TOURNIQUET TEST MATERIALS: BP apparatus appropriate for age Position the patient: either supine or sitting position is appropriate.

The BP cuff should cover 2/3 of the upper arm. Get the BP Get the mean pressure between systolic and diastolic values taken from the patient. ex. 120/ 70 Mean Pressure= 120 plus 70 divided by 2= 95 Inflate the BP cuff and maintain at the mean pressure { ex. 95mmHg } for 5 minutes. Deflate cuff and observe for appearance of petechiae on the volar surface of the forearm. Count the number of petechiae per square inch. Positive reaction: >20 petechiae per square inch Source : Del Mundo SKIN PINCH TEST Position the patient: supine Pinch the abdominal skin at the lateral side of the rectus abdominis. Observe for skin tenting or poor retraction. If skin remains tented for more than 2 seconds, it is considered poor skin turgor. Source : WHO/IMCI KERNIGS SIGN (BENT-KNEE LEG RAISING TEST) The patient lies supine with the legs relaxed. Flex the patients leg at the hips and knees then gradually straighten the knee When the thigh reaches the vertical position, gently, straighten the knee. Positive: pain and increased resistance to extending the knee BRUDZINSKIS SIGN With the patient supine and relaxed, place your hand under the patients occiput and gently attempt to flex the neck. Normally, it bends freely. Positive: flexion of the hips and knees Source: Bates ADMINISTERING AN INTRADERMAL INJECTION 1. Wash hands. 2. Prepare the medication from the vial or ampule for drug withdrawal. 3. Prepare the patient. 4. Explain that the medication will produce a small bleb, a small raised area like a blister. 5. Select and clean the site.
Cleanse the skin at the site using firm circular motion starting at the center and widening the circle outward. Allow the area to dry thoroughly.

6.

Prepare the syringe for injection.

Remove the needle cap while waiting for the antiseptic to dry. Expel any air bubbles from the syringe. Small bubbles that adhere to the plunger are of no consequence. A small amount of air will not harm the tissues.

Grasp the syringe in your dominant hand, holding it between thumb and forefinger. Hold the needle almost parallel to the skin surface, with the bevel of the needle up. The possibility of the medication entering the subcutaneous tissues increases when using an angle greater than 15 degrees or if the bevel is down.

7.

Inject the fluid.

With the non dominant hand, pull the skin at the site until it is taut. For example, if using the ventral forearm, grasp the patients dorsal arm and gently pull it to tighten the ventral skin. Taut skin allows for easier entry of the needle and less discomfort for the patient. Insert the tip of the needle far enough to place the bevel through the epidermis into the dermis. The outline of the bevel is visible under the skin surface.

ADMINISTERING A SUBCUTANEOUS INJECTION 1. Wash hands. 2. Prepare the medication from the vial or ampule for drug withdrawal. 3. Prepare the patient. 4. Explain that the medication will produce a small bleb, a small raised area like a blister. 5. Select and clean the site.
Select a site free of tenderness, hardness, swelling, scarring, itching, burning or localized inflammation. Select a site that has not been used frequently. These conditions could hinder the absorption of the medication and also increase the likelihood of injury and discomfort at the injection site. Cleanse the skin at the site using firm circular motion starting at the center and widening the circle outward. Allow the area to dry thoroughly. Place and hold the swab between the third and fourth fingers of the nondominant hand, or position the swab on the clients skin above the intended site. Using this technique allows the swab to be readily accessible when the needle is withdrawn.

6.

Prepare the syringe for injection.

Remove the needle cap while waiting for the antiseptic to dry. Expel any air bubbles from the syringe. Small bubbles that adhere to the plunger are of no consequence. A small amount of air will not harm the tissues.

7.

Inject the medication.

Grasp the syringe in your dominant hand by holding it between the thumb and fingers. With the palm facing to the side or upward for a 45 degree angle insertion, or with the palm downward for a 90 degree angle insertion, prepare to inject. Using the nondominant hand, pinch or spread the skin at the site, and insert the needle using the dominant hand and a firmly steady push. The most important consideration is the depth of the subcutaneous tissues in the area to be injected. If the patient has more than inch of adipose tissues in the injection site, it would be safe to administer the injection at a 90 degree angle with the skin spread. If the patient is thin or lean and lack adipose tissues, the subcutaneous injection should be given with the skin pinched and the 45 degree to 60 degree angle. When the needle is inserted, move your dominant hand to the end of the plunger. Aspirate by pulling down on the plunger. If blood appears in the syringe, withdraw the needle, discard the syringe and prepare a new injection. If blood does not appear, continue to administer the medication. Subcutaneous medications may be dangerous if placed directly in the bloodstream; they are intended for subcutaneous tissues, where the absorption time is greater. Inject the medication by holding the syringe steady and depressing the plunger with a slow, even pressure. Holding the syringe steady and injecting the medication at an even pressure minimized discomfort for the patient.

8.

Remove the needle. Remove the needle slowly and smoothly, pulling along the line of insertion while depressing the skin with
your nondominant hand. Depressing the skin places counteraction on it and minimized the patients discomfort when the needle is withdrawn. When bleeding occurs, apply pressure to the site with dry sterile gauze until it stops. Bleeding rarely occurs after subcutaneous injection.

ADMINISTERING AN INTRAMUSCULAR INJECTION 1. Wash hands. 2. Prepare the medication from the vial or ampule for drug withdrawal. 3. Prepare the patient. 4. Explain that the medication will produce a small bleb, a small raised area like a blister. 5. Select and clean the site. Select a site free of tenderness, hardness, swelling, scarring, itching, burning or localized inflammation. Select a site that has not been used frequently. These conditions could hinder the absorption of the medication and also increase the likelihood of injury and discomfort at the injection site. Cleanse the skin at the site using firm circular motion starting at the center and widening the circle outward. Allow the area to dry thoroughly. Place and holdthe swab between the third and fourth fingers of the nondominant hand, or position the swab on the clients skin above the intended site. Using this technique allows the swab to be readily accessible when the needle is withdrawn. 6. Prepare the syringe for injection. Remove the needle cap while waiting for the antiseptic to dry. Expel any air bubbles from the syringe. Small bubbles that adhere to the plunger are of no consequence. A small amount of air will not harm the tissues. 7. Inject the medication using the z-track technique. Using the ulnar side of the nondominant hand, to pull the skin approximately 2.5cm to the side. Pulling the skin and the subcutaneous tissues or pinching the muscle makes it firmer and facilitates needle insertion. Grasp the syringe in your dominant hand by holding it between the thumb and fingers (as if holding a pencil), pierce the skin quickly and smoothly at a 90 degree angle and insert the needle into the muscle. Using a quick motion lessens the patient;s discomfort. Hold the barrel of the syringe with your nondominant hand and aspirate by pulling back on the plunger with your dominant hand. Aspirate for 5 to 10 seconds. If the needle is in a small blood vessel, it takes time for the blood to appear. If the blood appears in the syringe, withdraw the needle, discard the syringe and prepare a new injection. Inject the medication by holding the syringe steady and depressing the plunger with a slow, even pressure (approximately 10 seconds per milliliter). Holding the syringe steady and injecting the medication at an even pressure minimized discomfort for the patient. Injecting the medication slowly promotes comfort and allows time for tissues to expand and begin absorption of the medication.

8.

Withdraw the needle.

Withdraw the needle slowly and smoothly, pulling along the line of insertion. This minimizes tissue injury. Apply gentle pressure at the site with a dry sponge. Do not massage the site. Massaging the site can increase the discomfort of the injection and can result in tissue irritation. When bleeding occurs, apply pressure to the site with dry sterile gauze until it stops.

9.

Discard the uncapped needle and attached syringe in the proper receptacle.

PEDIATRIC THERAPEUTICS: Computed by weight [mkd (mg/kg/day) or mkdose (mg/kg/dose)] MKDay for most drugs like antibiotics and MKDose for STAT and PRN medications like the Emergency drugs, Paracetamol etc. Vitamins, Preparations for cough and colds- based on the age, not the weight Steps: 1. Know the weight of your patient, the recommended dosage of the drug, dosing interval, and the available preparations of the drug 2. Get the total dosage per day by multiplying the weight by the recommended mkd

3. Get the amount per dose by dividing total dosage per day by the frequency the drug will be given 4. Ratio and proportion using the available preparations to determine the volume per dose to provide computed dosage Example: A 5 year old female, 20kg, at the OPD being treated as a case of Bacterial Pneumonia, for whom you want to give Amoxicillin 1. Recommended dosage for Amoxicillin: 30-50 mg/kg/day o Dosing interval: 3x daily o Available Preparations: drops- 100mg/ml; Suspensions- 125mg/5ml, 250mg/5ml 2. 20 kg x 30 mg/kg/day= 600 mg/ day is the total dosage 3. 600 mg/day /3 (dosing intervals)= 200 mg/dose 4. Among the available preparations, it is best to use the 250mg/5ml suspension since it is closest to the desired dose 250mg = 200mg = 4ml per dose 5ml ?ml :. 4ml of amoxicillin should be given thrice daily in order to provide therapeutic dose of the drug Some Pearls: 1. Use the preparation that would necessitate the smallest volume for ease of administration. 2. Always use drops for children below 2 years old. 3. Round-off your answer to the nearest multiple of 5 or 2.5 ml that way you can easily instruct the caregivers on the administration using teaspoons i.e. tsp= 2.5 ml, 1 tsp= 5ml, 1 tsp= 7.5 ml 4. In our example above, it is easier for the mother to give the child 5 ml or 1 tsp 3x/day than measure 4ml without the benefit of a medicine glass. 5. Re-check if this is still within the recommended dosage by dividing the total dosage provided by the given volume of the drug by the patients weight. In our example: a. 1tsp= 5ml giving as 250mg of amoxicillin/ dose given 3x/day = 250mg x 3 = 750 mg/day / 20 kg = 35 mg/kg/day-still within the range 6. Use the MIMs or PPD to check for available preparations of the drugs. Check the Appendices in Nelsons and del Mundo for recommended dosages