1. Background: Reconstitution of Medications (p. 367)
Some meditations are stable in the liquid state for only short periods of time.
Once mixed, a medication is good for only 1 to 14 days.
The mixing process is called reconstitution.
Many facilities reconstitute medications in the pharmacy.
Nurses may have to add and mix medications just before administration or in the home setting.
Powder is the solute; liquid is the solvent or diluent.
Always determine both the type and amount of diluent to be used for reconstituting medications.
Read and follow the label or package insert directions carefully to ensure that your client receives the intended dosage.
Consult a pharmacist or other appropriate resources if there are any questions.
Never assume!
NURSING APPLICATION:
Do you think Ms. Jackson would be able to mix a medication? What should the nurse do if Ms. Jackson has a medication of this type ordered when she is discharged?
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2. Calculation When Final Concentration is Not Stated (p. 376)
Directions may not state final concentration in unit of measure per milliliter
Example: Available 1 g of powder, add 2.5 mL diluent to yield 3 mL of solution containing 1 g
Concentration is calculated as follows:
1 g : 3 mL = x mg : 1 mL (needs conversion)
1000 mg : 3 mL = x mg : 1 mL
x = 333 mg per mL
Review basic principles for reconstitution, page 367.
Drug manufacturer provides directions for reconstitution, including information regarding the number of milliliters of diluent or solvent that should be added, as well as the type of solution that should be used to reconstitute the medication.
The concentration (or strength) of the medication after it has been reconstituted according to the directions is also indicated on some medications.
The directions for reconstitution must be read and followed carefully.
NURSING APPLICATION:
Explain to Ms. Jackson's family why the nurse would need to add a solution to a powder before giving an injection.
Copyright © 2011 by Elsevier Inc. All rights reserved.

3. Reconstitution of Non-injectable Solutions (Enteral Feedings) (p. 382)
Nutrition via gastrointestinal tract to clients who are unable to ingest food
Blended foods or feeding formulas
Administered in different ways:
Bolus: several times a day
Continuous: throughout the day or for a limited time period, delivered by electronic pump
Sample: Jevity® at 65 mL per hr via gastrostomy tube
Feedings may be started at dilute strengths to prevent intolerance.
The principles of reconstitution can be applied to nutritional liquids.
Enteral feeding solutions are formulated to be administered in full strength; however, the nurse may, on occasion, need to dilute the enteral solution before administering it. Before beginning calculations, discuss enteral feedings.
NURSING APPLICATION:
Ms. Jackson is unable to feed herself, and enteral feedings have been ordered. Explain to the family why the feeding is reconstituted.
Copyright © 2011 by Elsevier Inc. All rights reserved.

4. Common Medication Errors with Insulin (p. 404)
From Cohen, M. (2007) Medication Errors, ed 2
Incorrect rates programmed into insulin pumps
Incorrect concentrations of insulin used to prepare dose
Use of tuberculin syringes to prepare dose (10-fold errors)
Look-alike names and packaging
Miscommunication of orders
“U” read as “0” instead of units (e.g., 5 U read as 50)
Insulin is used in the treatment of diabetes mellitus, is a hormone secreted by the islets of Langerhans in the pancreas.
It is a necessary hormone for glucose use by the body. Individuals who do not produce adequate insulin experience an increase in their blood sugar (glucose) level.
Accuracy in insulin dosing is critical.
NURSING APPLICATION:
It has been determined that Ms. Jackson will need to have insulin. What is a major safety concern when giving insulin? Why?
Copyright © 2011 by Elsevier Inc. All rights reserved.

5. Appearance of Insulin (p. 408)
Clear insulins
HumulinR (regular): short acting, can mix
Humulog (lispro): short acting, can mix
Novolog (aspart): short acting, can mix
Apidra (glulisine): short acting, can mix
Levemir (detemir): LONG acting, CANNOT mix
Lantus (glargine): LONG acting, CANNOT mix
Cloudy
NPH: can mix, combined mixture will be cloudy
Draw up clear mixable insulin first
The availability of the premixed combination insulins has also reduced the need for clients to mix insulins
DO NOT SHAKE INSULINS; gently roll in palms.
NURSING APPLICATION:
Is it still recommended that insulin be kept in the refrigerator?
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6. Measuring Insulin in a U-100 Syringe (p. 410)
Concentration is almost always 100 units per mL
No calculations are required.
Various types of syringes are used:
Lo-Dose:
0.5 mL capacity to deliver 50 units
30-unit syringe (0.3 mL) is even more accurate
Two types of 1 mL syringes:
Single scale
Odd-even scale: read on appropriate side for the dose being delivered (e.g., 16 units on even side, 17 units on odd)
Never use "U" for units (ISMP and TJC)
Insulin order must be written clearly and contain certain information to prevent errors in administration.
An error in administration can cause harmful effects to a client.
NURSING APPLICATION:
Why is there no need for calculations when giving insulin?
Copyright © 2011 by Elsevier Inc. All rights reserved.

7. Measuring Two Types of Insulin in Same Syringe (p. 418)
ALWAYS draw up regular or other short-acting insulin FIRST (solutions are clear); then draw up cloudy (NPH and admixtures such as 70/30)
Mix only same types, such as HumulinR with HumulinN, or NovolinR with NovolinN
NEVER mix Lantus or Levemir!
Both are clear too!
Sometimes individuals may require two different types of insulin for control of their blood sugar levels (e.g., NPH and regular).
To reduce the number of injections required, it is common to mix two insulins in a single syringe.
Regular insulin is always drawn up in the insulin syringe first: clear then cloudy insulin.
Drawing regular insulin up first prevents contamination of the regular insulin with other insulin. This sequence is extremely important.
NURSING APPLICATION:
Explain why it is important to use only the same types of insulins.
Copyright © 2011 by Elsevier Inc. All rights reserved.

8. Sequence for Mixing Insulins (p. 419)
Gently roll vials in palm to even suspension before withdrawing medication.
Cleanse tops of both vials with alcohol.
Inject air equal to dose of cloudy type into that vial first (do not touch solution with needle).
Remove needle from cloudy vial.
Using same syringe, inject air equal to needed dose into regular or other short-acting mixable insulin (clear); invert bottle and withdraw.
Remember, do not shake insulin.
Cloudy insulin should be rolled gently between the palms of the hands to mix it before it is drawn up.
Shaking creates bubbles in addition to breaking down the particles and causing clumping.
NURSING APPLICATION:
What should be done if the nurse drops one of the bottles of insulin?
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9. Sequence for Mixing Insulins (cont'd) (p. 419)
Remove needle from regular vial and check for bubbles (small bubbles can alter dose). Tap if necessary to remove bubbles.
Invert “cloudy” vial, insert needle into solution, and withdraw to desired total dosage. Stabilize plunger to avoid contamination with or loss of “clear” insulin.
The total volume should equal the total number of units ordered.
Insulins mix instantly; they do not remain separated. Insulin that has been overdrawn cannot be returned to the vial.
Insulin doses are always checked by two (2) nurses!
Have second nurse tell you what you have; do not tell the nurse what you have drawn.
Show second nurse your syringe and the vials.
NURSING APPLICATION:
Why should two nurses check insulin?
Copyright © 2011 by Elsevier Inc. All rights reserved.