Here are the steps to solve this problem: 1) Convert 15.4 lbs to kg: 15.4 lbs = 7 kg 2) The dosage range is 75-150 mg/kg per day 3) To calculate the dosage for this order: 7 kg * 150 mg/kg = 1050 mg per day 4) The doctor's order of 200 mg every 8 hours is: 200 mg * 4 times per day = 800 mg per day 5) The doctor's order of 800 mg per day is within the recommended dosage range of 75-150 mg/kg per day (which is 1050-2100 mg per day for this patient). Therefore, the doctor's order is within the desired dosage range

1. PEDIATRIC HEALTH NURSING
UNIT III : PHARMACOLOGICAL CARE ASPECTS WHILE
DEALING WITH PEDIATRIC PATIENTS
MUHAMMAD SULIMAN
Post RN BSc.N
ROYAL COLLEGE OF NURSING
SWAT
15/25/2015

2. Introduction
Adults and children respond to drugs differently. Disparities
include the absorption, distribution, metabolism and
elimination of the drug by the body as well as differences in
formulation, dosage and administration.
Medications that are used commonly in paediatric practice
do have well-articulated details such as age/weight dosing,
implications for breast-feeding and important information
related to drug absorption, distribution, elimination and
adverse events. It is imperative that the clinician caring for
children utilises this information to maximise the benefits
of pharmacological agents.

3. Cont…
It is important to recognise that the nature, duration of effect
and intensity of a drug's action are related not only to the
intrinsic properties of the drug itself but also to the drug's
interaction with the patient to whom it has been administered.
Therefore, effective and safe drug therapy in neonates,
infants, children and adolescents requires an understanding of
the differences in drug action, metabolism and disposition that
are determined developmentally.
Nearly all pharmacokinetic parameters change with age and
as a result, paediatric drug dosages must be adjusted
accordingly. Likewise, issues such as medication
administration and formulation have concordance
implications in paediatrics.

4. Cont…
• Birth to 1 year of age have greater percentage
of body water
• Age 1 to 12 years metabolize drugs more readily
than adults
• Children at risk for overdose, toxic reactions, and
death
– Due to immature physiological processes
• E.g., absorption, distribution, metabolism,
excretion

5. Before you make a start
• Familiarize yourself with your local medicines policy and
procedures
• Be aware of PNC Code of Conducts, PMDC Standards for
Medicines Management
• Understand why your patient has been prescribed this
medication, check the care plans as well as dose, possible
adverse effects, contraindications and special precautions
• Check prescription charts regularly. Omission is the second
most common reason for medication error
• Gather together the prescription chart, keys and second RN
to act as checker if required
• Wash your hands

6. Check prescription chart
• Has the correct patient identification. Full name, NHS
number and/or hospital number if required by local policy
• Has a completed and signed confirmation of allergy status
on the front of the chart
• Provides a clear legible prescription of medication to be
administered. If this appears ambiguous it is safer to
request that the prescription chart is rewritten.
Prescriptions should include date of prescription, the
generic drug name, route, dosage, date and time to be
administered and the prescriber’s printed name and
signature
• Remember All checks should be completed independently

7. Preparing the medicine
• With the second checker, select the correct medication
and check that it is within the expiry date. Consider
formula/spoon/oral syringe preference for children
• Check that the dose prescribed is correct for the age
and weight of the patient using a reference source
• Independently calculate the volume of liquid or
number of tablets required. Compare answers.
Recalculate if you disagree
• Measure the dose required. Both practitioners should
witness all stages of the process and confirm the
amount prepared. Both nurses should undertaken at
bedside checks together

8. Administering the medicine
• Check that the patient’s name, date of birth and NHS
number on the name band correlate with these details on
the prescription chart
• If possible, ask the patient/parent to tell you his/her name
and date of birth
• Check the allergy section on the prescription chart for
contraindications to administration
• Explain purpose of the medication to the patient/ family and
gain consent for administration
• The patient/family/non-registered nurse/play specialist may
wish to be involved in the administration procedure.
Remember This must always be performed under the
supervision of an RN who remains accountable for any
delegation of this task

9. Closing the intervention
• After administering the medication both nurses should sign
the prescription chart to evidence that the medication has
been given
• Offer the patient a drink, particularly if the medicine has an
unpleasant taste
• Record reasons for non-administration of the drug on the
prescription chart and in the nursing documentation
• Make the patient comfortable. Offer bravery rewards if
appropriate. Ask whether there are any further
interventions required. Inform the patient and/or family
when you will be returning
• Dispose of equipment safely with clean spacers as required.
Wash your hands
• Observe patient for adverse effects

10. Involving the child, young person
and family
The admission process for children and young people should
assess and record details of the child or young person’s
prescribed medication, together with their preferences for
when this is usually taken and how all medications are
usually given (e.g. tablet, syrup, spoon, syringe). Many
children’s hospitals operate parent administration
procedures that maintain home routine, facilitate integrated
family and health care partnership working and help to
protect against medication errors (Crawford 2012). The
role of the children’s nurse in this process is to provide
support to families but remain mindful of the NMC (2010)
requirement to ascertain that medication has been
administered as recorded.

11. Cont…
Medications dispensed by hospital pharmacies for
discharge frequently do not include guidance on
usage. NICE (2009) estimate that 33–50% of all
patients with long-term conditions do not take
medication as directed, potentially at a cost of over
£100 million per year. As children and young people
are reliant upon parental understanding of medicine
regimes for their well-being, they are particularly
vulnerable. The children’s nurse therefore has a key
role in explaining rationale for dose, frequency,
specific instructions and adverse effects of
medication to children, young people and their
parents and carers.

12. Medicines safety
Medication error was the most frequently reported
adverse incident reported during an NPSA (2009)
patient safety review. Ten per cent of errors affected
the 0–4 year age group. The most common error was
incorrect dose, followed by omitted doses and
incorrect frequency. It is widely acknowledged that
although these events are preventable, health care
providers will never achieve a position of zero
medication incidents (Chang and Mark 2011). What
is important is that children’s nursing learns from
these events and as advocated by the Children and
Young People’s Health Outcomes Forum (2012),
initiate bundles of interventions to reduce their
frequency.

13. Administering Medications to
Children
• Safe pediatric dosages calculated by:
– Body weight
• Measured in mg per kg, mcg per kg, etc.
– Body surface area (BSA)
• Measured in m2

14. Calculation formula
Dose = What you want × Amount it is in
What you have
For example: you need to administer 60mg
paracetamol which comes as a 120-mg in 5-
mL preparation:
Dose = 60/120 × 5 = ½ × 5 = 5/2 = 2.5mL

15. Units of measurement
1 gram (g) = 1000 milligram (mg)
1 milligram (mg) = 1000 microgram (μg)
1 microgram (μg) = 1000 nanogram (ng)
1 litre (L) = 1000 millilitres (mL).

16. Calculating IV fluid rates
Rate = volume/time
Example 500mL over 4 hours
Rate = 500/4 = 125mL/hour

17. Principles of drug calculations
The metric system
To undertake drug calculations it is imperative to
understand the units of measurement used in
the prescribing and administration of drugs.
The units are expressed using the System
International within the standard metric system
of weights and measures (Blair 2011).

18. Units Abbreviations Conversions
Kilogram kg 1kg = 1000 g
Gram g 1g = 1000 mg
Milligram mg 1 mg = 1000 microgram
Microgram Do not abbreviate NA
Litre L 1 L = 1000 m L
Millilitre m L NA
Cont…

19. Proportions
Many calculations that are undertaken on a children’s ward
are based on weight and volume. This is because a
dosage weight of drug has been dissolved in a volume of
liquid. For example, an elixir that contains the dose
strength of 125 mg in 5 mL means that in every 5 mL of
liquid will be 125 mg of the drug.
Strength of the medicine 125 mg in 5 mL
If you halve the dose 62.5 mg in 2.5 mL
If you double the dose 250 mg in 10 mL

20. Fractions
A useful resource when undertaking drug calculations is to
learn common fractions expressed as a decimal. This is
helpful when calculating dosages from ampoules.
½ = 1.5 ¼ = 0.25 1/5 = 0.2
2/4 = 0.5 2/5 = 0.4
3⁄4 = 0.75 3⁄5 = 0.6
4⁄5 = 0.8
Worked example
If you require half of a 1-mL ampule you will require 0.5 mL

21. Dividing and multiplying by 10, 100 and 1000
Many drug doses and stock strengths are given in multiples
of 10. A useful skill is to be able to recognize when a
dose is a multiple of 10 or 100 and understand their
relationship.
10 mg 10 × 1 mg
100 mg 10 × 10 mg
20 mg 10 × 2 mg
50 mg 10 × 5 mg
1000 mg 10 × 100 mg

22. Formula method
This method requires relevant numerical figures to be
inserted into an equation, which once solved provides the
necessary volume of liquid or number of tablets that
need to be administered
• What you want (prescription) ÷ What you have (stock strength) × What its in (volume)
= Volume to be administered
• What you want (prescription) ÷ What you have (stock strength) = Number of tablets to
be administered
Worked examples
• You need to administer 120 mg paracetamol
The dose strength available is 120 mg paracetamol in 5 mL
= 120 ÷ 120 × 5 = 5 mL

23. Cont…
• You need to administer 25 mg prednisolone
This is available in 5 mg tablets
= 25 ÷ 5 = 5 tablets
Children and Young People’s Nursing at a Glance, First Edition. Edited by
Alan Glasper, Jane Coad, and Jim Richardson.
© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons,
Ltd. Companion website: www.ataglanceseries.com/nursing/children

24. Numeracy
It is vital that paediatric nurses have sound
numeracy skills to assist them within a range of
health care activities. One such activity is drug
calculation and administration. Poor numeracy
skills may lead to medication errors. While
recognizing that medication errors are
multifactorial, lack of competence in basic
calculation is often reported as a key area of
concern for many trusts (Fry and Dacey 2007).

25. Estimation
Being able to estimate the answer sought is essential in
drug calculations. Many medication errors occur as the
practitioner has not thought through what a sensible
answer or dose would be. A moment taken to
approximate the calculation will prevent serious errors,
such as a misplaced decimal point (Hutton 2009).
Using a calculator:
Paediatric nurses should be able to undertake non-complex
drug calculations without the use of a calculator. A
calculator provides an answer to the equation that is
keyed in; if the equation is incorrect it is easy to generate
the wrong answer.

26. Cont…
However, it would be acceptable to calculate the dose
needed and then check the answer using a calculator.
For more complex drug calculations, it may be
necessary to use a calculator, although the correct
answer should be estimated to ensure the calculation is
correct.
Checking the dose:
Before administering a drug to a child the nurse must be
sure that the prescribed dose is correct. While errors
may be made by prescribers as well as those who
administer the prescription, accountability sits with
both. Double checking is recommended for complex
drug calculations.

27. Cont…
Checking must involve each nurse independently undertaking
the calculation and then both checking the answer together
(NMC 2010b). There are some academics who believe that
double checking may increase the risk of error as each
become complacent and rely on the other to spot an error.
This is why it is imperative that nurses undertake the
calculation independently before doing it jointly.
Recommendations for practice:
Medication administration incidents are most frequently due to
the wrong dose, delayed or omitted medication or the wrong
medication being administered (NPSA 2009; Nursing Times
2012), with the most frequently cited error being calculation
error.

28. Cont…
Health care organizations must ensure that they implement
routine and regular assessment of their clinical staff’s
numeracy skills. This should form part of their
mandatory clinical update and continued professional
development. It is hoped that the implementation of
such strategies will lead to an increased awareness of the
importance of numeracy and thus an improved quality
of care of patients and a reduced risk of medication
errors (Warburton 2010).

29. Key points
• Understand professional responsibility and accountability.
• Understand units of measurement.
• Possess sound knowledge of calculation formulas.
• Estimate the required volume and/or number of tablets.
• Double check when appropriate.
• Employers should demonstrate yearly assessment of
practitioner’s numeracy skills.

30. PRACTICE TESTS
Example 1
A child is prescribed 100mg fluconazole, which is supplied as
capsules, each containing 50mg. The nurse must work out
how many capsules to give. Two 50mg capsules would
provide 100mg of drug – easy! Let’s look at how you got
that answer:
The dose prescribed, or what you want, was 100mg.
The dose per available capsule, or what you’ve got, was 50mg.
To get two capsules, you divided 100 by 50.
Dose = what you want / what you’ve got = 100/50 = 2 capsules

31. Cont…
Example 2
A toddler is prescribed flucloxacillin 250mg. This drug is available
in syrup form, 125mg in 5ml. How much should you give?
First estimate a sensible dose. If 5ml contains 125mg, then you’ll
need more than 5ml for a dose of 250mg. In fact you can
probably see that 125 is half of 250 and so a dose of 10ml is
required. Would using the formula give this answer?
what you want / what you’ve got = 250 / 125 = 2
The answer is 2. Is this right? Two ‘what's’?

32. Cont…
It can’t be 2mls because we have estimated that it should be
more than 5mls.
Remember that each 125mg dose of what we have, is contained
in 5ml and so the answer is two lots of 5ml, in other words,
10ml. So, to get the correct answer, we also need to multiply
by the measure that the available drug is in. Let’s add this to
the formula to make it work for this type of prescription.
Dose = what you want / what you’ve got x what’s it’s in
Check by substituting the values we have above.
The answer is 10ml, which is what we had already decided.

33. Practice exercises
Use the formula to work out the volume you would give
for the following:
1. A child is prescribed oral chloral hydrate 250mg. The drug
is available as an elixir containing 200mg in 5ml.
2. Prescription is oral phenobarbital (phenobarbitone) 45mg.
It is available as 15mg in 5ml.
3. Metronidazole comes as 100mg in 20ml. The child is
prescribed 75mg IV.
4. Oral paracetamol 80mg is prescribed. It is available as a
syrup with 120mg in 5ml.
5. Baby is to have 25 microgram digoxin IV. It is available as
500 microgram in 2ml.

34. Dosage By Weight Questions
Given the weight of a patient and a dosage specified in
terms of weight, calculate the necessary dosage.
These problems are a type of pediatric dosage
calculations.
Formula:
Weight in Kg * Dosage Per Kg = Y (Required Dosage)
Example: A doctor orders 200 mg of Rocephin to be taken
by a 15.4 lb infant every 8 hours. The medication label
shows that 75-150 mg/kg per day is the appropriate
dosage range. Is this doctor's order within the desired
range?

35. Cont…
Weight in Kg * Dosage Per Kg = Y (Required Dosage)
Convert 15.4 lb to kg. lb → kg ( ÷ by 2.2 )
15.4 lb ÷ 2.2 = 7 kg
7 kg * 75 mg/kg = 525 mg (Minimum Desired Dosage)
7 kg * 150 mg/kg = 1,050 mg (Maximum Desired Dosage)
24 hours in one day and the medication is ordered every
8 hours.
24 hrs / 8 hrs = 3 times per day doctor ordered medication
200 * 3 = 600 mg ordered per day
600 mg is within the desired range of 525-1,050 mg
Yes doctor has ordered a dosage within the desired range.

36. Cont…
Example: Solumedrol 1.5 mg/kg is ordered for a child
weighing 74.8 lb. Solumedrol is available as 125 mg / 2mL.
How many mL must the nurse administer?
Weight in Kg * Dosage Per Kg = Y (Required Dosage)
Convert 74.8 lb to kg. lb → kg ( ÷ by 2.2 )
74.8 lb ÷ 2.2 = 34 kg
34 kg * 1.5 mg/kg = 51 mg
This is now an ordinary Mass/Liquid For Liquid Question. 51
mg is ordered and the medication is available as 125 mg / 2 mL.
Ordered Have x Volume Per Have = Y (Liquid Required)
51mg/125mg x 2 mL = 0.82mL

37. Summary
Developmental changes in body composition, body
proportions and relative mass of the liver and
kidneys affect pharmacokinetics of a drug among
different ages (e.g. neonates, infants, children
and adolescents).
The capacity for drug metabolism and elimination
is the greatest between the first and second years
of life when the size of the kidney and liver
(relative to body weight) are at their maximum.

38. Cont…
Remember that body surface area (relative to body
mass) is greatest in the infant and young child
(as compared to the older child and adult) and
thus, consideration must be given to potential
systemic absorption of topically applied drugs.
The loading dose of a drug is primarily related to
its volume of distribution, whereas the
maintenance dose is a function of drug
clearance.

39. Cont…
Clearance of most drugs is primarily dependent on
hepatic metabolism, with the excretion of drug and
metabolites completed by the kidneys (and to a lesser
extent, the liver).
In general, between 1 year of age and puberty, hepatic
and renal function is not only equal to, but may
exceed, normal adult levels of functioning.
Children of the same age come in many different sizes.
Always calculate drug dosages in mg/kg (especially
among children less than 20 kg) and adjust the dose
to the available preparations.

40. Cont…
In asthma management it is imperative to match the
correct medication with the appropriate drug
delivery device and the child's development.
The ideal medication is one that tastes good, is only
given once a day, does not require refrigeration,
comes in the right strength and is cheap, safe in
kids and highly effective. Unfortunately, this
combination does not exist; choose the closest
option.