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CHAPTER 49

Pediatric Medication Administration


and Calculations

CRITICAL THINKING What Should You Do?


The nurse is preparing to administer a medication that has an unpleasant taste to an
infant. What should the nurse do to minimize this unpleasant effect?
Answer located on p. 553.

I. Oral Medications
A. Most oral pediatric medications are in liquid or suspension form because children
usually are unable to swallow a tablet.
B. Solutions may be measured by using an oral plastic syringe or other acceptable
measurement or administration device; the device used depends on the
developmental age of the child (Fig. 49-1).

FIGURE 49-1 Acceptable devices for measuring and administering oral medication
to children (clockwise from bottom left): Measuring spoon, plastic syringes,
calibrated nipple, plastic medicine cup, calibrated dropper, hollow-handled
medicine spoon. (From Hockenberry M, Wilson D: Wongs essentials of pediatric
nursing, ed 7, St. Louis, 2005, Mosby.)

C. Medications in suspension settle to the bottom of the bottle between uses, and
thorough mixing is required before pouring the medication.
D. Suspensions must be administered immediately after measurement to prevent settling
and resultant administration of an incomplete dose.
E. Administer oral medications with a child sitting in an upright position and with the
head elevated to prevent aspiration if the child cries or resists.
F. Place a small child sideways on the lap; the childs closest arm should be placed
under the adults arm and behind the adults back; cradle the childs head and hold
the childs hand, and administer the medication slowly with a plastic spoon, small

plastic cup, or syringe.


G. If a tablet or capsule has been administered, check the childs mouth to ensure that it
has been swallowed; if swallowing is a problem, some tablets can be crushed and
given in small amounts of pured food or flavored syrup (enteric-coated tablets,
timed-release tablets, and capsules should not be crushed).
H. Follow generally accepted medication administration guidelines for children (Box
49-1).

BOX 49-1

Medication Administration Guidelines for Children

Two identifiers are required before medication administrationsuch as name,


medical record number, birth date.
Obtain information from parents about successful methods for administering
medications to their children.
Ask parents about any known allergies.
To avoid aspiration, liquid forms of medication are safer to swallow than other
forms.
Straws often help older children swallow pills.
Avoid putting medications in foods such as milk, cereal, or baby food because it may
cause an unpleasant taste to the food, and the child may refuse to accept the same
food in the future. In addition, the child may not consume the entire serving and
would not receive the required medication dosage.
If the taste of the medication is unpleasant, it is acceptable to have the child pinch the

nose and drink the medication through a straw.


Offer juice, a soft drink, or a frozen juice bar after the child swallows a medication.
Always read the pharmacological indications for administration. Some items such as
fruit syrups can be acidic and should not be used with medications that react
negatively in an acid medium.
Record the most successful method of administering medications and pertinent
nursing prescriptions on the childs care plan for other nursing staff to follow; this
notation also saves the child frustration, fear, and anxiety.
Data from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St.
Louis, 2013, Mosby; and Perry S, Hockenberry M, Lowdermilk D, Wilson D:
Maternal-child nursing care, ed 4, St. Louis, 2010, Mosby.

Newborns and infants have an immature liver and immature kidneys, and
therefore metabolism and elimination of medications is delayed.
II. Parenteral Medications
A. Subcutaneously and intramuscularly administered medications
1. Medications most often given via the subcutaneous route are insulin and some
immunizations.
2. Any site with sufficient subcutaneous tissue may be used for subcutaneous
injections; common sites include the central third of the lateral aspect of the upper
arm, the abdomen, and the central third of the anterior thigh.

3. The safe use of injection sites is based on normal muscle development and the
size of the child; the preferred site for intramuscular injections in infants is the
vastus lateralis, but agency policies and procedures need to be followed (Table
49-1 and Fig. 49-2).

TABLE 49-1 Intramuscular Injections: Amount of Medication (mL)


by Muscle Group

Data from Kee J, Marshall S: Clinical calculations: With applications to general and
specialty areas, ed 7, St. Louis, 2013, Saunders.

FIGURE 49-2 Intramuscular injection sitevastus lateralis. Landmarks are

indicated by asterisks. (From Hockenberry M, Wilson D: Wongs essentials of


pediatric nursing, ed 9, St. Louis, 2012, Mosby.)

4. The usual needle length and gauge for pediatric clients are 12 to 1 inch and 22 to
25 gauge; needle length also can be estimated by grasping the muscle between the
thumb and forefingerhalf the resulting distance would be the needle length.
5. Pediatric dosages for subcutaneous and intramuscular administration are
calculated to the nearest hundredth and measured by using a tuberculin syringe;
always follow agency guidelines.
6. Place a plain or decorated adhesive bandage over the puncture site to help the
child view the experience in a pleasant way.
B. Intravenously administered medications
1. Intravenous (IV) medications are diluted for administration.
2. When an infant or child is receiving an IV medication, the IV site needs to be
assessed for signs of inflammation and infiltration or extravasation immediately
before, during, and after completion of each medication.
3. IV medication may be administered continuously by adding the medication to an
IV solution bag and infusing it through a primary infusion line.
4. IV medications may be administered intermittently; several doses may be
administered in a 24-hour period.
5. Medications for IV administration are diluted according to the directions
accompanying the medication and according to the health care providers

(HCPs) prescriptions and agency procedures.


6. Infusion time for IV medications is determined on the basis of the directions
accompanying the medication, the HCPs prescription, and agency procedures.
7. Determine agency procedures related to the volume of flush (normal saline) for
peripheral IV lines and for central lines.
8. The flush volume (3 to 20 mL) must be included in the childs intake; the flush is
usually administered before administering an IV medication and after the IV
medication is completed and is infused at the same rate as the medication.
C. Intermittent IV medication administration
1. Children receiving IV medications intermittently may or may not have a primary
IV solution infusing.
2. If a primary IV solution is infusing, the medication may be administered by IV
piggyback via a secondary line.
3. If a primary IV solution does not exist, an indwelling infusion catheter is used for
medication administration, and the medication may be administered by push,
piggyback, or retrograde method; medication administration instructions must be
checked for dilution and infusion time procedures.
4. All intermittent medication administrations are preceded and followed by a
normal saline flush to ensure that the medication has cleared the IV tubing and that
the total dose has been administered.
5. Electronic devices such as controllers or pumps are used to regulate and
administer IV fluids and intermittent IV medications.

D. Special IV administration sets


1. Special IV administration sets, such as a burette, may be used for medication
preparation and administration via piggyback.
2. These special sets are all microdrip sets calibrated to deliver 60 drops (gtt)/mL.
3. The total capacity of these special IV administration sets is 100 to 150 mL,
calibrated in 1-mL increments so that exact measurements of small volumes are
possible.
4. The medication is mixed with the appropriate amount of diluent, added to the
special IV administration set, and allowed to infuse at the prescribed rate.
5. The special IV administration set needs to be labeled clearly to identify the
medication and fluid dosage added.
6. During medication infusion time, a label is attached that indicates that the
medication is infusing.
7. During the flush infusion time, a label is attached indicating that the flush is
infusing.
E. Retrograde IV injection
1. In this method of administration, the medication is mixed with the appropriate
amount of diluent in a syringe.
2. The IV tubing is clamped close to the child, the medication is injected through the
port in the direction of the burette, the tubing is unclamped, the prescribed rate is
set, and the medication is allowed to infuse over the prescribed time.
F. Syringe pump for IV medication administration

1. A syringe containing the medication is fitted into a pump that is connected to the
IV tubing through a Y connector.
2. The medication is administered over the prescribed time.
The 24-hour fluid intake must be monitored closely, and all IV fluid amounts
including the amount of flush volume need to be documented accurately to
prevent overhydration. For children, the maximal amount of IV fluid
administered in a 24-hour period varies and is usually based on body weight
and other factors. Check the HCPs prescription and agency guidelines for the
procedures for the administration of IV fluids and medications.
III. Calculation of Medication Dosage by Body Weight
A. Conversion of body weight (Box 49-2)

BOX 49-2

Conversion of Body Weight

Measurements
1 lb = 16 oz
1 kg = 2.2 lb
Pounds to Kilograms
1 kg = 2.2 lb
When converting from pounds to kilograms, divide by 2.2. Kilograms are expressed
to the nearest tenth.
Kilograms to Pounds
1 kg = 2.2 lb

When converting from kilograms to pounds, multiply by 2.2. Pounds are expressed to
the nearest tenth.

B. Calculation of daily dosages


1. Abbreviations (Box 49-3)

BOX 49-3

Common Measurement Abbreviations

Abbreviation
BSA
g
gr
kg
lb
m2
mcg
mg
mL
SA

Meaning
Body surface area
Gram(s)
Grain(s)
Kilogram(s)
Pound(s)
Square meters
Microgram(s)
Milligram(s)
Milliliter(s)
Surface area

2. Dosages are expressed in terms of milligrams per kilogram per day, milligrams
per pound per day, or milligrams per kilogram per dose.
3. The total daily dosage usually is administered in divided (more than one) doses
per day.
4. Express the childs body weight in kilograms or pounds to correlate with the
dosage specifications.

5. Calculate the total daily dosage.


6. Divide the total daily dosage by the number of doses to be administered in 1 day.
IV. Calculation of Body Surface Area (BSA)
A. The BSA is determined by comparing body weight and height with averages or
norms on a graph called a nomogram.
B. Not all children are the same size at the same age; the nomogram is used to determine
the BSA of a child.
C. Look at the nomogram (Fig. 49-3), and note that the height is on the left-hand side of
the chart and the weight is on the right-hand side of the chart.

FIGURE 49-3 West nomogram for estimation of surface areas in infants and
children. First, find height; next, find weight; finally, draw a straight line connecting
the height and weight. The body surface area (in square meters [m2]) is indicated
where a straight line connecting the height and weight intersects the surface area (SA)
column or, if the child is approximately of normal proportion, from weight alone
(yellow area). (From Hockenberry M, Wilson D: Wongs essentials of pediatric

nursing, ed 7, St. Louis, 2005, Mosby.)

D. Place a ruler across the chart.


E. Line up the left side of the ruler on the height and the right side of the ruler on the
weight; read the BSA at the point where the straight edge of the ruler intersects the
surface area (SA) column.
F. The estimated SA is given in square meters (m2).
G. Box 49-4 gives a sample practice question using the nomogram.

BOX 49-4

How to Use the Nomogram

Example: Use the nomogram (see Fig. 49-3) and calculate the body surface area
(BSA) for a child whose height is 58 inches and weight is 12 kg.
1. Look at the nomogram chart and note that the height is on the left-hand side of the
chart and the weight is on the right-hand side.
2. Place a ruler on the chart and line up the left side of the ruler on the height and the
right side of the ruler on the weight; read the BSA at the point where the straight
edge of the ruler intersects the surface area (SA) column.
3. The estimated SA is given in square meters.
Answer: 0.66 m2

V. Calculation Based on BSA


A. When dosage recommendations for children specify milligrams, micrograms, or units

per square meter, calculating the dosage is simple multiplication (Box 49-5).

BOX 49-5

Calculating Medication Dosage

When dosage recommendations for children specify milligrams, micrograms, or units


per square meter, calculating the dosage is simple multiplication.
Example: The dosage recommendation is 4 mg/m2. The child has a body surface
area of 1.1 m2. What is the dosage to be administered?
Answer:
1.14 mg = 4.4 mg

B. When dosage recommendations are specified only for adults, a formula is used to
calculate a childs dosage from the adult dosage (Box 49-6).

BOX 49-6

Calculating a Childs Dosage from the Adult Dosage

When dosages are specified only for adults, a formula is used to calculate a childs
dosage from the adult dosage. The adult dosage is based on a standardized body
surface area (BSA) of 1.73 m2.
Example: A health care provider has prescribed an antibiotic for a child. The
average adult dose is 250 mg. The child has a BSA of 0.41 m2. What is the dose for
the child?
Answer: 59.24 mg
Formula:

VI. Developmental Considerations for Administering Medications


A. When administering medications to children, developmental age must be taken into
consideration to ensure safe and effective administration.
B. General interventions
1. Always be prepared for the procedure with all necessary equipment and
assistance.
2. For a hospitalized child, ask the parent or child or both if the parent should or
should not remain for the procedure.
3. Determine appropriate preadministration and postadministration comfort
measures.
4. Try to make the event as pleasant as possible.
C. Box 49-7 lists developmental considerations when giving medications.

BOX 49-7

Developmental Considerations for Administering Medications

Infants
Perform procedure quickly, allowing the infant to swallow; then offer comfort
measures, such as holding, rocking, and cuddling.
Allow self-comforting measures, such as the use of a pacifier.

Toddlers
Offer a brief, concrete explanation of the procedure and then perform it.
Accept aggressive behavior, within reasonable limits, as a healthy response, and
provide outlets for the toddler.
Provide comfort measures immediately after the procedure, such as touch, holding,
cuddling, and providing a favorite toy.
Preschoolers
Offer a brief, concrete explanation of the procedure and then perform it.
Accept aggressive behavior, within reasonable limits, as a healthy response, and
provide outlets for the child.
Provide comfort measures after the procedure, such as touch, holding, or providing a
favorite toy.
School-Age Children
Explain the procedure, allowing for some control over the body and situation.
Explore feelings and concepts through therapeutic play, drawings of own body and
self in the hospital, and the use of books and realistic hospital equipment.
Set appropriate behavior limits, such as it is all right to cry or scream, but not to bite.
Provide activities for releasing aggression and anger.
Use the opportunity to teach about how medication helps the disorder.
Adolescents
Explain the procedure, allowing for some control over body and situation.

Explore concepts of self, hospitalization, and illness, and correct any


misconceptions.
Encourage self-expression, individuality, and self-care needs.
Encourage participation in the procedure.
Data from McKenry L, Salerno E: Mosbys pharmacology in nursing, St. Louis, 2003,
Mosby.

CRITICAL THINKING What Should You Do?


Answer: When administering a medication with an unpleasant taste to an infant, the
nurse should draw the required dose into a syringe without the needle, and place the
syringe into the side and toward the back of the infants mouth; the medication should
be administered slowly, allowing the infant to swallow.
Reference
Hockenberry, Wilson (2010), p. 1033.

PRACTICE QUESTIONS
493. The nurse is providing medication instructions to a parent. Which statement by
the parent indicates a need for further instruction?
1. I should cuddle my child after giving the medication.
2. I can give my child a frozen juice bar after he swallows the medication.
3. I should mix the medication in the baby food and give it when I feed my
child.
4. If my child does not like the taste of the medicine, I should encourage him to
pinch his nose and drink the medication through a straw.
494. A health care providers prescription reads ampicillin sodium 125 mg IV every
6 hours. The medication label reads 1 g and reconstitute with 7.4 mL of
bacteriostatic water. The nurse prepares to draw up how many milliliters to
administer one dose?
1. 1.1 mL
2. 0.54 mL
3. 7.425 mL
4. 0.925 mL
495. A pediatric client with ventricular septal defect repair is placed on a
maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the
clients weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin
to be given twice daily. The nurse prepares how much digoxin to administer to

the client at each dose?


1. 0.5 mg
2. 2.5 mg
3. 0.25 mg
4. 0.37 mg
496. Sulfisoxazole (Gantrisin), 1 g orally four times daily, is prescribed for an
adolescent with a urinary tract infection. The medication label reads 500-mg
tablets. The nurse has determined that the dosage prescribed is safe. The nurse
administers how many tablets per dose to the adolescent?
1. 12 tablet
2. 1 tablet
3. 2 tablets
4. 3 tablets
497. Penicillin G procaine (Wycillin), 1,000,000 units IM (intramuscularly), is
prescribed for a child with an infection. The medication label reads 1,200,000
units per 2 mL. The nurse has determined that the dose prescribed is safe. The
nurse administers how many milliliters per dose to the child?
1. 0.8 mL
2. 1.2 mL
3. 1.44 mL
4. 1.66 mL

498. The nurse prepares to administer an intramuscular injection to a 4-month-old


infant. The nurse selects which best site to administer the injection?
1. Ventrogluteal
2. Dorsal gluteal
3. Rectus femoris
4. Vastus lateralis
499. Atropine sulfate, 0.6 mg intramuscularly, is prescribed for a child
preoperatively. The nurse has determined that the dose prescribed is safe and
prepares to administer how many milliliters to the child? Fill in the blank (refer
to figure).
Answer: ________ mL

ANSWERS
493. 3
Rationale: The nurse would teach the parent to avoid putting medications in foods because it may give an
unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child

may not consume the entire serving and would not receive the required medication dosage. The mother should
provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and
providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child
swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the
medication through a straw.
Test-Taking Strategy: Note the strategic words need for further instruction. These words indicate a negative
event query and the need to select the incorrect statement made by the mother. Read each statement carefully
and think about the statement that may be unsafe and may not provide an accurate dose to the child. This will direct
you to the correct option.
Review: Medication administration guidelines for children
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Client Education; Safety
Reference: Potter et al (2013), p. 591.

494. 4
Rationale: Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move
the decimal point three places to the right:
1 g = 1000 mg
Formula:

Test-Taking Strategy: Focus on the subject, milliliters per dose. Convert grams to milligrams first. Next, use the
formula to determine the correct dose, knowing that when reconstituted, 1000 mg = 7.4 mL. Verify the answer
using a calculator.
Review: Medication calculations
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Perry et al (2012), pp. 494-495.

495. 3
Rationale: Calculate the daily dosage by weight first:
0.07 mg/day 7.2 kg = 0.5 mg/day
The HCP prescribes digoxin twice daily; two doses in 24 hours will be administered:

Test-Taking Strategy: Focus on the subject, mg per dose, and note that the question states twice daily and each
dose. Calculate the dosage per day by weight first, and then determine the milligrams per each dose by dividing the
total daily dose by 2. Verify the answer using a calculator.
Review: Medication calculations
Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity


Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Potter et al (2013), pp. 576-577.

496. 3
Rationale: Change 1 g to milligrams, knowing that 1000 mg = 1g. Also, when converting from grams to milligrams
(larger to smaller), move the decimal point three places to the right:
1 g = 1000 mg
Next, use the formula to calculate the correct dose.
Formula:

Test-Taking Strategy: Focus on the subject, tablets per dose. Convert grams to milligrams first. Next, use the
formula to determine the correct dose and verify the answer using a calculator.
Review: Medication calculations
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Potter et al (2013), pp. 574-575.

497. 4
Rationale: Use the medication calculation formula.
Formula:

Test-Taking Strategy: Focus on the subject, milliliters per dose. Use the formula to determine the correct dose,
and verify the answer using a calculator.
Review: Medication calculations
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Potter et al (2013), pp. 576-577.

498. 4
Rationale: Intramuscular injection sites are selected on the basis of the childs age and muscle development of the
child. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 4-month-old infant.
The sites identified in options 1, 2, and 3 are unsafe.
Test-Taking Strategy: Note the strategic word best, and focus on the age of the child identified in the question.
Thinking about the physiological development of the muscle groups in an infant at 4 months of age will assist in
directing you to the correct option.
Review: Pediatric medication administration guidelines

Level of Cognitive Ability: Applying


Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Hockenberry, Wilson (2011), p. 1035.

499. 1.5 mL
Rationale: Use the formula for calculating the medication dose.
Formula:

Test-Taking Strategy: Focus on the subject, the milliliters to be administered. Note that the medication label
indicates that there is 0.4 mg/mL. Use the formula to determine the correct dose, and verify the answer using a
calculator.
Review: Medication administration guidelines
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessImplementation
Content Area: Fundamental SkillsMedications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference: Perry, Potter, Elkin (2012), p. 494.