Download Key Pediatric Nursing Interventions

Developmentally Appropriate
Explanations for Medications for
Children
• Nurses need a solid understanding of growth and development
to ensure safe administration of medications to children and to
give developmentally appropriate explanations for the
medication to children and their caregivers.
– Why the drug is needed
– What the child will experience
– What is expected of the child
– How the parents can participate and support
their child
Eight Rights of Pediatric Medication
Adapt administration principles and techniques to
meet the child’s needs.
Note that medication administration, regardless of
the route, requires a solid knowledge base about
the drug and its action and...how to calculate!
– Right medication
– Right patient
– Right time
– Right route of
administration
– Right dose
– Right
documentation
– Right to be
educated
– Right to refuse
Pharmacodynamics vs.
Pharmacokinetics
• Pharmacodynamics
– Behavior of medication at the cellular level
– Affected by the physiologic immaturity of some body systems in a
child
• Pharmacokinetics
– Movement of drugs throughout the body via absorption,
distribution, metabolism, and excretion
– Affected by the child’s age, weight, body surface area, and body
composition
• Biotransformation
– the alteration of chemical structures from their original form
allowing for the eventual excretion of the substance
– Is affected by the same variations affecting distribution in children
Factors Affecting Distribution of
Medication in Children
• Medication distribution is altered in infants and young children
– Increased metabolic rate
– Higher percentage of body water than adults
– More rapid extracellular fluid exchange
– Decreased body fat
– Liver immaturity, altering first-pass elimination
– Differences in hepatic enzyme production
– Decreased amounts of plasma proteins available for drug
binding
– Immature blood–brain barrier, especially neonates, allowing
permeation by certain medications
Factors Affecting Absorption of
Medications in Children
• Although a drug’s mechanism of action is the same in any
individual, the physiologic immaturity of some body
systems in a child can affect a drug’s pharmacodynamics.
• Factors that affect absorption of medications into the
child's bloodstream.
– Oral medications: slower gastric emptying, increased intestinal
motility, a proportionately larger small intestine surface area,
higher gastric pH, and decreased lipase and amylase secretion
compared with adults
– Intramuscular absorption: amount of muscle mass,
muscle tone and perfusion, and vasomotor instability
– Subcutaneous absorption: decreased perfusion
– Topical absorption of medications: increased due to greater
body surface area and greater permeability of infant’s skin
Factors Affecting Metabolism of
Medications in Children
• The immaturity of the kidneys until age 18 months
to 2 years affects the Renal BF, GFR, and active
tubular secretion resulting in a longer half-life and
increases potential for toxicity of drugs excreted by
the kidneys
Determining Children’s Doses by Body
Weight
• Weigh the child.
– If the child’s weight is in pounds, convert it to
kilograms (divide the child’s weight in pounds by
2.2).
• Check a drug reference for the safe dose range (e.g.,
10 to 20 mg/kg of body weight).
• Calculate the low safe dose.
• Calculate the high safe dose.
• Determine if the dose ordered is within this range.
Impact on Medications
• Infants and young children require very small
doses of medication, thus making accurate
calculation/ measurement very important
• Calculate dosage based on Body Weight (kg) or Body
Surface Area (m2) to ensure the child receives the correct
drug dosage within a safe therapeutic range
– Body weight = mg/kg/day or mg/kg/dose
(commonly)
– BSA (m2) =
8
Impact on Medications
• Compare ordered dosage to recommended dosage
• If dosage seems unsafe, consult with ordering
practitioner before administering
• Use special measuring devices to accurately
provide the prescribed dosage
• Measuring out a dose with common
household utensils is unacceptable
• Monitor child closely for signs/ symptoms of
toxicity
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Guidelines to Determine BSA
1. Measure the child’s height.
2. Determine the child’s weight.
3. Using the nomogram, draw a
line to connect the height
measurement in the left column
and the weight measurement in
the right column.
4. Determine the point where this
line intersects the line in the
surface area column. This is the
BSA, expressed in meters
squared (m2).
Forms of Oral Medications
• Review the forms of oral medications (liquids [elixirs, syrups, or
suspensions], powders, tablets, and capsules) and how they are
administered to children.
• Demonstrate the proper technique for administering medication
to children via the oral, rectal, ophthalmic, otic, intravenous,
intramuscular, and subcutaneous routes.
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Liquids
Elixirs
Syrups
Suspensions
• Powders
• Tablets
• Capsules
SIM LAB
• when using a dropper or oral syringe (without
a needle) for infants or young children, they
should direct the liquid toward the posterior
side of the mouth, give the drug slowly in
small amounts (0.2 to 0.5 mL), and allow the
child to swallow before more medication is
placed in the mouth.
Providing Atraumatic Care When
Administering Medications
• The nurse should encourage the child to participate in care
and provide the child with developmentally appropriate
options.
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Using comforting positions
Using topical anesthetic prior to injections
Educating the child and parents
Preventing medication errors
• Discuss interventions to decrease discomfort and pain for
the child who is to receive an injection.
• It is essential to ensure the child doesn't
move to prevent injury.
Ears
• Younger than 3
– Pull pinna down and back
• Older than 3
– Pull pinna up and back
naso-gastric, and naso-jejunal feedings
• ADVANTAGES
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The major advantage of over gastrostomy or jejunostomy feeding are:
they do not require surgery.
the tubes can be inserted quickly
they can be used either for short periods or intermittently with relatively
low risk.
• DISADVANTAGES
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The disadvantages of NG feeding may include:
nose or throat irritation and discomfort (especially if used long-term);
increased mucus secretion;
partial blockage of the nasal airways (problematic if suffer allergies
or colds)
• Naso-gastric feeding can occasionally contribute to recurrent
earache and sinusitis.
• With infants, NG feeding can become relied upon and decrease
the suck/swallow mechanism.
Intramuscular Injection Sites
• Intramuscular administration of medication is used infrequently
in children because it is painful and children often lack adequate
muscle mass.
• Note that immunizations are frequently administered IM.
Discuss the preferred IM injection sites for children, needle size,
and solution amount.
Subcutaneous vs. Intradermal
• Subcutaneous (SQ) administration
– Distributes medication into the fatty layers of the body
– Insulin administration, heparin, and certain immunizations
• Intradermal (ID) administration
– Deposits medication just under the epidermis
– Tuberculosis screening and allergy testing
Intravenous
• Most medications given by the IV route must be given at a specified
rate and diluted properly to prevent overdose or toxicity due to the
rapid onset of action that occurs with this route.
• Use of the IV route requires that the child have an IV device inserted,
peripherally or centrally.
• Preferred sites for peripheral IV medication administration, including
the hands, feet, and forearms, and in infants, the scalp if all other
veins fail.
• Central IV therapy usually is administered through a large vein,
such as the subclavian, femoral, or jugular vein or the vena cava.
The tip of the device lies in the superior vena cava just at the
entrance to the right atrium.
• Numerous devices for central venous access are available, and the
type chosen depends on the duration of the therapy, the child’s
diagnosis, the risks to the child from insertion, and the ability of
the child and family to care for the device.
• Although central venous access devices can be used short term,
the majority are used for moderate- to long-term therapy.
Factors Affecting the Choice of
Equipment for IV Therapy
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IV therapy is determined by:
The solution or medication to be administered
The duration of the therapy
The age and developmental level of the child
The child’s status
The condition of the child’s veins
Equipment used for peripheral venous access
including peripheral intermittent infusion devices or
saline or heparin locks
EMLA Cream
• a eutectic mixture of lidocaine 2.5% and
prilocaine 2.5%
• EMLA cream is a local anesthetic
(numbing medication)
• It works by blocking nerve signals in your
body.
• EMLA cream is used to numb normal
intact
Principles of Atraumatic Care Managing IV Therapy
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Gather equipment before approaching child.
Select hand rather than wrist or upper arm veins.
Ensure adequate pain relief.
Allow anesthetic to prepared site to dry.
Use a barrier to avoid pinching the skin.
If needed, use a device to trans-illuminate
the vein.
Make only two attempts to gain access.
Encourage parental participation.
Coordinate care with other departments.
Secure line with minimal amount of tape.
Protect the site from bumping
Administering IV fluids to an infant or
child
• Requires close attention to the child’s fluid status.
• Place the formula for determining the amount of
fluid to be administered in a day (24 hours)
• 100 mL per kg of body weight
for the first 10 kg
• 50 mL per kg of body weight for
the next 10 kg
• 20 mL per kg of body weight for the
remainder of body weight in kilograms
Administering IV fluids to an infant or
child (PER HOUR)
• The simple method we are going to look at is known as
the 4:2:1 method. This method will give you a quick way
of calculating the required mls per hour
• 4 ml/kg/hr for the first 10 kg,
• adding 2 ml/kg/hr for the second 10 kg
• and 1 ml/kg/hr for each kg over 20 kg.
• The most accurate way to do this is to compare their
current weight with their pre-morbid weight, that is, their
weight before they became ill.
• This is usually not practical and so the less accurate
method of clinically assessing their deficit must be used:
Urine Output
• In addition to monitoring the fluid infusion, the nurse
should closely monitor the child’s output.
• Note that the expected urine output for children and
adolescents is 1.0 to 2.0 mL/kg/hour.
• When measuring the output of an infant or child who is
not toilet trained or who is incontinent, weigh the
diaper to determine the output.
REMEMBER: 1 gram = 1ml of fluid
Measures to Reduce Complications
With TPN
• Nutritional support can be administered IV through
a peripheral or central venous catheter.
• Parenteral nutrition given via a central venous
access is termed total parenteral nutrition (TPN).
• The concentration and components of the solution
determine the type of parenteral nutrition.
• Review the guidelines for administering TPN and
how nurses can prevent complications
Measures to Reduce Complications
With TPN
• Monitor the child’s vital signs closely for changes.
– FEVER
• Adhere to strict aseptic technique .
• Ensure that the system remains a closed system at all
times.
• Use occlusive dressings.
• Adhere to agency policy for flushing of the catheter and
maintaining catheter patency.
• Assess intake and output frequently.
• Monitor blood glucose levels and obtain
laboratory tests as ordered to evaluate for
changes in fluid and electrolytes.
• VIEW: TPN Instructions for Parents under,” STUFF”