CHAPTER 17: ADMINISTRATION OF MEDICATION AND INTRAVENOUS SOLUTIONS PYRAMID POINTS CHAPTER 17: ADMINISTRATION OF MEDICATION AND INTRAVENOUS SOLUTIONS

PYRAMID POINTS I. Medication Administration Assess medication order Ask client about medication allergies Assess client’s understanding of medications, intravenous (IV) solutions ordered Assess client concerns about medications Assess five rights prior to and during administration process Assess vital signs prior to, during, and after administration, depending on medication Document administration of medication and client’s response to medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS II. Drug Measurement Systems Metric system Basic units are meter, liter, gram Apothecary and household systems Common apothecary units include grain, dram, ounce Common household units include tablespoon, teaspoon, minim, drop Additional common drug measures Milliequivalent (mEq) expresses the number of grams of a medication contained in 1 milliliter (mL) of a normal solution Unit measures medication in terms of action, not physical state Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS III. Conversions Between metric units Convert larger to smaller, multiply by 1000, or move decimal point three places to right Convert smaller to larger, divide by 1000, or move decimal point three places to left Between household and metric systems First step in calculation of dosages can use method of ratio and proportion Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IV. Celsius and Fahrenheit Temperature To convert Fahrenheit to Celsius: Subtract 32 from temperature in °F; divide result by 1.8 To convert Celsius to Fahrenheit: Multiply temperature in °C by 1.8; then add 32 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS V. Medication Labels Always check expiration dates Contains generic and trade name Check medication label against physician’s orders, medication administration record Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VI. Medication Orders Need to be written using accepted abbreviations, acronyms, symbols as well as per agency guidelines If nurse has any questions or sees inconsistencies, contact person who wrote order immediately Components of complete medication order Name of client Date, time when order written Name of medication Dosage of medication Medication route Time, frequency of administration Signature of person writing order Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VII. Oral Medications Scored tablets: Contain indented mark for breakage into partial doses if needed Enteric-coated tablets: Covering on medication that delays absorption until medication reaches small intestine Capsules: Contain powdered or oily medication in gelatin cover Liquids: Contain specific amount of medication in a given amount of solution Medicine cup: Capacity of 30 mL or 1 ounce; calibrated to measure teaspoons, tablespoons, fluid drams; pour medication while cup is at eye level Syringes: Used for volumes less than 5 mL Calibrated droppers: Used for infants, children; calibrations in mL, drops, or minims Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VIII. Parenteral Medications Injection route, including IV, intramuscular (IM), subcutaneous, or intradermal Single-use ampules, single- and multiple-dose vials, premeasured syringes and cartridges No more than 3 mL IM or 1 mL subcutaneous should be administered in one site Always question, verify excessively large or small volumes of medication Standard 3-mL syringe used to measure most medications; calibrated in tenths of a milliliter Calibrations on syringe read from top black ring on syringe, not middle or bottom ring Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VIII. Parenteral Medications (continued) Prefilled medication cartridge Standard medication doses rounded to nearest tenth Volumes larger than 3 mL, use 5-mL syringe calibrated in fifths Syringes available in 10-, 20-, and 50-mL sizes Tuberculin syringe holds 1 mL and is calibrated in hundredths of a mL; each one tenth marked on the metric scale Insulin syringe When combining regular and NPH insulin, draw regular insulin first, then NPH Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IX. Injectable Medications in Powder Form Used if medication is unstable when stored in solution form Powders must be dissolved with sterile diluent, usually sterile water or normal saline; follow directions that accompany the vial Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS X. Calculating the Correct Dosage Double-check dosage and question an order that calls for more than three tablets Double-check parenteral dosages and question an order that has amount that is too large a dose Nurse is legally responsible for medications administered, even if incorrect dose was prescribed All dose measures must be in same medication system Round standard injection doses to tenths; measure in 3-mL syringe Round small critical amounts or children’s dosages to hundredths; measure in 1-mL tuberculin syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS XI. Percentage and Ratio Solutions Percentage solutions Express number of grams of medication per 100 mL of solution Ratio solutions Express number of grams of medication per total milliliters of solution Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS XII. Calculating Medications Commonly used formula Desired/available  quantity = amount per dose Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS XIII. Intravenous Flow Rates Monitor IV flow rate every 30 minutes for adult, every 15 minutes for child If IV is running slow, collaborate with physician to increase flow rate appropriately Don’t speed up IV rate to catch up if infusion is behind schedule When increasing IV rate, assess cardiac and respiratory systems for signs of cardiac overload Rate flow of IV generally measured as mL/hr Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Volume per hour calculated in drops per minute IV tubing size directly correlated with drops/mL, which affects flow rate IV flow rate formula Total volume  drop factor divided by time in minutes = drops per minute Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS XIV. Electronic Flow Rate Regulators Controller Pump Works on same principle of gravity as regular IV drip; flow rate maintained by rapid compression and decompression of IV tubing by machine Height of solution bag is critical; thus, solution bag must be maintained at height of 36 inches above controller Flow rate set on controller as mL/hr Pump Physically pumps fluids against resistance; gravity not a factor Height of solution bag is not a factor Flow rate set as mL/hr Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS XV. Calculation of Infusions Ordered by Unit Dose Most common medications measured by units are heparin sodium and regular insulin Calculate by determining amount of medication per 1 mL; then determine infusion rate (mL/hr) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

The client is to receive 1000 mL of D5W at a rate of 100 mL/hr The client is to receive 1000 mL of D5W at a rate of 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? 1. 10 drops 2. 13 drops 3. 17 drops 4. 20 drops Answer: 3 Rationale: The first step is to determine how many hours the IV will last. This requires simple division of the total volume of mL to be infused (1000 mL) by the total mL per hour (100 mL), which is 10 hours. Then, convert hours to minutes, which is 600 minutes. Next, use the formula to calculate the flow rate: Total volume in mL  drop factor = flow rate in drops per minute Time in minutes 1000 mL  10 drops = 10,000 = 16.6, or 17 drops per minute 600 minutes 600 Test-Taking Strategy: Use the formula for IV drip rates when calculating these IV problems. Remember that you need to determine the time factor for the infusion and convert hours to minutes. Be careful with the multiplication and division and verify the answer with a calculator. Review IV flow rate formulas if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M. (2004). Fundamentals of nursing (2nd ed., p. 598). St. Louis: W.B. Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

The physician orders an intramuscular dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? 1. 0.25 mL 2. 0.8 mL 3. 1.5 mL 4. 8 mL Answer: 2 Rationale: Use the formula for calculating the appropriate medication dosage. In this question, performing a conversion is not necessary. The information needed to perform this calculation is the physician’s order (250,000 units of penicillin G benzathine [Bicillin]) and the available amount of 300,000 units/mL. Next, use the formula to calculate the dosage: Desired  mL = mL per dose Available 250,000 units__ = mL per dose 300,000 units/mL 250,000 = 0.83 mL 300,000 Test-Taking Strategy: Follow the formula for the calculation of the correct dose. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process—implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M. (2004). Fundamentals of nursing (2nd ed., p. 598). St. Louis: W.B. Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.