2. © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 14 Parenteral Dosages and Other Medication Administration Forms PowerPoint ® Presentation to accompany: Math and Dosage Calculations for Healthcare Professionals Fourth Edition Booth, Whaley, Sienkiewicz, and Palmunen

3. 14-2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 14.1 Calculate doses of parenteral medication in solution and select a syringe based on the dosage calculation. 14.2 Calculate doses of medication expressed in percent or ratio format. Learning Outcomes

4. 14-3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 14.3 Calculate doses of reconstituted parenteral medications. 14.4 Differentiate other medication administration forms and equipment. Learning Outcomes

5. 14-4 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms  Absorption rate  Inhalant  Instillations  Metered dose Inhalers (MDIs)

6. 14-5 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Introduction  Parenteral medications Bypass the digestive tract Include  Injections  Inhalants  Rectal drugs  Transdermal drugs

7. 14-6 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Introduction (cont.)  Injection types & absorption rates Intravenous (IV) – 30 to 60 seconds Intramuscular (IM) – 10 minutes or more Subcutaneous (Subcut) – 15 minutes or more Intradermal (ID) – sustained rate

8. 14-7 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution  Injections mixtures that contain the drug dissolved in an appropriate liquid  Dosage or solution strength the amount of drug contained within a volume of solution

9. 14-8 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages In Solution (cont.)  Dosage strength expressed in milligrams per milliliter as a percent  Lidocaine 1% = 1 g lidocaine /100 mL as a ratio  Epinepherine 1:1000 = 1 g epinepherine / 1000 mL

10. 14-9 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages In Solution (cont.)  Physician’s order – the amount of medication  Calculate – milliliters of solution that contains the desired dose

11. 14-10 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages In Solution (cont.)  Follow the ABCs of dosage calculation. Start with H, Q, and D Step A: Convert

12. 14-11 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages In Solution (cont.) Step B: Calculate  Proportion  Dimensional Analysis  Formula Method Step C: Think!...Is It Reasonable?

13. 14-12 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Syringe Sizes  After you determine the amount to give, you must select the appropriate syringe and needle.

14. 14-13 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Syringe Sizes (cont.) Rule 14-1 Rule 14-1 Selecting a syringe: 1.If the amount of injection to administer is 1 mL or more, use a standard 3 mL syringe.

15. 14-14 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Syringe Sizes (cont.) Rule 14-1 Rule 14-1 (cont.) 2.If the amount of injection to administer is less than 1 mL, use a 1-mL tuberculin syringe. 3.If the amount of injection to administer is less than 0.5 mL, use a 0.5-mL tuberculin syringe.

16. 14-15 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Amount to be administered is calculated at 0.6 mL. Which syringe would you use? Since this is less than 1 mL and greater than 0.5 mL, a tuberculin syringe should be used. Example

17. 14-16 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Rule 14-2 Rule 14-2 Rounding the Amount to Administer: 1.Round volumes greater than 1 mL to the nearest tenth (one decimal). 2.Round volumes less than 1 mL to the nearest hundredth (two decimals).

18. 14-17 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Amount to be administered is calculated to be 1.66 mL The volume is greater than 1 mL – round to the nearest tenth – 1.7 mL Example

19. 14-18 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Amount to be administered is calculated to be 0.532 mL. The volume is less than 1 mL – round to the nearest hundredth – 0.53 mL. Example

20. 14-19 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.)  Can the amount to be administered be safely injected into one site? If not, divide the amount into equal (or nearly equal) parts. Administer them in separate sites.

21. 14-20 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Rule 14-3 Rule 14-3 Maximum volumes for injections: Intramuscular Injections Adult 3 mL Adult Deltoid (arm)1 mL Child (6-12 years old)2 mL Child (0-5 years old)1 mL Infant (premature)0.5 mL Subcutaneous injections1 mL

22. 14-21 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Ordered: Compazine 7.5 mg IM On hand: Compazine 5 mg/mL Find the amount to administer and select the proper syringe. Example

23. 14-22 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) H = 5 mg Q = 1 mL D = 7.5 mg Step A No conversion is needed. Example (cont.)

24. 14-23 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Step B Use method of choice to calculate amount to administer. 7.5 mg / 5 mg x 1 mL = A 1.5 x 1 mL = 1.5 mL = A Example (cont.)

25. 14-24 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Calculating Parenteral Dosages in Solution (cont.) Step C Desired dose is 1.5 times the dose on hand, so it is reasonable. Standard 3 cc syringe is used since amount to administer is greater than 1 cc. Example (cont.)

26. 14-25 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format  Medications labeled as percents or ratios must be converted before calculating amount to administer. Percent (per 100) means grams per 100 mL. Ratio means gram per mL.

27. 14-26 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format Rule 14-4 Rule 14-4 When a solution strength is expressed as a percent or ratio: 1. Convert the percent or ratio to a dosage strength of g/mL, mg/mL, or units/mL.

28. 14-27 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format Rule 14-4 Rule 14-4 (cont.) 2. Calculate the amount to administer; then apply Rules 14-1 to 14-3.

29. 14-28 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format (cont.) Find the amount to administer and select the proper syringe. Ordered: magnesium sulfate 300 mg IM On hand: magnesium sulfate 10% solution Patient: 75 pound 8 year-old female Example

30. 14-29 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format (cont.) H = 10 g Q = 100 mL D = 300 mg Step A Convert 10 % solution = 10 g (H) / 100 mL (Q) D : 300 mg = 1 g : 1000 mg 300 x 1 g = D X 1000 300 g / 1000 = 0.3 g = D Example (cont.) 0.3 g

31. 14-30 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format (cont.) Step B Calculate using method of choice. 0.3 g / 10 g x 100 mL = A 0.03 x 100 mL = A 3 mL = A Example (cont.)

32. 14-31 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format (cont.) Step C The concentration of the medication is 1 to 10, so the volume to be administered should be 10 times the desired dose. 3 is 10 times larger than 0.3, so it is reasonable. Example (cont.)

33. 14-32 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medications Expressed in Percent or Ratio Format (cont.) The amount to administer is 3 cc, so a standard 3 cc syringe can be used. However, because the patient is 8 years old, the medication must be given in divided doses. Example (cont.)

34. 14-33 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Find the amount to administer, and select appropriate syringe. Answer: 0.4 mL Ordered: 0.4 mg Epinephrine stat On Hand: Epinephrine 1 : 1000 Solution Use a 0.5 mL tuberculin syringe.

35. 14-34 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Find the amount to administer. Ordered: Zinacef 500 mg IM On Hand: Zinacef (cefuroxime for injection) 750 mg reconstituted with 3mL sterile water. Dosage strength after reconstitution is 225 mg/mL Answer: 2.2 mL in a standard 3 mL syringe

36. 14-35 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications  Medications that lose potency quickly in solution are supplied in powdered form; are reconstituted using an appropriate diluent.

37. 14-36 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.)  Determine the solvent to be used to dilute medication. Sterile water Saline Bacteriostatic solution  Some meds are packaged with the appropriate solvent.

38. 14-37 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.)  Some medications are mixed with lidocaine. This decreases pain on injection. Label or package insert indicates when lidocaine can be used. Must have a physician’s order to use it.

39. 14-38 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Rule 14-5 Rule 14-5 To reconstitute a powdered medication: 1.find the directions; 2.use a sterile syringe and aseptic technique to draw up the diluent;

40. 14-39 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Rule 14-5 Rule 14-5 (cont.) 3.inject the diluent into the medication vial; 4.agitate the mixture by rolling, inverting, or shaking the vial.

41. 14-40 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Rule 14-5 Rule 14-5 (cont.) 5.make sure the powdered medication is completely dissolved. The solution must be free of visible particles.

42. 14-41 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.)  Use the specified amount of diluent. Too much – Dosage strength will be incorrect. Too little  Powder may not dissolve completely.  Dosage strength will be incorrect.

43. 14-42 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Rule 14-6 Rule 14-6 When storing a medication after reconstitution: 1.record the date, the time of expiration, and your name or initials; 2.for multiple-dose medications, also record the solution strength.

44. 14-43 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Amount of diluent = 5 mL Route = IV only Diluent = 0.9% NaCl without preservatives Instructions = shake to dissolve Solution strength = 38 mg/mL Storage = no refrigeration Example

45. 14-44 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Ordered: Gemcitabine HCl 125 mg IVSS On hand: see label H = 38 mg Q = 1 mL D = 125 mL Example (cont.)

46. 14-45 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Step A No conversion is necessary. Step B Calculate amount to administer using preferred method. 125 mg / 38 mg x 1 mL = A 3.29 x 1 mL = A 3.3 mL = A Example (cont.)

47. 14-46 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Reconstituting Powdered Medications (cont.) Step C Dose ordered (125 mg) is greater than 3 time that of dose on hand (38 mg), so 3.3 mL is reasonable. Example (cont.)

48. 14-47 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error Alert! Select the correct instructions for the strength and route ordered.

49. 14-48 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice How much diluent should you add to this vial? What are the storage instructions? Answer: 1 mL Answer: store between 2° and 8° C

50. 14-49 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Ordered: Synagis 75 mg IM Q8H On hand: What is the amount to administer? Answer: 0.75 mL

51. 14-50 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms  Intradermal (ID) injections Small doses given under first layer of skin 0.1mL or less administered with tuberculin syringe Most often used for diagnostic testing

52. 14-51 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Drops Also called instillations Deliver medication to nose, eyes, and ears Administered with droppers Administered with plastic squeeze bottles  Use equipment that comes with drugs that are administered as drops or sprays.  Sprays Deliver medication to nose and throat Administered with plastic squeeze bottles Administered with atomizers

53. 14-52 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Mists Inhaled by patient Delivered with the following equipment  Vaporizers  Nebulizers  Meter dose inhalers (MDIs)

54. 14-53 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Inhalants Metered dose inhalers (MDI)  An MDI is a measured dose of medication in a puff.  Read manufacturer’s instructions.  Techniques for use Closed mouth Open mouth Closed mouth with spacer

55. 14-54 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Nebulizers  Liquids mixed with sterile saline solution Single doses (sterile saline must be added) Single doses premixed with saline Multiple-dose containers (come with special droppers)  Physician specifies solution strength and amount to administer. Other Medication Administration Forms (cont.)

56. 14-55 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Vaginal Medications Douche Tablet or suppository  Rectal Medications Enema Suppository

57. 14-56 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Topical medications Applied directly to the skin  Gels  Creams  Ointments  Pastes Follow manufacturer’s instructions.

58. 14-57 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Other Medication Administration Forms (cont.)  Transdermal Systems Patches  Release liquid medication at a constant rate  Dosage strength expressed in mg or mcg per hour Ointments and creams

59. 14-58 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Ordered: Transderm Nitro 0.8 mg/h top On hand: 0.1 mg/h, 0.2 mg/h and 0.6 mg/h What is the amount to administer? Answer: 2 patches; 1 – 0.2 mg/h and 1 – 0.6 mg / h

60. 14-59 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary  In this chapter you learned to: calculate doses of parenteral medication in solution and select syringes based on dose calculation.

61. 14-60 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary  In this chapter you learned to: calculate doses of medication expressed in percent or ratio format; calculate doses of reconstituted parenteral medications.

62. 14-61 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary  In this chapter you learned to: differentiate other medication administration forms and equipment.

63. 14-62 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge How would you interpret a label that reads as follows? Heparin 1:5000 Answer: Each 1 mL contains 5000 units of heparin.

64. 14-63 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge What kind of syringe would you use to administer 0.4 mL IM? What kind of syringe would you use to administer 2.3 mL IM? Answer: 0.5 mL tuberculin syringe Answer: 3 mL standard syringe

65. 14-64 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge What is the maximum amount of medication that can be administered IM in one site to an adult? Answer: 3 mL

66. 14-65 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge A 20% solution means that there is 20 g in how many mL? Answer: 100 mL

67. 14-66 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. End of Chapter 14 The best way to escape from a problem is to solve it. -- Alan Saporta