Show Summary Details
Page of

Administration of medicines in children’s and young people’s nursing 

Administration of medicines in children’s and young people’s nursing
Chapter:
Administration of medicines in children’s and young people’s nursing
DOI:
10.1093/med/9780199641482.003.0003
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy).

Subscriber: null; date: 16 October 2017

Pharmacology

Medical pharmacology is the science of drugs and how they interact with the human body. These chemical interactions can be divided into two areas:

  • Pharmacokinetics: how the body handles a drug

  • Pharmacodynamics: how a drug works (Administration of medicines in children’s and young people’s nursing Pharmacodynamics, p. [link]).

Pharmacokinetics

If a drug is to have an effect on the cells of the body, it must be in the right place, for the right amount of time, and at the right concentration. The concentration is very important if the drug is to be therapeutic:

  • Too high, it may well become toxic.

  • Too low, it will be non-therapeutic.

Drugs are administered by a variety of routes using a variety of formulations in order to have a desired response. The desired response will only happen if a therapeutic level is maintained and this, in turn, relies on bioavailability. The bioavailability of a drug is defined as the proportion of the administered dose that reaches the circulation, e.g. intravenous (IV) drug administration would equal 100% bioavailability (see Fig 3.1). Factors that will affect bioavailability should be considered in any situation where drugs are being used.

Drugs are usually metabolized within the liver by specific enzyme pathways. The time taken for the plasma level of the drug to be reduced by one-half is known as the half-life, or t ½.

Pharmacokinetic data about a drug will tell us what dose to give, how often to give it, and what other factors to take into consideration. Pharmacokinetic processes can be divided into four stages (see Fig 3.2):

  • Absorption: depends on many factors, e.g. whether the drug is water- or fat-soluble, how it is formulated, and what else is in the gut at the same time.

  • Distribution: depends on quality of blood flow, binding of the drug to protein carriers, which is a real issue with polypharmacy because of carrier competition. Of particular importance in children:

    • the blood–brain barrier may be compromised in neonates

    • fat levels are low in the newborn

    • protein binding is also lower in the first few months of life.

  • Metabolism in the liver will produce new products called metabolites; these are usually waste products but with some formulations they will be the active component of the drug. Factors such as blood flow through the liver and the size of the liver are important, particularly in neonates.

  • Elimination of the drug, usually via the kidney. Decreased blood flow and poor kidney function will lead to a serious accumulation in the body of drug or drug metabolites. Administered drugs are also eliminated by the gut, sweat glands, and, sometimes forgotten with young babies, via the mother’s breast milk, which may contraindicate the child’s medication.

Further reading

Greenstein B, Gould D (2008). Trounce’s Clinical Pharmacology for Nurses, 18th edn. Elsevier, London.Find this resource:

    Administration of medicines in children’s and young people’s nursing Electronic Medicines Compendium (eMC) website: www.medicines.org.uk

    Pharmacodynamics: the study of how drugs work

    Most drugs produce their effect by acting on proteins called receptors. These receptors are genetic in origin and allow cells to communicate with the outside or internally. Receptors usually respond to synaptic transmitters or hormones.

    The interaction of the drug and the receptor depends on the fit of the drug molecule to the receptor. The better the fit, the more specific the drug. Sometimes a drug molecule will affect more than one receptor and may produce unwanted side effects.

    Action of drugs

    Drugs act by:

    • Replacing chemicals that are deficient—hormones, minerals, vitamins

    • Interfering with cell functions and metabolic pathways by stimulating or inhibiting normal levels of activity—clotting disorders, inflammation, and hormone disorders

    • Acting against invading or abnormal cells—antibiotics, anticancer drugs

    • Interfering with the function of receptor sites themselves, enhancing responses (agonists) or preventing normal responses (antagonists).

    Agonist drugs (Fig 3.3) bind to the receptor site and improve the response to normal stimulation, thus producing a reaction that will result in improved cell function, e.g. metformin hydrochloride increases the receptor sensitivity to insulin in diabetics.

    Antagonist drugs (Fig 3.4) bind to the receptor site and block normal function and cell activity, e.g. tamoxifen prevents the oestrogen molecule docking with a receptor, thus preventing cell growth stimulation in breast tumours.

    Prescribing for children

    It is useful to use the following terminology:

    • Neonate: birth to 1 month

    • Infant: 1 month to 2 years

    • Child: 2–12 years

    • Adolescent: 12–18 years.

    Children are not ‘mini adults’. Paediatric doses should be calculated from paediatric baseline data and should not be just a modified adult dose.

    Further reading

    Greenstein B, Gould D (2008). Trounce’s Clinical Pharmacology for Nurses, 18th edn. Elsevier, London.Find this resource:

      Administration of medicines in children’s and young people’s nursingBNF for Children. www.bnfc.org

      Topical applications

      Skin thickness/sensitivity/condition should be taken into account when applying topical treatments.

      Skin thickness

      • Face: 0.12 mm, thinnest on lips and around eyes

      • Body: 0.6 mm

      • Palms and soles: 1.2–4.7 mm.

      Emollients

      Hydrate and soften the skin. Can be applied to all skin surfaces. Act as a barrier to water and external irritants, for all dry or scaling disorders. Their effects are short lived so frequent applications are needed. Applying immediately after washing maximizes the hydration effect. Allow to soak in for 20–30 min before applying other topical treatments such as steroids. The greasier (liquid and white soft paraffin, emulsifying ointments), the more effective. Some emulsifying ointments can also be used as a soap substitute and are very effective when used in conjunction with a bath emollient (Table 3.1).

      Table 3.1 Vehicle types of emollient topical applications

      Vehicle types

      Description

      Uses

      Creams

      Light emulsions with high water content (60%).Contain preservatives

      ‘Wet’ skin; easy to apply, well absorbed

      Barrier creams

      Water repellent, often contain silicone

      Protection of intact skin, e.g. round stomas, pressure sores, nappy area

      Easy to apply, not sticky

      Not to be used over acute skin lesions

      Ointments

      Water in oil emulsions, greasy, often in soft paraffin base

      Chronic dry conditions (eczema) encourage hydration as stay on skin longer so can be more effective; antipruritic

      Gels

      Consistency between creams and ointments, have high water content but can burn skin

      Particularly suitable for face and scalp; antipruritic

      Lotions (shake)

      Alcohol base may cause stinging. Contain insoluble powders that leave deposit on skin

      Cooling effect often preferred on hairy skin, e.g. calamine lotion; antipruritic

      Pastes

      Stiff preparations with high proportion of finely powdered solids. Impregnated bandages

      Circumscribed, chronic lichenified lesions. Bandages may be left on for several days

      Antiseptics and cleansing lotions

      Care must be taken that correct dilution is used to avoid risk of burning and irritation

      Cleansing infected and weeping lesions

      Apply liberally in downward strokes following hair growth to prevent folliculitis. Rubbing in should be avoided as this creates heat and irritation and can cause damage to delicate skin cells. Nurses should wear gloves when applying topical medications.

      Topical steroids

      • Treatment of inflammatory conditions, e.g. eczema.

      • Apply no more than twice daily.

      • Ointments provide better absorption and often less irritation, apply thinly following ‘fingertip units’ (FTUs) (Table 3.2).

      • One FTU (500 mg) is sufficient to cover area twice that of a flat adult palm.

      • 1% hydrocortisone may be used for infants under 1 year and on face for all ages.

      • Occlusion increases potency up to tenfold.

      • Use least potent preparation which is effective for severity of condition (Table 3.3).

      • Avoid prolonged use, especially on face and around eyes.

      Table 3.2 Coverage of topical steroids by fingertip units (FTUs)

      Age

      Number of adult FTUs

      Face + neck

      Arm + hand

      Leg + foot

      Trunk (front)

      Trunk (back) + buttocks

      3–6 months

      1

      1

      1.5

      1

      1.5

      1–2 years

      1.5

      1.5

      2

      2

      3

      3–5 years

      1.5

      2

      3

      3

      3.5

      6–10 years

      2

      2.5

      4.5

      3.5

      5

      Table 3.3 Potency of topical steroids

      Potency classification

      Example

      Mild

      Hydrocortisone 0.5%, 1%, 2.5%

      Moderate

      Clobetasone

      Potent

      Mometasone, betamethasone, fluticasone

      Very potent

      Clobetasol (rarely used for children)

      Side effects

      • Mild to moderate potency are associated with few side effects. Absorption though skin rarely causes adrenal suppression.

      • Locally, excessive and long-term use of potent strengths can result in:

        • skin thinning

        • striae

        • telangiectasis

        • fine hair growth

        • easy bruising

        • perioral dermatitis.

      • Pigment changes are caused by eczema, not by topical steroids.

      Further reading

      NMC (2008). Standard for Medicine Management. NMC, London. Administration of medicines in children’s and young people’s nursinghttp://www.nmc.org.uk/standards/additional-standards/standards-for-medicines-management/Find this resource:

        Administration of medicines in children’s and young people’s nursing British Association of Dermatology website: www.bad.org.uk

        Administration of nose medications

        It is important to explain to the child or the carer how to instil nasal medications. Because of the shape of the nose, it is important that nose drops are applied in such a way that they are able to reach the sinuses.

        • Wash your hands with soap and water, dry your hands.

        • Ask the child to blow their nose, or help them to do so. Before instilling nasal drops or spray, clean away any nasal discharge or dried secretions using moist cotton wool balls.

        Nasal drops

        • Position the child for instilling nose drops by laying the child on the bed with the head and neck extended over the side of the bed; or the child could lie on the bed with a pillow placed under their shoulders so their head is tilted. For an older child, it may be easier to stand with their head downwards and forwards. Administering nasal drops to an infant is best performed by two carers. The infant should be positioned across one carer’s knee with the infant’s head extended and slightly dipped. The second carer can administer the drops.

        • Drops can be placed in one nostril with the head slightly turned to that side. The head should be maintained in that position for 30 s and then the drops can be instilled into the other nostril. If the head is not turned to the side on which drops are instilled the solution may slide directly through the nose and into the back of the throat.

        • Avoid touching the dropper on the nose or anything else.

        Nasal spray

        • The child should hold their head in an upright position.

        • The spray nozzle is inserted into the nostril.

        • The spray should be directed away from the septum toward the outer portion of the eye or top of the ear on that side. It is easier if the right hand is used to spray the left nostril and left hand to spray the right nostril.

        • The device should be activated as recommended by the manufacturer.

        • Deliver the number of sprays prescribed.

        • The child should gently breathe in or sniff during the spraying.

        • Wash your hands with soap and water, dry your hands.

        Further reading

        Benninger MS, Hadley JA, Osguthorpe JD, et al. (2004). Techniques of intranasal steroid use. Otolaryngology and Head and Neck Surgery, 130, 5–24.Find this resource:

          Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

            NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/standards/additional-standards/standards-for-medicines-management/Find this resource:

              Administration of ear medications

              Simple eardrops can be administered by the child’s carer, but it is important to explain to the child and carer how to administer eardrops for the medication to be effective (see Table 3.4).

              Table 3.4 Administration of ear drops

              Action

              Rationale

              1. 1. Wash hands with soap and water, dry hands; keep the eardrops clean; avoid touching the dropper on the ear

              To prevent cross-infection

              1. 2. Explain procedure in a way appropriate to child’s level of understanding

              To promote partnership and compliance

              1. 3. Warm drops by holding container in hand

              To promote patient comfort

              1. 4. If the drops are in a suspension, shake well before using

              To ensure equal distribution of medication

              1. 5. Infants and toddlers should be laid across the carer’s lap, older children lie supine with head turned to one side; affected ear uppermost

              To allow easy access to affected ear

              1. 6. In children <3 years, pull the pinna gently down and back, for older children pull the pinna gently up and back

              To straighten the ear canal; the internal anatomy of the ear canal changes as the child grows

              1. 7. Hold the dropper ~2 cm above the ear canal and instil the correct number of drops into the ear canal

              1. 8. Massage the tragus just in front of the ear

              To help propel drops down the ear canal

              1. 9. Advise child to stay in that position for about 3–5 min (use distraction such as TV)

              To allow the solution to seep down to the eardrum

              1. 10. Repeat with the other ear if required

              1. 11. Wash hands with soap and water, dry hands

              To prevent cross-infection

              1. 12. Document appropriately

              To comply with procedures for safe administration of medicines

              Further reading

              Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                  Administration of medicines in children’s and young people’s nursing Primary Ear Care Centre website: www.earcarecentre.com

                  Administration of eye medications

                  See Table 3.5 for procedure for administering eye medications.

                  Table 3.5 Administration of eye medications

                  Action

                  Rationale

                  1. 1. Assess need for medication and check medication correctly prescribed

                  Eye medication is just as important as other forms of medication

                  If wrong medication or dose is given, it can be harmful to the patient

                  1. 2. Gather equipment and wash hands:

                    • Tissues (clean) or gauze (not cotton wool)

                    • Eye medication

                  Prevent cross-infection and avoid unnecessary interruption of procedure

                  1. 3. Explain procedure as appropriate for child’s age and understanding, and to parents/carers, if present

                  Promotes partnership with child and family, gains consent

                  1. 4. Select correct eye for instillation of eye medication, as per prescription

                  To ensure medication administered as prescribed

                  1. 5. Position child appropriately:

                    • Swaddle infant

                    • Ensure head is flat and child is still

                  To prevent injury and promote comfort

                  If instilling eye drops:

                  1. 6. Take off bottle top (check prescription)

                    • With the child’s eyes closed, drop medication as prescribed into inner corner of the eye (next to the nose)

                  To prevent discomfort

                    • Wait for drop to disappear. If it remains visible, gently pull down lower lid and watch drop roll in

                    • Wipe away excess medication

                  To prevent irritation

                    • Drops can be instilled as above, if eyes open also

                  1. 7. Distract child if necessary to ensure they allow drop to be instilled

                  Can be an emotionally difficult procedure

                  If instilling eye ointment:

                  1. 8. If using ointment, gently pull down lower lid and squeeze in 2 cm along the lower lid

                  For ease of administration

                  1. 9. With the eyes closed, gently wipe with a clean tissue, if necessary

                  To aid comfort

                  1. 10. Praise/congratulate the child

                  Procedure can be emotionally difficult

                  1. 11. Put the top firmly back on the tube/bottle

                  To prevent spillage or cross-infection

                  1. 12. Wash your hands again

                  To prevent cross-infection

                  1. 13. If several different eye medications are due, administer 5 min apart

                  To enable drops to be absorbed

                  1. 14. Do not share bottles/drops with other patients

                  To prevent cross-infection

                  1. 15. Store as directed and discard as per instructions

                  To ensure safe practice is maintained

                  1. 16. Report and document any reaction as per local protocol

                  To ensure safe care and prevent harm

                  1. 17. Document on prescription chart

                  To prevent drug error

                  Further reading

                  Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                    Watkinson S, Seewoodhary R (2008). Administering eye medications. Nursing Standard, 22(18), 42.Find this resource:

                      Administration of nebulizers

                      See Table 3.6 for procedure for administering nebulizers.

                      Table 3.6 Administration of nebulizers

                      Action

                      Rationale

                      1. 1. Identify the correct patient

                      Safe drug administration

                      1. 2. Assess child’s need for nebulizer

                      Nebulizer therapy enables the delivery of bronchodilators, steroids, antibiotics, mucolytics, adrenaline, and normal saline

                      1. 3. Gather equipment and then wash hands

                      Prevent cross-infection

                      1. 4. Select appropriate nebulizer system for drug, connect face mask to nebulizer and nebulizer to gas source:

                        • Mouthpiece or mask?

                      Mouthpiece increases aerosol delivery

                      Masks need to be tight fitting to avoid drug getting into eyes

                      Drug delivery is reduced if mask held away from face

                        • Appropriate compressor or gas source?

                      In acute asthma, croup, and anaphylaxis, oxygen must be used as hypoxia can occur

                      If there is a risk of CO2 retention, e.g. cystic fibrosis, air should be used

                        • Select appropriate flow rate

                      Most nebulizers work on 6–10 L/min, driving gas should be set at 6–8 L/min

                        • Place compressor on firm surface

                      To avoid cold, dusty air being drawn into compressor

                      1. 5. Prepare required drug:

                        • Measure required amount of drug using a needle and syringe

                      The prepared ‘nebule’ is often a higher dose than required for children, therefore the required dose will need to prepared

                        • Dilute if necessary with normal saline

                      2–2.5 mL fill is satisfactory for most nebulizers; however, delivery is maximized by a 4 mL fill and this is recommended for steroids and antibiotics Diluting with water could provoke bronchospasm

                        • Discard syringe and needle in sharps box

                      Prevent needlestick injury

                      1. 6. Explain procedure to child and carer in an age-appropriate way

                      Understanding will enhance concordance, reduce anxiety and gain consent

                      1. 7. Where possible child should sit up to keep the nebulizer upright

                      Level of drug delivery is reduced due to abnormal breathing pattern if child is crying

                      1. 8. Discourage the child from talking or having a dummy in the mouth during nebulization

                      To maximize delivery of drug

                      1. 9. Encourage normal tidal breathing through the mouth

                      Duration of nebulization is important for compliance; should take no longer than 10 min

                      1. 10. Endpoint is when spluttering occurs—tap pot and continue nebulizing for 1 min

                      Drug output remains high at this point

                      1. 11. At end of nebulization:

                        • Turn off airflow and reassess condition of child

                      To detect any change in child’s condition

                        • Wash face if mask was used, especially if steroids used

                      To promote comfort To avoid skin irritation from drug particles

                        • Decontaminate nebulizer equipment after use

                        • Wash nebulizer and dry thoroughly

                      To prevent bacterial contamination To remove remnant drug crystals which could block nebulizer nozzles

                        • Clean hands

                      To prevent cross-infection

                      Further reading

                      Coyne I, Neill F, Timmins F (eds) (2010). Clinical Skills in Children’s Nursing. Oxford University Press, Oxford.Find this resource:

                        Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                          Administration of medicines in children’s and young people’s nursing PharmaWeb. How to Use a Nebuliser. www.pharmweb.net/pwmirror/pwz/patient/pharmwebpatinf5.html

                          Administration of oral drugs

                          See Table 3.7 for the procedure for administering oral drugs.

                          Table 3.7 Administration of oral drugs

                          Action

                          Rationale

                          1. 1. Wash hands

                          To prevent cross-infection

                          1. 2. Check what is prescribed, when it is due

                          Give right medicine at right time

                          1. 3. Is the prescription dated and signed?

                          Legal requirement

                          1. 4. Check dose is appropriate for condition being treated and child’s age/weight/surface area:

                            • A second, independent, check of calculations is recommended

                          Dosage accuracy

                          1. 5. Check that child’s name, date of birth, and identification number on identity band match those on prescription chart

                          Give medicine to right child

                          1. 6. Confirm above steps with parent/older child if possible, prepare child with age-appropriate information

                          Effective partnership, gain consent

                          1. 7. Offer choice of formulations (liquid/tablet/capsule) if available

                          Acceptability

                          1. 8. Ensure storage of medication has been correct

                          Potency

                          1. 9. Calculate volume of liquid/number of tablets/capsules:

                            • If possible, avoid dividing tablets or dissolving/dispersing tablets in a specified volume of water to prevent partial consumption of the medication

                          Dosage accuracy

                          1. 10. Child may prefer a crushed tablet or contents of a capsule with a small spoonful of yoghurt or ice cream.

                            • ► Modified-release preparations will lose their modified-release properties

                          Acceptability

                          1. 11. Avoid adding drug to large quantities of drink/food

                          Accuracy and potency

                          1. 12. Check container, label, and expiry date:

                            • Liquids which have been reconstituted will have an expiry date based on date of reconstitution in addition to an expiry date for the dry powder preparation

                          1. 13. Shake liquids before opening

                          To mix contents

                          1. 14. If dose <5 mL, always draw up using an oral syringe

                          Dosage accuracy

                          1. 15. Do not draw up more than one medicine into the same syringe because medications are generally licensed to be absorbed in the acid environment of the stomach and may interact if mixed outside of this environment

                          1. 16. Explain treatment to child/parent

                          Concordance

                          1. 17. Offer choice of delivery method (spoon, oral syringe or medicine cup), where possible

                          Acceptability

                          1. 18. Offer medicines to an infant before a feed, unless contraindicated

                          1. 19. Seek cooperation through play and patience

                          Compliance

                          1. 20. If cooperation from young child unobtainable, sit child on adult’s lap with one arm tucked under the adult’s arm and other arm secured by adult’s same arm and hand

                          Reduced risk of inhalation of medicine through struggling

                          1. 21. Never threaten child with an injection as an alternative

                          Coercion

                          1. 22. Stay with the child until medicine has been taken

                          Safe administration of medicines

                          1. 23. A drink may usually be given after medicine

                          To wash it down

                          1. 24. Praise child for taking medicine

                          Encourage compliance

                          1. 25. Wash hands

                          To prevent cross-infection

                          1. 26. Document procedure

                          Safe administration of medicines

                          Further reading

                          Coyne I, Neill F, Timmins F (eds) (2010). Clinical Skills in Children’s Nursing. Oxford University Press, Oxford.Find this resource:

                            Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                              NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                Administration of medicines in children’s and young people’s nursing Royal Pharmaceutical Society website: www.rpharms.com

                                Administration of rectal medications

                                Rectal administration of medicine is invasive and therefore not routinely used. However, it may be used when a child cannot take medication orally or to clear the lower bowel in cases of severe constipation.

                                • The administration of rectal medication (Table 3.8) may be contraindicated if there is any rectal bleeding or diarrhoea, or if the child has any anatomical anomaly of the anus or rectum.

                                • Two adults must normally be present when the procedure is performed (one as chaperone).

                                Table 3.8 Administration of rectal medication to children

                                Action

                                Rationale

                                Preparatory phase:

                                1. 1. Identify the correct patient

                                Safe drug administration

                                1. 2. Explain procedure to the child/ family using age-appropriate language

                                To minimize distress by preparing the child/family and gain consent

                                1. 3. Ensure privacy

                                To avoid unnecessary embarrassment and maintain privacy and dignity

                                1. 4. Where appropriate and possible, encourage the child to empty their bladder before the procedure

                                A full bladder may cause increased discomfort during the procedure

                                1. 5. Wash hands or clean with gel rub and assemble equipment; prescribed medication, lubricating jelly, disposable gloves, tissues, disposable incontinence pad

                                To prevent cross-infection and ensure safety by the use of appropriate equipment

                                Do not cut suppositories as this prevents accurate measurement of the medication being administered

                                Performance phase:

                                1. 6. Position the child lying on left side, knees well flexed; upper leg more flexed than the lower leg

                                To ease the passage of the medication/suppository/tube into the rectum

                                1. 7. Place disposable incontinence pad under child’s hips and buttocks

                                To reduce potential infection caused by soiling

                                1. 8. Put on disposable gloves

                                To avoid embarrassing the child if medication ejected

                                1. 9. Lubricate tapered end of the suppository or the insertion end of the enema

                                Enables easy movement into rectum

                                1. 10. Separate child’s buttocks

                                To view anus

                                1. 11. Lubricated end first gently insert the suppository or enema tube into the rectum beyond the anal sphincter

                                Ensures correct positioning of suppository

                                1. 12. If administering an enema, gently squeeze the contents into the rectum and remove the tube

                                Rapid infusion could cause damage to the child’s colon

                                1. 13. Hold buttocks together

                                Relieves pressure on anal sphincter reducing urge to expel the suppository or enema fluid

                                1. 14. Explain location of nearest toilet

                                In case of urgent need

                                1. 15. Ask child to retain medication in rectum as long as possible

                                Efficacy of the medication

                                1. 16. Dispose of clinical waste and gloves, wash hands

                                To prevent cross-infection

                                1. 17. Reassure and praise child

                                To reward compliance

                                1. 18. Document procedure

                                To prevent drug errors by accurate recording of administered medications

                                Further reading

                                Coyne I, Neill F, Timmins F (eds) (2010). Clinical Skills in Children’s Nursing. Oxford University Press, Oxford.Find this resource:

                                  Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                                    NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                      Administration of an intramuscular (IM) injection

                                      See Table 3.9 for the procedure for administering IM injections and Table 3.10 for injection sites.

                                      Table 3.9 Administration of an IM injection

                                      Action

                                      Rationale

                                      1. 1. Identify the correct patient

                                      Safe drug administration

                                      1. 2. Explain procedure to child and family

                                      Increases understanding, decreases fear and gains consent

                                      1. 3. Consider moving child to a treatment area to avoid the bed area becoming associated with pain

                                      1. 4. Assess validity of prescription

                                      Safe drug administration

                                      1. 5. Check that the dose, drug, time, and route are correct

                                      Limited drugs may be given IM

                                      1. 6. Gather and inspect all equipment and its packaging:

                                      Reduces risk of cross-contamination

                                        • If damaged or past expiry date discard and then wash hands:

                                        • Clean receptacle for syringe

                                        • Appropriate syringe; < 2 mL advised for IM injection

                                      Decreases pain and facilitates absorption

                                        • 21 G needle to draw up (23 G from glass ampoule, consider filter)

                                      Prevents shards of glass being drawn up

                                        • 23 G or 25 G needle to inject

                                        • Drug and appropriate diluent

                                        • Sharps bin

                                      Safe sharps disposal

                                      1. 7. Prepare and draw up drug. Change needle:

                                      Ensures needle not blunted

                                        • Check with second nurse as governed by local policy. Check child’s nameband

                                      Reduces risk of drug errors

                                      1. 8. Wear disposable gloves

                                      Protects hands from accidental contact with blood

                                      1. 9. Reassure child

                                      Injection more painful in tensed muscle

                                      1. 10. Choose site for injection

                                      1. 11. Help child into a comfortable position, uncover site

                                      1. 12. Ensure area to be injected is socially clean

                                      Prevents introduction of dirt Routine use of alcohol wipes not recommended

                                      1. 13. Pull skin at injection site to one side (Z track technique)

                                      Decreases leakage of drug into subcutaneous tissue

                                      1. 14. Rapidly plunge the needle into the muscle at 90º

                                      To ensure muscle mass is penetrated

                                      1. 15. Aspirate for blood:

                                        • If blood present discard and start again

                                      Ensures injection not given into blood vessel

                                      1. 16. Slowly inject fluid, ~1 mL per 10 s

                                      Allows fluid to dissipate, reduces pain

                                      1. 17. After a few seconds withdraw needle, use a dry sterile gauze swab to apply gentle pressure at site:

                                      Do not massage site; could cause tissue irritation

                                        • Discard syringe and needle in sharps box immediately

                                      Prevent needlestick injury

                                        • Dispose of clinical waste and gloves, wash hands

                                      To prevent cross-infection

                                      1. 18. Ensure child settled

                                      To lessen distress

                                      1. 19. Document procedure

                                      Reduce drug errors by accurate recording

                                      Table 3.10 Injection sites

                                      Ventrogluteal

                                      Consistent presence of muscle—can be used in emaciated/ young patients with little risk of injury

                                      Vastus lateralis

                                      Easily accessible, little risk of injury

                                      Deltoid

                                      Little muscle mass—small volumes only

                                      Dorsogluteal

                                      Risk of nerve/artery damage. Sizeable muscle—larger volumes

                                      Rectus femoris

                                      Painful but suitable for self-injection

                                      Further reading

                                      Coyne I, Neill F, Timmins F (eds) (2010). Clinical Skills in Children’s Nursing. Oxford University Press, Oxford.Find this resource:

                                        Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                                          NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                            Administration of a subcutaneous (SC) injection

                                            See Table 3.11 for the procedure for administering a SC injection.

                                            Table 3.11 Administration of a subcutaneous injection

                                            Action

                                            Rationale

                                            1. 1. Identify the correct patient

                                            Safe drug administration

                                            1. 2. Explain procedure to child/family

                                            Ensures understanding of procedure and gains consent

                                            1. 3. Consider use of local anaesthetic cream

                                            Decreases pain

                                            1. 4. Assess validity of prescription. Check that dose, drug, time and route are correct

                                            Safer drug administration

                                            1. 5. Gather and inspect all equipment and its packaging

                                            1. 6. If damaged or past expiry date discard and then wash hands:

                                            Reduces risk of cross-contamination

                                              • Clean receptacle to carry syringe

                                              • Syringe: <1 mL advised for SC

                                              • 21 G needle to draw up (23 G from glass ampoule); 25 G needle to inject

                                            Prevent shards of glass being drawn up with drug

                                              • Drug of appropriate strength and diluent

                                              • Sharps bin

                                            Safe sharps disposal

                                            1. 7. Draw up drug, change needle

                                            Ensures needle not blunted

                                              • Check with second nurse as governed by local policy. Check child’s nameband

                                            Reduces risk of drug errors

                                            1. 8. Wear disposable gloves

                                            To protect hands from accidental contact with blood

                                            1. 9. Reassure child

                                            To lessen distress of injection

                                            1. 10. Choose site, ensuring regular rotation

                                            Decreases risk of skin irritation

                                            1. 11. Do not inject into moles, scars, inflamed or oedematous tissue:

                                              • Abdomen (preferred site)

                                              • Lateral aspects of thighs

                                              • Lateral aspects of upper arms

                                              • Buttocks

                                            Unpredictable absorption rate from this tissue

                                            1. 12. Help child into comfortable position, uncover site

                                            1. 13. Ensure area to be injected is socially clean

                                            Prevents introduction of dirt

                                            Routine use of alcohol wipes not recommended

                                            1. 14. Using non-dominant hand, pinch up and hold a fold of skin in the chosen area:

                                            Ensures needle enters subcutaneous tissue

                                              • Rapidly plunge the needle in at 45°

                                            Rapid needle entry reduces pain.

                                              • Release skin pinch

                                            Pain increased if injected into compressed tissue

                                              • Slowly inject fluid

                                            Allows fluid to dissipate, reduces pain

                                            1. 15. After a few seconds quickly withdraw needle:

                                              • Discard syringe and needle in sharps box

                                            To prevent needle stick injury

                                              • Dispose of clinical waste and gloves, wash hands

                                            To prevent cross-infection

                                              • Ensure child settled

                                              • Document procedure

                                            Reduce drug errors by accurate recording

                                            Further reading

                                            Coyne I, Neill F, Timmins F (eds) (2010). Clinical Skills in Children’s Nursing. Oxford University Press, Oxford.Find this resource:

                                              Kelsey J, McEwing G (eds) (2008). Clinical Skills in Child Health Practice. Elsevier, Oxford.Find this resource:

                                                NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                                  Administration of an intravenous (IV) bolus

                                                  See Table 3.12 for procedure for administering an IV bolus.

                                                  Table 3.12 Administration of an IV bolus

                                                  Action

                                                  Rationale

                                                  1. 1. Explain procedure to child and family

                                                  Increases understanding, decreases fear, gains consent

                                                  1. 2. Assess validity of prescription. Check the dose is correct and is suitable for/rate of IV bolus

                                                  Safe drug administration

                                                  Only selected drugs may be given by IV bolus

                                                  1. 3. Gather equipment and wash hands:

                                                  Reduces risk of cross-contamination

                                                    • Consider wearing gloves/safety clothing

                                                  Prevent contact with toxic drugs

                                                    • A clean receptacle in which to carry equipment

                                                  Reduces risk of cross-contamination

                                                    • Two syringes, 5 mL or over, of appropriate size for drug and flush

                                                  Apply less pressure than smaller syringes

                                                    • 21 G needle to draw up (23 G from glass ampoule)

                                                  Prevents shards of glass being drawn up

                                                    • Drug and appropriate diluents, saline flush

                                                    • Sharps bin

                                                  Reduces risk of sharps injury

                                                    • Alcohol wipe

                                                  1. 4. Prepare and draw up drug:

                                                    • Clean hands and put on non-sterile gloves

                                                  Reduces risk of cross-contamination

                                                    • Draw up prescribed medication and saline flush

                                                  Flush required to ensure line patent and prevent adverse mixing of drugs

                                                    • Discard needles in sharps bin

                                                    • Check with second nurse, as governed by local policy. Check child’s nameband

                                                  Reduces risk of drug errors

                                                  1. 5. Reassure child

                                                  Lessens distress

                                                  1. 6. Expose cannula site. Observe for signs of pain, redness, and swelling

                                                  To assess for signs of tissue irritation

                                                  1. 7. Wipe port of cannula with alcohol wipe for 30 s. Allow to dry naturally until visibly dry

                                                  Ensures port is clean

                                                  1. 8. Introduce syringe with drug into port; unclamp line; apply gentle, consistent pressure, delivering drug at recommended rate; observing for redness/swelling; clamp line; remove syringe

                                                  • Lessens risk of tissue damage

                                                  • Decreases risk of adverse drug reaction

                                                  1. 9. Repeat above step to administer the saline flush, delivering at the same rate as the drug

                                                  Deliver any drug remaining in the line at the required speed

                                                  1. 10. Discard all material as per local policy; re-dress cannula site

                                                  1. 11. Document that the drug has been given

                                                  To prevent drug error

                                                  Further reading

                                                  NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                                    Administration of medicines in children’s and young people’s nursingGreat Ormond Street Hospital for Sick Children. Aseptic Non Touch Technique (ANTT) for Intravenous Therapy. http://www.gosh.nhs.uk/health-professionals/clinical-guidelines

                                                    Epidural analgesia

                                                    Epidural analgesia is the administration of analgesics, normally local anaesthetic drugs with or without opioids, into the epidural space. This technique enables analgesics to be given close to the spinal cord and spinal nerves and is a widely used method of managing acute pain in children. A catheter is introduced into the epidural space when the child is asleep, at such a level to ensure that the appropriate spinal nerves are blocked. The administration of epidural analgesia can be done by bolus dosing or continuous infusion. A steady analgesic effect may be difficult to maintain with bolus dosing but it can be useful in some situations. Continuous delivery of drug agents, administered through an infusion pump, can provide a more consistent level of pain control, titrated to meet patients’ individual needs.

                                                    Any staff involved in the care of a child with epidural analgesia must be appropriately trained.

                                                    Level of administration

                                                    • Thoracic: used in the treatment of pain after major abdominal and thoracic surgery.

                                                    • Lumbar: used to provide analgesia after orthopaedic and other limb surgery, urological surgery, and pelvic surgery.

                                                    • Caudal: useful approach for younger children having various surgical procedures, e.g. circumcision, inguinal herniotomy, lower abdominal surgery.

                                                    Suggested nursing care

                                                    • Regular monitoring is important for early detection of drug-related side effects, to detect intensity of pain, and for early detection of signs of epidural procedure complications.

                                                    • Follow local guidelines for assessment and monitoring requirements of a child receiving epidural analgesia.

                                                    • Monitoring may include:

                                                      • pain scoring (at rest and on movement), to assess efficacy of analgesia

                                                      • sedation levels, heart rate, and respiratory rate

                                                      • motor block

                                                      • pulse oximetry, O2 saturation, blood pressure

                                                      • urinary pattern

                                                      • device check.

                                                    Potential complications

                                                    • Motor blockade: can increase the risk of pressure sores in lower limb surgery

                                                    • Hypotension

                                                    • Dural puncture: can occur when the dura matter is accidentally punctured during the placement of the epidural catheter

                                                    • Catheter migration

                                                    • Urinary retention

                                                    • Haematoma: from trauma to an epidural blood vessel during catheter insertion

                                                    • Epidural infection

                                                    • Other complications if opioids are used:

                                                      • respiratory depression

                                                      • sedation

                                                      • nausea and vomiting

                                                      • pruritus.

                                                    Further reading

                                                    National Patient Safety Agency (2007). Epidural Injections and Infusions. NPSA, NHS Direct, London.Find this resource:

                                                      NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource:

                                                        Administration of medicines in children’s and young people’s nursingFaculty of Pain Medicine of the Royal College of Anaesthetists (2010). Best Practice in the Management of Epidural Analgesia in the Hospital Setting. www.aagbi.org/sites/default/files/epidural_analgesia_2011.pdf

                                                        Administration of medicines in children’s and young people’s nursingNational Patient Safety Agency (2007). Patient Safety Alert 21: Safer Practice with Epidural Injections and Infusions. www.nrls.npsa.nhs.uk/resources/?EntryId45=59807

                                                        Entonox® administration

                                                        Entonox® (nitrous oxide) is a homogeneous gas containing 50% nitrous oxide and 50% oxygen compressed into a cylinder. It is a potent analgesia with properties comparable to those of strong opioids.

                                                        Entonox® is an effective analgesia for use in labour and can be used for short-term pain relief for children having a variety of painful procedures such as joint injections, change of dressings, or venous cannulation. It is very soluble in the blood so it is delivered very quickly to the brain to produce an analgesic effect.

                                                        Nitrous oxide is an anaesthetic gas and should always be administered following local set criteria and guidelines. It diffuses more rapidly than nitrogen and can expand in enclosed air-containing spaces within the body, therefore care should be taken with use.

                                                        Entonox® can be used as a form of self-administered analgesia, but the child must be able to cooperate by using the mouthpiece to release the demand valve and inhale the gas. If unable to do so, an alternative method of analgesia must be used.

                                                        Contraindications for Entonox® use

                                                        • Age

                                                        • Airway abnormality

                                                        • Breathing problems

                                                        • Head injury with impaired consciousness

                                                        • Raised intracranial pressure

                                                        • Signs of basal skull fracture

                                                        • Intestinal obstruction

                                                        • Vitamin B12 deficiency

                                                        • Middle-ear obstruction

                                                        • Uncorrected congenital heart disease

                                                        • History of gastro-oesophageal reflux.

                                                        Nursing management

                                                        • Where patient-controlled Entonox® is being used, assess each child on an individual basis to determine appropriateness for use.

                                                        • Any member of staff involved in Entonox® administration should be competently trained in its use and be aware of the safety issues surrounding the use of Entonox®, e.g. use in a well-ventilated room to avoid accumulation; risks for use during early pregnancy; monitoring requirements; concurrent sedatives in use, etc.

                                                        • Follow local guidelines regarding fasting recommendations for children before using Entonox®.

                                                        • Complete a medical checklist before Entonox® administration, and monitor appropriately throughout the procedure.

                                                        Further reading

                                                        Administration of medicines in children’s and young people’s nursingBOC. Medical Gas Data Sheet. Entonox 50% Nitrous Oxide, 50% Oxygen Medicinal Gas Mixture. www.boconline.co.uk/internet.lg.lg.gbr/en/images/Entonox410_43539.pdf

                                                        Patient-controlled analgesia

                                                        Patient-controlled analgesia (PCA) is the administration of analgesia, usually an opioid, infused from a hand-held button attached to a pre-programmed computerized pump. The pump is programmed with a suitable dose of analgesia calculated on the child’s age and body weight. This allows the child to have control over their own analgesia, which has considerable psychological benefits. It also allows the child the chance to anticipate painful procedures and self-administer appropriate analgesia. A maximum dose per hour + lockout time period is programmed into the pump to ensure the child cannot overdose, thus ensuring safety. Previous studies have found that delivery of a continuous infusion alongside PCA for the first night following surgery can help to give the child a better sleep pattern. The handset is still available for use for breakthrough pain.

                                                        Considerations for patient selection

                                                        • Cognitive development: must be old enough to understand the concept of PCA.

                                                        • Understanding: must be able to understand how to use the PCA correctly, including the principles of the lockout time, allowing the analgesia time to take effect, and safety issues.

                                                        • Physical ability: those with physical disabilities or reduced conscious levels may not be suitable for PCA.

                                                        Safety issues

                                                        • Pump programming should be carried out by an appropriately trained person.

                                                        • Inappropriate use by parents or other family members. Clear explanation and information about PCA is essential.

                                                        • Accidental syphonage: standard use of a non-return anti-free-flow valve should be used to prevent free flow of opioid into the patient and prevent reflux of drug up concurrent infusion lines.

                                                        Nursing management

                                                        • Close monitoring and observation by competently trained staff. Follow local policies for monitoring and recording.

                                                        • Monitoring may include:

                                                          • pain scoring (at rest and on movement) to assess efficacy of analgesia and determine appropriate use

                                                          • sedation, nausea, SaO2, and respiratory rate recordings to ensure early detection and treatment of opioid-induced side effects

                                                          • device check to ensure correct delivery of opioids and detect any potential problems that may occur.

                                                        Further reading

                                                        Administration of medicines in children’s and young people’s nursingGreat Ormond Street Hospital for Sick Children. Patient Controlled Analgesia/Nurse Controlled Analgesia. http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/analgesia-use-patientproxy-patient-controlled-analgesia-palliative-care

                                                        Administration of controlled drugs

                                                        The control of drugs is defined in UK law by the Misuse of Drugs Act 1971 and regulations in 1985 and 2001. Five schedules of drugs are identified. Drugs subject to control by nurses lie within schedules 2 and 3. These drugs have stringent regulations regarding prescription, requisition, storage, administration, and disposal and recording (Table 3.13).

                                                        Table 3.13 Procedure for administration of a controlled drug

                                                        Action

                                                        Rationale

                                                        1. 1. Identify the correct patient

                                                        Safe drug administration

                                                        1. 2. Explain procedure to child and family

                                                        Increases understanding, decreases fear, and gains consent

                                                        1. 3. Collect the Ward Controlled Medicine Record Book

                                                        A record must be kept of controlled drugs stored and used

                                                        1. 4. Registered nurse plus checker collects keys for controlled drug cupboards

                                                        The person in charge of the of the clinical area has the keys or knows where they are at all times

                                                        1. 5. Together they unlock the cupboards, identify the medicine to be administered, check the number of tablets/ampoules against the stock register. If this is accurate they then remove the required dose for the prescription and complete the controlled medicines record identifying the amount of the drug remaining. The remaining medicine is returned to the cupboard which is then locked appropriately

                                                        Controlled medicines must be stored as required by law. Stocks of all controlled drugs in the area must be checked by two people (one a registered nurse) every 24 h to meet legal requirements

                                                        1. 6. If not all the medicine is required but cannot be returned for storage (e.g. part of an ampoule) then this must be disposed of safely and recorded

                                                        1. 7. The medicine should be administered to the patient following the procedural guidelines relating to administration route

                                                        1. 8. The registered nurse and the checker must then sign the prescription sheet and the controlled drugs record book

                                                        An immediate, accurate record must be made of all medicines administered, wasted, or refused by the patient and signed/dated legibly

                                                        Controlled drugs must be administered by a registered nurse and witnessed by another person who also signs the Ward Controlled Medicine Record Book, checks the stock balance is correct, and signs the child’s drug treatment chart. The qualification of the second checker depends on local policy. Within UK hospitals, local policies usually require storage within a securely locked cupboard inside another locked cupboard with an identified key holder.

                                                        Controlled drugs

                                                        These drugs are used to manage pain, enable procedures, or facilitate sedation. Some anticonvulsants are also included. As with any medication, nurses must be aware of the nature of the drug given and the potential outcomes that may occur. Children’s nurses are advised to use the British National Formulary for Children, as recommended by the Royal College of Paediatrics and Child Health.

                                                        The use of controlled drugs requires effective communication with children and their families. Parents may express worries that their child may become addicted to the drugs prescribed, and they need to be prepared for the effects of the drugs they may observe in their child.

                                                        Further reading

                                                        Royal Pharmaceutical Society of Great Britain (2004). Fitness to Practice and Legal Affairs Directorate. Fact Sheet Two: Controlled Drugs and Hospital Pharmacy. RPS, London.Find this resource:

                                                          Administration of medicines in children’s and young people’s nursingHealth Act (2006). Part 3: Drugs, Medicines and Pharmacies. Chapter 1: Supervision of Management and Use of Controlled Drugs. www.legislation.gov.uk/ukpga/2006/28/contents/enacted

                                                          Safe storage of medicines

                                                          All medicines should be stored and handled in a safe and secure manner.

                                                          Rationale

                                                          To ensure continuing safety of the patient and to meet the requirements of the Medicines Act 1968, Misuse of Drugs Act 1971, Use and Control of Medicines 1989, and the Control of Substances Hazardous to Health Regulations 2002.

                                                          Storage methods

                                                          These include:

                                                          • Lockable cupboards, used to store tablets, capsules, mixtures, injections.

                                                          • Fridges reserved solely for the storage of medicines marked with ‘store in a refrigerator’. Fridges must be fitted with approved temperature monitoring.

                                                          • Lockable medicine trolleys, for storing all the oral drugs in current use in the ward or department, except for drugs controlled by the Misuse of Drugs Act. Trolleys must be immobilized when not in use.

                                                          • Lockable controlled drugs cupboard which contains only those medicines controlled by the Misuse of Drugs Act and marked Controlled Drugs. No other drugs/items should be kept in this cupboard.

                                                          • Lockable immobilized bedside medicine storage cupboards for storage of patient’s own drugs and those supplied for that patient, if appropriate.

                                                          • Lockable security-sealed containers for transportation or moving of medicines.

                                                          The senior nurse/midwife in charge has overall responsibility in the clinical area for the safekeeping of medicines. However, all staff handling medicines must be security conscious.

                                                          • The medicine cupboard and trolley keys must be kept separate from all other keys and, if not in immediate use, should be held by the nurse in charge.

                                                          • The keys to the controlled drug cupboard should be kept on a separate ring from keys to other medicine cupboards.

                                                          • Sterile fluids should be stored in a clean designated area only for this use.

                                                          • Emergency boxes for resuscitation purposes should be stored in their sealed container with their tamper-proof seals intact, ideally in a closed drawer on the resuscitation trolley.

                                                          • All cleaning materials must be stored in a separate locked cupboard.

                                                          • Entrances to pharmacies and other controlled areas should have solid doors, fitted with security locks and alarms.

                                                          • Stationery such as order books and blank prescription forms should be locked in a cupboard.

                                                          Further reading

                                                          Administration of medicines in children’s and young people’s nursingControl of Substances Hazardous to Health Regulations (2002). www.hse.gov.uk/coshh/

                                                          Administration of medicines in children’s and young people’s nursingDepartment of Health, Social Services and Public Safety Information Office (2005). The Safe and Secure Handling of Medicines: A Team Approach (The Revised Duthie Report 2005). http://www.dhsspsni.gov.uk/the-safe-and-secure-handling-of-medicines.pdf

                                                          Calculating doses of medicines

                                                          Prescription of medication to obtain therapeutic doses in children is based on a dose/weight relationship and will vary significantly through the developmental years as the child’s weight increases. To accommodate this, pharmaceutical companies prepare many medications in liquid form so that different doses of medication can be drawn from one stock solution.

                                                          Although medical practitioners are legally responsible for the correct prescription of the medication, nurses are accountable for ensuring the correct calculated dose is administered. Figure 3.5 shows a typical prescription chart used in a children’s ward.

                                                          Fig 3.5 Example of a typical prescription chart.

                                                          Fig 3.5 Example of a typical prescription chart.

                                                          The metric system is used to describe the units of medication. If stock solutions are prepared in grams (g) and the prescription is in milligrams (mg) then before a calculation can be made a conversion is necessary so that prescribed dose and stock dose are in the same units. Some medications that exert a therapeutic effect at very low doses may be prescribed in micrograms but supplied in milligrams (mg) in stock solutions. If conversion to similar units is not achieved, then a magnitude error in the calculation will occur, leading to overdose. Another conversion is now necessary to convert the quantity of medication (milligrams or micrograms) into a volume (millilitres) of the solution to be administered.

                                                          An equation can be set up to deal with both conversions at the same time:

                                                          What is required (prescribed dose)×available dilution (stock volume)What is available (stock dose)

                                                          A child is prescribed 125 mg of antibiotic from stock solution of 250 mg/5 mL:

                                                          125mg250mg×5mL

                                                          This can be simplified to:

                                                          12×5mL=2.5mL

                                                          The units (mg) on the top and bottom of the equation are the same, so they cancel each other.

                                                          Suppose a child is prescribed 800 micrograms of metoclopramide from a stock solution of 5 mg/5 mL. Because the units of the doses are different, one must be converted so that they are the same.

                                                          There are 1000 micrograms in 1 mg, therefore

                                                          800 micrograms=0.8 mg (by dividing 800 by 1000).

                                                          Equation:

                                                          0.8mg5mg×5mL

                                                          To simplify the equation, divide the top and the bottom by 5:

                                                          0.81×1mL=0.8mL

                                                          Example calculations

                                                          Calculate the amount of solution to be given from stock solutions.

                                                          1. Question 1. You have a stock vial of 5 mg in 1 mL. What volume would give a dose of 80 mg?

                                                            • Answer …

                                                          2. Question 2. You have a stock bottle of 50 mg in 1 mL. What volume would give a dose of 280 mg?

                                                            • Answer …

                                                          3. Question 3. You have a stock bottle of folic acid 2.5 mg in 5 mL. What volume would give a dose of 3.5 mg?

                                                            • Answer …

                                                          4. Question 4. You have a stock bottle of 4 mg in 5 mL. What volume would give a dose of 6 mg?

                                                            • Answer …

                                                          5. Question 5. You have a stock bottle of 5 mg in 5 mL. What volume would give a dose of 800 micrograms?

                                                            • Answer …

                                                          6. Question 6. You have a stock bottle of 50 micrograms in 1 mL. What volume would give a dose of 80 micrograms?

                                                            • Answer …

                                                          Answers: (1) 16 mL; (2) 5.6 mL; (3) 7 mL; (4) 7.5 mL; (5) 0.8 mL; (6) 1.6 mL.

                                                          Further reading

                                                          NMC (2008). Standard for Medicine Management. Nursing and Midwifery Council, London. Administration of medicines in children’s and young people’s nursingwww.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-standards-for-medicines-management.pdfFind this resource: