DRUG ADMINISTRATION Standards Practices and Principles Fundamentals in

DRUG ADMINISTRATION: Standards, Practices and Principles Fundamentals in Pharmaceutical Computations Dr. J. Domenech

LEARNING OBJECTIVES q At the end of the lecture discussion, RNs are expected to: q Enumerate principles, standards, guidelines in drug preparation and administration q Identify vital functions, roles & responsibilities as RNKs in drug preparation and administration q Calculate with 100 percent accuracy, completeness & organization based on standardized conversion system, equation and units of measurement q Appreciate the value and virtue of patience, humility, cooperation, respect and dignity for human life in congruence with drug preparation and administration

FLORENCE NIGHTINGALE’S PLEDGE v I solemnly pledge myself before God and the presence of this assembly to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious to mind and body and not take or knowingly administer any harmful drugs. I will do all in my power to hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my profession. v With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care”. Thus…

KNOWLEDGE, SKILLS, ATTITUDES AND VALUES • • Pharmacologi c aspects in nurses’ contextualities Promotion of health Prevention of illness Restoration of physiologic processes Provision of palliative effect Maintenance & sustenance of wellness Aid in diagnosis Treatment of diseases

Rules and Techniques for Giving Medicines v Verify all new or questionable orders on the medication administration record (MAR) against the physician orders for completeness v Prepare medications in a quiet environment v Wash hands thoroughly before measuring or preparing a medication v Collect all necessary equipments v Review MAR carefully (medication, dosage, route, expiration, date and frequency) v Research drug compatibilities, purposes, contraindications, S/E, & appropriate routes v Find medication for individual client v Accurate calculation is needed v Check expiration dates and signs of decomposition

Rules and Techniques for Giving Medicines v Compare labels three times • When removing package from drawer • Before preparing the medication • After preparing the medication v Be sure medications are identified for each client v Check for any allergies and perform special assessment before administration v Confirm patient’s identity • Ask the name v Check the identification wrist band • Check the bed tag (least reliable) • Check the photo in bed

Rules and Techniques for Giving Medicines

Rules and Techniques for Giving Medicines v Observe 10 Rights in giving each medication v Do not give medicine that someone else prepared. • Institution policies may require having a colleague double check medication such as insulin or heparin v If using a computer – controlled dispensing system, follow agency policy

Guides to the Administration of Some Specific Agents v Cough syrups are given undiluted in small amount and in frequent doses v Laxatives or cathartics are given between meals and on an empty stomach; those that act quickly be given just before breakfast or those requiring a longer time for action should be given at night (laxative lubricant 12 -18 hours action) v Bitter or unpleasant tasting drugs are given in capsule form as a coated pill or in effervescent preparations v Oils taken in liquid form should be chilled • Castor oils taken with a lemon juice ¼ NAHCO 3 in effervescing action

Guides to the Administration of Some Specific Agents v Drugs that are destroyed by digestive juices are given in enteric coated pills v Drugs are given several hours after meals for rapid action v Drugs to aid digestion are given one half before meals v Fe and Iodine preparations are given diluted and given with a straw v Sedatives are given with warm milk to increase and hasten desired effect of the drug v Bitter stomachaches, given to stimulate appetite should be given undiluted and with no attempt to disguise the taste

Rules for Measuring Medications v Measure the amount of drug ordered, using a calibrated measure v Do not converse while preparing the medication v Make sure that medicine glasses are dry before pouring or measuring a medication v Cleanse the mouth of every bottle after use before replacing it v Measure drops v Hold the medicine glass at eye level

Rules on Labels v Give medication only from a clearly labeled container v Read the label three times v Never give a drug from an unmarked bottle or box v Pour medicine from the bottles on the side opposite the label v Labels on medicine containers should be changed only by the pharmacists v If a drug has two commonly used names, both names should appear on the label

Rules for Giving Medications v Give the medication at the time for which it is ordered v Always identify the patient before giving the medication v If medication is refused or cannot be administered, notify the lead head nurse v Remain at the bedside until the patient has taken the medication v Administer only those medicines which you have measured, poured and prepared v Never give two drugs together, unless ordered to do so v When a patient goes to the OR, all orders for medication are DC v When special tests are being done, medications due at the particular time are omitted they are resumed when next due v A mistake in medication must be reported immediately to the lead head nurse or charge nurse

Rules for Recording Drugs Administered v Record if an ordered medication is refused or if cannot be administered v Record each dose of medicine soon after it is administered v Use standard abbreviations in recording medications v Record only those medicines which you have administered v Record time, kind and dose of drug given v Record effect, especially any unusual effect v Never record a medication as given before it has been administered “IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE. ”

Care of Drugs and Medicine Cabinet Bottles, boxes & other containers Must be kept closed Ointments, liniments, talcum powder, rubbing alcohol Must be kept in a separate environment Oils, serums, vaccines, liver extracts Must be placed in a refrigerator Extreme colds prevents them from becoming rancid and makes the oil a little more palatable Emergency Drugs Must be kept in a box or tray, readily attainable Labels Defaced or soiled should be changed by the pharmacists Medicines in unusual appearance Returned to the pharmacy & discarded

Care of Drugs and Medicine Cabinet Floor Drugs Checked twice daily Two containers for each floor drug Unused drugs for a patient being dismissed Should be sent back to the pharmacy Medicines sent home for patients Complete directions are employed Medicine Cabinet Adjacent to sink Adequate light Shallow Proper drug classification of drug supplies Individual basis (UNIT DOSE FORM) Drug per container/patient Opiates & narcotics Separate compartment & locked Narcotic nurse with the key Poison Label POISON, separate and roughened surface DRUG SUPPLY - UNIT DOSE FORM System of packaging and labeling each dose by pharmacy supplied in a 24 hour time period Replacement, constant monitoring of availability DRUG SUPPLY – STOCK SUPPLIED Dispensed and labeled in large quantities Stock supplies kept in a secured area

RNKs CAN ALLAY PATIENT’S SUFFERING THROUGH WRONG MEDICATION AND NON COMPLIANCE TO STANDARDS, PRINCIPLES AND GUIDELINES D I G N I F I E D D E A T H

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 1. A nurse makes a medication error. The best action is to A. Document in the patient’s record the error by either noting the omission of a drug or adding the drug given if it does not appear on the medication record B. Document in the patient’s record the error by either noting the omission of a drug or adding the drug as given even if it does not appear on the medication record; describe the circumstances surrounding the error. C. Do not document any error on the patient’s record. Document only on the incident or quality assurance report. D. Document in the patient’s record the error by either noting the omission of a drug or adding the drug as given if it does not appear on the MAR; also document on the incident or quality assurance report.

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 2. Among the following patient’s right, which is not included? A. Right route B. Right medicine C. Right site of administration D. Right patient

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 3. Which of the following nursing actions is most helpful for the patient with dysphagia? A. Placing the patient in a sitting position B. Mixing the medication with food C. Turning the patient toward you D. Dissolving the medication in a glass of water

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 4. It is important not to leave medication at the bedside because A. You will not be able to document that the patient actually took the medication B. It may fall on the floor C. The patient may forget to take it D. It takes time to return and check with the patient later

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 5. Buccal medications are those A. Placed between the cheek and the gum B. Placed under the tongue C. Injected into the buttocks D. Swallowed with water

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 6. Topical rinses have of the following actions: A. Systemic effect when swallowed B. Decreased microorganisms and tooth decay C. Increased the ability to taste D. Local effect through exposure to the mucous membrane

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 7. Administration of which of the following requires the use of sterile technique? (1) Ophthalmic medications (2) Nasal medications (3) Vaginal medications (4) Rectal medication A. 1 only B. 1, 2, and 3 C. 1 and 3 D. 2, 3, and 4

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 8. For safety and accuracy of medication being administered to the patient, one of the considerations is the three checks. Which of the following is not applicable? A. Reading the label after the medications has been administered. B. Reading the label before preparing. C. Reading the label before picking the medication in the locker. D. Reading the label after withdrawing the medication from the container.

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 9. Which is the following route has the faster effect? A. Sublingual B. Intravaginal C. Inhalers D. Intravenous

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 10. It is a medication order that is to be given once at specified time. A. Stat order B. Single order C. Standing order D. PRN order 11. “Multivitamins 1 tab daily” is an example of: A. Stat order B. Single order C. Standing order D. PRN order 12. A finely divided drug particles dispersed in liquid medium, when suspension is left standing, particles settle at the bottom of container A. Aqueous B. Suspension C. Syrup D. Powder

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 13. Requires that the effectiveness of the medication be administered by client’s response to the medication; it is appropriate to determine the extent of side effects and adverse reaction supports which of the following medication golden rule? A. Right evaluation B. Right assessment C. Right education D. Right documentation 14. Which of the following is not a principle for giving medications? A. Be knowledgeable about medications that you administer. B. Do not leave medication at bedside. C. When a medication error is made, report it immediately to the nurse in charge and/or physician. D. Practice clean technique.

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 15. The following are rules for measuring medications, except: A. Wash hands thoroughly before measuring medications. B. Do not converse with anyone while preparing a medication. C. Cleanse the bottom of each medicine bottle before replacing it after use. D. Make sure that the medicine glasses are dry before pouring the medication. 16. Mrs. Brown is to receive a medication PO qid. This means A. by mouth every other day B. before meals every day C. after meals every day D. by mouth four times a day

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 17. When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician that the nurse was unable to give the client this medication 18. The nurse is administering medication in an extended care facility. The client answers to Mr. Smith and Mr. Brown. What is the best way for the nurse to correctly identify the client before administering the medications? A. Ask the client's name. B. Check the arm band. C. Check the name on the bed. D. Check the name on the room door.

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 19. Zantac is ordered for an adult client. The nurse mistakenly administered Xanax. What is the most appropriate action for the nurse to take? A. Notify the physician and document in the nurse's notes that the physician was notified of the error. B. Notify the supervisor, complete a medication error incident report, and document in the nurse's notes that an incident report was completed. C. Notify the house supervisor, assess client carefully, and document only if adverse or untoward effects occur. D. Notify the physician, complete an incident report, and document the notification of the physician and any assessments made.

TEST DRILL APPLICATION, CRITICAL THINKING, RECALL AND RECOGNITION 20. While preparing to give a morning medication, the first nursing action is to: A. Read the label B. Check for the right dose C. Wash hands D. Check for the right time 21 – 25 FIVE RIGHTS OF DRUG ADMINISTRATION

DOSAGE AND SOLUTIONS

TEST DRILL 1 Mastery, Recall and Recognition PERFORMANCE INDICATORS ANSWERS 1 -5 Functions of Medicine/drug/medication Curative, diagnostic, palliative, promotive 6. Drug that is placed under the tongue SL 7. Priority of drug preparation/administration Patient’s safety 8. Drug that is slowly absorbed in a specified period of time Timed release drug 9 -12 Drug Nomenclature Brand, generic, official, chemical 13. OD Right eye 15. Used with other drug that potentiates one’s drug action Adjunctive/adjunct 16 -20. 5 R’s of drug administration Route, dose, patient, time, Dr. J. Domenech ©

TEST DRILL 2 Mastery, Recall and Recognition 1. A type of medication order which is carried out until the specified period of time, or until it is discontinued by another order. A. Single Order B. Stat Order C. Standing Order D. PRN Order 2. This type of medication order indicates that the medication is given immediately without cause of delay. A. Single Order B. Stat Order C. Standing Order D. PRN Order Dr. J. Domenech © 3. This type of medication order is used for a medication given once at a specified time. A. Single Order B. Stat Order C. Standing Order D. PRN Order 4. This type of medication order permits the nurse to give a medication when in his/her judgment the patient requires it. A. Single Order B. Stat Order C. Standing Order D. PRN Order

TEST DRILL 3 Recall and Recognition Write the corresponding LETTER to drugs ordered by the physician. A – Single order B – Stat order C – Standing order D – Prn order 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Ampicin 250 mg IV q 8 hr ANST Phenergan 50 mg @ 10 am before surgery. Dulcolax 10 mg 4 tabs @ h. s. Hemostan 250 mg IM q 6 hours for bleeding Ponstan 500 mg p. o. TID x 6 doses Biogesic 500 mg p. o. stat Demerol 25 mg IM q 4 hr for 2 days Claritin 10 mg p. o. BID Multivitamins 1 tab daily Ampicillin 500 mg IV push TID ANST CYRUZ POLERO TUPPAL RN MSN DMS © 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. C A C D C C C

DEFINITION v DOSAGE • Is the amount of a medicine or agent prescribed for a given patient or condition Dr. J. Domenech © v DOSE • Is the measured portion of medicine to be taken at one time

FACTORS AFFETCING DOSAGE q q q q q Age Sex Condition of the patient Psychological factors Environmental factors Temperature Methods of administration Genetic factors Body weight Dr. J. Domenech ©

PRESCRIPTION v Ebers Papyrus – the real literature dealt with pharmacy v Is an order written by a physician Dr. J. Domenech © v v Date Patient’s name Address Inscription (name & quantities) v Subscriptions (instructions to the pharmacists) v Sig. (signa) gives directions to the patient v Physician signature, address, registry number

SAMPLE PRESCRIPTION Arellano University and Medical Center Name of Patient Address Sex Calcidrine Expectorant Sig 4 0 z ½ tsp q. 4 h for cough Dr. Juan dela Cruz Lic. # 9875043 Dr. J. Domenech © Date

a. d. or A. D. Right ear a. s. or A. S. Left ear a. u. or AU each ear or both ears HHN Hand held nebulizer I. D. Intradermal route I. M. or IM Intramuscular route I. T. Intrathecal route I. V. or IV Intravenous route IVP Intravenous push IVPB Intravenous piggyback NGT Nasogastric tube od or O. D. Right eye os or O. S. Left eye ou or O. U. Each eye or both eyes po or P. O. or PO By mouth P. R. or PR By rectum SQ, sub q, subcut Subcutaneous route SL or s. l. Sublingual route S & S RN MSN DMS © CYRUZ POLERO TUPPAL Swish and swallow V or P. V. Vaginal route

Ac or P. C. Before meals ad lib As desired / needed ASAP As soon as possible b. i. d. or BID Twice daily (not the same as q 12 °) h. s. or HS At bedtime (hour of sleep) NOC Nighttime [archaic usage] pc or P. C. After meals p. r. n. or PRN As needed q or Q Every q AM Every morning q hr Every hour q. d. or QD Every day q. i. d. or QID Four times a day q. o. d. or QOD Every other day q (Q) 1°, 2°, 3°, 4°, 6°, 8°, or 12°, etc Every 1, 2, 3, 4, 6, 8, 12 hours. (Concept is based on a day and administering on a routine sequential basis to maintain therapeutic blood levels. ) stat or STAT Immediately! [not when you can get around to it] t. i. d. or TID Three times daily (not the same as q 8°) CYRUZ POLERO TUPPAL RN MSN DMS ©

amp Ampule cap(s) Capsule(s) DS Double-strength elix Elixir LA Long-acting liq Liquid sol Solution supp Suppository S. R Sustained release susp Suspension syr Syrup tab Tablet tinct or tr Tincture CYRUZ POLERO TUPPAL RN MSN DMS © ung Ointment

Dram (Notice "2 humps". ) (Docs should not be using this, but you may see it. There is a significant difference in the volume between this [4 ml] and ounce [30 ml]. ) Ounce (Notice "3 humps". ) (Docs should not be using this, but you may see it. ) cc or CC Cubic centimeter gm Gram gr Grain gtt (s) Drop (s) IU International units (best to write out) kg Kilogram L mcg or µg mg m. Eq ml Mn, m oz __ ss or ss sliver Liter Microgram (should be written out--safety issue) Milligram Milliequivalent Milliliter [preferable for volume] Minim [rarely used, except in some math exams] Ounce One-half (archaic use) in NICU, a small slice of a suppository T or Tbs Tablespoon CYRUZ TUPPAL RN MSN DMS © tsp POLEROTeaspoon U Unit (best to write out)

AMA (Leave) against medical advice _ c with D/C or DC Discontinue G Gauge (of needle) HO House officer (doctor on call) KVO Keep vein open. LOC Laxative of choice (Look for context when written, ie. , could be "level of consciousness" when related to neurological exam. ) MR x _ May repeat (x) times [This should be written out due to risk for error. ] MOC In peds, mother of child FOC In peds, father of child (may also be frontal occiputal circumference) (read the context) NKA No known allergies N. P. O. , NPO, or npo Nothing by mouth OTC Over the counter qs A sufficient quanity Rx Prescription, sometimes Treatment ® Right _ s Without (if must abbreviate, use w/o) __ ss One-half (should avoid this form) TO Telephone order (Need to follow the hospital policy re this. ) CYRUZ TRA POLERO TUPPAL RN MSN DMS © VO To run at (IV flow rate) Verbal order (What is hospital policy re this? )

The interdisciplinary health care team should limit abbreviations to standard acceptable use. Sometimes Doctor's orders and notes and nurse's transcription of doctor's orders and their narrative notes contain so many shortcuts (abbreviations) that it is difficult to interpret safely. µg __ ss or ss OD Micrograms should be written out, insist on it! Write out one-half or 1/2 clearly. Ordered daily? Write out daily. QD, if legible, should be acceptable. n or N Nightly? QN? Write out nightly or use hs. d or D Daily? Write out how many days. BT w/o Ordered at bedtime? Write out bedtime or use the standard hs. Without? (See Miscellaneous use page. ) Numerical numbers should be carefully written. Nurses should pay attention to use of the decimal in designating dosages, ie, Ativan 0. 5 mg, not Ativan. 5 mg. [If one fails to note the decimal, then it could be interpreted as 5 mg. ] Capoten 50 mg should not be written as Capoten 50. 0 mg. [If one fails to note the decimal, then it could be interpreted as 500 mg. ] Another issue to consider is use of the international designation of the number 7 ( ) to CYRUZ POLERO TUPPAL RN MSN DMS © prevent mistaking it for the number 1.

CONVERSION EQUATION BASIC TECHNIQUES Metric, Household and Apothecary Measurement DR. J. DOMENECH © NLE REVIEW RESOURCE CENTER INC. UNIVERSAL PRINCIPLE: The key is to clarify the 2 parts of the equation (what to give and what is available) Be guided with the conversion table and formula Basic arithmetic +, -, /, x SAFETY

Conversion within Systems v Metric System • Based on decimal system, basic unit is 10 • Units of measurement Meter (m) for Length, Gram (g) Kilogram (kg) Pounds (lbs) Milligram (mg) Microgram (mcg) for Weight Liter (l) Milliliter (ml) Cubic Centimeter (cc) for Volume • ZERO is placed in front of the decimal for values less than 1 (0. 7) • Basic arithmetic (division or multiplication) • mg to g or ml to l = divide the number by 1000 Dr. J. Domenech ©

Conversion within Metric Systems v To convert within the metric system, set up a RATIO WITH THE CONVERSION FACTOR ON THE RIGHT AND DESIRED INFORMATION ON THE LEFT, CROSS MULTIPLY, DIVIDE TO FIND “X” and COMPLETE THE NEEDED MATH EQUATION. a. _______= _______ (skeleton) a. b. v REMEMBER: TO KEEP RATIOS EQUAL: WHATEVER IS DONE TO ONE SIDE MUST BE DONE TO THE OTHER e. f. Conversion: 1000 mg = 1 g 5000 mg = 1000 mg x 1 g (X) (1000 mg) = (5000 mg)/ 1 g (X) (1000 mg) = (5000 mg) (1000 mg) X = (5) (1) g X=5 g v E. g. convert 5000 mg to g Dr. J. Domenech © c. d.

Test Drill 4 Conversion Equation a. a. b. MATRIX GUIDE _______= _______ (skeleton) e. Conversion: 1000 mg = 1 g 5000 mg = 1000 mg x 1 g (X) (1000 mg) = (5000 mg)/ 1 g (X) (1000 mg) = (5000 mg) (1000 mg) X = (5) (1) g f. X=5 g c. d. Dr. J. Domenech © v Convert the ff using a sequential approach 1. 136 kg = lb 2. 476 kg = lbs 3. 666 mg = g 4. 1478 ml = L 5. 3758 L = ml 6. 9000 cc = L 7. 780 g = mcg 8. 14344 mg = mcg 9. 88 lb = kg 10. 7 L = cc

Conversion within Systems: HOUSEHOLD SYSTEM v Least accurate v Used to inform of the size of a liquid dose v Calibrated oral syringe or dropper should be used instead for accuracy v Teaspoon (tsp) Tablespoon (tbsp) Ounce (oz) Cup Drop (gtt) Micro drop (mcgtt) Dr. J. Domenech © v a. b. c. d. Convert 3 tsp to drop 60 gtts = 1 tsp 3 tsp = 1 tsp X 60 gtts (1 tsp) (X) = (3 tsp) (60 gtts) 1 tsp e. X = 3 (60 gtts) f. X = 180 gtts

TEST DRILL 5 Conversion Equation v a. b. c. d. MATRIX GUIDE Convert 3 tsp to drop 60 gtts = 1 tsp 3 tsp = 1 tsp X 60 gtts (1 tsp) (X) = (3 tsp) (60 gtts) 1 tsp e. X = 3 (60 gtts) f. X = 180 gtts Dr. J. Domenech © v Convert the ff 1. 70 tsp to drop 2. 5 tbsp to oz 3. 8 oz to tbsp 4. 15 drops to tsp 5. 12 tsp to oz

Conversion from One System to Another v Conversions must be memorized by heart v Convert 90 gtts = ml a. 15 gtts = 1 ml Or => 15 : 1 : : 90 : X b. 90 gtts = 15 gtts X 1 ml c. 15 gtts (X) = (90 gtts) (1 ml) 15 gtts d. X = 6 ml Dr. J. Domenech ©

Dosage Calculation v Calibrated containers are available for oral liquids & liquid injectables v Be sure all conversions are done first. The technique of using ratios is the same FORMULA Desired Amount of Drug_ Amount of Drug on Hand X Dr. J. Domenech © = = Unknown Quantity (X) Known Quantity of Drug Desired Dosage(D) X Quantity (Q) Stock on Hand (S)

Dosage Calculation for Scored Tablet 1. 2000 mg of a drug is ordered. It is available as a scored tablet containing 4 g. How many tablet/s should the nurse administer? 2. Calculation a. b. c. d. e. 1000 mg = 1 g 2000 mg = X tablets 4000 mg 1 tablet 4000 mg (X) = 2000 mg (1) X = 0. 5 tablet Give ½ tab Dr. J. Domenech © v 3000 mg of a drug is ordered. It is available as a scored tablet containing 7 g. How many tablet/s should the nurse administer?

Dosage Calculation for Liquid 1. The order is for potassium chloride (KCL) 20 m. Eq. The bottle is labeled KCL elixir 10 m. Eq. /ml. How many ml will be given? a. Desired amount of drug is 20 m. Eq(D); amount of drug on hand is known (S) 10 m. Eq. b. Unknown quantity is (X), known quantity (Q) is 1 ml. Dr. J. Domenech © 1. a. Calculations 20 m. Eq = X 10 m. Eq 1 ml b. (10 m. Eq) (X) = (20 m. Eq) (1 ml) 10 m. Eq c. X = 2 ml d. Give 2 ml of potassium chloride (KCL) Or Ratio / proportion 10 : 1 : : 20 : X X = 20 / 10 = 2 ml

Dosage Calculation for Liquid MATRIX GUIDE a. 20 m. Eq = X 10 m. Eq 1 ml b. (10 m. Eq) (X) = (20 m. Eq) (1 ml) 10 m. Eq c. X = 2 ml d. Give 2 ml of potassium chloride (KCL) Dr. J. Domenech © v The order is for potassium chloride (KCL) 50 m. Eq. The bottle is labeled KCL elixir 35 m. Eq. /ml. How many ml will be given?

A. Dosage Calculation for a Capsule 1. The order is for Nembutal gr i ss. The bottle contains Nembutal 100 mg/capsule. How many capsules should RNK give to ease the patient’s suffering? 2. Calculations A. First convert to EQUAL MEASUREMENTS a. 1 gr = 60 mg { gr i ss = 1. 5 gr } b. 1 gr = 1. 5 gr Or => 1 : 60 : : 1. 5 : X 60 mg X c. (X) (1 gr) = (60 mg) (1. 5 gr) d. (X) (1 gr) = (60 mg) (1. 5 gr) 1 gr e. X = 90 mg Dr. J. Domenech ©

B. Dosage Calculation for a Capsule B. Desired amount of drug is 90 mg (D); amount of drug on hand is 100 mg (S) C. Unknown quantity is (X); known quantity is 1 capsule (Q) D. Calculate the dosage a. 90 mg = X Or => 100 : 1 : : 90 : X 100 mg 1 capsule b. (100 mg) (X) = (90 mg) (1 capsule) 100 mg c. X = 0. 9 capsule d. The RNK will administer 0. 9 capsule to kill the patient E. Since part of a capsule, drop or suppository cannot be given (0. 9 capsule), RNK WILL ADMINISTER 1 CAPSULE TO KILL THE PATIENT Dr. J. Domenech ©

Dosage Calculation for a Capsule MATRIX GUIDE A. CONVERT TO EQUAL MEASUREMENTS a. 1 gr = 60 mg b. 1 gr = 1. 5 gr 60 mg X c. (X) (1 gr) = (60 mg) (1. 5 gr) d. (X) (1 gr) = (60 mg) (1. 5 gr) 1 gr e. X = 90 mg B. CALCULATE THE DOSE a. 90 mg = X 100 mg 1 capsule b. (100 mg) (X) = (90 mg) (1 capsule) 100 mg c. X = 0. 9 capsule Dr. J. Domenech © 1. The order is for Nembutal gr XX. The bottle contains Nembutal 100 mg/capsule. How many capsules should RNK give to ease the patient’s suffering? 2. The order is codeine sulfate gr 20. The container labeled as Codeine Sulfate 50 mg/capsule. How many capsule/s should YOU give so as the patient’s suffering will end?

Dosage Calculation for Parenteral Medications 1. The order reads codeine gr ss. The vial reads codeine 60 mg/cc. How many ml should be given? v Convert to equal measurements a. 60 mg = 1 gr b. 60 mg = 60 mg X 1 gr c. (60 mg) (X) = (60 mg) (1 gr) 60 mg d. X = 1 gr Dr. J. Domenech © 2. Then calculate the dosage v D = 0. 5 gr S = 1 gr Q = 1 ml a. 0. 5 gr = X 1 gr 1 ml b. (X) (1 gr) = (0. 5 gr) (1 ml) c. X = 0. 5 ml

Dosage Calculation for Reconstituted Powder Critical vs. Extraneous Information 1. Mefoxin 1 g is ordered. Mefoxin 2 g is on hand. Add 4. 3 ml to equal 5 ml solution. Critical Information? -The dosage (1 g) -The end concentration (2 g/5 ml) Extraneous Information not needed for calculating? - Mixing instructions (Adding the 4. 3 ml to the vial tells you that this is the volume necessary to add to the powder to yield a specific concentration) Can you figure how much volume the powder has in the vial? (0. 3 ml) Dr. J. Domenech © 2. Desired amount (D) is 1 g, Amount of drug on hand (S) is 2 g 3. Unknown quantity is X, known quantity is 5 ml a. 1 g = X 2 g 5 ml b. (2. 0 g) (X) = (5 ml) (1 g) 2 g 1 ml c. X = 2. 5 ml Or => 2 g : 5 ml : : 1 g : Xml

Dosage Calculation in Children (Pediatric Dosages) Rules Description Young’s Rule - Not valid after 12 y/o. If the child is small enough, dosage reduction be computed with Clark’s Rule Age of child____ X Ave Adult Dose Age of child + 12 Weight of child 150 Clark’s Rule Fried’s Rule Formula - Calculates dosages for infants less than 2 y/o X Ave Adult Dose Age In Months X Ave Adult Dose 150 THESE RULES ONLY GIVE APPROXIMATE DOSAGES. Thus… USE Dr. J. Domenech ©

Dosage Calculation in Children (Pediatric Dosages) v Body Surface Area (BSA): most accurate method for calculating pediatric dosages • West nomogram = if BSA is not known, draw a line from height on the nomogram; the point intersection on surface area is the BSA • FORMULA USING SURFACE AREA (mm) 150 lbs or 1. 73 mm – average BSA of an adult CHILD DOSE = surface area (mm) x ADULT DOSE 1. 73 mm Dr. J. Domenech ©

Dosage Calculation in Children (Pediatric Dosages) FORMULA CHILD DOSE = surface area (m 2) x ADULT DOSE 1. 73 mm Dr. J. Domenech © The adult dose is 100 mg Demerol; the child weighs 20 kg and is 40 inches a. . 77 m 2 X 100 mg = X 1. 73 m 2 b. 0. 45 X 100 mg = X c. 45 mg = X

Dosage Calculation in Children (Pediatric Dosages) 1. Pediatric dosages can also be calculated by weight (mg/kg) 2. The order is Phenobarbital 2 mg/kg of body weight, for the patient weighs 25 kg. 3. Calculations Or => 1 kg : 2 mg : : 25 kg : X mg a. 2 mg = 1 kg X 25 kg b. (1 kg) (X) = (2 mg) (25 kg) 1 kg c. X = 50 mg Dr. J. Domenech ©

What if ? Need to perform an “ACCURATE I & O" and the infant does not have a foley? What to do? Dr. J. Domenech ©

What if? Rationale WEIGH DIAPER In gram and milliliter? When weighing diapers, the measurement is "grams". When we think about volume of urine output we think "ml". A 'gram' and a 'ml' are equivalent when measuring water. In the clinical setting, however, we use gram and ml as equivalent when measuring urine by diaper weights. It is the best noninvasive method we currently have and is close enough for clinical decision making. The process is to weigh the diaper on a gram scale, but record the output in 'ml'. Dr. J. Domenech ©

Safety Related Issues in Pedia Patients Children cannot tolerate adult doses. Microtubing Most Pediatric nursing units have a policy that children under a certain age with IV fluids / IV medications will be placed on an infusion pump. Sometimes critical thinking is required to deliver the medication/fluid in the most expedient, safe manner for the individual child's needs. Buretrol Infusion Pump

Child's Weight Data / Volume to be given 1) 6. 5 kg ? ml / day (maintenance) ? ml / hour (maintenance) ? 2/3 maintenance (ml/day) ? 2/3 maintenance (ml/hr) ? 1. 5 maintenance (ml/day) ? 1. 5 maintenance (ml/hr) Dr. J. Domenech ©

Dosage Calculations for IV Medications v To calculate know the flow rate, need to know the drop factor (10, 15, 20 gtts/ml) v Micro drop is always 60 gtts. ml v FORMULA gtts/min = Amount of Solution (V) Time in Minutes cc/hr Volume/Hour akin to micro drop/minute computation Dr. J. Domenech © = = X Drop Factor (gtts/ml)

Dosage Calculations for IV Medications gtts/min = cc/hr Amount of Solution (V) Time in Minutes = Dr. J. Domenech © X Volume/Hour gtts factor v The nymphomaniac doctor quack ordered 3 L of PNSS for a dying patient. The IV is set to run for 24 hours. The RNK will regulate the IV to how many (a) ml/hr, (b) gtts/min if the drop factors are: (c) 10, (d) 15, (e) 20.

TEST DRILL 5 Dosage Equation v THREE GROUPS IN A CLASS v Choose one member per group to show computation. 5 point added per correct answer v Two – minute time allotment v Group test drill grade = individual test drill grade v The order reads codeine gr ss. The vial reads codeine 60 mg/cc. How many ml should be given? v The order is penicillin 750 000 units. The vial reads 300 000 u/2 ml. How many ml will be given? v The order is 1000 ml NSS over 8 h; drop factor is 10 gtts/ml. Regulate the IV to how many gtts/min? Dr. J. Domenech ©

TEST DRILL 6 v The order is 1000 ml D 5 NS over 24 hours. Drop factor is 60 gtts/ml and an hour of 60 minutes. Amount of fluid X Drip factor Time (always in minutes) 1000 cc X 60 gtts/cc 24 hr X 60 min = 60000 1440 = 41. 66 = 42 gtts/min v The order reads Digoxin 0. 375 mg once daily. The bottle reads Digoxin 0. 25 mg per tablet. How much should the nurse administer? v 0. 375 mg / X = 0. 25 mg / 1 tab X = 0. 375 / 0. 25 = 1. 5 tab or { 0. 25 : 1 : : 0. 375 : X } v The order is chloral hydrate 200 mg. The bottle reads chloral hydrate 0. 1 g/cap. Give ______ cap 1 gm = 1000 mg => 0. 1 gm = 100 mg 200 mg / X = 100 mg / 1 cap X = 200 / 100 = 2 cap or { 100 : 1 : : 200 : X } Dr. J. Domenech ©

TEST DRILL 7 v The order is penicillin 50 000 units. The vial reads penicillin 500 000 units. Add 4. 3 ml to yield 5 ml. Give _____ ml. v The order is for 1. 2 million units of penicillin G (Bicilin) IM. Available is 600 000 units/ml. How much should the nurse administer? v Order is 2000 ml D 5 W over 24 hours. Drop factor is 15 gtts/ml. Run IV at ____ gtts/min. Dr. J. Domenech © v 50, 000 / X = 500, 000 / 5 ml (X)(500 K) = (50 K)(5) X = 250, 000/500, 000 = 0. 5 ml v 1. 2 M / X = 600 K / 1 ml X = 1. 2 M / 600 K = 2 ml Amount of fluid X Drip factor Time (always in minutes) 2000 cc X 15 gtts/cc 30000 24 hr X 60 min = 1440 = 20. 8 = 21 gtts/min

TEST DRILL 8 v Enoxaparin sodium (Lovenox) 30 mg SC q. 12 hours is ordered. The label reads 30 mg/0. 3 ml. How much should the nurse administer? v The order is for meperidine 50 mg IM q. 4 hours prn. The label reads meperidine 7 mg/ml. How much should the nurse administer? v DOSAGE = 30 mg = 0. 3 ml X = 30 mg X 0. 3 ml / 30 mg = 0. 3 mls v Meperidine 50 mg intramuscularly immediately; 7 mls DOSAGE = 7 mg = 1 ml X = 50 mg X 1 ml / 7 mg = 7 mls v Dr. J. Domenech © Levenox 30 mg SC q. 12 hrs; 0. 3 mls DOSE ORDERED / AVAILABLE x VOLUME

TEST DRILL 9 v An adult is on continuous IV heparin therapy for thrombophlebitis. The IV contains 15 000 units of heparin in 500 cc of 5% dextrose (D 5 W) at the rate of 20 cc per hour. How many units per hour is the client receiving? v The order is for Ancef 1 gram IV in 50 cc 5% dextrose to run in over 30 minutes every 6 hours. The administration set delivers 10 gtts/cc. What should the drip rate be? Dr. J. Domenech © 15, 000 U X 20 cc/hr 60 min 50 cc X 10 gtts/cc 24 hr X 30 min = = 300, 000 60 = 5, 000 U 500 720 = 0. 69 = 0. 7 gtts/min

TEST DRILL 10 v Physician orders Garamycin 60 mg IM. Dose on hand is 40 mg/ml. v Dose ordered 250 000 units of Penicillin G. Available dosage 300 000 units per 1. 2 ml. v Dose ordered Gantrisin 2 g. Dose on hand is 500 mg/tab. v Dose ordered Aspirin 600 mg. Dose on hand is gr V. v Dose ordered Keflin 250 mg. Dose on hand Keflin 6 g. v Dose ordered Meperidine 25 mg. Dose on hand Meperidine 0. 05 g/ml. v Dose ordered Rubrumin 1 mg. Dose on hand 1000 mcg/cc. v Dilantin suspension is labeled 100 mg/4 cc. How many cc is required to give a 250 mg per dose? v The doctor orders ATSO 4 0. 0006 g. The dose available is 0. 4 mg/cc. v The doctor orders Ephedrine 100 mg. The dose is 0. 05 g/cc. Dr. J. Domenech ©

TEST DRILL 11 v The doctor orders Atropine Sulfate 0. 2 mg. Dose available is 0. 4 mg/cc. v Dose ordered Sodium Salicylate 0. 6 g. Dose on hand is 300 mg in each scored tablet. v The doctor orders Codeine SO 4 15 mg. The dose available is 0. 03 g in each scored tablet. v The doctor orders Benadryl 50 mg. Dose on hand 0. 025 g in each capsule. v The medication order is Meprobomate 0. 2 g. Dose on hand is 400 mg per scored tablet. v Morphine SO 4 15 mg is ordered. Dose on hand is 0. 005 g per tablet. v NAHCO 3 is ordered 1 g. Dose on hand is 400 mg/ 4 ml. v The doctor orders sodium salicylate 1200 mg. Dose on hand is 0. 6 g in 4 ml. v The order is to administer 150 mg sodium benzoate. Dose on hand is an ampule labeled 0. 5 g in 2 ml. v The order reads 500 mg penicillin. Dose on hand is in solution 3 g per 6 ml. Dr. J. Domenech ©

TEST DRILL v Order of an initial cortisone acetate of 425 mg. Dose on hand is in suspension labeled as 25 mg/ml. v Dose ordered is Lanoxin 0. 125 mg. Dose on hand is 0. 062 mg per cc. v Dose ordered Vistaril 15 mg. Dose on hand is 25 mg/cc. v Dose order is 250 mg Chloromycetin liquid. Dose available is 32 mg/ml. v Phenobarbital gr ss is ordered. Dose available is Phenobarbital 0. 30 mg. v A physician orders 1 L of NS to infuse over 12 hrs. The drop factor is 15 gtts per 1 ml. A nurse prepares to set the flow rate at how many drops per minute? v Cefuroxime (Axetil) 1 g in 50 ml NS is to be administered over 30 minutes, a drop factor is 15 drops per 1 ml. A nurse sets the flow rate at how many drops per minute? v A physician orders 1 unit of PRBC to infuse over 4 hrs. The unit contains 250 ml, the drop factor is 10 drop per 1 ml. A nurse prepares to set the flow rate at how many drops per minute? v The order reads PNSS 1000 ml to run for 12 hrs. How ml/hr should the nurse monitor and the accurate flow rate? If the nurse started to run the infusion at 10: 30 in the morning, at what time should the IVF be consumed? v D 5 0. 3 NACL 1 L to run for 8 hrs is ordered. Compute for the ml/hr and the flow rate the nurse should regulate the IVF if the drop factor is 20 drops per 1 ml. Dr. J. Domenech ©

LAST TOPICS FOR MIDTERM PERIOD FRIDAY MONDAY v Medication Administration Routes v Parts of Syringes v Medication Cards v Special Consideration in Various Routes/Sites of DA • Oral • Parenteral and various routes v EXAMINATION (TWO SETS) • Intramuscular • Intradermal • Subcutaneous Dr. J. Domenech © • SET A • 1: 00 PM – 1: 45 PM • Application, mastery, recall and recognition (100 items) 1: 45 PM – 2: 00 PM Break • SET B • 2: 00 PM – 3: 00 PM • Dosage and Calculations (100 items)

WEDNESDAY Orientation, Review & Checking of Examination, Activity Work TOPICS DISCUSSED 1. 2. 3. 4. 5. TERMS DEFINITION ABBREVIATIONS STANDARDS, GUIDELINES, PRINCIPLES DP/DA DOSAGE AND CALCULATION TOPICS FOR FINAL PERIOD • • • Dr. J. Domenech © Administration of medication in various routes • Lecturers: 1. Mrs. Norma F. Arobel, MAN, RN 2. Mrs. Delia T. Bromo, MAN, RN 3. Mrs. Alicia Lopez, MAN, RN Performance Evaluation Checklist Return Demonstration Submitted and signed Waiver Statement prior to RETDEM Group assignment or individual basis for various equipments, supplies and materials used in drug administration