NUR243 Chapter 13 Key Pediatric Nursing Interventions

Reduce the Risk of Health Care - Associated Infections Central Line

Implement evidence-based practices to prevent central line - associated bloodstream infections. Note: This requirement covers short - and long-term central venous catheters and peripherally inserted central catheter lines (PICC). STEPS: When Caring for a child with a central line ensure to follow evidence-based policies and procedures strictly.

Expect Urine output for children and adolescents to be

1 to 2 mL/kg/hour

IV Fluid Administration 24 hour calculation

100 mL per kg of body weight for the first 10 kg 50 mL per kg of body weight for the next 10 kg 20 mL per kg of body weight for the remainder of body weight in Kg

Infants and young children - the absorption of Topical medications

A greater Body Surface Area leads to an increased absorption of topical medications. Absorption in infants is also increased due to greater permeability of the infant's skin. This can result in adverse effects not seen in adults.

Intravenous Administration

Administration of IV medications is not traumatic, the placement of the IV however is. the veins of a child are small and easily irritated. Knowledge of all drugs given to children is important for the nurse, For IV drugs the nurse must know the rate it is be be given and the proper dilution to avoid overdose and toxicity. As well as careful maintenance of the site to prevent complications. Primary method of medication administration is the syringe pump for a precise rate of infusion. A volume control device may also be used where medication is added to compatible fluid and then infused at the ordered rate. Direct IV push is given when therapeutic blood levels must be reached quickly to achieve the desired effect and typically reserved for emergency situations. medication is appropriately diluted and pushed over a certain period of time, 2-3 minutes. Care must be used to prevent fluid overload which may occur due to flushing needed to maintain IV patency and prevent drug incompatibilities, and from the administration of multiple drug therapies.

Infants and young children - Orally administrated medications absorption

Affected by slower gastric emptying, increased intestinal motility, a proportionately larger small intestine surface area, higher gastric pH, and decreased lipase and amylase secretion compared with adults.

Infants and young children - IM administrated medications absorption

Affected by the amount of muscle mass, muscle tone and perfusion, and vasomotor instability

Infants and young children - Distribution of medications

Affected by: Higher percentage of body water than adults More rapid extracellular fluid exchange Decreased body fat Liver immaturity, altering first-pass elimination Decreased amounts of plasma proteins available for drug binding Immature blood-brain barrier, especially in neonates, allowing permeation by certain medications

Infants and young children - the metabolism of medications

Altered because of differences in hepatic enzyme production and the child's increased metabolic rate. The immaturity of Kidneys increases the half life and the potential for toxicity of drugs primarily excreted by the kidneys.

Infants and young children - SQ Absorption

Altered by decreased perfusion

If the IV site was in the arm at or near the antecubital space,

Apply pressure until bleeding stops. Do not have the child bend his or her arm after removal of the device as this is not sufficient pressure to prevent hematoma formation.

Always Administer Medications Promptly,

Assist the child in holding still using a comforting position for the child, and reward positive behavior. the child's past experiences may affect how the child reacts. Always approach positively, Convey the belief that they can accomplish this needed behavior. Never label a child as "Bad"

Teaching Guidelines Administering Oral Medications

Be firm when telling your child its time for medications. Allow your child to choose an appropriate liquid to help swallow the medication or drink after taking it.. Limit the choices Never bribe or threaten your child to take his or meds Never refer to the meds as candy Be honest about the taste of the meds. If needed and appropriate mix it with another food such as apple sauce, yogurt, or syrup to help mask the taste No not mix with formula or baby food Always check with your prescriber and pharmacy about opening capsules or crushing tablets. If you are giving a liquid using an oral syringe or dropper, place the meds slowly along the inside of the cheek. never squirt forcibly to the back of the child's throat. Always praise child after taking the medication and provide comfort and cuddling.

Pharmacodynamics

Behavior of the medication at the cellular level. Because of a child's physiologic immaturity of some body systems the body may not respond to a drug as intended. The effect may be enhanced or diminished.

Infiltration

Inadvertent infusion of a nonirritant solution or medication into the surrounding tissue. Inspect insertion site every 1 to 2 hours for inflammation or infiltration note inflammation, warmth, redness, induration, or tender skin. Note infiltration, cool, blanched or puffy skin. Use transparent dressing. In children the IV is changed when it is clinically indicated. Chlorhexidine-impregnated sponge (biopatch) dressings may be used to help prevent infection in children older than 2 months of age. Always follow agency or institution policy and procedures regarding site care.

Preventing medication errors by

Confirm child's weight Always weigh in kilos Double check med calculations; utilize another health care provider when possible, especially for high-risk medications If a dose seems unusually small or large, verify the order Utilize medication ordering and dispensing systems if available Always report medication errors or near-miss errors to help prevent future mistakes Utilize the Joint Commission's official "do not use" list If a parent, caregiver, or child question whether a medication should be given, listen attentively, answer their questions, and double-check the order.

IV sites

Either Peripheral vein or central vein. PIV include hands, feet, and forearms. In neonates and infants scalp veins may also be used. Scalp veins are easily viewed and do not have valves so the device may be inserted in either direction. The area of the scalp vein must also be free of hair to enhance visualization. When selecting an IV site in an extremity, always choose the most distal site. Doing so prevents injury to the veins superior to the site and allows additional access sites should complications develop in the most distal site. Central IV therapy usually is in a large vein, subclavian, femoral, or jugular vein or the vena cava. The tip of the device lies in the superior vena cava just at the entrance to the right atrium. usually inserted surgically percutaneously and exits in the chest under the clavicle.

Providing Atraumatic Care

Encourage the child to participate in care and provide the child with developmentally appropriate options, such as which fluid to drink with the medication or which flavor of ice pop to suck on before or after the administration. When possible apply topical anesthetic such as eutectic mixture of local anesthetic Cream (EMLA) or vapocoolant spray to the site just before injection when possible. Inject most painful injection last. Use distraction techniques, music, books, blowing bubbles or a pinwheel for deep breathing exercises. Make sure child does not move to prevent injury for injections, for a young child at least two adults should hold him or her. Research supports children experience less pain and decreased fear if they are sitting versus lying down when receiving an injection Use positions that are comforting to the child, such as therapeutic hugging, during injections. have the child sit on the caregiver's lap with the caregiver holding the child's arms and legs to his or her body. After administration, encourage the parents or caregivers to hold and cuddle the child and offer praise.

Enternal nutrition is indicated for children who have a functioning gastrointestinal tract but cannot ingest enough nutrients orally. The child may be unconscious or have a severly debilitating condition that interferes with his or her ability to consume adequate food and fluids. Other conditions include

Failure to thrive Inability to suck or tiring easily during sucking Abnormalities of the throat or esophagus Swalloeing difficulties or risk for aspiration Respiratory distress Metabolic conditions Severe gastroesophageal reflux disease (GERD) Surgery Severe trauma Enteral feedings cost less, are associated with fewer complications, and are considered safer than parenteral feedings. tube misplacement is a serious complication

When Flushing or administering Medications through a PICC line

Follow the manufacturer's recommended syringe size, because PICC lines are fragile. Using a larger-volume syringe exerts less pressure on the PICC, thereby reducing the risk of rupture

Principles of atraumatic care with insertion of an IV therapy device.

Gather all equipment needed before approaching the child. If possible, select a site using hand veins rather than wrist or upper arm veins to reduce the risk of phlebitis. Avoid sites where excessive movement may occur, such as the lower extremity veins and areas of joint flexion if possible because these are associated with an increased risk of thrombophlebitis and other complications. Ensure adequate pain relief using pharmacologic and nonpharmacologic methods prior to insertion of the device. Allow the antiseptic used to prepare the site to dry completely before attempting insertion. Use a barrier such as gauze or a washcloth or the sleeve of the child's gown under the tourniquet to avoid pinching or damaging the skin If the child's veins are difficult to locate, use a device to transilluminate the vein (The bright light illuminates the vein's size and direction of travel). Make only two attempts to gain access; if you are unsuccessful after two attempts, allow another individual two attempts to access a site. If still unsuccessful, evaluate the need for insertion of another device. Some facilities have policies in place allowing only one stick per nurse with a maximum of two sticks; then the doctor needs to be notified unless the situation is an emergency. Encourage parental participation as appropriate in helping to position the child or to provide comfort positioning, such as therapeutic hugging Coordinate care with other departments such as the lab for blood specimen collection to limit the number of venipunctures for the child. Secure the IV line using a minimal amount of tape or transparent dressing. Protect the site from bumping by using a security device such as the IV house dressing.

Discontinuing the IV Device Atraumatic Care

If appropriate, allow the child to assist in removing the tape or dressing. This gives the child a sense of control over the situation and also encourages his or her cooperation. Use water or adhesive remover to help loosen the tape If a transparent dressing is in place, gently lift off the dressing by pulling up opposite corners using a motion parallel to the skin surface Avoid using scissors to cut the tape, but if cutting the tape is necessary, be sure that the child's fingers are clear of the tape and scissors. Turn off the infusion solution and pump Once all tape and dressings are removed, gently slide the IV device out using a motion opposite that used for insertion. Apply pressure to the site with a dry gauze dressing and then cover with a small adhesive bandage. If possible, allow the child to choose the bandage.

Total parenteral nutrition TPN

If for any reason the TPN infusion is interrupted or stops, be prepared to begin an infusion of a 5 to 10% dextrose solution at the same infusion rate as the TPN. This helps prevent rebound hypoglycemia that may occur due to the increased insulin secretion by the child's body in response to the use of the highly concentrated TPN solution.

Gastrostomy (surgical insert through abdominal wall into stomach, Jejunostomy (Abdominal wall into jejunum)

Indication- Long-term enteral feedings or when esophageal atresia or stricture is present. Jejunostomy tubes are indicated when gastric feeding is not tolerated. Nursing Implications- The inner section of the tube is below the skin surface with the tip located in the stomach or jejunum. The outer section appears above the skin surface at the insertion site and ahas an opening or feeding port to which the feeding solution is attached. Low-profile gastrostomy button) is flush with the abdominal surface. The flip top opening is anchored by a dome that fits against the stomach wall. Less conspicuous, it allows the child to be more active and mobile. After initial insertion, the tube length is measured from the insertion site to the far end of the tube and recorded. This measurement is checked at least daily to insure that the tube has not moved. There are many different devices available. For any gastrostomy or jejunostomy tube, the type and size of the tube inserted as well as the amount required to fill the balloon, if present, should be known.

Nasoduodenal (nose to duodenum) Nasojejunal (Nose to jejunum)

Indication- Short term enteral feeding. Indicated if child has trouble digesting food, cannot use his or her gastrointestinal tract secondary to congenital anomalies or surgery, or is at risk for or has a history of severe reflux or aspiration Nursing Implications - Silicone and polyurethane tubes with weighted tip allow tube to pass from pylorus into small intestines. Agency may require special training in order to place at bedside; may also be performed in radiology. Length of use same as nasogastric or orogastric tubes

Nasogastric (nose to stomach), Orogastric (inserted mouth to stomach)

Indication- short term enteral feeding, Orogastric usually limited to young infants only Nursing Implications- Long-term use or repeated insertion causes irritation and discomfort. Silicone and polyurethane tubes are very flexible and more comfortable: they require a stylet or guide wire for insertion. Length of long-term use varies according to the type of tube used and the institution protocol. Periodically the nasogastric tube is removed and inserted via the opposite nostril to prevent pressure on the nasal mucosa. maintaining orogastric placement between feedings can be difficult due to oral secretions.

Guidelines for Solution amount, needle length, and Needle Gauge for IM injections

Infant <12 mo - Vastus Lateralis (anterolateral) 0.5 mL - 5/8 to 1 inch, 22-25 gauge Toddler 12 mo - 2 y - 0.5 - 1 mL Vastus Lateralis, Deltoid 0.5 mL, Ventrogluteal 1mL - 5/8 to 1 inch 22-25 gauge Preschooler 3 to 5 y - 1 mL Vastus Lateralis, 0.5 Deltoid, 1.5 Ventrogluteal - 5/8 to 1 inch 22-25 gauge School Age 6 to 10 y - 1.5 - 2 mL Vastus Lateralis, 0.5 - 1 mL Deltoid, 1.5 to 2 mL Ventrogluteal - 5/8 to 1.5 inch - 22-25 gauge

Growth and Development Issues Related to Pediatric Medication Administration - Adolescent

Issue - Development of Identity, benefiting from much more control over their care Nursing Intervention - Approach in same manner as adults, with respect and sensitivity to their needs. Maintain the adolescent's privacy as much as possible

Growth and Development Issues Related to Pediatric Medication Administration - School-aged

Issue- Development of industry, benefiting from being a part of their care; Generally very cooperative. Nursing intervention - Explain to the child in simple terms the purpose of the medication. Seek their assistance, such as putting pills in the cup or opening the packet, and allow a broader range of choices. Establish a reward system to enhance their cooperation, if necessary.

Growth and Development Issues Related to Pediatric Medication Administration - Preschooler

Issue- Development of initiative, which is fostered when they sense they are helping Nursing intervention - Provide an opportunity to play with the equipment and respond positively to explanations and comforting. Provide choices that are possible and keep them simple. Do not ask, "Will you take your meds now?" Involve parents in the medication administration. Be aware that giving suppositories is particularly upsetting to this age group because of their fears of bodily intrusion and mutilation

Growth and Development Issues Related to Pediatric Medication Administration - Infant

Issue- Development of trust, which is fostered by consistent care; Development of stranger anxiety later in infancy Nursing Intervention- Involve parents in medication administration to reduce stress for infant. Ensure that parents hold and comfort infant during intervention

Growth and Development Issues Related to Pediatric Medication Administration - Toddler

Issue- Developments of autonomy with displays of negativism: Rituals, routines, and choices necessary to maintain some sense of control. Nursing Intervention _ Follow routines and rituals from home in giving meds, if these are safe and positive approaches. Involve parents in Med Administration. Offer simple choices (e.g. Do you want mom or me to give your medicine?). Allow child to touch or handle equipment as appropriate

Methods for verification of feeding tube placement

Obtain radiographic confirmation of proper tube placement in children who are considered high risk aspiration, such as children with neurologic impairment, children obtunded, sedated, unconscious, critically ill, reduced gag reflex or static encephalopathy, or when nonradiologic methods are not feasible or bedside results are conflicting. Non radiologic verification is used in children who are not considered high risk for aspiration, document pH of aspirate, document insertion distance and external length of tube in the chart. Mark and document the tube's exit site from the nose or mouth. Use bedside techniques at regular intervals to determine proper tube positioning Measuring pH Gastric secretions have a pH less than 5. Small intestine secretions pH greater than 6, A pH greater than 6 can occur with respiratory or esophageal placement, with proper tube placement when feedings are given continuously, or if the child is receiving acid inhibiting medications. Therefore, if the pH is greater than 5 additional assessment is warranted

Peripheral Access Devices

Over the needle catheters or winged-infusion sets, commonly referred to as "butterflies" or scalp vein needles. Use the smallest gauge catheter with the shortest length possible to prevent traumatizing the child's fragile veins.

Peripherally inserted Central catheter (PICC)

Short- to moderate - term therapy Insertion via a peripheral vein such as basilic, cephalic, or brachial vein Catheter typically threaded into superior vena cava; Distal tip terminates in the superior venal cava, or proximal right atrium Insertion via saphenous vein with tip terminating in inferior vena cava above the diaphragm for infants Single or multiple lumens Can be inserted at the bed side and required additional training and advanced skill.

If Bedside methods are conflicting, The NGT was difficult to place or the child is at high risk, such as children with swallowing problems, children with altered levels of consciousness, or children in the intensive care unit,

Radiologic verification is recommended Checking for tube placement is a priority before administering any intermittent tube feeding and periodically during continuous tube feedings, regardless of the type of tube being used.

Rights of Pediatric Medication Administration

Right Medication - Check order and expiration dates. KNow action of medication and potential side effects. Ensure that the medication provided is the medication that is ordered. Right Patient - Confirm child Identity in two ways. Childrend may deny their identity in an attempt to avoid unpleasant situation, play in another child's bed, or remove ID bracelet. Confirm identity each time medication is given. Verify child's name with caregiver to provide additional verification. Use technology when available. Right Time - Give within 20 to 30 minutes of the ordered time. For a medication given on an as-needed basis, know when it was last given and how much was given during the past 24 hours Right Route of Administration - Check ordered route and ensure this is the most effective and safest route for this child; clarify any order that is confusing or unclear. Give the medication by the route ordered. If there is a need to change route, always check with prescriber. Right Dose - Calculate the recommended dose according to child's weight and double-check your calculations. Always question the pharmacist and/or prescriber if the ordered dose falls outside the recommended dose range. Unusually large or small volumes or dosages should always be verified. Right Approach - Consider child's developmental level. Provide age Appropriate explanations

Subcutaneous and Intradermal Administration

SQ distributes medication into the fatty layers of the body. Primarily for insulin, heparin and certain immunizations, MMR. Amount of tissue differs among children. preferred sites include Anterior thigh, lateral upper arms and abdomen. Use 3/8, or 5/8 inch 23- 25 gauge needles. pinch up the skin to isolate the tissue from the muscle or pull it taut depending on the amount of tissue present with non dominant hand. Insert the needle at 45 to 90 degree angle, release the skin and inject the medication. REmove the needle at the same angle it was injected. Intradermal- Deposits mediation just under the epidermis. the forearm is the usual site for administration. Usually for TB or allergy testing. uses a 1ml syringe with a 5/8in and 25-27 gauge needle, insert with the Bevel up. beneath the skin at 5 to 15 degree angle. keep finger and thumb resting on sides to keep proper angle.

If the child vomits during feeding

Stop the feeding immediately and turn the child onto his or her side or sit him or her up.

Implanted Ports

Surgically inserted by a physician Stainless steel port with a polyurethane or silicone catheter attached. Catheter tip lying in subclavian or jugular vein; port implanted under skin in a SQ pocket, usually on the upper chest wall Port is covered completely by skin and visible only as a slight bulging on the chest; Possibly more appealing to the older child and adolescent because there are no visible parts or dressings Access to port via a specially angled, noncoring needle (huber needle) Site preparation and pain relief measures necessary before accessing the port Lowest risk for central line - associated blood stream infection

Pharmacokinetics

The movement of drugs throughout the body via absorption, distribution, metabolism and excretion. Infants and young children - the absorption of orally, IM, or SQ is erratic and may be decreased. The absorption of topical medications is increased and can result in adverse effects not seen in adults.

Guidelines for Administering Medications Via Gastrostomy or Jejunostomy Tubes

Verify Correct placement Give liquid medications directly into the medication port. Draw appropriate amount into syringe and clean air. Mix powdered medications well with warm water first. If medication is in pill or capsule form, verify it is OK to crush or open. then crush tablets or open capsules and mix with warm water to prevent tube occlusion Label each syringe appropriately Give medications one at a time. Flush the tube with water after administrating each medication unless contraindicated to ensure that the entire amount of medication has been given and to prevent tube occlusion Not all medications can be placed directly into the duodenum or jejunum. Always check tube placement before administering the medication. Flush the tube to maintain patency.

Nontunneled Central Venous Catheter (CVC)

Usually used short term One or more lumens percutaneous insertion most commonly via the subclavian, internal jugular, or femoral vein with he tip of the catheter at the top of the superior vena cava just above the right atrium Useful for Emergency situations Catheter sutured in place at the exit site Increased rate of central line associated blood stream infection than tunneled CVC

Intravenous Therapy

The quickest and most effective, method of administration. Safety is crucial. The nurse must have a solid knowledge base about the fluids or medications to be given as well as a thorough understanding of the child'd physical and emotional development. Venipuncture can be terrifying, and painful for both children and their caregivers.

Rectal Administration

These medications are typically supplied in the form of suppositories. this is not a preferred route because children's absorption of the drug may be erratic and unpredictable. The method is also invasive. It is extremely upsetting for toddlers and preschoolers, as well as embarrassing for school-age and adolescents. Administer above the anal sphincter. Younger than 3- pinky finger Older than 3 - Index finger. If a bowel movement occurs in 10 to 30 minutes examine the stool for the suppository. Notify the prescriber if it is present to determine whether the medication should be given again.

Educating The child and Parents

They need to know what medications they are giving and why, how to give them and what to expect from the drug, including adverse effects. Insure thorough instructions including frequency of administration, when the next dose is due, and length of time the medication is to be given. Emphasize the importance of completing the prescribed dose. Advise against home measuring devices (spoons), and to always use the calibrating device given with the medication. If medication is given via injection parents need to learn how to properly administer injections. Encourage questions and concerns. Provide tips on the best ways to administer the medication to their child.

Nasal Administration

Typically drops and sprays. Medication should be at room temperature. Help may be needed to ensure position for younger children. Have the child blow his or her nose or use the bulb syringe to clear nasal passage of secretions. Position supine with head hyperextended to ensure drops will flow to the back of the nares. A pillow or folded towel may be used to support the hyperextension. place the ip of the dropper just at or inside the nasal opening, do not touch the nares with the dropper to avoid stimulating a sneeze. The sneeze can contaminate the drop solution . maintain hyperextension for at least 1 minute to ensure drops have come in contact with the nasal membranes. For sprays, position head upright with head tilted slightly back and place the tip of the spray bottle just inside the nasal opening and tilted toward the back. Hold one nostril closed have child breathe in with the spray. Use gentle force, too much force can push the spray solution and secretions into the sinuses or eustachian tube. In young infants, instill the medication in one naris at a time, since they are obligate nose breathers.

Otic Administration

Typically in the form of ear drops. It may be upsetting because child can not see what is happening. Explain procedure to the younger child in terms that child can understand to help allay fears. For the older child explain the purpose and procedure to gain cooperation. For children younger than 3 pull pinna down and back. 4 years old pinna is pulled up and back. make sure ear drops are room temperature, using cold eardrops can cause pain, vertigo or vomitting when they reach the eardrum. Child will be supine or side lying, with affected ear exposed. Instill the prescribed amount of meds using a dropper be careful not to contaminate the tip of the dropper. Have child remain in the position for a several minutes. massage the area anterior to the affected ear to promote passage of the medication to instill. If necessary place cotton ball loosely to the ear canal to prevent leaking.

Inserting Peripheral IV Access Devices

Used for most IV therapies, prior to insertion, review the child's diagnosis and medical history for information that may affect therapy, such as a site selection or insertion. For example a child who has a history of chronic illness may have heightened fears and anxieties related to insertion due to his or her previous experiences or difficulty in accessing IV sites. Use nondominant extremity if possible. Determine the purpose and length of the IV therapy and the type of fluid or medication that is to be administered. The device needs to be at an adequate gauge for it to allow the medication into the vein, and at the same time allowing blood flow around the device to promote dilution of the infusion Establish Rapport. Inform about the IV therapy and what to expect. Be honest with the child. Explain it will hurt for only a short amount of time. USE THERAPEUTIC PLAY TO ASSIST THE CHILD IN PREPARATION AND COPING FOR THE PROCEDURE. The insertion of an IV device is traumatic

PIV devices

Used for short term use, 3 to 5 days.

Tunneled central venous catheter

Usually for long-term use Catheter inserted by a physician via small incision in jugular, femoral, or subclavian vein and tunneled in the subcutaneous tissue under the skin Initially sutured in place to stabilize position; sutures removed after approximately 1 to 2 weeks when cuff on catheter attaches to subcutaneous tissue Single or multiple lumens Some have valves that prevent backflow of blood and air entrance

When measuring the output of an infant or child who is not toilet trained or who is incontinent

Weigh the diaper to determine the output. Remember that 1 g of weight is equal to 1 mL of fluid

Enteral Nutrition

commonly called tube feedings. Gavage feedings - nasogastric or orogastric tube feedings Gastrostomy feedings involve the insertion of the gastrostomy tube through an opening in the abdominal wall and into the stomach.

Oral Administration

have many forms including liquids (elixirs, syrups, or suspensions), powders, tablets, and capsules. crushing a time release medication allows immediate absorption of the entire dose, and can have lethal consequences. Shake liquid medications to distribute medication concentrations. Use the medicine cup or syringe with proper calibration instead of household cups or measuring spoons. Never Force an oral medication into a child's mouth or pinch the child's nose. Doing so increases the risk for aspiration and interferes with the development of a trusting relationship. parental involvement in medication administration when possible helps decrease stress on the child and provides an opportunity for teaching and evaluating parental techniques.

Instilling air into the tube and then auscultating for the sound

is no longer considered a viable method for checking tube placement as it has consistently proven to be unreliable

Preventing medication Errors

medication errors are three times higher in pediatrics compared to adults. Weight-based dosing calculations, fractional dosing, and the need to the use of decimal points. many drugs in pediatrics are formulated and packaged for adults and lack U.S. Food and Drug Administration (FDA) approval and dosing guidelines for children. Children are vulnerable to medication errors as they vary in weight, BSA, and organ maturity which effect their Ability to metabolize and excrete medications; they depend on others for medication and they need special compound medication formulations. confirming the child's identity and double-checking the dosage before administration of any medication are two critical safeguards that play a major role in preventing medications errors.

Intramuscular Administration

medication is delivered to the muscle, and is not often used because it is painful and children often lack adequate muscle mass for medication absorption. IM is used for certain medications and immunizations. The needle size - gauge is determined by the viscosity of the medication, and it must be long enough to reach the muscle and also the size of the child's muscle Injection site - Vastus Lateralis in under 12 months or anterolateral thigh muscle, in certain circumstances the gluteal muscle may be considered. (previous damage to the muscle). older than 12 months Vastus Lateralis, Anterolateral thigh muscle or Deltoid if there is sufficient mass present. Deltoid is used in children older than 3 years. Insertion of the needle should be at a 90 degree angle. CDC recommends rapid injection of Im without aspiration (2015). many experts no longer recommend use of the dorsogluteal site at any age due to the risk of damaging nerves and vasculature and the possibility of a suboptimal immune response.

Ophthalmic Administration

supplied in drops or ointments Provide age appropriate explanations to gain cooperation. Have child keep eyes closed before administration of the medication. Ensure that med is at room temperature. Try to give when child is not crying, and help to hold hands to avoid eye injury. Place child in supine positions with neck hyperextended. Rest the heel of your hand on the child's forehead to stabilize it. Retract lower eye lid and place med in conjunctival sac; Be careful not to touch the tip of the medication on the eye and maintain a sterile technique. For Drops place the prescribed number of drops in each eye. For Ointment apply the med in a think ribbon from inner canthus outward without touching the eye or lashes. If child is old enough to cooperate instruct child to gently close eyes to allow med dispersement. uncooperative children may need to be immobilized. One to Two drops in the inner canthus of a closed eye can be administered while the child is supine, then instruct the child to open the eyes so that the medication can enter the eye.

Midline Catheters or Peripherally inserted central catheter (PICC)

use for therapy that is to exceed 6 days, they are longer than PIV but still remain outside the central veins and can stay in for up to 2 months. they are seated deep in the cephalic or basilic veins, but the tip does not extend past the axilla.

Central Access Devices

used when the child lacks suitable peripheral access, and requires IV fluid or medication for a prolonged period of time, or is to receive specific treatments such as the administration of highly concentrated solutions or irritating drugs like chemotherapeutic agents. Advantageous because it provides vascular access without the need for multiple IV starts, decreasing discomfort and fear. However they are associated with complications such as infection, sepsis, and thrombosis due to partial occlusion of the vessel. Chest radiograph is performed after a central venous access device is inserted to verify proper placement. nothing is administered until correct placement is confirmed.