Adults and children are different in many ways. Although some drugs and administration routes are similar, the nursing management of drug therapy varies greatly.

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It is unethical to exclude children from drug studies and not to include child-specific prescribing information on labels for drug used in children.

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Almost all pediatric drug dosage are based on the weight of the child in kilograms. mg/kg= drug/weight

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body surface area

BSA= weight (kg) x height (cm)

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      3,600

The body surface area is the external surface of the body expressed in square meters. The ratio of body surface area to weight is inversely proportional to length; therefore the infant/young child who is shorter and weighs less than adult has relatively greater surface area.

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Using a nomogram is less accurate than using the formula to determine body surface area.

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A drug's mechanism of action is the same in all individuals at all ages. what distinguishes individual responses is the ability of the organ systems to function fully and appropriately..

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Because a child's age, growth, and maturation can affect ADME, dosages must often be lowered to account for immature or impaired body systems in neonates and infants.

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The infant's GI tract is acidic and thus has a higher pH than that of an adult. Moreover, a premature infant's immature GI tract secretes less acid than the full-term newborn's or older child's. As the GI tract matures, the gastric pH decreases and becomes more acidic, reaching adult values at 1 year of age.

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Route of administration also affects absorption. Drugs administered IM or SC are affected by age.

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There is an increased absorption of topical drugs is common in pediatric patients, especially infants because they have a greater body surface area. and the infant's skin exhibits greater permeability as well.

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Newborn 75%-85%

infant 85%

1 yr old 65%

2 yr old 60%

adult 50%-60%

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In the neonate and infant, more free drug is available because less drug is bound to plasma proteins, resulting in increased blood levels of drugs, which in turn can cause greater adverse effects and toxicity in infants.

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Besides more than one drug compete for binding sites in the pediatric body, other naturally occurring substances in body can also compete for fewer binding sites.

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Infants experience exaggerated CNS reponses to other drugs targeted for other body system.

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The immaturity of the neonatal and infant liver results in decreased or incomplete metabolism of many drugs, which may necessitate lower drug dosages or an increased interval between doses to achieve appropriate blood levels.

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In children with liver disease, drug metabolism is further complicated by the liver's inability to detoxify drugs. A child with an immature live or compromised liver function is at risk for drug toxicity.

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Drugs requiring oxidation for metabolism are frequently more rapidly metabolized in children than in adults because children have a faster resting respiratory rate. These types of drugs, children may require higher dosages or more frequent adminstration schedules than adults do to maintain therapeutic blood levels

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Most drugs are eliminated from the body through the urine. Drug elimination requires a functioning renal system, and its effectiveness depends on glomerular filtration rate, tubular reabsorption, and maturity of the renal system.

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The neonate, especially the preterm infant, has immature  kidneys, and renal excretion of drugs is slow.

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Drugs with a narrow margin between effective and toxic dose must be administered at longer dosage intervals to prevent toxicity. At about 3 months of age, the infant's kidneys can concentrate urine at the adult level, but urinary excretion remains low until the child is about 30 months old, when the kidneys become functinally mature.

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A few drugs are excreted through the biliary tree into the intestinal tract. Biliary blodd flow is decreased during the first few days of life, during which careful monitoring of drug levels and signs and sysptoms of toxicity is imperative.

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Approximately 3.5 of the adverse effects accounted for half of the reported deaths in children. About one fourth of the tatal adverse effects reported were related to exposure from the mother during pregnancy, delivery, or lactation.

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Some adverse effects on body systems occur only at specific phases of development. i.e. teracycline administered to a child between the ages of 4 mos. and 8 yrs, stain the permanent teeth. Glucocorticoids to a child of any age will suppress growth if the child has not matured to full adult size

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Diarrhea decreases intestinal transit time and therefore decreases the time available for drug absorption.

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Drugs may be administered IV to infant through a peripheral site. In the neonate and infant, the scalp's many superficial veins offer easy access i.e. the superficial temporal vein, nondominant hand, forearm, upper arm, feet, and antecubital fossa.

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Scalp veins are appropriate for children upto 18 mos.

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One of the adverse effects in pediatric drug aministration is psychological distress in the child or parent. The nurse who uses knoledge of age-related emotional needs and communication techniques can greatly help relieve this emotional distress and enhance compliance with drug therapy.

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Nursing management of drug therapy for pregnant women is challenging for several reasons. 1) nursing care is needed for both the patient and the fetus because most drugs pass through the placental membrane or through breast milk. 2) during pregnancy physiologic changes occur and may alter the patient's response to a drug.

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Pharmacotherapeutics are no different in a prgnant woman than in a woman who is not pregnant. The important consideration in drug therapy for prgnant women is the potential  adverse effects on the fetus.

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Progesterone increases respiratory tidal volume by 30-40%, with a 50% increase in minute volume, enhancing the absorption of drugs that are inhaled.

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Plasma lipid levels increase throughout pregnancy as a result of the more levels increase throughout pregnancy as a result of the more complete absorption and decreased elimination of fats during pregnancy.

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Drugs that are lipophilic (fat soluble) and not bound to protein pass easily through the placenta's lipid membrane.

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Drugs that are widely distributed throughout the mother's body are usually minimally passed into breast milk, producing low drug concntrations in breast milk.

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Drugs with increased lipd solubility and low protein binding (CNS agents), pass more easily and may produce high drug concentrations in breast milk, because breast milk contains a high percentage of fat.

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Low molecular wights and those with organic bases may become "trapped" in breast milk because of its low pH, PRODUCING HIGH DRUG CONCENTRATION.

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By third trimester, an increase in renal plama flow cause greater capillary pressures, requiring an increase in filtration by 50% and contributes to increased excretion rates. Therfore, drug excretion rates may be increased during pregnancy.

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Two dramatich physical change occur during pregnancy: 32 wks gestation cardiac output increased to 50%; and 2nd trimester on, arterial blood pressure is decreased. These condition necessitate careful evaluation of a drugs pharmacodynamics.

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A review of all drugs approved in US found that the teratogenic risk in human pregnancy was still undeterminded for more than 90% of those drugs.

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A drug is traditionally identified as a teratogen based on the finding of animal teratology studies. and are problematic because animal models. Non human primates are good predictors of human teratogenicity because they are the most genetically similar to humans. but rarely use because expense--rodents are usually used.

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The ultimate assessment of drug safety during pregnancy, unfortunately, comes from the use of the drugs in humans. The use of Pregnancy Registries to find out info on their experience in using chronic or acute medication.

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All contraindicated drugs have been reported to cause signs and symptoms in the infant or produce and adverse effect with lactation. Academy of pediactrics states that this list of medication is not complete.

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The two major considerations when evaluating adverse effedts od drug therapy in prgnant women are common side effects of pregnancy and the adverse effect that maternal drug therapy can have on the fetus.symptoms like nausea, vomiting, hypotension fatigue, heart palpatations may mask the adverse effects making it more difficult to assess.

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The minimum therapeutic dose should be used for as short a time as possible during pregnancy. Or delayed until after the first trimester.

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There is a decline in general organ and system function with normal aging.

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___ is defined as a person who is 65 yrs of age or older.

young-old (65-74); middle-old (75-84), and old-old (85-older)

Because GI motility decreases in older adults, substances move faster through the GI tract.

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-decreased body mass

-reduced levels of plasma albumin

-less effective blood-brain barrier

-fat increases

-body water decreases

-fat to lean muscle mass

Amounts of plasma alpha-1 acid glycoproteins, which principally bind and transport alkaline-basedd drugs, are not depressed in older adults

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1)liver size; 50% decrease metabolicc active hepatocytes

2)Cardiac output declines as well as blood flow to the liver; less bloodborne oxygen available, liver's capacity to remove many by-products is reduced

3) the overal ability of the liver to metabolize drugs and other chemicals is reduced.

Aging affects the efficiency of both phases of metabolic activity but tends to alter phase I more than it alters phase II reactions.

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-glomerular filtration

-renal tubular secretion

Nonadherence does not always mean that the patient directly refuses to follow drug therapy schedule, it may indicate that the patient cannot adhere to drug course for various reasons.

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__ occurs when actual changes in body cells, secondary to tolerance, cause the body to "need" drug for homeostasis. without--withdrawl syndrome.

heroin, morhine, alcohol, benxo, barbs, nicotine, and caffeine

Physical dependence alone does not define addiction. a pt may be physically dependent on a drug without showing behavior patterns associated with addiction.

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