Pediatric IV & Med Admin

Weight-verified dosing, safety range checks, and dual-verification for pediatric medications.

For educational use only. Always verify with clinical judgment and facility protocols.

Weight-verified medication safety for pediatric patients.

Patient Name

Age

Weight (kg)

Weight Verified By

Two Nurses Confirmed Weight

Medication Name

Ordered Dose

Unit

Safe Dose Range Low (mg/kg/day)

Safe Dose Range High (mg/kg/day)

Within Safe Range: Unable to determine

Route

Administration Time

IV Site Location

IV Site Condition

High-Alert Medication: Two-Nurse Double-Check Completed

Patient Response / Adverse Effects

Parent/Guardian Notification Completed

PEDIATRIC IV & MEDICATION ADMINISTRATION Within Safe Range: Unable to determine Route: IV push

Tip: Customize the template using the options on the left. The signature [NursingWorksheets.com] is added automatically when you copy.