Levi Adriano Santana, RN

Academic Instructor BSU College Of Nursing BSU College of Science Chief Nurse Apalit Doctors Hospital Inc Certified BLS/ ACLS Provider Philippine Heart Association/ Philippine College of Cardiology

NURSING PHARMACOLOGY
Dosages

Emergency and Disaster Responder MMDA Public Safety Division

Ways to calculate dosage:

Formula Method

Challenge: Must remember the extra step of changing D and H to same unit of measurement. Also may have extra variables such as body weight, times per day, etc.

D V H

Amount to Give

Ways to calculate dosage:

Ratio and Proportion

Linear Ratio and Proportion

500mg : 1 tab :: 1 g : x tabs

Fractional Ratio and Proportion

Product of the means equals the product of the extremes. The products of cross multiplication in a proportion are always equal

500mg 1g 1tab xtabs

Necessities for Student Success in Dosage Calculations Review of basic math functions fractions
and decimals
Adding Subtracting Multiplication Division

Students must memorize equivalents

The 4 main questions

What is the order? What is on hand? Do you need any equivalents? Where are you going? (or what are you being asked to give?)

Start with conversions

240 mg = ______ grains

240mg 1

Start with conversions

240 mg = ______ grains

4

240mg 1grain 1 60mg

1

grains

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

What is the order?

40mg 1dose

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

What is on hand?

40mg 10 ml 1dose 80 mg

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

Do you need any equivalents?

40mg 10 ml 1dose 80 mg

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

Where are you going? (or what are you being asked to give?)

40mg 10ml ________ ml 1dose 80mg

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

Begin by cross canceling labels

40 mg 10 ml ________ ml 1dose 80 mg

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

Labels left should be what you are looking for

40 mg 10 ml ________ ml 1dose 80 mg

Order: Lasix 40 mg PO daily Dose on Hand: 80 mg/10 ml

Do the math

40 mg 10 ml 5 ________ ml 1dose 80 mg
2
1

What about problems with different units of measurement?

Order: digoxin elixir 0.05 mg PO daily Label: Digoxin 50 mcg per ml How many milliliters will you give?

1ml 0.05mg 1000 mcg 1mg 1dose 50 mcg 1

20

1 ml

Complex Problems
Order: Augmentin 12.5mg/kg PO every 12 hours. Child weighs 22 lbs. Pharmacy sends a 75 ml bottle of Augmentin labeled 125mg/5ml. How many milliliters will you pour from the bottle?

12 .5mg 5ml 1kg 22 lbs kg / dose 125 mg 2.2lbs 1 pt.

12.5 5 1 22 1375 5 1 125 2.2 1 275

ml

What about IV problems?

Order: 250ml 5% D/W IV in 2.5 hours. Tubing package reads 15 gtts/ml. How many gtts/min will you adjust the IV?

gtts 250ml 15gtts 1hr 25 ___ 60 min . min 2.5hrs 1ml

250 15 1 3750 25 2.5 1 60 150

Physicians order Daypro 1200 mg bid.

1200 mg 1cap 1dose 600 mg

1

cap

Order: Estratab 1250mcg daily

1250 mcg 1tab 1mg 1dose 1.25 mg 1000 mcg

1250 1 1 1250 1 1 1.25 1000 1250

1 ta
b

Practice Problems

Your patient may receive Dilaudid 3 mg IM q3h for pain. Dilaudid is supplied in 1-ml ampules containing 4 mg. How many milliliters will you administer?

3mg 1ml = 0.75 ml 1dose 4mg

The physician orders heparin 2500U subq. You have heparin, 5000U per ml. How many ml will you administer?

1ml 2500u 5000u 1dose

2

1 ml 2

Your patient needs morphine gr 1/6 SQ stat for chest pain. You have a 20 ml vial labeled 15mg/ml. How many milliliters will you give?

1 / 6 gr 1ml 60mg 0.67 ml 1gr 1dose 15mg

1 / 6 x 60 60 / 6 10 0.67 15 15 15

A patient with tachycardia has an order for Brevibloc to be started at 50 mcg/kg/min. The concentration is Brevibloc 5 g in 500ml of D5W. The patient weighs 176 pounds. How many ml/h should the IV pump be programmed for?
50mcg 500ml 176lbs. 1kg 60 min 1mg 1g 1000mcg 1000mg 1hour kg / min 5g 2.2lbs 1 pt .
1 25 1

24ml/hr

50 500 176 1 1 1 60 24 1 5 1 2.2 1000 1000 1

1 1 2 1 40 1

2 80

12

Reconstitution
Reconstitution problems ask the nurse to dissolve a drug (typically a powder) whose quantity is usually expressed in grams or milligrams in:
a specific quantity of a liquid (usually measured in milliliters). Frequently, the liquid is normal saline (0.9% NS) or D5W. Conceptually, this is identical to dissolving 1 teaspoon of table salt in 1 cup of hot water.

25

Reconstitution
Order: 350 mg of the drug to be given q8h IV. How many mL will you give per dose? Supply: The drug is available in 500 mg containers. The label tells the nurse to dissolve the powder in 25 mL of normal saline (NS).

26

Reconstitution
Which pairs of data do you find in the problem? 350 mg every 8 hours. (every 8 hours means: 1 dose.) 500 mg of the powder is dissolved in 25 mL of NS.
What is the answers label for your calculation? How many mL/dose? Can you isolate all of the components that are 27 required to solve this problem? (YES, of course

Answer Reconstitution

mL/dose = (25 mL/500 mg) * (350 mg/dose) = 17.5 mL/dose

28

Reconstitution
Order: 250 mg of the drug to be given q8h IV. How many mL will you give per dose? Supply: The drug is available in 1g containers. The label tells the nurse to dissolve the powder in 50 mL of normal saline (NS).

29

Answer Reconstitution
mL/dose = (50 mL/1 g) * (1 g/1000 mg) * (250 mg/dose) = 12.5 mL/dose

30

Reconstitution
Order: 20 mg/Kg of the drug to be given q8h IV. Patient weighs 50 pounds. How many mL will you give per dose?
Supply: The drug is available in 500 mg containers. The label tells the nurse to dissolve the powder in 5 mL of normal saline (NS). With which data pair is the dose a factor? Why?
31

Answer Reconstitution

mL/dose = (5 mL/500 mg) * (20 mg/1 Kg/1 dose) * (1 Kg/2.2 lbs) * (50 lbs/1)

= 4.545 rounds up to 4.55 mL/dose

Dose is only related mg/Kg.

32

Reconstitution Graphic
5 million Units in 3.2 mL

1 million Units/1 mL

The patient

Which medication source DIRECTLY affects the patient?

33

10-34

IV Solutions

Intravenous (IV) fluids

Delivered directly into the bloodstream via a vein

Includes
Solutions Medications Blood

Rapid effect

Results can be fatal if wrong medication or dosage is given.

10-35

IV Solutions FUNCTIONS

Replacement
Electrolytes Fluids

KVO fluids
Keep Vein Open Maintain an IV line

Maintenance
Fluid balance Electrolyte balance

Therapeutic
Delivers medication to patient

10-36

IV Solutions IV LABELS
Solution

labels

Name of components The exact amount of components

10-37

IV Solutions IV LABELS
(cont.)

Rule 10-1 In abbreviations for IV

solutions:

Letters identify components

Numbers identify concentration

10-38

IV Solutions IV LABELS (cont.)

Example

5% dextrose in Lactated Ringers solution might be abbreviated in any of the following ways:

D5LR

D5LR

5%

D/LR D5%LR

10-39

IV Solutions COMMONLY
USED ABBREVIATIONS
ABBREVIATION SOLUTION

D10W D5W W; H2O NS; NSS LR

RL

10% dextrose in water 5% dextrose in water Water Normal saline (0.9% NaCl) Lactated ringers
Ringers lactate

10-40

IV Solutions COMMONLY
USED ABBREVIATIONS (cont )
ABBREVIATION SOLUTION

NS; NSS

One-half normal saline solution (0.45% NaCl) 1/ NS; 1/ NSS One-third normal saline solution 3 3 (0.3% NaCl) NS; NSS One-fourth normal saline solution (0.225% NaCl)

10-41

IV Solutions
IV CONCENTRATIONS

5% Dextrose contains 5 g of dextrose per 100 mL Normal saline

0.9% saline Contains 900 mg, or 0.9 g, of sodium chloride per 100 mL.

Normal saline

0.45% saline Contains 450 mg, or 0.45 g, of sodium chloride per 100 mL

10-42

IV Solutions
IV CONCENTRATIONS (cont.)

Choice of solution is based on patient requirements

Isotonic IV solutions

Do not affect fluid balance of cells and tissues D5W, NS, LR

10-43

IV Solutions
IV CONCENTRATIONS (cont.)

Hypotonic IV solutions

Move fluid into surrounding cells and tissues Restore proper fluid level in cells and tissues Used to correct dehydration 0.45% NS, 0.3% NS

10-44

IV Solutions
IV CONCENTRATIONS (cont.)

Hypertonic IV solutions

Draw fluid from cells and tissues into blood stream Used to correct severe fluid shifts (burns) 3% Saline

10-45

IV Solutions
IV CONCENTRATIONS (cont.)

Rule 10-2
Patients with normal electrolyte levels are likely to receive isotonic solutions. Patients with high electrolyte levels will receive hypotonic solutions.

Patients with low electrolyte levels will receive hypertonic solutions.

10-46

IV Solutions COMPATIBILITY

Additives
Medications, electrolytes, and nutrients If not prepackaged, will have to mix.

10-47

IV Solutions
COMPATIBILITY (cont.)
Rule 10-3 Before combining any medications, electrolytes, or nutrients with an IV solution, be sure the components are compatible.

10-48

IV Solutions
COMPATIBILITY (cont.)
Examples of incompatible medications/solutions Ampicillin D5W Cefotaxime sodium
Diazepam Dopamine HCl

Sodium bicarbonate
Potassium chloride Sodium bicarbonate

Penicillin
Penicillin Sodium bicarbonate

Heparin
Vitamin B complex Lactated Ringers

Tetracycline

Calcium chloride

10-49

IV Equipment

Primary Line

Bag or bottle of IV solution 500 mL or 1000 mL

Tubing
Drip

chamber Clamp regulate IV Injection ports

Add medication or compatible fluid Attach a second line

10-50

Roller clamp

Injection ports

Drip chamber

10-51

IV Equipment (cont.)

Tubing

Macrodrip
Larger

drops in drip chamber Infusion rates of 80 mL/h or more

Microdrip
Smaller

drops in drip chamber Infusion rates less than 80 mL/h and KVO Pediatric and critical care IVs

10-52

IV Equipment MONITORING

Manually

Hang the bag hung 36 inches above patients heart Adjust flow rate using roller or screw clamps
Usually

adjusted in gtt/min

10-53

IV Equipment MONITORING
(cont )

Electronic devices

Rate controllers
Gravity

Pincher

maintains flow rate sounds when preset flow rate is not maintained

Alarm

10-54

IV Equipment MONITORING
(cont.)
Infusion
Apply

pumps

pressure to deliver set volume per minute

Sensor

/alarm

Improper

rate Empty bag

Must

monitor site for infiltration

10-55

IV Equipment MONITORING
(cont.)
Syringe

pumps
is inserted into pump
medications

Syringe

Incompatible

or fluids Pediatric doses

Provide

precise control over rate

10-56

IV Equipment MONITORING
(cont.)

Patient-Controlled Analgesia (PCA) Device Patient controls medication within preset limits per physicians order
Records
Used

number of times button is pushed

to monitor effectiveness of pain relief prescription

10-57

IV Equipment MONITORING
(cont.)
Volume

control sets
accuracy of

Improve

Manual

IV setups Electronic rate controllers Small volumes of fluids or medications

Uses:

pediatric or critical care IVs Examples: Buretrol, Soluset, and Volutrol

10-58

Peripheral and Central IV Therapy

Peripheral

IV Therapy

Accesses the circulatory system through a peripheral vein

Hand,

forearm, foot, leg Scalp vein in infants

10-59

Peripheral and Central IV Therapy (cont.)

Central IV Therapy

Central line provides direct access to major veins

Used when patient needs:

Large

amounts of

fluids A rapid infusion of medication Infusion of highly concentrated solutions Long-term IV therapy

10-60

Peripheral and Central IV Therapy (cont.)

Central IV Therapy

PICC peripherally inserted central catheter

Inserted

into arm vein and threaded into a central vein

Port-A-Cath
Surgically

placed under the skin for access to central vein Accessed through the skin For intermittent use

10-61

Peripheral and Central IV Therapy (cont.)

Rule 10-4 Never flush a sluggish IV with a syringe.
May push a clot into the circulatory system

10-62

Peripheral and Central IV Therapy (cont.)

Pain or swelling at the site

Infiltration
Needle

or catheter becomes dislodged from the vein

Fluid infuses into the surrounding tissues Signs

Swelling Discomfort Coolness

at the infiltration site Sizeable decrease in flow rate

10-63

Peripheral and Central IV Therapy (cont.)

Phlebitis
Inflammation Causes
Irritation

of the vein
Signs

by IV additives Movement of needle or catheter Long-term IV therapy

/ Symptoms
at or near

Pain

site Heat Redness Swelling at site

10-64

Peripheral and Central IV Therapy (cont.)

Treatment of infiltration or phlebitis

Stop IV infusion Restart in a different site

10-65

Practice
Matching:

D Isotonic F Hypotonic
I Hypertonic

E Central line
H Phlebitis C Infiltration

B PCA G Macrodrip A Microdrip

A. B. C. D. E. F. G. H. I.

60 gtt/mL Patient controls medication Fluid infuses into tissues For normal electrolyte levels PICC For high electrolyte levels 15 gtt/min Inflammation of a vein For low electrolyte levels

10-66

Calculating Flow Rates

Flow rate - how fast the IV infuses

Calculated from
Amount of fluid to be infused

Length of time for infusion

Expressed as milliliters per hour

10-67

Calculating Flow Rates

(cont.)

Rule 10-5

To calculate flow rates in milliliters per hour, identify the following:

V (volume) expressed in milliliters T (time) expressed in hours (convert units as necessary) F (flow rate) rounded to nearest tenth

Use the formula method with

or dimensional analysis

to determine the flow rate in milliliters per hour.

10-68

Calculating Flow Rates

(cont.)
Example

Find the flow rate

Ordered: 500 mg ampicillin in 100 mL NS to infuse over 30 minutes

Convert minutes to hour: 30 60 = 0.5 hr Flow rate = 200 mL/hr

10-69

Calculating Flow Rates

(cont.)

Manually regulated IVs

Calculated as gtt/min Macrodrip

Microdrip tubing

Smaller drops Drop factor: 60 gtt/mL

Larger drops Drop factors: 10 gtt/mL, 15 gtt/mL, or 20 gtt/mL

10-70

Calculating Flow Rates

(cont.)

Rule 10-6 To determine the flow rate (f) in

drops per minute:
1. Change the flow rate mL/h (F) to gtt/min (f) using

the formula:
F = flow rate; mL/hr C = calibration factor of tubing; gtts/mL 60 = number of minutes in 1 hour

2. Round to nearest whole number.

10-71

Calculating Flow Rates

(cont.)
Example

Find the flow rate in drops per minute that is equal to 35 mL/hour using 60 gtt/mL microdrop tubing.

f = 35 gtt/min

10-72

Calculating Flow Rates

(cont.)
Counting

drops is not precise

Check IV hourly to see if it is on schedule Before adjusting the rate, check facility policy

10-73

Calculating Flow Rates

(cont.)

Rule 107 To adjust the flow rate:

Recalculate the infusion using the volume remaining in the IV and the time remaining in the order.

Check the guidelines at your facility before adjusting the flow rate.

10-74

Calculating Flow Rates

(cont.)
Example
Original Order: 1500 mL NS over 12 hours The IV was infusing at an original rate of 42 gtt/min using 20 gtt/mL macrodrip tubing. After 3 hours, 1200 mL remain in the bag.

Flow rate adjustments must not exceed 25%.

10-75

Calculating Flow Rates

(cont.)
Example (cont.)
Use formula

f = 44 gtt/min
25% of original rate of 42 gtt/mL = 10.5 Rate can be adjusted up or down within a range of 32.5 to 52.5 gtt/min. Rate can be adjusted to 44 gtt/min.

10-76

Practice
Calculate flow rate then determine if an adjustment is necessary.
Adjustment cannot exceed 25%. Ordered: 250 mL NS over 2 hours (10 gtt/mL tubing) After 30 minutes 100 mL infused.

10-77

Practice
Answer
Original drop rate Adjusted rate

f = 21 gtt/min

f = 17 gtt/min

25% of 21 = 5.25 Adjustment range = 15.75 to 26.75 You may adjust this infusion.

10-78

Infusion Time and Volume

If not specified in the order you may have to calculate

Duration if fluid volume and flow rate is known Fluid volume if the duration and flow rate is known

10-79

Infusion Time and Volume (cont.)

Rule 10-8 To calculate infusion time in hours
(T), identify the:
V (volume) expressed in milliliters

F (flow rate) expressed in milliliters per hour

Fractional hours by multiplying by 60

V T F

Use this formula or dimensional analysis to find T, the infusion time in hours.

10-80

Infusion Time and Volume (cont.)

Example Find the total time to infuse.

Ordered: 1000 mL NS to infuse at a rate of 75 mL/h T = 13.3 Total time to infuse the solution = 13 hours and 20 minutes

10-81

Infusion Time and Volume

(cont.)
Example

Find the total time to infuse. Ordered: 750 mL LR to infuse at a rate of 125 mL/hr started at 11 p.m.
T=6 The total time to infuse is 6 hours.

10-82

Infusion Time and Volume (cont.)

Rule 10-9 To calculate the time when an
infusion will be completed,

You must know:

1. The time the infusion started in military time 2. The total time in hours and minutes to infuse the solution ordered

10-83

Infusion Time and Volume (cont.)

Rule 10-9 (cont.)
Since each day is only 24 hours long, when the sum is greater than 2400 (midnight), you must start a new day by subtracting 2400. This will determine the time of completion, which will be the next calendar day.

10-84

Infusion Time and Volume (cont.)

Example Determine when the infusion will be completed. Ordered: 750 mL LR to infuse at a rate of 125 mL/hr and was started at 11 p.m. on 02/04/14 Infusion time = 6 hours 11 p.m. = 2300 hrs 2300 + 6 hours = 0500 or 5:00 a.m. on 02/05/14

10-85

Infusion Time and Volume (cont.)

Rule 10-10 To calculate infusion volume:
Use the formula V = T x F or dimensional analysis to find V the infusion volume in mL.

T (time) must be expressed in hours

F (flow rate) must be expressed in milliliters per hour

10-86

Infusion Time and Volume (cont.)

Example Find the total volume infused in

5 hours if the infusion rate is 35 mL/h.

V = 5 h 35 mL/h
V = 175 mL 175 mL will infuse in 5 hours

10-87

Infusion Time and Volume (cont.)

Example Find the total volume infused in

12 hours if the infusion rate is 200 mL/h. V = 12 h 200 mL/h V = 2400 mL 2400 mL will infuse in 12 hours

10-88

Intermittent IV Infusions

IV medications may be administered intermittently with or without continuous IV therapy.

Delivered through
IV secondary line Saline Heparin lock

10-89

Intermittent IV Infusions
SECONDARY LINES

Piggyback or IVPB
IV setup attaches to a primary line Infuse medications or other compatible fluids on an intermittent basis IVPB bags are smaller: 50, 100, or 150 mL

10-90

Intermittent IV Infusions
INTERMITTENT PERIPHERAL INFUSION DEVICES
Saline
An

or heparin locks

infusion port attached to an already inserted IV needle or catheter. direct injection of medication or infusion of IV medications.

Allow

10-91

Intermittent IV Infusions
INTERMITTENT PERIPHERAL INFUSION DEVICES (cont.)

No continuous flow of fluids

Requires flushing 2 to 3 times per day

Saline lock uses saline as the flush Heparin lock uses heparin, an anticoagulant, as the flush

10-92

Intermittent IV Infusions
(cont.)

Preparing and Calculating Intermittent Infusions

Flow rate is calculated the same as regular IV infusions. Amount of fluid may be less and time to infuse may be less than an hour. To calculate the flow rate you will need to change the number of minutes into hours.

10-93

Intermittent IV Infusions
(cont.)
Rule 10-11 When preparing medication for an intermittent IV infusion: Reconstitute the medication using the label and package insert.
Calculate amount to administer and the flow rate.

10-94

Intermittent IV Infusions
(cont.)
Example Ordered: Eloxatin 75 mg in 250 mL D5W IV piggyback over 90 minutes Reconstitute with 20 mL of water for injection. Dosage strength see label Calculate the amount to administer and the flow rate.

10-95

Intermittent IV Infusions
(cont.)
Example (cont.) Amount to administer Flow rate using 15 mL + 250 mL

A = 15 mL
F = 177 mL/h

10-96

Practice
Find total infusion time: Ordered: 650 mL 0.45 NS at 40 mL/h started at 0315 08/09/08 T = 16.25 hours Total infusion time = 16 hr 15 min When will this IV be completed?
7:30 p.m. 08/09/08

10-97

Practice
Find the volume to administer: Ordered: D5NS at 65 mL/hr for 8 hours V = 8 h x 65 mL/h V = 520 mL

Ordered: NS at 100mL/h for 45 min V = 0.75 h x 100 mL/h V = 75 mL

10-98

Apply Your Knowledge

Identify four functions of IV fluids.
ANSWERS 1.Replacement 2.Maintenance 3.KVO 4.Therapeutic

10-99

Apply Your Knowledge

How many mg of sodium chloride is in 100 mL of normal saline?
ANSWER 900 mg NaCl

How many mg of sodium chloride is in 100 mL of 0.45% NS?

ANSWER 450 mg NaCl

10-100

Apply Your Knowledge

When you adjust the IV flow rate, what percentage of the original flow rate should you not exceed? ANSWER 25%

Flushing a sluggish IV will not cause harm. Flushing may push a clot True / False into the circulatory system
causing an obstruction.

10-101

End