Professional Documents
Culture Documents
Practical 10
Practical 10
OF MEDICATION
AND DRUG
SUPPLEMENT
Structure
10.0 Objectives
10.1 Introduction
10.2 Safety Measures in the Administration of Drugs
10.3 Possible Errors in Drug Administration
10.4 Routes for Administration of Drugs
1004.1 Oral Route
1004.2 Injection Route
1004.3 Rectal Route
100404 Inhalation Route
10.4.5 Topical Route
10.0 OBJECTIVES
After completing this practical, you should be able to:
• become familiar with the actions of the more commonly used groups of
drugs;
• recognize the fact that narrow margins exist between therapeutic level and
toxic level in some drugs;
10.1 INTRODUCTION
In Practical 9 you have learnt about how to perform therapeutic procedures.
Now as you know all the therapeutic and diagnostic conditions require
administration of medication. You are already swift in performing this activity.
But to administer drugs to paediatric patients is a more specialized skill. Although
the physician prescribes medications, and gives a written order to prevent
misunderstanding, you as a nurse has the responsibility for administering most
drugs. The need for accuracy in preparing and giving drugs to children is even
greater than with adult patients. Since the paediatric dose is often relatively small
in comparison with the adult dose, a slight increase in the amount of a drug
62
administered represents a greater proportional error, as there exist a narrow Administration of Medication
and Drug Supplement
margin between therapeutic level and toxic level in some drugs.
,
10.2 SAFETY MEASURES IN THE
ADMINISTRATION OF DRUGS
It is essential to revise the five "Rights" before administration of medication to
the paediatric group. These as you know are:
The sixth right added recently is "the right of the parents and child to know" the
drug they are receiving, its action and side effect, thus reducing the chances of
misuse as they would be likely to use it unsafely if they were not given the
information.
For example, if the child was receiving Tablet Eptoin for convulsion and the
mother had not noticed the convulsion which her child was having as they were
of mild nature. She may find that after this particular medication the baby sleeps.
And, hence, may administer it when the baby is irritable or crying to make the
child sleep, thinking the baby will have peaceful sleep and this ifself can be
harmful.
iv) ~.:ilure of the nurse to recognize that the medical officers and pharmacy
departments may make errors.
If you are in doubt, do not give the medication, however no medication should be
omitted without the medical officers order.
Oral
Rectal
Injection Intradermal
Hypodermic (subcutaneous)
Intramuscular
Intravenous
Intrathecal
Inhalation
Topical Inoculation
Eye
Nose
Ear
Now we shall revise the procedure for each one of above mentioned routes of
drug administration.
Equipment
• Prescription sheet
• Medicine measures
• Millilitre measures
• 1 ml syringe
• Glass of water.
Procedure
• Confirm that medicine contained in the bottle is prescribed for the child.
For example, if liquid, shake the bottle first to mix the content.
• Hold the measure at eye level and keep a finger at the appropriate
graduation and pour the medication.
• Replace the stopper and place the measure containing medicine on a small
tray and take to the child's bedside with the medicine card.
• Rinse the measuring glass to wash off the residue. e.g. if elixir of digoxin is
to be measured the best is to use 1 ml syringe for accurate dose.
• Tip the tablet from the container into a spoon after checking to see if it is
the prescribed drug. Then crush it between two spoons or in a crusher or it
can be dissolved in a tea spoon of water, and administered. It can be mixed
with jam or fruit juice or sugar or honey.
• Talk to the child before administering the medicine. Seat the child in your lap
to achieve better control, the child can be restrained in a sheet or sit with his
right arm tucked under your (nurse's) left arm. Then you can control his left
arm as you administer the medicine as shown in Fig. 10.1, 10.2 and 10.3.
65
Nursing Techniques in
Paediatric Care-Il
Fig. 10.1: Administering oral drugs Fig. 10.2: Administering oral drugs
(with cup/spoon) with dropper)
You should take care that the child does not inhale the medicine when he is
struggling.
• After medicine is administered orally, wipe bottles and close container and
replace in the cupboard. The used measure glass, spoon, droppers are
thoroughly washed, rinsed and dried before replacing in the cupboard.
Activity 1
Administer in your paediatric ward following oral medication using different
measuring. methods:
• 3 drops of vitamin C
For administration of a drug in less than 0.1 ml. 1 ml Mantoux syringe bearing
0.01 ml (11100 ml) graduation is essential. Special syringes for administration of
insulin are graduated in 20 units/m).
Needles used should be preferably disposable, sharp and straight needle for each
injection.
It is essential to remember the colour code used by each manufacture for their
own brand of needle according to the diameter of the needle lumen and length.
Injections, can be administered intramuscular, subscutaneous, intra-venous,
hypodermic intrathecal depending on the type of drug to be administered.
Equipment
Tray containing:
• Medication card
• Drug Vial
• File
• Kidney tray
Procedure
This method requires strict aseptic method. As the protective skin is punctured
and micro-organisms can easily gain entry.
Hence, ensure that the articles are sterile and hands thoroughly washed and
dried before you handle the syringe.
Remember
• Take out the appropriate drugs and once again check with patients papers/
injection card.
• The needle is attached to the syringe and the needle is left sheathed untill
required.
Now we shall see how to use multi dose and single dose vials.
• Insert the needle through the rubber diaphragm at right angle and inject air.
• Read the syringe at eye level and adjust with the point of the needle still in
the bottle.
• Reinsert the needle into the sheath until ready for use.
• Draw the medication in required amount in the syringe and eject the excess
back into the ampoule.
• Reinsert the needle into its sheath until ready for use.
• Take a swab of spirit and the tray and go to patient's bed side. Check once
again if its the right patient, drug, dose and time.
• Appropriate site is selected and after immobilizing the child, inject the drug.
The right technique should be used when administering the drug.
• Withdraw the needle and firmly massage the site. With a swab to enhance
circulation and quick absorption of the drug; discard the swab in a Kidney
tray or dustbin.
• Record in nurses notes and chart in order book or TPR chart, if required.
• Wash the syringe, if disposable then dispose the needle separately in a sharp
instrument bin and the syringe separately in another bin.
• Absorption is slower by this route. Hence those drugs which are gradually
absorbed are to be given.
• Commonly chosen site is usually outer aspect of the upper arm and the
anterior or lateral aspects of the thigh.
• Pinch the skin between the thumb and first or second finger of the left hand
and the needle is inserted at an angle of 45 to within 2 mm.
0
• With the left hand support the needle on the syringe and with the right hand
inject the fluid smoothly, and slowly into the subcutaneous tissue.
68
• When the contents of the syringe is ejected w.i~hdraw the needle and hold Administration of Medication
and Drug Supplement
the swab over the site.
• It the patient gets the drug through this route often, rotate the site. If the
drug is insulin, insert the needle at 90° to reduce formation of fibrous tissue.
• Ventrogluteal area.
• Vastus lateralis (infant and young child).
• Gluteal region (Children who have been walking for 1 year at least).
• Deltoid (any age), needle guage usually used is 25-22 guage. 1Yzinch needle
for gluteus maximus .
. Ventrogluteal: The site is easily located in a triangle formed by placing index
finger on the arterior superior spine and middle finger on the iliac crest. The
needle is held perpendicular to skin. (Fig. lOA)
.:~'~l
(, \ / ')\ Iliac crest
(
(/et!
/frl~,
J
'.: "~'~
.r ~
lV
~r;\
.
;1.
.'
Superior anterior
Iliac tubercle
v:: .
- /; /'
,:--.'
t
.-\
'V
\
, "
~ ~.l)
\(1
Injection site for the ventral gluteal muscle,
The injection can be given directly below the iliac crest in line with the lateral
thigh.
Infant can be held in cradle position with arms and legs secured by mother or
assistant.
Vastus lateralis and Rectus Femoris: For vastus lateralis locate greater
trochanter of femur and knee then divide this area into three and give the
if'.~~..:~ion
in the middle third, while injecting compress the muscle slightly.
(Fig. 10.5)
The needle should be injected in lateral thigh anterior to femur and needle
perpendicular to thigh or slightly angled towards anterior thigh. 69
Nursing Techniques in To inject the rectus femoris muscle, angle the needle on a straight front to back
Paediatric Care-Il
course in the midanterior portion of the thigh.
Greater --t--f--;.
trochanter
Injection
site
Lateral
condyle------+-
The site is above a line connecting the posterior superior iliac spine and the
greater tronchanter of the femur.
• The site is above a line connecting the posterior superior iliac spine and
greater trochanter of the femur.
• Since this muscle develops with it is used only after the child is walking for
at atleast one or more years.
Detoid Site: The muscle is small in children and infants. Hence, can
accommodate small amount of medication. The site is located between the
acromion and the arm pit olecranon process. Measure 2 finger breadth below the
acromian process. Grasp muscle at injection site and compress between thumb
70 and finger.
Administration of Medication
and Drug Supplement
• Ensure that the muscle is stretched or pinched between the thumb and
forefinger of the left hand to prevent drug exuding back on withdrawal of
the needle.
• Do not insert full length of the needle, as it can be difficult to withdraw and
may break off at the hilt as it is the weak points. Secondly, if the muscle is
not well developed it can easily hit the bone.
• Create "I ight negative pressure after injecting the needle by withdrawing the
piston as it help to reveal if blood vessel is damaged and the needle must be
immediately withdrawn if blood is seen and reinserted in another site.
• When giving iron injection use "Z" technique so that staining and leakage of
the drug is prevented.
• If the child is prescribed more than one drug to be given through intra-
muscular route at the same time; it is considered less traumatic to give all
the drugs through one needle provided it is not contraindicated to mix
different drugs. Certain drugs are essential to be given by separate needles
e.g. barbiturates, cortisone acetate, digoxin, chloramphenicol, tetracyclines,
erythromycin, procaine, penicillin, phenytoin, etc.
• The needle should be inserted swiftly and withdrawn but the drug should be
injected slowly to avoid painful distension of the tissue.
• Record the drug, dose and time given in the nurse's note/order book/injection
sheet.
Exercise
Administer Inj. Gentamycin IM to child and write down the steps you followed.
Equipment
• Select the vein. A vein in the antecubital fossa i.e. the cephalic or median
basilic is usually selected and the elbow extended.
• Make the vein prominent by constriction above the site with the hand of the
assisting nurse or a rubber tourniquet can be used. If the vein on the dorsum
of the hand is selected and digital constriction is applied around the wrist
precaution should be taken not to occlude the radial pulse.
• Once the vein is prominent clean the area with spirit and let it dry.
• Gently enter the vein. Once blood is seen in the scalp vein tubing release the
pressure.
• Inject the drug kept ready and close the scalp vein opening, two way set can
also be connected and kept.
• It is essential not only that the correct drug and volume of drug dosage be
used but also that the desired concentration of the drug reach the site where
it can be most effective.
• If the infusion of fluid is slow, then the drug actually reaching the child is
delayed and hence there can be mistiming of peak level in the blood.
72
• Do not change the set immediately after injecting the drug as there can be Administration of Medication
and Drug Supplement
some loss of drug with the discarded set.
• If the rate of infusion is almost the same as the rate of clearance, the drug
serum level may be close to non-existent. Hence, those drugs with high rate
of clearance should not be administered by this method.
• The length of time needed to infuse the drugs e.g. drugsIike calcium
gluconate, soda bicarb are to be given slowly.
• Some drugs given intravenously are very toxic or irritating to body tissues
outside the intravascular system. Hence, it is important to check the site of
infusion for proper placement and signs of infiltrations.
• Administer the drug within the stability time period when mixed.
• Do not mix antibiotic with each other or with vitamins and any other
supplements as they may inactivate them.
• Ensure that the arm is well immobilized strapping to the arm board.
Exercise
i) Select a child receiving IV drugs. Calculate and administer the drugs.
Suppositories
Its a cone-shaped gelatinized preparation sometimes containing medicine.
Equipment
Tray containing:
• Gloves
• Kidney tray to receive used gloves
Procedure
• Provide privacy
• Place the child in left lateral position with flexed lower limb, draw the
buttocks to the edge of the bed, place a mackintosh under the buttocks, child
is well draped leaving the buttocks exposed.
• Place infant in supine position, with a pillow under his head and back and
diaper under buttocks. Gentle restraint may be needed.
• With the gloved hand insert the lubricated suppository through the anal
sphincter to the length of index finger. The anal area is cleansed and the
glove and gauze piece is discarded. If there is tendency for the suppository
to be expelled, the buttock may be held together for few minutes.
Enema
Enema may be given for the purpose of cleansing, for therapeutic purpose; to
relieve intra-cranial pressure, abdominal distension, intusssception and for
diagnostic purpose.
The procedure has to be done in the same way as for an adult patient. But its
essential to remember that small tubing will be required and more precaution to
be taken and the amount of fluid required is less. The tube should be inserted 2
to 4 inches only. Hang solution reservoir not higher than 30-45 cm above the
infant's hips.
Purpose
Equipment
Nelson's Inhaler, cover, Gauze measure, flat bowl or tray, prescribed drug like
tincture of bezoin 5 ml or menthol crystals, paper napkin/tissue/handkerchief/
sputum mug.
Procedure
• Cover the mouth piece with gauze and position it opposite to the air inlet.
• Cover the inhaler with linen and place on a flat bottomed bowl or tray.
• Instruct the child to take deep breath through mouth and breath out through
the nose; give for 7-10 minutes.
Precaution
• Ensure child is well positioned.
• Ensure that the fluid is not filled above the air inlet.
Drops are instilled into the nose, ear and' eyes of the child in much the same way
as they are in the adult with the following exceptions.
• The dose of medication may be smaller than the amount the adult receives.
• The use of a medicine dropper that has a smooth tip to prevent injury.
Purpose
Procedure
• Tilt his head back and stabilize it in the crook of your arm by pressing it
between your arm and body.
• Ensure that he does not sneeze; as the medication will be sprayed out.
• If child is older, place in supine in a bed with a pillow under his shoulders to
'hyperextend his head over the pillows. After instilling keep the head below
the level of the shoulder for 3 to 5 minutes.
Equipment
Points to Remember
Ensure the drops come in contact with the surface of the posterior portions
of the nose.
If nose is filled with secretions, suction with a soft rubber bulb nasal syringe.
Keep drops and dropper separate for individual child or at least use separate
droppers for several children.
Rotate the head when drops are instilled in the right nostril to right side
similarly when drops are instilled in left, rotate head to left side.
Activity 2
Select a child receiving nasal decongestion drops and administer the same.
76
Eye Drops Administration of Medication
and Drug Supplement
Medication is instilled in the form of drops or ointment. (See Fig. 10.9)
Purpose
• To dilate pupil e.g. Atropine 1 per cent, drosyn 5 per cent or 10 per cent
Equipment
Eye drops, pipette/tube with ointment, sterile cotton swabs, medication card,
Kidney tray.
Procedure
• Clean the eye using sterile distilled water or boiled cooled water.
• Position the child in supine position if young child preferable mumify the
child with blanket or baby sheet.
• Rest your right hand on the forehead of the child, and with the index finger
and thumb using mild traction to hold both lids apart.
• The dropper is held a few millimeters over the lower-fornix and while the
child looks upward, the medication is expressed within the conjuntival sac.
An alternative to instill drops is when the child looks downwards. The solution is
expressed into the upper-fornix.
Precaution
• Do not touch the tip of dropper or nozzle to the conjunctiva of the eye.
• Do not put solution/drops directly into the cornea.
Activity
Select two children receiving eye drops and eye ointment and practice
administering the same.
Ear Drops
Now we shall discuss the procedure of instilling ear drops. (Fig 10.10)
Purpose
• To soften wax (4 per cent sodium bicarbonate, olive oil, wax solvent etc.)
• To relieve the pain due to otitis media (phenol drops etc.)
• To treat infection of the external auditory meatus (e.g. chloramphenicol or
neomycin ear drops etc.)
• To float out small insect (e.g. olive oil).
Equipment
Ear drops, pipette/dropper, medication card.
Procedure
Place a small well loosened cotton swab in the outer meatus to absorb the
excess solution.
Points to Remember
• Do not insert the dropper into the ear canal or hold it too far from the ear.
• Do not instill cold drops as it comes in contact with the tympanic membrane
the child can experience pain or severe vertigo.
• Do not tightly plug the ear as it can block the free flow of discharge from
the ear canal.
Activity 3
Practice administering eye drops to childreri of various age groups and write
down the steps used.
On admission, the child can be weighed as required during his stay in hospital. It
is also essential to remember while using age of the child, that children of the
same age group vary considerably in size. So age alone prove a poor guide to
those calculation specially where the child is very sick.
i) Young's Rule
.Calculating the dose of a drug according to age.
x Adults dose
_A-=g_e_o_f_C_h_il_d = Child's dose
Age + 12
e.g. A child aged 8 years, suffering from tuberculosis requires to be given Inj.
Streptomycin Intramuscularly. Calculate the dose.
8
= X 1000 mg (lgm) = Child's dose
8 + 12
8
= -xlOOOmg
20
800mg
=
2
= 400 mg 79
Nursing Techniques in ii) Clark's Rule
Paediatric Care-II
Calculating the child's dosage of a drug according to body weight.
Adult dose = 1 gm
12
- x 1000 mg = Child's dose
150
2
= -xl000mg
15
= 133 mg
ill) Percentage method of estimating paediatric drug dosage
As a child has a relatively greater surface area than an adult and requires
relatively larger dose of a drug than his weight alone would suggest.
Using surface area, a child's dose may be estimated by the following formulae.
0.85 1
= -- =- or 50 per cent of the adult dose
170 2
For the infant under one year of age, the drug dose is usually calculated on
weight basis, the dose/kg body weight being estimated from the required dose for
a 1 year old child i.e. 25 per CCl1t of the adult dose. Since the child of one year
weighs about 10 kg.
e.g. If the adult dose of a drug is 60 mg. the dose for a child of 1 year = 15 mg
for an infant weighing (i.e. 25 per cent of adult dose)
6
= -x15mg
10
3
= -x15mg
5
= 9mg
Formula: for administration of the drugs
D
-xQ=A
H
Desired Strength
80 ------ = Fractional amount of stock solution required
Strength in hand
e.g. Stock bottle of streptomycin for intramuscular use, contains 1 gm. or Administration of Medication
1000 mg/4 ml. and Drug Supplement
Strength required
Strength available
100
1000 in 4 ml
Example 2
Stock bottle of Elixir and Digoxin is prepared as 0.05 mg or 50
microgrammes in 1 ml.
Strength required
Strength available
0.125.
=--Ill
1 m1 Of-Ill
125. 1 ml
0.05 50
:.1250f1ml
50
25 5 1
=- of 1\ml - of 1 ml. 2.5 Of 2- ml
10 ' 2 2
Example 3
Calcium gluconate is prepared as 10 per cent solution.
FOf Sita the prescribed dose is 100 mg (0.1 gm).
100 ml contains 10 g
.. 10 ml contains 1 gm
1 ml contains 0.1 g
ii) Calculate the following drugs tobe given IV, Inj. Ampicillin 100 mg, Inj.
Gentamycin 5 mg and Calcium Gluconate 10% -1 mg. 81
Nursing Techniques in Guideline-Administration of Medication
Paediatric Care-II
Name
Age
Bed No.
MRD No.
Date of admission
Drug Sheet/Medication Sheet
.~
#'
It is essential to be aware of side effect and complication and the antidote that
can be given for side effect and reaction.
If the precaution are followed and drugs administered with skill and right
technique, they can be made less painful for the young patients.
82