Chapter 38

• Medication administration for children

  • It is one of the most challenging interventions in nursing
  • Children vary greatly in size and individual need
• Medication administration for children

  1. Assessing child's weight in kilograms

  2. Determining right form and route of medicine

  3. Establishing accurate dose using mg/kg formula or nomogram
• Medication administration routes in children

  Oral, intranasal, transdermal, topical, rectal, injection (subcutaneous, intradermal, IM, IV, intraosseous, epidural), inhalation
• Pharmacokinetics in children

  • Absorption, distribution, metabolism, and excretion processes are influenced by immaturity of body systems
  • Intensity and duration of drug action is affected
• Absorption


  Transfer of drug from point of entry into bloodstream, influenced by route, concentration, and acidity
• Distribution


  Movement of drug through bloodstream to site of action, children have more fluid in interstitial spaces
• Metabolism


  Conversion of drug into active or inactive form, faster in children so more frequent dosing needed
• Excretion


  Elimination of drug or metabolites, limited until 12 months when kidney function matures
• Adverse drug effects in children

  • May experience unique or exaggerated side effects due to immature liver function or rapid growth
  • Newborns may suffer effects from drugs taken by mother prenatally or in breastmilk
• Safe storage of drugs

  • Young children do not appreciate overdose risks, so medicines must be locked away
  • Placing out of reach is not sufficient as toddlers can climb well
• Safe administration of drugs to children

  1. Determine right drug, dose, route, time, action

  2. Observe for right response

  3. Ensure parents/child have right information
• Oral administration


  • Children under 3 cannot swallow pills, ability varies by child not age
  • Liquid, chewable, or meltaway forms best for young children
  • Administer with child's head raised to avoid choking
• Intranasal administration

  Nasal drops and sprays are easy to administer and well absorbed
• Ophthalmic administration

  Eye medications like antibiotics are dropped into conjunctival sac
• Restraining a child while giving medicine

  • May cause them to be frightened afterward or for future administration
  • Taking time to sit and comfort the child afterward (or let a parent do this) is as important as checking the correct dosage of the drug because promoting the child's psychological well-being is crucial
• Intranasal administration

  Drugs are well absorbed across the nasal mucosa, so this route is an effective means of drug administration and can be a route for important and even life-sustaining drugs
• Ophthalmic administration

  • Frightening for children because the eyes are a sensitive area and a natural reflex occurs to avoid contact with the eyes
  • Children know that getting something such as dust in their eye can be very painful
  • Infants and preschoolers generally may need to be restrained for eye drop administration
• Ophthalmic administration procedure

  1. Prepare the child first, with a developmentally appropriate explanation

  2. Place the child on his or her back

  3. Open the eyes of infants and preschoolers by gently but firmly pressing on the lower lid with the thumb and on the upper lid with the index finger

  4. A school-age child or adolescent will open their eyes cooperatively, but you may need to rest a hand on the eyelid to keep the eye open long enough for the drug to be administered
• Optic administration

  • Difficult for children to accept because they have been told many times not to put anything into their ears
  • Ear drops are generally administered for an earache, which is sharp, excruciating pain, a child may worry having medicine put into the ear will make the pain even worse
  • A child's inability to watch what is happening may contribute to the child's fear
• Optic administration procedure

  1. Be honest with the child and provide information that is developmentally appropriate

  2. Ear drops must always be used at room temperature or warmed slightly because cold fluid may exacerbate pain and may also cause severe vertigo as it touches the tympanic membrane
• Rectal administration

  Administering medication to children through the rectum is recommended to assist in absorption across the mucous membrane of the intestine and also avoids the danger of aspiration in certain situations such as seizures or when a patient is unconscious

  
• Transdermal/topical administration

  • Children are more tolerant of this type of application because it may provide immediate relief of symptoms
  • Older children may be able to assist with topical applications with your supervision
  • Be certain they wash their hands afterward so they do not lick any extra off their fingers and inadvertently take it orally
• Intramuscular and subcutaneous administration

  • IM injections are rarely prescribed for children admitted to the hospital because many children do not have sufficient muscle mass for easy deposition of medication and they are also painful
  • IM injections may be used in an emergency department and are commonly used for immunization

  
• Subcutaneous pump infusion

  • Continuous subcutaneous pump infusion using a medication pump is the administration of a medication by the constant infusion into the subcutaneous tissue
  • Continuous pump infusions supply a constant level of medicine to sustain consistent blood levels
  • The disadvantage is that a child must be careful to protect the catheter at the insertion site from being dislodged

  
• Autoinjection syringes

  • Some medicines, such as insulin, come prepared in auto-inject syringes that children are able to use to self-inject as soon as they are about 5 or 6 years old
  • Such injectable syringes have advantages in that they are prefilled with the correct amount of medicine, the needle is small, and the spring that causes the needle to inject the medication acts quickly, reducing pain during injection
• Intravenous therapy

  • A fast and effective means of maintaining fluid and electrolyte balance, producing therapeutic levels of drugs quickly, to provide nutritional support and offer blood or blood product replacement
  • The amount, type, and rate of IV fluids for children are prescribed carefully to prevent fluid overload
  • IV fluid may be infused into a peripheral vein, a central venous access device, or a peripherally inserted central venous catheter

  
• Determining fluid and caloric needs of the child

  It is important to understand the principles of IV therapy, including the fluid and caloric needs of children (which differ significantly from those of the adult), to protect against overhydration, underhydration, or electrolyte imbalances such as hyponatremia
• Obtaining venous access

  1. The needle size for IV therapy varies depending on the solution and the rate at which it will be administered

  2. Sites frequently used for IV insertion in young children or infants include the veins on the dorsal surface of the hand or on the flexor surface of the wrist, leg and foot veins, and in infants, a scalp vein over the temporal area

  
• Determining the rate and amount of fluid administration

  • Because children's hearts and circulatory systems are smaller than those of adults, IV fluid must be infused at a slower rate to keep the child's cardiovascular system from becoming quickly overloaded
  • Infusion pumps are required in most settings for infants and children receiving IV fluids and when giving potent medications and always for small children because they regulate the flow accurately to a few drops per minute

  
• Intravenous medication administration

  1. Medications may be added to an IV line as a small, one-time administration (bolus), a fluid chamber infusion, or by piggyback for larger children

  2. Identify the child before adding medicine to an IV line

  3. Ensure that the drug to be injected is compatible with the IV fluid being infused

  
• Intermittent infusion devices

  • Devices that maintain open venous access for medicine administration while allowing children to be free to move about without being restricted by IV tubing and pumps
  • A vein on the back of the hand is generally chosen as the IV site
  • The saline lock is flushed as frequently as hospital policy requires to keep it patent

  
• Central venous access catheters and devices

  • Venous access for long-term IV therapy can be obtained using a tunneled catheter inserted into the vena cava just outside the right atrium
  • These semi permanent catheters are used to administer bolus or continuous infusions of medications and fluid

  
• Intraosseous infusion

  • Infusion of fluid into the bone marrow cavity of a long bone, usually the distal or proximal tibia, the distal femur, or the iliac crest
  • Because the bone marrow communicates directly with the circulatory system, fluid reaches the bloodstream as quickly by this route as if it were administered intravenously
  • All fluids that can be administered intravenously, including whole blood or medication, can also be administered by this route