1. Pediatric Medication Administration
Bowden & Greenberg
Chapter 3
By Nataliya Haliyash

2. General Guidelines
The responsibility of giving medications to children is a serious one.
½ of all medications on the market today do not have a documented safe use in children.
Children are smaller than adults and medication dosage must be adjusted.
Children react more violently.
Drug reactions are not predictable.

3. General Guidelines
The impact on growth and development must be considered when giving drugs to children
Double checking is always best
Must double check these meds:
Lanoxin,
insulin,
heparin

4. Pediatric Drug Administration
Pediatric drug therapy should be guided by the child’s age, weight and level of growth and development
The nurse’s approach to the child should convey the impression that he or she expects the child to take the medication
Explanation regarding the medications should be based on the child’s level of understanding

5. The nurse must be honest with the child regarding the procedure
It may be necessary to mix distasteful medication or crushed tablets with a small amount of honey, applesauce, or gelatin
Never threaten a child with an injection if he refuses an oral medication
All medications should be kept out of the reach of children and medications should never be referred to as candy

6. Oral Medications GI tract provides a vast absorption area for meds.
Problem: Infant / child may cry and refuse to take the medication or spit it out.

7. Oral Medications
Do not use if child has vomiting, malabsorbtion or refusal
Kids < 5 find it difficult to swallow tablets
Use suspension or chewable forms
Divide only scored tablets
Empty capsules in jelly
Do not call medication ‘candy’

8. Nursing Intervention Infant:
Place in small amount of apple sauce or cereal
Put in nipple without formula
Give by oral syringe or dropper
Have parent help
Never leave medication in room for parent to give later.
Stay in room while parent gives the po medication

9. Nursing Interventions
Toddler:
Use simple terms to explain while they are getting medication
Be firm, don’t offer to have choices
Use distraction
Band-Aid if injection / distraction
Stickers / rewards

10. Nursing Intervention Preschool: Offer choices Band-Aid after injection
Assistance for IM injection
Praise / reward / stickers

11. Nursing Intervention School-age
Concrete explanations, do not just say “it won’t hurt”
Choices
Interact with child whenever possible
When the child is old enough to take medicine in tablet or capsule form, direct him or her to place the medicine near the back of the tongue and to immediately swallow fluid such as water or juice
Medical play

12. Nursing Interventions
Adolescent
Use more abstract rationale for medication
Include in decision making especially for long term medication administration

13. Nursing Alert
For liquid medications, an oral syringe or medication cup should be used to ensure accurate dosage measurement. Use of a household teaspoon or tablespoon may result in dosage error because they are inaccurate.
Bowen & Greenberg

14. Household Measures Used to Give Medications

15. Oral Medication Administration
Depress the chin with the thumb to open infant’s mouth
Using the dropper or syringe, direct the medication toward the inner aspect of the infant’s cheek and release the flow of medication slowly
Note: child’s hands are held by the nurse and child is held securely against the nurses body.

16. Oral Medications Hold child / infant hands away from face
For infant: give in syringe or nipple
DO NOT ADD TO FORMULA
Small child: mix with small amount of juice or fruit, give in syringe or allow the child to hold the medicine cup and drink it at own pace if he/she is big enough
Parent may give if you are standing in the room

17. Oral Medication: older child
TIP: Tell the child to drink juice or mild after distasteful medication. Older child can such the medication from a syringe, pinch their nose, or drink through a straw to decrease the input of smell, which adds to the unpleasantness of oral medications.

18. Intramuscular Medications
Rarely used in the acute
setting.
Immunizations
Antibiotics
Use emla
a local skin anaesthetic that is applied to the skin prior to procedures such as needles, to help prevent pain.

19. IM Injection: interventions
TIP: Tell the child it is all right to make noise or cry out during the injection. His or her job is to try not to move the extremity.

20. IM Injection Keep needle outside of child’s visual field
Secure child before
giving IM injection.
Hold, cuddle, and comfort the infant after the injection
Inspect injection site before injection for tenderness or undue firmness
Whaley & Wong

21. Nursing Alert Rocephin is often given in the ER.
Hold order for IV antibiotic once admitted.
Physician order may indicate to delay IV antibiotic administration for 12 to 24 hours.
Potential medication administration error.

22. IM Injection Sites
Vastus Lateralis
Deltoid
Dorsogluteal

23. Vastus Lateralis: Largest muscle in infant / small child.
0.5 ml in infant
1 ml in toddler
2 ml in pre-school
Use 5/8 to 1 inch (2.5 cm) needle
Compress muscle tissue at upper aspect of thigh, pointing the nurse’s fingers toward the infant’s feet
Needle is inserted at a 90-degree angle.
Bowden & Greenberg

24. Deltoid Use ½ to 1 (2.5 cm) inch needle 0.5 to 1 ml injection volumes
More rapid absorption than
gluteal regions.
Bowden & Greenberg

25. Dorsogluteal
Gluteal muscle does not develop until a child begins to walk; should be used for injections only after the child has been walking for a year or more
Should not be used in
children under 5 years.
½ to 1 ½ inch needle
1.5 to 2 ml of injected
volume.
Bowden & Greenberg

26. Eye Drops Eye: Pull the lower lid down
Rest hand holding the dropper with the medication on the child’s forehead to reduce risk of trauma to the eye.

27. Eye Drops Pull the lower lid down Rest hand holding the
dropper with the medication
on the child’s forehead to
reduce risk of trauma to
the eye.
Whaley & Wong

28. Ear Drops
Whaley & Wong

29. Ear Drops
In children younger than age 3 years the pinna is pulled down and back to straighten the ear canal
In the child older than 3 years, the pinna is pulled up and back.

30. Nose Drops Position child with the head hyper extended
to prevent strangling
sensation caused by
medication trickling into
the throat.
Whaley & Wong

31. Nose drops Act as vasoconstrictors excessive use may be harmful
Discontinued after 72 hours
Congested nose will impair infants ability to suck
Give 20 minutes before feeding
Have kleenex
Keep child’s head below the level of shoulders for 1 to 2 minutes after instillation

32. Rectal Usually sedatives and antiemetics Use little finger
Insert beyond anal sphincter
Apply pressure to anus by gently holding buttocks together until desire to expel subsides

33. Intravenous Medications
IV route provides direct access into the vascular system.
Adverse effects of IV medication administration:
Extravasation of drug into surrounding tissue
Immediate reaction to drug

34. IV Medication Administration
Check your institution's policy on which drugs must be administered by the physician and which must be verified for accuracy by another nurse.
All IV medications administered during your pediatric rotation must be administered under direct supervision of your clinical instructor.

35. IV Medication Administration
Check for compatibilities with IV solution and other IV medications.
Flush well between administration of incompatible drugs.
IV medications are usually diluted.

36. Nursing Alert
The extra fluid given to administer IV medications and flush the tubing must be included in the calculation of the child’s total fluid intake, particularly in the young children or those with unstable fluid balance.
Bowden & Greenberg

37. Nursing Alert Hourly assessment Documentation
Patency, infiltration, inflammation, rate, pain, LTC
Use mini/micro drip chamber for control

38. IV Medications IV push = directly into the tubing
Syringe pump = continuous administration
Buretrol = used to further dilute drug

39. IV Push Morphine Solu-medrol Lasix Drug that can safely be
administered
over 3 to 5
minutes.
Bowden & Greenberg

40. IV push
Medication given in a portal down the tubing – meds that can be given over a 1-3 minute period of time.
Lasix: diuretic
Morphine sulfate: pain
Demerol: pain
Solu-medrol: asthmatic

41. IV Pump
Bowden & Greenberg

42. Syringe pump
Accurate delivery system for administering very small volumes
ICU
NICU

43. IV Buretrol
Bowden & Greenberg

44. A buretrol or volutrol is an intravenous delivery device attached between the IV fluid bag and the intravenous catheter. It is used to deliver IV fluids in a safe manner to children and medications* in some nursing units.
Usual volume capacity is 150 ml. Some units have a policy that a buretrol will be used on all children under 10 kg while others may state 20 kg. Individual units vary on policy.
In practice: Make note of hospital/unit policy for use of buretrols. Current theory is that buretrols should be used for children weighing <10-15 kg.

45. IV Buretrol Buretrol acts as a second chamber
Useful when controlling amounts of fluid to be infused
Useful for administering IV antibiotics / medications that need to be diluted in order to administer safely

46. Example:
John is a pediatric client in a hospital in which the policy is to place all children on IV therapy on a buretrol and to only fill the buretrol no more than two-three hours worth of fluid. The nurse fills the buretrol to 90 ml at 10 a.m. If John’s IV is running at 34 ml per hour, how long will it be before the nurse will need to fill it again?

47. Calculate: 1 hr 60 min = 0.65 hr X min 1 x 39.00 X 39
90 ml ÷ 34 (ml/hr) = 2.65 hrs However, 0.65 hrs = ? minutes.
1 hr
60 min =
0.65 hr
X min
1 x
39.00 X 39

48. Answer = 39 minutes Add this to the 2 hours. 10 a. m
Answer = 39 minutes Add this to the 2 hours a.m. + 2 hr 39 minutes = 12:39 p.m.
Answer: At 12:39 p.m. the buretrol will need more fluid added so that air does not get into the tubing.

49. Intravenous Therapy

50. Central Venous Line
Whaley & Wong

51. Central Venous Line
A large bore catheter that are inserted either percutaneously or by cut down and advanced into the superior or inferior vena cava
Umbilical line may be used in the neonate
Used for long term administration of meds
Used for chemotherapy
Total parental nutrition

52. Child With Central Venous Line
Whaley & Wong

53. Type of fluid Glucose and electrolytes Maintenance Potassium added
Crystalloid: Normal Saline or lactated ringers
Fluid resuscitation
Acute volume expander
Colloid: albumin / plasma / frozen plasma

54. Complications Infiltration Catheter occlusion Air embolism Phlebitis
Infection

55. Infiltration Infiltration: fluid leaks into the subcutaneous tissue
Signs and symptoms:
Fluid leaking around catheter site
Site cool to touch
Solution rate slows are pump alarm registers down-stream-occlusion
Tenderness or pain: infant is restless or crying

56. Catheter Occlusion Fluid will not infuse or unable to flush
Frequent pump alarm
Flush line
Check line for kinks

57. Air embolism The IV pump will alarm when there is air in the tubing
Look to see that there is fluid in the IV bag or buretrol
Slow IV rate
Remove air from tubing with syringe

58. Phlebitis Often due to chemical irritation
When medications are given by direct intravenous injection, or by bolus (directly into the line) it is important to give them at the prescribed rate.
Always check the site for infiltrate before giving an IV medication

59. Signs and symptoms: phlebitis
Erythema at site
Pain or burning at the site
Warmth over the site
Slowed infusion rate / pump alarm goes off

60. Reason for pump alarm Needs to have volume re-set
Needs more IV solution in bag or buretrol
Kinked tubing at infusion site
Child lying on tubing
Air in tubing
Infiltrated at site of infusion

61. Clinical Pearls If alarm states upward occlusion Look at IV bag
Look at fluid level in buretrol
Look to see if ball in drip chamber is floating
If alarm states downward occlusion
Look to see that all clamps are open
Look to see if line is kinked
Irrigate with normal saline or heparin

62. Q & A ?