chapter 38 medication administration and safety for infants and children
NEONATE
0.5-1 ML
5-10 mins
how many minutes to not expel suppository?
3 ml
safe volume for adolescents
increase use of computer systems
(electronic medical records - EMR, computerized physician order entry - CPOE) reduces medication errors, improves communication, and improves medication regimen - DO not replace responsibility
medication reconciliation
Upon admission a list of all medications, including over-the-counter and herbal, taken at home is obtained Nurse compares list to what was prescribed with hospital admission Nurse identifies and communicates discrepancies
psychological and developmental factors affecting medication administration in children
ALWAYS APPROACH CHILD ACCORDING TO THEIR DEVELOPMENTAL LEVEL Always provide appropriate explanations Always give child choices Toddler holding med cup Restraints are NOT necessary Unless when injecting a medication→ another staff member may hold child during administration to avoid injury Parents may help distract or comfort Praising Helps gain trust and cooperation with future administration Rewarding Encourages and reinforces appropriate behavior - stickers Honesty nurses should be honest when explaining the administration process - unpleasant taste, painful or uncomfortable, approximately how long pain will last, what child can do to help (not move or hold cup)...pinching and stinging may be used for description
Administration : young- school age children
Chewable tablets, older children may be able to swallow tablets or capsules Always check ability to swallow
administration of blood: monitor closely
Child should be closely monitored during blood administration Guidelines for nursing care Baseline vitals before administration Then assess vitals every 15 minutes for the first 1-2 hours The hourly until infusion is complete Rate of infusion for packed red blood cells is about 5 mL/kg/hr over no more than 4 hours
toddlers
Ages 2-3 Magical thinking and may associate medication administration (mostly invasive) as for of punishment Age-appropriate explanation using play Allow older toddlers to examine equipment before procedure May sit on parents laps Praise, cuddling, reward
preschoolers
Ages 3-5 Magical thinking may use therapeutic play and participation Offer as much control and choices as possible (juice or milk) May need staff member to hold child still Adhesive bandages are important b/c they believe band-aid will "make it better"
intravenous catheter monitoring
Assess and monitor IV catheter site at least every HOUR Assess for signs of infiltration, phlebitis, and/or infection Assess for warmth, redness (erythema), blanching, swelling (edema), pain, red streaking and exudate...if noted stop infusion and notify physician IV catheters only changed when clinically indicated due to fragile veins, difficulty accessing, and stress IV fluid bags are changed every 24 hours IV tubing changed 96 hours - 7 days Change IV bags and tubing more frequently when administering TPN, blood products, or lipids
differences in body fluids
Body fluid in infants is about 75% of body weight; whereas in younger children it is about 60% of body weight --infants have greater fluid volume per weight - this may require a higher dose per kilo of water-soluble medication to achieve desirable effects Medication must be adjusted during illnesses to avoid overdosing or underdosing ---Most body fluid is in extracellular fluid compartment so with certain illness this fluid may be lost rapidly leading to fluid depletion
topical adminitration
Can produce local and systemic effects Creams, ointments, lotions, patches, and paste Adhesive, transdermal patches release medication continuously over a prescribed time period Changed at scheduled intervals...must tell child not to remove patch Applied to clean dry skin, free of any irritations, bruises, or abrasions Must wear gloves to apply patch
implanted venous access device (PORT-A-CATH)
Catheter connected to a port or reservoir Port is placed under skin and accessed with a non-coring needle through the skin Allows child to participate in typical childhood activities except high-impact contact with chest
central venous access devices
Catheters placed directly into major blood vessels For administration of IV fluids, medications, blood products, and parenteral nutrition over prolonged periods of time Require routine care like dressings and flushing - When transparent dressing recommend cleaning site and changing dressing every 7 days In most cases each lumen is flushed with heparinized saline every 24 hours and after each medication administration or blood draw Strict aseptic technique because directly in central venous system
intravenous catheter insertion: EUTECTIC mixture of local anesthetics (EMLA) anesthetic cream
Cleanse site with soap and water and dry Place a mound of EMLA cream (2.5 g or half of a 5-g tube) on site and cover with an occlusive transparent dressing. DO NOT rub into skin... Leave in place for a minimum of 1 hour and no longer than 4 hours Take dressing off and remove all the cream from the site Begin venipuncture...the numbing effect will last for up to 1-2 hours
administration of blood: confirm ABO blood type and Rh factor
Compatibility and blood has been cross-matched for this child Required that TWO nurses verify child identity, ABO/Rh type, donor number, expiration date and time Patent IV line 22-24 gauge Infusion rate may be slower for packed red blood cells Tubing includes a filter to filter any particles from blood Tubing connected with a Y connecter to another line with normal saline available for infusion IV pump is used for precise regulation of rate
administering intravenous medication
Continuous or intermittent infusion Always check compatibility of medication to be infused with an intermittent infusion with the IV solutions, IV tubing to be used, concentration of IV administration, the volume of the diluted medication, suggested administration rate, amount of flush needed`
infusion rates and methods
Daily IV infusions are ordered on an hourly basis according to the daily maintenance fluid requirements and rates Use formula to calculate the daily maintenance fluid requirements and rates based on rates Documentation should include type of IV fluid, site, rate ordered, and the actual amount of fluid infused IV fluid amount administered should be verified by the nurse on an hourly basis even if on an infusion pump...IV pumps may malfunction and lead to fluid overload
intravenous bolus push admin
Delivered over a certain period (a few minutes) Use port closest to the insertion site - Volume of medication small usually less than 5 mL Always check the IV site prior to medication administration Cleansed port with alcohol wipe, attach needleless system (cannot contaminate tip), occlude the IV (pinch) above the tube and push the medication in small amounts , then un-pinch and allow IV solution to run in between push If medication is not compatible with IV solution or is going into an intermittent infusion port, flush the tubing with 2-3 mL of normal saline before and after medication administration Administer medication at the exact prescribed rate over the required period of time Assess child during and immediately after administration to monitor for signs of adverse effects
intradermal injections
Dermis layer of skin below the epidermis Inner aspect of forearm or on upper back Used for Allergy testing or tuberculosis (TB) screening (PPD) Needle gauge 25-27 gauge Needle size 3/8 - 5/8-inch length Maximum volume 0.1 mL Don gloves, cleanse skin, allow to dry, turn bevel of needle up, insert gently at a 5 to 15-degree angle, inject slowly to form a bleb or wheal
GI motility or transit time though GI tract
Eating increases peristaltic activity Infants up to 8 months tend to have prolonged motility - Diarrhea can also alter intestinal motility by increasing peristaltic movement - The longer the transit time through the intestine, the more medication is absorbed; whereas shortened transit time decreases absorption
administration: infants
Elixir or suspension form using an empty nipple or oral syringe Upright or semi upright position Gently apply pressure to cheeks to open mouth If using nipple, place nipple in mouth and then add med when infant begins to suck If using oral syringe, place syringe along side of cheek and administer slowly and infant sucks
preparation
Ensure correct dose is drawn Physician order specify dosage in milligram (mg), NOT milliliter (ML) for liquid medication Use milliliter only systems with dosing syringes For disease 5 mL or less use oral syringe designed for oral administration Larger volumes may be poured into calibrated plastic medicine cup ( hold up 30 mL= 1oz) May mix sprink;e, powder, or crushed tablet with small amount (1-3 teaspoons) of nonessential food (applesauce, pudding, or liquid) Never mix with formula b/c may alter taste and child may not want to take the formula Check compatibility with food prior to mixing
infants
Essential administration techniques to prevent aspiration of liquid or oral medications or adverse effects from medications - Ask for help from other staff members for squirmy infants Always inform parents of medication being administered - to prevent medication errors Cuddling and comforting before and after is important
administration of blood products
Explain procedure to parents and child Child may feel frightened from seeing the blood...take into consideration developmental level when explaining administration to child Also review with parents' reason, how long it will take, what they will see and feel...obtain information from parents about any prior blood administrations and any reactions that may have occurred
administration of injections
Faster and more reliable absorption but can be stressful and threatening to child- Depending on the child's developmental level, explain reasons, any sensations, length of time may last - Distractions...sing, breathing Parents may stay to comfort and support child or may opt to leave if they feel they are unable to cope with stress - To avoid injury may need to limit child's movement during administration (swaddle or have another staff member hold child) May need to use oral sucrose for infants, vapocoolants, and topical anesthetic like EUTECTIC mixture of local anesthetics (EMLA) cream to reduce or eliminate injection pain Documentation after injection must include amount, site, and how child tolerated- If an immunization documentation must also include manufacturer, lot number, and any reactions
school age
Fear loss of control, pain, and injury Understand more complex explanations as "why' medication is needed Offer choices Often cooperate may need distractions (squeezing hand, watching a video, listening to music) Praise and rewards still important in this age group
adolescents
Fear separation from peers and loss of control Understand adult explanations Praise cooperation Offer distractions Help find outlets for frustrations (draw, write)
Ophthalmic Administration
Form of drops or ointments - If refrigerated allow to warm to room temperature Gently remove any exudates using a sterile gauze move from inner to outer canthus Use a different pad for each eye Shake suspensions before instilling Neck gently hyperextended Eye drops instilled into conjunctival sac...look upward while gently pulling lower lid down and away from eye...do not contaminate tip of bottle Eye ointment applied along inside ridge of lower eyelid from inner to outer canthus
absorption: ORAL ROUTE
Four factors influence absorption along the gastrointestinal tract (GI) gastric acidity gastric emptying time GI motility or transit time through the GI tract function of pancreatic enzymes
intravenous catheter insertion
Gauge 22-26 dependent on vein size and type of fluid Consider developmental age when choosing access site Explain procedure...see...feel...expect Assess fear and anxiety and teach coping strategies in advance Use interventions to decrease or eliminate pain from IV insertion May need staff member to hold down child to avoid injury Preformed in treatment room with all supplies gathered previously Parents may remain in room but are NOT expected to hold child down Explain procedure every step of the way Apply tourniquet and select site (avoid nondominant hand or forearm) Start with most distal veins May use transillumination, near infrared light, or ultrasound After insertion attach a well-padded arm board to prevent injury and keep IV intact Clear plastic shield (IV House Ultradome) is applied over site for protection Document procedure
rectal administration
Have localized effect on the GI tract (ex. To promote defecation) May also have systemic effect like decreasing fever Reserved for times when child cannot eat or drink or is unable to tolerate oral intake (nausea or vomiting) Increase risk for injury to anal and rectal tissues Do not use this method if rectum is full of stool, is child has rectal disease, or recent rectal surgery Explain reason, steps, and what child can do to help
intravenous infusion monitoring
IV infusion pumps accurately control infusion rate Programmed with IV fluid limits to avoid accidental fluid overload Some facilities require pumps be set to deliver no more than a 2 hour fluid volume
inhaler use
If more than one inhaler and one is an inhaled steroid, this one should be administered last
other routes: IV
Immediate available for absorption in a child because peripheral circulation is less reliable and more responsive to changes in the environment; this may lead to vasoconstriction or vasodilation which affects absorption of parenteral medications Also cardiovascular system is less able to accommodate large or rapid changes in volume which can lead to fluid overload with poorly controlled IV infusions Immediate available for absorption Cardiovascular system is less able to accommodate large or rapid changes in volume Intramuscular (IM) Children have less muscle mass -fewer injection sites Blood flow to muscle tissue can be unpredictable -can ↑ or ↓absorption
other routes: topical
Infants and younger children have thinner outer skin layer and larger body surface area (BSA) to weight ratio Infants have more skin surface area relative to weight, absorption is greater Skin Ph also varies with age which can affect absorption of topical medications Children are more prone to skin irritations - common skin irritations - contact dermatitis
gastric acidity
Infants gastric secretions are less acidic (secretions slowly increase during the first two years of life) Eat more frequently so they have food and gastric enzymes in their stomach most of the time Formula or milk increases alkalinity of gastric enzymes thus decreasing absorption of medications that need an acidic environment; however, it increases absorption of medications that require a more alkaline environment - serum drug levels will be impacted by this
subcutaneous injections
Injected into connective tissue just below dermal layer Used for medications that provide sustained effects (heparin, insulin, and certain immunizations) Outer posterior aspect of upper arm and anterior aspects of the thigh (may use abdomen 2 in radius around umbilicus for repeated injections) Needle gauge 25-27 gauge Needle length 3/8 - 5/8 inch long Volume 0.5-1 mL Don gloves, cleanse skin, allow to dry, gently pinch skin, insert at 45-degree angle (may do 90 degree angle with a ½ in needle), insert needle darting motion, release tissue, inject med, remove needle, gentle pressure. DO not massage
gastric emptying time
Intermittent and unpredictable in infants Slower than in older children which leads to a delay in time of medication reaching intestinal absorption site
continuous intravenous medications
Intravenous intermittent infusion administration Infusion pumps are used to ensure safety of intermittent infusion (via piggy-back) Can run concurrently or sequentially with a primary infusion line Always verify compatibility of medication to be infused with IV solutions Another type of IV pump is a syringe pump, prefilled syringe with medication premixed by pharmacy...attached to primed low-volume tubing Label syringe or IV bag containing medication ALWAYS CHECK THE SIX RIGHTS
Administration : toddlers and preschoolers
Liquid from oral syringe or medicine cup Allow child to hold cup or syringe praise/ reward
differences in protein
Medications bind to plasma proteins - mainly albumin for distribution Only free unbound medication is absorbed Preterm and newborn children have less levels of plasma protein - potentially increasing adverse drug effects
excretion
Most medications are excreted through the renal system (lower glomerular filtration rate and less efficient renal tubular function) Newborns renal system is immature infants are also not able to concentrate urine Renal immaturity leads to inadequate amounts of medication being filtered out of the circulatory system and therefore being excreted this leads to medication circulating longer in the blood reaching toxic levels in the blood Fluid volume loss (dehydration) also decreases ability to excrete and can affect serum drug levels
metabolism
Most medications are metabolized in the liver Preterm or newborn infants may have immature metabolic enzyme systems so may not metabolize all the medication given in one dose Toddlers and preschoolers may metabolize medication faster than adults so they may need higher doses or more frequent administration to achieve the desired therapeutic affect of certain medications such as pain medication
nasal administraion
Mucous membranes allow for rapid systemic absorption Remove excess mucous by gently suctioning the nose with a bulb syringe For better results use saline nose drops, followed by gentle suction, 20-30 minutes prior to feedings Supine, with head slightly hyperextended Instill number of drops into each naris and instruct to hold still for about one minute Instruct not to blow nose after administration
inhalation therpay
Nebulizer or a metered-dose inhaler (handheld delivers puffs of medication) Nebulized medication is diluted in normal saline solution Can be delivered through facemask or plastic mouthpiece Nebulized medication can be delivered along with oxygen Metered-dose inhalers may be used with a spacer Initial and ongoing education is essential in ensuring effectiveness of treatment...demonstration and return demonstration Must also be taught on how to clean and maintain nebulizer at home
family education
Nurse must provide thorough verbal and written instructions on all medications to be taken at home Include dose, administration times, therapeutic effects, possible side effects and adverse reactions Emphasize the need to take medications as prescribed including finishing the full course of prescribed antibiotics, not changing doses, and returning for follow-up appointments Emphasize the need to keep medications locked up With any medication administration procedure, the best way to ensure teaching is effective use DEMONSTRATION with RETURN-DEMONSTRATION
function of pancreatic enzymes
Pancreatic enzyme activity may be altered in infants for the first 3 months while GI system matures Medications that require certain pancreatic enzymes for dissolution and absorption may not be converted to a form that is appropriate for intestinal action
differences in fat percentages
Percentage of body fat also varies with age...in infants its about 16% of body weight and slightly increases during the first year...then decreases again in a preschool child- Percentage of body fat affects distribution of fat-soluble medications
otic administration
Placed supine with head turned Gently clean any exudate with sterile gauze Never place any item into ear for cleaning Otic solutions should be warmed to room air - Child older than 3 pull pinna up and back...for child younger than 3 pull pinna down and back Place cotton loosely into outermost portion of ear canal Place on unaffected side for 5-10 minutes
distribution
Refers to concentration of medication in body fluids and tissues
concentration
Safe therapeutic levels maximize desired effect of medication and reduces risk of toxicity Peak and trough serum levels may be ordered to monitor medication concentrations -
inhaler use
Shake inhaler well Attach spacer to inhaler Tilt head back, take a deep breath and slowly exhale Place mouthpiece in mouth and depress the inhaler canister Ask child to slowly and deeply inhale ("big breath in") and hold breath for 10 seconds Remove inhaler and ask child to slowly exhale Wait 1-2 minutes between puffs Ask child to rinse mouth with water after each use
tunneled central lines (BROVIAC OR HICKMAN)
Surgically implanted and held in place by a Dacron cuff in subcutaneous tunnel Commonly placed in external jugular vein but may also be seen in cephalic, axillary, subclavian, femoral, saphenous, and internal jugular veins Tip of catheter is threaded until it rests at the junction of the superior vena cava and right atrium
intravenous therapy
Used for fluids & electrolytes, total parenteral nutrition (TPN), blood products, and medications
intramuscular injection
Used for immunizations - Determine injection site in advance Site will be dependent on age, size, muscle mass, and volume and properties of medication- For infants and toddlers use VASTUS LATERALIS - For children 3-18 use DELTOID VENTROGLUTEAL may be used for infants, children, and adolescents Avoid dorsogluteal due to potential damage to sciatic nerve - Rectus femoris is not recommended for children - Needle size and length depends on size, amount of body fat, injection site, and child's muscle mass at site of injection - Needle size 22-25 gauge
vaginal adminitration
Used primarily for school-age or adolescent girls - Used for topical treatment with anti-infective agent for vaginal infection Explain procedure, reason for medication, and what they can do to help Ask to void Place in supine position with sole of feet together and knees resting on bed Use drapes for privacy Gently spread labia, lubricate tablet, suppository, or applicator with water-soluble lubricant Have patient take deep breath and gently insert vaginal medication approximately 7.5 - 10 cm along the posterior wall of vagina Remain in SUPINE position for at least 10 minutes
venous access device : intermittent infusion ports
Used to administer medications without having a running IV line Port is flush and accessed when fluid or medication is needed Routine flushing to maintain patency every 8-12 hours...follow facility policy Also flush with normal saline before and after each medication administration
peripherally inserted central catheter PICC
Used when IV access is needed for longer periods of time Long silicone catheter threaded through an introducer via a peripheral vein of upper arm (cephalic or brachial) until tip reaches the superior vena cava...then the introducer is removed, and placement is confirmed by x-ray Covered with a BIOPATCH and then a transparent dressing...site should be monitored frequently for any signs of infection Dressings changed 24 hours after insertion and then every 7 days...must remain dry and intact May be left in place for a few weeks to months and is usually used for prolonged antibiotic use at home Frequent complication include phlebitis, infection, thrombosis, and catheter occlusion
administration of oral medications
Widely used Available in liquid (elixir or suspension), tablet or capsule, chewable tablet, and sprinkle (powder form) If a child cannot swallow tablets or capsules... may have to give in liquid form or chewable tablet→ if not available, then check if can be crushed or contents emptied
older child 6-14yrs
deltoid- 0.5-1ml ventrogluteal- 1.5-2 ml vastus lateralis - 1.5-2 ml
adolescent 15yr- adult
deltoid- 1 mL ventrogluteal- 2-3ml vastus lateralis- 2-3 ml
young child 3-6yrs
deltoid: 0.5 mL ventrogluteal: 1.5ml vastus lateralis: 1.5-2 ml
toddler
deltoid: 0.5 mL ventrogluteal: 1mL vastus lateralis: 1-1.5 mL
blood-brain barrier
does not fully mature until about 2 years of age Barrier is LESS selective allowing distribution of medications into the central nervous system may lead to encephalopathy with certain medication - Immature central nervous system can lead to paradoxical effects of medications Ex: meds that cause sedation in adults may cause hyperactivity in children
**monitor for adverse reactions of blood
fever or chills, headache, nausea, pain at insertion site, or difficulty breathing Never leave child alone during infusion If a reaction is suspected, STOP infusion immediately and notify physician...Start an infusion of NORMAL SALINE through new tubing to maintain patency of line...Continue to monitor vital signs, hourly urine output, and send samples of the child's blood and urine to laboratory per physician orders
notify physician
if a child vomits or spits up after med what should you do?
upon discharge reconciliation includes...
includes clear, detailed, written instructions of all medications to be given at home as well as communicating medication to next healthcare provider
trough
is the level at which serum concentration is the lowest...usually obtained just before next scheduled dose
if medication is needed while in school
physician must complete an order form with specific instructions such as dose, purpose of use, potential side effects and adverse reactions, and specific times medication should be given a parent consent form must also be signed medication must be supplied to school nurse in original pharmacy container
Pharmacokinetics
relates to how a medication travels through the body over time "What does the body do to the drug?" Absorption Distribution Metabolism Excretion
Pharmacodynamics
relates to what the medication does when traveling through the body over time "What does the drug do to the body?"
0.5 ml
safe volume for infants&youngchildren
peak
the concentration of the medication after it has been distributed
left side with right leg slightly flexed
what position for rectal adminitration?
gag reflex
what should you access prior to medication administration ?
INFANT
vastus lateralis 1ML
premature
vastus lateralis 0.5 ML
GI tract feed tube
where can you also administer oral meds?
