1356358597 medicationselfstudypacketforpre orientationwithpedi1212

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ELLIOT HEALTH SYSTEM PATIENT CARE SERVICES INPATIENT, SURGICAL SERVICES, & EMERGENCY SERVICES

MEDICATION ADMINISTRATION REVIEW PACKET

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Elliot Hospital

Department of Clinical Education & Professional Development

You are receiving this self-study packet to prepare for the medication calculation exam, which will be administered during nursing orientation (Tuesday, the day following New Hire Orientation). Please study carefully.

Various methods of calculation are presented here. Please focus on a method that you are familiar with. You are expected to answer 100% of calculations on the exam accurately. Calculators will be provided. No written notes or formulas will be allowed.

Directions:  Review the orientation self-study packet [note: pages 13-15 are

required for nurses hired into areas with pediatric patients]

 Complete the sample tests  Review the correct answers provided  Review additional resources for support in performing calculations as needed

References:  Boyer, Mary Jo (2006) Math for Nurses. Philiadelphia: Lippincott, Williams and Wilkens

 Picker Gloria (2004) Dosage Calculations New York: Thomson Delmar Learning

Medication Safety Guidelines 1. When giving medications, make sure to verify the 7 RIGHTS RIGHT PATIENT RIGHT DRUG RIGHT DOSE RIGHT ROUTE RIGHT TIME RIGHT REASON RIGHT DOCUMENTATION 05/2014

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2. Whenever there is a change in your patient’s physical or emotional status, QUESTION the possibility of a drug reaction.

Call extension the Adverse Drug Reaction hotline (ext 4473) and leave a voice mail regarding the adverse drug reaction.

3. Before administering any unfamiliar drug to your patient, LOOK IT UP! Lexi-Comp is The Elliot Hospital’s only official reference for looking up medications, side effects, interaction potential, food and drug interactions as well as patient information pamphlets. This reference can be accessed from the Pharmacy Web page on IKE (local intranet).

4. When mixing two IV or IM medications, ALWAYS CHECK THE COMPATIBILITY CHART located on each floor, Lexi-Comp Online OR check with a pharmacist.

5. Digoxin, Lasix and Heparin are the drugs the RN most frequently administers IV push on the medical-surgical units – check policies if you have a question as to whether other medications can be given IV on your unit.

6. Heparin, Insulin, Epidurals, Narcotic Drips, Chemotherapy, PCA’s, TPN and Hypertonic (3%) Normal Saline are considered HIGH ALERT MEDICATIONS and require a second RN to check the medication before administration or dose change. * Refer to the EHS policy site for the High Alert Medication Policy.

7. Food and drug interactions are an important consideration for discharge planning. A few examples of important patient teaching content are:  Alcoholic beverages and certain foods should not be taken with MAO inhibitors (Nardil, Parnate) as it may result in hypertensive crisis.  Milk should not be taken with Tetracyclines since it renders the drug inactive.

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 Antacids should not be taken with Cipro since antacids inactivate the drug.

8. Elliot Health System unapproved abbreviations: •Decimal point without a leading zero (ex: .5 mg should be 0.5 mg) •Trailing zero (ex: 3.0 mg) •IU •MgSO4 •MSO4, MS •q.d. or QD •q.o.d. or QOD •U or u Abbreviations to avoid: •> and < •A.D., A.S., A.U. •cc •ug •O.D., O.S., O.U. •SQ or SC •TIW or tiw •Mag EQUIVALENTS: Gtt/min = ml/hr 1 gm = 1000mg 1000 ml = 1 liter 1 mg = 1000 mcgs 30 ml = 1 fluid ounce 1 kg = 2.2 lb 5 ml = 1 teaspoon (lbs  2.2 = kg) (kg x 2.2 = lb) Conversion Pearl: To calculate medications that are different units of measure, you must convert to like units.

Convert to smaller unit.

Example: Order: Tigan 0.30 grams daily Tigan 100 mg capsules on hand Convert 0.30 grams to mg by moving decimal point 3 spaces to right 0.30 grams = 300 mg Give 3 capsules, 100 mg each 05/2014

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CALCULATIONS 1. When the prescribed or desired drug dosage is different from what is available or â&#x20AC;&#x153;on-hand,â&#x20AC;? a dosage calculation is necessary to determine the amount of drug to give: Formula #1 desired dose (D) x (Q) quantity dose on hand is in = amt to give dose on hand (H) Example: Lasix 120 mg daily is prescribed. Lasix 40 mg tabs are on hand.

120 mg x 1 tab = 3 tabs 40 mg Formula #2 (Ratio-Proportion Method) Same Example as Above: Lasix 120 mg daily is prescribed. Lasix 40 mg tabs are on hand.

40 mg = 1 tab

120 mg x

x = 120mg 40 mg

40mgx = 120mg

X = 3 tabs

2. To calculate IV infusions for milliliters per hour : total volume = milliliters per hours total time (hours) Example: 500 ml of NS to infuse over 4 hours. What is the ml/hr?

500 ml = 125 ml/hr 4 hrs 3.To calculate intravenous drops per minute (gtt/min):

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volume in ml x drop factor = gtt/min total time to infuse in minutes Example: Physician order states infuse NS at 80 ml/hr. You cannot fine an infusion pump. Using a micro infusion set (60 drops/ml) calculate the gtt/min.

80 ml x 60 = 80 gtt/min* 60 min *Note when using a micro infusion set, the ml/hr is the same as the gtt/min Example: Physician orders 500 ml fluid challenge over 30 minutes for a urine output of 20 ml last hour. Using a macro set (10 drops/ml) calculate the gtt/min 500ml x 10 = 167 gtt/min 30 minutes

IMPORTANT NOTE :Always check the IV tubing package for the drop factor.

4. To calculate drug concentration: Amount of drug in solution* = concentration of drug in solution Total volume of solution (amount of drug/ml, expressed as mg/ml, mcg/ml, or units/ml) *NOTE: Always convert amount of drug in solution to same metric equivalent as ordered dose: i.e. convert gm to mg, or mg to mcg by moving decimal three places to the right.

Example: What is the drug concentration of our standard Heparin solution?

20,000 units = 40 units/ml 500 ml

To calculate doses based on body weight: Ordered dose per kilogram x patient weight in kg = dose

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Example: The physician prescribed Spectrobid 25 mg/kg for a 22 pound 12 month old. The med is to be given q 12hr. The child would receive ________mg every 12 hr.

Convert 22 lb to kg: 22 รท 2.2 = 10 kg

25 mg x 10 kg = 250 mg every 12 hr

To calculate dose NOT based on body weight: Calculation of flow rate for dose per hour: ordered dose = drug concentration

flow rate in ml/hr or gtts/min

Example : The physician orders 25 mcg/hr of Octreotide on your patient who has a GI bleed. The standard concentration is 1200mcg in 500 ml. What is the rate in ml/hr?

Calculate the concentration: 1200 mcg = 2.4 mcg/ml 500ml

25 mcg/hr = 10.4 ml/hr 2.4 mcg/ml

DOSAGE CALCULATION PRACTICE EXERCISES 1. If an order reads 0.25 gm of Chloramphenicol (Chloromycetin), how many mg would you administer to the patient?

2. A patient must receive 1.5 mg of dexamethasone (Decadron) 05/2014

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p.o. The tablets available are 0.5 mg each. How many tablets will you give to the patient?

3. The order is 0.75 gm of aminophylline (Aminophylline) IV. The vial reads aminophylline 250 mg in 10 mL. How many milliliters will you administer?

4. One thousand milliliters of D5W is to infuse over 12 hours.

A. Calculate the rate of infusion in mL/hour.

B. Then the number of drops per min. Drop factor: 10 gtts = 1mL. 5. Order: 500 ml 10% dextrose in water IV are to be infused in four hours. The drop factor is 10 gtt = 1 mL. How many milliliters per hour will the patient receive?

6. Valium 2 mg IV is ordered. The medication is available for injection as 5 mg/ml. You would administer ___________ mL. 7. Calculate the drip rate for 1000ml D5 .45 N/S to run at 85 ml/hour. The gtt factor is 10 gtts = 1mL. 8. Dr. Smith orders 20,000 units of aqueous heparin to infuse as a continuous drip in 500 mL D5W at 25 ml/hr. How much heparin is this patient receiving per hour?

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CALCULATION ANSWER SHEET 1. 0.25 gm x 1000 mg = 250 mg of chloramphenicol 2. 1.5 mg = 3 tabs 0.5 mg 3. 0.75 gm x 1000 mg = 750 mg (desired dose in mg)

4.

10 ml = x ml 250 750 ml

= 7500 250

= 30 ml

a. 1000ml = 83 ml/hr 12 hr b. 83 ml x 60 min

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X = 13.8 gtts/min (or 14) 5. 500ml = 125 ml/hr 4 hr 6. 2 mg x 1 ml = 5 mg

0.4 ml

7. 85 ml/hr x 10 = 14 gtts/min 60 min

(ml/hr x gtt factor = gtts/min) 60 min

8. 20,000 units = x units = 500,000 = 1,000 units/hr 500 mL 25 mL 500

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Pediatric Medication Math Tips

This section applies to those nurses working in areas that care for pediatric patients.

EHS Resources: 



Acceptable Pharmacy Dosing and Medication References: o Lexi-Comp-Available via IKE or via link in E-MAR. o The Teddy Bear Book (resource for parenteral drugs). o Neofax (infants in the NICU).

During the day (Mon-Fri) we have a Pediatric Pharmacist available on Pedi, PICU, and NICU for questions.

Tips on Administering Medications to Infants and Children: For all medication routes consider:  Approach the child confidently and expect success. Involve parents and caretakers in the medication giving process by asking questions about how the child takes medications, “How does Suzy take medicine at home?” “Do you have a routine at home that makes the process easier for her”.  Offer children reasonable choices. Do not ask “would you like to take your medication now” That is often met with a “no”. A better approach may be to say “I have some medication for you to take now Suzy. Would you like to take this with some juice or a Popsicle?” Or “I have some medication to give you now, would you like me or mommy to give it to you?”  Be honest when describing the taste or smell of medication. If you tell the child it tastes good, like chocolate, and it doesn’t, then they will be mistrustful of you with other procedures during the hospitalization. Medication should not be presented like candy. The child should understand that this medication will help them feel better. Older children may want to know what the medication is for or how it will help them. Give age appropriate explanations.  Offer children lots of praise for their cooperation. Stickers can be a great reward for young children. Do not incorporate punishment or threats into 05/2014

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medication administrations. Many children have anxiety around being in the hospital and are worried that something will hurt or scare them. Child-Life Specialist are a good resource for helping to explain to the child why medication is important and providing play and distraction to help with medication administration. Child Life Office X3416.

Oral medication considerations: o Liquids are easiest for infants and toddlers. Older toddlers or preschoolers may prefer a chewable tablet when available. Discuss with the parents which form child would prefer if there is an option. o Oral syringes (obtained from Pharmacy) are use to draw up liquid medications using weight based doses. Measuring with spoons or droppers has been shown to be inaccurate. o When tablets must be crushed mix in a small amount of sterile water, beverage, or soft food. Check with pharmacy for compatibility issues.

Avoid mixing medication in essential food, like formula, as the child may begin to refuse those foods. o When giving oral meds to infants: Position the child in a semi-fowler position with parent or caregiver cuddling and gently restraining infant.

Place syringe in infant’s mouth along the tongue directed towards the check. Administer slowly 0.5-1ml at a time, allow the infant time to swallow. If the infant uses a pacifier this may assist in the swallowing of the medication. o Toddlers and pre-schoolers may want to give themselves the medicine and find the oral syringe and medication cups novel. Children of this age like to show some independence from their parents and want to show “I can do this myself!” o School-age or adolescent child: Many children this age can swallow pills but it is best to check with the parent or child first. This may be a place to offer options to the child. o When multiple routes exist (i.e. Tylenol ordered for po or pr) attempt the least invasive route first. Young children may view hospitalization as punish or they are sick because they were bad. Older children may look at an invasive route as breach of their privacy or embarrassment.

Once again, when reasonable choices exist, offer them to the child and the parents.

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Pediatric Medication Math Tips: Helpful conversion to keep in mind when calculating pediatric doses:  2.2 lbs=1kg  1kg=1,000 grams  1mg=1,000 mcg  1 liter=1,000 ml  Lexi-Comp is the EHS reference for pediatric dosages.

Sample Problem 1: Jane is 20 lbs and is ordered for acetaminophen 120 mg po q 6hrs prn pain/fever. Is this an acceptable weight base dose for Jane?

1.

2.

3.

4.

20/2.2=9.09 or round to 9 kg as a medication weight.

Lexi-comp reference dosing for acetaminophen is 10-15 mg/kg every 6 hours.

9 x 10= 90mg and 9 x 15= 135 mg.

Yes, 120 mg is within Jane weight-base dose.

Sample Problem 2: Johnny is 25 lbs and is ordered for 250 mg of amoxicillin po every 8 hours. Is this an acceptable weight base dose for Johnny?

1. 25/2.2=11.3 or round to 11 kg.

2. Lexi-comp reference states for amoxicillin 20-100mg/kg/day divided every 8-12 hours.

3. 11 x 20=220 (remember to divide by 3. This “3” is from the 3 doses Johnny will get in 24 hours is the medication is given every 8 hours). 220/3=73 4. 11 X 100=1100/3=366.

5. Yes, 250 mg is an acceptable weight base dose.

Our Computerized Physician Order Entry (CPOE) via EPIC (our electronic documentation system) provider the medical staff with many of these references ranges and assists the Provider with accurately calculating doses. When the nurse verifies the medication, that verification assumes they are insuring this does is accurate and safe for the child.

Some high alert medications require a second nurse witness that should be checking calculations and any infusions set-up in the Alaris pump.

Remember in Pediatrics that decimal points are important and if not calculated carefully can lead to under or over dosages of medications.

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Pediatric Fluid Calculations:

In pediatrics we often look at what the child’s maintenance fluid will be which is once again based on the child’s weight.

Maintenance fluid is often considered when the child is dehydrated or is at risk for fluid volume deficit. Nursing assessment helps determine the degree of deficit plus the child’s urine output which is usually 1-2 ml/kg/hr. If the child is in a fluid deficit the physician will often look at the child’s maintenance and increase that volume by 1, 1.5 or 2X that volume.

Maintenance Fluid Calculation: Use 4.2.1 Rule: for hourly rate  0-10kg: 4 ml/kg/hr  Next 10-20kg: 2ml/kg/hr  Over 20 kg: 1ml/kg/hr Sample Problem 1: Sam is 22 kg and has been admitted with vomiting and diarrhea.

What is Sam’s maintenance fluid? How about 1.5 X maintenance?

10(4) + 10(2) + 2(1)= 62 ml/hr is Sam’s maintenance.

62(1.5)=93 ml/hr is 1.5 X Sam’s maintenance.

We would expect Sam’s Urine output to be at least 22 ml per hour if he is adequately hydrated.

Pediatric Fluid Bolus= 20 x weight in kg.

Sam’s fluid bolus would be 440 ml.

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