Pediatric Drug Calculations

Drug dosages differ greatly from adults because of physiologic differences Neonates and infants have immature kidney and liver function-delays metabolism and elimination of many drugs Decreases drug absorption- neonates have delayed gastric emptying, children younger than 3 years old has decreased gastric secretions

 Have lower concentration of plasma proteins can cause toxicity with highly protein bound drugs Young children have less total body fat and more body water All injections must be given in a manner that minimizes physical and psychosocial trauma

Frieds Rule
applies to children younger than 1 year of age

Childs dose (age <1 yr) = infants age (in months) x average adult dose 150 months

Youngs Rule
for children 1 to 12 years of age

Childs dose (1- 12 yrs) = childs age (in years) x average adult dose Childs age (in yrs) + 12

Clarks Rule
uses the childs weight to calculate and assumes that the adult dose is based on a 150 lb person

Childs dose =weight of child ( in pounds) x average adult dose 150

Paediatric Guidelines for IM injections According to Muscle Group

Amount by Muscle Group (ml) AGE Birth to 4months Infants Toodlers Preschool and older children Adolescents Vastus lateralis 0.5-1 0.5-1 0.5-2 2 Gluteus Maximus Not safe Not safe 0.5-1 0.5-2 Ventrogluteal 0.5-1 1 0.5-1 2-3 Deltoid Not safe Not safe 0.5-1 0.5-1

2-5

1-1.5

TEMPERATURE CONVERSION
Fahrenheit to Celsius

C= F- 32
1.8

C = F-32 x 5
9

 Celsius to Fahrenheit

F= 1.8 C +32

F= [(C x9)/ 5] + 32

LIFE SPAN CONSIDERATIONS

Beginning to end of life body changes in many ways Changes that have an effect on the four phases of drug action

Drug Therapy during Pregnancy

A fetus is exposed to many of the same substances as the mother, including any drugs that she takes. First trimester period of greatest danger of drug induced developmental defects. The FDA classifies drugs according to their safety for use during pregnancy

FDA Pregnancy Categories

Category A no risk to fetus Category B little or no risk Category C animal studies shows risk to fetus Category D risk to human fetus has been proven; may be used in lifethreatening conditions Category X avoid during pregnancy due to proven risk to human fetu

Neonatal and Pediatric Patients

CLASSIFIACTION OF YOUNG PATIENTS AGE RANGE Younger than 38 week gestation Younger than 1 month 1 month to younger than 1 year 1 year to younger the 12 y/o CLASSIFICATION Premature or preterm infant Neonate or newborn infant Infant child

Absorption
Gastric ph is less acidic because acidproducing cells in the stomach are immature until approximately 1-2 years of age. Gastric emptying is slowed because of slow or irregular peristalsis First pass elimination by the liver is reduced because of the immaturity of the liver and reduced level of microsomal enzymes Intramuscular absorption is faster and irregular

Distribution
Total body water is 70% to 80% in full term infants, 85% in premature NBs, 64% in children 1-2 years Fat content is lower in young patients because of greater total body water Protein binding is decreased More drugs enter the brain because of immature blood brain barrier

Metabolism
Levels of microsomal enzymes are metabolism because the immature liver has not yet producing enough Older children may have increased and require higher dosages once hepatic enzymes are produced

Excretion
GFR and tubular secretion and reabsorption are all decreased in young patients because of kidney immaturity Perfusion to the kidneys may be decreased and result in reduced renal function, concentrating ability, and excretion of drugs NB : Strictly follow the guidelines for Pediatric dosage calculations

The Elderly Patients

PHYSIOLOGIC CHANGES
SYSTEM Cardiovascular PHYSIOLOGIC CHANGE
Dec. CO = Dec. Absorption and Dist. Dec. Blood flow=Dec. Absorption and Dist. Increased PH = altered absorption Decreased peristalsis =dec. Gastric emptying

Gastrointestinal

Hepatic Renal

Decreased enzyme and blood flow =decreased metabolism Decreased blood flow, function, and GFR =dec. excretion

Absorption
Gastric PH is less acidic because of gradual reduction in the production of HCL acid in the stomach Gastric emptying is slowed because of a decline in smooth muscle tone and motor activity Movement throughout the GIT is slower Blood flow to the GIT is reduced by 40%decreased CO and Perfusion Absorptive surface area is decreased because the aging process blunts and flattens villi

Distribution
40 to 60 y/o, total body water is 55% in males, 47% in females, over 60 y/o, total body water 52% in male, 46 in females Fat content is increased because of decreased lean body mass Protein binding sites are reduced because of decreased production of proteins by the aging liver and reduced protein intake

Metabolism
The levels of microsomal enzymes are decreased because the capacity of the aging liver to produce them is reduced Liver blood flow is reduced by approximately 1.5% per year after 25 years of age, which decreases hepatic metabolism

Excretion
GFR is decreased by 40% to 50% primarily because of decrease blood flow The number of intact nephrons is decreased

MEDICATION ERRORS

Medication error
defined as any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

Types of Medication Errors

Common types of medication errors include:
Administering the wrong dosage Prescribing the wrong dosage Prescribing the wrong medication all together Prescribing medication that cannot safely be mixed with other medications the patient is currently taking Failing to check a patients medical history to determine whether or not the patient can safely consume the drug Dispensing the wrong medication Including the wrong dosage instructions on the prescription bottle

Contributing factors Miscommunication Look-alike medication names Confusion of generic and brand names Major causes of error: Distractions and interruptions during administration Illegible written orders Incorrect dosage calculations Similar drug names and packaging

Examples of Errors
Prescribing: Illegible handwriting or unclear orders Non-compliance with order-writing guidelines Wrong order form used Therapeutically incorrect orders Decimal point errors Documenting -Improper therapeutic screening of order at time of taking order off by nursing or pharmacy (dose, allergy check) Incorrect/incomplete transcription of order on MAR or Kardex Not transcribed onto MAR or Kardex Pharmacy transcription error Incorrect documentation of medication administered

 Incorrectly dispensed/reconstituted/labeled by pharmacy Incorrectly diluted/reconstituted/labeled by nursing Administration -Misread orders/MAR/Kardex/label Forgot to give Incorrect pump setting/drip rate Gave to wrong patient Incorrect dose calculation Incorrect administration Equipment/device/tubing problem (e.g., tubing disconnects, tubing clamped) Monitoring -Improper monitoring of drug effect (e.g., narcotic administered to patient with low RR

Reporting and Responding to Medication Errors

Checking the patient by assessing all relevant parameters and documenting accordingly Assessing patient for effects of the drugs and consulting reference materials and colleagues as needed. Performing medication reconciliation to verify all of the patients correct medications at each point of care

 Regularly asking the patient to verify his or her identity and date of birth Completing ME reporting forms after contacting the health care team. Monitoring the progress of patients condition regularly Thinking and acting critically and modifying nursing practice to prevent further errors

Medication Reconciliation
A procedure that seeks to prevent medication errors through the ongoing assessment and updating of every patients list of medications throughout the health care process and the timely communication of such information to both patients and health care team. Involves three steps

1. VERIFICATI ON - Collection of patients medication information with a focus on medications currently used ( Prescription and OTC) 2. Clarification - Professional review of this information to ensure that medications and dosages are appropriate for the patient

3. RECONCILIATION - Further investigation of any discrepancies and documentation of relevant communications and changes in medication orders. To ensure ongoing accuracy of medication use, these steps should be repeated at each stage of health care delivery: 1. Admission
2. Status Change ( Critical to stable) 3. Patient Transfer 4. Discharge

Nursing Measures to Prevent Medication Errors

Minimize the use of verbal and telephone orders List the indication next to drug order on the medication record Avoid use abbreviations, medical shorthand, and acronyms Never assume anything about any drug order or prescription including route

 If a medication order is questioned for any reason, never assume that the prescriber is always correct. Always act as patients advocate. Do not try to decipher illegibly written orders If in doubt of the correctness of the order, double check with the prescriber Compare the medication order against what is on hand Never use trailing zeros

Other measures....
Carefully read all labels for accuracy, expiration dates, and dilution requirements Be familiar with techniques of administration Encourage the use of both trade and generic name in drug orders Always double check a medication products labeling

 Always verify new medication administration records if they have been rewritten or re entered for any reason

Client Education for Medication Usage

Find out what drug you're taking and what it's for. Rather than simply letting the doctor write you a prescription and send you on your way, be sure to ask the name of the drug. Find out how to take the drug and make sure you understand the directions Keep a list of all medications, including OTC drugs, as well as dietary supplements, medicinal herbs, and other substances you take for health reasons, and report it to your health care providers.