PEDIATRIC SKILLS LAB

ADMINISTRATION OF INJECTABLE MEDICATIONS

THE FIVE RIGHTS!
-THE RIGHT PATIENT
-THE RIGHT DRUG
-THE RIGHT TIME
-THE RIGHT DOSE
-THE RIGHT ROUTE

IMPORTANT STEPS TO REMEMBER:

-COMPARE MAR (MEDICATION ADMINISTRATION RECORD) WITH ORDER

-LOOK UP MEDICATION IN FORMULARY AND REVIEW SAFE DOSE
RANGE, ACTION, SIDE EFFECTS, AND DRUG INTERACTIONS
-DOUBLE CHECK DRUG ALLERGIES
-PERFORM ACCURATE MEDICATION CALCULATIONS (OBTAIN CHILD'S
WEIGHT IN KG OR CONVERT LBS TO KG (1KG=2.2LBS)
-CALCULATE SAFE RANGE

INTRAMUSCULARE ADMINISTRATION:

-MUST CONSIDER TISSUE SIZE, MASS, AND AGE

-ESSENTIAL TO IDENTIFY LANDMARKS IN ORDER TO IN SELECT
CORRECT LOCATION
-VASTUS LATERALIS SITE MOST COMMON IN PEDIATRICS
-NEEDLE LENGTH/GAUGE SELECTION INVOLVES NURSING JUDGEMENT:
LONG ENOUGH TO INJECT PAST SUBCUATANEOUS TISSUE INTO
MUSCLE BUT NOT BEYOND INTO BONE
-RESTRAINTS OR MORE THAN ONE NURSE MAY BE NEEDED TO GIVE
INJECTION SAFELY IF CHILD AGITATED: USE DISTRACTION AND HAVE
PARENTS PRESENT TO HELP ALLEVIATE ANXIETY
-AFTER THE MEDICATION IS DRAWN INTO THE SYRINGE CHANGE THE
NEEDLE PRIOR TO ADMINISTRATION. INSERTION OF THE NEEDLE
THROUGH A VIAL STOPPER DULLS THE TIP OF THE NEEDLE, AND
RESIDUAL MEDICATION ON THE NEEDLE MAY IRRITATE TISSUE AND/OR
MUSCLE
-AFTER INJECTION CHILDREN SHOULD BE COMFORTED AND GIVEN A
REWARD

SUBCUTANEOUS ADMINISTRATION:

-SITES SIMILAR TO ADULTS-SUBCUTANEOUS TISSUES OF THIGH AND

UPPER ARM MOST COMMON
-NEEDLE LENGTH/GAUGE SHORTER THAN WITH IM IN ORDER TO INJECT
ONLY INTO SUBCUTANEOUS TISSUE
-RESTRAINT/SUPPORT SIMILAR TO ABOVE
PRACTICE:
UTILIZE SCENARIOS (ATTACHED)
CHOOSE APPROPRIATE SITES FOR IM VS. SQ
IDENTIFY LANDMARKS
STUDENTS SHOULD CHOOSE APPROPRIATE SIZE NEEDLE (LENGTH &
GAUGE) ACCORDING TO SCENARIO

SAMPLE MEDICATION CALCULATIONS:

ODER: PHENERGAN 20MG IM Q 6 HOURS

WEIGHT: 99 LBS
PEDIATRIC DOSE: 0.25-0.5MG/KG/DOSE
AVAILABLE: PHENERGAN 25MG/CC

CALCULATION: 99LBS= 45 KG
25MG = 20MG
1CC X

X= 0.8CC (3.2CC/DAY = 80MG/DAY)

RANGE: 0.25-0.5MG/KG/DOSE= 11.25-22.5MG/DOSE THEREFORE

20MG DOSE IS APPROPRIATE

ORDER: HYDROXYZINE 12 MG IM Q 6 HOURS

WEIGHT: 24 KG
PEDIATRIC DOSE: 0.5-1MG/KG/DOSE Q 6 HOURS
AVAILABLE: HYDROXYZINE 25MG/CC

CALCULATION:

25MG = 12 MG
1CC X

X= 0.48 CC (1.92CC/DAY)= 48 MG/DAY)

RANGE: 0.5-1 MG/KG/DOSE = 12-24 MG/DOSE THEREFORE DOSE OF

12 MG IS APPROPRIATE
IM SCENARIO #1

BJ IS RECOVERING FROM SURGERY IN WHICH HE HAD HIS ARM

REPAIRED FOR A COMPOUND FRACTURE. THE MD HAS ORDERED
KETOROLAC 17.5MG Q 6 HOURS FOR PAIN.

WEIGHT: 77 LBS
SAFE DOSAGE RANGE: 0.5MG/KG/DOSE Q 6 HOURS
DRUG AVAILABLE: KETOROLAC 30MG/CC

IS THIS A SAFE DOSE FOR BJ?

WHAT VOLUME WILL YOU INJECT?

IM SCENARIO #2

Johnny is a 3 year old with pneumonia complicated by his cystic

fibrosis. The MD has ordered Gentamicin 48 mg IM q 6 hours for the
infection.
Johnny's weight: 34 lbs
Safe dosage range: 2.5-3.5 mg/kg/dose
Drug available: 40mg/cc

Is this a safe dose for Johnny?

What volume will you inject?

 PEDIATRIC INTRAMUSCULAR INJECTION SITES

SITE RECOMMENDED PROS & CONS

AGE
Vastus Infant-Adult • Largest muscle group in
Lateralis Preferred for children children < 3 yrs of age
< 3 years of age • Can tolerate large
injection volumes (0.5-2.0
cc)
• Area free of important
nerves or blood vessels
Ventroglute Infant-Adult • Can tolerate large
al Consider for children injection volumes
> 3 years of age • Area free of important
vessels or nerves
• Easily accessible site
• Health care providers
often unfamiliar with site
Dorsoglutea Contraindicated in • Large muscle mass in
l children < 3 years older children
Patient must have • Can tolerate large
been walking > 1year injection volumes
• Danger of injury to sciatic
nerve
• Exposure of site may
cause embarrassment in
older children
Deltoid Infant-Adult • Small muscle mass
• Can tolerate only small
injection volumes (0.5-
1.0cc)
• Easily accessible site
• Rapid absorption rate
• Danger of radial nerve
injury in young children

ADAPTED FROM ENPC PROVIDER MANUAL, 1998

 PEDIATRIC SKILLS LAB
Administration of PO Medications

THE FIVE RIGHTS!

-The right patient
-The right time
-The right drug
-The right route
-The right dose

Important Steps to Remember:

-Compare MAR (medication administration record) with order
-Look up medication in formulary and review safe dose range, action,
side effects, and drug interactions
-Double check drug allergies
-Perform accurate medication calculations (obtain child's weight in kg
or convert lbs to kg ( 1 kg = 2.2 lbs)
-Calculate safe range

DEVICES FOR MEASUREMENT:

-Calibrated syringe most accurate
-Calibrated measuring cup for doses > 10cc: the bottom of the liquid
meniscus is the measuring point
-Calibrated droppers, medication teaspoon designed specifically for
med administration
-Household teaspoons can vary-not accurate
-One teaspoon = 5 cc

DELIVERY OF ORAL MEDICATIONS:

-Depends upon child's ability to suck, swallow, drink, or chew
-Oral liquids preferred until about 5 years of age
-Most children at least 21/2 years of age may be able to take chewable
form
-Medications can be crushed & mixed with solution (ie, G-tube); check
with pharmacist first for drug/food interactions. Do not crush time
release or enteric coated

TECHNIQUES FOR ADMINISTRATION:

-Child should be secure & comfortable; crying can increase risk of
aspiration
-Beginning at toddlerhood, children should be told they are receiving
medication
-Do not try to "hide" it, even if mixed with pleasant tasting vehicle
-Position infants/toddlers in semi-sitting, cradle in lap, sitting on own or
if in bed the head lifted to facilitate swallowing
-Place med half-way down tongue on side of oral cavity, slow delivery
(1-1.5cc/squirt to prevent aspiration)
-To assist with swallowing, hold mouth closed and lift chin
-Try not to force administration: use patience & reassurance, be firm
yet gentle, give older children some independence in taking
medication
-If older children/adolescents can swallow pills, make sure patient has
indeed swallowed med: check under tongue/sides of cheeks

PRACTICE CALCULATIONS:

ORDER: Benadryl 25 mg PO q 6 hours

WEIGHT: 55 lbs
DOSE: 5 mg/kg/day
AVAILABLE: Bendadryl 12.5 mg/5cc

Calculation: 55 lbs = 25 kg
12.5 mg = 25 mg
5cc x

X= 10cc q 6 hours (40ml/day= 100 mg/day)

Safe range: 5/mg/kg/day = 5 mg x 25 = 125mg/day therefore dose is

appropriate

ORDER: Gantrisin 1.5 gm PO qid

WEIGHT: 30.4 kg
DOSE: 150-200 mg/kg/day
AVAILABLE: Gantrisin 500 mg tablets

Calculation: 500mg = 1500 mg

1 x

x= 3 tablets qid (6000mg/day)

Safe range: 150-200 mg/kg/ day = 4560-6080mg/day therefore dose

is appropriate
 TIPS FOR MEDICATION ADMINISTRATION

ROUTE CONSIDERATION
Otic • Children < 3 years of age, pull pinna down and back.
• Children > 3 years of age, lift pinna up and back.
Nasal • Have parent hold the child across their lap with the child's head down. Place the child's
arm closest to the parent around the parent’s back. Firmly hug the child's other arm and
hand with their arm; snuggle the head between the parents body and arm.
Eye • Explain the procedure. Tell the child the medication will feel cool.
• Have the child lie on their back with their hands under their buttocks.
• Have the child look up.
• Provide distractions.
Oral • Infants: Administer medication in nipple, follow with 5cc of sterile water. Medication
can also be administered with a syringe and dropper; place the syringe / dropper
between the gum and cheek. Administer no more than 1/2cc of medication at one time.
• Chewable tablets: Do not administer to children without teeth. Give them something
to drink afterwards.
• Caplets: Do not crush enteric-coated caplets.
• Capsules: Do not open up if medication is sustained - release. Check with pharmacy
before opening any capsules for administration.
• Avoid mixing medications with formula as the infant may refuse the formula thereafter.
• When mixing medications with food or fluids, use as little as possible, because they may
not be able to finish all the food or fluids.
Rectal • Consult a pharmacist prior to cutting a suppository; the medication is not necessarily
distributed evenly through the suppository (i.e., acetaminophen suppositories must be
divided lengthwise, not widthwise).
Subcutaneous • Usual amount of administration is 0.5 - 1.0cc.
(SQ) • Sites include deltoid, anterior thigh, anterior abdominal wall, or inter/subscapular
region.
• Insert needle at a 90o angle.
• Needle size: Infant or thin child 25 or 26g, 3/8".
Larger child 25 or 26g, 5/8".
Intramuscular (IM) • See discussion in this skill station.
• For the immunocompromised child, cleanse the site with Betadine and alcohol.
• Consider placing a wrapped ice cube on the site for approximately one minute prior to
injection.
Intravenous (IV) • Use as little diluent as needed.
Long-term Venous • May require a special needle to pierce the port (e.g., MediPort requires a Huber needle).
Access Devices • Certain catheters are above the skin (Groshong catheters) while others are under the skin
(Port-a-Cath, Infus-A-Port, MediPort).
• May require daily or weekly flush to maintain patency (Hickman / Broviac and
Groshong catheters). Implanted ports must be flushed monthly and after each infusion.
• Above the skin catheters may be damaged by sharp instruments and are at risk of being
pulled out.
• The Hickman / Broviac catheter must be clamped or have a clamp nearby; the Groshong
catheter should not be clamped (contains a two-way valve).
 PEDIATRIC SKILLS LAB
ASSSESSMENT

• Review of pediatric assessment (pertinent for

hospitalized child, not exhaustive)
• Students will receive an assessment outline in their
Clinical Reference Manuals as well
I. General Appearance
a. Content, comfortable, agitated, restless
b. Activity, alertness
c. Quality of cry if present
d. Well or poorly nourished
e. Respiratory effort
f. Color
g. Hydration
h. Mobile or confined to bed
II. Equipment
a. Be aware of equipment during entire exam
b. IV, epidural, trach tube, pulse ox, heart monitor,
dressing/drains, G-tube
c. Make sure emergency equipment at bedside:
oxygen, suction, BVM, call button, "core sheet" with
calculated emergency medications (may be
institution specific)
III. Skin
a. Color/temperature
b. Hydration (turgor)
c. Rashes, lesions, bruises
d. Nails (capillary refill)
e. Blanching

IV. Head
a. symmetry
b. sutures/ridges (may be felt up to 6 mos.)
c. fontanelles (posterior closes by 2 mos; anterior by
18 mos)
d. lesions

V. Eyes
a. general appearnace(sunken, swollen, eye contact)
b. pupils (PERRLA), strabismus
c. able to focus & follow objects
d. conjunctiva (discharge, redness)
VI. Ears
a. symmetry
b. gross hearing

VII. Nose
a. Drainage, crusting
b. Pain, tenderness, foul odor

VIII. Mouth
a. mucous membranes (lips, gums, inside cheeks)
b. symmetry of tongue
c. palate/pharynx
d. teeth/cavities
IX. Neck
a. Mobility
b. Symmetry
c. Pain, visible masses
X. Lungs
a. symmetry, accessory muscle involvement with
breathing
b. listen to breath sounds when patient not crying (if
possible)
c. rate of respirations, adventitious sounds, work of
breathing
d. infants & young children have abdominal breathing
XI. Heart
a. auscultate heart sounds (apical pulse for full
minute)
b. note heart rate regularity, murmurs
c. perfusion status (central vs peripheral pulses)
XII. Abdomen
a. symmetry
b. umbilicus
c. bowel sounds in all four quadrants
d. femoral pulses
XIII. Genitalia
a. MALE: urinary meatus at tip of penis, discharge,
redness
b. Circumcised or uncircumcised
c. Both testes descended
d. FEMALE: urinary meatus and vaginal openings
visible
e. discharge, redness
f. labia symmetrical
 XIV. Anus
a. anal sphincter tone
b. fissures
XV. Extremities
a. symmetrical
b. color, temperature
c. ROM, gait
d. Fingers/toes

XVI. Back
a. symmetrical
b. deformities
c. scoliosis (scapula equal, iliac crests equal)
d. tufts of hair at base of spine

XVII. Neuro:
INFANTS: babinski positive (up to age 2yrs.)
Equal plantar/palmer reflex
Tonic neck reflex (up to 5 mos.)
Moro reflex (up to 5 mos.)
OLDER CHILDREN: fine & gross motor coordination age
specific
Senses intact
Language
Memory
Abstract thinking
XX. Vital Signs
a. HR RR during chest exam
b. Temp at beginning or end
c. BP may be upsetting in infants, may leave for last

XXI. HELPFUL TIPS: communicate with parents

throughout assessment, let them know what you are
doing, talk to child, explain what you are looking at
before you do it so they are less anxious, talk to
infants as well even if they don't understand;
soothing voice helps provide comfort. Illicit parents'
concerns and any changes or improvements they
have noticed since last assessment.

Revised: Karen LeDuc, MS RN CPN CNS 2006