Medication Prescribing Guidelines for Children

Introduction:

The present essay is based on a case scenario of a six year old boy named Alfie which is a pseudonym assigned as per the guidelines the General Data Protection Rule (GDPR, 2018) who got admitted to the surgery department of healthcare organisation with symptomatic manifestations of tonsillitis. To alleviate his sufferings he was admitted for the surgical procedures of tonsillectomy. Therefore, the present assignment will be divided into two parts where the first part or Section A will detail about the process associated with non medical prescription along with the medication prescribing guidelines for the health care practitioners or professionals for the children which will involve the issues related to the administration of the convert group of medications. The next part or the Section B of the assignment will discuss about the recommended dosage, appropriate route of administration, the Absorption, Distribution, Metabolism, And Excretion (ADME) and the associated contraindications of the drug “ibuprofen” in the light of the above mentioned case scenario. It will further highlight about the calculations involved while administering the required dosage of specific volume, the sub therapeutic dosage, the half life of the drug and the range for the therapeutic application along with the associated prospected toxicity.

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A Case Study:

The case study detailed about the six year old children, Alfie which is a pseudonym assigned as per the guidelines the General Data Protection Rule (GDPR, 2018) and his body weight was found to be 22 Kg. He got admitted to the surgery department of healthcare organisation with symptomatic manifestations of tonsillitis. To alleviate his sufferings the physicians advised him to get admitted for performing the surgical procedures of tonsillectomy.

Pre Medical History and Background:

According to his past medical background it was evident that he had suffered due to frequent relapse infection of streptococcal tonsillitis, however the other medical notes were nothing to be mentioned as such with respect to the clinical point of view. As evident from the past medical history, that was Alfie first admission at healthcare clinic for any medical procedures to be done. He was staying alone as his mother could not stay with him as she was having another three year old baby.

Recent Medical Records:

The vital signs of Alfie was checked and recorded after admission to the hospital. The heart rate of Alfie was recorded to be 130 beats/ minute, the respiratory rate (RR) was 29 breaths / minute and his blood pressure was 115mmHg systolic 60mmHg diastolic. He also reported about the soaring of his throat and he was feeling thirsty all the time. However, he was also very unwilling to drink any fluid. The healthcare professional assessed his pain score utilizing the Wong and Baker Faces Pain Rating Scale (1988) where he scored 8 within 10.

Medical Assessment:

Alfie was prescribed by the physicians with the oral medications paracetamol and ibuprofen, though he was very reluctant to intake the medication ibuprofen in the absence of his mother.

Accurate Procedure for the prescription of Medications:

The term “medication management” was formulated by the United Kingdom Medicines and Healthcare Products Regulatory Agencies (MHRA) which means the accompanying -

“The clinical, cost-effective and safe use of medicines to ensure patients gets the maximum benefit from the medicines they need, while at the same time minimising potential harm”

Furthermore, as per the variant of the National Prescribing Centre, 2002 it is characterized as the preparation of the medication by utilizing an arrangement of strategies and practices which confirms that how a medication should be overseen by the NHS and the patients. In addition to this, there is an immense role played by the healthcare practitioners with regard to the prescription of the drugs (BRADY, et al, 2009).

The following roles that must be played by the HCPs with regard to accurate prescribing of medications:

vThe HCP must be enrolled within a healthcare or medical facility providing services or organisations

The prescription of the drug has to be conducted within the overall route of the routine service carried within a healthcare centre only by an employed or the registered HCP.

The prescribed drug must be generated only within the usual track of terms that are enlisted by the medical clinic setting (BRADY, et al, 2009; Choo, et al, 2010).

According to the reports of ABA, 2000 the HCPs should ensure the following “five rights of delegation” which is crucial for the correct prescribing of the medication namely: the right individual; right assignment; right situations; right orientation and correspondences along with right form of monitoring and assessment.

McGill, 2006 highlighted that in light of the proof of the best practice the arrangement and the prescribing of the medicine should be finished by that specific HCP only. They should likewise hold the responsibility of the organization of the prescription managed and must not request the observing of their work by some other associates. Moreover, twofold checking or repeated checking of the prescriptions is obligatory if there should arise an occurrence of utilization of medicine of “high alertness” (Hemingway, 2014). It altogether lessens drug blunders and guarantees great simultaneously safe management of the medicines. The HCP must take the accountability of the prescriptions made and they must be able to give adequate justification for their decision if required (ABA, 2005). According to the guidelines of the Good Medical Practice they must possess knowledge about their restraints and should be up to date with regard to their skills and knowledge and competencies for the purpose of prescribing and management of medication. In case of any doubts concerning prescription the drug, the HCP must interact with their senior colleagues along with that they must be aware about the guidelines of the British National Formulary (BNF) and British National Formulary for Children (BNFC) (Dickens, et al., 2006). Another important aspect of correct prescription is that HCP must be aware about what they are prescribing and how it would assist the patients in alleviating their symptoms along with their contraindications. Detailed history of the patient concerned must be documented before prescriptions and the opinion and beliefs of the patient must be addressed and honoured in accordance to the patient centred care approach by the NMC code, 2018. The patient or their carers must be educated everything about the treatment procedures and the associated side effects. In case of shared decision making approach with any colleague for prescribing medications, the judgement must be taken in accordance to the best fitting interest of the patient concerned (Bulechek, et al., 1999; Otero, et al., 2014). If the prescribing has to be done via online or telephonic assessment then the HCP must be totally ensured about the health details of the patient and the consent of the patient must be obtained prior to prescribing as per the guidelines. The HCP must be very cautious about the prescription of any “unlicensed drugs” as they are only allowed to do so in certain cases of psychiatry, paediatrics and palliative care but only with accurate justifications (Deans, 2005). In case of Alfie, the prescribing guideline of BNFC was taken into consideration.

Valentine, et al., 2015 highlighted that the aspect of “convert medication” is when drugs are regulated within a hidden arrangement. The drugs could be covered up via food, drink or through a tube feeding without the information or assent of the individual patient accepting them. The aspect of medication prescribing by the HCPs is considered to be extremely crucial for the children as they should exhibit the effective expertise of the aspects of management of medication and estimation of accurate portion of the medication at the time of prescribing or administering. The HCPs should screen the reaction of the youngsters with regard to the endorsed medicines; taking crucial care or dealing with the hazard related, for example, the “human errors” during prescribing. They should function as a group with the kids and their families or carers for giving compelling consideration (Manias, 2015).

The pharmacology of the drug ibuprofen:

The medication ibuprofen is considered to be the first categorization of the derivatives of propionic acid and mechanistically a Non Steroidal Anti-Inflammatory Drug (NSAID). The drug is administered or prescribed to patients for alleviating their symptomatic manifestations of fever, pain and inflammation. According to the spontaneous adverse drug reaction reporting system the drug ibuprofen is considered to be a safe drug (Manias, 2004).

The action mechanism of the drug is that it acts by the strategy of non selective inhibition of Cyclo-Oxygenase-1 (COX-1) and Cyclooxygenase-2 (COX-2). These two enzymes often referred as Prostaglandin-Endoperoxide Synthase (PTGS) are involved within our physiological system for the production of prostaglandins. The drug is considered because of its sound antipyretic and analgesic functioning (Kaufman, et al., 2010). Moreover, NHS, England had set the guidelines for the prescription of drug ibuprofen with regard to the dosage and strength based on the age of the patient. Therefore, it is advisable that the HCP must go through the required guidelines carefully before prescribing such as the drug should never be administered at empty stomach as it may upset the stomach of the child. So the best time to prescribe the drug for the child patient is with or immediately after the meal. According to the NHS, England the drug ibuprofen can be prescribed for sub therapeutic dosage of 200mg per dosage for the maximum limit of three times per day for the children within the age group of children of 7 to 9 years. The child patient Alfie was about six year old therefore, he was prescribed with dosage according to the guidelines of NHS. For children aged in between 10 – 11 years, it is advisable with sub therapeutic dosage of 200-300 mg of doses whereas for the age group of 12 – 17 years, sub therapeutic dosage of 200 – 400mg of doses of the medication can be prescribed for a maximum limit of three times within a day as per NHS guidelines. There should be at least a gap of six hours in between the two doses (Ngo, 2010). With regard to the form of prescription the drug can be prescribed in the forms of extended release tablets, syrup for children either once or twice daily or as covert medication along with milk or food every day by the physician. However, again according to NHS, England if the drug is administered in the form of syrup then the bottle has to be shaken well before administering to mix the contents well and it is advised to feed the child with the aid of spoon or syringe for the right amount of medication. For Alfie, the drug was administered in the form of convert medication as he was not willing to take the drug via direct administration orally. It will be also helpful as it would hinder or prevent the stomach upset of the child patient. To administer the drug as covert medication, it was applied in the form of granules that was stirred with little portion of the food such as yoghurt or any liquid, however caution should be applied that the drug should not be administered with hot food or liquid. The HCP must take into consideration while administering the medication to the child Alfie that he should swallow the food or drink right away without chewing. The whole amount of the food should be eaten by the child at that particular time only as the food with the drug mixed up could not be left for later. Another important preventive aspect that the HCPs musts practice while administering the medication is that they should never administer the drug ibuprofen with other pain killer such as paracetamol in this case scenario. Both the drug should be given at different timings. They must also consider that while prescribing the drug if the patient had fever even though after the administration of ibuprofen, for the next time paracetamol should be prescribed instead as per the NHS practice guidelines (Rainsford, 2011).

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After the administration of the drug ibuprofen, the highest concentration of the medication is accomplished within the serum inside 1-2 hours. It is also evident that the patient should feel better after 20 – 30 minutes of the intake of the drug ibuprofen. The medication is not soluble in water with PKa estimation of 5.3 (Vinks, 2015).The medication is quickly changed in the body with a serum half life of 1.8-2 hours and the whole medication (approximately 90%) is disposed of from the body inside 24 hours after the last up taking of the medication through the urine. Nearly 99% of the drug stays within the plasma as bound to protein. The maximum part of digestion of the medication happens within the hepatic system and the little segment that gets discharged from our system stays unaltered. The medication can be given to the patient in the fasting conditions or before having meals which will yield a similar concentration within serum inside a similar time period. However, in the event that the medication is managed after supper, there is a decrease observed with regard to the pace of assimilation of the drug. The entirety of the above data should be precisely recorded according to the nearby health administration rules. It is the part of the duty of the HCPs to train the patient and their family members about the employments of the medications in a far reaching way to avoid any medication error, if the medication is self administered by the patient (Vinks, 2015). Data in regards to the action mechanism or pathway of the drugs, the conceivable symptoms, indicative highlights of the unfriendly responses of the drugs, the conceivable collaboration of the prescriptions with different medications and with the food consumption, the guidelines and the insurances to follow in regards to the course, time, and method of organization of the drugs, the significance behind sticking to the endorse treatment and detailing after the customary follow up are the piece of HCP's job as per the NMC guidelines of the management of medication. The health care professionals should examine about retention the medication which has demonstrated any unfriendly responses for the patient or if the patient is reluctant to take the medication with the concerned physician as in the case of patient Alfie (Bushra, et al, 2010).

It is advisable to check the sensitivity or the allergy status of the patient to the drug before prescribing ibuprofen. Alfie was found to be not sensitive or allergic to the drug therefore prescribed with ibuprofen. The reported toxicity of the drug ibuprofen among children are discomfort observed within the gastric system, tendency to vomit, rash due to allergy caused by medications, inflammation of the face, throat and even arms due to retention of fluid and reduced hunger and retching. This drug should not be prescribed for patients associated with other co morbidities such as any allergy induced reactions after the intake of drug aspirin, asthma and urticaria. Some few scientific articles are there on the contraindications of the drug ibuprofen within the range of dosage 1200 mg to 2400 mg every day related to expanded risk of cardiovascular problems. As Alfie did not report to have any pre medical records of cardiovascular, cerebrovascular and renal problems therefore, the medicine was safely administered to him. However, it must be taken into care by the HCP that after the administration of the drug, the child is suffering from any pain within the stomach, vomiting blood or blood passing through urine, stool is dark in colour or not and also if the child reports ringing within the ear. These symptomatic indications may point towards some severe forms of diseases such as gastric bleeding, ulcer, CV thrombotic events, Intraventricular haemorrhage, infection of the respiratory passage, hypoglycaemia and hypocalcaemia. Moreover, based on the report or findings of clinical trials the therapeutic range of ibuprofen was found to be at the most within 3200 mg/day to 2400 mg of ibuprofen.

Calculation of the accurate doses of the prescribed medications with the use of mathematical skills:

As evident from the scientific evidences of several authors, the HCPs should have solid capacity of the numerical estimations as off-base computation of the medication portion can prompt potential clinical blunders. In addition to this it is also evident that with the prescription or administration of over the dose of ibuprofen may bring about tipsiness, quick development of the eye, slower pace of breathing and bluishness of the lips, mouth and nose. Along these lines, to maintain a strategic distance from any drug mistakes the dosage of the drug must be managed at the perfect amount with the aid of mathematical calculations. During this time the numerical count capacity of the medical caretakers assumes the job as the portion must be titrated against the reaction. As indicated by the rules of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) any health care professional must not be incredibly reliant on the adding machines at the time of preparations of the dosage of medications (Haigh, et al, 2002; Wright, et al, 2005; Saville, et al, 2001).

For instance the calculations of the dosage of the drug can be made by using the formula:

For the volume calculation for dosage administration via injection:

Prescription for the patient x stock volume (in mL) = given volume (mL)

Stock strength Available

For the calculation of the dosage based on the weight or mass of the patient (Single dose):

Dosage to be administered = prescribed x weight of the patient

Calculations based on body mass based on Total Daily Dose (TDD)

Now and then the portion of a medication is composed as a Total Daily Dose (TDD) generally given in 3 or 4 partitioned dosages.

It is significant that the HCP must notice the distinction between a TDD and a solitary dosage (McQueen, et al., 2010).

The medicine was calculated based on the body weight of Alfie which is 22 Kg.

Conclusion:

The assignment critically discussed the role of healthcare professionals with regard to correct prescription or administration of medications. Depending on the case scenario of Alfie, the activities of the nurses with regard to administration of medications to children and the aspect of convert medication had also been analysed. The second part of the essay dealt with the pharmacology and pharmacokinetics of drug ibuprofen, the correct dosage calculation, half life of the drug, the varied routes for application of the drug along with the associated contra indications were discussed.

References:

ABA, A.B.A., 2000. Review of scope of practice for nursing and midwifery: final report/An Bord Altranais. -3663.

BRADY, A.M., MALONE, A.M. and Fleming, S., 2009. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management, 17(6), pp.679-697.

Choo, J., Hutchinson, A. and Bucknall, T., 2010. Nurses' role in medication safety. Journal of nursing management, 18(7), pp.853-861.

McGill, P., Papachristoforou, E. and Cooper, V., 2006. Support for family carers of children and young people with developmental disabilities and challenging behaviour. Child: Care, Health and Development, 32(2), pp.159-165.

Hemingway, S., 2014. Medication management in mental health: nurses’ perceptions of their work with service users and carers. Mental Health Nursing, 34(6), pp.18-23.

Dickens, G., Doyle, C. and Calvert, J., 2006. Reducing medication administration errors in learning disability nursing. Nurse Prescribing, 4(11), pp.470-474.

ABA, A.B.A., 2005. Review of nurses and midwives in the prescribing and administration of medicinal products: final report/[An Bord Altranais, National Council for the Professional Development of Nursing and Midwifery]. -3632.

Bulechek, G.M. and McCloskey, J.C., 1999. Nursing interventions: Effective nursing treatments. Saunders.

Otero, M.J., Moreno-Gómez, A.M., Santos-Ramos, B. and Agra, Y., 2014. Developing a list of high-alert medications for patients with chronic diseases. European journal of internal medicine, 25(10), pp.900-908.

Deans, C., 2005. Medication errors and professional practice of registered nurses. Collegian, 12(1), pp.29-33.

McGuinness, M.L. and O’Halloran, S., National Policy for Nurse and Midwife Medicinal Product Prescribing in Primary, Community and Continuing Care.

Valentine, M.A., Nembhard, I.M. and Edmondson, A.C., 2015. Measuring teamwork in health care settings: a review of survey instruments. Medical care, 53(4), pp.e16-e30.

Manias, E., 2015. Communication relating to family members' involvement and understandings about patients' medication management in hospital. Health Expectations, 18(5), pp.850-866.

Haigh, S., 2002. How to calculate drug dosage accurately: advice for nurses. Professional nurse (London, England), 18(1), pp.54-57.

Wright, K., 2005. An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today, 25(6), pp.430-436.

Nursing and Midwifery Council (Great Britain), 2008. Standards for Medicines Management: Safeguarding the Health and Wellbeing of the Public Through Professional Standards. Nursing & Midwifery Council.

Bushra, R. and Aslam, N., 2010. An overview of clinical pharmacology of Ibuprofen. Oman medical journal, 25(3), p.155.

Saville, D.J., 2001. Influence of storage on in-vitro release of ibuprofen from sugar coated tablets. International journal of pharmaceutics, 224(1-2), pp.39-49.

Manias, E., Beanland, C., Riley, R. and Baker, L., 2004. Self‐administration of medication in hospital: patients’ perspectives. Journal of advanced nursing, 46(2), pp.194-203.

Kaufman, G. and Fernandes, T., 2010. Developing patient group directions for medicines management. Nursing Standard (through 2013), 24(48), p.50.

Ngo, S.N., Stupans, I., Leong, W.S. and Osman, M., 2010. Appropriate use of non‐prescription ibuprofen: a survey of patients' perceptions and understanding. International Journal of Pharmacy Practice, 18(1), pp.63-65.

Rainsford, K.D., 2011. Fifty years since the discovery of ibuprofen.

Vinks, A.A., Emoto, C. and Fukuda, T., 2015. Modeling and simulation in pediatric drug therapy: application of pharmacometrics to define the right dose for children. Clinical Pharmacology & Therapeutics, 98(3), pp.298-308.

McQueen, D.S., Begg, M.J. and Maxwell, S.R., 2010. eDrugCalc: an online self‐assessment package to enhance medical students' drug dose calculation skills. British journal of clinical pharmacology, 70(4), pp.492-499.

Information Commissioner’s Office. 2018. Guide to the General Data Protection Regulation (GDPR). (Online). Available at:

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