Special considerations for age groups

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Special considerations for age groups

• Pediatrics
• Elderly
• Pregnancy

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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

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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.

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Older infant and young child

• differences produce less obvious alterations in
  drug response.
• Better absorption, utilization and excretion

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Examples of drugs alterations

•    Penicillin antibiotics
•    Aminoglycosides
•    Digoxin

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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

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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.

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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

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Preparation and administration of medications to
children

• Calc by milligram/kilogram/hour or day
• mg/kg/d
• Amt of drug in relation to childs 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

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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

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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
• Childs wt is ________ kg
• Safe recommended dosage of child is _______
• Is the order safe?
• How many ml will you administer?
• .

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Preparation and administration of medications to
children

• Step 1. Chg wt to kg 2.2 lb in each kg
• Child weighs 34.32 lb
• Childs 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?

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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)

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Body Surface Area

• Determined by using a childs ht and wt along
  with the West nomogram
• See Edmunds page 91

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Body Surface Area

• Childs wt/ht
• 6 kg/110 cm
• 5 kg/19 in
• 25 kg/70 cm
• 30 lb/90 cm
• 160 lb/200 cm

• BSA

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Body Surface Area

• Childs 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

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Body Surface Area

• Calculate pediatric dosage using a formula
• BSA in m2/1.7 X adult dose childs dose
• Child wt 24 lb
• Adult dose is 100 mg

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Body Surface Area

• Calculation of dosage based on BSA means of
  converting adult dose to a safe pediatric dose.
• Three steps to calculation
• Determine childs wt in kg
• Calculate BSA in sq mtrs (m2)
• Calculate pediatric dosage using a formula
• BSA in m2/1.7 X adult dose childs dose

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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.

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Distribution of drugs that are fat-soluble

• Digoxin
• lithium
• Gentamicin
• meperidine
• phenytoin
• theophylline.

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Lipid soluble drugs

• diazepam (Valium)
• some antidepressants
• antipsychotics.

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Decrease in serum protein (albumin)

• results in greater free concentration of highly
  protein-bound drugs such as
• phenytoin,
• warfarin,
• naproxen,
• Phenobarbital
• some antidepressants.

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decr in hepatic (liver) mass and decr blood flow

• Affects drugs that have a high first-pass
  metabolism
• Includes drugs such as diazepam, barbiturates

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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.

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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.

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Drugs of concern

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

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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.

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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 others ailments and
  exchange medications.

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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.

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Teratogenic drugs

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

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Top 10 drugs/ chemicals pregnant women exposed to

• analgesics
• Antacids
• Antibiotics
• Antiemetics
• Antihistamines
• Diuretics
• Alcohol
• iron supplements
• Sedatives
• vitamins

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Drugs contraindicated while Breastfeeding

• cocaine, lithium, methotrexate, amphentamines,
  nicotine, ergatomine, and others

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PRODUCTS/ MEDICATIONS USED THROUGHOUT LIFESPAN

• IMMUNIZATIONS-
• ANTIDIABETIC AGENTS-
• ANTIHYPERTENSIVE AGENTS-
• CHOLESTEROL-LOWERING AGENTS-
• OBESITY DRUGS-
• ANTIDEPRESSANT MEDICATIONS-
• ASPIRIN-

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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.

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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

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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.

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Noncompliance, cont

• 5.    increases when multiple drugs are taken at
  same time or when frequent intervals.
• 6.    increases when unpleasant side effects.