Pediatric Considerations

Considerations for the Adolescent Patient

Age-oriented developmental considerations include physical changes, cognitive level and abilities, emotional factors, and impact of chronic illness Sleep requirements and metabolic rates may greatly increase during the teen years, along with appetite and food consumption, which may affect the scheduling of and response to drugs.. Cognitive theorists have posited that adolescents progress from concrete to abstract reasoning.

Pediatric Age Classification

Classification Age Term neonate:Birth at 38 or more weeks' gestation to 27 days Infant/toddle: 28 days to 23 months Children:24 months to 11 years Adolescent:12 years to 16 or 18 years (regional difference)

When administering drugs to children, follow these basic principles:

honesty, respect, age-appropriate teaching and explanations, attention to safety, atraumatic care, use of the least amount of restraint necessary (e.g., swaddling a neonate), providing positive reinforcement for age-appropriate cooperation, refraining from use of negative messages or behaviors, and upholding family-centered principles. These standards may be used throughout the pediatric life span and highlight the need for nursing interventions that are sensitive, individualized, and caring

Pharmacokinetics

may be defined as the study of the time course of drug absorption, distribution, metabolism, and excretion.

Pharmacodynamics

refers to the mechanisms of action and effects of a drug on the body and includes the onset, peak, and duration of effect of a drug. It can also be described as the intensity and time course of therapeutic and adverse effects of drugs. The variables of pharmacokinetics—absorption, distribution, metabolism, and excretion—all affect the parameters of pharmacodynamics.

Injections

Injections should never be given to a sleeping child with the intent to surprise the child with a quick procedure. The child may subsequently experience a lack of trust and may be reluctant to sleep in the future.

Excretion

Renal excretion is the predominant means of drug elimination. The glomerular filtration rate (GFR) in term neonates is roughly 30% that of adults. During infancy, the GFR rises, and by 12 months, it reaches adult levels. Nurses must carefully monitor renal function, urine flow, and drug effectiveness to evaluate the impact of drug administration on patient status.

2. A child is ordered to receive naloxone intravenously STAT. The 189 child's weight is 20 kg, and the recommended child's dosage is 0.01 mg/kg. Naloxone is available in a 400 mcg/mL solution. How much drug will the nurse plan to administer?

0.5mL

3. A child who weighs 88 pounds is ordered to receive 3 mg/kg of a drug. The drug is available in a 15 mg/mL elixir. How much drug will the patient receive?

8mL

Principle of Atraumatic Care

Atraumatic care principles should be used when possible. Donna Wong's Principle of Atraumatic Care is "the philosophy of providing therapeutic care through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and families." Atraumatic care is achieved by decreasing the separation of children from their family members or caregivers, identifying family and patient stressors, decreasing pain, and providing care within the framework of a collaborative partnership.

Distribution

Drug distribution is affected by factors such as body fluid composition, body tissue composition, protein-binding capability, and effectiveness of various barriers to drug transport. In neonates and infants, the body is about 75% water, compared with 60% in adults. Until about age 2 years, the pediatric patient requires higher doses of water-soluble drugs to achieve therapeutic levels Neonates and infants have decreased protein concentrations compared with adults, and they have fewer protein receptor sites with an affinity for drug binding in the first 12 months after birth; this results in higher levels of unbound drug and an increased risk of drug toxicity. Bilirubin molecules may bind with protein receptor sites, which makes the sites unavailable to drugs or displaces drugs from binding sites, allowing large amounts of drug to remain free and available for effect.

Pediatric Drug Dosing and Monitoring

Drugs for pediatric patients are ordered based on either the child's weight in kilograms (mg/kg) or body surface area (BSA; or mg/m2 ). Body surface is based on a percentage of adult surface area (1.73 m2 ). Dosing must also consider the individual child's status, including age, organ function, health, and route of administration.

Metabolism

Infants have reduced hepatic blood flow and drug-metabolizing enzymes; however, by the time they reach 1 year of age, hepatic blood flow has reached that of an adult. Whereas drug-metabolizing enzymes reach an adult level at around age 11, it is important to understand that the isoenzymes involved in the cytochrome P450 system—CYP1, CYP2, and CYP3 —develop at different rates and demonstrate individual 176 variation.

Dosage Form Variability for Pediatric Age Groups

Neonates: 0-4 weeks ??? Infants: 1 month-2 years Liquids—small volumes (syrups, solutions) Children: 2-5 years Liquids; effervescent tablets dispersed in liquids; sprinkles on food Children: 6-11 years Solids (chewable tablets, orally disintegrating tablets, oral films) Adolescents: 12-18 years Solids (typical adult dosage forms—tablets, capsules)

n drug injection or venipuncture

When drug injection or venipuncture is necessary, topical anesthetic protocols may be followed to reduce the pain associated with the procedure. Agents such as eutectic mixture of local anesthetics (EMLA), topical liposomal 4% lidocaine cream (LMX4), or a vapocoolant spray may be effective in reducing the pain and fear associated with invasive procedures, such as injection or venipuncture, in children.

8. Which of the following strategies are helpful when working with adolescent patients to promote adherence? (Select all that apply.) a. Allow flexibility in the treatment plan. b. Use future-oriented examples and consequences to support the need for drug therapy. c. Guarantee the adolescent patient privacy when obtaining history. d. Set up a mutually developed drug contract.

a. Allow flexibility in the treatment plan. d. Set up a mutually developed drug contract.

6. A nurse caring for a child with developmental delay prepares to teach the patient about prescribed drugs. Which actions are essential to ensure patient safety? (Select all that apply.) a. Assess the child's developmental age. b. Assess for side effects the same as those experienced by adults. c. Consider the actions and uses of the drug. d. Focus on the child's chronologic age. e. Involve the family in teaching sessions.

a. Assess the child's developmental age. c. Consider the actions and uses of the drug. e. Involve the family in teaching sessions.

7. The Principle of Atraumatic Care includes (select all that apply): 190 a. Pain management b. Collaborative care with family members c. Restraining infants to administer drugs d. Keeping the child apart from family members when administering drugs

a. Pain management b. Collaborative care with family members

5. A parent is learning to administer drug to a school-age child. Which strategy will the nurse teach the parent to achieve cooperation in a child of this age? a. Enlisting physical restraint b. Establishing drug contracts c. Providing age-appropriate explanations d. Tolerating violent reactions

c. Providing age-appropriate explanations

4. The nurse understands the differences between drug excretion in children and that in adults. With this knowledge, what does the nurse consider when administering drugs to children? a. Most children need a higher dose of drug, so the nurse will contact the physician for an increase in the ordered dose. b. Children excrete drugs rapidly, so the nurse must assess carefully for therapeutic effects of the drug. c. The most important assessment is to evaluate for drug accumulation, because the excretion of drugs is slower in children. d. Excretion of most drugs is the same in children as in adults, but assessments are important to avoid side effects.

c. The most important assessment is to evaluate for drug accumulation, because the excretion of drugs is slower in children.

Pediatric Drug Administration

family-centered careis essential to ensuring safety during and after health care interventions, especially drug administration.Teaching is directed toward both family members or caregivers and patients, commensurate with the cognitive level of the child.

Preventing Drug Administration Errors in Pediatric Pharmacology

• Owing to developmental factors and smaller body size, infants and young children may receive drug dosages much different from those of adults. Careful calculations, double-checking math, and checking with another registered nurse can prevent errors in drug administration. • Ensure that families understand the units of measurement for a drug. Confusion may occur with the discussion of metric, household, and other measurement systems. • For safety when administering injectable drugs to children, use the smallest syringe that ensures the most exact measurement of the drug. • Use the correct drug and procedure to ensure safe dosing. Dilutions, different concentrations, and different solutions of a prescribed drug can complicate administration of appropriate pediatric dosages. • Infants and children may not be able to confirm identity, allergies, or drugs. The nurse must be positive of such information before drug administration. • Nurses must be vigilant for severe side effects or adverse reactions to drugs because information on pediatric drug response is limited. • Regulatory agencies caution that drug administration errors are more common in pediatric patients, which warrants increased precautions in drug administration.

The following are tips to enhance safe drug administration and facilitate comfort:

• Toddlers may react violently and negatively to drug administration. Simple explanations, a firm approach, and enlisting the imagination of a toddler through play may enhance success. • Preschoolers are fairly cooperative and respond well to ageappropriate explanations. Allowing some level of choice and control may facilitate success with preschool children. • School-age children, although often cooperative, may fear bodily 180 injury and should be permitted even more control, involvement in the process, and information. • Age-appropriate fears related to pain, changes in body image, and injury are prevalent among older school-age and adolescent patients. The nurse should establish a positive rapport with the patient, develop the plan of care in collaboration with the patient, and ensure privacy in all aspects of drug administration.