Amy E. Irwin, DNP, MS, RN
Denver School of Nursing

• Correct fluid and electrolyte imbalances
• Administer medications
• Administer blood products
• Administer nutrients

• The largest visible vein is not necessarily the preferred one
• Consider the comfort of the patient
• Consider the position and extent restraint
• Consider the vessel’s ability to maintain a needle
• Consider the solution to be infused

• INFANT
– Handle infant gently, speak softly
– Avoid arm used for thumb sucking
– Cuddle immediately after insertion
– Don’t feed immediately prior to insertion
– Avoid presence of extra personnel to minimize stranger anxiety

• TODDLER/PRESCHOOLER:
– Prepare child immediately prior to procedure
– Give simple explanations in concrete terms
– Explain that you will help child hold still
– Emphasize that the IV is not punishment

• SCHOOL-AGER
– Prepare child ahead of time, but on the day of insertion only
– Give the child choices as appropriate
– Give positive reinforcement after completion

• ADOLESCENT
– Prepare teenager several hours to a day before procedure
– Approach discussions on a more adult level
– Discuss fears related to procedure
– Include teen in decisions

• Hands
• Forearm
• Feet
• Scalp
**Note if the child is a thumb sucker,etc

• Use the largest catheter you can successfully insert
• Catheter Sizes:
Newborn: 24, 22 gauge
Infant < 1 year: 24, 22 gauge
1 – 8 years: 22, 20, 18 gauge
8 years and older: 20, 18, 16 gauge

• Minimizes or prevents pain from needle puncture for an IV, blood sample, or implanted port access.
• Apply EMLA cream to the selected site 60 minutes before the procedure.
• Cover at least two sites in case the first attempt is not successful.

• Mechanical factors predispose IV infusion to shorter dwelling time
• Mechanical factors include:
Insertion site
Length of catheter
Size of vessel
Vessel fragility
Activity level of the patient
Forceful administration of boluses of fluid
Infusion of vessicants or irritants through small vessels

• Infiltration (extravasation)
– Fluid leaks into subcutaneous tissue

• Catheter Occlusion
– Blockage usually by clotted blood or precipitate
• Air Embolism
– Air enters circulation & travels to right side of heart
• Phlebitis
– Injury to vein without clot
– Inflammation of the blood vessel

• Thrombophlebits
– Inflammation of a blood vessel with thrombus formation
• Infection
– Introduction of pathologic organisms locally or systemic
• Metabolic derangement
– Imbalance in electrolytes, minerals, glucose & proteins

• Used in emergency situations when a peripheral vein cannot be accessed
• Needle is inserted into the medullary cavity of a bone
• Used to administer fluid and medications
• Safe and reliable method for rapid administration

• Using aseptic technique, prep site with povidone-iodine solution
• Use 18 gauge in infants < 3 months of age
• Use firm, gentle pressure in a twisting motion to insert needle
• Insert perpendicular to site, or at a slight angle away from nearest joint
• Stop when you feel a “pop” and attempt to aspirate and/or flush
• Secure tubing to leg to prevent pulling on insertion site
• Flush meds with 5 – 10 cc NS
• Requires pressure for fluids to run

• Calibrated volume & control chamber with a limited capacity & an automatic shutoff mechanism
– Ie. Buretrol, Metriset
• Standard of Practice
– All IV meds should be placed on a syringe pump if child is < 6 months

• Drip chamber with microdropper delivering 60 gtts/min or 60cc/hr
• Tubing compatible with pump, catheter adapter for needleless systems
• Standard of practice: All IV sites should be checked and reprogrammed every hour
• Armboards are utilized to maintain integrity of IV site (may also require restraints)

• IV fluids are administered for the following reasons:
– To provide water, electrolytes, nutrients
– To replace water, correct electrolyte deficits
(replacement)

• Isotonic: electrolyte content approximately 310 meq/L
– Examples: D5W, D10W, NS, LR
•
Hypotonic: electrolyte content less than
250meq/L (never used in children)
– Examples: No examples in pediatrics
•
Hypertonic: electrolyte content exceeds 375 meq/L
– Examples: 3% saline, D5.45NaCl, D5.9NaCl

• Fluid calculations are based on weight in kilograms
Maintenance Fluid Intake
0 – 10 kg weight needs 4 cc/kg/hr
11 – 20 kg weight needs 2 cc/kg/hr additional
21 kg plus weights needs 1 cc/kg/hr additional

23 kg Child
Calculate:
•
10 x 4=40
•
10 x 2=20
•
3 x 1=3
Total maintenance fluid requirements=63cc/hr

22 kg Child who is “fluid-restricted” at 2/3 maintenance due to kidney failure
Calculate:
10 x 4 = 40
10 x 2 = 20
1 x 2 = 22
Total maintenance fluid = 62 cc/hr
At 2/3 maintenance = ?

Factors Influencing Pediatric Drug
Administration
• Children vs. Adults
• Physiological differences
• Immature kidney and liver function

Factors Influencing Pediatric Drug
Administration
• Slow gastric emptying time.
• Decreased gastric acid secretion in children under 3 years of age
• Lower concentration of plasma proteins

Additional Variations to consider with
Pediatric IV medications
• Patient weight in kilograms
• Patient fluid status/maintenance rate
• Patient diagnosis (fluid restriction?)
– Renal
– Cardiac
• Additional medications to administer
• Volume of IV tubing
– Need to flush med through after administration

• 1. Calculate Safe dose (mg/kg)
• 2. Calculate amount to administer (cc)
• 3. Calculate final concentration or dilution for IV medications
• 4. Calculate rate of infusion
• 5. Set pump accordingly
• 6. Flush med! (same rate as administered)

• 12 kg child
– 825 mg Ancef q8h
• Follow each step!
– 1. Safe dose?
– 2. Amount to administer?
– 3. Final concentration?
– 4. Rate of infusion?
– 5. Does it make sense?

• Mg/kg x patient weight
• Example: 12 kg Child
Ordered: Ancef 825 mg IV q 8 h
Recommended 200-400mg/kg/Day
Dose on hand: 200mg/cc
Pt wt. = 12 kg
200 x 12 = 2400mg/Day
400 x 12 =4800mg/Day

• Divide by 3 (for Q 8 hours) for the safe dose:
– 2400 divided by 3 = 800mg/kg/dose
– 4800 divided by 3 = 1600mg/kg/dose
– Therefore the DOSE IS SAFE because it falls within the range

• Dose on hand (concentration from pharmacy) = 200mg/cc
• 200mg : 825mg =4.12cc to administer
1cc x
200x = 825 x=4.12cc

3. Calculate Final Concentration
(Dilution)
Recommended: 125 mg / 5cc infuse over 30”
125 mg : 825mg = 33.0cc dilution required
5cc x

• Volume
– 4.12 cc med + 33.0cc dilution = 37.12 total
– Desired minutes: 30
37.12 x 60 = 74 cc/hr
30
Set pump at 74 cc/hr

• After completing all of your calculations….
• DOES IT MAKE SENSE??

• It is the RNs responsibility to know
1. Why a specific product is being given
2. A safe volume over a safe time has been ordered
3. The common side effects of giving the product
• No solutions other than normal saline and 5% albumin should be in IV tubing used to administer blood products

• Once a blood product has been issued from the blood bank, the transfusion must be completed within 4 hours
• Tubing is changed after blood products are given unless one unit is followed immediately by the next, in that case multiple units can be given with the same infusion set

• Most infusion sets are limited to 4 units, and all infusion sets are limited to 4 hours (whichever occurs first).
• All blood components must be administered through an infusion set with an in-line filter designed to retain blood clots and particles potentially harmful to the recipient
• Platelets, fresh frozen plasma, and cryoprecipitate do not need to be cross-matched; however, a blood type is necessary to pick the appropriate products. If the patient has a blood bank history, no specimen is required.

Assessment, Administration, and
Tranfusion Reactions:
• Complete assessment prior to starting the transfusion including: Vital Signs (Temp, HR,
RR, BP), Skin (color, temp, and condition),
Breath sounds, Description of the IV infusion site
• Observe the patient during the first 5-10 minutes of the transfusion to watch for immediate signs of acute reaction
• Complete reassessment at 15 minutes into transfusion

Assessment, Administration and
Transfusion Reactions (Cont.)
• Then hourly VS and IV site checks, as well as 1 hour after transfusion
• Document: physical assessment and reason for transfusion, VS prior to and at
15 min/ and hourly
• If a transfusion reaction is suspected immediately STOP the transfusion and notify a physician.

Blood Group
O
A
B
AB
Rh Type
Positive
Negative
Compatible RBC’s Compatible
Plasma/Platelets
O O, A, B, AB
A, O
B, O
A, AB
B, AB
AB, A, B, O AB
RBC Rh Type Plasma Rh Type for
Transfusion
Positive or Negative Positive or Negative
Negative Positive or Negative