**7. Drug management in pediatric nursing**

Many drugs can be stored under room temperature (5-25°C). And some drugs need to be protected against sunlight. The list of drugs to be stored and not to be stored in refrigerator should be attached on the refrigerator in service. No IV drug including the diluted ones with more than 24-hour preservation period should be kept more than 24 hours. Preservation period for oral drugs explicitly written at the prospectuses are acceptable. If there is no period stated they are discharged after 30 days. That is why the first opening and discharge dates are always noted on the oral drugs (Çavuşoğlu, 2000).

Vital signs and clinical findings should be carefully evaluated. Therapeutic and toxic drug effects should be closely monitored. Kidney functions should be evaluated by monitoring the input-output liquid. The track of serum levels on drugs with limited therapeutic boundary should be ensured. The volume of the administered drug should be continuously monitored. With drugs requiring special safety measures those measures should be followed to the letter. The drugs which are not risky to administer on infants should be tagged with catchy titles and be kept away from the preparation area. One should be careful against potential side effects of the drugs which are underutilized and have limited reported experience on infants (Çetinkaya &Tengir, 2006). In terms of dose, some drugs are readjusted for infants by breaking the tablet, opening capsules, mixing with different liquids, or weighing the raw drug. Whether the drug was given at desired dose or if its bioavailability and microbial stabilities were variable cannot be determined when this method is used. Therefore, it is recommended not to resort to these methods unless otherwise is strictly required (Young & Mangum, 2010).

When a drug is administered the aim is to get the desired effects while keeping undesired ones at minimum. Pediatric nurse evaluates the response of the infant to drug and is the one to interfere if necessary. The knowledge of medication principles for newborns ensures a reliable drug administration (Çetinkaya &Tengir, 2006).

The following information should be obtained from parents before administering any drugs:


Drug effectiveness and the tolerance of infants can be determined by the help of these questions. Besides, infant's development level, the needle size and suitable gauge for injection, how and when infants should be prepared can also be found out.

To avoid mistakes and to ensure safe, reliable drug administration, the principle called "*eight corrects*" is of a significant importance:

Many drugs can be stored under room temperature (5-25°C). And some drugs need to be protected against sunlight. The list of drugs to be stored and not to be stored in refrigerator should be attached on the refrigerator in service. No IV drug including the diluted ones with more than 24-hour preservation period should be kept more than 24 hours. Preservation period for oral drugs explicitly written at the prospectuses are acceptable. If there is no period stated they are discharged after 30 days. That is why the first opening and discharge

Vital signs and clinical findings should be carefully evaluated. Therapeutic and toxic drug effects should be closely monitored. Kidney functions should be evaluated by monitoring the input-output liquid. The track of serum levels on drugs with limited therapeutic boundary should be ensured. The volume of the administered drug should be continuously monitored. With drugs requiring special safety measures those measures should be followed to the letter. The drugs which are not risky to administer on infants should be tagged with catchy titles and be kept away from the preparation area. One should be careful against potential side effects of the drugs which are underutilized and have limited reported experience on infants (Çetinkaya &Tengir, 2006). In terms of dose, some drugs are readjusted for infants by breaking the tablet, opening capsules, mixing with different liquids, or weighing the raw drug. Whether the drug was given at desired dose or if its bioavailability and microbial stabilities were variable cannot be determined when this method is used. Therefore, it is recommended not to resort to these methods unless otherwise is

When a drug is administered the aim is to get the desired effects while keeping undesired ones at minimum. Pediatric nurse evaluates the response of the infant to drug and is the one to interfere if necessary. The knowledge of medication principles for newborns ensures a

The following information should be obtained from parents before administering any

• What are the names, doses, schedules and taking reasons of previously administered

• If newborn is breastfed, it should be found that whether the mother uses any drug or

• Does the infant or family know the reason why the drug has been prescribed or what

Drug effectiveness and the tolerance of infants can be determined by the help of these questions. Besides, infant's development level, the needle size and suitable gauge for

To avoid mistakes and to ensure safe, reliable drug administration, the principle called

**7. Drug management in pediatric nursing** 

strictly required (Young & Mangum, 2010).

• Is the newborn allergic to any drugs?

"*eight corrects*" is of a significant importance:

drugs:

drugs?

not.

reliable drug administration (Çetinkaya &Tengir, 2006).

• How does the newborn response to drug treatment?

are its desired effects (as well as potential side effects)?

injection, how and when infants should be prepared can also be found out.

dates are always noted on the oral drugs (Çavuşoğlu, 2000).


Pediatric drug doses are calculated according to body weight and body surface. Body surface area of the infants in proportion to their weight is much larger than that of the children and adults. This is why the dose for infants calculated with body surface is much higher than that calculated with body weight. Therefore, during the premature term and infancy periods body surface area is not used for dose calculation purposes (Çetinkaya &Tengir, 2006).

Generally, pediatric drug doses are described as gram or milligram per kilogram of body weight. Safe dose amounts differ according to infant's age and his/her ability to metabolize the drug. Before any drug is administered the recommended dose is checked and rechecked whether it should have been calculated properly. So there should be a drug guide in each pediatric unit (Çetinkaya &Tengir, 2006).

Since the pediatric doses are relatively fewer than adult ones, any mistake in the amount may have serious consequences. The biggest responsibility in drug administration falls onto nurses. The nurse should be well aware of the pharmacokinetic and pharmacodynamic effects of the drugs in order to assess the clinical effects and risky conditions (Çetinkaya &Tengir, 2006).

The Administration and Dose of Most Frequently Used Drugs in Pediatrics 337

• Administration of wrong dose because of the resemblance between Adult Vitamin K (10

• Though not exactly a drug administration, vaccination at wrong doses through mistaking adult and infant versions of Diphtheria-Tetanus vaccine. Moreover, the administration of DTaP and Hib combination vaccine on inappropriate age groups in terms of their effectiveness on infants (although pentaxim or infanrix can be received under 1 year of age, combination vaccines, in general, has low effectiveness on such

• To confuse Vecuronium (1mg/ml) (preparation: 0.25 mg/0.25 ml) and Cisatracurium (2 mg/ml) (preparation: 0.5 mg/0.25 ml (Used for avoiding muscle paralysis. Sedation

In this sense, the physician requests should be re-checked, any questions in mind should be asked to physician and be well understood, and the medication should be carried out on time and be recorded appropriately; by this way, any medical or legal danger caused by the drug mistakes either by nurses or physicians can be avoided. Since the pediatric doses are relatively fewer than those for adults, any quantitative mistake may lead to serious

• Physical difficulty during the administration (handling small tablets, or unpacking drug

It is noteworthy again that the pediatric nurse to administer drug on patients should find out first that if the dose and route of the administration asked by physician is appropriate or not. The nurse should be careful for potential drug interactions. Infant's developmental characteristics affect the techniques and approaches used in drug administration. The infant and parents should be prepared besides with the drug. Attentive observation should be performed in and after the process. Observations about administration should be recorded. Patient should be kept well-monitored against undesired effects prior to administration. It is important to provide information and consultation services to the patient and/or family

In conclusion, any mistake in drug amount for infants may have serious consequences. Nurse should be well informed about the preparation and administration of the drugs. Nurse should know about his/her legal responsibilities that might require in the process, and the pharmacologic properties of drugs. Nurse should also know about the generic and commercial names of drugs, and remain utmost careful during the administration. Pediatric

nurses, in particular, should always update their knowledge about drugs.

mg/ml) and Neonatal Vitamin K (1 mg/0.5 ml) ampoules

The factors leading to inadequate adaptation to prescribed drugs:

• Not obtaining the prescription, or not having it at the pharmacy

• Repelling formulations (e.g. unpleasant taste) (Kayaalp, 2001).

• Occurrence of actual side effect, or the thought of side effects appearing

• To confuse Vancomycin and Heparin vials

effective) (Sauberan et al, 2010).

consequences (Çetinkaya &Tengir, 2006).

• Unclearness of the purpose regarding drug use • Surmising the ineffectiveness of the drug

• Unclearness of the instructions regarding drug intake

infants).

container)

about drugs.

For premature infants, newborns and early infants the immatureness of their body systems affects the drug administration. Among the factors accompanying toxicity of drugs are an immature enzyme system in the liver, decrease of the protein fields that drugs bind, and immature kidney system. Likewise, drugs leading to acid-base imbalance also affect toxicity. For example, overdose of salicylates can easily lead to metabolic acidosis in infants. The drug level in serum, its side effects and urinary excretion should be evaluated to avoid drug toxicity (Çetinkaya &Tengir, 2006).

The electrolyte - fluid balance is closely monitored during drug treatment. Newborns have limited ability to concentrate urine, so they should be provided with adequate liquid to discharge both drugs and metabolites. Dehydration may increase the drug toxicity risk. An immature blood - brain barrier also serves for drug toxicity. The immature myelination of the central nervous system increases the permeability of blood - brain barrier. The myelination forming this barrier is not fully mature until the infant is 2 years old. As the permeability of blood - brain barrier increases during the diseases like meningitis and brain tumor, side effects of the drugs administered into central nervous system should be monitored closely (Çetinkaya &Tengir, 2006).

The skin absorption rate of the topical drugs is significant. Infants have a thin layer of dermis and epidermis, hence their absorption rate would be greater compared to adults. Besides, greater body surface in proportion to weight is an important factor when drug is administered on wide skin surface. Infants, therefore, should be monitored for their sensitiveness to the drugs applied on skin surface (Çetinkaya &Tengir, 2006).

If the patients taking numerous drugs together yield different findings than the anticipated results in the light of laboratory findings, drug interactions should be taken into consideration. Some drugs affect the absorption of other drugs through the gastrointestinal system (GIS). This interaction or behavior results from changes in pH, changes in flora, and drug binding to intestine lumen. For example, antacids do not only cause intestinal pH to change; but also inactivate the drugs by binding to them (Çetinkaya &Tengir, 2006).

The period of drug use differs from 1 week to 5 weeks before any symptom appears; following the next dose the symptoms reappear instantly. Redness, fever, joint pain and inflammation, lymphadenopathy, eosinophilic leukopathy can be observed (Çetinkaya &Tengir, 2006).

*Drug Mistakes Caused by Nurse:* Administration of drugs prior to a non-official request, administration of drugs without a physician's request, administration of wrong drug because of misspelling or resemblance in appearance, miscalculation of drug dose or administration at wrong dose, inattention to information provided on the drug container or package, forgetting the administration (Çetinkaya &Tengir, 2006).

Medical mistakes have a potential of becoming 8 times more harmful at the newborn intensive care units. One of those mistakes is the administration of the similar drugs at different concentrations given in different doses, whereas other mistakes could be systemrelated.

These are the most common mistakes made on newborns regarding drug administration:


For premature infants, newborns and early infants the immatureness of their body systems affects the drug administration. Among the factors accompanying toxicity of drugs are an immature enzyme system in the liver, decrease of the protein fields that drugs bind, and immature kidney system. Likewise, drugs leading to acid-base imbalance also affect toxicity. For example, overdose of salicylates can easily lead to metabolic acidosis in infants. The drug level in serum, its side effects and urinary excretion should be evaluated to avoid drug

The electrolyte - fluid balance is closely monitored during drug treatment. Newborns have limited ability to concentrate urine, so they should be provided with adequate liquid to discharge both drugs and metabolites. Dehydration may increase the drug toxicity risk. An immature blood - brain barrier also serves for drug toxicity. The immature myelination of the central nervous system increases the permeability of blood - brain barrier. The myelination forming this barrier is not fully mature until the infant is 2 years old. As the permeability of blood - brain barrier increases during the diseases like meningitis and brain tumor, side effects of the drugs administered into central nervous system should be

The skin absorption rate of the topical drugs is significant. Infants have a thin layer of dermis and epidermis, hence their absorption rate would be greater compared to adults. Besides, greater body surface in proportion to weight is an important factor when drug is administered on wide skin surface. Infants, therefore, should be monitored for their

If the patients taking numerous drugs together yield different findings than the anticipated results in the light of laboratory findings, drug interactions should be taken into consideration. Some drugs affect the absorption of other drugs through the gastrointestinal system (GIS). This interaction or behavior results from changes in pH, changes in flora, and drug binding to intestine lumen. For example, antacids do not only cause intestinal pH to

The period of drug use differs from 1 week to 5 weeks before any symptom appears; following the next dose the symptoms reappear instantly. Redness, fever, joint pain and inflammation, lymphadenopathy, eosinophilic leukopathy can be observed (Çetinkaya

*Drug Mistakes Caused by Nurse:* Administration of drugs prior to a non-official request, administration of drugs without a physician's request, administration of wrong drug because of misspelling or resemblance in appearance, miscalculation of drug dose or administration at wrong dose, inattention to information provided on the drug container or

Medical mistakes have a potential of becoming 8 times more harmful at the newborn intensive care units. One of those mistakes is the administration of the similar drugs at different concentrations given in different doses, whereas other mistakes could be system-

These are the most common mistakes made on newborns regarding drug administration:

sensitiveness to the drugs applied on skin surface (Çetinkaya &Tengir, 2006).

change; but also inactivate the drugs by binding to them (Çetinkaya &Tengir, 2006).

package, forgetting the administration (Çetinkaya &Tengir, 2006).

toxicity (Çetinkaya &Tengir, 2006).

monitored closely (Çetinkaya &Tengir, 2006).

&Tengir, 2006).

related.


In this sense, the physician requests should be re-checked, any questions in mind should be asked to physician and be well understood, and the medication should be carried out on time and be recorded appropriately; by this way, any medical or legal danger caused by the drug mistakes either by nurses or physicians can be avoided. Since the pediatric doses are relatively fewer than those for adults, any quantitative mistake may lead to serious consequences (Çetinkaya &Tengir, 2006).

The factors leading to inadequate adaptation to prescribed drugs:


It is noteworthy again that the pediatric nurse to administer drug on patients should find out first that if the dose and route of the administration asked by physician is appropriate or not. The nurse should be careful for potential drug interactions. Infant's developmental characteristics affect the techniques and approaches used in drug administration. The infant and parents should be prepared besides with the drug. Attentive observation should be performed in and after the process. Observations about administration should be recorded. Patient should be kept well-monitored against undesired effects prior to administration. It is important to provide information and consultation services to the patient and/or family about drugs.

In conclusion, any mistake in drug amount for infants may have serious consequences. Nurse should be well informed about the preparation and administration of the drugs. Nurse should know about his/her legal responsibilities that might require in the process, and the pharmacologic properties of drugs. Nurse should also know about the generic and commercial names of drugs, and remain utmost careful during the administration. Pediatric nurses, in particular, should always update their knowledge about drugs.

The Administration and Dose of Most Frequently Used Drugs in Pediatrics 339

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c : Compatible (can be given together or can be mixed)

x : Incompatible ( cannot be mixed, cannot be administered consecutively through the same path) ? : Unknown

Table 1. Compatibility Chart of Some of the Most Frequently Used Drugs in Pediatrics (Katzung, 1998; Loeb, 1990; Trissel, 1992; Wong et al, 1992; Young & Magnum, 2008).

#### **8. References**

338 Complementary Pediatrics

c : Compatible (can be given together or can be mixed)

? : Unknown

x : Incompatible ( cannot be mixed, cannot be administered consecutively through the same path)

Table 1. Compatibility Chart of Some of the Most Frequently Used Drugs in Pediatrics (Katzung, 1998; Loeb, 1990; Trissel, 1992; Wong et al, 1992; Young & Magnum, 2008).


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