Download West 11 orientation - Children`s Hospital of Wisconsin

Welcome to West 11
and Medication
Administration
Summer, 2014 Clinical Practicum
MSOE
West 11
• 24-bed acute care unit
• general medical patients
• Specialties:
– gastroenterology
– endocrine/diabetes
– cystic fibrosis
– pulmonary
– adolescent eating disorders
– failure to thrive
A little about you:
•
•
•
•
•
•
•
Name/nickname
What is your favorite TV show
What are your past times
One thing that no one knows about you
Why become a nurse
What is your experience with kids/families
Area of interest; plans after graduation
Let’s Talk Pediatrics
• What excites you about this clinical
rotation?
• What frightens you about this clinical
rotation?
• What have you heard about Children’s
Hospital?
• What questions do you have?
Pediatric Considerations
–
–
–
–
–
–
–
–
Greater percent of total body weight is water
Greater insensible loss
Greater potential for dehydration
Infants have decreased ability to concentrate urine
More susceptible to fluid/electrolyte shifts
Decreased glycogen storage
Higher metabolic rates
Drugs metabolize at different rate than adults
Tips for Pediatric Assessment
– Varies with child
– Approach slowly
– Non-invasive assessment
FIRST and involved
system LAST
– Allow child to play with
equipment
– Do procedures on toys or
parents first
– Save intrusive procedures
for last
 Do as much as
possible with the child
being held by parent
– Give kids toys to play with
during history-taking time
– Make assessment a game
– Get down to child’s level
– Ask history questions of
child, if old enough
– If directions necessary,
keep them simple
– Use praise
– Use distraction
Initial Assessment Impression
– Facial expression
– Posture
– Activity level/behavior
– Skin assessment
– Overall state of health
– ‘gut feeling’
Hydration Status
– Weight
– Mucous membranes
– Skin turgor
– Tears
– Urine output
– Fontanel
– History: vomiting, diarrhea, etc.
Metrics
• Pediatric fluids and medication doses
are calculated by weight in kilograms
• Patient’s weight - kilograms BUT parents
often do not know what this means
• Need to be able to convert to pounds for
the family
• Conversion: 2.2 lb = 1 kg
Calculations
• Child weighs 88 lbs, what is the weight in
kg?  88 lbs divided by 2.2 kg = 40 kg
• Child weighs 22 kg, what is the weight in
pounds?  22 kg times 2.2 lbs – 48.4 lbs
• Child weighs 6 lbs what is the weight in
kg?  6 lb divided by 2.2 kg = 2.72 kg
Fluid Maintenance
• Critical: Must know your child’s fluid
maintenance
• Includes IV and oral/GT/JT intake
• Hourly documentation of fluid intake (IV,
po, g-tube, j-tube) is required
• Fluids used to administer IV medications
must be included in the hourly fluid
volumes
Fluid Maintenance
MUST BE DONE on all kids!!
Daily Fluid Maintenance
< 10 kg
10 – 20 kg
20 kg
100 ml/kg
1000 ml + 50 ml/kg
1500 ml + 20 ml/kg
Hourly Fluid Maintenance
< 10 kg
10 – 20 kg
> 20 kg
4 ml/kg
40 ml + 2 ml/kg
60 ml + 1 ml/kg
Let’s work out daily fluid needs
Daily Fluid Maintenance
 8.2 kg child: 8.2 kg x 100 cc = 820cc/Day
 12.6 kg child: 10 kg x 100 cc = 1000cc
Plus: 2.6 kg x 50 cc
= 130 cc
Total:
1130cc/day
 28.2kg child: 10 kg x100 cc = 1000cc
Plus: 10 kg x 50 cc = 500 cc = 1500 cc
Plus: 8.2 kg x 20 = 164 cc = 1164 ml
Total:
1664 cc/day
(Hourly total: total fluids/24)
Let’s work out hourly fluid needs
Daily Fluid Maintenance
 8.2 kg child: 8.2 kg x 4 ml = 32.8 ml/hour
 12.6 kg child: 10 kg x 4 ml = 40 ml
Plus: 2.6 kg x 2 ml
= 5.2 ml
Total:
45.2 ml/hour
 28.2kg child: 10 kg x 4ml = 40 ml/hour
Plus: 10 kg x 2 ml = 20 ml = 60 ml/hour
Plus: 8.2 kg x 1 = 8.2 ml = 68.2 ml/hour
Total: (per day-> hourly fluids x 24)
Practice Scenario
• Marisa is a 10 year old admitted to the unit
with pneumonia. She weighs 80 lbs.
• What is her weight in kilograms?
• What is her hourly fluid maintenance
requirements?
• What is her daily fluid maintenance
requirements?
80 lbs - using daily fluid equation
 80 lbs/2.2 kg = 36.4 kg
 First 10 kg = 1000 ml
 Second 10 kg = 500 ml
 Remaining: 16.4 kg x 20 =
 Fluid maintenance/day =
1000 ml
+
500 ml
+
360 ml
1860 ml/day
 Fluid maintenance/hour->1860/24=77.5 ml/hour
80 lbs - using hourly fluid equation
80 lbs/2.2 kg = 36.4 kg
First 10 kg = 4 ml
40 ml
Second 10 kg = 2 ml x 10 + 20 ml
Remaining: 16.4 kg x 1ml + 16.4 ml
Fluid maintenance/day = 76.4 ml/hour
Fluid maintenance/day ->1834 ml/day
Some more practice
Calculate the daily and hourly fluid
maintenance
• 4.8 kg
• 222 pounds
• 34.5 kg
• 18.2 pounds
• 16.2 kg
What information is unique to
pediatrics?
•
•
•
•
•
•
Fluid Maintenance
Medications: safe dose, safe calculations,
IV: dilution, safe range, infusion time
Policy and Procedures
Growth and Development
Teaching strategies
Drug dosing in infants and
children
• Doses based on weight
• Accurate drug dose is critical since
infants/children do not have the
mature physiological responses to
compensate for drug errors
General guidelines for administration
of medications to pediatric patients
•
Growth and development
– Developmental age = functional level of the child.
– Strategies consistent with the child's developmental
level -> to ensure safe and effective medication
administration.
– Assessing the child's temperament can led to
determining best method of administering a medication.
• Honesty, reward, and praise help to gain trust
and cooperation
• Ask parent or other staff member to assist
• Provide rewards for good behavior
and for trying
Strategies for
Medicating Children
Infants
Toddlers
Preschoolers
School-age
Adolescents
Cuddle and comfort
Use play, minimize restraint, give
praise and stickers as rewards
Offer choices
Provide choices, explanations,
distraction, and support
Explain, allow participation in
decisions, praise cooperation,
provide outlet for frustrations
HONESTY, REWARD, & PRAISE ARE KEY!
BEFORE giving a med
MUST know
•
•
•
•
•
•
•
Generic & brand name of drug
Action of drug
Reason child is receiving med
Recommended safe dosage
Common side effects
Nursing implications
Teaching implications for family
Oral Medications
• Infants – may take liquid med out of nipple, oral
syringe, or medication dropper.
• Toddlers & Preschoolers – may use oral
syringe, dropper, or medication cup.
• Pre-school & School-age – may use chewable
tablet
“He spit it up” = notify the physician
BEFORE giving another dose!
Need to remember the basics.
•
•
•
•
1 teaspoon = 5 ml
1 tablespoon = 15 ml
1 ounce = 30 ml
1000 mg = 1 gram
Medication Safety
• Where do I find medication calculation info:
– Safe dose range
– Dilution infusion
– Time to infuse
– Compatibility
• LexiComp drug book
• Drug Handbook
•
•
•
•
•
•
•
•
•
SAFETY
Increased opportunities for error -> weight-based dosing for all medications
Potential for more serious consequences: limited reserves of smaller children.
Most recognized errors>computation of dosage; dosing interval; transcription of drug
orders ; drug preparation or conflicts with prescribed dosages
Children are at particular risk for these errors -> dosage individualization requiring
dosage equations.
Dosages calculated on weight ->significantly different from adults.
Computation error can result in a significant under or over-dosage.
‘ten-fold’ error (e.g., a misplaced decimal point can mean a ten-fold change in the
appropriate dosage of medication)
One example: Jose Eric Martinez; ill two-month-old with signs of CHF
MD ordered IV Digoxin; a decimal point error in calculating appropriate dosage ->
infant given dose that was 10 times safe dose -> cardiac arrest and child died
• AS THE NURSE YOU ARE THE LAST PERSON TO ENSURE
THE SAFE DOSE BEFORE THE PATIENT RECEIVES THE
MEDICATION –
• HUGE RESPONSIBILITY
NEED TO READ CAREFULLY
• Read the medication information carefully
–
–
–
–
–
Some are the dose ranges are for 24 hours
Some are the dose ranges are for q 8 hours
Some are the dose ranges are for q 12 hours
Some safe dose information is per dose range
Some safe dose information is per day range
Med Calculation
Check MD order
Calculate parameters of safe dose and
safe range
Is the patient’s ordered dose within the
safe range?
– If yes, what do you do?
– If no, what do you do?
Two year old: weight is 36 lbs
Amoxicillin 215 mg, po, tid for pneumonia
 Convert lbs -> kg
 36 lb divided by 2.2 kg = 16.36 kg
 Recommended safe range:
(PO < 40 kg: 6.7 to 13.3 mg/kg q 8 hours)
– 16.36 kg x 6.7 mg = 109.6 mg q 8hours
– 16.36 kg x 13.3 mg = 217.5 mg q 8 hours
– Safe range: 110 mg to 218 mg Q 8 hours
 Question  Is the dose safe?
How much to you give?
• Amoxicillin suspension is dispensed as
250 mg per 5 ml. How much do you give?
– 250 mg / 5 ml = 215 mg / X ml
– Give 4.3 cc po every 8 hours
Giving Medications:
Intravenous Route
Fluid Maintenance
Key concepts
• Pediatric population requires keen awareness of
fluid maintenance; Fluid overload must be
avoided.
• Minimal and maximum dilution is important for
medication safe administration
• REMEMBER: you are the last person to touch
the med before it touches the patient
Fluid Maintenance
Key concepts
• Policies reflect specific pediatric considerations
for children who are receiving IV fluids/IV
medication
• IVF and meds must be placed on an infusion
pump or syringe pump, unless in defined
emergency situations.
• Infusion time is critical information.
ALARIS IV pumps
All IV infusions
must be on an
infusion pump,
except in critical
defined situations
Large volume medications
With Alaris pumps:
* medication volumes greater than 60 ml
* secondary infusion
* separate Alaris channel used for medication
administration and IV fluids
Med Flush
• The MD will not order to flush the line after
medication – institution policy
• From IV pump to patient –> 30 ml of IV line
• The line must be flushed to ensure all mediation
is given to patient
• SO, flush is 30 ml after each medication
Syringe pump: for infusions less
than 60 mls
•Used for many
medications - both
continuous infusion and
intermittent medications
•Syringe size from 3ml to
60 ml (but preferable to
use 5 ml syringe or
larger)
• Allows for smaller
volume for med flushes 
Tubing med flush volume
is 1 ml.
Med Flush for syringe pump
• The MD will not order to flush the line after
medication – institution policy
• From syringe pump to patient –> 1 ml of IV line
(microtubing)
• The line must be flushed to ensure all mediation
is given to patient
• Flush is typically 2-3 ml after each medication
Intravenous calculations
•
•
•
•
•
•
•
•
•
•
•
Medication order
Allergies
Weight
Fluid maintenance – per day/per hour
Safe dose
PIV or CVL - will effect dilution of medication
Dilution
Infusion time
Infusion rate
Syringe pump or mini bag
Discuss how you are going to give the medication
IV rate calculation
• Formula:
Amount of fluid x 60 (min)
Time in minutes for infusion
• OR:





60 minutes: multiple volume in infuse x 1
30 minutes: multiple volume in infuse x 2
20 minutes: multiple volume in infuse x 3
15 minutes: multiple volume in infuse x 4
10 minutes: multiple volume in infuse x 5
•Medication order: Cefuroxime 725 mg IV Q 8 hours
• Allergies: No known allergies
• Weight: 14.5 kg
• Fluid maintenance – per day: 1225 cc/day; Per hour: 51 cc/hour
• Safe dose -- 50 mg/kg/dose THUS 50 mg x 14.5 kg = 725 mg/dose •SO DOSE IS SAFE
• PIV or CVL - child has PIV
• Dilution 20-40mg/ml 
-> 725 mg/20= 36,2cc
-> 725mg/40 = 18.3 cc  DILUTION RANGE IS 18.3 cc and 36.2 cc
Pharmacy sends up 36.2 cc
• Infusion time: 30 minutes
• Infusion rate:
-> 36.2 cc x 2 = 72 cc/hour
Syringe pump or piggy back bag?
• medication volume less than 60 ml, sent up in syringe – use syringe pump
Practice
• Jose: 5 year old, 50 lbs: MD order for 750 mg of
Ancef (Cefazolin) Q 8 hours.
• Pharmacy sends vial of powdered Ancef. The
direction for dilution states: ‘dilute the powder
with 10 ml of sterile water to make a
concentration of 1 gram per 10 ml’.
• How many ml’s will you need to draw up for
Jose’s dose?
Reconstitution math
• 1 gm = 1000mg
1000 mg = 750 mg
10 ml
X
1000 x = 7500mg
1000
1000
X = 7.5 ml to be drawn up from vial
Medication order: Ancef 750 mg IV, Q 8 hours
Peripheral IV
•
•
•
•
•
•
•
•
Allergies – NKDA
Weight: 50 lbs - 22.7 kg
Fluid maintenance – per day/per hour 1554 ml/day AND 64.75 ml/hour
Safe dose: is 33.3 mg/kg/dose = 756 mg/dose - dose is SAFE
PIV or CVL: child has a peripheral IV (PIV)
Dilution factor: 40 mg/ml: 750 mg/20 = 37.5 ml
Infusion time: 30 min so: 37.5 x 2 = 75 ml/hour
Infusion rate: 75 ml/hour
Syringe pump or mini bag? Syringe since volume is less than 60 ml
Medication order: Ancef 750 mg IV, Q 8
hours: Central line
•
•
•
•
•
•
•
•
Allergies – NKDA
Weight: 50 lbs - 22.7 kg
Fluid maintenance – per day/per hour 1554 ml/day AND 64.75 ml/hour
Safe dose: is 33.3 mg/kg/dose = 756 mg/dose - dose is SAFE
PIV or CVL: child has a central line (CVL)
Dilution factor: 20 mg/ml: 750 mg/40 = 18.74 ml
Infusion time: 30 min so: 18.75 x 2 = 37.5 ml/hour
Infusion rate: 37.5 ml/hour
Syringe pump or mini bag: volume is less than 60 ml so use syringe pump
Key points - IV med administration
•
•
•
•
•
•
•
Weight and fluid maintenance
Allergies
What is safe dose
Does child have PIV or a CVL
Any cardiac/renal/fluid restrictions
If < 60 ml total use syringe pump
If > 60 ml will be dispensed in mini bag
PREP TIME
• What Baseline Information Do I Need To Get
– Admitting diagnosis and previous health history
– Weight, height; fluid requirements
– Medical and nursing orders
– Medications
– Policy and Procedures
– Medical tests and procedures
– Age: developmental and cognitive
Again
welcome to West 11
•
•
•
•
•
?
?
?
?
?