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Aims To provide basic knowledge on safe and effective administration of medicines to children At the end of this session, student should be able to: Identify the routes for drug administration Identify the guidelines for administering oral medication in children Describe the psychological approach prior to giving medication Identify the physiological differences in drug administration between children & adult Describe the nursing responsibilities in drug administration Identify the safety precautions in giving medications Route for drug administration Oral – swallowed or via NG tube Sublingual or buccal Rectal Intravenous Intramuscular Subcutaneous Intradermal Inhalation Topical Intracardiac Intraosseous Intrathecal Intraosseous Long bones in infants are filled with marrow which contains vascularized sinusoids. These sinusoids eventually drain into the systemic venous circulation. The marrow cavity acts as a rigid vein, and so will not collapse, even in the face of severe volume loss Intra-thecal Guidelines for oral administration in children 1. Follow safety precaution 2. Select appropriate dispenser Calibrated cup Syringe Dropper Measuring spoon Nipple Con’t… 3. 4. 5. Measure accurately Prepare medication – for children that have difficulty in swallowing tablets, crush tablet (except when contraindicated) and then mix with syrup or juice. Avoid mixing medications with essential food item such as milk etc. Psychological approach prior to giving medication 1. 2. 3. Always approach according to their developmental level & given age-appropriate explanations & give as much choice as possible in the procedure Be honest, give reward & praise – this is to gain the child’s trust and cooperation The child should be told if procedure will be painful or uncomfortable Con’t… 4. 5. Restraints may be necessary for safe administration of certain medications e.g. injection Never scold a child for his failure at giving cooperation. Body Composition Body fluid content – % of ECF (extra-cellular fluid) ↑ in children than adults Body fat content -% of body fat change as the child grow Muscle mass - 38% less than adult Body Proportion Child’s height ↑ 3.5 times between birth and childhood Weight ↑ 20 times Body Fat Content 1. % of body fat change as the child grow Infant – 16% 1 year old child 23% 2. % of body fat is an important consideration when administering fat soluble medications to children. 3. Because body fat must be saturated with a fat-soluble medication before blood levels are detectable, doses must often varied to achieve the desired effect Muscle mass Children muscle mass is approx. 38% less than adult Infant’s body weight – 25% muscle Adult’s body weight – 40% muscle Children has smaller muscle mass – fewer sites are available for IM injection Blood flow to muscles in young children is variable and may also affect absorption of injected medications Body fluid content 85% - premature newborn, 60% - children 2 years above, 50% - adult % of ECF (extra-cellular fluid) ↑ in children than adults Rule of thumb – the vol. of total body fluid ↓ as age ↑ Children require an ↑ dose per kg of a water soluble medication to achieve the desired effect Body surface Area(BSA) The total suface area of the human body. used in many measurements in medicine, including the calculation of drug dosages and the amount of fluids to be administered IV. Infant has more BSA compared to adult BSA (Body surface area) ↑ 7 times administration of chemotherapy drugs – calculated by using the BSA BSA Calculation The calculation is from the formula of DuBois and DuBois: BSA = (W 0.425 x H 0.725) x 0.007184 where the weight is in kilograms and the height is in centimeters. Points to remember Infants have a lower body fat and higher body water contents than adult: Infants receiving lipid-soluble drugs require smaller doses than adults – liver metabolised lipid soluble drugs Infants receiving water-soluble drugs require larger doses than adults – kidney excretes water-soluble drugs Factors affecting drug disposition in children Factors affecting drug disposition in children 1. 2. 3. 4. Oral absorption- the movement of a drug into the bloodstream. Distribution - movement of drug to various tissues of the body eg fat, muscle, and brain tissue Metabolism - chemical alteration of a drug by the body. Excretion All these factors are affected by the body system Body system Liver Kidney Neurological system Cardiovascular system Gastro-intestinal system Skin site of most drug metabolism metabolic enzyme systems are only partially developed at birth, newborns have difficulty metabolizing certain drugs. Therefore, smaller doses of medications are needed to achieve the desired effect Responsible for the excretion of medications Renal immaturity – medications may not be filtered out of the circulating blood volume & excreted in the urine. Instead, the medications may circulate longer & reach toxic blood levels. e.g. loss of fluid would decrease the child’s ability to excrete medications, dehydration can have serious effect on the child. Complete maturation of renal function is not reached until 6-8 months Neurological system ‘Blood-brain barrier’ is not fully mature until the child is about 2 years old Immaturity of the ‘blood-brain barrier’ causes the brain to be less selective, as a result encephalopathy may occur with many medications e.g. medications that normally cause sedation in adults have the opposite effect in many children & cause hyperactivity What is ‘Blood-brain barrier’? a separation of circulating blood and cerebrospinal fluid (CSF) in the central nervous system (CNS). It occurs along all capillaries and consists of tight junctions around the capillaries that do not exist in normal circulation prevents potentially harmful substances such as certain medications, radioactive ions, and viruses, from entering the parenchyma of the brain Cardiovascular system Unable to accommodate large or rapid changes in volume, thus fluid overload may result if IV infusions are not fully monitored Gastro-intestinal system Children less than 3 years – slow gastric emptying and decrease gastric acid secretion Therefore cause slower absorption of oral medications Skin Children have a large BSA Epidermis is thinner – allows more water loss and faster absorption of topical medications Therefore high risk of overdose REST FOR 10 MINUTES Nursing responsibilities during drug administration Accurately interpret prescriptions Safe storage Maintain knowledge base Accurate documentation Adhere to Nursing and Midwifery Code of Professional Conduct (NMC) Legal and Ethical Considerations Nursing and Midwifery Code of Professional Conduct (NMC Before administering any medication, the nurse must have : 1) A current license to practice nursing 2) A clear policy statement that authorizes the act. 3) A medication order signed by a practitioner licensed with prescriptive purposes. Legal and Ethical Considerations Nursing and Midwifery Code of Professional Conduct (NMC Never administer a drug unless you know: 1) Why the drug is ordered. 2) The expected actions. 3) Usual dosing. 4) Proper dilution. 5) Route & rate of administration. 6) Minor side effects. 7) Adverse effects. 8) Contraindications or special considerations. Legal and Ethical Considerations Nursing and Midwifery Code of Professional Conduct (NMC) The Nurse must be accurate in the calculation, preparation and administration of medications. The nurse must do a thorough assessment, collect data at regular intervals, record observations in the chart both therapeutic and adverse effects Safety precautions in administering medications 1. Check the 10 ‘R’ for correctness:- right drug - right dosage - right time - right route - right child - right to refuse - right documentation - right assessment - right evaluation - right education Proper Medication Orders Essential parts of a Drug Order: 1) Full name of patient 2) Date/time of order 3) Name of drug 4) Dosage 5) Route 6) Frequency 7) Signature of person writing order Con’t… Any allergies 3. Double check drug and dosage with another staff nurse 4. Be aware of the drug-drug interaction or food-drug interaction 5. Document all drugs administered 6. Monitor child for side-effects 7. Be prepared for serious side-effects 2. General Safety Tips of Drug Administration Wash hands DO NOT give medication prepared by another individual other than the pharmacist Do not return to stock/vial Do not leave at bedside Never leave unattended Do not give if toxicity Sign out narcotics/record waste NEVER recap a needle Errors If medication error occurs Admit the error – don’t try to cover it up Notify physician Take emergency/first aid measures, prn Complete proper reporting form NEVER record terms “by mistake”, “on error”, “unintentionally” DO NOT record error in patient chart Safety precautions in administering medications right documentation THE RIGHT TO A COMPLETE AND CLEARLY WRITTEN ORDER. It is no longer good practice to accept orders when the dosage is written as "1 tablet." Verbal orders should never be taken and telephone orders should only be taken if the physician is not physically present. Nurses cognitively know this but often in the interest of saving time may be tempted not to practice it. Nurses who write orders for physicians are placing their license and their patients at risk. right to refuse THE RIGHT TO HAVE THE CORRECT DRUG ROUTE AND DOSE DISPENSED Nurses administer medications but it is the pharmacy’s duty to dispense medications correctly. Safety precautions in administering medications right assessment Adult drugs may be passed through breastmilk – check safety if mother is breastfeeding right evaluation THE RIGHT TO STOP, THINK, AND BE VIGILANT WHEN ADMINISTERING MEDICATIONS When we are about to administer a drug we are unfamiliar with, we have the right to stop and find out about this new drug. If we need to ask other nurses or professionals about this drug or check the policy for giving this drug, we need to stop and do so. Will this take additional time? Yes. Will others think we are stupid? Maybe. Will some people become irritated with us? Probably. right education THE RIGHT TO HAVE ACCESS TO INFORMATION Nurses have the right to expect updated and easily accessible drug information Problems in administering medication and errors The following steps should be taken: a) If a child refuses medication then this should be clearly recorded on the medication chart, in the shift plan and in the child’s notes. Every encouragement should be given to ensure the medication is taken however a child must not be forced to take medication. If a child refuses medication, medical advice must be sought. b) If medication is spat immediately and the tablet is recovered unspoiled, give the tablet again. If a liquid medication is spat out and it is unclear if some of the initial dose has been swallowed medical advice must be sought. c) If a tablet is dropped or liquid is spilled or spoiled prior to administration, then re-administer using a fresh dose. Note that a second dose has been given on the medication chart, in the shift plan, and in the child’s notes. d) When a dose is re-administered from medication sent from home a check must be made that there are sufficient doses for the remainder of the child’s stay. If there are not enough doses to re-administer then the parents must be contacted to bring in more. e) If a child vomits within 30 minutes of taking their medication medical advice should be sought as it may be appropriate to re-administer the medication. If the vomiting occurs after 30 minutes the medication should not be re-administered and advice should be sought at the earliest opportunity. f) Do not re-administer inhalers where they appear not to have worked properly. Some of the medication may have been administered. g) The manager must be informed immediately of any instances of a missed dose or error in the medication process and medical advice must be sought. An incident form should be completed by the person involved.