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Course: Pediatric Nursing

Topic: Pediatric Drug Administration- Part III

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the proper technique for administering otic, ophthalmic, intranasal, inhalation, intraosseous, and intrathecal medications in children.
Discuss the role of nurses in the administering medication to children.

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Medication Administration Routes in Children

Other Routes:

Otic
Ophthalmic
Intranasal
Inhalation
Intraosseous
Intrathecal

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Medication Administration: Otic

Outer ear should be cleaned for debris with recommended wipes prior to medication administration
Positioning

Sitting position
Or, lying with affected ear facing upwards

Straighten ear before instilling medication

Children younger than 3 years age: Pull pinna down and backward
Children older than 3 years: Pull pinna up and backward

Check temperature of medication drops before administering

If cold, warm the container between hands to body temperature

Ernstmeyer & Christman, 2021

Children’s Minnesota, 2015

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Medication Administration: Otic

Ernstmeyer & Christman, 2021

Children’s Minnesota, 2015

Instilling medication drops:

Nozzle of dropper should not touch skin

Run drops along the side of ear canal, instead of falling into the center of the opening

Maintain the position of the child for few minutes
Monitor for dizziness, nausea post administration

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Case Study

A nurse is administering an otic medication to a 2-year-old.

When the nurse tries to lie the child on their side to instill the medication into the affected ear, the child begins to struggle and scream so that the nurse is unable to effectively instill the drops.

How could the nurse position the child differently in this situation to improve cooperation?

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Medication Administration: Ophthalmic

When both eye drops and eye ointment are prescribed, administer eye drops first.
Cleanse discharge/debris present near eye using clean gauze saturated with warm water or normal saline.
Child may sit up and tilt their head to face ceiling, or lie down.
Create a pouch by pulling on the lower lid exposing conjunctiva.

Ernstmeyer & Christman, 2021

Healthwise, 2020a

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Administration of Ophthalmic Medications

Eye ointment:

Apply ½ inch of ointment into lower conjunctiva, starting from inner canthus and moving outwards
Instruct child to close eye and roll it to spread ointment

Eye drops:

Instill a drop into lower conjunctivita, instruct to close eyelids
Apply gentle pressure to inner canthus for a few seconds

(Prevents medication from entering lacrimal duct)

Wait for 3-5 minutes before administering another drop or ointment

Ernstmeyer & Christman, 2021

Healthwise, 2020a

Healthwise, 2020b

Gudjel, 2021

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Eye Drops Administration

Eye Ointment Administration

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What Would the Nurse Do?

A nurse is caring for a 3-year-old with a corneal abrasion.

What instructions should the nurse give to the parent regarding how to apply the antibiotic ointment to their child’s eye at home?

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The nurse should provide education to the parent in simple, understandable language with practical tips so the parent can be successful at home. Example of education the nurse might provide:

- If there is drainage from the eye, wash it away with some warm water before applying the ointment

- It can be helpful to have someone help the nurse hold the child’s head still while applying the ointment otherwise they may move their head quickly and the nurse could hurt their eye by accident with the tube of ointment

- The child can sit or lie while the nurse put in the ointment, but I’ve often found that it’s easiest to have them lie down so that there is something firm behind their head. That way, they can only move their head from side to side instead of backwards and forwards as well, which will help the nurse (or whoever is helping the nurse) to keep their head still

- Another tip for safely applying the ointment is to keep the heel of the hand pressed against their forehead or cheek as the nurse put in the ointment. This will help to steady the hand and also moves the hand along with their head if they start moving, which will help to prevent the nurse from accidentally scratching the eye with the ointment tube

- When they’re ready to apply the ointment, pull down on the lower eyelid to make a little pocket just beneath their eye (nurse can demonstrate on their own eye or point this out to parent if they apply ointment before the child leaves so parent can visualize what to do). Squeeze the ointment into that little pocket starting at the corner of their eye by their nose all the way to the outer edge of their eye

- After the nurse have applied the ointment, ask the child to close their eyes and then look around while their eyes are closed (rolling the eyes) to spread the ointment across the eye

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Medication Administration: Intranasal

If old enough, encourage child to ‘blow nose’ prior to instillation of intranasal medications
Tell the child that the atomiser goes in the nose and it is soft

If appropriate show younger children an example of a syringe with an atomizer attached (without medication)
Let them feel it

Doses greater than 0.5mL may be split between the nostrils to avoid loss of medication via sneezing

Ernstmeyer & Christman, 2021

Alberta Health Services, 2019

European Medicines Agency, 2013

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Medication Administration: Intranasal (Continued)

Using atomizer:

Sit the child at a 45 degree angle for the procedure
Do not instruct children ‘to take a big sniff’

(Can displace medication to mouth rendering it less effective or prolonging its time to full effect)

Using syringe without atomizer:

Lay child in supine position
Slowly drip the medication into nare allowing for absorption between each drop

Children’s Health Queensland Hospital and Health Service, 2022

Ernstmeyer & Christman, 2021

Alberta Health Services, 2019

European Medicines Agency, 2013

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Medication Administration: Inhalation

Inhalation medications can be administered in three ways:

Metered Dose Inhaler (MDI)
Dry Powder Inhaler (DPI)
Small Volume Nebulizer

MDI, also called ‘puffer’:

Recommended to be used with spacer, regardless of age
Attach mask to spacer for children unable to ensure a good mouth seal over spacer
Shake puffer and spacer well between administration of each dose

Children’s Health Queensland Hospital and Health Service, 2020

Ernstmeyer & Christman, 2021

University of Calgary, n.d

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MDI with Spacer in Older Children

MDI with Spacer and Mask Attached

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Medication Administration: Inhalation (Continued)

DPI:

Medicine in powder form should be breathed in quickly and strongly through mouth, and held in for 10 seconds

Reconsider appropriateness for children under 5-6 years age

Nebulizers:

Ideal for administration of inhaler medications in infants
Instruct older children to take slow deep breaths to inhale fine mist through mouthpiece or mask
Encourage coughing after treatment, provide oral care

Ernstmeyer & Christman, 2021

Ben-Joseph, 2017

Healthwise Staff, 2020c

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Special Nursing Consideration for Inhaler Medication in Children

Position child in sitting or high-fowler’s position (Enhances deep breathing and optimal medication absorption)
Wait 1-5 minutes between puffs of medication
Medications with corticosteroid: Ensure the child gargles and rinse with clean water after administration (Decreases risk of fungal infection)
Clean inhalers as per manufacturer’s instructions
Track medication doses in MDI and DPI
Instruct parent/family to obtain refills before running out of doses

Ernstmeyer & Christman, 2021

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Medication Administration: Intraosseous (IO)

Only professionals trained in intraosseous access should perform the procedure
Indications:

Children at risk of cardiopulmonary arrest without intravenous access
Critical emergency where intravenous access is not achieved within 60 seconds
Oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the child’s needs for fluids and/or medications when intravenous access is unobtainable

Perth Children’s Hospital, 2021

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Intraosseous Sites in Children

Proximal tibia 2-3 cm below the tibial tuberosity

Distal tibia proximal to the medial malleolus

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Medication Administration: Intraosseous (Continued)

Contraindications for IO access:

Below fractures
Below open injury
Infection or burn at potential site
Bone Pathology (osteoporosis, osteogenesis imperfecta)
Site of previous IO insertion

Perth Children’s Hospital, 2021

Complications:

Dislodgement, Extravasation
Compartment syndrome
Infections – cellulitis or osteomyelitis
Bone fracture or growth plate injury
Pain
Fat and bone microemboli

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Special Considerations for IO Medication Administration

IV fluids will need to be infused under pressure (pump or pressure bag) or bolused using 20mL syringe

(Gravity is insufficient to drive fluid through IO)

IO access should not be used for longer than 24 hours
Monitor IO site, especially in first hour and every 4 hours after that for signs of infection, extravasation, or compartment syndrome

If present, remove IO access and inform doctor

Perth Children’s Hospital, 2021; Sá et al., 2012

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Special Considerations for IO Medication Administration (Continued)

Hourly neurovascular observation (NVO) on the limb with IO access

(From the time of insertion, during first 24 hours)

Every 4 hours NVO for 48 hours post removal of IO access

Ambulation discouraged until IO catheter is removed to reduced risk of dislodgement

Splint and immobilize limb with IO access

Clinical vital signs should be taken from other limbs without IO access

Perth Children’s Hospital, 2021

Sá et al., 2012

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Medication Administration: Intrathecal

Minimally invasive procedure aimed at releasing drugs directly into the subarachnoid space of the spinal cord
Intrathecal access is obtained by anesthesiologist or trained provider in operating room
Performed under local anesthesia with procedural sedation or general anesthesia
Indications:

Chronic non-malignant pain
Muscle spasticity
Cancer-related pain

Shah & Padalia, 2021

Di Napoli et al., 2022

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Medication Administration: Intrathecal (Continued)

Contraindications:

Systemic infection, known allergies to materials in the implant, active intravenous drug abuse, psychosis or dementia, and infection at the implantation site.

Relative contraindications:

Atrophied patient (underweight BMI), ongoing anticoagulation that cannot be discontinued, active bleeding, high opioid tolerance, lack of social or family support, and lack of access to medical care.

Shah & Padalia, 2021

Di Napoli et al., 2022

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Intrathecal Medication Administration Devices

Subcutaneous pump:

Allows for different infusion methods

Continuous (fixed) infusion mode

Administer drug continuously through 24 hours

Flexible infusion mode

Allows customization and changing of doses as per client’s needs throughout 24 hours

Client-controlled analgesia infusion mode:

Allows administration of prefixed doses ‘on-demand’ by the client

Shah & Padalia, 2021

Di Napoli et al., 2022

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Intrathecal Medication Administration Devices

Port-a-cath device

Inexpensive, easy to work with
Medication can be injected manually
Greater risk of infection compared to subcutaneous pump

Catheter: Positioned in the intrathecal space of the spinal cord
External device (programmer): Allows an extra dosage of medication when needed

Shah & Padalia, 2021

Di Napoli et al., 2022

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Role of Nurses in Medication Administration via Different Routes

Ensures prescribed medication matches the route to be administered
Informs child and parents about the procedure

Obtains their consent and cooperation

Solicits help from the parents, where possible, to

Stabilize/immobilize medication administration site in the children
Distract the child, or calm the child during the procedure

Use aseptic technique to administer the mediation through otic, ophthalmic, intranasal and inhalation route

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Role of Nurses in Medication Administration via Different Routes

Use sterile technique to assist in obtaining IO access and Intrathecal access
Monitor and manage complications related to IO and Intrathecal routes
Support and educate parents on administration of medication through otic, ophthalmic, intranasal and inhalation at home safely

Should includs information about how to clean MDI, DPI
‘Teach-back’ and demonstration from children, parents

Document medication, dose, route, time, and child’s response

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What Would the Nurse Do?

A nurse is caring for a critically ill child at risk for cardiopulmonary arrest. The team is not able to establish IV access, so intraosseous access is established instead.

The nurse connects normal saline to the intraosseous line to give a fluid bolus by gravity.

The nurse opens the clamp on the line but the fluid does not start flowing.

What should the nurse do next?

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Red Flags

Allergic reaction to medication
Dizziness, nausea

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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References:

Alberta Health Services. (2019, May 13). Intranasal Medication Administration- Pediatrics. https://extranet.ahsnet.ca/teams/policydocuments/1/clp-ed-intranasal-med-admin-peds-hcs-239-01.pdf

Ben-Joseph, E.P. (2017, August). What are nebulizers and inhalers?. The Nemours Foundation. https://kidshealth.org/en/parents/nebulizer-inhaler.html

Children’s Health Queensland Hospital and Health Service. (2022, February). Queensland Paediatric Emergency Care Nursing Skill Sheets : Medication Administration -Intranasal. Queensland Government. https://www.childrens.health.qld.gov.au/qpec-nursing-skill-sheets/

Contact info: info@nursesinternational.org

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References:

Children’s Health Queensland Hospital and Health Service. (2020, March). Queensland Paediatric Emergency Care Nursing Skill Sheets : Medication Administration -Salbutamol MDI. Queensland Government. https://www.childrens.health.qld.gov.au/qpec-nursing-skill-sheets/

Children’s Minnesota. (2015, August). Patient and family education materials: Ear drops. https://www.childrensmn.org/educationmaterials/childrensmn/article/15673/ear-drops/

Di Napoli, R., Esposito, G., Cascella. M. (2022, February 5). Intrathecal Catheter. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549790/

Contact info: info@nursesinternational.org

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References:

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Skills. Chippewa Valley Technical College. , licensed under CC BY 4.0. https://www.xanedu.com/higher-education/solutions/open-rn

European Medicines Agency. (2013). Guideline on pharmaceutical development of medicines for paediatric use. https://www.ema.europa.eu/en/pharmaceutical-development-medicines-paediatric-use

Gudgel, D.T. (2021, March 10). How to put in eye drops. [Review of article How to put in eye drops by N.L.Herz]. American Academy of Ophthalmology. https://www.aao.org/eye-health/treatments/how-to-put-in-eye-drops

Contact info: info@nursesinternational.org

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References:

Healthwise Staff. (2020a, August 31). Using Eye Ointment. [Review of article Using Eye Ointment by K. Romito, M.J. Gabica, A.C. Poinier, A. Husney, & C.J. Rudnisky]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=tw9192

Healthwise Staff. (2020b, August 31). Eyedrops. [Review of article Eyedrops by K. Romito, M.J. Gabica, A.C. Poinier, A. Husney, & C.J. Rudnisky]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zm6234&lang=en-ca#zm6234-sec

Contact info: info@nursesinternational.org

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References:

Healthwise Staff. (2020c, October 26). Learning About Nebulizers for Children. [Review of article Learning About Nebulizers for Children by A.Husney & M.J.Gabica]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?hwid=abn2668&

Perth Children’s Hospital. (2021, October). Intraosseous Access. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Intraosseous-access

Shah N, Padalia D. (2021, July 12). Intrathecal Delivery System. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538237/

Contact info: info@nursesinternational.org

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References:

Sá, R. A., Melo, C. L., Dantas, R. B., Delfim, L. V. (2012). Vascular access through the intraosseous route in pediatric emergencies. Acesso vascular por via intraóssea em emergências pediátricas. Revista Brasileira de terapia intensiva, 24(4), 407–414. https://doi.org/10.1590/s0103-507x2012000400019

University of Calgary. (n.d.). Community Pediatric Asthma Service: Using your MDI alone is not recommended. https://cumming.ucalgary.ca/research/icancontrolasthma/asthma-devices/mdi-alone

Contact info: info@nursesinternational.org

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