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Peds Exam 2
Care of Hospitalized Child and Med Admin pt 2
| Question | Answer |
|---|---|
| complications for excessive dosing in peds | is much more serious |
| some drugs are based on | age, weight and condition |
| Physiological Considerations Pharmacokinetics | absorption distribution metabolism excretion |
| absorption | Gastric pH Prolonged gastric emptying Increased skin permeability- neonate and infants |
| gastric pH in infants | it is increased which increases drug absorption, adult pH is reached by 2 years |
| Prolonged gastric emptying | neonates have this so med will be absorbed in small intestine which can have a delayed effect |
| Increased skin permeability- neonate and infants | so this means if there's a topical med, there could possibly be systemic effects |
| distribution | Higher proportion water Lower proportion body fat Immature blood brain barrier |
| Higher proportion water | infants have higher percentage of body water so if it is a water soluble drug, there will be increased distribution so will need higher dose |
| Lower proportion body fat | if lipid soluble med, child is at toxicity risk because not getting distributed to fat |
| immature BBB | more meds at risk for permeating BBB |
| metabolism | Hepatic clearance - immature liver and kidneys increased metabolic rate |
| excretion | Kidney functioning: decreased GFR, decreased renal tubular absorption and secretion |
| nursing assessment | Medication and food allergies Appropriateness of medication dose- age, weight Child’s developmental age Child’s physiological and psychological condition Tissue and skin integrity when administering IM, SQ, and topical IV patency for IV meds |
| use weight based dosing unless | use weight based dosing for the most part unless child is morbidly obese then they may exceed the adult max |
| Nursing Interventions | Calculate safe dosage by weight, age, diagnosis Notify provider Independent double check for high-risk meds Use 2 patient identifiers Allow choices for child Prepare child according to age and developmental stage |
| Notify provider if | Dosage outside safe range Inappropriate route |
| Use 2 patient identifiers | Name and birthdate |
| if child is at least 65kg, then | can most often use adult dosing but just be sure to calculate adult max |
| choices you can allow child to make regarding meds | arm or leg, parent or nurse |
| Developmental Considerations | Physical/motor development Never give option not to take! |
| Physical/motor development | Ability to swallow pills? Injection sites - is muscle big enough to handle the med? |
| infant considerations | involve the parents |
| toddler considerations | Follow routine Simple choices Touch equipment Allow to take themself if able |
| preschooler considerations | Allow play time with equipment (stuffed animal, doll) Simple choices Suppositories very upsetting Give band aide after injection - fix everything Allow to take themself if PO med |
| middle/school age considerations | Purpose explained in simple terms Have child help- they are in industry stage Reward |
| adolescent considerations | same as adults, maintain privacy |
| for oral administration, assess this first | Ability to swallow pills |
| what kind of measuring device should you use for oral admin | smallest measuring device possible, 1ml instead of 10ml |
| if crushing pill, | mix in smallest amount liquid ( 1 tsp) or soft food (applesauce) - never mixed in full carton bc you don't know if they'll eat it all Avoid mixing in formula - never mix in anything essential bc they may not want anymore |
| where to administer oral meds | side of tongue/mouth or buccal pocket (cheek) Small amounts for infants Watch for swallowing |
| do not refer to medicine as | candy, but also don't refer to it negatively |
| never do this to a child when taking oral meds | Never hold infant's/child's nose, they can coordinate their own breathing but you can not so you don't know when to let go |
| if child is ketogenic or no glucose diet, not allowed | to have med in oral suspension bc that contains carbs so you need to crush pill and use water |
| Administration via Feeding Tube | Assess proper placement Small tubes, flush in between meds!!! NG, ND, GT, GJ |
| for gastric feeds in infant | hold and encourage sucking |
| IV meds rate of admin | Push vs infusion - some can be both Min and max infusion times |
| IV assessment | Infiltration vs fear, difficult to determine if child is actually in pain or just doesn't like the IV touched |
| often times, when children have IVs | they don't like the idea of them so won't like you standing over them to push but if you hook up to a pump it will be like out of sight out of mind |
| IV sites | scalp, feet, central lines- groin |
| if med is less than 50ml, | it is given in syringe pump - like baby from clin with krabbes |
| piggyback administration is used | always! |
| flush tubing | at same rate to ensure all of med is given |
| hourly maintenance IVF in children | 421 rule 4 mL/kg/hr for the first 10 kg of body weight 2 mL/kg/hr for the next 10 kg 1 mL/kg/hr for each kg over 20 kg |
| optic administration | Supine or sitting position Extend child’s head and ask them to look up, heel of hand on their forehead |
| eye drops | Pull lower eye lid downward Apply in conjunctiva pocket |
| eye ointments | Administer from inner to outer canthus Give before bed or nap because this will blur the vision |
| atraumatic care and eye meds | Apply pressure inner eyelid- retains in eye, prevents systemic absorption Administer ointment before nap or sleep |
| otic administration | Position prone or supine with affected ear upward |
| otic admin in younger than 3 years | Pull pinna/auricle downward and straight back |
| otic admin in older than 3 years | Pull pinna/auricle upward and back |
| Atraumatic care in otic admin | Warm refrigerated medications to room temperature btwn hands to prevent nausea and vertigo Push tragus in after drops and child won't. have to stay on their side the whole time |
| Metered- Dose Inhaler (MDI) Spacer and facemask | allow for child to breathe in med properly take off the cap and shake inhaler stand up and breathe out inhaler in mouth and as breathe in, push down inhaler hold breath for 10 sec and wait 1 min btwn pumps |
| nasal administration | Clear nasal passages first Position with head hyperextended Prime applicator, administer one nostril at a time Instruct not to blow nose afterwards Inform child they may taste medication Don't let dropper touch nose Atraumatic care |
| Position with head hyperextended for nasal admin | Use pillows under shoulders Football hold for infants |
| atraumatic care for nasal admin | Insert vertically, then aim out and back (NOT IN) |
| rectal administration | Avoid if contraindicated Explain procedure Wash hands, gloves Lubricate suppository Insert into rectum past rectal and anal sphincters Gently hold the cheeks together afterward Observe diaper within 15 min Cut lengthwise if needed |
| contraindications for rectal med | neutropenia, thrombocytopenia, rectal surgery |
| when explaining procedure to preschooler, | use child life!! |
| how far to insert for small and older child | Small child < 0.5 inches Older child 1 inch |
| when you lubricate suppository, avoid | handling because it will get soft and hard to insert |
| injections | Age-based norms for site, needle length and gauge Site determined by age, amount and frequency Plan on needing to restrain child Can require splitting dose into 2 separate injections |
| Atraumatic care for injections | topical Lidocaine- 1 hr before Freeze spray "elsa spray" Buzzy - desensitizes pain receptors Distraction Infant- sucrose on pacifier (only for pain), Non-nutritive sucking (5-8 min only, not for NPO) Decreased pain if sitting vs lying position |
| subcutaneous injection sites | Anterolateral thigh- < 12 months Upper arm- > 12 months Abdomen- adolescent |
| for infant subq injections | do not use abdomen, use thigh |
| insertion of subq injections | 90-degree angle 45-degree angle- if little fat |
| volumes for subq are limited so | if infant or small child: <.5ml preschooler: 1ml this is why some injections may need to be split into two injections |
| IM sites | Vastus Lateralis < 3 years old Deltoid > 3 years old |
| for IM injections, always | rotate sites |
| IM injection max volumes by age | Infants- 0.5 ml - will need 2 sep shots at exact same time so its only 1 procedure Toddler 0.5-1ml Preschooler 1ml School age (6-10 years) 1.5-2ml Late school age/adolescent up to 3 ml |
| intraossesous injections | Temporary Used in emergent situations Anterior tibia- commonly only used in emergency or if not able to get access within 90sec and patient is arresting |
| safety first with meds | Do not administer if outside safe dosage Do not leave medication at bedside Do not give a med that you/pharmacist did not prepare Dispose of syringes/needles in sharps container - even oral Caps choking hazard or skin breakdown if laying on |
| if dose is outside safe range | call MD with questions |
| Teaching Patient and Families | Educate Assess understanding Return demonstration Provide written instructions Assist with scheduling |
| what to educate patients and families on with meds | use, side effects, drug/dietary interactions, complete full course antibiotics |
| general principles for pain management | Include both nonpharmacologic and pharmacologic Use oral route, when possible, to avoid painful routes Anticipate and treat side effects Referral to pain service |
| Anticipate and treat side effects- opioids | Pruritus and or Constipation |
| Nonpharmacological Measures | Physical measures Behavioral Cognitive Complementary and alternative medicine |
| Physical measures for pain mngmt | Heat, cold, massage, containment, Kangaroo care, non-nutritive sucking |
| Behavioral measures for pain mngmt | Relaxation Behavioral contracting |
| Cognitive measures for pain mngmt | Distraction - music or game Guided imagery - assist in imaginary experiences Positive self-talk |
| Complementary and alternative medicine | Acupuncture |
| Pharmacological Measures: WHO reccommendations | Two step approach: mild pain or moderate to severe pain then add |
| for mild pain, | Non-opioid, nonsteroidal anti-inflammatory (NSAIDS) > 6 months Can combine with acetaminophen |
| for moderate to severe pain, use mild pain regimen then add | Opioid- Morphine sulfate, hydromorphone, fentanyl, oxycodone |
| Pharmacological Measures | Dosing at regular intervals Appropriate route Adapted to individual Narcan should always be available |
| Appropriate Routes | Oral -preferred: Peak effect 1-2 hours Topical/ transdermal: Lidocaine and prilocaine- cream or gel- for punctures, Fentanyl- > 12 years Intravenous: Bolus, patient-controlled analgesia (PCA), family- controlled analgesia, Rapid onset |
| complications | Chronic pain syndromes |
| nursing actions for complications | Assess pain Administer meds in a timely fashion Evaluate and monitor response to interventions Make recommendations for alternate med if needed |
| Strategies for Painful Procedures | Explaining procedure to kids Maintain contact with parent for toddlers and preschoolers Perform procedure as quickly as possible Encourage comfort item from home - blanket, toy Use distraction, Child Life!! DO NOT cluster painful procedures |
| Explaining procedure to kids differs based on age | < 6 years immediately before it happens so there isn't too much time to think > 6 years- give time to process and ask questions Be honest!! |
| DO NOT cluster painful procedures, only exception is | when the dose is too big for one injection and needs to be split up into 2 shots |
Created by:
leh195