Lifespan Considerations in Pharmacotherapy PDF

Lifespan Considerations in Pharmacotherapy PART 1 Prepared By Jonathan Q. Ibalio, MD College  Beginning with conception and continuing throughout the lifespan, the organs and systems within the body undergo predictable phys...

Lifespan Considerations in Pharmacotherapy PART 1 Prepared By Jonathan Q. Ibalio, MD College  Beginning with conception and continuing throughout the lifespan, the organs and systems within the body undergo predictable physiological alterations that influence the absorption, metabolism, distribution, and elimination of medications. Nurses must have knowledge of such changes to ensure that drugs are delivered in a safe and effective manner to clients of all ages. The purpose is to examine how principles of developmental physiology and lifespan psychology apply to pharmacotherapeutics. Lifespan Considerations in Pharmacotherapy  To collaborate effectively with the client, healthcare providers must consider the biophysical, psychosocial, ethnocultural, and spiritual characteristics that are unique to the client. To provide holistic and individualized care for the person receiving pharmacotherapy, nurses must understand normal growth and developmental patterns that occur throughout the lifespan. Growth characterizes the progressive increase in physical (body) size. Development refers to the functional evolution of the physical, psychomotor, and cognitive capabilities of a living being. Lifespan Considerations in Pharmacotherapy  It is from this benchmark that deviations from the norm can be recognized so that health pattern impairments can be addressed appropriately. The very nature of pharmacology requires that the specifics of age, growth, and development for each client be considered in relation to pharmacokinetics and pharmacodynamics Lifespan Considerations in Pharmacotherapy  Pharmacotherapy During Pregnancy and Lactation  The nurse caring for the pregnant or lactating woman faces the challenge of concurrently being responsible for the health and safety of two persons, knowing that most medications cross the placenta and are secreted in breast milk. Despite potential risks to the fetus, first-trimester use of prescription drugs has increased by more than 60% in the past 30 years (Mitchell et al., 2011). With the availability of the Internet, women may choose to search for drug information online, but Peters et al. (2013) found that even lists of “safe” drugs found in web-based information were inadequate and might provide false reassurance to women about the adverse effects posed by drugs taken during pregnancy Lifespan Considerations in Pharmacotherapy  The decision to initiate pharmacotherapy during pregnancy and lactation is made in collaboration with the pregnant client, with consideration of the risks and benefits for her and her fetus. Most drugs have not been tested in pregnant women and infants. When possible, drug therapy is postponed until after pregnancy and lactation, or safer alternatives are attempted. There are some conditions, however, that are severe enough to require pharmacotherapy in pregnant and lactating clients. Lifespan Considerations in Pharmacotherapy  These conditions include pre-existing illness, maternal illness unrelated to the pregnancy, and complications related to pregnancy. For example, if the client has epilepsy, hypertension, or a psychiatric disorder prior to the pregnancy, it could be unwise to discontinue therapy during pregnancy or lactation. Conditions such as gestational diabetes and gestational hypertension occur during pregnancy and must be treated for the safety of the growing fetus. In all cases, healthcare practitioners evaluate the therapeutic benefits of a given medication against its potential adverse effects and support the woman who may feel guilty for taking medically necessary drugs during pregnancy. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Pregnancy The placenta is a semipermeable membrane through which some substances are passed to the fetus and by which others are blocked. The fetal membranes contain enzymes that detoxify certain substances as they cross the membrane. For example, insulin from the mother is inactivated by placental enzymes during the early stages of pregnancy, preventing it from reaching the fetus. In general, drugs that are water soluble, ionized, or bound to plasma proteins are less likely to cross the placenta. Lifespan Considerations in Pharmacotherapy Pharmacokinetics During Pregnancy During pregnancy, major physiological and anatomical changes occur in the endocrine, gastrointestinal (GI), cardiovascular, circulatory, and renal systems. Some of these changes alter the pharmacodynamics of drugs administered to the client and may affect the success of pharmacotherapy. Lifespan Considerations in Pharmacotherapy Pharmacokinetics During Pregnancy Absorption: Hormonal changes as well as the pressure of the expanding uterus on the blood supply to abdominal organs affect the absorption of drugs. Gastric emptying is delayed, and transit time for food and drugs in the GI tract is slowed by progesterone, which allows a longer time for absorption of oral drugs. Gastric acidity is also decreased, which can affect the absorption of certain drugs. Changes in the respiratory system during pregnancy— increased tidal volume and pulmonary vasodilation—may cause inhaled drugs to be absorbed more quickly. Lifespan Considerations in Pharmacotherapy Pharmacokinetics During Pregnancy Distribution and metabolism: Hemodynamic changes in the pregnant client increase cardiac output and plasma volume and change regional blood flow. The increased blood volume (up to 50%) in the woman’s body causes dilution of drugs and decreases plasma protein concentrations, affecting drug distribution. Blood flow to the uterus, kidneys, and skin is increased, whereas flow to the skeletal muscles is diminished. Lifespan Considerations in Pharmacotherapy Pharmacokinetics During Pregnancy Alterations in lipid levels may alter drug transport and distribution, especially during the third trimester. Drug metabolism is significantly altered during pregnancy (Isoherranen & Thummel, 2013) and increases for certain drugs, most notably anticonvulsants such as carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene, Epival), which may require higher doses during pregnancy. Lifespan Considerations in Pharmacotherapy Pharmacokinetics During Pregnancy Excretion: By the third trimester of pregnancy, blood flow through the kidneys increases by 50% to 70%. This increase has a direct effect on renal plasma flow, glomerular filtration rate, and renal tubular absorption. Therefore, drug excretion rates may be increased, affecting dosage timing and onset of action. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy The prenatal stage is the time span from conception to birth. This stage is subdivided into the embryonic period (conception to 8 weeks) and the fetal period (8 to 40 weeks or birth). In terms of pharmacotherapy, this is a strategic stage because the health and welfare of both the pregnant client and the baby in utero are taken into consideration (Figure 6.1). Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy Pharmacologically, the focus must be to eliminate potentially toxic agents that may harm the mother or unborn child. Agents that cause fetal malformations are termed teratogens. The baseline incidence of fetal malformations is approximately 3% of all pregnancies. Chemical and drug exposure, including alcohol and tobacco use, accounts for about 10% to 12% of these malformations. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy The placenta is a temporary organ that allows for nutrition and gas exchange between the mother and the fetus. As much as 10% of the mother’s cardiac output circulates through the placenta. Although the blood of the mother does not circulate through the fetus, capillary-like structures in the placenta allow an extensive exchange of substances. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy The placenta offers a degree of protective filtration of the maternal blood, preventing certain harmful substances from 1 reaching the fetus. Nutritional substances such as vitamins, fatty acids, glucose, and electrolytes freely pass from mother to fetus. Most drugs cross the placenta and pass from mother to fetus by simple diffusion. A few drugs cross by way of active transport. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy The role the placenta plays in drug metabolism is under study. It is known that metabolic enzymes are present in the placenta and likely contribute to drug metabolism. What is not known with certainty is how a particular drug is metabolized through the placenta. Some drugs may be metabolized extensively and presumably have little or no effect on the developing fetus, whereas other drugs may be altered to become toxic metabolites capable of harm. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy It should be understood that drugs may cause fetal harm without crossing the placenta or entering the fetal blood. For example, certain drugs may cause constriction of placental blood vessels, impairing nutrient exchange. Other drugs can alter maternal physiology to such an extent that the fetus is affected. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy Multiple factors affect the transfer of drugs across the placenta. These variables are the same as those that affect the movement of substances across other biological membranes, and they include: The plasma drug level in the mother Lipid solubility characteristic of the drug The drug’s molecular size Drug protein binding capability Drug ionization Blood flow to the placenta Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy During the first trimester (conception to 3 months) of pregnancy, when the skeleton and major organs begin to develop, the fetus is at greatest risk for developmental anomalies. If teratogenic drugs are used by the mother, major fetal malformations may occur, or the drug may even precipitate a spontaneous abortion. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy Unfortunately, accidental exposure can occur because the mother may take a medication before she knows she is pregnant. Whenever possible, drug therapy should be delayed until after the first trimester of pregnancy. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy During the second trimester (4 to 6 months) of pregnancy, the development of the major organs has progressed considerably; however, exposure to certain substances taken by the mother can still cause considerable harm to the fetus. The nurse-client relationship is vital during this time, especially in terms of teaching. A woman who is pregnant can mistakenly believe that her unborn infant is safe from anything she consumes because the “infant is fully formed and just needs time to grow.” Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy During prenatal visits, the nurse must be vigilant in assessing and evaluating each client so that any mistaken beliefs can be clarified. During the third trimester (7 to 9 months) of pregnancy, blood flow to the placenta increases and placental vascular membranes become thinner. Such alterations allow the transfer of more substances from the maternal circulation to the fetal blood. Lifespan Considerations in Pharmacotherapy Gestational Age and Pharmacotherapy As a result, the fetus will receive larger doses of medications and other substances taken by the mother. Because the fetus lacks mature metabolic enzymes and efficient excretion mechanisms, medications will have a prolonged duration of action in the unborn child Lifespan Considerations in Pharmacotherapy Pregnancy Drug Categories  The drug pregnancy categories developed by the United States Food and Drug Administration (FDA) to rate medications as to their risks during pregnancy. Table 6.1 shows the six pregnancy categories, which guide the healthcare team and the client in selecting drugs that are the least hazardous for the fetus. Nurses who routinely work with women who are pregnant must learn the pregnancy categories for medications commonly prescribed for their clients. Lifespan Considerations in Pharmacotherapy  Examples of category D or X drugs that have been associated with teratogenic effects include testosterone, estrogens, ergotamine (Ergomar), all angiotensin-converting enzyme (ACE) inhibitors, methotrexate, thalidomide (Thalomid), tetracycline, valproic acid, and warfarin (Coumadin). In addition, alcohol, nicotine, and illicit drugs such as cocaine also affect the unborn child. Lifespan Considerations in Pharmacotherapy  It is impossible to experimentally test drugs for teratogenicity in human subjects during clinical trials. Although drugs are tested in pregnant laboratory animals, the structure of the human placenta is unique. Drug pregnancy categories are extrapolated from these animal data and may be crude approximations of the actua risk to a human fetus. The actual risk to a human fetus may be much less, or magnitudes greater, than that predicted from animal data. Lifespan Considerations in Pharmacotherapy  No prescription drug, over-the-counter (OTC) medication, or herbal product should be taken during pregnancy unless the physician verifies that the therapeutic benefits to the mother clearly outweigh the potential risks to the fetus. The current A, B, C, D, X, and N pregnancy labelling system is simplistic and gives no specific clinical information to help guide nurses or their clients as to whether a medication is truly safe. Lifespan Considerations in Pharmacotherapy  The system does not indicate how the dose should be adjusted during pregnancy or lactation. Most drugs are category C, as very high doses often produce teratogenic effects in animals. The FDA is in the process of updating these categories to provide more descriptive information on the risks and benefits of taking each medication. The new labels are expected to include pharmacokinetic and pharmacodynamic information that will suggest optimum doses for the childbearing client. Lifespan Considerations in Pharmacotherapy  To gather this information, the FDA is encouraging all pregnant women who are taking medication to join a pregnancy registry that will survey drug effects on both the client and the fetus or newborn. Evaluation of a large number of pregnancies is needed to determine the effects of a medication on the fetus. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation Pharmacotherapy During Lactation Breastfeeding is highly recommended as a means of providing nutrition, emotional bonding, and immune protection to the neonate. Many drugs, however, are able to enter breast milk in small amounts, and a few have been shown to be harmful. As with the placenta, drugs that are ionized, water soluble, or bound to plasma proteins are less likely to enter breast milk. Central nervous system (CNS) medications are very lipid soluble and thus are more likely to be present in higher concentrations in milk and can be expected to have a greater effect on an infant. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation Although concentrations of CNS drugs in breast milk are found in higher amounts, they often remain at subclinical levels. Regarding the role of protein binding, drugs that remain in the maternal plasma bound to albumin are not able to penetrate the mother’s milk supply. For example, warfarin is strongly bound to plasma proteins and thus has a low level in breast milk. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation It is important for the nurse to understand factors that influence the amount of drug secreted into breast milk. This allows the nurse to aid the client in making responsible choices regarding lactation and in reducing exposure of her newborn to potentially harmful substances. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation The amount of drug that passes to the infant during lactation depends on multiple factors: – Plasma drug level in the mother. The higher the dose of drug taken by the mother, the more will be secreted into breast milk. It is therefore standard practice that if a drug must be prescribed for a lactating client, the lowest effective dose should be ordered. – Solubility of the drug. Highly lipid-soluble drugs enter the milk at higher concentrations. Drugs that act on the CNS are usually lipophilic and have a tendency to penetrate milk at higher concentrations. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation – Molecular size and protein binding. Some drugs, such as heparin and insulin, are simply too large to pass through membranes by passive diffusion. In addition, when drugs are highly protein bound, they are less likely – Drug ionization. Milk is slightly more acidic than plasma; the pH of milk is 7.2 and of plasma is 7.4. This pH gradient allows weakly basic drugs to transfer more readily into breast milk and accumulate due to ion trapping. to enter the milk than those that are free. – Drug half-life. Drugs with short half-lives will be metabolized and eliminated quickly by the mother. This results in smaller amounts being secreted into breast milk. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation It is imperative to teach the mother that many prescription medications, OTC drugs, and herbal products may be excreted in breast milk and have the potential to affect her child (Figure 6.2).. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation The same guidelines for drug use apply during the breastfeeding period as during pregnancy: drugs should be taken only if the benefits to the mother clearly outweigh the potential risks to the infant. The nurse should explore the possibility of postponing pharmacotherapy until the baby is weaned or perhaps selecting a safer, non-pharmacological alternative therapy. If a drug is indicated, it is sometimes useful to administer it immediately after breastfeeding, or when the infant will be sleeping for an extended period, so that the longest possible time elapses before the next feeding. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation This will reduce the amount of active drug in the mother’s milk when she does breastfeed her infant. The nurse can assist the mother in protecting the child’s safety by teaching her to avoid illicit drugs, alcohol, and tobacco products during breastfeeding. Also, the mother should be advised to consult a healthcare provider before taking any OTC drugs or herbal products Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation When considering the effects of drugs on the breastfeeding infant, the amount of drug that actually reaches the infant’s tissues must be considered. Some medications are destroyed in the infant’s GI system, are unable to be absorbed through the wall of the GI tract, or are rapidly metabolized by the liver. Therefore, although many drugs are found in breast milk, some are present in such small amounts that they cause no harm. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation The last key factor in the effect of drugs on the infant relates to the infant’s ability to metabolize small amounts of drugs. Premature, neonatal, and ill infants may be at greater risk for adverse effects because they lack drug metabolizing enzymes. Medications that pass into breast milk are indicated in drug guides. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation Nurses who work with women who are pregnant or breastfeeding should refer to this information. Table 6.2 shows selected drugs that are compatible with breastfeeding and those that should be avoided. Table 6.3 lists classes of medications that may cause serious problems in a baby after breastfeeding. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Lactation Ask pregnant mothers to completely abstain from alcohol during pregnancy because a safe level of alcohol consumption during pregnancy has not yet been established. There is a lack of conclusive evidence surrounding the effects on the fetus of either social or moderate drinking. Lifespan Considerations in Pharmacotherapy Pharmacotherapy During Childhood  Infancy is the period from birth to 12 months of age. During this time, nursing care and pharmacotherapy are directed toward safety of the infant, proper dosing of prescribed drugs, and teaching parents how to administer medications properly. The nurse should assess the infant’s normal routines at home and attempt to follow these routines as closely as possible while the infant is hospitalized. Parents should be kept informed of specific orders for the infant, such as fluid restrictions. Encourage the parents to participate in the care of the infant as much as they are able. Lifespan Considerations in Pharmacotherapy  Medications administered at home to infants are often given via droppers into the eyes, ears, nose, or mouth. Infants with well-developed sucking reflexes may be willing to ingest oral drugs with a pleasant taste through a bottle nipple. Infant drops are given by placing the drops in the buccal pouch for the infant to swallow. Oral medications should be administered slowly to avoid aspiration. If rectal suppositories are administered, the buttocks should be held together for 5 to 10 minutes to prevent expulsion of the drug before absorption has occurred. Lifespan Considerations in Pharmacotherapy  Special considerations must be observed when administering intramuscular (IM) or intravenous (IV) injections to infants. Unlike adults, infants lack well-developed muscle masses, so the smallest needle appropriate for the drug—preferably a 1 cm (3/8- inch) needle—should be used. The vastus lateralis is the preferred site for IM injections because it has few nerves and is relatively well developed in infants. The gluteal site is usually contraindicated because of potential damage to the sciatic nerve, which may result in permanent disability. Lifespan Considerations in Pharmacotherapy  Because of the lack of choices for injection sites, the nurse must take care not to overuse a particular location, as inflammation and excessive pain may result. For IV sites, the feet and scalp often provide good venous access. After gaining IV access, it is important that the IV remain secured so that the infant does not dislodge it. It is also important to check the IV site frequently and assess for signs of inflammation or infiltration. Lifespan Considerations in Pharmacotherapy  Medications for infants are often prescribed in milligrams per kilogram per day (mg/kg/24h) rather than according to the infant’s age in weeks or months. An alternate method of calculating doses is to use the infant’s body surface area (BSA). Because the liver and kidneys of infants are immature, drugs will have a greater impact due to their prolonged duration of action. For these reasons, it is important to consider age and size in determining safe dosages of medications for infants. Lifespan Considerations in Pharmacotherapy  From early infancy, the natural immunity a child receives from the mother in utero slowly begins to decline. The child’s developing immune system must then take over. Childhood diseases that were once damaging or fatal can now be controlled through routine immunizations. The nurse plays a key role in educating parents about the importance of keeping their child’s immunizations current. Lifespan Considerations in Pharmacotherapy Medication Safety for Pediatric Clients The nurse is often responsible for administering medications to children. The importance of accurate drug dosage calculations, proper administration techniques, proper efforts to minimize adverse effects, and the need for overall safety cannot be overemphasized. Principles of safe medication practice for pediatric clients are identical to those of adult clients. Medication safety is a team approach. Lifespan Considerations in Pharmacotherapy Medication Safety for Pediatric Clients Every level of responsibility is involved, including hospital-wide policies, prescriber actions, pharmacy guidelines, nursing interventions, and client and family adherence. Responsibility for preventing medication errors in pediatric clients is shared by every member of the team. The safety and effectiveness of a medication regimen depends on proper procurement, storage, and administration of the drug. In the hospital setting, nurses are responsible for adherence to the basic rules of drug administration: right client, right drug, right route, right dose, at the right time. Lifespan Considerations in Pharmacotherapy Medication Safety for Pediatric Clients Younger pediatric clients may not be able to accurately identify themselves; therefore, it is imperative that the nurse use precautions to ensure that the right child receives the prescribed medication. The nurse must check the child’s identification band against the medication record. Most hospitals’ policies require that drugs such as digoxin (Lanoxin, Toloxin), heparin, insulin, chemotherapeutic agents, opioid analgesics, and barbiturates be double-checked with another nurse prior to administration. If the nurse suspects that a dose of medication ordered by the prescriber is outside the normal range, it is the nurse’s responsibility to question the order because some drugs can be lethal to pediatric clients. The nurse should regularly check reputable online drug information sources for the most recent information on pediatric drugs and their adverse effects and can consult with the pharmacist as an additional resource. Lifespan Considerations in Pharmacotherapy Nursing Actions and Guidelines a) Check medication calculations with another professional member of the healthcare team. b) Confirm client identity before administration of each dose. c) Be familiar with medication ordering and dispensing systems. d) Verify drug orders before medication administration. e) Verify unusually large or small volumes or dosage units for a single client dose. Lifespan Considerations in Pharmacotherapy Nursing Actions and Guidelines f) When a client, parent, or caregiver questions whether a drug should be administered, listen attentively, answer questions, and double-check the medication order. g) Remain familiar with the operation of medication administration devices and the potential for errors with such devices, particularly patient-controlled analgesia (PCA) or infusion pumps. Lifespan Considerations in Pharmacotherapy Nursing Education and Communication 1. Develop and maintain continuous education programs for nursing competencies in devices used for pediatric medication administration, particularly PCA and infusion pumps. 2. Develop and maintain a pediatric medications knowledge base. 3. Discuss medication orders with the prescriber whenever possible. 4. Integrate and provide education for the client and caregiver regarding the medication regimen. Lifespan Considerations in Pharmacotherapy Nursing Education and Communication 5. Record and verify client identity, weight, allergies, and previous medication use. 6. Be aware of and be involved in ongoing error-tracking systems and pharmacy programs. Encourage blame-free error reporting. 7. Ensure that all staff members understand the method of reporting and are knowledgeable about the healthcare agency’s system for reporting errors. Lifespan Considerations in Pharmacotherapy Calculating Drug Dosages for the Pediatric Client Nurses must consistently update their skills in calculating pediatric doses because errors in drug administration may have serious consequences. Drug dosage calculation for pediatric clients should be individualized, and nurses should take into consideration the child’s age, height, weight, maturational state, and body surface area. All drug calculations for pediatric clients in critical care settings should be double-checked by the pharmacist and another nurse prior to administration. Lifespan Considerations in Pharmacotherapy Calculating Drug Dosages for the Pediatric Client Two common procedures for calculating pediatric dosages are the body weight method and the body surface area method. Use of the body weight method requires a calculation of the number of milligrams of drug, based on the child’s weight in kilograms (mg/kg). A unit of time is usually included; for example, gentamicin (Garamycin) 5 mg/kg/24h. The body weight method is simple, and a dose can be calculated quickly. Lifespan Considerations in Pharmacotherapy Calculating Drug Dosages for the Pediatric Client However, the serum concentrations of many drugs are not proportional to body weight, and body weight does not take into consideration pharmacokinetic variables such as changes in metabolism and elimination rates. The body surface area (BSA) method uses an estimate of the child’s BSA. This method is believed to be the most valid basis for dosage because it is related to certain physiological functions that account for the pharmacokinetic differences in pediatric clients. The BSA method better estimates blood volume, metabolism, and the effects of drugs. Measurements of the fluid volume compartment and the serum concentrations of drugs also correlate well with the BSA. Lifespan Considerations in Pharmacotherapy Calculating Drug Dosages for the Pediatric Client Using the BSA method, the child’s height and weight are plotted on a nomogram (Figure 6.4), and a line is drawn between the two points. The point at which the line intersects the surface area (SA) line is the child’s BSA. The dose is calculated as BSA ÷ 1.73 × Adult dose × Pediatric dose. Other methods, including electronic calculators, are used to estimate pediatric doses. Each method has specific advantages and disadvantages. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence Because of their smaller size and immature or developing organ systems, pediatric clients are more susceptible to adverse effects. The nurse may find it challenging to identify adverse effects because infants and young children often do not have the maturity or verbal skills to accurately describe their feelings following medication administration. Identifying pediatric adverse effects will depend on the skill and ability of the nurse in assessing subtle changes in a client’s response. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence For example, a child on diuretics should have strict intake and output measurements to help determine whether the drug is working properly. Excessive weight gain could be caused by edema resulting from poor kidney excretion, or weight loss might be due to excessive diuresis. Signs of ototoxicity may go unnoticed for a long time unless someone checks that the child no longer responds to verbal commands. It may be necessary to consult a psychologist to identify signs of suicidal ideation from antidepressant use in adolescents. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence Most types of adverse effects that occur in children age 1 or older are the same as those seen in adults. As with adults, the majority of adverse effects are dose related; therefore, the nurse must pay close attention to the proper dose and frequency of drug administration. Knowing specific drugs and their adverse effects in the adult population will help the nurse to quickly identify signs and symptoms of adverse effects in pediatric clients. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence For example, antibiotics such as amoxicillin (Amoxil) frequently result in diarrhea in both adults and children. Antianxiety agents, antidepressants, and antipsychotic drugs that cause CNS depression will likely cause drowsiness in both adults and children A few types of adverse effects are specific to children due to their immature or developing organs and tissues. For example, tetracycline must be avoided in the neonate because of the potential for permanent staining of the teeth. Sulfonamides can cause jaundice in neonates, and aspirin is contraindicated in children with fever due to the potential for Reye’s syndrome. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence Glucocorticoids can inhibit growth. Like adults, children may also experience drug interactions. Drugs that are most likely to contribute to drug interactions in pediatric clients are those with high potency, narrow therapeutic index, and extensive protein binding, and those that affect vital organ functions or hepatic metabolism. Often parents’ first response to their child’s illness is to provide home remedies. OTC and herbal treatments are extremely common in some households, and research suggests that their use is on the rise among a large segment of the population. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence The nurse must become aware of commonly used OTC and herbal remedies in order to advise the families about their pros and cons. Parents must understand that OTC and herbal therapies may have adverse effects of their own and may interact with prescription medications. Herbal remedies commonly used in homes include St. John’s wort, Echinacea, ginseng, licorice, and sassafras Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence A drug will fail to achieve optimum therapeutic outcomes if it is not taken properly. Adherence, also called compliance, is taking the drug according to the instructions on the label or those provided by the prescriber. Maximizing adherence to the medication regimen is a major goal of the pediatric nurse. The nurse must assess the client and family to determine factors that could affect the family’s ability to assist the child with the medication regimen and to develop strategies that will enhance medication adherence. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence The more complex, expensive, and inconvenient the medication regimen, the less likely the child and family will adhere. Children are most likely to adhere to their medication regimen if the following conditions exist: – High expectations of successful outcome of the therapy – Supportive family members who are able to communicate with the prescriber Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence – Positive interactions with the nurse and caregivers – Minimal adverse effects from the medications – Simple, short-term, inexpensive regimen with minimum disruption to daily routine Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence The nurse works with the child and family to enhance adherence by applying direct measures. The child and family should be asked directly whether they have doubts about their ability to adhere to the regimen. If there is doubt, the nurse should explore the areas of concerns with the family and start by teaching the importance of the drug, route of administration, expected outcomes, and possible adverse effects. Lifespan Considerations in Pharmacotherapy Adverse Drug Reactions in Children and Promoting Adherence For long-term drug therapy, the nurse may have to arrange follow-up appointments to assess drug responses or to administer the oral drug to the child and observe the drug being swallowed. This technique is known as directly observed therapy (DOT). In extreme cases when the child does not appear to be responding appropriately to the prescribed regimen, periodic measurement of plasma drug levels can help to determine the amount of drug ingested and whether it has been taken as prescribed. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Pharmacotherapy of Toddlers Toddlerhood is the age from 1 to 3 years. During this period a toddler displays a tremendous sense of curiosity. The child begins to explore, wants to try new things, and tends to place everything in the mouth. This becomes a major concern for medication and household product safety.. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers The nurse must be instrumental in teaching parents that poisons come in all shapes, sizes, and forms and include medicines, cosmetics, cleaning supplies, arts and crafts materials, plants, and food products that are improperly stored. Parents should be instructed to request child-resistant containers from the pharmacist and to store all medications in secure cabinets. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Toddlers can swallow liquids and may be able to chew solid medications. When prescription drugs are supplied as flavoured elixirs, it is important to stress that the child not be given access to the medication. Drugs must never be left at the bedside or within easy reach of the child. For a child who has access to a bottle of cherry- flavoured acetaminophen, the tasty liquid may produce a fatal overdose. About half of all poisonings reported to poison control centres occur in children younger than 6 years old. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Nurses should educate parents about the following means to protect their children from poisoning: – Read and carefully follow directions on the label before using drugs and household products. – Ask a healthcare provider (e.g., pharmacist, nurse, physician) if unsure of correct dosing. – Store all drugs and harmful agents out of the reach of children and in locked cabinets. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers – Keep all household products and drugs in their original containers. Never put chemicals in empty food or drink containers. – Always ask for medication to be placed in child-resistant containers. – Never tell children that medicine is candy. – Keep a bottle of syrup of ipecac in the home to induce vomiting. Do not give this medication unless instructed to do so by a healthcare provider. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers – Keep the number for the poison control centre near phones, and call immediately on suspicion of a poisoning. – Never leave medication unattended in a child’s room or in areas where the child plays. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Administration of medications to toddlers can be challenging for the nurse. At this stage, the child is rapidly developing increased motor ability and learning to assert independence but has extremely limited ability to reason or understand the relationship of medicines to health. Giving long, detailed explanations to the toddler will prolong the procedure and create additional anxiety. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Short, concrete explanations followed by immediate drug administration are best for this age group. Physical comfort in the form of touching, hugging, or verbal praise after medication administration is important. Oral medications that taste bad should be mixed with a vehicle such as jam, syrup, or fruit puree, if possible. The medication may be followed with a carbonated beverage or mint-flavoured candy. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Nurses should teach parents to avoid placing medicine in milk, orange juice, or cereals because the child may associate these healthy foods with bad-tasting medications. Pharmaceutical companies often formulate pediatric medicines in sweet syrups to increase the ease of medication administration. IM injections for toddlers may be given into the vastus lateralis muscle. IV injections may use scalp or feet veins; additional peripheral site options become available in late toddlerhood. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Toddlers Suppositories may be difficult to administer due to the resistance of the child. For any of these invasive administration procedures, having a parent in close proximity will usually reduce the toddler’s anxiety and increase cooperation. Ask the parent prior to the procedure if he or she would like to assist. The nurse should take at least one helper into the room to assist in restraining the toddler, if necessary. Lifespan Considerations in Pharmacotherapy Thank you…