms Find recommended safe dose range Drug Handbook Resource Calculate safe dose range mg/kg Compare with ordered dose Clarify with physician if dose is below minimum or above maximum range

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Calculating Maintenance Fluids

Formula: 100 ml/kg/day for first 10 kg of body weight 50 ml/kg/day for next 10 kg of body weight 20 ml/kg/day for each kg above 20 kg of body weight
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Rights to Follow
Allow adequate time for drug administration Gain the childs trust
Never lie to the child

Consider the childs developmental level Prevent choking

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Administration Methods
Liquid medications are administered using an infant dropper, syringe without a needle, or a small spoon Schedule medication when the infant is hungry

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Parenteral Medications
Explain the procedure to the child and to the parents. Use additional materials such as:
Booklets Coloring books Puppets Dolls IV setup with colored water

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Painful Procedures
Allow the parents to stay. Painful procedures should be done in a separate room designated as the owie room. Use a firm positive manner. Assemble equipment first. Maintain the childs safety.
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Intramuscular Injections
Vastus lateralis is the preferred site for children under the age of 3. Ventrogluteal site is the preferred site for children over the age of 3. The child should be walking. * Those who are receiving injections in the dorsogluteal site must be instructed to lie on their stomach with the toes pointing inward to relax the buttocks muscle

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(continued)

Anterior view of the location of the vastus lateralis muscle in a young child.
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Considerations for IV administration

Site selected must not limit child activities Gauge?? Methods for IV administration - direct IV push (or 5 minutes or less) - soluset method - syringe pump
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Poisoning in Children
Syrup of ipecac??? Vomiting must not be induced if the child is comatose, poison is corrosive, or if it is a petroleum base Activated charcoal or magnesium sulfate given by health care professionals have proven to be safe and more effective in preventing gastric absorption of poison 24

Final Step in Administering Drugs to Children

Evaluate drug action Remember
Children are vulnerable. Be kind and patient. Enjoy the children; you will receive more than you give. Children generally have short attention span (1 to 5 minutes/ depends on year of development)

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Drug Therapy for Geriatric Clients

Chapter 6

Drug Consumption
Age 65 = increasing population growth
Elderly are estimated to consume approximately 1/3 of all prescription drugs Estimate elderly use 3/4 of over-thecounter drugs Polypharmacy Complicated by sensory impairment, social isolation, inadequate nutrition, and poverty

Absorption
Diminishes with increased age GI concerns

Reduced stomach acid (HCl) GI absorptive surface area is reduced Prolonged gastric emptying rate Use of laxatives and bran reduce absorption Blood flow to the intestines is reduced Reduced muscle tone in the stomach and intestines

Distribution
Water loss Muscle loss Fatty tissue increase Protein binding: decreased capacity

Metabolism
General decline as age increases Causes are obscure; possibly due to:
Reduced blood flow to the liver

Excretion
Measure creatinine function
Blood flow to the kidneys reduced Renal function is reduced Loss of intact nephrons * The elderly are more likely to experience drug toxicity, because of accumulation of drugs

Drug Receptors
Internal drug receptors may change
Results in diminished or greater responses Close monitoring is required

Other Factors
Memory loss Sensory loss Multiple health problems Multiple medications at multiple times Use of multiple pharmacies

Other Factors
Economic factors Lack of education Communication problems Cultural considerations Diet therapy

Points to Remember
Because of memory lossthe elderly may understand instructions given, but then forget the instructions shortly after unless written down Elderlies are prone to the risk of self-medicationdue to sharing. Client response to therapy must be evaluated such as excessive sedation and orthostatic hypotension

Assessing the Elderly

History of drug allergies Current prescriptions Current non-prescriptions Herbal supplements Home Environment Social support Financial concerns Physical limitations

Implementation
Oral medications
Position for administration: high Fowlers Speak clearly and slowly. Offer the most important medication first. Have plenty of liquid available. Do not rush the elderly client.

Intramuscular Medications
Use ventrogluteal site. Avoid deltoid muscle. Avoid vastus lateralis because of loss of muscle mass.

IV Medications
Flow rate must be carefully monitored to prevent circulatory overload Signs/ symptoms of fluid overload

Storage
Safe storage of medications
Keep out of the reach of grandchildren and other young children.

Evaluation
Evaluate
Communication: Does client understand? Can they understand regimen, dosage, adverse effects, s/s to report, importance of compliance Can they demonstrate safe administration Do they experience any idiosyncratic responses

Teachings
Use visual aids Avoid use of blue and green, or yellow and white, as elderly often have difficulty distinguishing these colors Alcohol abuse is often left unrecognized

Promoting Health
Prevent infections. Improve nutrition. Encourage exercise and activity. Facilitate social interaction. Promote restful sleep.