7. Medication Administration and Safety for Infants and Children

Question 1

Pharmacokinetics in Children

> Difference between pharmacokinetics and pharmacodynamics

Question 2

___ relates to what the medication does when traveling through the body over time

* What does the drug do to the body?

Answer 2

Pharmacodynamics

Question 3

___ relates to how a medication travels through the body over time

* What does the body do to a drug?”

> ___

> ___

> ___

> ___

Answer 3

Pharmacokinetics

Absorption

Distribution

Metabolism

Excretion

Question 4

Oral route

4 factors influence absorption along the gastrointestinal tract (GI)

> Gastric acidity

> Gastric emptying time

> GI motility or transit time through the GI tract

> Function of pancreatic enzymes

Question 5

Gastric acidity

* Infants’ gastric secretions are less acidic (secretions slowly increase during the first two years of life)

> Eat more frequently so they have food and gastric enzymes in their stomach most of the time

> Formula or milk increases alkalinity of gastric enzymes thus decreasing absorption of medications that need an acidic environment; however, it increases absorption of medications that require a more alkaline environment - serum drug levels will be impacted by this

Answer 5

Gastric emptying time

> Intermittent and unpredictable in infants

> Slower than in older children which leads to a delay in time of medication reaching intestinal absorption site

Question 6

GI motility or transit time through the GI tract

> Eating increases peristaltic activity

> Infants up to 8 months tend to have prolonged motility

> Diarrhea can also alter intestinal motility by increasing peristaltic movement

> The longer the transit time through the intestine, the more medication is absorbed; whereas shortened transit time decreases absorption

Question 7

Function of pancreatic enzymes

> Pancreatic enzyme activity may be altered in infants for the first ___ months while GI system matures

> Medications that require certain pancreatic enzymes for dissolution and absorption may not be converted to a form that is appropriate for intestinal action

Answer 7

3

Question 8

Other Routes

* Intravenous (IV)

> Immediately available for absorption in a child because peripheral circulation is less reliable and more responsive to changes in the environment; this may lead to vasoconstriction or vasodilation which affects absorption of parenteral medications

> Also cardiovascular system is less able to accomodate large or rapid changes in volume which can lead to fluid overload with poorly controlled IV infusions

> Immediate available for absorption

> Cardiovascular system is less able to accomodate large or rapid changes in volume intramuscular (IM)

> Children have less muscle - fewer injection sites

> Blood flow to muscle tissue can be unpredictable - can ↑ or ↓ absorption

Answer 8

Topical

> Infants and younger children have thinner outer skin layer and larger body surface area (BSA) to weight ratio

> Infants have more skin surface area relative to weight, absorption is greater

> Skin pH also varies with age which can affect absorption of topical medications

> Children are more prone to skin irritations - common skin irritations - contact dermatitis

Question 9

Differences between baby and adult skin

Baby skin

> Faster rate of water loss

> Less NMFs (Natural Moisturizing Factor)

> Less melanin pigments

> Smaller corneocytes

> Thinner stratum corneum, epidermis

Answer 9

Differences between baby and adult skin

Adult skin

> Slower rate of water loss

> More NMFs (Natural Moisturizing Factor)

> More melanin pigments

> Larger corneocytes

> Thicker stratum corneum, epidermis

Question 10

?

Refers to concentration of medication in body fluids and tissues

Answer 10

Distribution

Question 11

Differences in Body fluids

* Body fluid in infants is about ___% of body weight; whereas in younger children it is about ___% of body weight

> Infants have greater fluid volume per weight - this may require a higher dose per kilo of water-soluble medication to achieve desirable effects

* Medication must be adjusted during illnesses to avoid overdosing or underdosing

> Most body fluid is in extracellular fluid compartment so with certain illness this fluid may be lost rapidly leading to fluid depletion

Answer 11

75%

60%

Question 12

Differences in Fat percentages

> Percentage of body fat also varies with age… in infants is about 16% of body weight and slightly increases during the first year…then decreases again in a preschool child

> Percentage of body fat affects distribution of fat-soluble medications

Answer 12

Differences in proteins

> Medications bind to plasma proteins - mainly albumin for distribution

> Only free unbound medication is absorbed

> Preterm and newborn children have less levels of plasma protein - potentially increasing adverse drug effects

Question 13

Blood-Brain Barrier

> Does not fully mature until about ___ years of age

> Barrier is LESS selective allowing distribution of medications into the central nervous system
→ May lead to encephalopathy with certain medication

> Immature CNS can lead to paradoxical effects of medications
→ e.g. meds that cause sedation in adults may cause hyperactivity in children

Answer 13

2

Question 14

Metabolism

> Most medications are metabolized in the ___

> Preterm or newborn infants may have immature metabolic enzyme systems so may not metabolize all the medication given in one dose

> Toddlers and preschoolers may metabolize medication faster than adults so they may need higher doses or more frequent administration to achieve the desired therapeutic effect of a certain medication such as pain medication

Answer 14

liver

Question 15

Excretion

* Most medications are excreted through the renal system (lower glomerular filtration rate and less efficient renal tubular function)

* Newborns renal system is immature

* Infants are also not able to concentrate urine

Answer 15

* Renal immaturity leads to inadequate amounts of medication being filtered out of the circulatory system and therefore being excreted
> This leads to medication circulating longer in the blood reaching toxic levels in the blood

* Fluid volume loss (dehydration) also decreases ability to excrete and can affect serum drug levels

Question 16

Concentration

* Safe therapeutic levels maximize desired effect of medication and reduces risk of toxicity

* Peak and trough serum levels may be ordered to monitor medication concentrations

Question 17

___ is the level at which serum concentration is the lowest…usually obtained just before the next scheduled dose

Answer 17

Trough

Question 18

___ is the concentration of the medication after it has been distributed

Answer 18

Peak

Question 19

Psychological and Developmental Factors affecting Medication Administration in Children

Answer 19

* ALWAYS APPROACH CHILD ACCORDING TO THEIR DEVELOPMENTAL LEVEL

* Always provide appropriate explanations

* Always give child choices
> Toddler holding med cup

* Restraints are NOT necessary
> Unless when injecting a medication - another staff member may hold child during administration to avoid injury

Question 20

* Parents may help distract or comfort

* Honesty
> Nurses should be honest when explaining the administration process - unpleasant taste, painful or uncomfortable, approximately how long pain will last, what child can do to help (not move or hold cup)…pinching and stinging may be used for description

Answer 20

* Praising
> Helps gain trust and cooperation with future administration

* Rewarding
> Encourages and reinforces appropriate behavior - stickers

Question 21

Infants

* Essential administration techniques to ___ ___ of liquid or oral medications or adverse effects from medications

* Ask for help from other staff members for squirmy infants

* Always inform parents of medication being administered - to prevent medication errors

* Cuddling and comforting before and after is important

Answer 21

prevent aspiration

Question 22

Toddlers

* Ages __-__

* Magical thinking and may associate medication administration (mostly invasive) as for of punishment

* Age-appropriate explanations using play

* Allow older toddlers to examine equipment before procedure

* May sit on parents’ laps

* Praise, cuddling, rewards

Answer 22

2-3

Question 23

Preschoolers

* Ages __-__

* Magical thinking may use therapeutic play and participation

* Offer as much control and choices as possible (juice or milk?)

* May need staff member to hold child still

* Adhesive bandages are important because they believe a Band-aid will “make it better”

Answer 23

3-5

Question 24

School-age

> Fear loss of control, pain, and injury

> Understand more complex explanations as to “why” medication is needed

> Offer choices

> Often cooperate but may need distractors (squeezing hand, watching a video, listening to music)

> Praise and rewards still important in this age group

Answer 24

Adolescents

* Fear separation from peers and loss of control

* Understand adult explanations

* Praise cooperation

* Offer distractions

* Help find outlets for frustrations (draw, write)

Question 25

Calculating Dosages

> National Patient Safety Goals
* Improving the safety of using medications in an effort to decrease medication errors

> Verify accuracy of dose ordered

> 1st recommended dose for medication is checked and a calculation is performed to ensure right dose has been ordered

mg/kg/day

Answer 25

> 2nd recommendation for number of divided doses is confirmed

Every four hours…three times a day…every 12 hours

> Last, ensure route of administration is correct

Question 26

Medication Administration Procedures

Answer 26

* AVOID ERRORS

> “SIX RIGHTS” - right patient/child, right drug, right dose, right time, right route, and right documentation

> Check order…transcribed correctly…allergies noted?

> Always double check dosage calculation - make sure accurate child weight

> Ask another nurse to double check with certain medications
→ Insulin, oral hypoglycemic agents, dextrose hypertonic IV solution (20% or greater), narcotics/opioids, epidural/intrathecal administered medications, chemotherapeutic agents, digoxin or other inotropic medications, anticoagulants, anesthetic and moderate sedation drugs, potassium chloride, hypertonic sodium chloride, magnesium sulfate injection

Question 27

Medication Reconciliation

* Upon admission a list of all medications, including over-the-counter and herbal, taken at home is obtained

* Nurse compares list to what was prescribed with hospital admission

* Nurse identifies and communicates discrepanices

“medication reconciliation”

* Assess parent’s knowledge of child’s medication

> Name, dose, number of times a day, knowledge of side effects, adverse reactions, last time taken

Answer 27

* Upon discharge reconciliation includes clear, detailed, written instructions of all medications to be given at home as well as communicating medication to next healthcare provider

* Increased use of computer systems (electronic medical records - EMR, computerized physician order entry - CPOE) reduces medication errors, improves communication and improves medication regimen - do not replace responsibility

Question 28

Administration of Oral Medications

* Widely used

* Available in liquid (elixir or suspension), tablet or capsule, chewable tablet, and sprinkle (powder form)

* If child cannot swallow tablets or capsules…may have to give in liquid form or chewable tablet - if not available, then check if can be crushed or contents emptied

Answer 28

Not recommended to crush time-released medications

extended-release XR, controlled-release CR, sustained-release (SR), enteric-coated (EC)

* Assess gag reflex and ability to swallow prior to medication administration

Question 29

Preparation

* Ensure correct dose is drawn

* Physician orders specify dosage in milligrams (mg), NOT milliliters (mL) for liquid medications

* Calculate mL dose based on concentration (mg/mL) available

* Use milliliter only systems with oral dosing syringes

* For doses 5 mL or less use oral syringe designed for oral administration

Answer 29

* Larger volumes may be poured into calibrated plastic medicine cups (hold up to 30 mL = 1 oz)

* May mix sprinkle, powder, or crushed tablet with small amount (1-3 teaspoons) of nonessential food (applesauce, pudding, or liquid)

* Never mix with formula because may alter taste and child may not want to take the formula

* Check compatability with food prior to mixing

Question 30

Preparation - Example Question

Four-year-old

Order: Acetaminophen (Tylenol) 240 mg PO

Available: Acetaminophen 160 mg/5 mL

How many milliliters (mL) will the nurse administer?

Use cup or syringe?

Answer 30

Answers: 7.5 mL; cup

Question 31

Administration

> Differs according to child’s age and developmental level

> Infants

* Elixir or suspension form using an empty nipple or oral syringe

* Upright or semi-upright position

* Gently apply pressure to cheeks to open mouth

* If using nipple, place nipple in mouth and then add med when infant begins to suck

Answer 31

* If using oral syringe, place syringe along side of cheek and administer slowly and infant sucks

Question 32

Administration: Toddlers & Preschoolers

* Liquid from oral syringe or medicine cup

* Allow child to hold cup or syringe

* Praise/reward

Answer 32

Administration: Young school-age children

* Chewable tablets, older children may be able to swallow tablets or capsules

* Always check ability to swallow

Question 33

Administration

* Always administer in an upright position

* Offer food or fluid after administration (formula, juice or ice pop)… allow older children to choose

* If child vomits or spits up medication… NOTIFY physician…they may order another dose depending on how long since last dose, type of medication, and amount of emesis

Answer 33

* Oral medications can also be administered into GI tract via a feeding tube
> Verify tube placement

> Flush with water before and after each medication administration

Question 34

Administration of Injections

* Faster and more reliable absorption but can be stressful and threatening to child

* Depending on the child’s developmental level, explain reasons, any sensations, length of time may last

* Distractions…sing, breathing

* Parents may stay to comfort and support the child or may opt to leave if they feel they are unable to cope with stress

* To avoid injury may need to limit the child’s movement during administration (swaddle or have another staff member hold child)

Answer 34

* May need to use oral sucrose for infants, vapocoolants, and topical anesthetic like EUTECTIC mixture of local anesthetics (EMLA) cream to reduce or eliminate injection pain

* Documentation after injection must include amount, site, and how child tolerated

* If an immunization, documentation must also include manufacturer, lot number, and any reactions

Question 35

Intramuscular Injections

* Used for immunizations

* Determine injection site in advance

* Site will be dependent on age, size, muscle mass, and volume and properties of medication

* For infants and toddlers use ___ ___

* For children age 3-18 use ___

Answer 35

VASTUS LATERALIS

DELTOID

Question 36

* ___ may be used for infants, children, and adolescents

* Avoid dorsogluteal due to potential damage to sciatic nerve

* Rectus femoris is not recommended for children

* Needle size and length depends on size, amount of body fat, injection site, and child’s muscle mass at site of injection

* Needle size 22-25 gauge

* Needle length 1/2 - 1 1/2 inches…may use larger if med is viscous

Answer 36

VENTROGLUTEAL

Question 37

* Safe volumes ___ mL for infants and young children - ___ mL for adolescents

* Don gloves, cleanse skin with antiseptic swab or pad, let dry, insert needle at 90° angle in a quick dart motion, slowly inject at rate of 1 mL/10 seconds, remove needle, apply pressure, DO NOT rub

* Aspirating prior to administration is discouraged

Answer 37

0.5; 3

Question 38

Guidelines for Maximum Safe Volumes for Intramuscular Injections

Question 39

Which site?

Deltoid / Ventrogluteal / Vastus Lateralis

* Can hold large fluid volumes

* No major nerves or blood vessels

* Reports of less pain

* Heel of hand on greater trochanter, thumb pointed toward groin, index finger over anterior superior iliac spine and middle finger over posterior iliac crest to form a V between 2 fingers, inject in center of V

Answer 39

Ventrogluteal

Question 40

Which site?

Deltoid / Ventrogluteal / Vastus Lateralis

* Children over 2

* Only use 0.5-1 mL

* Close to radial and axillary nerve

* Faster absorption

* Locate acromion process top of arm, inject 2 finger spaces below acromion

Answer 40

Deltoid

Question 41

Which site?

Deltoid / Ventrogluteal / Vastus Lateralis

* Anterior lateral thigh

* Can tolerate large volumes

* No large nerves or blood vessels

* Easy to access

* Greater trochanter and knee joint, divide space into thirds, inject into outer aspect of middle third

Answer 41

Vastus Lateralis

Question 42

Subcutaneous Injections

* Injected into connective tissue just below dermal layer

* Used for medications that provide sustained effects (heparin, insulin, and certain immunizations)

* Outer posterior aspect of upper arm and anterior aspects of the thigh (may use abdomen 2 in radius around umbilicus for repeated injections)

* Needle gauge __-__ gauge

* Needle length 3/8-5/8 inch long

* Don gloves, cleanse skin, allow to dry, gently pinch skin, insert at 45° angle (may do 90° angle with a 1/2 in needle), insert needle darting motion, release tissue, inject med, remove needle, gentle pressure; DO NOT massage

* Volume ___-___ mL

Answer 42

25-27

0.5 - 1

Question 43

Intradermal Injections

* Dermis layer of skin below the epidermis

* Inner aspect of forearm or on upper back

* Used for allergy testing or tuberculosis (TB) screening (PPD)

* Needle gauge __-__ gauge

* Needle size 3/8 - 5/8 inch length

* Maximum volume ___ mL

* Don gloves, cleanse skin, allow to dry, turn bevel of needle up, insert gently at a 5 to 15° angle, inject slowly to form a bleb or wheal

Answer 43

25-27

0.1

Question 44

Rectal Administration

* Have localized effect on the GI tract (e.g. to promote defecation)

* May also have systemic effect like decreasing fever

* Reserved for times when child cannot eat or drink or is unable to tolerate oral intake (nausea or vomiting)

* Increase risk for injury to anal and rectal tissues

* Do not use this method if rectum is full of stool, if child has rectal disease, or recent rectal surgery

* Explain reason, steps, and what child can do to help

Answer 44

* Position on left side with right leg slightly flexed, provide draping, distraction and deep breathing exercise to help relax external sphincter

* Place water-soluble lubricant on suppository

* Advise to take deep breath and bear down to relax sphincter, depending on size of anus, use index or little finger to gently insert suppository through the anus and past the internal sphincter (1.5-2.5 cm)

* After insertion hold buttocks together for about 5 minutes

* Instruct not to expel suppository for 5-10 minutes

Question 45

Vaginal Administration

* Used primarily for school-age or adolescent girls

* Used for topical treatment with anti-infective agent for vaginal infection

* Explain procedure, reason for medication, and what they can do to help

* Ask to void

* Place in supine position with soles of feet together and knees resting on bed

* Use drapes for privacy

Answer 45

* Gently spread labia, lubricate tablet, suppository, or applicator with water-soluble lubricant

* Have patient take deep breath and gently insert vaginal medication approximately 7.5-10 cm along the posterior wall of vagina

* Remain in supine position for at least 10 minutes

Question 46

Ophthalmic Administration

* Form of drops or ointments

* If refrigerated allow to warm to room temperature

* Gently remove any exudates using a sterile gauze; move from inner to outer canthus

* Use a different pad for each eye

* Shake suspensions before instilling

* Neck gently hyperextended

Answer 46

* Eye drops instilled into conjunctival sac…look upward while gently pulling lower lid down and away from eye…do not contaminate tip of bottle

* Eye ointment applied along inside ridge of lower eyelid from inner to outer canthus

Question 47

Otic Administration

* Placed supine with head turned

* Gently clean any exudate with sterile gauze

* Never place any item into ear for cleaning

* Otic solutions should be warmed to room air

* Child older than 3 pull pinna up and back…for child younger than 3 pull pinna down and back

Answer 47

* Place cotton loosely into outermost portion of ear canal

* Place on unaffected side for 5-10 minutes

Question 48

Nasal Administration

* Mucous membranes allow for rapid systemic absorption

* Remove excess mucous by gently suctioning the nose with a bulb syringe

* For better results use saline nose drops, followed by gentle suction, 20-30 minutes prior to feedings

* Supine, with head slightly hyper-extended

Answer 48

* Instill number of drops into each naris and instruct to hold still for about one minute

* Instruct not to blow nose after administration

Question 49

Topical Administration

* Can produce local and systemic effects

* Creams, ointments, lotions, patches, and paste

* Adhesive, transdermal patches release medication continuously over a prescribed time period

* Changed at scheduled intervals… must tell child not to remove patch

Answer 49

* Applied to clean dry skin, free of any irritations, bruises, or abrasions

* Must wear gloves to apply patch

Question 50

Inhalation Therapy

* Nebulizer or a metered-dose inhaler (handheld delivers puffs of medication)

* Nebulized medication is diluted in normal saline solution

* Can be delivered through facemask or plastic mouthpiece

* Nebulized medication can be delivered along with oxygen

Question 51

* Metered-dose inhalers may be used with a spacer

* Initial and ongoing education is essential in ensuring effectiveness of treatment… demonstration and return demonstration

* Must also be taught on how to clean and maintain nebulizer at home

Question 52

Inhaler use

* If more than one inhaler and one is an inhaled steroid, this one should be administered last

* Shake inhaler well
* Attach spacer to inhaler
* Tilt head back, take a deep breath and slowly exhale
* Place mouthpiece in mouth and depress the inhaler canister

* Ask child to slowly and deeply inhale (“big breath in”) and hold breath for 10 seconds

* Wait __-__ minutes between puffs

* Ask child to rinse mouth with water after each use

Answer 52

1-2 minutes

Question 53

Intravenous Therapy

* Used for fluid and electrolytes, total parenteral nutrition (TPN), blood products, and medications

> Intravenous catheter insertion
→ Gauge 22-26 dependent on vein size and type of fluid
→ Consider developmental age when choosing access site
→ Explain procedure…see…feel…expect
→ Assess fear and anxiety and teach coping strategies in advance

→ Use interventions to decrease or eliminate pain from IV insertion
→ May need staff member to hold down child to avoid injury

Answer 53

→ Performed in treatment room with all supplies gathered previously
→ Parents may remain in room but are NOT expected to hold child down
→ Explain procedure every step of the way
→ Apply tourniquet and select site (avoid nondominant hand or forearm)

→ Start with most distal veins
→ May use transillumination, near infrared light, or ultrasound
→ After insertion attach a well-padded arm board to prevent injury and keep IV intact

→ Clear plastic shield (IV House Ultradome) is applied over site for protection
→ Document procedure

Question 54

Intravenous catheter insertion

> EUTECTIC mixture of local anesthetics (EMLA) Anesthetic Cream

* Cleanse site with soap and water and dry

* Place a mound of EMLA cream (2.5 g or half of a 5 g tube) on site and cover with an occlusive transparent dressing; DO NOT rub into skin

* Leave in place for a minimum of 1 hour and no longer than 4 hours

Answer 54

* Take dressing off and remove all the cream from the site

* Begin venipuncture… the numbing effect will last for up to 1-2 hours

Question 55

Intravenous catheter monitoring

> Assess and monitor IV catheter site at least every HOUR

* Assess for signs of infiltration, phlebitis, and/or infection

* Assess for warmth, redness (erythema), blanching, swelling (edema), pain, red streaking and exudate… if noted stop infusion and notify physician

* IV catheters only changed when clinically indicated due to fragile veins, difficulty accessing, and stress

Question 56

> IV fluid bags are changed every ___ hours

> IV tubing changed ___ hours - ___ days

* Change IV bags and tubing more frequently when administering TPN, blood products, or lipids

Answer 56

24

96 hours - 7 days

Question 57

Intravenous infusion monitoring

> IV infusion pumps accurately control infusion rate

> Programmed with IV fluid limits to avoid accidental fluid overload

> Some facilities require pumps to be set to deliver no more than a 2-hour fluid volume

Answer 57

Infusion rates and methods

> Daily IV infusions are ordered on an hourly basis according to the daily maintenance fluid requirements and rates

> Use formula to calculate the daily maintenance fluid requirements and rates based on rates

> Documentation should include type of IV fluid, site, rate ordered, and the actual amount of fluid infused

> IV fluid amount administered should be verified by the nurse on an hourly basis even if on an infusion pump…IV pumps may malfunction and lead to fluid overload

Question 58

Formula for Calculating Daily Fluid Requirements

Question 59

Administering Intravenous Medications

> Continuous or intermittent infusion

* Always check

→ Compatability of medication to be infused with an intermittent infusion with the IV solutions,

→ IV tubing to be used,

→ concentration of IV administration,

Answer 59

→ the volume of the diluted medication,

→ suggested administration rate, and

→ amount of flush needed

Question 60

Intravenous bolus (push) administration

* Delivered over a certain period (a few minutes)

* Use port closest to the insertion site

* Volume of medication small usually less than 5 mL

* Always check the IV site prior to medication administration

* Cleanse port with alcohol wipe, attach needleless system (cannot contaminate tip), occlude the IV (pinch) above the tube and push the medication in small amounts, then un-pinch and allow IV solution to run in-between push

Answer 60

* If medication is not compatible with IV solution or is going into an intermittent infusion port, flush the tubing with 2-3 mL of normal saline before and after medication administration

* Administer medication at the exact prescribed rate over the required period of time

* Assess child during and immediately after administration to monitor for signs of adverse effects

Question 61

Administering Intravenous Medications: Continuous or intermittent infusion/intravenous intermittent infusion administration

* Infusion pumps are used to ensure safety of intermittent infusion (via piggy-back)

* Can run concurrently or sequentially with a primary infusion line

* Always verify compatability of medication to be infused with IV solutions

Answer 61

* Another type of IV pump is a syringe pump, prefilled syringe with medication premixed by pharmacy…attached to primed low-volume tubing

* Label syringe or IV bag containing medication

* ALWAYS CHECK THE SIX RIGHTS

Question 62

Venous Access Devices

Question 63

> Intermittent infusion ports

* Used to administer medications without having a running IV line

* Port is flushed and accessed when fluid or medication is needed

* Routine flushing to maintain patency every 8-12 hours…follow facility policy

* Also flush with normal saline before and after each medication administration

Question 64

> Central venous access devices

* Catheters placed directly into major blood vessels

* For administration of IV fluids, medications, blood products, and parenteral nutrition over prolonged periods of time

* Require routine care like dressings and flushing

Answer 64

* When transparent dressing… recommend cleaning site and changing dressing every 7 days

* In most cases each lumen is flushed with heparinized saline every 24 hours and after each medication administration or blood draw

* Strict aseptic technique because directly in central venous system

Question 65

> Central venous access devices: tunneled central lines (Broviac or Hickman catheters)

* Surgically implanted and held in place by a Dacron cuff in subcutaneous tunnel

* Commonly placed in external jugular vein but may also be seen in cephalic, axillary, subclavian, femoral, saphenous, and internal jugular veins

* Tip of catheter is threaded until it rests at the junction of the superior vena cava and right atrium

Question 66

> Central venous access devices: implanted venous access device (port-a-cath)

* Catheter connected to a port or reservoir

* Port is placed under skin and accessed with a non-coring needle through the skin

* Allows child to participate in typical childhood activities except high-impact contact with chest

Question 67

> Central venous access devices: Peripherally inserted central catheter (PICC)

* Used when IV access is needed for longer periods of time

* Long silicone catheter… threaded through an introducer via a peripheral vein of upper arm (cephalic or brachial) until tip reaches the superior vena cava…then the introducer is removed, and placement is confirmed by x-ray

* Covered with a BIOPATCH and then a transparent dressing… site should be monitored frequently for any signs of infection

Answer 67

* Dressings changed 24 hours after insertion and then every 7 days… must remain dry and intact

* May be left in place for a few weeks to months and is usually used for prolonged antibiotic use at home

* Frequent complications include phlebitis, infection, thrombosis, and catheter occlusion

Question 68

Administration of blood products

> Explain procedure to parents and child

* Child may feel frightened from seeing the blood… take into consideration developmental level when explaining administration to child

* Also review with parent’s reason, how long it will take, what they will see and feel… obtain information from parents about any prior blood administrations and any reactions that may have occurred

Question 69

> Confirm ABO blood type and Rh factor

* Compatability and blood has been cross-matched for this child

* Required that 2 nurses verify child identity, ABO/Rh type, donor number, expiration date and time

* Patent IV line 22-24 gauge

* Infusion rate may be slower for packed red blood cells

* Tubing includes a filter to filter any particles from blood

Answer 69

* Tubing connected with a Y connector to another line with normal saline available for infusion

* IV pump is used for precise regulation of rate

Question 70

> Monitor closely

* Child should be closely monitored during blood administration

* Guidelines for nursing care

→ Baseline vitals before administration

→ Then assess vitals every 15 minutes for the first 1-2 hours

→ Then hourly until infusion is complete

→ Rate of infusion for packed red blood cells is about 5 mL/kg/hr over no more than 4 hours

Answer 70

→ Monitor closely for S/S of adverse reaction: fever or chills, headache, nausea, pain at insertion site, or difficulty breathing

→ Never leave child alone during infusion

→ If a reaction is suspected, STOP infusion immediately and notify physician... start an infusion of NORMAL SALINE through new tubing to maintain patency of line…continue to monitor vital signs, hourly urine output, and send samples of the child’s blood and urine to laboratory per physician orders

Question 71

Family Education

> Nurse must provide thorough verbal and written instructions on all medications to be taken at home
→ Include dose, administration times, therapeutic effects, possible side effects and adverse reactions

* Emphasize the need to take medications as prescribed including finishing the full course of prescribed antibiotics, not changing doses, and returning for follow-up appointments

* Emphasize the need to keep medications locked up

Answer 71

* With any medication administration procedure, the best way to ensure teaching is effective is to use DEMONSTRATION with RETURN DEMONSTRATION

* If medication administration is needed while in school
→ Physician must complete an order form with specific instructions such as dose, purpose of use, potential side effects and adverse reactions, and specific times medication should be given

→ A parent consent form must also be signed

→ Medication must be supplied to school nurse in original pharmacy container