Administration Procedures

Because the margin of safety is minimal in pediatric patients, accuracy is a prime consideration when administering medications. Inaccurate dosage calculations can result in a tenfold or more dosage error if the decimal point is in the wrong place. Always check medication doses for accuracy in the following areas: (1) recommended dosage in mg/kg/day, (2) number of divided doses recommended (e.g., every 4 hours, three times a day [t.i.d.], every 12 hours), and (3) recommended route of administration. To further avoid errors, follow these procedures:

•    Adhere to the “six rights” of medication administration: right child, right drug, right dose, right time, right route, and right documentation.

•    Check the orders to be sure that all information is correctly transcribed. Note any allergies.

•    Always double-check medication calculations before administration. Be sure the child's weight is accurately recorded.

•    Double-check calculations of medications provided by the pharmacy in a unit dose form. Consult with the physician or pharmacist if there is any question about a dose.

•    Ask another nurse to double-check the following medications: o —    Insulino —    Narcoticso —    Chemotherapyo —    Digoxin or other inotropic drugso —    Anticoagulantso —    K+ and Ca++ salts

Many institutions also require two nurses to check any medication given by continuous infusion or by medication syringe pump.

Administering Oral Medications

The oral route is the most widely used and economic method of administering medications. It is also one of the least reliable methods of administration because absorption is affected greatly by the presence or absence of food in the stomach, gastric emptying time, GI motility, and stomach acidity. The oral route can be less predictable also because of medication loss to spillage, leaking, or spitting out.

Oral medications are available in liquid (elixir or suspension), tablet or capsule, chewable tablet, or sprinkle (powder) forms. If the child cannot swallow tablets or capsules, the nurse determines whether the medication is available in a liquid form and, if it is not, determines whether it can be crushed.

Before administering oral medications, the nurse assesses the child's gag reflex and ability to swallow. The oral form used should be tailored to the child's developmental level and ability to successfully take the form prescribed. An assessment of the way the child takes medications at home also helps determine the proper form. Some older infants and toddlers can successfully take crushed tablets but refuse liquid forms.

Medication Preparation

When preparing to administer an elixir or suspension, the nurse first ensures that the correct dose is drawn for administration. Physicians' orders often specify the dosage in milligrams, not milliliters, for liquid medications. It is important to calculate the milliliter dose properly, based on the number of milligrams per milliliter in the liquid medication on hand.

Because tableware spoons vary in volume, use a calibrated spoon or dropper designed for medication administration. Calibrated syringes (preferably oral administration syringes) should be used for doses less than 5 ml or doses that are not in 5-ml increments. Pour larger volumes into calibrated plastic medicine cups. Avoid using paper measuring cups because their volumes tend to vary.

If a tablet is to be crushed and mixed with food or is available as a sprinkle or powder, mix it with a nonessential food, such as applesauce or pudding, not orange juice or formula. Giving medication with a favorite food can alter the flavor of the food. Avoid using syrup or other high-sugar substances. Never give infants medication or foods mixed with honey, because honey has been known to cause infantile botulism.

Determine a medication's compatibility with food before giving it to the child. Mix any medication with a small amount (5 to 10 ml) of food or liquid, and give it to the child before a feeding, if not contraindicated.

Sustained-release tablets or capsules should never be crushed because their function is to release the medication slowly over a long period. Enteric-coated tablets (tablets covered with a substance that prevents the drug from

dissolving until it reaches the intestine) can have an unpleasant taste or odor if crushed. Crushing also interferes with the function of the enteric coating.

Medication Administration

The method of administering oral medications differs according to the child's age and developmental level. Infants usually receive elixir or suspension forms of oral medications. Administer these with an empty nipple or oral syringe. First place the infant in an upright or semi-upright position. The position used for feeding the infant can be used for administering medications. Open the infant's mouth by applying gentle pressure to the chin or both cheeks. If using a nipple, place the nipple in the infant's mouth and add the medication to the empty nipple when the baby begins to suck. Unpleasant-tasting medications should not be given through a nipple because the taste can cause a future aversion reaction to the nipple, thus interfering with feeding.

If using an oral syringe or medicine dropper to administer the medication, place the syringe or dropper gently in the infant's mouth along the side of the cheek and squirt the medication in slowly as the infant sucks (Fig. 38-3

Administering an oral medication with an oral syringe to an infant. (Courtesy Parkland Health and Hospital System, Dallas, TX.)

). Aiming the medication toward the back of the throat is dangerous because it can cause choking and aspiration.

Toddlers and preschoolers can easily take liquid medications from an oral syringe or medicine cup. If the liquid medication has an unpleasant taste, offer to let the child take it through a straw. If a straw is used, cut the straw in half to avoid a loss of medication. Allowing children to take their own medication, giving rewards as incentives, and providing choices that fit into the medication regimen enhance autonomy.

Preschoolers can usually manage chewable tablets without difficulty. Most older children can swallow tablets or capsules. The nurse, however, should determine whether the child can swallow pills. If not, the nurse should determine whether the medication can be crushed and mixed with food or a small amount of liquid. If the child cannot swallow tablets or capsules and the tablets or capsules cannot be crushed, the nurse needs to contact the pharmacy to identify another form for administration (elixir or suspension). If the child can swallow tablets and capsules, ask what the child prefers for the “chaser” (usually water or juice).

Administer oral medications with the child in an upright or slightly recumbent position. The nurse should always use the least amount of force or restraint possible to administer the medication safely and avoid choking and aspiration. The child who is reluctant to take a necessary medication can be positioned in the nurse's lap, as follows:

•    Seat the child sideways on your lap, facing your dominant hand. •    Hug the child by bringing the arm closest to your body under your

arm and around your waist or back. •    Bring your nondominant arm around behind the child's neck, and

hold the child's free arm or hand with yours. This position cradles the child's head between your arm and body (see Fig. 38-3).

•    If the child is very resistant, secure the child's legs between yours as well.

If the child vomits or spits up after the administration of medication, notify the physician. Another dose may need to be reordered depending on how long it has been since administration, the type of medication, and the amount vomited.

Alternative Oral Routes

Oral medications can be administered directly into the GI tract through a feeding tube. If the medication is to be administered through a feeding tube, verify tube placement before administration (see Chapter 37) and, depending on the type of tube (e.g., transpyloric), determine whether the tube is the proper route for the medication. After the medication is administered, flush the tube with water to ensure the medication has reached the GI tract and to prevent blockage in the tube.

Administering Injections

Injected medications are rapidly absorbed by diffusing into either plasma or the lymphatic system. Although injection results in faster and more reliable absorption than the oral route, injections are stressful and threatening to children and are not preferred. Injections are used most often for one-time doses of antibiotics (e.g., ceftriaxone for the initial treatment of severe infection), immunizations, iron administration, purified protein derivative (PPD) and allergy skin testing. Injections are potentially more dangerous in infants than in older children because of the infant's decreased muscle mass and variable blood flow to muscles.

Appropriately preparing the child for injections can reduce emotional and anticipatory concerns. Depending on the child's developmental level, explain the reason for the injection, any sensations the child might experience, and the length of time they are anticipated to last. Tell the child that the injection is not a punishment but is needed to make the child better or keep the child healthy. Practice counting, singing, deep breathing, or other distraction techniques with the child in advance.

Offer parents the option to leave if they feel unable to cope with the procedure; inform them when the procedure is completed. Most parents prefer to remain. Some are willing to help reassure the child or hold the child during the procedure.

To reduce the risk of injury, it is sometimes necessary to restrain the child before administering an injected medication. Restraint can be accomplished by swaddling the child or obtaining the assistance of another health care professional. Toddlers and older children often respond better to injections if parents can hold and comfort them during the procedure (Fig. 38-4

Figure 38-4  Two methods of restraint for intramuscular (IM) injection at the vastus lateralis site. (Left, Courtesy Parkland Health and Hospital System Community Oriented Primary Care Clinic, Dallas, TX. Right, Courtesy Cook Children's Medical Center, Fort Worth, TX.)

). The parent, however, must feel confident in the ability to keep the child still enough to prevent injury.

Children perceive injections to be very painful. Even with the best preparation, it is hard for a child to understand that the pain of an injection lasts only seconds. Ice applied to the anticipated injection site for several minutes before the injection can numb the pain sensation, but it can also reduce blood flow to the area, interfering with absorption. Topical anesthetic agents, such as eutectic mixture of local anesthetics (EMLA) cream, also have been shown to be effective in reducing injection pain (see Chapter 39, p. 1003).

Children can be taught to deal with the pain of an injection using guided imagery, distraction, or other methods, such as taking a deep breath and blowing out the pain or turning the “pain switch” off (Kachoyeanos & Friedhoff, 1993).

Careful documentation of the injection is also important. Documentation includes recording the amount of medication injected and the site used. If the child will receive several injections, it is important to rotate sites to prevent tissue irritation and possible muscle atrophy and wasting. Federal vaccine regulations now require nurses to record the vaccine manufacturer and lot number for each immunization given, as well as any prior vaccine reaction the child might have incurred.

Preparing and Administering Intramuscular Injections

When filling a syringe for an injection, it is important to remember that most syringes and needle hubs contain approximately 0.2 ml of dead space. Therefore, to keep the dose accurate, do not flush the needle and hub after injection. On the rare occasion that a Z-track method is used (a method in which a small air bubble locks in the medication), the dead space in the hub of the needle must be taken into account so as not to overdose.

Select the site before the child is given an injection; the site should be soft, well vascularized, and healthy. It is important to avoid puncturing blood vessels, nerves, or bones and also to avoid injecting medications intended for IM administration into subcutaneous tissue. Inadvertent injection into any of these areas can result in accidental IV injection, pain, tissue sloughing, or nerve damage. The preferred IM injection sites in children are shown in Table 38-1

TABLE 38-1 

Site Key Points Site Key Points

Vastus lateralis

Located on the anterior lateral thigh. Well developed at birth. Good choice for all age-groups but usually used in children younger than 3 yr. Able to tolerate larger

Dorsogluteal Located by drawing a diagonal line between the posterior superior iliac spine and the greater trochanter of the femur. The dorsogluteal muscle is

Site Key Points Site Key Points

volumes and not located near vital structures, such as nerves and blood vessels. To locate the appropriate site, divide the leg into thirds; give the injection into the middle outer third.

found above and lateral to this line. It develops with walking, so it should not be used until the child has been walking for at least 1 year. The child should be asked to “toe in” to avoid tensing the muscle. Can hold 1 to 2.5 ml but has the slowest and poorest absorption of all sites.

   

Ventrogluteal Located by placing the heel of the hand on the greater trochanter with fingers pointed toward the child's head. Place the index finger over the anterior superior iliac spine and the middle finger along the iliac crest posteriorly as far as possible to form a V. The injection is given in the center of the V.Site is safe for intramuscular (IM) injection in children older than 18 mo because it is free of major blood vessels and nerves. Can generally hold larger volumes (up to 2.5 ml in adolescents).

Deltoid Use the part of the muscle located about two fingerwidths below the acromion process. This site is not used for injection in young children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into muscle mass. This is the least painful site for injecting smaller volumes.

Site Key Points Site Key Points

Care should be taken to avoid bone and joint.

   

Preferred Intramuscular Injection Sites in Children

.

Select an appropriate needle size (21 to 25 gauge) and length (½ to 1½ inches) for the injection. Use the smallest size and length that will safely and comfortably administer the medication. For example, a viscous medication is less painful when injected through a larger-gauge needle. Also, consider the amount of body fat, the distance to the muscle, the size of the muscle, the volume of medication, and the properties of the medication.

CRITICAL TO REMEMBER

Guidelines for Maximum Safe Volumes for Intramuscular Injections

Safe volumes for IM injection range from 0.5 ml to 2.5 ml, depending on the age and size of the child. Wipe the injection site with a skin cleanser, and allow to dry. Insert the needle at a 90-degree angle with a quick darting motion. Pull back gently on the plunger to aspirate for blood. If blood is noted, withdraw the needle to avoid giving the medication IV. Change the needle and the site. If no blood is noted, give the injection slowly. Unless contraindicated, massage the injection site afterward.

Administering Subcutaneous Injections

A subcutaneous injection is given into the tissue that lies just below the skin. This type of administration is used for medications that provide a sustained effect (e.g., heparin, insulin). A subcutaneous injection should be given only into healthy tissue. If circulation is impaired (e.g., because of edema,

decreased temperature, shock), a subcutaneous injection should not be used because absorption will be altered.

CRITICAL THINKING EXERCISE 38-3

You need to immunize an infant with hepatitis vaccine. The infant's dose is 2.5 mcg. The type of vaccine you have on hand delivers 5 mcg/ml. How many milliliters will you give the infant?

Preferred subcutaneous injection sites are the fat pads located above the iliac crests, hips, lateral upper arms, and anterior thighs (Fig. 38-5

Figure 38-5  Two of the preferred subcutaneous injection sites in children. The fat pads above the iliac crests and hips may also be used.

). Children requiring frequent subcutaneous injections (e.g., children with type I diabetes mellitus) also use the abdomen, avoiding the 2-inch radius around the navel (Caffrey, 2003). Rotate sites to avoid the development of abscesses and to facilitate drug absorption. Record the site of the subcutaneous injection to avoid using the same site and causing tissue irritation.

Subcutaneous injections are usually given with a small (25- to 27-gauge), short (no more than ½- to ⅝-inch) needle to ensure that the medication is not inadvertently given IM. Insulin syringes come with even shorter, thinner needles (28 to 30 gauge; 5/16-inch). Volumes for subcutaneous injections are small, usually averaging 0.5 ml. Because the needle is so small and narrow, changing to a new needle after withdrawing medication through the stopper of a vial makes the injection more comfortable for the child.

Clean the site with alcohol, and allow it to dry. Pinch the tissue to raise the fatty tissue from the muscle. The angle of needle insertion is usually 45 degrees, although some practitioners insert the ½-inch or 5/16-inch needle

at a 90-degree angle. Unless the child has little subcutaneous tissue, the short needle does not reach the muscle, even if it is inserted at a straight angle. Massage the insertion site after administration unless massage is contraindicated for the injected medication, such as heparin.

If subcutaneous injections are to be ongoing (e.g., insulin administration), pay special attention to client education. Older children and adolescents can usually learn to perform this procedure without difficulty.

Intradermal Injections

Intradermal injections enter just below the outer layer of skin, the epidermis, and usually on the inner aspect of the forearm or on the upper back. They are most often used for testing (e.g., allergy, PPD). The needle is small (25 to 27 gauge) and short (½ to ⅝ inch). The volume is also small (usually 0.1 ml). After cleaning the site with alcohol and allowing it to dry, turn the bevel of the needle up and insert gently at a 15-degree angle. The needle will barely penetrate the skin. Inject the medication to form a wheal (similar in appearance to an insect bite) (Fig. 38-6

Figure 38-6  Intradermal injection site and technique.

). If the injection does not form a wheal or if bleeding is noted after the injection, administration was probably too deep and should be repeated. If several intradermal injections are made in the same area, each site should be marked with permanent ink for later identification.

The child who is to receive multiple injections might benefit significantly from carefully supervised needle play. In needle play, the child uses a syringe and needle to give shots to a doll. The nurse uses this play to prepare the child for injections and to help the child gain a sense of mastery over the experience of receiving an injection. The nurse offers a brief explanation of what will occur and why the child must receive an injection. Through therapeutic play, the child's anxiety is decreased.

Rectal Administration

The rectal route of administration is unreliable and is not used as often as other routes. It is most often reserved for times when a child cannot tolerate the oral route (e.g., because of nausea and vomiting). It has many possible complications, including the Valsalva response, rectal perforation, and other damage to the rectum or anus.

This route should not be used if the rectum is full of stool. Rectal administration is stressful for children because they fear intrusive procedures. Carefully prepare the child, and give an explanation about the procedure. Tell the child the reason the medication is being given in this form and what the child can do to help. The child is also told whether the suppository must be retained or expelled.

Position the child on the left side with the right leg flexed, and expose the rectal area sufficiently for visibility. Adequate draping is essential for preschool and older children. Often the child needs help to relax. Distraction and deep-breathing exercises can help the child relax the external sphincter. Lubricate the suppository well with a water-soluble lubricant before inserting.

Advise the child to take a deep breath or bear down if possible to relax the sphincter further. Then gently insert past the internal sphincter. The child's rectal vault is not as long as an adult's, and the distance required to place medication is approximately 1 to 2 cm (½ to 1 inch). After insertion, hold the child's buttocks together until the urge to expel the suppository has passed.

Vaginal Administration

Although the vaginal route is not often used in infant, toddler, or preschool-age girls, it might be required for school-age or adolescent girls, most often to treat candidal infections or possibly for birth control. It is essential to explain the procedure, why it is indicated, and how the child can help.

Ask the child to void, and then assist her into a supine position with the soles of her feet together and her knees resting on the bed (frog-leg position). Remember to drape the child and provide privacy. Using a gloved hand, gently spread the labia so that the vaginal orifice is visible. If necessary, lubricate the tablet, suppository, or applicator with warm water or a water-soluble lubricant. Have the client take a deep breath, and then gently insert the vaginal tablet, suppository, or applicator approximately 9 to 10 cm (3½ to 4 inches) along the posterior wall of the vagina. To reduce discomfort, the nurse should follow the natural angle of the vagina by pointing the finger or applicator toward the sacrum.

After the procedure is completed, the child might need to remain in a supine position for a time. Older school-age children and adolescents can be taught to instill their own vaginal medications. It is important that these girls receive good education and give a return demonstration of the procedure, especially if the instillations are contraceptives.

Ophthalmic Administration

Instillation of ophthalmic preparations is a clean rather than sterile procedure (Procedure 38-1

Procedure 38-1

Administering Ophthalmic Preparations

PURPOSE: To treat an eye infection, dilate pupils for diagnostic testing, or keep eyes moist.

1.    Explain the purpose for the medication or lubricating drops. Tell the child how to help with the procedure. Explain that the child might experience blurred vision for a short time afterward.

2.    Gather needed equipment: eye drops or ointment, gauze pads, and tissues. Wash your hands before proceeding. Wear gloves if contact with exudates is expected.

3.    Assist the child into a supine position with the neck slightly hyperextended (e.g., by placing a rolled towel or small blanket under the shoulder blades).

4.    If the drops are to be instilled into an infant's eyes, obtain assistance in restraining the child's arms and head or use a mummy wrap as necessary.

5.    Instruct an older child to look upward, and gently pull the lower lid down and away from the eye.

6.    Place the drops or a ribbon of ointment into the space between the eye and lower lid, taking care not to contaminate the end of the dropper or tube.

7.    If both drops and ointment are ordered, the drops should be administered first. If they are placed after the ointment, they will not be absorbed.

8.    Have the child look down as the lower lid is released. Encourage the child to close both eyes and keep them closed for several seconds. Hand the child a tissue to gently blot any excess medication.

9.    As with any procedure, praise the child for cooperation and

assistance. Document the medication in the appropriate location.

). Most pediatric ophthalmic solutions are available as either drops or ophthalmic ointment. If these preparations are refrigerated, allow them to warm to room temperature before instillation.

Before administering, note the expiration date and inspect the drops for color changes or cloudiness. Shake all suspensions well before instillation. Gently remove any exudate by wiping the child's eye with a sterile gauze pad from the inner to outer canthus. If exudates are dry or crusted, wipe with a warm, wet compress. Use a different pad for each eye.

Otic Administration

Otic procedures are clean rather than sterile procedures except in the case of a ruptured tympanic membrane (Procedure 38-2

Procedure 38-2

Administering Otic Drops

PURPOSE: To treat inflammation or infection of the ear canal, relieve pain, or prevent otitis externa.

1.    Explain any expected sensations to the child in developmentally appropriate terms (e.g., “It may sound like there is a butterfly flying inside your ear.”), and describe how the child can help. Assistance in restraining a young child might be necessary.

2.    Gather the following equipment: otic drops and cotton pieces. Wash your hands before the procedure.

3.    Position the child lying down with the affected ear up or sitting with the head turned so the affected ear is up.

4.    Brace the administering hand against the child's head above the ear.

For a child older than 3 years, pull pinna up and back.

5.    If the child is 3 years or younger, pull the pinna of the ear back and down, holding near the lobe. If the child is older than 3 years, pull the pinna back and up.

6.    Insert the required number of drops. Then gently massage the tragus (anterior portion) to ensure that the drops reach the tympanic membrane.

7.    Pack cotton loosely into the canal, if ordered. Instruct the child not to remove the cotton or place anything inside the ear.

8.    Keep the child on the unaffected side for several minutes after the administration. If medication is to be administered in both ears, the procedure should be repeated in the other ear after a wait of at least 1 minute.

9.    Document the medication in the appropriate place.

For an infant or a child younger than 3 years, grasp the pinna at the lobe and pull down and back.

). Because cold ear drops can cause pain when they come in contact with the tympanic membrane, otic solutions should be allowed to warm to room temperature before administration.

Before administering ear drops, gently clean any exudate from the outer ear with sterile gauze. Because the risk of rupturing the tympanic membrane is high, never attempt to place anything inside the ear to clean the canal.

Nasal Administration

Although the mucous membrane route is generally used only for localized treatment, it has fairly rapid systemic absorption and may be used for the administration of certain systemic medications (e.g., antidiuretic hormone).

When administering nose drops to an infant, the nurse or parent removes any excess mucus by gently suctioning with a bulb syringe before administration. To make eating more comfortable, saline nose drops followed by gentle suction should be given 20 to 30 minutes before feedings.

Receiving nose drops is stressful for young children, who might feel that they are drowning during the instillation. A thorough explanation of what the child will feel, why the medication has been ordered (“to help unstop your nose”), and what the child needs to do to help is necessary. Assistance with restraint may be necessary with the young child, or mummy restraint or swaddling may be used.

Assist the child into a supine position, and hyperextend the neck slightly by placing a rolled towel or small blanket under the shoulder blades. Keeping the head in a midline position, instill the number of drops ordered into each naris. The head is kept in the same position to allow the drops to reach the ethmoid and sphenoid sinuses. Then briefly have the child turn the head slightly in each direction and back to midline to disburse the medication to the maxillary and frontal sinuses.

After the drops have been instilled, the child remains in a supine position for several minutes to allow the medication to be distributed to the sinuses. Instruct the child not to blow the medication out of the nose. Praise all efforts at cooperation.

Topical Administration

Because skin is relatively impermeable when intact and has a large surface area, topical administration of drugs is generally limited to localized treatment. If the medication is applied to abraded skin, over a large area, or over a long period, however, systemic effects can result. Solvents added to the medication to break down skin oils and occlusive dressings also increase absorption. Monitor the child carefully for systemic absorption effects.

As with all other procedures, explain what will be done, why it will be done, and what sensations the child will experience. Clean the skin gently to remove any exudate, scales, or other residue, and allow it to dry. To avoid contaminating the container, place the estimated amount of medication on a sterile pad. Wear gloves, and apply the ointment or cream as ordered or as

recommended by the manufacturer. Cover the site afterward with a sterile pad if ordered. Encourage the child to avoid touching or scratching the area, and praise the child for cooperation.

Inhalation Therapy

Respiratory medications, used frequently in children, are delivered either by nebulizer or a metered-dose inhaler—a hand-held device that delivers “puffs” of medication for inhalation. Although many inhaled medications have an unpleasant taste or smell, this route is a relatively nonthreatening form of medication delivery. Monitoring for desired therapeutic effects and systemic effects is essential because most medications used for inhalation have systemic side effects.

Nebulized medications are diluted in normal saline and administered with a hand-held small-volume nebulizer (SVN or HHN). The SVN device aerosolizes the medication for the child to inhale. Medication can be delivered through a mask or through a plastic mouthpiece held between the lips or close to the face (Fig. 38-7

Figure 38-7  Administration of nebulized medication to an infant. (Courtesy Children's Medical Center, Dallas, TX.)

). A mask is preferred for young children because they are seldom able to successfully hold a mouthpiece in place for the required length of time. Encourage the child to breathe deeply and slowly during the treatment.

Metered-dose inhalers offer an inexpensive, portable means of delivering inhaled medications. Many people, particularly children, have difficulty using a metered-dose inhaler correctly. The effectiveness of these medications is increased with the use of an inhalation aid, such as a spacer device. A spacer is a cylindric piece of hard or expandable plastic that attaches to the mouthpiece of the inhaler and is attached to a mouthpiece or mask. The child depresses the inhaler, and the medication enters the spacer, allowing the child time to deeply inhale the medication. For people who cannot afford a commercial spacer, a small plastic commercial water bottle can be used; an opening large enough for the inhaler mouthpiece can be cut into the large end, and the bottle opening at the other end is small enough to fit into the child's mouth. (See Procedure 38-3

Procedure 38-3

Using a Metered-Dose Inhaler

PURPOSE: To deliver medication directly to the respiratory system.

1.    Verify the physician's order for medication or medications to be administered and number of puffs.

2.    If one of the medications is an inhaled steroid, administer it last. 3.    Explain the procedure to the child and parent or caregiver. It is

often helpful to demonstrate the use of the inhaler and to explain specifically what the child is expected to do.

4.    Place the inhaler in the spacer. Tell the child not to inhale too quickly or the spacer will whistle.

5.    Tell the child to exhale (“big breath out”) and place the spacer mouthpiece in the mouth or the spacer mask over the face. The child might be more comfortable holding the spacer and helping you.

6.    Tell the child that you will squeeze the inhaler and release the medication into the spacer. Then direct the child to inhale (“big breath in”) slowly. You may need to talk the child through this process.

7.    Encourage the child to hold the breath for about 10 seconds or until you count slowly to 5.

8.    Ask the child to exhale and then take another breath from the spacer and hold it for 10 seconds.

9.    Repeat with another puff, if ordered. Praise the child for cooperation.

10.  Rinse the inhaler adapter and spacer with cool water. Return the equipment to the medication room or designated area. Document.

for directions to use a metered-dose inhaler.)

Although both forms of delivering inhaled medications are effective, the nebulized medication offers the advantage of delivery with supplemental oxygen to children in an acute episode of respiratory distress. Nebulized medications can also be delivered to an unconscious or intubated child by inserting the aerosol administration device in-line between the child and a bag-valve-mask.

Educating the parent and child is important to ensure the effectiveness of this form of medication delivery. The technique must be demonstrated and a return demonstration given. Use of the metered-dose inhaler should be reviewed at each return visit.