Administration of Medications in Pediatrics By Dr. Nahed Said El-nagger

Learning Objectives Prepare medications for administration. Administer drugs to patients by variety of routes. Calculating dosage formulas. Demonestrates nurses role in drug administration.

Purposes of drug administration Hydrate body cells and tissues. Relieve symptoms. Promote health and prevent disease. Aid in diagnosis.

Essential parts of a drug order The child’s name, room and bed number. Date and time the order is written. Drug name. Dosage of drug Time and frequency of administration Route of administration Signature of the person writing the order.

Ten rights of medication administration Right medication Right dose Right time Right route Right child Right child/caregiver education Right documentation Right assessment Right evaluation

Rules Calculating dosage formulas 1. Calculating on basis of age: Adult dose X the child’s age = child dose 150 )a. Fried’s rule)used for infant under 2years Ex. Digoxin is prescribed for a 15 month old infant using formula 0.25mg.

Rules Calculating dosage formulas 1. Calculating on basis of age: Adult dose X the child’s age (Yrs) = child dose Child’s age + 12 )b. Young’s rule). Ex. If the adult dose is 600mg every 6 hrs, the 3 years old child is follows:

Rules Calculating dosage formulas II.Calculation on basis of Weight: Weight of the child in (kg)X adult dose = child dose 70 )Clark’s rule).accurate for 2 years child& more Ex. Aspirin (10mg) is prescribed for 2 years old child who wt. is 14 kg.

Routes of drug’s administration 1. Oral administration

Routes of drug’s administration 2. Topical route (eye, oral, nose, ear, rectal, skin ) applied directly to the mucus membrane are absorbed quickly, may cause systemic effects. Drugs applied on the skin are absorbed into the dermis where they have a local effect.

Routes of drug’s administration Eye administration (drops or ointment)

. Buccal In buccal administration a medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves Provide a local effect

. Rectal

3. Respiratory route Inhalants such as Oxygen, & Nebulizer

4. Parenteral Subcutaneous Intramuscular Intradermal Intravenous The Parenteral route is defined as other than through the alimentary or respiratory tract , that is by needle. More common routes: Subcutaneous Intramuscular Intradermal Intravenous

Subcutaneous Route: Into the subcutaneous tissue, just below the skin (45 angle). Used for immunization as Measles (0.5 ml in the right arm). Can administer only small volume. Not use needle more than 1.5 ml. Used for insulin injection.

Intradermal Under the epidermis (into the dermis) Used for immunization of B.C.G (Bacillus of Calmette- Gurein( 0.05 ml in the left upper arm. Disadvantage Amount of drug administered must be small Breaks skin barrier

Intramuscular Can administer large volume than subcutaneous. Into a muscle Can administer large volume than subcutaneous. Drug is rapidly absorbed. Used in drug administration & immunization of: - DPT (0.5ml left thigh) - Hepatitis B (0.5ml Right thigh).

Intramuscular injection

Intramuscular Injection   Purpose :- A drug is administered by intramuscular route when: A more rapid action is required than oral. Giving medication into muscle.

Intramuscular Injection Equipment :- Tray. Appropriate syringe and needle size. Spirit lotion in container and swabs. Prescription sheet. Drug to be administered (vial or ampoule). Sterile saline bottle or ampoule of sterile distilled water.

Intramuscular Injection Explain to the parent or to the child what you plan to do. Rationale: To reassure the child or the parent through knowing of what will happen and to gain co-operation. 2. Select the site.

Vastus lateralis (for infant and young child). Recommended Injection Sites for children: Vastus lateralis (for infant and young child). Rectus femoris (for infant and young child). Ventrogluteal area (any age). Gluteal region (children who have been walking for at least one year). Deltoid muscle for older child.

Intramuscular Injection

Intramuscular Injection

Intramuscular Injection The proper location for an injection is in the upper outer quadrant of either buttock.

Intramuscular Injection Upper arm (deltoid muscle)

Intramuscular Injection Wash hands. To avoid transferring of microorganisms. Hold infant in cradle position with arms and legs secured by mother or assistant. To avoid movements leading to unnecessary injury.  

Intramuscular Injection Clean the site with an antiseptic swab using a circular motion from inner to outer. Remove the needle cover. Expel air bubbles unless one is to be left.

The muscle mass of the thigh to be injected in firmly grasped in one hand to stabilize the limb and compress the muscle mass for injection with other hand.

Intramuscular Injection Insert the needle at 90degree angle using quick darting motion. This angle facilitates medication to reach muscle.

Intramuscular Injection Stretch the skin taut between thumb and forefinger. Grasping the muscles in children increases muscle mass and insures needle placement. In muscle belly rather than striking bone.

Intramuscular Injection Fix the syringe with left hand and aspirate before injecting if blood is revealed, the needle must be withdrawn and reinserted. To avoid injuring to the small vessels or nerves.

Intramuscular Injection Inject the content of syringe slowly. To avoid distention of tissues. Press the cotton against the injection site and pull the needle quickly. Move the limb or massage the site with sponge, if bleeding occurs apply pressure (with dry sponge) to the site until it stops.

Intramuscular Injection Dispose of supplies according to agency procedures. To protect you and others from injury and contamination. Hold the child and try to please or give him/her any toy according to his age. .

Intramuscular Injection Wash hands. Record the medication time, date, route, site, dosage, how the child tolerated the medication administration, any observation and signature.

Intravenous therapy Definition It is an effective and efficient method of supplying fluid directly into veins producing rapid effect with availability of injecting large volume of fluid more than other method of administration.

Indications of I.V. therapy Intravenous infusions are used when: Childs need fluids, electrolytes, or nutritional supplements. Infuse blood or blood products. Administration of intravenous medications.

Types of Intravenous Solutions Isotonic solutions: Most IV solutions are isotonic, having the same concentration of solutes as blood plasma. Isotonic solutions are often used to restore vascular volume. E.g. 0.9% NaCl ( normal saline ) . Lactated Ringer’s. 5% dextrose in water ( D5W ).

Types of Intravenous Solutions (cont.) Hypertonic solutions : Have a greater concentration of solutes than plasma. E.g. 5% dextrose in normal saline(D5NS ). 5% dextrose in 0.45% NaCl. 5% dextrose in lactated Ringer’s. Hypotonic solutions : Have a lesser concentration of solutes. E.g. 0.45% NaCl (half strength normal saline ) and 33% NaCl (one-third normal saline).

Categories of intravenous solutions according to their purpose: Nutrient solutions. Electrolyte solutions. Volume expanders.

Parenteral Nutrition (PN) Parenteral nutrition is a form of nutritional support that supplies protein, carbohydrate, fat, electrolytes , vitamins, minerals, and fluids via the IV route to meet the metabolic functioning of the body.

Venipuncture Sites Age. Length of time the infusion is to run. The site chosen for Venipuncture varies with the client’s: Age. Length of time the infusion is to run. Type of solution used. Condition of vein.

Commonly used Venipuncture sites For infants: Veins in the scalp and dorsal foot veins are often used.

Catheter Selection Butterfly. Only used for scalp veins, sometimes used for obtaining blood samples procedure only. Discouraged due to shorter dwell time. Catheter used in newborn services is in sizes 24 gauge, and 22 gauge).

Vein Selection The first choice of sites is the periphery to maximize available vein sites. In neonates, the veins of the anterior aspect of the hands and feet are the most visible. Scalp IVs are to be avoided. If necessary, this is usually performed by an ANP Veins used for long line insertion are not to be cannulated.

Select a site in where the vein is relatively straight the area is not bruised there is a vein that has not been infiltrated previously.

Consider: the baby's size, age, and gestation the type and rate of infusion(s) and/ or medications infusing why the baby needs an IV. Is this the baby's last dose of antibiotics? Could they be given I.M. instead? Is the baby almost on full feeds?

Central Venous Catheters Are inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium.

Central Venous Catheters (cont.) Indications: Long term IV therapy or parenteral nutrition. IV medications that are damaging to vessels ( chemotherapy).

I.V. infusion methods 1. I.V. Bolus (I.V. push): The term bolus refers to a substance that is given all at one time. This method is used to achieve as an immediate effect (as in an emergency).

I.V. infusion methods (cont.) 2. Continuous-drip infusion: Continuous-drip infusion is the slow instillation (over several hours) of a parenteral fluids and diluted drugs in large volume (500-1000ml).

I.V. infusion methods (cont.) 3. Intermittent infusion: It is one in which I.V. medication is given within a relatively short period of time (minute up to 1 hr) or at specific intervals (e.g. every 4 hours).

Intravenous Equipment Correct client. Correct IV solution. Proper catheter for Venipuncture. IV start kit. Correct tubing.

Equipment of I.V. therapy I. Solution containers: Solution containers are available in various sizes (50, 100, 250, 500, or 1000 ml); may be plastic or glass.

Equipment of I.V. therapy (cont.) II. I.V. administration sets: They can be classified as primary, secondary (volume-controlled set and piggyback), and parallel or Y infusion sets. Syringe Pump

Equipment of I.V. therapy (cont.) 1. Primary sets: Micro drip sets, also called a minidrip or pediatric set, used when small volumes are being delivered (e.g. less than 50ml/hr), have a drip rate factor (DRF) of 60 drops/ml fluid.

Equipment of I.V. therapy (cont.) 2. Secondary sets: Volume-controlled set Also called metered-volume chamber as show frequently used with infants or in adult for intermittent infusion of medication, infusing small amount of fluid (100-150ml) over long period, and where the volume administered is critical.

IV catheters

Regulating and Monitoring IV Infusions Drip factor: The number of drops delivered per milliliter of solution varies with different infusion sets.

Drip factor Milliliters per Hours total infusion volume = ml/h total infusion time

Drip factor (cont.) Drops per Minute: = total infusion volume in drop factor total time of infusion in minutes

Complications of IV Cannulation Local and systemic infections Phlebitis Thrombus Air Embolism Accidental insertion into an artery Bleeding if disconnected Extravasation

Signs and symptoms of infiltration include: swelling pain coolness of skin leakage at site erythema blistering lack of blood return

Recognition and Prevention of IV Infiltration Injuries An IV infiltration can be disastrous to a neonate's skin. Tissue necrosis can occur, as well as full thickness skin and muscle necrosis is possible. Plastic surgery may be necessary in extreme cases. It is extremely important to observe IV sites closely, at least hourly, more often in cases of high infusion rates, caustic solutions, and small fragile veins.

Prevention Measures Avoid butterflies for infusion. Avoid areas difficult to immobilize. Avoid dorsum of foot in active babies, especially larger babies in cots. Always expose the IV  site if the baby is in a cot Secure so site is clearly visible.

Prevention Measures Tape loosely enough to maintain circulation. Dilute medications per drug protocol. Assess catheter site and distal region hourly Stop infusion immediately if signs of infiltration are present. 

Taping Peripheral IV Cannulae IVs are taped so the site directly over the tip of the cannula is visible for observing signs of infiltration. Tape is not to be placed over pre-existing tapes. If an IV require re-taping, existing tape must be removed first. Tape so that it will be easy to remove. Consider making tabs at the ends of each tape to help with easier removal.

Taping Peripheral IV Cannulae DO NOT use scissors to remove tapes. Nailbeds need to be visible for assessing peripheral circulation. Do not tape too tightly which could interfere with circulation of the extremity.

Taping Peripheral IV Cannulae Tape in a way that is developmentally appropriate for that baby. If the IV is in the hand, ensure fingers are flexed over armboard and thumb is free. Feet are to be taped in an anatomical position with toes visible. Minimize restrictive movement as much as possible. Make sure baby will be comfortable after taping.

The End THANK YOU