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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:
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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
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Oral – swallowed or via
NG tube
Sublingual or buccal
Rectal
Intravenous
Intramuscular
Subcutaneous
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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
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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
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Body fluid content – % of
ECF (extra-cellular fluid) ↑
in children than adults
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Body fat content -% of
body fat change as the
child grow
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Muscle mass - 38% less
than adult
Body Proportion
Child’s height ↑ 3.5 times between birth and
childhood
 Weight ↑ 20 times
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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
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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
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Body surface Area(BSA)
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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.
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Points to remember
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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
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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
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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
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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
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What is ‘Blood-brain barrier’?
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a separation of circulating blood and cerebrospinal
fluid (CSF) in the central nervous system (CNS).
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It occurs along all capillaries and consists of tight
junctions around the capillaries that do not exist in
normal circulation
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prevents potentially harmful substances such as
certain medications, radioactive ions, and viruses,
from entering the parenchyma of the brain
Cardiovascular system
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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
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Skin
Children have a large BSA
 Epidermis is thinner – allows more water
loss and faster absorption of topical
medications
 Therefore high risk of overdose
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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)
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Legal and Ethical Considerations
Nursing and Midwifery Code of Professional
Conduct (NMC
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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
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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)
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The Nurse must be accurate in the
calculation, preparation and administration
of medications.
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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
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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
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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
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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
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Safety precautions in administering medications
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right documentation
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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.
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right to refuse
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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
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right assessment
 Adult drugs may be passed through breastmilk – check safety if mother is
breastfeeding
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right evaluation
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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.
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right education
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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.