1. Lifespan and Cultural Modifications
Chapter 5
Lifespan and Cultural Modifications
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

2. Patient Factors the May Affect Drug Action
U.S. Food and Drug Administration (FDA)
Establishes standards that require drug companies to provide consumers with specific drug information
Information printed on product package insert (PPI)
Information includes:
Description of therapeutic response
Side effects
Adverse effects
Possible drug interactions
What legislation gave authority to the U.S. Food and Drug Administration to establish specific standards for drug companies?
Many patient variables influence a drug’s action. These include body weight, age, illness, pregnancy and breastfeeding, genetics, cumulative drug effects, individual psychology, and dependence.
Although it is impossible to test a drug in every patient scenario, the FDA works to ensure extensive testing has been done to ensure patient safety.
The FDA has the authority to pull a medication that is correlated to increased adverse effects within the population.
Have you heard of any drugs the FDA has endorsed or pulled from the market recently?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

3. Special Considerations for the Pediatric Patient
Variables have a profound impact on drug action and effect
Neonates (less than 1 month of age)
Small body mass
Low body fat content
High body water volume
Increased membrane permeability
How would small body mass affect the action of a drug in the neonate?
How would low body fat content affect the action of a drug in the neonate?
How would high body water volume affect the action of a drug in the neonate?
How does increased membrane permeability affect the action of a drug in the neonate?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

4. Special Considerations for the Pediatric Patient (cont.)
Variables have a profound impact on drug absorption
No gastric acid present at birth
No intestinal bacteria or enzyme function present
Delayed gastrointestinal transit time
Immaturity of liver, kidney, and renal excretion systems
The immaturity of many body systems at birth affects the absorption of drugs in the neonate.
Between 1 and 24 months of age, a decrease in total body water, increase in body mass, decrease in membrane permeability, and changes in body fat produce less obvious changes in drug response.
As a result of a high metabolic rate and rapid turnover of body water, infants have greater fluid, calorie, and drug dosage requirements than adolescents.
As the organ systems mature, drug absorption, metabolism, and excretion is enhanced.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

5. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Absorption
Three principles in the pediatric patient
The physiologic status of the infant or child determines the blood flow at the site of intramuscular or subcutaneous drug administration.
Compared with older children and adults, premature infants have immature and unstable body processes.
A newborn’s skin, particularly in premature infants, has a greater ability to absorb some chemicals because of its greater hydration.
Many factors affect blood flow to IM and SC sites. In premature infants with little muscle mass, absorption in these sites is highly irregular. In older children, muscle size and circulation affects the rate of medication absorption. There is more rapid absorption from the deltoid muscle than from the vastus lateralis; absorption is slowest from the gluteal muscles.
The immaturity of body processes in premature infants and the variability in drug absorption increases the potential for adverse and toxic drug effects.
With some drugs used in pediatrics (e.g., anticonvulsants, cardiac glycosides), the difference between a helpful dose and a harmful or toxic dose is quite small. This is referred to as a narrow therapeutic margin.
Transdermal patches are generally contraindicated in the pediatric population because absorption is enhanced, increasing the risk of overmedication.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

6. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Distribution
Two factors
The chemical properties of the drug (do not vary)
The physiologic factors specific to the patient (do vary)
What are some of the variable factors we’ve discussed regarding the pediatric patient?
How would these factors influence drug distribution?
Do the chemical properties of a drug vary between brand names?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

7. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Metabolism
The majority of drug metabolism, or biotransformation, takes place in the liver.
In general, drug metabolism in infants is much slower than that in older children and adults.
Until 3 to 4 years of age, children have the ability to increase production of liver enzymes.
Neonates have a decreased ability to metabolize drugs.
Why can even Tylenol (acetaminophen) be toxic to an infant?
What does “slow clearance rate” mean?
What lab values reflect kidney function?
What does a medication’s “half-life” mean?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

8. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Excretion
Renal system may still be immature at birth
Decreased glomerular filtration
Decreased tubular secretion
Decreased tubular reabsorption
System still maturing over the first year of life
Drug clearance can be compromised
Sick infants requiring drugs such as penicillins, aminoglycosides, and digoxin must be monitored closely for drug toxicity. Drug dosages should be based on plasma drug levels.
The growth spurt and increase in adrenal steroid and sex hormones, male muscle mass, female body fat, and stability of body temperature affect adolescent drug response.
The variability in the pediatric patient’s response to drugs from infancy through adolescence increases the importance of assessing this population closely for drug sensitivity.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

9. Adverse Drug Reactions
Children are exposed to drugs directly and indirectly
Transplacentally during pregnancy or delivery
Direct administration
Through ingested breast milk
Infants and extremely ill children have a greater risk for drug interactions and adverse effects.
What are other ways children may be indirectly exposed to drugs?
Although the number of adverse drug reactions in children is unknown, studies have generally found the rate to be similar to that of adults.
Adverse drug reactions may have profound immediate, delayed, or long-term effects on a child’s neurologic and somatic development.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

10. Special Considerations for the Geriatric Patient
React differently to medications than younger adults
Drugs absorbed, metabolized, and excreted more slowly and less completely
Variability in drug response and clearance related to aging organ systems and overall health or illness
Patients age differently; body responses vary
As a person ages, variables that affect the absorption, distribution, metabolism, and excretion of medications increase.
The overall importance of changes in the absorption of drugs in aging patients is not completely clear.
The distribution of drugs may be delayed in geriatric patients. The lowest dose of a drug is administered initially, and then the dosage is increased gradually.
A decrease in liver mass, reduction in hepatic flow, change in nutritional status, and fluid overload secondary to disease processes may result in a decrease in the liver’s ability to metabolize medications.
Decreased renal function in the geriatric patient increases the incidence of adverse reactions to drugs.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

11. Geriatric Patient Teaching
Drug non-adherence related to:
Drug cost
Difficulty obtaining
Diminished cognitive abilities
Lack of desire to take on schedule
Depression
Feelings of being overwhelmed with physical needs
Physical disabilities requiring assistance to administer
Changes in the aging body’s ability to respond to and process medications, even OTC and vitamin products, makes monitoring the elderly patient for signs and symptoms of drug side effects and toxicity a vital part of nursing care.
Owing to multiple-drug regimens and the increased risk of drug interactions, thorough patient education that involves significant others in the home is essential.
What resources are available to assist the elderly with drug administration?
Is the geriatric patient able to understand the same information as a young adult?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

12. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Women’s Health Issues
Medications Used by Women
Females differ from males in hormonal make-up.
Medication needs often related to:
Urogenital tract infections
Menstruation
Infertility
Pregnancy
Menopause
Females may respond differently than males do to medications.
Medications used by females include antifungal agents, folic acid, iron, oral contraceptives, hormones, and fertility drugs.
An increasing number of healthcare providers specialize in women’s health issues.
As more studies are conducted using female subjects, more will be learned about the variables within this group. For example, hormone replacement therapy was once a standard in menopausal females. Now long-term hormone replacement therapy is contraindicated, because it increases the risk of stroke, heart attack, breast cancer, and possibly dementia.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

13. Special Considerations for Pregnant and Breastfeeding Women
Medications and Pregnancy
1961, thalidomide
Teratogenic = likely to cause fetal or embryonic damage or malformations
Few “safe” medications during pregnancy
Weigh benefit of drug for mother against risk to fetus
Greater precautions have been taken since 1961 when thalidomide, a drug given to pregnant women to control nausea and vomiting, caused severe fetal malformations.
Several drugs have been confirmed as teratogens.
Recent updates to the FDA’s requirements for drug labeling will soon be reflected in product packaging. The older system of five categories of drugs based on an agent’s known level of risk to the fetus and breastfed infants will be replaced by drug information that includes a Risk Summary, Clinical Considerations, and a Data section.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

14. Medications, Pregnancy, and Breastfeeding
Some medications cross the immature blood-brain barrier of the fetus
Some medications cross the placenta to the fetus
Some medications pass into breast milk to the baby during nursing
The critical period for morphologic, or structural, teratogenic effects in humans lasts from about 2 to 10 weeks after the last menstrual period. A woman may not realize she is pregnant during this time.
It is best if a female stops taking all medications before she becomes pregnant.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

15. Medications Used Throughout the Lifespan
Immunizations
Essential for personal and national protection
Factors related to delay in receiving
Healthcare provider belief of need to delay related to symptoms of mild illness
Parental refusal from concern over adverse effects
Failure to immunize a child places the whole community at risk.
Risk to the child of harm from the disease is greater than risk from the immunization for the disease.
To encourage people to receive immunizations, the U.S. Department of Health and Human Services created the National Vaccine Injury Compensation Program. This program provides payment to individuals or families of individuals who have been injured by childhood vaccinations.
Greater attention must be given to immunizing adults and geriatric patients against disease. Many adults require “booster” immunizations.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

16. Medications Used Throughout the Lifespan (cont.)
Antidiabetic agents
Antihypertensive agents
Cholesterol-lowering drugs
Smoking-cessation products
Weight-loss drugs
Antidepressant medications
Impotence drugs
Aspirin
Caffeine
A variety of medications are commonly used throughout the lifespan.
Diabetes, hypertension, and hypercholesterolemia are increasing in incidence in the United States. These conditions have been linked to an increased incidence of heart attack and stroke, so pharmacologic management may be an essential component of treatment.
Studies have proven that second-hand smoke is as harmful as smoking. Therefore, stop-smoking products have increased in popularity.
Weight-loss drugs, antidepressant medications, and impotence drugs have proved effective in treating the corresponding medical conditions.
Aspirin is considered a first-line medication in the treatment of heart attack.
Caffeine may lead to an increased risk for miscarriage.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

17. Cultural Influences Related to Medications
Cultural assessment includes determining
Values
Religion
Dietary practices
Family lines of authority
Family life patterns
Beliefs and practices related to health and illness
Cultural diversity has increased in the United States and should be respected.
Cultural influences affect a patient’s interpretation of symptoms, illness treatment, life, and death and are part of the patient’s support system.
Some cultural characteristics are obvious; others are subtle. Never make assumptions or stereotype a cultural group.
Many healthcare workers come from a minority culture.
Do not treat a patient in a way you would want to be treated. Rather, treat the patient in the way he or she would want to be treated.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

18. Cultural Influences Related to Medications (cont.)
Health disparity
Health literacy
There is health disparity or inequality in health care for many minority groups.
Often result in at-risk patients receiving less health care
Patients are often unable to read or understand information about plans of care or medications.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

19. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Genetics
Mapping of human genome and research on genes and DNA
Diseases can be passed down through families who carry certain genes
Topic of increasing interest to researchers
Research on individual races has concluded that African Americans are genetically the most heterogeneous (different) in their genetic profile.
In people from some areas of the world, there are an unusually high number of cases of certain diseases, such as the thalassemia found in those of Eastern European and Mediterranean backgrounds.
Hemophilia and sickle cell disease are other diseases that are the result of inherited traits in a family’s DNA.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

20. Why People Don’t Take Their Medications
Six major reasons for patient nonadherence
Medications are for prevention
Increases with prolonged therapy
Treatment requires significant changes in behavior
Poor patient understanding
Complexity of treatment plan
Unpleasant side effects
The six major reasons for patient nonadherence are listed on the screen. What are some suggestions for increasing patient adherence to preventive medications?
What teaching principles would assist with patient understanding?
What characteristics are essential for the healthcare worker to portray to be effective in teaching a patient?
What would you say to a patient to encourage him to take a medication that has unpleasant side effects?
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.