Pediatric

Medication
Administration

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

General Guidelines
• The responsibility of giving medications to
children is a serious one.
• ½ of all medications on the market today
do not have a documented safe use in
children.
• Children are smaller than adults and
medication dosage must be adjusted.
• Children react more violently.
• Drug reactions are not predictable.
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
General Guidelines
• The impact on growth and development
must be considered when giving drugs to
children
• Double checking is always best
• Must double check these meds:
– Lanoxin,
– insulin,
– heparin

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Pediatric Drug Administration
• Pediatric drug therapy should be guided by the
child’s age, weight and level of growth and
development
• The nurse’s approach to the child should convey
the impression that he or she expects the child
to take the medication
• Explanation regarding the medications should be
based on the child’s level of understanding

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

• The nurse must be honest with the child
regarding the procedure
• It may be necessary to mix distasteful
medication or crushed tablets with a small
amount of honey, applesauce, or gelatin
• Never threaten a child with an injection if he
refuses an oral medication
• All medications should be kept out of the
reach of children and medications should
never be referred to as candy
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Oral Medications
• GI tract provides a vast absorption area
for meds.

Problem: Infant / child may cry and refuse

to take the medication or spit it out.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Oral Medications
• Do not use if child has vomiting,
malabsorbtion or refusal
• Kids < 5 find it difficult to swallow tablets
• Use suspension or chewable forms
• Divide only scored tablets
• Empty capsules in jelly
• Do not call medication ‘candy’

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nursing Intervention
• Infant:
– Place in small amount of apple sauce
or cereal
– Put in nipple without formula
– Give by oral syringe or dropper
– Have parent help
• Never leave medication in room for
parent to give later.
• Stay in room while parent gives the
po medication
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Nursing Interventions
• Toddler:
– Use simple terms to explain while they
are getting medication
– Be firm, don’t offer to have choices
– Use distraction
– Band-Aid if injection / distraction
– Stickers / rewards

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nursing Intervention
• Preschool:
– Offer choices
– Band-Aid after injection
– Assistance for IM injection
– Praise / reward / stickers

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

 Nursing Intervention
• School-age
– Concrete explanations, do not just say “it
won’t hurt”
– Choices
– Interact with child whenever possible
– When the child is old enough to take
medicine in tablet or capsule form, direct
him or her to place the medicine near the
back of the tongue and to immediately
swallow fluid such as water or juice
– Medical play Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Nursing Interventions
• Adolescent
– Use more abstract rationale for
medication
– Include in decision making especially
for long term medication
administration

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nursing Alert
• For liquid medications, an oral syringe or
medication cup should be used to ensure
accurate dosage measurement. Use of a
household teaspoon or tablespoon may
result in dosage error because they are
inaccurate.

Bowen & Greenberg

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Household Measures Used to Give
Medications

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Oral Medication Administration

• Depress the chin with the

thumb to open infant’s mouth
• Using the dropper or syringe,
direct the medication toward
the inner aspect of the infant’s
cheek and release the flow of
medication slowly
• Note: child’s hands are held by
the nurse and child is held
securely against the nurses
body.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Oral Medications
• Hold child / infant hands away from face
• For infant: give in syringe or nipple
• DO NOT ADD TO FORMULA
• Small child: mix with small amount of juice
or fruit, give in syringe or allow the child to
hold the medicine cup and drink it at own
pace if he/she is big enough
• Parent may give if you are standing in the
room
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Oral Medication: older child
• TIP: Tell the child to drink juice or mild
after distasteful medication. Older child
can such the medication from a syringe,
pinch their nose, or drink through a straw
to decrease the input of smell, which
adds to the unpleasantness of oral
medications.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Intramuscular Medications
• Rarely used in the acute
setting.
• Immunizations
• Antibiotics
• Use emla
– a local skin anaesthetic that is applied to the
skin prior to procedures such as needles, to
help prevent pain.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IM Injection: interventions
• TIP: Tell the child it is all right to make
noise or cry out during the injection. His
or her job is to try not to move the
extremity.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IM Injection
Keep needle outside of
child’s visual field

Secure child before

giving IM injection.

Hold, cuddle, and

comfort the infant after
the injection

Inspect injection site

before injection for
Whaley & Wong tenderness or undue
firmness
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Nursing Alert
• Rocephin is often given in the ER.
• Hold order for IV antibiotic once admitted.
• Physician order may indicate to delay IV
antibiotic administration for 12 to 24
hours.
• Potential medication administration error.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IM Injection Sites
• Vastus Lateralis

• Deltoid

• Dorsogluteal

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

 Vastus Lateralis:
Largest muscle in infant / small child.

0.5 ml in infant
1 ml in toddler
2 ml in pre-school

Use 5/8 to 1 inch (2.5 cm) needle

Compress muscle tissue at upper

aspect of thigh, pointing the nurse’s
fingers toward the infant’s feet

Needle is inserted at a 90-degree

angle.
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Bowden & Greenberg
 Deltoid
Use ½ to 1 (2.5 cm) inch needle

0.5 to 1 ml injection volumes

More rapid absorption than

gluteal regions.

Bowden & Greenberg Mosby items and derived items © 2005, 2001 by Mosby, Inc.
 Dorsogluteal
Gluteal muscle does not
develop until a child begins
to walk; should be used for
injections only after the child
has been walking for a year
or more
Should not be used in
children under 5 years.
½ to 1 ½ inch needle
1.5 to 2 ml of injected
volume.
Bowden & Greenberg Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Eye Drops
Eye:
• Pull the lower lid down
• Rest hand holding the dropper with the
medication on the child’s forehead to
reduce risk of trauma to the eye.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

 Eye Drops

Pull the lower lid down

Rest hand holding the

dropper with the medication
on the child’s forehead to
reduce risk of trauma to
the eye.

Whaley & Wong

Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Ear Drops

Whaley & Wong

Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Ear Drops
• In children younger than age 3 years the
pinna is pulled down and back to
straighten the ear canal

• In the child older than 3 years, the pinna

is pulled up and back.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nose Drops

Position child with

the head hyper extended
to prevent strangling
sensation caused by
medication trickling into
the throat.

Whaley & Wong

Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Nose drops
• Act as vasoconstrictors excessive use
may be harmful
• Discontinued after 72 hours
• Congested nose will impair infants ability
to suck
• Give 20 minutes before feeding
• Have kleenex
• Keep child’s head below the level of
shoulders for 1 to 2 minutes after
instillation
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Rectal
• Usually sedatives and antiemetics
• Use little finger
• Insert beyond anal sphincter
• Apply pressure to anus by gently holding
buttocks together until desire to expel
subsides

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Intravenous Medications
• IV route provides direct access into the
vascular system.
• Adverse effects of IV medication
administration:
– Extravasation of drug into surrounding
tissue
– Immediate reaction to drug

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IV Medication Administration
• Check your institution's policy on which
drugs must be administered by the
physician and which must be verified for
accuracy by another nurse.
• All IV medications administered during
your pediatric rotation must be
administered under direct supervision of
your clinical instructor.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IV Medication Administration
• Check for compatibilities with IV solution
and other IV medications.
• Flush well between administration of
incompatible drugs.
• IV medications are usually diluted.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nursing Alert
• The extra fluid given to administer IV
medications and flush the tubing must be
included in the calculation of the child’s
total fluid intake, particularly in the young
children or those with unstable fluid
balance.

Bowden & Greenberg

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Nursing Alert
• Hourly assessment
• Documentation
• Patency, infiltration, inflammation, rate,
pain, LTC
• Use mini/micro drip chamber for control

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IV Medications
• IV push = directly into the tubing

• Syringe pump = continuous

administration

• Buretrol = used to further dilute

drug

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

IV Push
•Morphine
•Solu-medrol
•Lasix

Drug that can

safely be
administered
over 3 to 5
minutes.

Bowden & Greenberg Mosby items and derived items © 2005, 2001 by Mosby, Inc.
IV push
• Medication given in a portal down the
tubing – meds that can be given over a 1-
3 minute period of time.
– Lasix: diuretic
– Morphine sulfate: pain
– Demerol: pain
– Solu-medrol: asthmatic

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Syringe pump
• Accurate delivery system for
administering very small volumes
– ICU
– NICU

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

• A buretrol or volutrol is an intravenous
delivery device attached between the IV
fluid bag and the intravenous catheter. It
is used to deliver IV fluids in a safe
manner to children and medications* in
some nursing units.
• Usual volume capacity is 150 ml. Some
units have a policy that a buretrol will be
used on all children under 10 kg while
others may state 20 kg. Individual units
vary on policy.
• In practice: Make note of hospital/unit
policy for use of buretrols. Current
theory is that buretrols should be used
for children weighing <10-15 kg.
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
IV Buretrol
• Buretrol acts as a second chamber
– Useful when controlling amounts of
fluid to be infused
– Useful for administering IV antibiotics /
medications that need to be diluted in
order to administer safely

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Example:
• John is a pediatric client in a hospital in
which the policy is to place all children
on IV therapy on a buretrol and to only
fill the buretrol no more than two-
three hours worth of fluid. The nurse
fills the buretrol to 90 ml at 10 a.m. If
John’s IV is running at 34 ml per hour,
how long will it be before the nurse will
need to fill it again?

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Calculate:
• 90 ml ÷ 34 (ml/hr) = 2.65 hrs However,
0.65 hrs = ? minutes.

1 hr 0.65 hr
=
60 min X min
1x = 39.00

X = 39

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

• Answer = 39 minutes Add this to the 2
hours. 10 a.m. + 2 hr 39 minutes =
12:39 p.m.

• Answer: At 12:39 p.m. the buretrol will

need more fluid added so that air does
not get into the tubing.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Intravenous Therapy

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Central Venous Line

Whaley & Wong Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Central Venous Line
• A large bore catheter that are inserted
either percutaneously or by cut down and
advanced into the superior or inferior
vena cava
• Umbilical line may be used in the neonate
– Used for long term administration of
meds
– Used for chemotherapy
– Total parental nutrition
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Child With Central Venous Line

Whaley & Wong Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Type of fluid
• Glucose and electrolytes
– Maintenance
– Potassium added
• Crystalloid: Normal Saline or lactated
ringers
– Fluid resuscitation
– Acute volume expander
• Colloid: albumin / plasma / frozen plasma
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Complications
• Infiltration
• Catheter occlusion
• Air embolism
• Phlebitis
• Infection

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Infiltration
• Infiltration: fluid leaks into the
subcutaneous tissue
• Signs and symptoms:
– Fluid leaking around catheter site
– Site cool to touch
– Solution rate slows are pump alarm
registers down-stream-occlusion
– Tenderness or pain: infant is restless
or crying
Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Catheter Occlusion
• Fluid will not infuse or unable to flush
• Frequent pump alarm
– Flush line
– Check line for kinks

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Air embolism
• The IV pump will alarm when there is air
in the tubing
– Look to see that there is fluid in the IV
bag or buretrol
– Slow IV rate
– Remove air from tubing with syringe

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Phlebitis
• Often due to chemical irritation
• When medications are given by direct
intravenous injection, or by bolus (directly
into the line) it is important to give them at
the prescribed rate.
• Always check the site for infiltrate before
giving an IV medication

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Signs and symptoms: phlebitis
• Erythema at site
• Pain or burning at the site
• Warmth over the site
• Slowed infusion rate / pump alarm goes
off

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Reason for pump alarm
• Needs to have volume re-set
• Needs more IV solution in bag or buretrol
• Kinked tubing at infusion site
• Child lying on tubing
• Air in tubing
• Infiltrated at site of infusion

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Clinical Pearls
• If alarm states upward occlusion
– Look at IV bag
– Look at fluid level in buretrol
– Look to see if ball in drip chamber is
floating
• If alarm states downward occlusion
– Look to see that all clamps are open
– Look to see if line is kinked
– Irrigate with normal saline or heparin
Mosby items and derived items © 2005, 2001 by Mosby, Inc.