NUR 105 Unit 6

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please dont mind the spelling =)

Active Transport

the active (energy-requiring) movement of a substance between differnt tissues via biomolecular pumping mechanisms contained within the cell membrane

Diffusion

the passive movement of a substance (e.g. drug) between differnt tissues from areas of higher concentration to areas of lower concentration

Elderly/geriatric

pretaining to a person who is 65 years of age or older (note some sources consider to be 55 or older)

Neonate

pretaining to a person younger than 1 month of age; newborn infant

Nomogram

a graphic tool for estimating drug dosages using various body measurments

Pediatric

pretaining to a person who is 12 years of age or younger
(-ofen identified as max. 16 years of age consult manufacturers guidelines for specific dosing info. table 3-2 on pg 38)

polypharmacy

the use of many differnt drugs concurrently in treating a patient. who often has several health problems

Most drug studies and articles on drugs have focused on

the population between 13 and 65 years of age

It is said that 75% of currently approved drugs by the FDA are lacking the

approval for pediatric use and therefore lack specific dosage guidelines for neonates and children.

A fetus is exposed to many of the same substances as the mother including

any drugs she takes (presription, nonprescription or street drugs)

The first trimester is usually the

period of greatest danger of drug-induced developmental defects

Transfer of both drugs and nutrients to the fetus occurs primarily by

diffusion across the placenta, although not all drugs cross the placenta.

the factors that contribute to the safety or potential harm of drug therapy during pregnancy can be broadly broken down into three areas:

drug properties
fetal gestational age
maternal factors

drug properties that impact drug transfer to the fetus include

drug's chemistry
dosage (include dose and duration of therapy)
concurrently administered drugs
(exs of relevant chemical properties include molecular weight, protein binding, lipid solubility, and chemical structure)

fetal gestational age greatest risk for drug-induced developmental defects is

druing the first trimester of pregnancy (fetus undergoing rapid cell porliferation, and the skeleton, muscles, limbs and vicveral organs are developing at their most rapid rate)

gestational age important in

-determining when a drug can most easily cross the placenta to the fetus

During the last trimester

-the greatest percentage of maternally absorbed drug gets to the fetus (aka drug transfer)
-bc increased blow to fetus/increased fetal surface area/increase amount of free drug in the mother's circulation

maternal factors

any change in the mother's physiology that could impact pharmacokinetic characteristics of drugs can affect the amount of drug to which the fetus may be exposed

Maternal liver and kidney function play a major role in

drug metaboliosm and excretion and are critical factors, espcially if the drug crosses the placenta. May result in higher drug levels than normal and/or prolonged drug exposure

maternal genotype

may also affect how and to what extent certain drugs are metabolized(pharmacogentics) which affects drug exposure of the fetus

the lack of certain enzyme systems may result in adverse drug effects to the fetus when

the mother is exposed to a drug that is normally metabolized by the given enzyme

Exs of when meds are needed in pregnancy bc potential for harm outweighs risk (to mother and fetus)

hypertension, epilepsy, diabetes, and infection

FDA classification for pregnancy based on

-mostly animal studies and limited human studies
-ethical issues related to studies on fetuses

Caterogy A

studies indicate no risk to human fetus

Category B

studies indicate no risk to animal fetus; information for humans is not available

Category C

Adverse effecs reported in animal fetus; info for humans is not available

Category D

possible fetal risk in humans reported; however, consideration of potentail benefits vs. risk may, in selected cases, warrant use of these drugs in pregnant women

Category X

fetal abnormalities reported and positive evidence of fetal risk in humans available from animal and/or human studies, these should not be used by pregnant women

breast-fed infants are

at risk for exposure to drugs consumed by the mother

the primary drug characterisics that increase the likelihood that a drug given to a breast-feeding mother will end up in the breast milk include

fat solubility
low molecular weight
nonionization
high concentration

breast milk is not

the primary route for maternal excretion
-drug levels in breast milk lower than blood

breast-feeding infants exposure is linked to

amount of consumption of milk

ultimate decision on a breast-feeding mother to take a drug is related to the

risk/benefit ratio (must be considered on a case by case basis)

younger then 38 wk gestation

premature or preterm infant

younger than 1 month

neonate or newborn infant

1 mo up to 1 yr

infant

1 yr up to 12 yr

child

physiologic factor most responsible for differnces in pediatric pts is

the immaturity of organs

rapid developing tissues may be more sensitive to certain drugs and therefore

smaller dosages my be required bc of this certain drugs are contraindicated during growth years

neonate considerations decreased

-first pass elimination bc of immaturity of liver
-GFR (AKA glomercular filtration rate... related to renal) and tubular and resorption bc of kidney immaturity
-Gastric emptying: slow or irregular peristalsis (AKA muscles for helping with digestion)
-fat content: lower in young pts bc of greater total body water

neonate considerations increased

-topical absorption
-gastric ph: less acidic bc acid producing cells in stomach less mature until 1-2 years of age

pediatric considerations

-Skin is thin and permeable
-Stomach lacks acid to kill bacteria
-Lungs lack mucus barriers
-Body temperature poorly regulated and dehydration occurs easily
-Liver immature drug metabolism impaired
-Kidneys immature drug excretion impaired

see table pg 38 pharmacokinetic changes in the neonate and pediatric pt

...

broslow tape

for emergencies: A reference at each color bar on the tape informs you of equipment sizes to perform emergency resuscitation on the child. A reference at each weight zone on the tape shows pre-calculated medication dosages.

BSA

the most accurate dosage fomula (body surface area)

for calculating a BSA you need

-drug order with drug name,dose, route, time and frequency
-info regarding available dosage forms
-peds pt height in cm and weight in kg
-BSA nomogram
-recommended adult drug dosage

BSA formula

BSA of child/BSA of adult X Adult dose= estimated child dose

BSA

BSA of child (m^2) X manufacturer's recommended dose/m^2= estimated child dose

pediatric usual stature

mg/kg/day (ex: usual dosage range per 24 hours in milligrams per kilogram)

1 kilogram =

2.2 pounds

childs weight should be given in

kilograms not pounds common source of med error and potential toxicity

General interventions with children for med adminstration

-always come prepared for procedure (all equipment, prepare for injections with needless syring)
-ask the parent and/ or child (if age appropriate) if the parent should not remain for the procedure (for in-hospital admin)
-assess for comfort methods that are appropriate before and after drug admin

med admin with infants

-while maintianing sage and secure positioning of the infant (with parent holding, rocking, cuddling, soothing) perform the procedure (injection) swiftly and safely
-allow self comforting(pacifier, fingers/thumb)

toddler med admin

-brief and concrete explanation
-some aggression
-provide comfort measures immediately after
-increase understanding though play (stuffed animals/needless syringes)
-age appropriate supervised playtime to release aggression

preschoolers med admin

-bried and concrete explanation
-provide comfort after procedure
-accept some aggresion
-magical thinking ("special medicine")
-parent very important in comfort and understanding

School-age child med admin

-explain
-allow some control
-provide comfort
-explore feelings and concepts (age appropriate)
-set behavior limits (okay to cry but not bite)
-provide activities to release aggression
-use opportunity to teach about receiving med and body funtion
-offer complete pic (need to take meds, relax deep breaths, med will help pain)

adolescents med admin

-prepare pt in advance
-allow for expression (time alone after procedure)
-encourage self-expression and individuality
-encourage participation in procedures as appropriate

Patient teaching pediatrics

-parents are the "client"
*many levels of understanding/experience
*assess level of knowledge and need for teaching
*don't assume

dont disquise in essential foods like ... but can use

-don't disquise in milk/juice
-can mix with pudding/ice cream

don not add drug(s) to fluid in a cup why?

bc the amount of drug consumed would then be impossible to calculate if entire fluid not taken

to help child tolerate meds unless contraindicated add

-add little H2O to elixirs

-avoid calling meds "candy"

let children know the dangers they might not understand if called candy

-keep meds out of reach in childproof containers

make sure all family members undstands this

document what works

ask family if they know of any tricks for particular child and if you or they have something that works document it for your future and the others involved in childs care

commonly prescibed drugs in elderly are...

antihypertensives
betablockers
diuretics
insulin
potassium supplements

the most commonly used OTC drugs for elderly people are...

analgesics
laxatives
nonsteroidal anitinflammatory drugs (NSAIDS)

about 1 in 3 elderly pts take

more than 8 differnt drugs each day with many taking over 15

>5 meds/day=

50% increased risk

>8 meds/day=

100% increased risk

common self-medication error for the elderly is

pill-splitting (saves on cost some insurance companies require this)

other factors of medication errors in the elderly

multiple pharmacies and/or prescribers
lack of adequate pt education and understanding

important to use one pharmacy b/c

they can monitor for drug interactions and duplicate therapy since most people see more than one presciber for specialty purposes

as the number of drugs a person takes increases so does the

risk of drug interaction

prescribing cascade

where a provider prescribes a medication to treat the advers effects of another medication

appropriate drug dose for the elderly can be

one half to two thirds of the standard adult dose
"start low and go slow" when prescribing the elderly drugs

creatinine

byproduct of muscle metabolism

pharmacokinetics

absorption
distribution
metabolism
excretion

absorption elderly gastric ph

less acidic bc of gradual production of HCI (hydrochloric acid) in the stomach

absorption elderly gastric emptying

is slowed due to decline in smooth muscle tone and motor activity

absorption elderly GI tract movement

is slow b/c of decresed muscle tone and motor activity

absorption elderly blood flow

decreased 40-50% b/c decreased cardac output and decreased perfustion

absorption elderly absorptive surface area is

-decreased b/c the aging process blunts and flattens villi

distribution elderly total body water

-adults 40-60 years old is 55% males 47% females
-over 60 years old is 52% males 46% females

distribution elderly fat content

increased because of decreased lean body mass

distribution elderly protein binding sites

are reduced b/c of decreased production of proteins by the aging liver and reduced protein

metabolism elderly levels of microsomal enzymes

decreased b/c the capacity of the aging liver to produce them is reduced

metabolism elderly liver blood flow

reduced by approximately 1.5% per year after 25 years of age (decreases hepatic metabolism)

excretion elderly glomerular filtration rate is

decreased by 40 to 50% primarily bc of decreased blood flow

excretion elderly the number of intact

nephrons is decreased

Assessment (nursing process peds)

Physical Assessment: Age,Ht & Wgt
Allergies
Medical History
Unusual responses
Use of OTC meds
Age-related issues
Growth & development (see more on pg 44)

Assessment (nursing process elderly)

Polypharmacy
List of all MDs
Home remedies
Dietary habits
Self-medication practices
Limitations
Kidney function
Liver function (see more on pg 45)

Nursing Diagnoses Risk for Injury

-related to adverse effects of meds or to the method of drug administration
-idiosyncratic reactions to drugs due to age-related drug sensitivity

nursing diagnoses deficient knowledge

related to info about drugs and knowing when to contact prescriber

planning goals

adheres to regimen
contact md when appropriate
free of complications

planning outcome criteria

states importance
follows instructions
shows improvement
takes meds without injury

written and oral instructions should be provided concerning

drug name
action
purpose
dosage
time of admin
route
adverse effects
safety of admin
storage
interactions
contraindications

simple is best

always try to simplify pts regimen and be especially alert to polypharmacy

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