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Pediatric Medication Administration

Presented by

Amy Davidson,RN, BScNUpdated March 2013

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Objectives

The Learner shall:

- Identify the differences between adult and pediatric medication administration for all routes of administration– Describe the decision making process associated with

intermittent IV and continuous medication administration– Prepare and administer medication correctly as per current

policies/procedure/guidelines– Document as per patient care policy (19.6) and Corporate

Administrative Directives (CAD) 2.3.4, 2.3.5 – Identify the medications they may administer within their current

scope of practice.

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Medicating a child is not just like medicating a small adult. Consider….

Physiologic differences- immature system in the neonate and children under 2 years of age means med administration is less predictable and riskier. Differences are related to the following factors:

• A. Diluting effect-distribution of body fluids + increased metabolic rate + inefficient concentration of urine = diluting effect of some meds. This means that children require a higher dose than normally expected.

• B. Permeability of membranes- Increased permeability of skin and blood-brain barrier = greater absorption of certain meds (danger of toxicity)

• C. Absorption of oral medication- Immature GI system increases transit time which can decrease absorption

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Oral Medication

Consider:• Child’s ability to suck, swallow, and drink• Position child upright, semi-upright

• Restraint may be needed

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Modes of Delivery

• Liquids- syringe (no needle)

- nipple (not if bad tasting)

• Pills/Capsules- Identify if child can swallow pills(may come in chewable, liquid or dissolvable)

- Crushing pills (if they can be crushed)drug retains taste thereforedilute in syrup (small amount) or mix with food such as juice, jam, yogurt

Remember: The child must take the whole dose so keep the volumes as low as possible yet still mask the taste!

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Oral meds continued…

• Do not pinch nose/aspiration risk• Pharmacy can make most meds into liquid suspension • If medication thrown up

-within 15 min, repeat dose

-greater than 15 min, confirm with the physician whether to repeat or not-consider... was part of med taken, type of med given, pill visible in emesis

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Medications via Gastric Tubes

• NG, NJ, GT,GJ and GJ/T possible modes• Always confirm placement first• Ideally flush with water, give med, flush with water again (consider

fluid restrictions and consistency of med)

• Try not to admin. crush pills per NJ as it tends to get clogged (may be unavoidable so crush well)

• G-tube, use proper accessories (as per Enteral feed presentation)

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Ophthalmic Instillations

Eye Drops:• Head back• Look up, retract lower conjunctive sac• Move dropper from outside, below child’s line of vision (to decrease

blinking)• Apply pressure to nasolacrimal duct (at inner corner of eye to

prevent med from being lost through nose)• Increase absorption if blinking is minimized (keep eyes closed)

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Ophthalmic Instillations

Ointment:• Squeeze onto conjunctive sac• Close eye (will spread med)

• If child will not open eye, apply to inner corner of the closed eye, then have child open eye which will spread medication

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Otic Instillations

• Head to side• Less than 3 years- pinna pulled down and back• Greater than 3 years- pinna pulled up and back

• Apply gentle pressure and massage outer ear to spread medication

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Inhalations Medications

• Will be covered in respiratory lecture

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Rectal Medications

• Route used to avoid IM injections and when fluids not well tolerated

(i.e. post-op vomiting)• Inappropriate route for neutropenic patients

• Prepare child emotionally as invasive and embarrassing

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PR Administration

• Positioning

-side-lying/upper leg flexed (older child)

-supine/knees flexed (infant, young child)• Lubricate• Depth- 5cm or less for small child

- 10cm or less for a full grown child• Pinch buttocks/get child to relax• Partial dose- cut suppository lengthwise

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SC and IM Injections

• Not routinely done• No other route• Never do alone• Use appropriate holds (not like this picture!)• IM Sites (rotate sites)

- most acceptable is vastus lateralis

-do not inject into posterior gluteal

- an alternative is the deltoid• Consult the Child Health policy 15.7

for IM injections

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IM Injections continued..

• Use short needle (1 inch)-90 degrees-aspirate-inject at moderate rate-withdraw clean

• Tent tissue• 1-2 ml maximum (depending on age and size of pt.)• Prepare child, involve Child Life• Comfort measures• Do not massage if irritating, anticoagulant

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Medication Specifics:Cyclosporine

• Oral form neoral• use syringe that comes with med• do not mix with grapefruit juice• mix with same fluid (i.e. milk, juice)• give on time/schedule with family• do not leave med sitting in syringe… breaks down med and• dose not received (important parent teaching point)• IV form Cyclosporine

– Non PVC tubing– Glass bottle– No extension tubing (T-connector is okay)– Label port of CVC used– Monitor trough levels

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Medication Specifics: Tacrolimus(FK506)

• Can be given I.V. or P.O• Doesn’t need a special syringe-just don’t leave it forever• Don’t give with grapefruit juice• Give on time• Make sure the blood levels are drawn before giving A.M. dose (if it is due).• Glass bottle with low-sorb tubing.• Check with pharmacy if being ordered with Cyclosporin- give at least 4 hrs apart

• Watch for: decrease healing ability, impaired renal function, increased glucose and KCL, increased risk of infection, neurotoxicity (tremors,H/A, LOC, depression), heart dysrhythemia.

• Many drug incompatibilities

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Adalat

• Consult 4E4 on how to draw up dose from a liquid capsule into a syringe….

• They have a poster in the med room outlining how best to accomplish giving a partial dose from the capsule.

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Captopril

• Doses are variable dependant on reason for use i.e. renal/cardiac

• Pre BP is always needed• Parameters for Systolic BP usually given• If initial dose or increase in dosage ensure post

Captopril BP is done q15 mins X 3 for each dose given in that 24 hr period

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Digoxin

• One minute apical beat is to be auscultated prior to administration• Hold dose and notify MD/NP immediately if heart rate is below

baseline for patient• Heart rate parameters for administration are may be given• Pre and post levels may be needed for monitoring of blood levels

(random levels are of no value)

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Low Molecular Weight Heparin(Enoxaparin, Lovenox, Tinzaparin)

• Given SC (consider use of Insuflon catheter)• Rotate sites with administration• Insuflon catheter must be changed every 7 days or at the first signs of

bruising• Pressure must be applied to site for 5 minutes after admin (very important

to prevent bruising!!!)• Do not massage site• Use Insulin syringes to admin as needle short and fine• For Enoxaparin 1 mg = 1 unit on insulin syringe• More detailed info to come with KidClot presentation

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Advantages of IV Medications

• Earlier onset of therapeutic effect• Faster absorption than other routes• Less discomfort than IM or SC

• Alternate route for NPO patients

• Alternate route for unconscious patient

• Provides emergency access

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Disadvantages of IV Medication

• Requires intravenous access• Once the medication enters the blood stream, it cannot

be retrieved• Extravasation of certain medications can cause tissue

injury

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Routes of IV Medication

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Methods of Administration of IV Medication

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Methods of Administration of IV Medication

• Continuous IV Medication

• Intermittent IV Infusion

• Direct IV

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Resources

• Regional Pharmacy Website http://www.intranet2.capitalhealth.ca/pharmacy

• Parenteral Drug Monographs (PDM)• Pharmacist

• e-CPS

• Formulary

• Other resources (Drug Information on Insites)

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Regional Pharmacy Website, http://www.intranet2.capitalhealth.ca/pharmacy

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Resources (cont’d)

• Parenteral Drug Manual– Individual drug monographs must be consulted for:

• Route of administration• Special training equipment or monitoring• Indications• Contraindications• Dosage• Administration/dilution• Adverse effects• Clinical implications• Stability• Compatibility and incompatibility

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What are the Steps in Administration?

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What are the Steps in Administration?

– Check Patient Care Order and Medication Administration Record (MAR)

– Follow Parenteral Drug Manual– Follow the rights and checks

– Gather supplies

– Prepare the medication

– Administration– Documentation

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3 Checks of IV Medication Administration

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Checks of IV Medication Administration

Compare the label of the medication container with the

MAR three times:

1. Before removing the medication from the storage container e.g. Pyxis, fridge, medication cupboard

2. When placing the medication in an administration delivery device e.g. syringe, buretrol

3. Before administering the medication to the patient

**Use at least 2 identifiers before giving the patient any medications

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Preparation of IV Medication

• Medications are prepared from the following forms:– Liquid form – vials and ampoules– Powdered form – vial containing a powdered

medication that needs to be reconstituted

• Available vials/ampoules:

– Single dose vials/ampoules

– Multi-dose vials (single patient use)– Double-chambered vials

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VialAmpoule

Vials/Ampoules

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Multi-dose Vial Labeling

• On patient’s label, add date, time, and initial

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Double Chamber Vial

Follow manufacturer’s directions for mixing

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Available IV Medication Preparations

• Commercially prepared medication bag/syringe e.g. NS with KCL, Flagyl

• Pharmacy prepared medication bag/syringe e.g. Heparin, Morphine

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Adding Medication to a Buretrol• Draw up correct amount of medication from the vial into

a syringe or pre-filled syringe from pharmacy• Swab injection port with chlorhexadine swab• Inject medication into buretrol

• Flush injection port with NS syringe

• Add correct amount of dilution to buretrol• Place medication label on buretrol • Program based on pump drug library (mL/hr)• Flush with 25mL and put medication label on line

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IV Medication Setup

• Buretrols used to administer intermittent and continuous medications

• If using a mini bag (eg. Flagyl), piggy-back through the injection port on the buretrol

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Options for Incompatibility

• How do you determine what line to run your med in?

• Compatible solution

-give med and flush (25ml) • Incompatible solution

- Y inline with compatible solution

- give med, flush

- maintenance stopped during infusion

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What about Maintenance Line?

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Complications of IV therapy

• Infection – local and systemic• Local infiltration• Phlebitis

• Speed Shock

• Embolism

• Fluid Overload

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IV Locks

• Saline locks for all peripheral lines with 3 ml q8hrs (08-16-24)

• Heparin locks for all central lines using 10 units/ml solution 3ml for most central lines (will discuss further in IV/CV lecture)

• Heparin 10 units/ml preservative free solution for all infants <30 days old

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Key Points

• ALWAYS check the parenteral drug monograph before giving any IV medication

• LPNs cannot give ALL IV medications; ensure you are permitted to administer the drug

• Remember to check compatibility with IV solution

• Ensure you have any special equipment or monitoring needed for certain drugs (eg. 0.22 micron filter, ECG monitoring)

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Key Points (cont’d)

• Check patency of IV and site (visualize) and document q 1 h• Consider size of patient and fluid restrictions when calculating rate

and concentration of infusion• Specialized Clinical Competencies are NOT permitted for inpatient

Stollery LPNs at this time.• RNs must obtain the required SCC before giving any of the

following meds: -Direct IV –Cytotoxic –Antineplastic – Cardiac Resusitation meds (only code team) – Inotropes

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Co-signing/Co-checking

• Policy 15.1 Independent Double Check for High Alert medication

• The only IV meds LPNs can give in this category are the IV narcotics and they must be co-signed by an RN

Remember

All checks require independent calculations and checks to the medication orders!

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LPN Med Admin in Pediatrics

• Please be aware that LPN scope will be changing at the Stollery. If you are unaware of what current scope is please see your CNE for a complete list.

• If in doubt, do not give the med until you have clarified your role and have an RN give the medication.

• Each Nurse is responsible to be aware of his/her scope of practice. As LPN scope can vary greatly please be aware of this.

• RNs need to know LPN scope to ensure they cover LPN meds as required.

• Open communication between team members is important to ensure all med are given on time and/or doubled up!

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Documentation

• Follow Policy 19.6, Nursing Documentation

http://www.intrandProceet2.capitalhealth.ca/uah-learningcentre/Policiesandures/Patient_CareP&P/19_Documentation/19_6.pdf

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Medication Administration Records

• Cerner computerized MARs are used here• MAR binder for each patient• Mars print each night at 2400 for next day• Patient ID stickers, signature log, scheduled MAR, PRN MAR and previous days

MAR all in binder• Yellow highlighter indicates med has been discontinued• Ensure signature on bottom right corner indicating MAR was checked by charge

nurse on nights.• If med hand written on MAR must have signature in left hand column indicating it

has been verified.• Make sure you read all instructions for each medication!• If it doesn’t look right to you --verify

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Remember the Rights!!

• You label all your medications and ID the patient with their bracelet. If they don’t have one on…don’t give the med. Have another staff who knows the patient to confirm his/her identity if a parent is not present. Put an ID bracelet on and then give your meds.

• Part of your initial assessment should include that your patient has an ID bracelet on.

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Rights of Medication Administration

1. Right medication

2. Right dose

3. Right time

4. Right route

5. Right patient (*including allergies)

6. Right reason

7. Right rate

8. Right documentation

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Psychological Management of Medication Administration

• Be honest• Timing and complexity of preparation depends on situation and

developmental stage of child• Provide support for the child and parents• Set limits• Use therapeutic play: before, after & during• Ensure safety• Ensure trust

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Medication Calculations

• Medication exercise to be done for practice, will review on Day 5 of Pediatric Orientation

• Medication Exam must be completed with 90% pass• You will write this exam during your on unit buddy shifts next week.• LPNs will complete a modified exam that is reflective of current

LPN scope at the Stollery (i.e. no Continuous IV).

• LPNs will be required to complete a checklist for Intermittent IV med admin. This requires 10 supervised administrations with an RN or CNE.

• LPNs hired now will attend the Continuous Med admin class with all other Stollery LPNs at a later date.

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