Ch 8. (Safe Administration of Medication)

Intravenous (IV) Medications

Peripheral venous access devices ■ Use a 24- to 20-gauge catheter. ■ Use for continuous and intermittent IV medication administration. ■ A child who requires short-term IV therapy may complete it at home with the assistance of a home health nurse.

Administer medications via a feeding tube.

■ Confirm placement. ■ Use liquid formulation. ■ Do not add medication to the formula bag. ■ Flush with water to clear tubing of residual medication.

Intradermal

- Administer on the inside surface of the forearm. - Use a TB syringe with a 26- to 30-gauge needle with an intradermal bevel. - Insert needle at a 15° angle. - Do not aspirate.

Nursing Interventions (Medication Administration)

- Calculate the safe dosage for medication. - Notify the provider if medication dosage is determined to be outside the safe dosage range, and for any questions about medication preparation or route. - Double-check high-risk and facility-regulated medications with a second nurse. - Perform the six rights of medication administration. - Use two client identifiers prior to administration: client name and date of birth. Use parent(s) for verification of infants or nonverbal children. However, two identifiers from the ID band must be confirmed: client name, date of birth, or hospital identification number. - Determine parental involvement with administration. - Allow the child to make appropriate choices regarding administration (choosing the left or right leg, whether the parent or nurse will administer the medication). - Prepare the child according to the developmental stage and age.

Injection Medications

- Change needle if it pierced a rubber stopper on a vial. - Secure the infant and child prior to injections. - Assess the need for assistance. - Avoid tracking of medication. - When selecting sites, consider: ■ Medication amount, viscosity, and type. ■ Muscle mass, condition, access of site, and potential for contamination. ■ Treatment course and number of injections. ■ Age and size of child.

Subcutaneous (SQ)

- Give anywhere there is SQ tissue. Common sites are the lateral aspect of the upper arm, abdomen, and anterior thigh. - Inject volumes of less than 0.5 mL. - Use a 1 mL syringe with a 26- to 30-gauge needle. - Insert at a 90° angle. Use a 45° angle for children who are thin. - Check policy for aspiration practices.

Rectal Medication

- Insert beyond both rectal sphincters. - Hold the buttocks gently together for 5 to 10 minutes. - Halve the medication lengthwise, if necessary. - Provide atraumatic care. ■ Perform the procedure quickly. ■ Use distraction.

Assessment

- Medication and food allergies - Appropriateness of medication dose for the child's age and weight - Child's developmental age - Tissue and skin integrity when administering IM, subcutaneous, and topical medications - IV patency when administering IV medications

Otic Medication

- Place the child in a prone or supine position with the affected ear upward. - Children younger than 3 years: pull the pinna downward and straight back. - Children older than 3 years: pull the pinna upward and back. - Provide atraumatic care. ■ Allow refrigerated medications to warm to room temperature prior to administration. ■ Massage the outer area for a few minutes following administration. ■ Play games with younger children.

Optic Medication

- Place the child in a supine or sitting position. - Extend head and ask the child to look up. - Pull the lower eye lid downward and apply medication in the pocket. - Administer ointments before nap or bedtime. - Provide atraumatic care. ■ If infants clinch their eyes closed, place the drops in the nasal corner. When the infant opens his eyes, the medication will enter the eye. ■ Apply light pressure to the lacrimal punctum for 1 minute to prevent unpleasant taste. ■ Play games with younger children.

Nasal Medication

- Position the child with the head extended. - Use a football hold for infants. - Provide atraumatic care. ■ Insert the tip into the naris vertically, then angle it prior to administration. ■ Play games with younger children.

Oral Medication

- This route of medication administration is preferred for children. - Determine the child's ability to swallow pills. - Use the smallest measuring device for doses of liquid medication. Use an oral medication syringe for smaller amounts, and a medication cup for larger amounts. - Avoid measuring liquid medication in a teaspoon or tablespoon. - Avoid mixing medication with formula or putting it in a bottle of formula because the infant may not take the entire feeding, and the medication may alter the taste of the formula. - Hold the infant in a semi-reclining position similar to a feeding position. - Hold the small child in an upright position to prevent aspiration. - Administer the medication in the side of the mouth in small amounts. This allows the infant or child to swallow. - Only use the droppers that come with the medication for measurement. - Stroke the infant under the chin to promote swallowing while holding cheeks together. - Teach the child to swallow tablets that aren't available in liquid form and can't be crushed. ■ Teach in short sessions using verbal instruction, demonstration, and positive reinforcement.

Intramuscular (IM)

- Use a 22- to 25-gauge, ½- to 1-inch needle. - Vastus lateralis is the recommended site in infants and small children. ■ Position the child supine, side lying, or sitting. ■ Inject up to 0.5 mL for infants. ■ Inject up to 2 mL in children.

Aerosol Medication

- Use mask for younger children. - Provide atraumatic care. ■ Allow parents to hold during treatment. ■ Use distraction.

Provide atraumatic care

■ Apply eutectic mixture of lidocaine and prilocaine (EMLA) to the site for 60 min prior to injection. ■ Change needle after puncturing a rubber stopper. ■ Use the smallest gauge of needle possible. ■ Secure the child firmly to decrease movement of the needle while injecting. ■ Use distraction. ■ Use play therapy. ■ Offer sucrose pacifiers to infants.

Provide atraumatic care

■ Decide to insert a PICC before multiple peripheral attempts. ■ Use a trans-illuminator to assist in vein location. ■ Avoid terminology such as a "bee sting" or "stick." ■ Attach an extension tubing to decrease movement of the catheter. ■ Use play therapy. ■ Apply EMLA to the site for 60 minutes prior to attempt. ■ Keep equipment out of site until procedure begins. ■ Perform procedure in a treatment room. ■ Use non-pharmacologic therapies. ■ Allow parents to stay if they prefer. ■ Use therapeutic holding. ■ Avoid using the dominant or sucking hand. ■ Cover site with a colorful wrap. ■ Swaddle infants. ■ Offer non-nutritive sucking to infants before, during, and after the procedure.

Provide atraumatic care.

■ Mix the medication in a small amount of sweet fluid. ■ Offer juice, a soft drink, or snack after administration. ■ Have the child pinch her nose before, during, and shortly after administration. ■ Add flavoring to medications. ■Use a nipple to allow the infant to suck the medication.

Deltoid

■ Position the child sitting or standing. ■ Inject up to 1 mL.

Ventro-gluteal

■ Position the child supine, side lying, or prone. ■ Inject 0.5 to 1.0 mL depending on muscle size of infant. ■ Inject up to 2 mL in children.

Central venous access devices

■ Short term: nontunneled catheter or peripherally inserted central catheters (PICC). ■ Long term: tunneled catheter or implanted infusion ports

Overview

● Growth and organ system maturity affect the metabolism and excretion of medications in infants and children. ● Administration of medications to the pediatric population can be challenging, and requires that a nurse be patient and creative. ● Pediatric dosages are based on age, body weight, and body surface area (BSA).