Pediatric Medication Administration

Comprehensive Nursing Guide

Oral Administration Intramuscular (IM) Intravenous (IV)

Introduction to Pediatric Medication Administration

Administering medications to children requires special considerations due to their developing bodies, varied sizes, and unique physiological processes. This guide provides comprehensive information on safely administering medications via oral, intramuscular (IM), and intravenous (IV) routes to pediatric patients.

Key Principles

Always verify the medication with patient identification
Calculate doses carefully based on weight
Consider developmental factors affecting administration
Document administration accurately
Monitor for adverse effects vigilantly

The Eight Rights of Pediatric Medication Administration

Right Patient

Verify patient identity using two identifiers (name, DOB, ID number)

Right Medication

Check medication three times: when taking it from storage, before preparation, and before administration

Right Dose

Double-check weight-based calculations and dose appropriateness

Right Time

Administer at prescribed time to maintain therapeutic levels

Right Route

Verify the prescribed route is appropriate and safe

Right Documentation

Record administration promptly and accurately

Right Reason

Understand why the medication is being given

Right Response

Monitor for desired therapeutic effects and adverse reactions

Mnemonic: “ABCDE TIPS” for Medication Safety

Assess the child thoroughly
Be vigilant with calculations
Check medication three times
Document administration properly
Evaluate response to medication
Think critically about each medication
Identify patient using two identifiers
Prepare medication correctly
Stay current with medication knowledge

Pediatric Medication Calculations

Accurate medication calculations are crucial in pediatric nursing. Most pediatric medications are dosed according to the child’s weight or body surface area (BSA).

Weight-Based Dosing Formula

Dose (mg) = Weight (kg) × Dose (mg/kg)

Example: A 20 kg child requires acetaminophen 15 mg/kg.

Dose = 20 kg × 15 mg/kg = 300 mg

Body Surface Area (BSA) Formula

BSA (m²) = √[(Height (cm) × Weight (kg))/3600]

Child’s Dose = (Child’s BSA ÷ Adult BSA) × Adult Dose

Often used for chemotherapeutic agents and other medications with narrow therapeutic windows

Commonly Used Conversion Factors

Conversion	Factor
Pounds (lb) to Kilograms (kg)	1 lb = 0.45 kg
Kilograms (kg) to Pounds (lb)	1 kg = 2.2 lb
Grams (g) to Milligrams (mg)	1 g = 1000 mg
Milligrams (mg) to Micrograms (mcg)	1 mg = 1000 mcg
Milliliters (mL) to Cubic Centimeters (cc)	1 mL = 1 cc

Safety Tip

Always double-check medication calculations with another nurse, especially for high-alert medications such as anticoagulants, insulin, opioids, and chemotherapy agents.

Oral Administration

IM Administration

IV Administration

Oral Medication Administration

Overview

Oral administration is the most common, convenient, and cost-effective route for pediatric medication delivery. It requires consideration of the child’s age, developmental level, and ability to swallow.

Common Forms

Tablets: Whole, scored, chewable, or crushable
Capsules: Some can be opened and mixed with food
Liquids: Solutions, suspensions, syrups, elixirs
Orally disintegrating tablets: Dissolve in the mouth
Powders: Reconstituted before administration

Age-Specific Considerations

Infants: Oral syringes, droppers, or nipple medication pacifiers
Toddlers: Medication cups, oral syringes, or mixed with small amounts of food
Preschoolers: Chewable tablets, oral syringes, or cups with clear instructions
School-age: Tablets, capsules with teaching about swallowing techniques
Adolescents: Standard tablet or capsule forms

Important Considerations

Never force oral medications to avoid aspiration
Use appropriate measuring devices (never household spoons)
Some medications should not be crushed or opened (extended-release, enteric-coated)
Mix medications with minimal amount of food (1-2 teaspoons)
Check for drug-food interactions before mixing with food

Procedure: Oral Medication Administration

Preparation

Perform hand hygiene
Gather necessary equipment:
- Medication order and chart
- Appropriate measuring device (oral syringe, medicine cup, dropper)
- Clean cup of water
- Optional: small amount of non-essential food (applesauce, pudding)
Calculate dose accurately and verify with another nurse if needed

Patient Identification

Identify patient using two identifiers (name, DOB, ID number)
Check for medication allergies
Explain procedure to child and caregiver using age-appropriate language

Medication Verification

Check medication label against order three times
Verify the “Eight Rights” of medication administration
Ensure medication has not expired

Administration Technique by Age

For Infants (0-12 months)

Position infant in semi-upright position in caregiver’s arms
Use calibrated dropper or oral syringe without needle
Administer small amounts (0.5-1 mL) at a time
Place medication along the side of the tongue or inside cheek (buccal cavity)
Allow infant to swallow between administrations

For Toddlers (1-3 years)

Position child sitting upright in caregiver’s lap
Use oral syringe, medication cup, or mix with small amount of food (if appropriate)
Approach calmly and positively
Consider using simple concepts like “taking medicine will help you feel better”
Offer praise after successful administration

For Preschoolers (3-5 years)

Position child sitting upright
Provide simple explanations and involve child in process
Use oral syringe, medication cup, or chewable tablets
Consider offering limited choices (e.g., “Do you want water or juice with your medicine?”)
Avoid calling medication “candy” or “treat”

For School-Age Children (6-12 years)

Position child sitting upright
Explain purpose of medication and steps involved
Teach swallowing techniques for tablets/capsules if appropriate
Provide positive reinforcement

For Adolescents (13-18 years)

Respect privacy and autonomy
Provide education about medication purpose and importance
Consider teaching self-administration for chronic medications

Follow-Up

Document administration immediately
Monitor for response to medication and any adverse effects
Provide positive reinforcement to child

Tips for Success

Use flavoring agents when approved and available
Chill liquid medications (if not contraindicated) to mask taste
Have child suck on ice pop before bitter medication to numb taste buds
For children learning to swallow pills, try progressive practice with candy sprinkles, then small candies before actual medication
Use positive reinforcement techniques like sticker charts for children on regular medications

Mnemonic: “NEON” for Successful Oral Medication Administration

Nurture a positive environment
Explain using age-appropriate language
Offer appropriate administration tools
Note response and provide positive reinforcement

Intramuscular (IM) Medication Administration

Overview

Intramuscular (IM) injections deliver medication directly into the muscle tissue, allowing for faster absorption than subcutaneous routes. In pediatrics, IM injections require special consideration for site selection, needle size, and injection techniques based on the child’s age and size.

Important Considerations

Minimize trauma and pain during administration
Select appropriate site based on child’s age and development
Use the smallest gauge and shortest needle appropriate for the medication
Limit volume per injection site based on age
Consider dividing doses if volume exceeds recommended amount

Maximum Recommended Volumes

Preterm infants: 0.1-0.2 mL
Term newborns: 0.2-0.5 mL
Infants (≤12 months): 0.5-1 mL
Toddlers (1-2 years): 1-1.5 mL
Preschoolers (3-5 years): 1.5-2 mL
School-age (6-12 years): 2 mL
Adolescents (≥13 years): 2-3 mL

IM Injection Sites in Pediatrics

Injection Site	Age Appropriateness	Landmarks	Advantages/Disadvantages
Vastus Lateralis (Anterolateral thigh)	All ages; preferred site for infants and toddlers	Middle third of the muscle, on the anterolateral aspect of the thigh	Advantages: Large muscle, few major blood vessels/nerves, best absorption Disadvantages: May cause anxiety in older children
Ventrogluteal (Hip)	All ages; especially good for children >7 months	Place palm on greater trochanter, index finger on ASIS, middle finger spread posteriorly, inject in center of triangle	Advantages: Free of major nerves/vessels, well-defined landmarks, thick muscle Disadvantages: Less familiar to some practitioners
Deltoid (Upper arm)	Children >3 years with adequate muscle mass; small volumes only (≤1 mL)	2-3 fingerbreadths below acromion process, in middle of lateral aspect of upper arm	Advantages: Easy access, good for small volumes Disadvantages: Small muscle, risk of injury to radial nerve/axillary nerve
Dorsogluteal (Buttock)	Not recommended for children <3 years; even in older children, considered least desirable	Upper outer quadrant of buttock, lateral and superior to a line from posterior superior iliac spine to greater trochanter	Advantages: Large muscle in older children Disadvantages: Risk of sciatic nerve injury, poor absorption, proximity to major blood vessels
Rectus Femoris (Anterior thigh)	All ages when vastus lateralis cannot be used	Middle third of the anterior thigh	Advantages: Easily accessible Disadvantages: Near femoral artery and nerve, may cause more discomfort

Needle Selection Guidelines

Age/Weight	Needle Length	Needle Gauge
Preterm/Newborns	⅝ inch (16 mm)	25-27G
Infants (1-12 months)	⅝-1 inch (16-25 mm)	23-25G
Toddlers (1-2 years)	1 inch (25 mm)	22-25G
Preschoolers (3-5 years)	1-1¼ inch (25-32 mm)	22-25G
School-age (6-12 years)	1-1¼ inch (25-32 mm)	20-22G
Adolescents (≥13 years)	1-1½ inch (25-38 mm)	18-22G

Note: Needle length should be adjusted based on patient’s BMI and injection site.

Important Considerations

IM injections are contraindicated in children with bleeding disorders unless the benefit outweighs the risk
Avoid injecting into areas with infection, inflammation, or poor circulation
Multiple immunizations should be separated by at least 1 inch (2.5 cm)
Aspiration (pulling back on plunger) is no longer routinely recommended for vaccines but may be required for other medications

Procedure: Intramuscular (IM) Medication Administration

Preparation

Perform hand hygiene
Gather necessary equipment:
- Medication order and chart
- Appropriate needle and syringe
- Alcohol swabs
- Clean gloves
- Bandage or gauze
- Age-appropriate distraction items
- Topical anesthetic (if ordered and time permits)
Calculate dose accurately and verify with another nurse if needed
Prepare medication using aseptic technique

Patient Identification and Preparation

Identify patient using two identifiers
Check for medication allergies
Explain procedure using age-appropriate language
Provide preparation time when possible
Position child appropriately with assistance:
- Infants: Have parent/caregiver hold in secure position
- Toddlers/Preschoolers: Sitting in parent’s lap or lying down with secure holding
- School-age/Adolescents: Sitting or lying position depending on site

Site Selection and Preparation

Select appropriate site based on child’s age and size
Locate anatomical landmarks carefully
Cleanse site with alcohol swab in circular motion from center outward
Allow alcohol to dry completely

Administration Technique

Don clean gloves
Use distraction techniques appropriate for child’s age
Hold syringe like a dart
With non-dominant hand, gently stretch or compress tissue to create firm injection site
Insert needle quickly at 90-degree angle
Stabilize syringe and slowly inject medication
Wait 10 seconds before withdrawing needle to prevent medication tracking
Apply gentle pressure with gauze (don’t rub)
Apply bandage if needed

Post-Injection Care

Dispose of sharps in appropriate container
Provide comfort measures and positive reinforcement
Document administration immediately
Monitor for adverse reactions and injection site complications

Pain Reduction Strategies

Apply topical anesthetic 30-60 minutes before injection when possible
Use vapocoolant spray immediately before injection (follow facility policy)
Consider buzzy device (vibration) to reduce pain sensation
Use age-appropriate distraction techniques:
- Infants: Pacifier, sucrose solution
- Toddlers/Preschoolers: Bubbles, toys, singing
- School-age: Counting, deep breathing, storytelling
- Adolescents: Music, conversation, guided imagery
Position parent/caregiver to provide comfort but not restraint

Mnemonic: “PINCH” for Safe IM Injections

Prepare medication and equipment correctly
Identify correct site using anatomical landmarks
Needle selection based on child’s size and site
Comfort measures to reduce distress
Hold securely but gently during administration

Intravenous (IV) Medication Administration

Overview

Intravenous (IV) medication administration delivers medications directly into the circulatory system, providing immediate onset of action. In pediatrics, IV administration requires meticulous attention to detail, precise calculations, and close monitoring due to children’s smaller fluid volumes and developing organ systems.

IV Administration Methods

IV Push (IVP/Bolus): Direct administration of medication into IV line
IV Piggyback (IVPB): Secondary infusion over a specified time
Continuous Infusion: Medication delivered at constant rate
Volume Control Sets: Small-volume chambers that limit infusion volume

Critical Safety Considerations

Double-check all calculations and have second nurse verify
Use infusion pumps with pediatric settings
Consider fluid volume restrictions
Be vigilant for infiltration and extravasation
Monitor for adverse reactions closely

Age-Specific Considerations for IV Therapy

Age Group	Common IV Sites	Catheter Size	Special Considerations
Neonates/Infants	Scalp veins, hands, feet, antecubital	24-26G	Extremely small fluid volumes; use volumetric pumps; high risk for fluid overload; umbilical vein option for neonates
Toddlers/Preschoolers	Hands, feet, forearm, antecubital	22-24G	May require sedation for IV placement; difficult to maintain IV site integrity with active children
School-Age	Hands, forearm, antecubital	20-22G	Fear of needles common; benefit from preparation and distraction; capable of understanding purpose
Adolescents	Hands, forearm, antecubital	18-22G	Prefer involvement in care decisions; privacy important; may have adult-sized vasculature but still require pediatric dosing

High-Alert Medications in Pediatrics

The following medications require special safeguards due to their high risk of causing harm:

Anticoagulants (heparin)
Insulin
Opioids
Neuromuscular blocking agents
Chemotherapeutic agents
Electrolytes (potassium, magnesium, sodium)
Vasoactive medications (dopamine, epinephrine)

Implementation strategies: Independent double-checks, smart pumps with guardrails, standardized concentrations, restricted access

Procedure: Intravenous (IV) Medication Administration

Preparation

Perform hand hygiene
Gather necessary equipment:
- Medication order and chart
- Appropriate medication in labeled syringe or container
- Compatible IV flush solution (0.9% sodium chloride)
- Alcohol swabs
- Clean gloves
- Infusion pump (as needed)
- IV tubing (as needed)
Calculate dose and infusion rate accurately
Have calculations independently verified by second nurse (especially for high-alert medications)
Prepare medication using aseptic technique

Patient Identification and Assessment

Identify patient using two identifiers
Check for medication allergies
Explain procedure using age-appropriate language
Assess IV site for patency, signs of infiltration, or phlebitis
Verify IV catheter size is appropriate for medication administration
Check compatibility of medication with current IV fluids

Medication Administration by Method

IV Push (Direct IV)

Don clean gloves
Clean injection port with alcohol swab for 15 seconds and allow to dry
Flush IV line with appropriate amount of 0.9% sodium chloride:
- Neonates/small infants: 1-2 mL
- Infants/toddlers: 2-3 mL
- Children/adolescents: 3-5 mL
Administer medication slowly at prescribed rate (usually slower than adult rates)
Follow facility policy for specific medication administration rates
Flush IV line again after medication administration
For central lines, use positive pressure technique when disconnecting

IV Piggyback (IVPB)

Verify medication compatibility with primary infusion
Prime secondary tubing with medication solution
Connect to primary line at injection port closest to patient
Set secondary container higher than primary container
Program infusion pump for appropriate rate and volume
For children with fluid restrictions, use mini-bags or volume control sets
Label tubing with date, time, and initials

Continuous Infusion

Prepare solution according to facility protocol
Label infusion with medication name, dose, concentration, date, time, and initials
Use appropriate tubing (non-DEHP for certain medications)
Prime tubing and remove air bubbles
Program smart pump with appropriate drug library and safety limits
Set rate according to prescribed dosage
Use in-line filter if required for specific medication
Secure all connections with Luer-Lock devices when possible

Monitoring and Documentation

Monitor vital signs before, during, and after administration per protocol
Assess IV site frequently for signs of complications
Document immediately:
- Medication name, dose, route, time
- IV site assessment
- Patient response
- Any adverse reactions
- Pump settings and rate changes
For continuous infusions, document regular checks per facility policy

Complication Management

Infiltration/Extravasation: Stop infusion immediately, elevate extremity, apply cold or warm compress per protocol, notify provider, document extent of injury
Phlebitis: Discontinue IV, apply warm compress, notify provider, document
Adverse Reactions: Stop infusion, maintain IV access, assess vitals, notify provider, prepare for emergency interventions
Occlusion: Do not force flush, attempt gentle aspiration, follow facility protocol for declotting or replace IV

IV Flow Rate Calculations

Flow Rate (mL/hr) = (Ordered Dose × Patient Weight × 60 min) ÷ (Concentration × Time in minutes)

For weight-based medication: Flow Rate (mL/hr) = (Dose in mcg/kg/min × Weight in kg × 60 min) ÷ Concentration in mcg/mL

Example: A 10 kg child is ordered dopamine 5 mcg/kg/min. The concentration is 400 mg in 250 mL (1600 mcg/mL).

Flow Rate = (5 mcg/kg/min × 10 kg × 60 min) ÷ 1600 mcg/mL = 3000 ÷ 1600 = 1.875 mL/hr

IV Administration Safety Tips

Use only infusion pumps with pediatric modes and dose error reduction systems
Standardize concentrations of high-risk medications across all pediatric units
Implement independent double-checks for high-alert medications
Use prefilled syringes when available to reduce preparation errors
Limit IV line entry points to reduce infection risk
Set lower pressure alarm limits for neonates and small infants
Consider dedicated lines for incompatible medications

Mnemonic: “CHILD-IV” for Safe Pediatric IV Administration

Calculate dose precisely and verify
Hands (wash thoroughly before preparation)
Identify patient using two identifiers
Line patency and compatibility check
Dilution appropriate for age/size
Infusion pump with pediatric settings
Vigilant monitoring for complications

Medication Route Selection in Pediatrics

Decision-Making Guide for Pediatric Medication Routes

Oral Administration

When to Choose:

Non-urgent medication needs
Patient can swallow safely
Medication available in oral form
GI tract functional
Predictable absorption acceptable

Advantages:

Non-invasive, less traumatic
No risk of injection complications
Often more cost-effective
Easier administration training for families

Limitations:

Slower onset of action
Variable absorption
Child may refuse
NPO status for procedures
First-pass metabolism

IM Administration

When to Choose:

Need for intermediate onset of action
IV access unavailable but oral not appropriate
Depot/sustained release needed
Vaccines requiring IM administration
Emergency situations without IV access

Advantages:

Faster onset than oral
Doesn’t require IV access
Useful for uncooperative patients
Appropriate for certain medications

Limitations:

Painful administration
Risk of tissue damage
Contraindicated in bleeding disorders
Volume limitations
Cannot be easily reversed

IV Administration

When to Choose:

Emergency/critical situations
Need for immediate drug effect
Precise titration required
NPO status or compromised GI function
Medications that require direct bloodstream delivery

Advantages:

Immediate onset of action
Precise control of blood levels
Bypasses absorption barriers
Can adjust or stop quickly if needed

Limitations:

Requires specialized skills
Risk of infection, phlebitis
Infiltration/extravasation risks
Rapid adverse reactions possible
Requires continuous monitoring

Route Selection Decision Flow

Is it an emergency?

Yes → IV

No ↓

Is patient NPO or unable to take PO?

Yes → IV or IM

No ↓

How quickly is medication needed?

Immediate → IV

Intermediate → IM

Can wait → PO

Summary: Pediatric Medication Administration

Key Points to Remember

Oral Administration

Age-appropriate devices are essential
Never force medications
Verify which medications can be crushed
Use minimal food when mixing
Position child appropriately to prevent aspiration

IM Administration

Select appropriate site for child’s age
Use correct needle length and gauge
Administer within volume limitations
Implement pain reduction strategies
Secure positioning is essential for safety

IV Administration

Double-check all calculations
Use appropriate infusion pumps
Monitor for complications vigilantly
Flush lines carefully before and after
Administer at appropriate rate for age

Universal Safety Principles

Always verify the Eight Rights of medication administration
Calculate doses based on weight or BSA and verify
Document administration promptly and thoroughly
Monitor for therapeutic and adverse effects

Use age-appropriate techniques and explanations
Involve parents/caregivers appropriately
Be aware of developmental considerations
Maintain compassionate, trauma-informed approach

Final Thoughts

Safe medication administration to pediatric patients requires specialized knowledge, meticulous attention to detail, and a developmentally appropriate approach. Remember that children are not simply “small adults” – their physiology, psychology, and medication responses differ significantly. By following the principles and procedures outlined in this guide, nurses can enhance medication safety and promote positive experiences for pediatric patients and their families.

Pediatric Fluid Requirement Calculations – Nursing Notes

Introduction to Pediatric Fluid Management

Fluid therapy is a critical component of pediatric care. Children differ from adults in their fluid needs due to their:

Higher percentage of total body water (TBW)
Higher metabolic rate and fluid turnover
Limited ability to concentrate urine
Greater body surface area-to-weight ratio
Reduced glycogen stores

Clinical Pearl

Accurate fluid management is essential in pediatric care as children can rapidly develop dehydration and electrolyte imbalances due to their physiological differences from adults.

Total Body Water (TBW) by Age

Basic Principles of Pediatric Fluid Balance

Pediatric fluid management requires understanding of three key components:

Maintenance Fluids

Fluids required to replace normal daily losses when the child is NPO (nothing by mouth)

Deficit Replacement

Fluids required to correct existing dehydration or fluid deficits

Ongoing Losses

Additional fluid requirements to replace continuing abnormal losses (vomiting, diarrhea, etc.)

Important Consideration

Total fluid requirement = Maintenance + Deficit + Ongoing losses

Maintenance Fluid Calculation Methods

1. Holliday-Segar Method (4-2-1 Rule)

The most commonly used method for calculating maintenance fluid requirements in children.

For the first 10 kg: 100 mL/kg/day (or 4 mL/kg/hour)

For the next 10 kg: 50 mL/kg/day (or 2 mL/kg/hour)

For each kg above 20 kg: 20 mL/kg/day (or 1 mL/kg/hour)

Mnemonic: “4-2-1”

4 mL/kg/hour for first 10 kg
2 mL/kg/hour for next 10 kg
1 mL/kg/hour for each kg above 20 kg

Example Calculation

For a 27 kg child:

First 10 kg: 10 kg × 100 mL/kg/day = 1000 mL/day
Next 10 kg: 10 kg × 50 mL/kg/day = 500 mL/day
Remaining 7 kg: 7 kg × 20 mL/kg/day = 140 mL/day
Total maintenance fluid requirement: 1000 + 500 + 140 = 1640 mL/day
Hourly rate: 1640 ÷ 24 = 68.3 mL/hour

2. Body Surface Area (BSA) Method

Used primarily for children with altered fluid and electrolyte requirements, obesity, or critical illness.

Maintenance fluid (mL/day) = 1500 mL × BSA (m²)

BSA Calculation (Mosteller formula):

BSA (m²) = √[(Height (cm) × Weight (kg)) ÷ 3600]

3. Caloric Expenditure Method

Based on the relationship between metabolic rate and fluid requirements.

100 mL of water required for every 100 kcal metabolized

Method	Advantages	Disadvantages	Best Used For
Holliday-Segar (4-2-1)	Simple to calculate, widely used	May overestimate needs in some conditions	Most pediatric patients
BSA Method	More accurate for certain populations	More complex calculation	Critically ill, obese patients
Caloric Expenditure	Physiologically based	Requires knowledge of metabolic rate	Patients with abnormal metabolic states

Deficit Calculation & Dehydration Assessment

Fluid deficit is calculated based on the degree of dehydration and the child’s weight.

Fluid Deficit (mL) = % Dehydration × Weight (kg) × 10

Clinical Pearl

A 10% dehydration means the child has lost fluid equivalent to 10% of their body weight. For a 10 kg child, this represents a 1 kg weight loss.

Clinical Assessment of Dehydration

Clinical Parameter	Mild Dehydration (3-5%)	Moderate Dehydration (6-9%)	Severe Dehydration (≥10%)
Mental Status	Normal, alert	Irritable, lethargic	Lethargic to comatose
Thirst	Slightly increased	Moderately increased	Very thirsty or too lethargic to indicate
Heart Rate	Normal	Increased	Significantly increased or bradycardia in severe cases
Pulse Quality	Normal	Decreased	Weak, thready
Breathing	Normal	Fast	Deep, rapid or shallow
Skin Turgor	Normal	Decreased	Significantly decreased, “tenting”
Mucous Membranes	Slightly dry	Dry	Very dry, parched
Tears	Present	Decreased	Absent
Fontanelle (infants)	Normal	Sunken	Markedly sunken
Urine Output	Slightly decreased	Decreased (<1 mL/kg/hr)	Minimal or absent

Example Deficit Calculation

For a 15 kg child with 7% dehydration:

Fluid Deficit = 7% × 15 kg × 10 = 1050 mL

Deficit Replacement Schedule:

Initial bolus (if needed for shock): 20 mL/kg = 300 mL
Remaining deficit: 1050 – 300 = 750 mL
Typically replaced over 24 hours along with maintenance fluids

Age-Specific Considerations

Neonates (0-28 days)

Higher percentage of TBW (75-80%)
Limited ability to concentrate urine
Immature kidneys with limited ability to excrete fluid loads
Careful monitoring of glucose (risk of hypoglycemia)
Typical maintenance fluid: D10W 0.225% NaCl at 60-100 mL/kg/day (increases over first week)

Infants (1-12 months)

High metabolic rate
Higher insensible water loss
Greater surface area to body weight ratio
Rapid development of dehydration
Typical maintenance fluid: D5W 0.2% NaCl at calculated rate

Children (>1 year)

Decreased TBW percentage with age
Better ability to concentrate urine
More stable fluid status than infants
Standard 4-2-1 rule applies well
Typical maintenance fluid: D5W 0.2% NaCl or D5W 0.45% NaCl

Critical Consideration

Always adjust fluid therapy based on the child’s clinical condition, electrolyte status, and ongoing assessment. The calculated values are guidelines, not absolute rules.

Practical Nursing Approach to Fluid Administration

Step-by-Step Process

Assessment

Evaluate the child’s hydration status, weight, vital signs, and clinical condition. Identify risk factors for fluid imbalances.

Calculate Requirements

Determine maintenance, deficit, and ongoing losses. Calculate total fluid requirements.

Plan Fluid Therapy

Select appropriate fluid type, rate, and schedule. Consider electrolyte needs and glucose requirements.

Administer Fluids

Ensure proper IV access, use infusion pumps, and set accurate rates. Double-check calculations with another nurse.

Monitor Response

Regularly assess vital signs, urine output, electrolytes, weight changes, and clinical status.

Adjust as Needed

Modify fluid therapy based on the child’s response, lab results, and changing clinical conditions.

Document

Record all assessments, calculations, interventions, and the child’s response to fluid therapy.

Special Clinical Scenarios

Diabetic Ketoacidosis (DKA)

Modified approach to prevent cerebral edema:

Calculate deficit based on 5-10% dehydration
Replace over 48 hours rather than 24 hours
Avoid rapid changes in serum osmolality
Monitor neurological status closely

Total fluids = Maintenance + Deficit (replaced over 48h) + Ongoing losses

Burns

Increased fluid requirements due to capillary leak and evaporative losses:

Parkland Formula: 4 mL × % BSA burned × Weight (kg)

Given over first 24 hours post-burn:

First half in initial 8 hours (from time of burn)
Second half over next 16 hours

Surgical Patients

Considerations for perioperative fluid management:

Account for NPO time (maintenance fluids)
Replace intraoperative losses
Consider third-space losses based on surgery type
Monitor for postoperative fluid shifts

Maintenance + Preoperative deficit + Intraoperative losses + Third-space losses

Mindmap of Pediatric Fluid Calculation

Clinical Decision Making in Fluid Therapy

FLUID Mnemonic for Safe Pediatric Fluid Administration

F – Formula calculations must be double-checked
L – Look at the whole patient, not just numbers
U – Understand age-specific requirements
I – Intake and output must be closely monitored
D – Document all assessments and interventions

Common Fluid Types and Their Indications

Fluid Type	Composition	Common Indications	Considerations
Normal Saline (0.9% NaCl)	154 mEq/L Na+, 154 mEq/L Cl-	Initial volume expansion, hyponatremia	Can cause hyperchloremic metabolic acidosis with large volumes
D5W (5% Dextrose in Water)	50 g/L glucose, no electrolytes	Provides free water, prevents hypoglycemia	Can cause hyponatremia if used alone; each liter provides 170 calories
D5 0.45% NaCl	50 g/L glucose, 77 mEq/L Na+, 77 mEq/L Cl-	Maintenance fluids in most children	Balance of both free water and electrolytes
D5 0.2% NaCl	50 g/L glucose, 34 mEq/L Na+, 34 mEq/L Cl-	Maintenance in infants	Lower sodium for infants’ specific needs
Lactated Ringer’s	130 mEq/L Na+, 4 mEq/L K+, 109 mEq/L Cl-, 28 mEq/L lactate	Volume replacement, more physiologic than NS	Contraindicated in liver disease (lactate metabolism)

Clinical Pearl

When administering IV fluids to children, always use infusion pumps with anti-free flow protection. Manually calculate and verify drip rates, and set appropriate alarm limits to prevent fluid overload.

Safety Alert

Signs of fluid overload include: increased respiratory rate, crackles on auscultation, periorbital edema, and increasing blood pressure. If these occur, slow or stop fluid administration and reassess.

Common Calculation Errors and How to Avoid Them

Error: Incorrect Weight

Problem: Using estimated rather than actual weight, or using pounds instead of kilograms.

Prevention: Always weigh the child when possible. Convert pounds to kilograms (1 kg = 2.2 lbs) when needed. Document weight in kg only.

Error: Calculation Mistakes

Problem: Arithmetic errors in applying formulas, especially with the 4-2-1 rule.

Prevention: Use a calculator, double-check all math, and have another nurse verify calculations.

Error: Decimal Point Errors

Problem: Moving decimal places incorrectly when converting between units.

Prevention: Write out all steps clearly, use leading zeros (0.1 not .1), and avoid trailing zeros (1 not 1.0).

Error: Not Adjusting for Clinical Status

Problem: Strictly following calculated values without considering the patient’s clinical condition.

Prevention: Regularly reassess the patient and adjust fluid therapy based on clinical response and lab values.

Practice Problems

Problem 1: Basic Maintenance Calculation

Question: Calculate the maintenance fluid requirements for a 6-year-old child weighing 18 kg.

Solution:

First 10 kg: 10 kg × 100 mL/kg/day = 1000 mL/day
Next 8 kg: 8 kg × 50 mL/kg/day = 400 mL/day
Total maintenance fluid requirement: 1000 + 400 = 1400 mL/day
Hourly rate: 1400 ÷ 24 = 58.3 mL/hour or approximately 58 mL/hour

Problem 2: Combined Maintenance and Deficit

Question: A 4-year-old child weighing 16 kg is admitted with moderate dehydration (7%). Calculate the total fluid requirement for the first 24 hours.

Solution:

Maintenance Calculation:

First 10 kg: 10 kg × 100 mL/kg/day = 1000 mL/day
Next 6 kg: 6 kg × 50 mL/kg/day = 300 mL/day
Total maintenance: 1000 + 300 = 1300 mL/day

Deficit Calculation:

Deficit = 7% × 16 kg × 10 = 1120 mL

Total Fluid Requirement:

Total = Maintenance + Deficit = 1300 + 1120 = 2420 mL/24 hours
Hourly rate = 2420 ÷ 24 = 100.8 mL/hour or approximately 101 mL/hour

Problem 3: Complex Scenario

Question: A 9-year-old child weighing 30 kg has 5% dehydration and ongoing losses of approximately 20 mL/kg/day due to diarrhea. Calculate the total fluid requirement for 24 hours.

Solution:

Maintenance Calculation:

First 10 kg: 10 kg × 100 mL/kg/day = 1000 mL/day
Next 10 kg: 10 kg × 50 mL/kg/day = 500 mL/day
Remaining 10 kg: 10 kg × 20 mL/kg/day = 200 mL/day
Total maintenance: 1000 + 500 + 200 = 1700 mL/day

Deficit Calculation:

Deficit = 5% × 30 kg × 10 = 1500 mL

Ongoing Losses:

Ongoing losses = 20 mL/kg/day × 30 kg = 600 mL/day

Total Fluid Requirement:

Total = Maintenance + Deficit + Ongoing losses = 1700 + 1500 + 600 = 3800 mL/24 hours
Hourly rate = 3800 ÷ 24 = 158.3 mL/hour or approximately 158 mL/hour

References

Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823-832.
World Health Organization. The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th ed. Geneva: WHO; 2005.
Friedman JN, Beck CE, DeGroot J, et al. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015;169(5):445-451.
Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009;14(4):204-211.
National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in children and young people in hospital. NICE guideline [NG29]. London: NICE; 2015.

Pediatric Restraint Application: Nursing Notes

Child Health Nursing: Application of Restraints

Comprehensive guide for nursing students on pediatric restraint procedures

Introduction

Restraints are physical, chemical, or environmental measures used to limit a patient’s mobility. In pediatric nursing, their application requires special considerations due to children’s developmental needs, safety concerns, and ethical implications. This guide provides comprehensive information on the appropriate use of restraints in pediatric settings.

Clinical Pearl

Restraints should always be the last resort after all other less restrictive alternatives have been attempted and proven ineffective.

Types of Pediatric Restraints

Physical Restraints

Extremity restraints: Limit movement of arms or legs
Vest/jacket restraints: Secure child to bed or chair
Mummy restraints: Wrap infant or toddler in blanket
Elbow restraints: Prevent child from bending elbow
Mittens: Prevent scratching or pulling at tubes

Chemical Restraints

Medications used to control behavior or restrict movement:

Sedatives
Anxiolytics
Antipsychotics

Note: Chemical restraints should be used with extreme caution in children and only under close medical supervision.

Environmental Restraints

Crib tops/nets: Prevent climbing out
Enclosed beds: Provide secured environment
Seclusion rooms: Used in psychiatric settings

Therapeutic Holding

Temporary, direct physical contact to restrict movement during procedures:

During IV insertion
During lumbar puncture
During wound care

Not technically considered restraint when used briefly for procedures.

Mind Map: Pediatric Restraint Decision Framework

Pediatric Restraint Decision

Is it necessary?

• Patient safety risk
• Treatment interference
• Alternatives tried

Is it appropriate?

• Least restrictive
• Age appropriate
• Properly sized

Is it monitored?

• Frequent reassessment
• Time-limited use
• Documentation

Indications for Restraint Use

Restraints should only be used when necessary for:

Safety Purposes

Preventing falls in confused or sedated patients
Preventing self-harm behaviors
Protecting from injury during seizures
Preventing removal of medical devices:

IV lines
Feeding tubes
Endotracheal tubes
Surgical drains
Wound dressings

Medical Procedures

Preventing interference during critical procedures
Immobilizing for certain diagnostic tests (e.g., CT scan)
Ensuring positioning after orthopedic procedures
Supporting treatment adherence when understanding or cooperation is limited

Warning

Restraints should NEVER be used for:

Staff convenience
Punishment or discipline
Substitute for adequate staffing
Alternative to appropriate behavioral management

Contraindications & Risk Factors

Contraindication/Risk Factor	Explanation
Recent traumatic experiences	Restraints may retraumatize children with history of abuse or trauma
Certain medical conditions	Respiratory conditions, certain cardiovascular issues, or compromised skin integrity
Agitation or combative behavior	May worsen behavioral issues; consider alternative management first
Some developmental disabilities	May cause distress without understanding the purpose
Cognitive impairment	May increase confusion, agitation, or delirium
Altered mental status	May worsen disorientation or cause psychological distress

RESTRAINT

A mnemonic for restraint alternatives and considerations:

R Reorient and reassure the child

E Environment modification to reduce risks

S Supervision by staff or family

T Therapeutic communication techniques

R Routine activities and schedules

A Assist with needs promptly

I Involve family in care

N Necessary only as last resort

T Time-limited use and frequent reassessment

Application Procedures

General Principles for All Restraint Types

Assessment and Preparation

Verify order, assess patient condition, gather necessary equipment, and explain procedure to child and family at appropriate developmental level.

Consent and Education

Obtain informed consent from parents/guardians when possible. Explain purpose, duration, and monitoring plan. Use developmentally appropriate language for the child.

Proper Sizing and Fit

Select appropriate size restraint based on child’s age and size. Ensure proper fit – should restrict movement while maintaining comfort (can fit 1-2 fingers between restraint and skin).

Safe Application

Apply restraint according to manufacturer instructions. Secure to bed frame (never side rails). Ensure all ties are properly secured with quick-release knots.

Documentation

Document type of restraint, reason for use, time of application, patient assessment, and education provided to family.

Mummy Restraint Procedure (Infants)

Place blanket flat in diamond position
Fold top corner down slightly
Place infant centered with shoulders at fold
Place infant’s right arm alongside body
Pull right corner of blanket firmly over body and tuck under left side
Place left arm alongside body
Pull left corner over body and tuck under right side
Fold bottom corner up and secure

For infants under 3 months, ensure nose and mouth are unobstructed to prevent risk of suffocation.

Extremity Restraint Procedure

Assess skin condition before application
Apply padding to vulnerable areas (wrists/ankles)
Wrap restraint around extremity, ensuring it’s not too tight
Secure with Velcro or ties
Attach to fixed portion of bed frame (never to side rails)
Position extremity in anatomically neutral position
Ensure circulation checks can be performed easily

Never secure restraints to movable parts of bed as this can cause injury when bed position is changed.

Jacket/Vest Restraint Procedure

Ensure child is wearing appropriate clothing (helps prevent skin irritation)
Select correct size based on child’s weight and chest circumference
Position vest with V-neck in front
Place child’s arms through armholes
Close vest securely at back or side (depending on design)
Check for proper fit (should be snug but not restrictive for breathing)
Secure ties to fixed portion of bed frame
Tie with quick-release knots that will hold securely but can be quickly released in emergency

Critical Safety Checks:

Ensure vest is not too tight – should allow for chest expansion
Position straps away from child’s neck to prevent strangulation
Monitor for signs of respiratory distress
Ensure vest doesn’t ride up toward neck
Keep bed in lowest position

Safety Considerations & Monitoring

Monitoring Requirements

Assessment	Frequency
Vital signs	Every 2 hours or per facility policy
Circulation checks of restrained extremities	Every 1-2 hours
Skin integrity	Every 2 hours
Hydration status	Every 2 hours
Elimination needs	Every 2 hours
Nutrition needs	Every meal time/feeding schedule
Restraint necessity assessment	Every 4 hours or per policy
Psychological assessment	Every shift

Potential Complications

Physical Complications:

Skin breakdown and pressure ulcers
Circulatory impairment
Nerve damage
Respiratory compromise
Altered thermoregulation
Urinary/bowel elimination issues
Reduced mobility leading to muscle weakness
Risk of aspiration

Psychological Complications:

Increased agitation and anxiety
Fear and distress
Post-traumatic stress reactions
Regression in developmental milestones
Decreased trust in healthcare providers
Feelings of punishment or abandonment

Clinical Pearl: CRAFT Approach to Safety Monitoring

C – Circulation

Check pulses, capillary refill, color, temperature of restrained extremities

R – Respiration

Monitor breathing pattern, rate, depth, ensure chest can expand fully

A – Alignment

Ensure body in physiologically correct position, prevent contractures

F – Friction

Check for rubbing of restraint against skin, use padding as needed

T – Tightness

Ensure restraint allows 1-2 finger space, not constricting

Ethical Considerations

Ethical Principles in Restraint Use

Autonomy

Respecting child’s right to independence and self-determination. Consider:

Age-appropriate involvement in decision-making
Explaining reason for restraints in developmentally appropriate way
Obtaining assent when possible (in addition to parental consent)

Beneficence & Non-maleficence

Acting in child’s best interest and avoiding harm:

Using restraints only when benefits outweigh risks
Selecting least restrictive method
Implementing proper monitoring to prevent complications
Removing restraints as soon as safely possible

Justice

Fair and equal treatment of all patients:

Applying restraint policies consistently
Not using restraints based on staff convenience
Ensuring adequate staffing to minimize restraint use

Dignity & Respect

Maintaining child’s dignity throughout process:

Ensuring privacy during application
Using trauma-informed approaches
Considering cultural and religious factors
Providing emotional support

Legal and Regulatory Framework

Restraint use in pediatric settings is governed by multiple regulations:

Joint Commission Standards – Require ongoing assessment, time limitations, physician orders, and detailed documentation
CMS Conditions of Participation – Outline specific requirements for patient rights regarding restraint use
State regulations – May have additional requirements specific to pediatric patients
Hospital policies – Should be followed for specific time frames, renewal of orders, and documentation requirements

Key Regulatory Requirements

Valid medical order required (verbal orders must be signed within timeframe per policy)
Orders must be time-limited (typically 24 hours)
Regular renewal of orders with reassessment
Use of least restrictive methods
Regular monitoring and documentation
Notification of parents/guardians

Nursing Care for Children in Restraints

Physical Care

Perform ROM exercises every 2 hours
Reposition every 2 hours
Provide skin care and assess integrity
Monitor vital signs
Assist with toileting/diaper changes
Ensure adequate nutrition and hydration
Remove restraints briefly (one at a time if necessary) during care

Psychological Care

Provide frequent reassurance
Explain procedures in age-appropriate language
Offer comfort items (blanket, stuffed toy)
Use distraction techniques during procedures
Encourage family presence and participation
Assess for signs of psychological distress
Use therapeutic play to process experience

Family Support

Provide clear explanation about need for restraints
Teach family about monitoring requirements
Involve in care when appropriate
Address concerns and feelings (guilt, anger)
Encourage participation in comfort measures
Update on reassessment of restraint necessity
Educate about alternatives to try at home if applicable

Documentation Requirements

Comprehensive documentation is essential for legal protection and quality care. Document:

Behavior necessitating restraint use
Alternative measures attempted before restraint
Type of restraint applied
Date and time of application
Patient/family education provided
Patient response to restraint

Ongoing assessments (vital signs, skin, circulation)
Care provided while in restraints
Times restraint was removed/reapplied
Reassessment of continued need
Patient behavior after removal
Date and time of discontinuation

RELEASE Mnemonic for Restraint Discontinuation

A systematic approach to assess readiness for restraint removal:

R Reason for initial restraint resolved?

E Environment safe and modified to reduce risks?

L Level of consciousness appropriate?

E Emotional status stable?

A Alternatives in place?

S Support available (staff/family)?

E Evaluate response to brief trial without restraint

Age-Specific Considerations

Age Group	Developmental Considerations	Recommended Approaches
Infants (0-12 months)	Developing trust vs. mistrust Limited understanding of procedures Need for physical comfort	Mummy restraints often most appropriate Provide pacifier, gentle touch Use soothing voice, music Encourage parent holding when possible
Toddlers (1-3 years)	Developing autonomy May view restraint as punishment Limited understanding of explanation Fear of separation from parents	Simple, concrete explanations Allow choice when possible (which arm first) Use therapeutic play with dolls Provide comfort object Ensure parent presence
Preschoolers (3-5 years)	Magical thinking May perceive illness as punishment Fear of bodily harm Developing initiative	Use simple explanations Avoid threatening language Use medical play therapy Incorporate favorite characters “Magic gloves” concept for mittens
School-Age (6-12 years)	Developing sense of industry Capable of understanding cause-effect Concern with bodily integrity May feel shame	Provide more detailed explanations Involve in decision-making when possible Set clear expectations and timeframes Emphasize safety purpose, not punishment Maintain privacy and dignity
Adolescents (13-18 years)	Developing identity Body image concerns Need for independence Privacy is paramount	Involve in decision-making process Explain rationale thoroughly Respect privacy concerns Consider chemical over physical when appropriate Contract for behavior when possible

Case Studies & Clinical Applications

Case Study 1: IV Protection in Toddler

2-year-old Maya is admitted with dehydration requiring IV fluids. She repeatedly attempts to remove her IV catheter despite verbal redirection and parental presence.

Nursing Approach:

Try alternatives first: distraction, parent holding affected arm, IV site covering with colorful bandage or “special bracelet” story
If unsuccessful, consider elbow restraints as least restrictive option
Explain to parents and child using developmentally appropriate language
Apply padded elbow restraints properly, ensuring comfort
Document alternatives attempted and ongoing assessments
Remove during supervised periods, especially during meals
Reassess need every 2-4 hours

Case Study 2: Post-Surgical Safety

8-year-old Jamal is recovering from appendectomy. In the post-anesthesia period, he is disoriented and attempting to climb out of bed, risking fall and surgical site injury.

Nursing Approach:

First, provide 1:1 supervision with family if possible
Lower bed to lowest position, activate bed alarm
If still at risk, discuss vest restraint with family and surgeon
Explain purpose to Jamal when more alert
Apply vest restraint properly during highest risk period
Conduct frequent assessments for pain, orientation, vital signs
Remove restraint when effects of anesthesia resolve and child is oriented
Document recovery progression and restraint necessity reassessments

Critical Thinking Exercise

Scenario: A 4-year-old child with developmental delay needs to have an MRI of the brain. The procedure requires complete stillness for 30 minutes, and the child has difficulty following instructions to remain still.

Consider the following questions:

What are the potential options for ensuring the child remains still during the procedure?
What are the benefits and risks of each option?
How would you approach this situation using the least restrictive methods first?
If restraint is necessary, what type would be most appropriate?
What preparation would you provide for the child and family?
What monitoring would be required during the procedure?

This exercise encourages critical thinking about the appropriate use of restraints, alternatives, and the balance between medical necessity and the child’s psychological wellbeing.

Summary & Key Points

Concept Map: Pediatric Restraints Overview

Pediatric Restraint Application

Types & Selection

Physical: Extremity, vest, mummy, elbow
Chemical: Medication-based
Environmental: Modified spaces
Select least restrictive first
Match to developmental stage

Application & Monitoring

Proper sizing critical
Secure to immovable parts
Check circulation q1-2h
Skin assessment q2h
ROM when possible
Continuous reevaluation

Ethical & Legal Aspects

Requires valid order
Time-limited use
Thorough documentation
Informed consent
Safety vs. autonomy balance
Regulatory compliance

Key Takeaways

Best Practices

Always try alternatives before restraint application
Use least restrictive method for shortest duration
Ensure proper documentation and ongoing assessment
Include family in education and decision-making
Consider developmental stage in all interventions
Follow facility policies and regulatory requirements

Critical Safety Points

Never restrain to movable parts of bed
Ensure proper fit (1-2 finger space)
Use quick-release knots for emergencies
Monitor circulation, skin integrity, and vital signs
Reassess need for restraint regularly
Document all monitoring and interventions

Final Clinical Pearl

The best restraint is the one you don’t have to use. A thoughtful, creative nursing approach that prioritizes alternatives, family involvement, and developmental considerations will often eliminate the need for physical restraints while maintaining patient safety.

References & Further Reading

American Academy of Pediatrics. (2018). Principles of pediatric patient safety: Reducing harm due to medical care. Pediatrics, 142(2), e20181645.
Bray, L., Snodin, J., & Carter, B. (2015). Holding and restraining children for clinical procedures within an acute care setting: An ethical consideration of the evidence. Nursing Inquiry, 22(2), 157-167.
Joint Commission. (2020). Standards for restraint and seclusion. Comprehensive accreditation manual for hospitals.
Köse, G., & Gözen, D. (2016). The effect of physical restraint on the physical and psychological responses of children during phlebotomy. Journal of Pediatric Nursing, 31(1), e93-e99.
Pediatric Nursing: Scope and Standards of Practice (2020). American Nurses Association and Society of Pediatric Nurses.
Stang, A.S., Wingert, A.S., Hartling, L., & Plint, A.C. (2013). Adverse events related to emergency department care: A systematic review. PLoS One, 8(9), e74214.

Pediatric Pain Assessment – Nursing Notes

Child Health Nursing: Pain Assessment in Children

Comprehensive nursing notes on assessment methods for pediatric pain

Key Point: Accurate pain assessment in children is crucial for effective management. Children express and experience pain differently than adults, requiring specialized assessment tools.

Introduction to Pediatric Pain Assessment

Pain assessment in children presents unique challenges due to their varying developmental stages and communication abilities. Unlike adults, children may lack the vocabulary or cognitive ability to accurately describe their pain. Nurses must use age-appropriate tools and observational skills to effectively assess pediatric pain.

Why Accurate Pain Assessment Matters

Ensures appropriate pain management
Prevents under/over treatment
Builds trust with pediatric patients
Allows monitoring of treatment effectiveness
Improves clinical outcomes

Challenges in Pediatric Pain Assessment

Limited verbal communication skills
Developmental variations
Fear and anxiety affecting expression
Cultural influences on pain expression
Parental presence affecting behavior

Mnemonic: “ASSESS” for Pediatric Pain

A – Age-appropriate tool selection

S – Self-report is gold standard when possible

S – Surroundings and context consideration

E – Expressions and behaviors observation

S – Systematic approach to assessment

S – Score documentation and reassessment

1. FACES Pain Rating Scale

The FACES Pain Rating Scale, developed by Wong and Baker, uses a series of facial expressions to help children communicate their pain level. It’s particularly useful for children aged 3-7 years who may struggle to quantify their pain numerically.

😊

No Hurt

🙂

Hurts Little Bit

😐

Hurts Little More

😕

Hurts Even More

😣

Hurts Whole Lot

😫

Hurts Worst

How to Use the FACES Scale

Explain to the child that each face represents a person who feels happy because they have no pain (hurt) or sad because they have some or a lot of pain.
Point to each face and describe the pain level it represents.
Ask the child to choose the face that best describes their own pain.
Record the number associated with the chosen face.

Clinical Tip: When using the FACES scale, position it at the child’s eye level and ensure they understand it represents pain levels, not emotions or feelings.

2. FLACC Scale

The FLACC (Face, Legs, Activity, Cry, Consolability) scale is an observational tool used primarily for children aged 2 months to 7 years who cannot communicate their pain verbally. It’s especially useful for post-operative pain assessment and for non-verbal or cognitively impaired children.

Categories	0	1	2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn, disinterested	Frequent to constant frown, clenched jaw, quivering chin
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking, or legs drawn up
Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense	Arched, rigid, or jerking
Cry	No cry (awake or asleep)	Moans or whimpers, occasional complaint	Crying steadily, screams or sobs, frequent complaints
Consolability	Content, relaxed	Reassured by occasional touching, hugging, or being talked to; distractible	Difficult to console or comfort

FLACC Scale Scoring and Interpretation

Each of the five categories is scored from 0-2, resulting in a total score between 0-10:

0: Relaxed and comfortable
1-3: Mild discomfort
4-6: Moderate pain
7-10: Severe pain or discomfort

Clinical Tip: When using the FLACC scale, observe the child for 2-5 minutes before scoring. For post-operative patients, observe during both rest and movement to get a comprehensive pain assessment.

Remember “FLACC” as:

Five Little Areas Children Communicate pain when they can’t use words

F
Face

L
Legs

A
Activity

C
Cry

C
Consolability

3. Numerical Pain Scale

The Numerical Pain Scale is typically used for children 8 years and older who can count and understand the concept of rating their pain intensity. This scale asks the child to rate their pain from 0 (no pain) to 10 (worst possible pain).

0 = No Pain

Child feels completely comfortable

4-6 = Moderate Pain

Pain interferes with activities

10 = Worst Pain

Pain is as bad as it could possibly be

How to Use the Numerical Scale

Explain that 0 means “no pain” and 10 means “the worst pain imaginable.”
Ask the child to choose a number that best represents their current pain level.
You may use visual aids (like a number line) to help them conceptualize the scale.
Record the number provided by the child.

Clinical Tip: Some children may overstate or understate their pain based on various factors. Cross-reference with behavioral observations and vital signs for a more comprehensive assessment.

Comparison of Pain Assessment Scales

Scale	Age Range	Type	Advantages	Limitations
FACES	3-7 years	Self-report	Visual, easy to understand, transcends language barriers	May confuse pain with emotions, requires cognitive understanding
FLACC	2 months – 7 years	Observational	Useful for non-verbal, young, or cognitively impaired children	Subjective observer assessment, not direct self-report
Numerical	8+ years	Self-report	Simple to administer, well validated, widely used	Requires numerical understanding, abstract concept for some

Pediatric Pain Assessment

FACES Scale

Visual self-report
Ages 3-7
0-10 scoring

FLACC Scale

Observational
Ages 2mo-7yrs
5 categories

Numerical Scale

Verbal self-report
Ages 8+
0-10 rating

Key Considerations

Development
Communication
Cultural factors

Documentation

Location
Duration
Intensity
Quality

Reassessment

After interventions
Regularly during care
With condition changes

Best Practices for Pediatric Pain Assessment

DO:

Use age-appropriate pain scales
Consider developmental stage and cognitive abilities
Involve parents/caregivers in the assessment process
Assess pain both at rest and during activity/movement
Document pain scores and interventions consistently
Reassess pain after interventions
Use multiple assessment methods when possible

DON’T:

Rely solely on physiological signs (HR, BP) to assess pain
Assume a child is not in pain if they’re playing or sleeping
Let personal biases influence your assessment
Use adult pain scales for young children
Dismiss a child’s self-report of pain
Forget to consider cultural influences on pain expression
Skip reassessment after providing pain interventions

Important Note: Pain is often undertreated in pediatric populations. Remember that all children, regardless of age or developmental status, can experience pain and deserve appropriate assessment and management.

Clinical Application

Case Study: 5-year-old Post-Tonsillectomy

Jacob is a 5-year-old boy who underwent a tonsillectomy 4 hours ago. He appears restless, is whimpering, and pulls away when you approach his bed.

FACES Assessment

Jacob points to face #6 (hurts even more)

Indicates moderate pain

FLACC Assessment

Face: 1, Legs: 2, Activity: 1, Cry: 1, Consolability: 1

Total: 6/10 – Moderate pain

Nursing Action

Administer prescribed analgesic, position for comfort, use distraction techniques, reassess in 30 minutes

Summary

FACES Pain Scale: Visual self-report tool suitable for children 3-7 years old.
FLACC Scale: Observational tool for children 2 months to 7 years or those who cannot self-report.
Numerical Scale: Self-report scale for children 8 years and older who understand numerical concepts.
Selection Factors: Choose the appropriate scale based on age, developmental level, and communication abilities.
Best Practice: Use multiple assessment methods when possible and always reassess after interventions.

Clinical Competency Checklist

Ensure proficiency in the following pediatric pain assessment skills:

☐ Demonstrate correct use of FACES scale

☐ Correctly score FLACC assessment

☐ Appropriately use numerical pain scale

☐ Select appropriate tool based on age/development

☐ Document pain assessments properly

☐ Reassess pain after interventions

☐ Communicate findings to healthcare team

☐ Educate family on pain assessment methods

References

Hockenberry MJ, Wilson D. Wong’s Nursing Care of Infants and Children. 11th ed. Elsevier; 2018.
Schechter NL, Berde CB, Yaster M. Pain in Infants, Children, and Adolescents. 3rd ed. Lippincott Williams & Wilkins; 2020.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297.
Wong-Baker FACES Foundation. Wong-Baker FACES® Pain Rating Scale. Retrieved from https://wongbakerfaces.org/
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2016;138(2):e20161822.