CHAPTER 5 MEDICATIONS AND CALCULATIONS METRIC SYSTEM metric system = decimal system based on the power of ten o basic

c units of measure are gram, for weight o liter for volume o meter for linear measurement conversion within the metric system are: o 1g = 1000mg o 1L = 1000mL o 1mg = 1000mcg

Metric Conversion applying larger units to smaller units, move one decimal place to the right for each degree of magnitude change for smaller units to larger units, move one decimal place to the left for each magnitude of change.

HOUSEHOLD SYSTEM this system of measurement is not as accurate as the metric system but because of the lack of standardization of spoons, cups and glasses. o When converting larger units to smaller units, you multiply the requested number by the basic equivalent value.

METRIC, APOTHECARY AND HOUSEHOLD EQUIVALENTS apothecary system is no longer used

METHODS FOR CALCULATION four general methods of calculation of drug doses: o basic formula o ratio and proportion o fractional equation o dimensional analysis individualized dosing, calculation by o body weight o body surface area all units of measure must be converted to single system, the system generally is on the drug label

INTERPRETING ORAL AND INJECTABLE DRUG LABELS brand name of the drug in large letters and the generic name in smaller lettering o dose per tablet, capsule or liquid is printed on drug label

Basic Formula

D V = A H
o D = desired dose

o o o

H = on-hand dose (drug dose on label of the bottle) V = vehicle (drug form) A = amount to be given to the client

Ratio and Proportion

H :V :: D : X
o H is the drug on hand o V = vehicle o D = desired dose o X = unknown amount Multiply the means and the extremes to get the answer.

Fractional Equation:

H D = V X
o H = dosage on hand o V = vehicle o D = desired dosage o X = unknown Dimensional analysis = calculation method known as units and conversion. Advantage of DA is that it decreases the number of steps required to calculate a drug dosage. Set up as one equation.

Body Weight Method (BW) allows for individualization of drug dose and involves the following: o convert pounds to kilograms o determine drug dose per BW by multiplying as follows: (drug) dose weight = dose (per day)

lb 2.2 = kg

BSA with the Square Root body surface area method is the most accurate for infants, children, older adults and clients who are on antineoplastic agents or whose body weight is low o determined by persons height and weight o multiply the drug dose ordered by the number of square meters you can find the BSA by using the square root and a fractional formula of height and weight divided by a constant:

BSA =

height weight 3131

height in INCHES weight in POUNDS 3131 = constant

CALCULATIONS OF ORAL DOSAGES Oral medications o advantages: Client frequently can take oral medications without assistance The cost of oral medication is usually less Oral medications are easy to store o Disadvantages: Variation in absorption as a result of food in GI tract and pH variation of GI secretions Irritation of the gastric mucosa Destruction or partial inactivation of the drugs by liver enzymes

TABLETS, CAPSULES AND LIQUIDS tablets come in different forms and drug strengths o most are scored and thus can be broken when half of the drug amount is needed capsules are gelatin shells that contain powder or time-release pellets sustained-release capsules and control-released capsules should not be crushed and diluted because that means the medication will be absorbed at a much faster rate than intended. o If client has difficulty swallowing, liquid form is given: Suspension Syrup Elixir Tincture Enteric-coated tablets must not be crushed because medication can irritate the gastric mucosa o Pass through stomach into the small intestine where the drugs coating dissolves and then absorption occurs Liquid medications are poured into a medicine cup that is calibrated in teaspoons, tablespoons and milliliters.

DRUGS ADMINSTERED VIA NASOGASTRIC TUBE Oral medications can be given through a nasogastric tube but should not be mixed with the entire tube feeding solution when medications cannot be taken by mouth because of : o inability to swallow o decreased level of consciousness o inactivation of the drug by gastric juices o desire to increase effectiveness parenteral route = option! Administered intradermally, subcutaneously, intramuscularly (IM), or intravenously (IV)

INJECTABLE PREPARATIONS appropriate drug container (vial or ampule) and correct selection of needle and syringe are essential

VIALS AND AMPULES vial = small glass container with aself-sealing rubber top o some are multi-dose vials and can be used over time ampule = small glass container with a tapered neck for snapping open and only using once drug labels on vials and ampules provide information: o generic and brand name of drug

o o o o SYRINGES -

drug dose in weight experiation date directions about administration if in powdered form, mixing instructions

syringe is composed of barrel, plunger and tip where the needle joins the syringe o available in a variety of types and sizes, most common: 3-mL 5-mL tuberculin insulin metal and plastic (for prefilled cartridges) 3-mL: o calibrated in 0.1mL marks and minims amount of fluid is dependent on black rubber end of plunger 5-mL: o calibrated in 0.2mL marks usually used when fluid needed is more than 2.5mL frequently used when reconstituting the drg drug form with sterile bacteriostatic water or saline tuberculin syringe o 1-mL and slender with markings in tenths and hundredths marked in minims also used if the amount of drug is less than 1mL and for pediatric and heparin dosages. Insulin syringe o Capacity of 1mL but insulin is measured in units Calibrated to the 2-unit mark and 100 units = 1mL

Prefilled Cartridges and Syringes packaged in prefilled and disposable cartridges o usually contains 0.1 to 0.2mL of excess drug solution, excess solution must be dispelled before administered

Needles two components to needle size: o gauge (diameter of the lumen) o length larger the gauge number, the smaller the lumen; smaller the gauge, the larger the lumen

INTERPRETING INJECTABLE DRUG LABELS drugs for injections are stored in liquid and powder o drugs in powder form must be reconstituted before use

INTRADERMAL INJECTIONS intradermal injection is usually used for skin testing o usually tuberculin syringe with a 25-gauge needle usually, inner portion of the forearm is used o needle inserted with the bevel pointing upward and do NOT aspirate

SUBCUTANEOUS INJECTIONS drugs injected into the subQ are absorbed slowly because there are fewer blood vessels in the fatty tissue o amount of drug solution administered is generally 0.5 to 1mL at a 45-, 60- or 90-degree angle two types of syringes used: tuberculin 3-mL

Calculations: generally use the basic formula or ratio and proportion or the fractional equation formula

INSULIN INJECTIONS insulin is prescribed and measured in the United STates Pharmacopeia units o use an insulin syringe o calibrated to correspond with 100 units of insulin o administered subQ

Types of Insulins clear or crystalline and cloudy because of the protamine, which is used to prolong the action of insulin in the body o only clear insulin can be given IV as well as subQ categorized as o fast-acting (Regular and lispro) o intermediate-acting (Humulin N) o long-acting (Lantus) Lantus cannot be mixed with regular insulin Detemir (Levemir) is a new insulin that has slow onset and duration of action that depends on dosage and cannot be mixed with regular insulin Lantus is an analog of human insulin o First long-acting and recombinant DNA human insulin for clients with type 1 and 2 diabetes mellitus Clear-color that is NOT to be given IV, only through subQ

*SEE TEXTBOOK FOR MIXING INSULIN METHOD (pg. 78) INTRAMUSCULAR INJECTIONS muscle has more blood vessels than fatty tissue, so injections given IM are absorbed more rapidly than those given by subQ needle gauges: 19 and 20 for thick and 20 and 21 for thin solutions o administered at a 90-degree angle

Powdered Drug Reconstitution certain drugs lose their potency in liquid form and their manufacturers package these drugs in powdered form o reconstituted using a diluent (bacteriostatic water or saline)

Mixing Injectable Drugs drugs mixed together must be compatible to prevent precipitation o to determine compatibility, check with drug reference texts and the pharmacy

three methods: mixing two drugs in the same syringe from two vials mixing two drugs in the same syringe from one vial and one ampule mixing two drugs in a prefilled cartridge from a vial *SEE TEXT FOR METHODS AND INSTRUCTIONS (pg. 80-81)

CALCULATIONS OF INTRAVENOUS FLUID administer fluids that contain water, dextrose, vitamins, electrolytes and drugs o direct absorption and fast action o IV Push (bolus) Two methods: o Continuous IV infusion = replaces fluid loss, maintains fluid balance, serves as a vehicle for drug administration o Intermittent IV infusion = used for drug administration Responsibilities during drug prep: o Knowing IV sets and drop factors o Calculating IV flow rates o Mixing and diluting drugs in IV fluids o Gathering equipment o Knowing the drugs and expected and untoward reactions

CONTINUING INTRAVENOUS ADMINISTRATION healthcare provider orders the IV solution in liters over a 24-hour period or milliliters per hour o calculates IV flow according to drop factor and the amount of fluids to be administered and the time period

Intravenous Sets infusion sets are marketed by Abbott, Cutter, McGaw and Travenol o drop factor = number of drops per milliliter o macrodrip set = large drops o microdrip set = small drops IV fluids given at a slow rate to Keep Vein Open (KVO) or To Keep Open (TKO) o Suspected or potential emergency situation for rapid administration of fluids and drugs

Calculations Method 1: Three-Step 1.

2.

3.

Method II: Two-Step

1.

2.

Method III: One-Step 1.

INTERMITTENT INTRAVENOUS ADMINISTRATION Some IV drugs are prescribed to be administered three to six times a day in small volumes of IV fluid o Usually over a period of 15 minutes to one hour Separate tubing for IV drugs, the secondary IV line set, is inserted into a port of the IV connector on the continuous or primary IV line set o this is intermittent IV therapy

Secondary Intravenous Sets without IV Pumps two IV sets available to administer IV drugs are o the calibrated cylinder with tubing o secondary IV setused mostly to infuse small volumes and for childrens IV solutions IV piggyback (IVPB) Current trend to IV medication administration is the use of premixed IV drugs in 50- to 500-mL bags o Prepared by the manufacturer or by the hospital pharmacy With mixed IV drugs, cost is higher but rsk is lower

INTERMITTENT INFUSION ADAPTERS/DEVICES continuous IV fluid infusion is to be discontinued and intermittent drug therapy is to begin, an adapter is attached to the IV catheter or needle where the IV tubing was disconnected. o Adapters have ports or stoppers where needles and tubing can be inserted as needed to continue drug therapy

DIRECT INTRAVENOUS INJECTIONS Meds given by the IV injection route are calculated in the same manner as medications for intramuscular o Route is often called IV push o Clinically, it is the preferred route for clients with more muscle mass or decreased circulation Rapid onset of action Calculation errors can have serious consequences

ELECTRONIC INTRAVENOUS REGULATORS pumps are electronic intravenous (IV) regulators used in hospitals and some community settings o deliver the IV solution against resistanceflow rate is set in milliliters per hour o do not recognize infiltration

IV pumps recommended for use with all central lines and peripheral lines Two types of flow control: Volumetric regulator = specific volume of fluid at a specific rate in mL/hr Nonvolumetric regulator = designed to infuse at a drop rate in drops/minute

Safety Considerations for IV Use all should be checked every half hour or hour common problems: o kinked tubing o infiltration o free flow IV rates

Infusion Pumps various types of infusion pumps are shown o syringe pump o single-infusion pump o dual-channel infusion pump o Symbiq infusion pump

PATIENT-CONTROLLED ANALGESIA another way to administer drugs via IV o objective is to provide uniform serum concentration of drugs thus avoiding drugs peaks and valleys o reasons for the use of PCA: effective pain control without client feeling oversedated considerable reduction in the amount of narcotic used clients feelings of having greater control over their pain o choices available regarding delivery: at client demand continuously continuously and supplemented by client demand health care providers order must include: o drug ordered o loading dose o PCA dose o Lockout interval during which PCA cannot be administered o Dose limit maximum client can receive in a specified time

Client Teaching inform client pain should be tolerable and not absent advise client of safety features instruct client in use of control button (button is released, medication is administered) have client report any side effects or adverse reactions

CALCULATING FLOW RATES FOR INTRAVENOUS DRUGS depends on drug dosing instructions which indicate amount of solution for dilution and length of infusion time o nurse must calculate drug dose from order and then calculate flow rate

secondary sets = find drops per minute, use calibrated sylinders or any other nonvolumetric regulator

volumetric regulators = find milliliters per hour

SEE FORMULAS (pg. 94)

PEDIATRIC DRUG DOSAGES two methods considered safe in pediatric drug dosing: o body weight 2 o body surface area or m

ORAL oral pediatric drug delivery usually requires use of measuring device because most drugs for small children are in liquid form o small plastic cup o oral dropper o measuring spoon o oral syringe some liquid medications come with their own oral dropper

INTRAMUSCULAR sites for IM drugs are chosen on the basis of age and muscle development of the child o injections should be given in a manner that minimizes physical and psychosocial trauma o distractions or brief restraint may be necessary o comfort measures should be immediately follow the injection