PEDI ATRIC SKILLS LAB ADMINISTRATION OF INJECTABLE MEDICATIONS

THE FIVE RIGHTS!-THE RIGHT PATIENT-THE RIGHT DRUG-THE RIGHT TIME-THE RIGHT DOSE-THE RIGHT ROUTE

IMPORTANT STEPS TO REMEMBER:

-COMPARE MAR (MEDICATION ADMINISTRATION RECORD) WITH ORDER-LOOK UP MEDICATION IN FORMULARY AND REVIEW SAFE DOSE RANGE, ACTION, SIDE EFFECTS, AND DRUG INTERACTIONS-DOUBLE CHECK DRUG ALLERGIES-PERFORM ACCURATE MEDICATION CALCULATIONS (OBTAIN CHILD'S WEIGHT IN KG OR CONVERT LBS TO KG (1KG=2.2LBS)-CALCULATE SAFE RANGE

INTRAMUSCULARE ADMINISTRATION:

-MUST CONSIDER TISSUE SIZE, MASS, AND AGE-ESSENTIAL TO IDENTIFY LANDMARKS IN ORDER TO IN SELECT CORRECT LOCATION-VASTUS LATERALIS SITE MOST COMMON IN PEDIATRICS-NEEDLE LENGTH/GAUGE SELECTION INVOLVES NURSING JUDGEMENT: LONG ENOUGH TO INJECT PAST SUBCUATANEOUS TISSUE INTO MUSCLE BUT NOT BEYOND INTO BONE-RESTRAINTS OR MORE THAN ONE NURSE MAY BE NEEDED TO GIVE INJECTION SAFELY IF CHILD AGITATED: USE DISTRACTION AND HAVE PARENTS PRESENT TO HELP ALLEVIATE ANXIETY-AFTER THE MEDICATION IS DRAWN INTO THE SYRINGE CHANGE THE NEEDLE PRIOR TO ADMINISTRATION. INSERTION OF THE NEEDLE THROUGH A VIAL STOPPER DULLS THE TIP OF THE NEEDLE, AND RESIDUAL MEDICATION ON THE NEEDLE MAY IRRITATE TISSUE AND/OR MUSCLE-AFTER INJECTION CHILDREN SHOULD BE COMFORTED AND GIVEN A REWARD

SUBCUTANEOUS ADMINISTRATION:

-SITES SIMILAR TO ADULTS-SUBCUTANEOUS TISSUES OF THIGH AND UPPER ARM MOST COMMON

-NEEDLE LENGTH/GAUGE SHORTER THAN WITH IM IN ORDER TO INJECT ONLY INTO SUBCUTANEOUS TISSUE-RESTRAINT/SUPPORT SIMILAR TO ABOVEPRACTICE:UTILIZE SCENARIOS (ATTACHED) CHOOSE APPROPRIATE SITES FOR IM VS. SQIDENTIFY LANDMARKSSTUDENTS SHOULD CHOOSE APPROPRIATE SIZE NEEDLE (LENGTH & GAUGE) ACCORDING TO SCENARIO

SAMPLE MEDICATION CALCULATIONS:

ODER: PHENERGAN 20MG IM Q 6 HOURSWEIGHT: 99 LBSPEDIATRIC DOSE: 0.25-0.5MG/KG/DOSEAVAILABLE: PHENERGAN 25MG/CC

CALCULATION: 99LBS= 45 KG25MG = 20MG 1CC X

X= 0.8CC (3.2CC/DAY = 80MG/DAY)

RANGE: 0.25-0.5MG/KG/DOSE= 11.25-22.5MG/DOSE THEREFORE 20MG DOSE IS APPROPRIATE

ORDER: HYDROXYZINE 12 MG IM Q 6 HOURSWEIGHT: 24 KGPEDIATRIC DOSE: 0.5-1MG/KG/DOSE Q 6 HOURSAVAILABLE: HYDROXYZINE 25MG/CC

CALCULATION:

25MG = 12 MG1CC X

X= 0.48 CC (1.92CC/DAY)= 48 MG/DAY)

RANGE: 0.5-1 MG/KG/DOSE = 12-24 MG/DOSE THEREFORE DOSE OF 12 MG IS APPROPRIATE

IM SCENARIO #1

BJ IS RECOVERING FROM SURGERY IN WHICH HE HAD HIS ARM REPAIRED FOR A COMPOUND FRACTURE. THE MD HAS ORDERED KETOROLAC 17.5MG Q 6 HOURS FOR PAIN.

WEIGHT: 77 LBSSAFE DOSAGE RANGE: 0.5MG/KG/DOSE Q 6 HOURSDRUG AVAILABLE: KETOROLAC 30MG/CC

IS THIS A SAFE DOSE FOR BJ?

WHAT VOLUME WILL YOU INJECT?

IM SCENARIO #2

Johnny is a 3 year old with pneumonia complicated by his cystic fibrosis. The MD has ordered Gentamicin 48 mg IM q 6 hours for the infection.Johnny's weight: 34 lbsSafe dosage range: 2.5-3.5 mg/kg/doseDrug available: 40mg/cc

Is this a safe dose for Johnny?

What volume will you inject?

PEDIATRIC INTRAMUSCULAR INJECTION SITES

SITE RECOMMENDED AGE PROS & CONSVastus Lateralis

Infant-AdultPreferred for children < 3 years of age

Largest muscle group in children < 3 yrs of age

Can tolerate large injection volumes (0.5-2.0 cc)

Area free of important nerves or blood vessels

Ventrogluteal

Infant-AdultConsider for children > 3 years of age

Can tolerate large injection volumes

Area free of important vessels or nerves

Easily accessible site Health care providers

often unfamiliar with siteDorsogluteal

Contraindicated in children < 3 years Patient must have been walking > 1year

Large muscle mass in older children

Can tolerate large injection volumes

Danger of injury to sciatic nerve

Exposure of site may cause embarrassment in older children

Deltoid Infant-Adult Small muscle mass Can tolerate only small

injection volumes (0.5-1.0cc)

Easily accessible site Rapid absorption rate Danger of radial nerve

injury in young children

ADAPTED FROM ENPC PROVIDER MANUAL, 1998

PEDIATRIC SKILLS LABAdministration of PO Medications

THE FIVE RIGHTS!-The right patient-The right time-The right drug-The right route-The right dose

Important Steps to Remember:-Compare MAR (medication administration record) with order-Look up medication in formulary and review safe dose range, action, side effects, and drug interactions-Double check drug allergies-Perform accurate medication calculations (obtain child's weight in kg or convert lbs to kg ( 1 kg = 2.2 lbs)-Calculate safe range

DEVICES FOR MEASUREMENT:-Calibrated syringe most accurate-Calibrated measuring cup for doses > 10cc: the bottom of the liquid meniscus is the measuring point-Calibrated droppers, medication teaspoon designed specifically for med administration-Household teaspoons can vary-not accurate-One teaspoon = 5 cc

DELIVERY OF ORAL MEDICATIONS:-Depends upon child's ability to suck, swallow, drink, or chew-Oral liquids preferred until about 5 years of age-Most children at least 21/2 years of age may be able to take chewable form-Medications can be crushed & mixed with solution (ie, G-tube); check with pharmacist first for drug/food interactions. Do not crush time release or enteric coated

TECHNIQUES FOR ADMINISTRATION:-Child should be secure & comfortable; crying can increase risk of aspiration-Beginning at toddlerhood, children should be told they are receiving medication-Do not try to "hide" it, even if mixed with pleasant tasting vehicle-Position infants/toddlers in semi-sitting, cradle in lap, sitting on own or if in bed the head lifted to facilitate swallowing

-Place med half-way down tongue on side of oral cavity, slow delivery (1-1.5cc/squirt to prevent aspiration)-To assist with swallowing, hold mouth closed and lift chin-Try not to force administration: use patience & reassurance, be firm yet gentle, give older children some independence in taking medication-If older children/adolescents can swallow pills, make sure patient has indeed swallowed med: check under tongue/sides of cheeks

PRACTICE CALCULATIONS:

ORDER: Benadryl 25 mg PO q 6 hoursWEIGHT: 55 lbsDOSE: 5 mg/kg/dayAVAILABLE: Bendadryl 12.5 mg/5cc

Calculation: 55 lbs = 25 kg12.5 mg = 25 mg5cc x

X= 10cc q 6 hours (40ml/day= 100 mg/day)

Safe range: 5/mg/kg/day = 5 mg x 25 = 125mg/day therefore dose is appropriate

ORDER: Gantrisin 1.5 gm PO qidWEIGHT: 30.4 kgDOSE: 150-200 mg/kg/dayAVAILABLE: Gantrisin 500 mg tablets

Calculation: 500mg = 1500 mg1 x

x= 3 tablets qid (6000mg/day)

Safe range: 150-200 mg/kg/ day = 4560-6080mg/day therefore dose is appropriate

TIPS FOR MEDICATION ADMINISTRATION

ROUTE CONSIDERATIONOtic Children < 3 years of age, pull pinna down and back.

Children > 3 years of age, lift pinna up and back.Nasal Have parent hold the child across their lap with the child's head down. Place the child's

arm closest to the parent around the parent’s back. Firmly hug the child's other arm and hand with their arm; snuggle the head between the parents body and arm.

Eye Explain the procedure. Tell the child the medication will feel cool. Have the child lie on their back with their hands under their buttocks. Have the child look up. Provide distractions.

Oral Infants: Administer medication in nipple, follow with 5cc of sterile water. Medication can also be administered with a syringe and dropper; place the syringe / dropper between the gum and cheek. Administer no more than 1/2cc of medication at one time.

Chewable tablets: Do not administer to children without teeth. Give them something to drink afterwards.

Caplets: Do not crush enteric-coated caplets. Capsules: Do not open up if medication is sustained - release. Check with pharmacy

before opening any capsules for administration. Avoid mixing medications with formula as the infant may refuse the formula thereafter. When mixing medications with food or fluids, use as little as possible, because they

may not be able to finish all the food or fluids.Rectal Consult a pharmacist prior to cutting a suppository; the medication is not necessarily

distributed evenly through the suppository (i.e., acetaminophen suppositories must be divided lengthwise, not widthwise).

Subcutaneous (SQ)

Usual amount of administration is 0.5 - 1.0cc. Sites include deltoid, anterior thigh, anterior abdominal wall, or inter/subscapular

region. Insert needle at a 90o angle. Needle size: Infant or thin child 25 or 26g, 3/8".

Larger child 25 or 26g, 5/8".Intramuscular (IM) See discussion in this skill station.

For the immunocompromised child, cleanse the site with Betadine and alcohol. Consider placing a wrapped ice cube on the site for approximately one minute prior to

injection.Intravenous (IV) Use as little diluent as needed.Long-term Venous Access Devices

May require a special needle to pierce the port (e.g., MediPort requires a Huber needle). Certain catheters are above the skin (Groshong catheters) while others are under the

skin (Port-a-Cath, Infus-A-Port, MediPort). May require daily or weekly flush to maintain patency (Hickman / Broviac and

Groshong catheters). Implanted ports must be flushed monthly and after each infusion. Above the skin catheters may be damaged by sharp instruments and are at risk of being

pulled out. The Hickman / Broviac catheter must be clamped or have a clamp nearby; the Groshong

catheter should not be clamped (contains a two-way valve).

PEDIATRIC SKILLS LABASSSESSMENT

Review of pediatric assessment (pertinent for hospitalized child, not exhaustive)

Students will receive an assessment outline in their Clinical Reference Manuals as well

I. General Appearancea. Content, comfortable, agitated, restlessb. Activity, alertnessc. Quality of cry if presentd. Well or poorly nourishede. Respiratory effortf. Colorg. Hydrationh. Mobile or confined to bed

II. Equipmenta. Be aware of equipment during entire examb. IV, epidural, trach tube, pulse ox, heart monitor,

dressing/drains, G-tubec. Make sure emergency equipment at bedside:

oxygen, suction, BVM, call button, "core sheet" with calculated emergency medications (may be institution specific)

III. Skina. Color/temperatureb. Hydration (turgor)c. Rashes, lesions, bruisesd. Nails (capillary refill)e. Blanching

IV. Heada. symmetryb. sutures/ridges (may be felt up to 6 mos.)c. fontanelles (posterior closes by 2 mos; anterior by

18 mos)d. lesions

V. Eyesa. general appearnace(sunken, swollen, eye contact)b. pupils (PERRLA), strabismusc. able to focus & follow objectsd. conjunctiva (discharge, redness)

VI. Earsa. symmetryb. gross hearing

VII. Nosea. Drainage, crustingb. Pain, tenderness, foul odor

VIII. Moutha. mucous membranes (lips, gums, inside cheeks)b. symmetry of tonguec. palate/pharynxd. teeth/cavities

IX. Necka. Mobilityb. Symmetryc. Pain, visible masses

X. Lungsa. symmetry, accessory muscle involvement with

breathingb. listen to breath sounds when patient not crying (if

possible)c. rate of respirations, adventitious sounds, work of

breathingd. infants & young children have abdominal breathing

XI. Hearta. auscultate heart sounds (apical pulse for full

minute)b. note heart rate regularity, murmursc. perfusion status (central vs peripheral pulses)

XII. Abdomena. symmetryb. umbilicusc. bowel sounds in all four quadrantsd. femoral pulses

XIII. Genitaliaa. MALE: urinary meatus at tip of penis, discharge,

rednessb. Circumcised or uncircumcisedc. Both testes descendedd. FEMALE: urinary meatus and vaginal openings

visiblee. discharge, rednessf. labia symmetrical

XIV. Anusa. anal sphincter toneb. fissures

XV. Extremitiesa. symmetricalb. color, temperaturec. ROM, gaitd. Fingers/toes

XVI. Backa. symmetricalb. deformitiesc. scoliosis (scapula equal, iliac crests equal)d. tufts of hair at base of spine

XVII. Neuro:INFANTS: babinski positive (up to age 2yrs.) Equal plantar/palmer reflex Tonic neck reflex (up to 5 mos.) Moro reflex (up to 5 mos.)OLDER CHILDREN: fine & gross motor coordination age specific Senses intact Language Memory Abstract thinkingXX. Vital Signs

a. HR RR during chest examb. Temp at beginning or end c. BP may be upsetting in infants, may leave for last

XXI. HELPFUL TIPS: communicate with parents throughout assessment, let them know what you are doing, talk to child, explain what you are looking at before you do it so they are less anxious, talk to infants as well even if they don't understand; soothing voice helps provide comfort. Illicit parents' concerns and any changes or improvements they have noticed since last assessment.

Revised: Karen LeDuc, MS RN CPN CNS 2006