Special considerations for age groups

1. Special considerations for age groups Pediatrics Elderly Pregnancy

2. PEDIATRIC PT Variations in Neonates: less than 1 month of age •      Smaller body mass •      Lower body fat content •      High body water volume •     Enhanced membrane permeability

3. Factors that influence drug absorption immediately after birth: •          Lack of gastric acid •          Absence of intestinal flora and enzyme function •          Decr gastrointestinal transit time •          Immature liver •          Incomplete development of renal excretion system •          Toxicity due to variable absorption.

4. Older infant and young child: • differences produce less obvious alterations in drug response. • Better absorption, utilization and excretion

5. Examples of drugs alterations: •    Penicillin antibiotics •    Aminoglycosides •    Digoxin

6. Adverse drug rxns in children • Incr in very ill children and infants • Infants exposed to drugs:        Transplacentally      Direct adminstration        Ingestion of breast milk • Paradoxical reactions:       hyperactive with antihistamines/choral hydrate Sleepiness with stimulants like Ritalin

7. children are not just small adults • Children are not just small adults who require a proportionally smaller dose of medication. • Respond differently to drugs, toxic effects may develop more quickly and stay around longer.

8. Preparation and administration of medications to children • Calculating • the right amount • of the right medication • to the right child at the right time • in the right way • Determining if a dosage is too high to be be safe • Determining if the dosage is too low to have the desired therapeutic effect

9. Preparation and administration of medications to children • Calc by milligram/kilogram/hour or day: • mg/kg/d • Amt of drug in relation to child’s wt in kg for 24 hrs. • Safe amt of drug always calculated in mg/kg in references • Normal amt of med given to children is less than that given to adults

10. Preparation and administration of medications to children • Calculated amt to be given in 24 hrs then divide by equal number of doses • Number of doses determined by recommended frequency of administration

11. Preparation and administration of medications to children • Example: • Amoxicillin 125 mg po • Child weighs 34.32 lb • You have amoxicillin suspension 125 mg/5ml • Usual dose is 20-50 mg/kg/day in divided doses every 8 hours • Child’s wt is ________ kg • Safe recommended dosage of child is _______ • Is the order safe? • How many ml will you administer? .

12. Preparation and administration of medications to children • Step 1. Chg wt to kg: 2.2 lb in each kg • Child weighs 34.32 lb • Child’s wt is ________ kg • Step 2. Determine safe recommended dosage or range. • You have amoxicillin suspension 125 mg/5ml • Usual dose is 20-50 mg/kg/day in divided doses every 8 hours Determine the total amt of medication ordered per 24 hrs_____ • Safe recommended dosage of child is _______ • Is the order safe?

13. Preparation and administration of medications to children • Step 3: calculate the actual dosage amt to be given: • amoxicillin suspension 125 mg/5ml • in divided doses every 8 hours (tid)

14. Body Surface Area • Determined by using a child’s ht and wt along with the West nomogram • See Edmund’s page # 91

15. Child’s wt/ht 6 kg/110 cm 5 kg/19 in 25 kg/70 cm 30 lb/90 cm 160 lb/200 cm BSA Body Surface Area

16. Child’s wt/ht 6 kg/110 cm 5 kg/19 in 25 kg/70 cm 30 lb/90 cm 160 lb/200 cm BSA 0.41 m2 0.81 m2 0.74 m2 0.58 m2 2.0 m2 Body Surface Area

17. Body Surface Area • Calculate pediatric dosage using a formula: • BSA in m2/1.7 X adult dose = child’s dose Child wt: 24 lb Adult dose is 100 mg

18. Body Surface Area • Calculation of dosage based on BSA: means of converting adult dose to a safe pediatric dose. • Three steps to calculation: • Determine child’s wt in kg • Calculate BSA in sq mtrs (m2) • Calculate pediatric dosage using a formula: • BSA in m2/1.7 X adult dose = child’s dose

19. Special considerations in GERIATRIC PATIENT Meds absorbed, metabolized, excreted more slowly, less completely. • Absorption: changes in GI tract with less acid output, delayed motility in the bowel, reduced blood flow slow down absorption. • Distribution: decrease in total body water and lean body mass thus less distribution in some areas which can result in a greater effect of the drug, or toxicity.

20. Distribution of drugs that are fat-soluble • Digoxin • lithium • Gentamicin • meperidine • phenytoin • theophylline.

21. Lipid soluble drugs • diazepam (Valium) • some antidepressants • antipsychotics.

22. Decrease in serum protein (albumin) • results in greater free concentration of highly protein-bound drugs such as: • phenytoin, • warfarin, • naproxen, • Phenobarbital • some antidepressants.

23. decr in hepatic (liver) mass and decr blood flow • Affects drugs that have a high first-pass metabolism • Includes drugs such as: diazepam, barbiturates

24. Excretion: • Great degree of variability in renal function changes with ageing thus the single most important physiologic factor resulting in adverse drug reactions. • Chronic diseases such as congestive heart failure, liver disease and conditions leading to dehydration affect renal function and thus affect dosing.

25. Adverse Reactions • Approx 90% of older people experience adverse rxns to drugs/ 20% of which require hospitalization. • Approx 30,000 people may die/yr as result of adverse drug rxns.

26. Drugs of concern • Tranquilizers • Sedatives • Drugs that alter mind/change perception • Drugs which cause dizziness or unbalanced. • Diuretics, cardiac drugs.

27. Sxs of toxic rxns and adverse drug effects to watch for in elderly: • Diminished level of mental function, incr fatigue, restlessness, irritability, depression, weakness, dizziness, headache, or disorientation. • Problems which interfere with appetite, balance, energy and lead to dehydration, weight loss, falls and immobility.

28. Noncompliance due to personal and environmental factors: • Cost of drug, difficulty in getting it from a pharmacy • poor memory and motivation to take drug, • depression, feeling overwhelmed by responsibility. • Arthritis or disabling disease • Poor eyesight… • People diagnose each other’s ailments and exchange medications.

29. Special considerations in PREGNANT AND BREASTFEEDING WOMEN • chronic diseases, such as seizure disorders, diabetes • Impact on fetus -Avoid those drugs with teratogenic potential • Times of greatest risk: • -first 2 wks after conception, fetal period from 57 days until term i.e. all of pregnancy.

30. Teratogenic drugs: • antithyroid compounds • aminoglycoside antibiotics • Thalidomide • Coumadin (warfarin) and other anticoagulants • Lithium • Anticonvulsants: phenytoin, valproic acid carbamezepine

31. Top 10 drugs/ chemicals pregnant women exposed to: • analgesics • Antacids • Antibiotics • Antiemetics • Antihistamines • Diuretics • Alcohol • iron supplements • Sedatives • vitamins

32. Drugs contraindicated while Breastfeeding • cocaine, lithium, methotrexate, amphentamines, nicotine, ergatomine, and others

33. PRODUCTS/ MEDICATIONS USED THROUGHOUT LIFESPAN • IMMUNIZATIONS- • ANTIDIABETIC AGENTS- • ANTIHYPERTENSIVE AGENTS- • CHOLESTEROL-LOWERING AGENTS- • OBESITY DRUGS- • ANTIDEPRESSANT MEDICATIONS- • ASPIRIN-

34. CULTURAL INFLUENCES RELATED TO MEDICATIONS Effective nursing care is dependent on an ability to assess the differences in individuals related to administration of medications based on many factors including culture.

35. FACTORS RELATED TO NONCOMPLIANCE WITH DRUGS • Omission: not taken • Commission: taking a medication not prescribed • Dosage error: not taking right dose • Scheduling error: wrong schedule

36. Major risks of noncompliance: 1. higher for preventative care medications than ‘important’ meds such as cardiac or anticonvulsant 2.  increases w duration especially in chronic disease such as hypertension, epilepsy, depression, diabetes 3.  highest for regimens that require significant behavior changes such as wt loss or smoking cessation 4.  common cause of noncompliance is poor understanding of instructions.

37. Noncompliance, cont: 5.    increases when multiple drugs are taken at same time or when frequent intervals. 6.    increases when unpleasant side effects.