The Joint Commission (TJC) list of abbreviations that should be spelled out.

Abbreviation Use Instead

q.d., Q.D. Write “daily” or “every day.”
q.o.d., Q.O.D. Write “every other day.”
U Write “unit.”
IU Write “international unit.”
MS, MSO4 Write “morphine sulfate.”
MgSO4 Write “magnesium sulfate.”
.5 mg Write “0.5 mg,” use zero before a decimal point when the dose is less than a whole.
1.0 mg Do not use a decimal point or zero after a whole number.

The following abbreviations could possibly be included in future Joint Commission “Do Not Use” lists. These abbreviations
are as follows:

Abbreviation Use Instead

c.c. Use “mL” (milliliter).
mg Use “mcg” (microgram).
. Write “greater than.”
, Write “less than.”
Drug name abbreviations Write out the full name of the drug.
Apothecary units Use metric units.
@ Write “at.”

Other abbreviations can be found in Chapter 3, page 53.

Metric and Apothecary Conversion

Metric Apothecary
1 1000 15
0.5 500 71⁄2
0.3 300 (325) 5
0.1 100 11⁄2
0.06   60 (64) 1
0.03   30 (32)   1⁄2
0.015   15 (16)   1⁄4
0.010   10   1⁄6
0.0006    0.6   1⁄100
0.0004    0.4   1⁄150
0.0003    0.3   1⁄200

Liquid Conversion (Approximate)

30 mL = 1 oz = 2 tbsp (T) = 6 tsp (t)
1
15 mL = ⁄2 oz = 1 T = 3 t
1000 mL = 1 quart (qt) = 1 liter (L)
500 mL = 1 pint (pt)
5 mL = 1 tsp (t)
4 mL = 1 fl dr
1 mL = 15 (16) minims (m) = 15 (16) drops (gtt)
© The Joint Commission 2016. Reprinted with permission.
Clinical Calculations
With Applications to General
and Specialty Areas
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Clinical Calculations
With Applications to General
and Specialty Areas
Eighth Edition

Joyce LeFever Kee, RN, MS

Associate Professor Emerita
College of Health Sciences
Department of Nursing
University of Delaware
Newark, Delaware

Sally M. Marshall, RN, MSN

Formerly, Nursing Service
Department of Veterans Affairs
Regional Office of Medical Center
Wilmington, Delaware

Katy Woods, RN, BSN, DNP-C

Nurse Anesthesia Specialty
University of Maryland
Baltimore, Maryland

Mary Catherine (Katie) Forrester, RN, MSN, ACNP-BC

Vanderbilt University Hospital Trauma and Burn Center
Nashville, Tennessee
 3251 Riverport Lane
St. Louis, Missouri 63043

CLINICAL CALCULATIONS WITH APPLICATIONS TO ISBN: 978-0-323-39088-0

GENERAL AND SPECIALTY AREAS, EIGHTH EDITION
Copyright © 2016 by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2013, 2009, 2004, 2000, 1996, 1992, 1988

Library of Congress Cataloging-in-Publication Data

Names: Kee, Joyce LeFever, author. | Marshall, Sally M., author. | Woods,
Katy, author. | Forrester, Mary Catherine, author.
Title: Clinical calculations : with applications to general and specialty
areas / Joyce LeFever Kee, Sally M. Marshall, Katy Woods, Mary Catherine
(Katie) Forrester.
Description: Eighth edition. | St. Louis, Missouri : Elsevier Inc., [2016]
|
Includes bibliographical references and index.
Identifiers: LCCN 2015046362 | ISBN 9780323390880
Subjects: | MESH: Drug Dosage Calculations | Pharmaceutical
Preparations--administration & dosage | Nurses’ Instruction
Classification: LCC RS57 | NLM QV 748 | DDC 615.1/4--dc23 LC record available
at http://lccn.loc.gov/2015046362

Senior Content Strategist: Yvonne Alexopoulos

Content Development Manager: Jean Sims Fornango
Senior Content Development Specialist: Danielle M. Frazier
Publishing Services Manager: Julie Eddy
Senior Project Manager: Mary G. Stueck
Design Direction: Brian Salisbury

Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my granddaughter, Kimberly Cibroski, BSN, Nurse,
Emergency Room, ChristianaCare, Newark, Delaware
Joyce Kee

In memory of my mother, Lois

Sally Marshall

To my parents, Bill and Rebecca, and my husband, Mark

Katie Forrester

To our nursing colleagues

Reviewers
Rose Mary Gee, PhD, RN Bobbi Steelman, BSEd, MAEd, CPhT
Assistant Professor Director of Education/Pharmacy Technician Program
School of Nursing Director
Georgia Southern University Daymar College
Statesboro, Georgia Bowling Green, Kentucky

Jessica Gonzales, ARNP, MSN, RN Collene Thaxton, RN, MSN

Nursing Instructor Associate Professor
Lake Washington Institute of Technology Mount Wachusett Community College
Redmond, Washington Gardner, Massachusetts

Lori A. McGill, DNP, RN

Professor
College of Nursing
RN-to-BSN Program
St. Petersburg College
Pinellas Park, Florida

vi
Preface to the Instructor
Clinical Calculations with Applications to General and Specialty Areas arose from the need to bridge the
learning gap between education and practice. We believe that this bridge is needed for the student to
understand the wide range of clinical calculations used in nursing practice. This book provides a compre-
hensive application of calculations in nursing practice.
Clinical Calculations has been expanded in this eighth edition on topics in several areas to show the
interrelationship between calculation and drug administration. The use of the latest methods, techniques,
and equipments are included: unit dose dispensing system, electronic medication administration record
(eMAR), computerized prescriber order system (CPOS), various methods of calculating drug doses with
the use of body mass index (BMI), ideal body weight (IBW) with adjusted body weight (ABW), insulin
pump, patient-controlled analgesia pumps, multi-channel infusion pumps, IV filters, and many more.
This text also provides the six (6) methods for calculating drug dosages—basic formula, ratio and propor-
tion, fractional equation, dimensional analysis, body weight, and body surface area.
The chapter, “Prevention of Medication Errors,” has been updated. It includes examples of the types
of medication errors, ways to prevent medication errors, and the “10 Rights” in drug administration. A
separate chapter, “Insulin Administration” has been added.
Clinical Calculations is unique in that it has problems not only for the general patient areas but also for
the specialty units—pediatrics, critical care, pediatric critical care, labor and delivery, and community. This
text is useful for nurses at all levels of nursing education who are learning for the first time how to calculate
dosage problems and for beginning practitioners in specialty areas. It also can be used in nursing refresher
courses, in-service programs, hospital units, home health care, and other settings of nursing practice.
This book is divided into five parts. Part I is the basic math review, written concisely for nursing stu-
dents to review Roman numerals, fractions, decimals, percentages, and ratio and proportion. A post-math
review test follows. The post-math test can be taken first and, if the student has a score of 90% of higher,
the basic review section can be omitted. Part II covers metric and household measurement systems used
in drug calculations; conversion of units; reading drug labels, drug orders, eMAR, computerized pre-
scriber order systems, and abbreviations; and methods of calculations. We suggest that you assign Parts I
and II, which cover delivery of medication, before the class. Part III covers calculation of drug and fluid
dosages for oral, injectable, insulin administration, and intravenous administration. Clinical drug calcula-
tions for specialty areas are found in Part IV, which includes pediatrics, critical care for adults and chil-
dren, labor and delivery, and community. Part V contains the post-test for students to test their competency
in mastering oral, injectable, intravenous, and pediatric drug calculations. A passing grade is 88%.
Appendix A includes guidelines for administration of medications (oral, injectable, and intravenous),
and Appendix B contains nomograms.
Each chapter has a content list, objectives, introduction, and numerous practice problems. The practice
problems are related to clinical drug problems that are currently used in clinical settings. Illustrations of
tablets, capsules, medicine cup, syringes, ampules, vials, intravenous bag and bottle, IV tubing, electronic
IV devices, intramuscular injection sites, central venous sites, and many other related images are provided
throughout the text.
Calculators may be used in solving dosage problems. Many institutions have calculators available. The
student should work the problem without a calculator and then check the answer with a calculator.

vii
viii PREFACE TO THE INSTRUCTOR

FEATURES FOR THE EIGHTH EDITION

• The chapter on prevention of medication errors has been updated, and a new chapter on insulin admin-
istration has been added.
• Problems using the newest drug labels are provided in most chapters.
• Six methods for calculating drug dosages have been divided into two chapters. Chapter 6 gives four
methods: basic formula, ratio and proportion, fractional equations, and dimensional analysis. Chapter
7 contains two individual methods for calculating drug doses: body weight and body surface area.
• Additional dimensional analysis has been added to the examples of drug dosing and to the answers to
practice problems in most of the chapters.
• Additional drug problems have been added throughout.
• Emphasis is placed on the metric system along with the household system of measurement.
• Several chapters have nomograms for adults and children.
• Explanation on the unit dose dispensing system, computer-based drug administration, computerized
prescriber order system, bar code medication administration, MAR, electronic medication adminis-
tration record (eMAR), and automation of medication dispensing administration are provided.
• Incorporation of guidelines for safe practice and the medication administration set by the Joint Com-
mission (TJC) and the Institute for Safe Medicine Practices (ISMP) are included.
• Explanation of the four groups of inhaled medications include: MDI inhalers with and without spac-
ers, dry powder inhalers, and nebulizers.
• Calculations by BMI, IBW, and ABW for obese and debilitated persons are presented.
• Body Surface Area (BSA or m2) using the square root method is included.
• Use of fingertip units for cream applications is illustrated.
• Explanations are provided for the use of the insulin pump, insulin pen injectors, and the patient-
controlled analgesic pump.
• Illustrations of new types of syringes, safety needle shield, various insulin and tuberculin syringes, and
needleless syringes are provided.
• Illustrations of pumps are provided, including insulin, enteral infusion, and various intravenous infu-
sion pumps (single and multi-channel, patient-controlled analgesia, and syringe).
• Coverage of direct intravenous injection (IV push or IV bolus) is provided with practice problems in
Chapter 11.
• Updated methods and information for critical care, pediatrics, and labor and delivery calculations are
presented.

ANCILLARIES

Evolve resources for instructors and students can be found online at http://evolve.elsevier.com/
KeeMarshall/clinical/
The Instructor Resources are designed to help you present the material in this text and include the
following:
• Test Bank—now with over 500 questions.
• TEACH consists of customizable Lesson Plans and Lecture Outlines, and PowerPoint slides. It is an
online resource designed to help you to reduce your lesson preparation time, give you new and creative
ideas to promote student learning, and help you to make full use of the rich array of resources in the
Clinical Calculations teaching package.
• Drug Label Glossary—includes all of the drug labels from the text. Instructors can search for labels
by trade or generic name.
• NEW VERSION! Drug Calculations Comprehensive Test Bank, version 4. This generic test bank con-
tains over 700 questions on general mathematics, converting within the same system of measurement,
converting between different systems of measurement, oral dosages, parenteral dosages, flow rates,
pediatric dosages, IV calculations, and more.
 PREFACE TO THE INSTRUCTOR ix

Student Resources provide students with additional tools for learning and include the following:
• NEW VERSION! Drug Calculations Companion, version 5. This is a completely updated, interactive
student tutorial that includes an extensive menu of various topic areas within drug calculations, such
as oral, parenteral, pediatric, and intravenous calculations. It contains over 600 practice problems cov-
ering ratio and proportion, formula, and dimensional analysis methods.
Preface to the Student
Clinical Calculations with Applications to General and Specialty Areas, eighth edition, can be used as a self-
instructional mathematics and dosage calculation review tool.
Part I, Basic Math Review, is a review of math concepts usually taught in middle school. Some stu-
dents may need to review Part I as a refresher of basic math and then take the comprehensive math test
at the end of the chapter. Others may choose to take the math test first. If your score on this test is 90%
or higher, you should proceed to Part II; if your score is less than 90%, you should review Part I.
Part II, Systems, Conversion, and Methods of Drug Calculation, should be studied before the class on
oral, injectable, insulin administration, and intravenous calculations, which are covered in Part III. In Part
II you will learn the various systems of drug administration, conversion within the various systems, chart-
ing (MAR and eMAR), drug orders, abbreviations, methods of drug calculation, how to prevent medica-
tion errors, and alternative methods for drug administration. You can study Part II on your own. Chapter
6, “Methods of Calculation,” gives the four methods commonly used to calculate drug dosages. You or the
instructor should select one of the four methods to calculate drug dosages. Use that method in all practice
problems starting in Chapter 6. This approach will improve your proficiency in the calculation of drug
dosages.
Part III, Calculations for Oral, Injectable, and Intravenous Drugs, is usually discussed in class and during
a clinical practicum. Before class, you should review the four chapters in Part III. Questions may be
addressed and answered during class time. During the class or clinical practicum, you may practice drug
calculations and the drawing up of drug
doses in a syringe. 116 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Part IV, Calculations for Specialty Areas,

is usually presented when the topics are
discussed in class. You should review the
content in these chapters—“Pediatrics,”
“Critical Care,” “Pediatric Critical Care,”
“Labor and Delivery,” and “Community”—
before the scheduled class. According to
the requirements of your specific nursing A B

program, this content may or may not be

Figure 8-3 A, Pill/tablet cutter. B, Silent Knight tablet crushing system. (B, Used with permission from
Links Medical Products, Inc., Irvine, California.)

covered. Pill/Tablet Cutter and Crusher

A pill or tablet cutter can be used to evenly split or divide a scored or unscored tablet. The pill cutter can-
Part V, Post-Test, has 65 post-test ques- not be used to cut/divide enteric-coated tablets or capsules, time-released, sustained-released, or con-
trolled-released capsules. Pill/tablet cutters can be purchased at a drug-store (Figure 8-3). If the patient
tions you should solve to determine your cannot swallow pills or tablets, best practice is to consult with the prescriber or pharmacist to find if a
liquid form of the drug is available. If the medication is not manufactured in liquid form, then a pill

competency in mastering oral, injectable,

crusher (Figure 8-3, B) can be used to reduce tablets to a powdered form that can be mixed with water,
juice, fruit sauce, or ice cream. Not all pills can be crushed; see Caution below.

intravenous, and pediatric drug calculations. CAUTI O N

C
Take a look at the following features so • Enteric-coated
E tablets have a special coating that allows them to move through the stomach and be
dissolved in the small intestine so that the medication doesn’t irritate the gastric mucosa.

that you may familiarize yourself with this •

•
Time-released, sustained-release, or controlled-release tablets slowly release drug over a period of time.
Layered tablets have medications that may be released at different times. The outer coating dissolves

text and maximize its value: quickly, and the tablet core will dissolve slowly.

Calculation of Tablets and Capsules

The following steps should be taken to determine the drug dose:
1. Check the drug order.
2. Determine the drug available (generic name, brand name, and dosage per drug form).
Caution boxes alert you to potential problems related 3. Set up the method for drug calculation (basic formula, ratio and proportion, fraction equation, or
dimensional analysis).
4. Convert to like units of measurement within the same system before solving the problem. Use the
to various medications and their administration. unit of measure on the drug container to calculate the drug dose.
5. Solve for the unknown (X).

x
 PREFACE TO THE STUDENT xi

Notes emphasize important points for students as they

learn material in each chapter.

You Must Remember boxes identify pertinent concepts

that students should commit to memory.
xii PREFACE TO THE STUDENT

NEW VERSION! Drug Calculations Companion, version 4. This is a completely updated, interactive
student tutorial that includes an extensive menu of various topic areas within drug calculations, such as
oral, parenteral, pediatric, and intravenous calculations. It contains over 600 practice problems covering
ratio and proportion, formula, and dimensional analysis methods.
Look for this icon at the end of the chapters. It will refer you to Drug Calculations
Companion, version 5 for additional practice problems and content information.

ACKNOWLEDGMENTS

We wish to extend our sincere appreciation to the individuals who have helped with this eighth edition:
Sara Ahmed, PharmD, BCPS, ChristianaCare Health Care System, Wilmington, Delaware; Sarah
Marshall Pragg, for her graphic design and editing; and to our husbands, Edward Kee and Robert
Marshall, for their support.

Joyce LeFever Kee

Sally M. Marshall
Contents
Part I: Basic Math Review, 1 Conversion in Metric and Household Systems
Number Systems, 2 by Liquid Volume, 29
Arabic System, 2 Conversion in Metric and Household Systems
Roman System, 2 by Length, 31
Conversion of Systems, 2
CHAPTER 3: Interpretation of Drug Labels,
Fractions, 3
Drug Orders, Bar Codes, MAR and eMAR,
Proper, Improper, and Mixed Fractions, 3
Automation of Medication Dispensing
Multiplying Fractions, 4
Administration, and Abbreviations, 36
Dividing Fractions, 4
Decimal Fractions, 4 Interpretation of Drug Labels, 37
Decimals, 6 Military (International) Time versus Traditional Time, 41
Multiplying Decimals, 6 Drug Differentiation, 42
Dividing Decimals, 7 Drug Orders, 42
Ratio and Proportion, 7 Unit-Dose Dispensing System (UDDS), 45
Percentage, 8 Computer-Based Drug Administration
Post-Math Test, 11 (CBDA), 47
Roman and Arabic Numerals, 11 Computerized Prescriber Order System
Fractions, 11 (CPOS), 47
Decimals, 12 Bar Code Medication Administration, 48
Ratio and Proportion, 13 Automation of Medication Dispensing
Percentage, 13 Administration, 49
Medication Administration Record (MAR and eMAR), 51
Abbreviations, 52
Part II: Systems, Conversion, Drug Measurements and Drug Forms, 52
and Methods of Drug Calculation, 15 Routes of Drug Administration, 52
CHAPTER 1: Systems Used for Drug Times of Administration, 53
Administration and Temperature “Do Not Use” Abbreviations, 53
Conversion, 16 The “Do Not Use” Abbreviation List, 53

Metric System, 17 CHAPTER 4: Prevention of Medication Errors, 56

Conversion Within the Metric System, 17
Preventing Medication Errors, 56
Apothecary System, 21
The Rights in Drug Administration, 58
Household System, 22 Right Patient, 58
Conversion Within the Household System, 22 Right Drug, 58
Temperature Conversion, 24 Right Dose, 59
Right Time, 59
CHAPTER 2: Conversion Within the Metric,
Right Route, 59
Apothecary, and Household Systems, 27
Right Documentation, 60
Units, Milliequivalents, and Percents, 27 Right to Refuse Medication, 60
Metric, Apothecary, and Household Right Assessment, 60
Equivalents, 28 Right Education, 60
Right Evaluation, 61

xiii
xiv CONTENTS

CHAPTER 5: Alternative Methods for Drug Part III: Calculations for Oral, Injectable,
Administration, 63 and Intravenous Drugs, 113
Transdermal Patch, 64 CHAPTER 8: Oral and Enteral Preparations With
Purpose, 64 Clinical Applications, 114
Types of Inhalers and Nebulizers, 65 Tablets, Capsules, Fluid, and Film Strips, 115
Purpose, 65 Pill/Tablet Cutter and Crusher, 116
Types, 65 Calculation of Tablets and Capsules, 116
Nasal Spray and Drops, 66 Liquids, 119
Purpose, 66 Calculation of Liquid Medications, 120
Eye Drops and Ointment, 68 Buccal Tablets, 121
Purpose, 68 Sublingual Tablets, 121
Ear Drops, 70 Calculation of Sublingual Medications, 122
Purpose, 70 Enteral Nutrition and Drug Administration,
Pharyngeal Spray, Mouthwash, and 140
Lozenge, 71 Enteral Feedings, 141
Purpose, 71 Enteral Medications, 142
Topical Preparations: Lotion, Cream, and
Ointment, 71 CHAPTER 9: Injectable Preparations
Purpose, 71 With Clinical Applications, 148
Rectal Suppository, 73 Injectable Preparations, 149
Purpose, 73 Vials and Ampules, 149
Vaginal Suppository, Cream, and Syringes, 149
Ointment, 74 Needles, 152
Purpose, 74 Intradermal Injections, 154
Intraosseous Access, 75 Subcutaneous Injections, 154
Purpose, 75 Calculations for Subcutaneous Injections, 155
Method, 75 Intramuscular Injections, 158
Intraspinal Access, 76 Drug Solutions for Injection, 159
Purpose, 76 Reconstitution of Powdered Drugs, 162
Method, 76 Mixing of Injectable Drugs, 163

CHAPTER 10: Insulin Administration, 188

CHAPTER 6: Methods of Calculation, 78 Insulin Syringes, 188
Drug Calculation, 78 Insulin Bottles, 189
Method 1: ​Basic Formula, 79 Sites and Angles for Insulin Injections, 190
Method 2: Ratio and Proportion, 80 Types of Insulin, 191
Method 3: Fractional Equation, 82
Mixing Insulins, 196
Method 4: Dimensional Analysis, 83
Insulin Pen Devices, 200
Insulin Pumps, 201
CHAPTER 7: Methods of Calculation for
CHAPTER 11: Intravenous Preparations
Individualized Drug Dosing, 97
With Clinical Applications, 205
Calculation for Individualized Drug
Intravenous Sites and Devices, 206
Dosing, 97
Intermittent Infusion Add-On Devices, 209
Body Weight (BW), 97
Body Surface Area (BSA or m2), 98 Direct Intravenous Injections, 210
Ideal Body Weight (IBW), 102 Continuous Intravenous Administration, 214
Adjusted Body Weight (ABW), 102 Intravenous Infusion Sets, 214
Lean Body Weight (LBW), 104
 CONTENTS xv

Calculation of Intravenous Flow Rate, 217 Basic Fractional Formula, 287

Safety Considerations, 217 Using Basic Formula to Find Volume per Hour or Drops
Adding Drugs Used for Continuous Intravenous per Minute, 287
Administration, 218 Using Basic Formula to Find Desired Concentration per
Types of Solutions, 218 Minute, 287
Tonicity of IV Solutions, 218 Using Basic Formula to Find Concentration of
Intermittent Intravenous Administration, 222 Solution, 288
Secondary Intravenous Sets, 223 Titration of Infusion Rate, 288
Adding Drugs Used for Intermittent Intravenous Determine Titration ​Factor Using Infusion Pump, 290
Administration, 223 Increasing or Decreasing Infusion ​Rates Using Infusion
ADD-Vantage System, 224 Pump, 290
Electronic Intravenous Infusion Pumps, 226 Determine Titration Factor Using a Microdrip IV Set, 291
Flow Rates for Infusion Pumps and Secondary Increasing or Decreasing Infusion Rates Using a
Sets, 228 Microdrip IV ​Set, 292
Total Amount of Drug Infused Over Time, 293

Chapter 14: Pediatric Critical Care, 307

PART IV: Calculations for Specialty
Areas, 247 Factors Influencing Intravenous
Administration, 307
CHAPTER 12: Pediatrics, 248
Calculating Accuracy of Dilution
Factors Influencing Pediatric Drug Parameters, 307
Administration, 248
Oral, 249 CHAPTER 15: Labor and Delivery, 315
Intramuscular, 249
Factors Influencing Intravenous Fluid and
Intravenous, 251
Drug Management, 315
Pediatric Drug Calculations, 251
Titration of Medications With Maintenance
Dosage per Kilogram Body Weight, 253
Intravenous Fluids, 316
Dosage per Body Surface Area, 255
Administration by Concentration, 316
Pediatric Dosage From Adult Dosage, 268 Administration by Volume, 317
Body Surface Area Formula, 268
Intravenous Loading Dose, 318
Age Rules, 268
Intravenous Fluid Bolus, 319
CHAPTER 13: Critical Care, 278
CHAPTER 16: Community, 326
Calculating Amount of Drug or Concentration
of a Solution, 280 Metric to Household Conversion, 327
Calculating Units per Milliliter, 280 Preparing a Solution of a Desired
Calculating Milligrams per Milliliter, 280 Concentration, 329
Calculating Micrograms per Milliliter, 281 Changing a Ratio to Fractions and Percentages, 329
Calculating Infusion Rate for Concentration Calculating a Solution From a Ratio, 330
and Volume per Unit Time, 281 Calculating a Solution From a Percentage, 331
Concentration and Volume per Hour and Minute With a Preparing a Weaker Solution From a Stronger
Drug in Units, 282 Solution, 331
Concentration and Volume per Hour and Minute With a Guidelines for Home Solutions, 332
Drug in Milligrams, 284 Hydration Management, 334
Concentration and Volume per Hour and Minute With a Calculate Daily Fluid Intake for an Adult, 334
Drug in Micrograms, 284 Standard Formula for Daily Fluid Intake, 334
Calculating Infusion Rates of a Drug for Calculate Daily Fluid Intake for a Febrile Adult, 335
Specific Body Weight per Unit Time, 286 Body Mass Index (BMI), 335
Micrograms per Kilogram Body Weight, 286 Calculate Body Mass Index Using Two Formulas, 335
xvi CONTENTS

PART V: Post-Test: Oral Preparations, Appendix A: Guidelines for

Injectables, Intravenous, and Administration of Medications, 377
Pediatrics, 341 General Drug Administration, 377
Oral Preparations, 342 Oral Medications, 378
Injectables, 351 Injectable Medications, 379
Direct IV Administration, 358 Intravenous Fluid and Medications, 379
Intravenous, 358
Pediatrics, 363 Appendix B: Nomograms, 382
References, 385
Index, 387
PART I
BASIC MATH REVIEW

Objectives • Convert Roman numerals to Arabic numerals.

• Multiply and divide fractions and decimals.
• Solve ratio and proportion problems.
• Change percentages to decimals, fractions, and ratio and
proportion.
• Demonstrate an understanding of Roman numerals, fractions,
decimals, ratio and proportion, and percentage by passing the
math test.

Outline NUMBER SYSTEMS

Arabic System
Roman System
Conversion of Systems
FRACTIONS
Proper, Improper, and Mixed Fractions
Multiplying Fractions
Dividing Fractions
Decimal Fractions
DECIMALS
Multiplying Decimals
Dividing Decimals
RATIO AND PROPORTION
PERCENTAGE
POST-MATH TEST
Roman and Arabic Numerals
Fractions
Decimals
Ratio and Proportion
Percentage

1
2 PART I Basic Math Review

The basic math review assists nurses in converting Roman and Arabic numerals, multiplying and dividing
fractions and decimals, and solving ratio and proportion problems and percentage problems. Nurses need
to master basic math skills to solve drug dosage problems for the administration of medication.
A math test, found on pages 11 to 14, follows the basic math review. The test may be taken first, and,
if a score of 90% or greater is achieved, the math review, or Part I, can be omitted. If the test score is less
than 90%, the student should do the basic math review section. Some students may choose to start with
Part I and then take the test.
Answers to the Practice Problems are at the end of Part I, before the Post-Math Test.

NUMBER SYSTEMS

Two systems of numbers currently used are Arabic and Roman. Both systems are used in drug
administration.

Arabic System
The Arabic system is expressed in the numbers 0, 1, 2, 3, 4, 5, 6, 7, 8, and 9. These can be written as whole
numbers or with fractions and decimals. This system is commonly used today.

Roman System
Numbers used in the Roman system are designated by selected capital letters, e.g., I, V, X. Roman num-
bers can be changed to Arabic numbers.

Conversion of Systems
Roman Number Arabic Number
I 1
V 5
X 10
L 50
C 100

The apothecary system of measurement uses Roman numerals for writing drug dosages. The Roman
numerals are written in lowercase letters, e.g., i, v, x, xii. The lowercase letters can be topped by a horizon-
tal line, e.g., i, v, x, xii. These can be written with or without a horizontal line over the numerals.
Roman numerals can appear together, such as xv and ix. Reading multiple Roman numerals requires
the use of addition and subtraction.

Method A
If the first Roman numeral is greater than the following numeral(s), then ADD.

EXAMPLES viii 5 5 1 3 5 8
xv 5 10 1 5 5 15

Method B
If the first Roman numeral is less than the following numeral(s), then SUBTRACT. Subtract the first
numeral from the second (i.e., the smaller from the larger).

EXAMPLES iv ​5 ​5 ​2 ​1 ​5 ​4
ix ​5 ​10 ​2 ​1 ​5 ​9
 PART I Basic Math Review 3

Some Roman numerals require both addition and subtraction to ascertain their value. Read from left
to right.

EXAMPLES xix 5 10 1 9 110 2 12 5 19

xxxiv 5 30 110 1 10 1 102 1 4 15 2 12 5 34

PRACTICE PROBLEMS u
​ ​I ​ROMAN NUMERALS
Answers can be found on page 9.

1. xvi 4. xxxix

2. xii 5. XLV

3. xxiv 6. XC

FRACTIONS

Fractions are expressed as part(s) of a whole or part(s) of a unit. A fraction is composed of two basic
numbers: a numerator (the top number) and a denominator (the bottom number). The denominator indi-
cates the total number of parts.

3 numerator 13 of 4 parts2
EXAMPLES Fraction:
4 denominator 14 of 4 parts, or 4 total parts2
The value of a fraction depends mainly on the denominator. When the denominator increases, for
example, from 1⁄10 to 1⁄20, the value of the fraction decreases, because it takes more parts to make a whole.

EXAMPLES Which fraction has the greater value: 1⁄4 or 1⁄6? The denominators are 4 and 6.

The larger value is 1⁄4, because four parts make the whole, whereas for 1⁄6, it takes six parts to make a
whole. Therefore 1⁄6 has the smaller value.

Proper, Improper, and Mixed Fractions

In a proper fraction (simple fraction), the numerator is less than the denominator, e.g., 1⁄2, 2⁄3, 3⁄4, 2⁄6.
(When possible, the fraction should be reduced to its lowest terms, e.g., 2⁄6 ​5 ​1⁄3 [2 goes into 2 and 6].)
In an improper fraction, the numerator is greater than the denominator, e.g., 4⁄2, 8⁄5, 14⁄4. (Reduce ­improper
fractions to whole numbers or mixed numbers, e.g., 4⁄2 ​5 ​2 [4⁄2 means the same as 4 ​ 4 ​2];
8
⁄5 ​5 ​13⁄5 [8 ​4 ​5, 5 goes into 8 one time with 3 left over, or 3⁄5]; and 14⁄4 ​5 ​32⁄4 ​5 ​31⁄2 [14 ​4 ​4, 4 goes into
14 three times with 2 left over, or 2⁄4, which can then be reduced to 1⁄2].)
A mixed number is a whole number and a fraction, e.g., 13⁄5, 31⁄2. Mixed numbers can be changed to
improper fractions by multiplying the denominator by the whole number, then adding the numerator,
e.g., 13⁄5 ​5 ​8⁄5 (5 ​3 ​1 ​5 ​5 1 3 ​5 ​8).
4 PART I Basic Math Review

Fractions may be added, subtracted, multiplied, or divided. Multiplying fractions and dividing frac-
tions are the two common methods used in solving dosage problems.

Multiplying Fractions
To multiply fractions, multiply the numerators and then the denominators. Reduce the fraction, if
­possible, to lowest terms.

1
1 3 3 1
EXAMPLES PROBLEM 1: 3 5 5
3 5 15 5
5

The answer is 3⁄15, which can be reduced to 1⁄5. The number that goes into both 3 and 15 is 3. Therefore
3 goes into 3 one time, and 3 goes into 15 five times.
1 6
PROBLEM 2: 365 52
3 3
A whole number can also be written as that number over one (6⁄1). Six is divided by 3 16 4 32 ; 3 goes
into 6 two times.
4 48 3
PROBLEM 3: 3 12 5 59
5 5 5

Dividing Fractions
To divide fractions, invert the second fraction, or divisor, and then multiply.

1 2
3 3 3 8 2
EXAMPLES PROBLEM 1: 4 1divisor2 5 3 5 5 2
4 8 4 3 1
1 1

When dividing, invert the divisor 3⁄8 to 8⁄3 and multiply. To reduce the fraction to lowest terms, 3 goes
into both 3s one time, and 4 goes into 4 and 8 one time and two times, respectively.

3
1 4 1 18 3
PROBLEM 2: 4 5 3 5
6 18 6 4 4
1

Six and 18 are reduced, or canceled, to 1 and 3.

2
2 5 11 6 22 2
PROBLEM 3: 3 4 5 3 5 54
3 6 3 5 5 5
1

Change 32⁄3 to an improper fraction and invert 5⁄6 to 6⁄5 and then multiply.
Reduce 3 and 6 to 1 and 2.

Decimal Fractions
Change fraction to decimal. Divide the numerator by the denominator.
3 0.75
EXAMPLES PROBLEM 1: 5 4q3.00 or 0.75
4
 PART I Basic Math Review 5

Therefore 34 is the same as 0.75.

12 1.5
PROBLEM 2: 5 8q12.0 or 1.5
8
8
40
40

PRACTICE PROBLEMS u
​ ​II FRACTIONS
Answers can be found on pages 9 and 10.
Round off to the nearest tenth unless otherwise indicated.
1. a. Which has the greatest value: 1⁄50, 1⁄100, or 1⁄150?
b. Which has the lowest value: 1⁄50, 1⁄100, or 1⁄150?
2. Reduce improper fractions to whole or mixed numbers.
a. 12
⁄4 ​5 ​ c. 22
⁄3 ​5

b. 20⁄5 ​5 ​ d. 32
⁄6 ​5

3. Multiply fractions to whole number(s) or lowest fraction or decimal.
a. 2⁄3 ​3 ​1⁄8 ​5 ​ c. 500
⁄350 ​3 ​5 ​5 ​

b. 22⁄5 ​3 ​33⁄4 ​5 ​ d. 400,000
⁄200,000 ​3 ​3 ​5 ​

4. Divide fractions to whole number(s) or lowest fraction or decimal.
a. ​2⁄3 ​4 ​6 ​5 ​ d. 1⁄150/1⁄100 ​5 ​(1⁄150 ​4 ​1⁄100) ​5 ​

b. ​1⁄4 ​4 ​1⁄5 ​5 ​ e. 1⁄200 ​4 ​1⁄300 ​5 ​

c. ​1⁄6 ​4 ​1⁄8 ​5 ​ f. 93⁄5 ​4 ​4 ​5 ​
48⁄5 ​4 ​4⁄1 ​5 ​

5. Change each fraction to a decimal.
a. 1⁄4 ​5 ​ b. ​
1
⁄10 ​5 ​ c. ​2⁄5 ​5 ​

d. 35⁄4 ​5 ​ e. ​78⁄5 ​5 ​

6 PART I Basic Math Review

DECIMALS

Decimals consist of (1) whole numbers (numbers to the left of decimal point) and (2) decimal fractions
(numbers to the right of decimal point). The number 2468.8642 is an example of the division of units for
a whole number with a decimal fraction.

Whole Numbers Decimal Fractions

2 4 6 8 • 8 6 4 2
T H T U T H T T
h u e n e u h e
o n n i n n o n
u d s t t d u
s r s h r s T
a e s e a h
n d d n o
d s t d u
s h t s
s h a
s n
d
t
h
s

Decimal fractions are written in tenths, hundredths, thousandths, and ten-thousandths. Frequently,
decimal fractions are used in drug dosing. The metric system is referred to as the decimal system. After
decimal problems are solved, decimal fractions are generally rounded off to tenths. If the hundredth col-
umn is 5 or greater, the tenth is increased by 1, e.g., 0.67 is rounded up to 0.7 (tenths).
Decimal fractions are an integral part of the metric system. Tenths mean 0.1 or 1⁄10, hundredths mean
0.01 or 1⁄100, and thousandths mean 0.001 or 1⁄1000. When a decimal is changed to a fraction, the denomi-
nator is based on the number of digits to the right of the decimal point (0.8 is 8⁄10, 0.86 is 86⁄100).

EXAMPLES PROBLEM 1: 0.5 is 5⁄10, or 5 tenths.

PROBLEM 2: 0.55 is 55⁄100, or 55 hundredths.
PROBLEM 3: 0.555 is 555⁄1000, or 555 thousandths.

Multiplying Decimals
To multiply decimal numbers, multiply the multiplicand by the multiplier. Count how many numbers
(spaces) are to the right of the decimals in the problem. Mark off the number of decimal spaces in the
answer (right to left) according to the number of decimal spaces in the problem. Answers are rounded off
to the nearest tenths.

EXAMPLES 1.34 multiplicand

32.3 multiplier
402
268
3.082 or 3.1 (rounded off in tenths)

Answer: 3.1. Because 8 is greater than 5, the “tenth” number is increased by 1.

 PART I Basic Math Review 7

Dividing Decimals
To divide decimal numbers, move the decimal point in the divisor to the right to make a whole number.
The decimal point in the dividend is also moved to the right according to the number of decimal spaces
in the divisor. Answers are rounded off to the nearest tenths.

EXAMPLES Dividend ​4 ​Divisor
2.46
2.46 4 1.2 or 5 ​
1.2
2.05 5 2.1
1divisor2 1. 2 q2.4 60 1dividend2
N N
24
60
60
0

PRACTICE PROBLEMS u
​ ​III DECIMALS
Answers can be found on page 10.
Round off to the nearest tenths.
1. Multiply decimals.
a. 6.8 ​3 ​0.123 ​5 ​ b. 52.4 ​3 ​9.345 ​5 ​

2. Divide decimals.
a. 69 ​4 ​3.2 ​5 ​ c. 100 ​4 ​4.5 ​5 ​

b. 6.63 ​4 ​0.23 ​5 ​ d. 125 ​4 ​0.75 ​5 ​

3. Change decimals to fractions.
a. 0.46 ​5 ​ b. ​0.05 ​5 ​ c. ​0.012 ​5 ​

4. W hich has the greatest value: 0.46, 0.05, or 0.012? Which has the smallest
value?

RATIO AND PROPORTION

A ratio is the relation between two numbers and is separated by a colon, e.g., 1;2 (1 is to 2). It is another
way of expressing a fraction, e.g., 1;2 ​5 ​1⁄2.
Proportion is the relation between two ratios separated by a double colon (<) or equals sign (5).
To solve a ratio and proportion problem, the inside numbers (means) are multiplied and the outside
numbers (extremes) are multiplied. To solve for the unknown, which is X, the X goes to the left side and
is followed by an equals sign.
8 PART I Basic Math Review

EXAMPLES PROBLEM 1: 1;2<2;X (1 is to 2, as 2 is to X)

means

extremes

Multiply the extremes and the means, and solve for X.

X ​5 ​4 (1 X is the same as X)

Answer: 4 (1;2<2;4)

PROBLEM 2: 4;8 ​:: ​X;12

8 X ​5 ​48
 ​ X ​5 ​48⁄8 ​5 ​6

Answer: 6 (4;8<6;12)

PROBLEM 3: A ratio and proportion problem may be set up as a fraction.

Ratio and Proportion

Fraction
2 4
  2;3<4;X 5 (cross-multiply)
3 X
  2 X ​
5 ​12 2 X ​5 ​12
   ​X ​
5 ​12⁄2 ​5 ​6  ​ X ​5 ​6

Answer: 6. Remember to cross-multiply when the problem is set up as a fraction.

PRACTICE PROBLEMS u
​ ​IV RATIO AND PROPORTION
Answers can be found on page 10.
Solve for X.
1. 2;10<5;X

2. 0.9;100 ​5 ​X;1000

3. Change the ratio and proportion to a fraction and solve for X.
3;5<X;10

4. It is 500 miles from Washington, DC, to Boston, MA. Your car averages 22 miles per 1 gallon
of gasoline. How many gallons of gasoline will be needed for the trip?

PERCENTAGE

Percent (%) means 100. Two percent (2%) means 2 parts of 100, and 0.9% means 0.9 part (less than 1) of
100. A percent can be expressed as a fraction, a decimal, or a ratio.
 PART I Basic Math Review 9

EXAMPLES
Percent Fraction Decimal Ratio
60% ​ 5 ​ 60
⁄100 0.6 60;100
0.45% 5 ​ ⁄100 or 45⁄10,000
0.45
0.0045 0.45:100 or 45:10,000

Note: ​
To change a percent to a decimal, move the decimal point two places to the left.

PRACTICE PROBLEMS u
​ ​V PERCENTAGE
Answers can be found on page 10.
Change percent to fraction, decimal, and ratio.

Percent Fraction Decimal Ratio

1. 2%
2. 0.33%
3. 150%
4. 1⁄2% (0.5%)
5. 0.9%

ANSWERS
I ​Roman Numerals

1. 10 ​1 ​5 ​1 ​1 ​5 ​16
2. 10 ​1 ​2 ​5 ​12
3. 20 (10 ​1 ​10) ​1 ​4 (5 ​2 ​1) ​5 ​24
4. 30 (10 ​1 ​10 ​1 ​10) ​1 ​9 (10 ​2 ​1) ​5 ​39
5. 40 (50 ​2 ​10) ​1 ​5 ​5 ​45
6. 100 ​2 ​10 ​5 ​90

II Fractions (Round off to the nearest tenths unless otherwise indicated.)

1. a. 1
⁄50 has the greatest value. 4. a. 2⁄3 ​4 ​6 ​5 ​2⁄3 ​3 ​1⁄6
b. 1
⁄150 has the lowest value.       5 ​2⁄18 ​5 ​1⁄9 ​5 ​0.11
2. a. 3 b. 1⁄4 ​4 ​1⁄5 ​5 ​
b. 4 1
⁄4 ​3 ​5⁄1 ​5 ​5⁄4 ​5 ​
c. 71⁄3 11⁄4, or 1.25 or 1.3
4
d. 52⁄6 or 51⁄3 1 1 1 8 4
3. a. 2
⁄24 ​5 ​1⁄12 c. 4 5 3 5 5 1.33, or 1.3
6 8 6 1 3
180 3
b. 12
⁄5 ​3 ​15⁄4 ​5 ​ 59 2
20 1 100
10 d. ⁄150 ​4 ​ ⁄100 ​5 ​
1 1
3
500 50 150 1
c. 355 5 7.1 3
350 7 5 ​2⁄3, or 0.666, or 0.67 or 0.7
7
2 e. ⁄200 ​4 ​ ⁄300 ​5 ​1⁄200 ​3 ​300⁄1 ​5 ​300⁄200 ​5 ​11⁄2, or 1.5
1 1

400,000
d. 3356 48 4 48 1 48
200,000 f. 4 5 3 5 5 2.4
1 5 1 5 4 20
10 PART I Basic Math Review

1 0.25 or 0.3 rounded off

5. a. 5 4q1.00
4
1 0.10 or 0.1
b. 5 10q1.00
10
2 0.40 or 0.4
c. 5 5q2.00
5
35 8.75 or 8.8 rounded off
d. 5 4q35.00
4
78 15.60 or 15.6
e. 5 5q78.00
5

III Decimals

1. a. 0.8364, or 0.8
30.123
6.8
984
738
0.8364, or 0.8 (round off to tenths: 3 hundredths is less than 5)
b. 489.6780, or 489.7 (7 hundredths is greater than 5)
2. a. 21.56, or 21.6 (6 hundredths is greater than 5, so the tenth is increased by one)
b. 28.826, or 28.8 (2 hundredths is less than 5, so the tenth is not changed)
.
c. 100 4 4.5 5 4.5 q100.N 0 5 22.2 , or 22 (rounded off to whole number)
.
N
d. 125 4 0.75 5 0.N 75q125.N00 5 166.6 , or 167 (rounded off to whole number)
3. a. 46⁄100 ​5 ​23⁄50    b. ​5⁄100 ​5 ​1⁄20    c. ​12⁄1000 ​5 ​3⁄250
4. 0.46 has the greatest value; 0.012 has the lowest value. Forty-six hundredths is greater than 12 thousandths.

IV Ratio and Proportion

1. 2 X ​5 ​50 4. 1 gal;22 miles<X gal;500

X ​5 ​25     22 X ​ 5 ​500
2. 100 X ​5 ​900       X ​ 5 ​22.7 gal
   X ​5 ​9 22.7 gallons of gasoline are needed.
3. 3⁄5 ​5 ​x⁄10 ​5 ​5 X ​5 ​30
      X ​ 5 ​6

V Percentage

Percent Fraction Decimal Ratio

1. 2 2
⁄100 0.02 2100
2. 0.33 or 0.3 0.33
⁄100 or 33⁄10,000 0.0033 0.33100 or 3310,000
3. 150 150
⁄100 1.50 150100
4. 0.5 0.5
⁄100 or 5⁄1000 0.005 0.5100 or 51000
5. 0.9 0.9
⁄100 or 9⁄1000 0.009 0.9100 or 91000
 PART I Basic Math Review 11

POST-MATH TEST

Answers can be found on pages 13 and 14.

The math test is composed of five sections: Roman and Arabic numerals, fractions, decimals, ratios and
proportions, and percentages. There are 60 questions. A passing score is 54 or more correct answers
(90%). A nonpassing score is 7 or more incorrect answers. Answers to the Post-Math Test can be found
on pages 13 and 14.

Roman and Arabic Numerals

Convert Roman numerals to Arabic numerals.
1. vii 3. xvi

2. xi 4. xiv

Convert Arabic numerals to Roman numerals.

5. 4 7. 29

6. 18 8. 37

Fractions
Which fraction has the larger value?
9. 1⁄100 or 1⁄150? 10. 1⁄3 or 1⁄2?

Reduce improper fractions to whole or mixed numbers.

11. 45
⁄9 ​5 ​ 12. 74
⁄3 ​5 ​

Change a mixed number to an improper fraction.

13. 52⁄3 ​5 ​

12 PART I Basic Math Review

Change fractions to decimals.

14. 2⁄3 ​5 (reduce to tenths) ​ 15. 1⁄12 ​5 ​(reduce to tenths)

Multiply fractions (reduce to lowest terms or to tenths).

16. 7⁄8 ​3 ​4⁄6 ​5 17. 23⁄5 ​3 ​5⁄8 ​5 ​ ​

18. 213⁄4 ​3 ​7⁄8 ​5 ​ 19. 44⁄5 ​3 ​32⁄3 ​5 ​

Divide fractions.
20. 1⁄2 ​4 ​1⁄3 ​5 ​ 22. 1⁄8 ​4 ​1⁄12 ​5 ​

21. 6 ⁄4 ​4 ​3 ​5 ​
3
23. 203⁄4 ​4 ​1⁄6 ​5 ​

Decimals
Round off decimal numbers to tenths.
24. 0.87 ​5 ​ 26. 0.42 ​5 ​

25. 2.56 ​5 ​

Change decimals to fractions.

27. 0.68 ​5 ​ 29. 0.012 ​5 ​

28. 0.9 ​5 ​ 30. 0.33 ​5 ​

Multiply decimals (round off to tenths or whole numbers).

31. 0.34 ​3 ​0.6 ​5 ​ 32. 2.123 ​3 ​0.45 ​5

Divide decimals.
33. 3.24 ​4 ​0.3 ​5 ​ 34. 69.4 ​4 ​0.23 ​5

 PART I Basic Math Review 13

Ratio and Proportion

Change ratios to fractions.
35. 3;4 ​5 ​ 37. 65;90 ​5 ​

36. 1;175 ​5 ​ 38. 0.9;100 ​5 ​

Solve ratio and proportion problems.

39. 2;3<8;X 41. 3;100 ​5 ​X;1000

40. 0.5;20<X;100 42. 5;25 ​5 ​10;X

Change ratios and proportions to fractions and solve.

43. 1;2<4;X 45. 0.9;10 ​5 ​X;100

44. 5;50<X;300

Percentage
Change percents to fractions.
46. 3% ​5 ​ 47. 27% ​5 ​ 48. 1.2% ​5 ​ 49. 5.75% ​5 ​

Change percents to decimals (round off to tenths, hundredths, or thousandths).

50. ​8% ​5 ​ 52. ​0.9% ​5 ​ 54. ​0.25% ​5 ​
51. ​15% ​5 ​ 53. ​3.5% ​5 ​ 55. ​0.45% ​5 ​

Change percents to ratios.

56. ​35% ​5 ​ 58. ​4% ​5 ​ 60. ​0.45% ​5 ​
57. ​12.5% ​5 ​ 59. ​0.9% ​5

ANSWERS ​ ​POST-MATH TEST
Roman and Arabic Numerals

1. 7 3. 16 5. iv 7. xxix
2. 11 4. 14 6. xviii 8. xxxvii
14 PART I Basic Math Review

Fractions

9. 1⁄100 15. 0.08 or 0.1 20. 1⁄2 ​3 ​3⁄1 ​5 ​3⁄2 ​5 ​11⁄2

9
28 7 27 1 9
10. ⁄21
16. or or 0.58 or 0.6 21. 3 5 ​ 5 2 1⁄4
48 12 4 3 4
1
1 3
13 5 1 12
11. 5 17. 3 5 13⁄8 5 15⁄8 22. 3 5 3⁄2 5 1 1⁄2
5 8 8 1
1 2

3
87 7 609 83 6
12. 24 ⁄3 18.
2
3 5 5 19.03 or 23. 3 5 249
⁄2 ​5 ​124.5 or
 4 8 32 19.0 or 19 4 1 125 whole
2
(rounded off ) number
24 11 264
13. 17
⁄3 19. 3 5 5 17.6
5 3 15
14. 0.66 or 0.7

Decimals

24. 0.9 27. 68⁄100 30. 33⁄100 33. 10.8

25. 2.6 28. 9⁄10 31. 0.204 or 0.2 34. 301.739 or 301.7
26. 0.4 29. 12⁄1000 32. 
0.95535,
or 0.96 or 1

Ratio and Proportion

1
5 X
35. ⁄43
41. 30 44. 5 45. 0.9⁄10 ​5 ​x⁄100
50 300
36. 1⁄175 42. 50 10 10 X ​5 ​90
1 4
37. 65
⁄90 43. 3 5 10 X ​5 ​300 X ​5 ​9
2 X
38. 9⁄1000 (cross-multiply) X ​5 ​30
39. 12 X ​5 ​8
40. 2.5

Percentage

46. 3⁄100 51. 0.15 56. 35;100

47. 27⁄100 52. ​0.009 57. 12.5;100 or 125;1000
48. 12⁄1000 53. 0.035 58. 4;100
49. 575⁄10,000 54. 0.0025 59. ​
0.9;100 or 9;1000
50. 0.08 or 0.1 55. ​0.0045 60. 0.45;100 or 45;10,000

Additional practice problems are available in the Mathematics Review section of Drug
Calculations Companion, version 5, on Evolve.
PART II
SYSTEMS, CONVERSION,
AND METHODS OF DRUG
CALCULATION

15
CHAPTER 1
Systems Used for Drug
Administration and Temperature Conversion

Objectives • Identify the system of measurement accepted worldwide and the system of measurement used
in home settings.
• List the basic units and subunits of weight, volume, and length of the metric
system.
• Explain the rules for changing grams to milligrams and milliliters to liters.
• Give abbreviations for the frequently used metric units and subunits.
• List the basic units of measurement for volume in the household system.
• Convert units of measurement within the metric system and within the household system.
• Convert Fahrenheit to Celsius and Celsius to Fahrenheit

Outline METRIC SYSTEM

Conversion Within the Metric System
APOTHECARY SYSTEM
HOUSEHOLD SYSTEM
Conversion Within the Household System
Temperature Conversion

The three systems used for measuring drugs and solutions are the metric, apothecary, and household
systems. The metric system, developed in 1799 in France, is the chosen system for measurements in the
majority of European countries. The metric system, also referred to as the decimal system, is based on units
of 10. Since the enactment of the Metric Conversion Act of 1975, the United States has been moving
toward the use of this system. The intention of the act is to adopt the International Metric System world-
wide. The metric system is known as the International System of Units, abbreviated as SI units. Eventually,
it will be the only system used in drug dosing.
The apothecary system dates back to the Middle Ages and has been the system of weights and mea-
surements used in England since the seventeenth century. It was brought to the United States from
England. The system is also referred to as the fractional system because anything less than one is expressed
in fractions. In the United States, the apothecary system is rapidly being phased out and is being replaced
by the metric system. You may omit the apothecary system if you desire.
Standard household measurements are used primarily in home settings. With the trend toward home
care, conversions to household measurements may gain importance.

16
 CHAPTER 1 Systems Used for Drug Administration and Temperature Conversion 17

METRIC SYSTEM

The metric system is a decimal system based on multiples of 10 and decimal fractions of 10. There are
three basic units of measurement. These basic units are as follows:
Gram (g, gm, G, Gm): unit for weight
Liter (l, L): unit for volume or capacity
Meter (m, M): unit for linear measurement or length
Prefixes are used with the basic units to describe whether the units are larger or smaller than the basic
unit. The prefixes indicate the size of the unit in multiples of 10. The prefixes for basic units are as
follows:

Prefix for Larger Unit Prefix for Smaller Unit

Kilo 1000 (one thousand) Deci 0.1 (one-tenth)
Hecto 100 (one hundred) Centi 0.01 (one-hundredth)
Deka 10 (ten) Milli 0.001 (one-thousandth)
Micro 0.000001 (one-millionth)
Nano 0.000000001 (one-billionth)

Abbreviations of metric units that are frequently written in drug orders are listed in Table 1-1.
­Lowercase letters are usually used for abbreviations rather than capital letters.
The metric units of weight, volume, and length are given in Table 1-2. Meanings of the prefixes are
stated next to the units of weight. Note that the larger units are 1000, 100, and 10 times the basic units
(in bold type) and the smaller units differ by factors of 0.1, 0.01, 0.001, 0.000001, and 0.000000001. The
size of a basic unit can be changed by multiplying or dividing by 10. Micrograms and nanograms are the
exceptions: one (1) milligram ​5 ​1000 micrograms, and one (1) microgram ​5 ​1000 nanograms. Micro-
grams and nanograms are changed by 1000 instead of by 10.

Conversion Within the Metric System

Drug administration often requires conversion within the metric system to prepare the correct dosage.
Two basic methods are given for changing larger to smaller units and smaller to larger units.

TABLE 1-1 Metric Units and Abbreviations

Names Abbreviations

Weight Kilogram kg, Kg

Gram g, gm, G, Gm
Milligram mg, mgm
Microgram mcg
Nanogram ng
Volume Kiloliter kl, kL
Liter l, L
Deciliter dl, dL
Milliliter ml, mL
Microliter mcL
Length Kilometer km, Km
Meter m, M
Centimeter cm
Millimeter mm
18 PART II Systems, Conversion, and Methods of Drug Calculation

TABLE 1-2 Units of Measurement in the Metric System With Their Prefixes
Weight per Gram Meaning

*1 kilogram (kg) ​5 ​1000 grams One thousand

1 hectogram (hg) ​5 ​100 grams One hundred
1 dekagram (dag) ​5 ​10 grams Ten
*1 gram (g) ​ ​1 gram One
1 decigram (dg) ​5 ​0.1 gram (1⁄10) One-tenth
1 centigram (cg) ​5 ​0.01 gram (1⁄100) One-hundredth
*1 milligram (mg) ​5 ​0.001 gram (1⁄1000) One-thousandth
*1 microgram (mcg) ​5 ​0.000001 gram (1⁄1,000,000) One-millionth
*1 nanogram (ng) ​5 ​0.000000001 gram (1⁄1,000,000,000) One-billionth

Volume per Liter Length per Meter

*1 kiloliter (kL) ​5 ​1000 liters 1 kilometer (km) ​5 ​1000 meters

1 hectoliter (hL) ​5 ​100 liters 1 hectometer (hm) ​5 ​100 meters
1 dekaliter (daL) ​5 ​10 liters 1 dekameter (dam) ​5 ​10 meters
*1 liter (l, L) ​ ​1 liter 1 metric (m) ​ ​1 meter
*1 deciliter (dL) ​5 ​0.1 liter 1 decimeter (dm) ​5 ​0.1 meter
1 centiliter (cL) ​5 ​0.01 liter 1 centimeter (cm) ​5 ​0.01 meter
*1 milliliter (mL) ​5 ​0.001 liter 1 millimeter (mm) ​5 ​0.001 meter
1 microliter (mcL) ​5 ​0.000001 liter

*Commonly used units of measurements.

Method A (Larger to Smaller)

To change from a larger unit to a smaller unit, multiply by 10 for each unit decreased, or move the deci-
mal point one space to the right for each unit changed.
When changing three units from larger to smaller, such as from gram to milligram (a change of three
units), multiply by 10 three times (or by 1000), or move the decimal point three spaces to the right.
Change 1 gram (g) to milligrams (mg):
a. 1 ​3 ​10 ​3 ​10 ​3 ​10 ​5 ​1000 mg
b. 1 g ​3 ​1000 ​5 ​1000 mg
     or
c. 1 g ​5 ​1.000 mg (1000 mg)
N
When changing two units, such as kilogram to dekagram (a change of two units from larger to
smaller), multiply by 10 twice (or by 100), or move the decimal point two spaces to the right.
Change 2 kilograms (kg) to dekagrams (dag):
a. 2 ​3 ​10 ​3 ​10 ​5 ​200 dag
b. 2 kg ​3 ​100 ​5 ​200 dag
     or
c. 2 kg ​5 ​2.00 dag (200 dag)
N
When changing one unit, such as liter to deciliter (a change of one unit from larger to smaller), mul-
tiply by 10, or move the decimal point one space to the right.
Change 3 liters (L) to deciliters (dL):
a. 3 ​3 ​10 ​5 ​30 dL
b. 3 L ​3 ​10 ​5 ​30 dL
    or
c. 3 L ​5 ​3.0 dL (30 dL)
N
 CHAPTER 1 Systems Used for Drug Administration and Temperature Conversion 19

A micro unit is one thousandth of a milli unit, and a nano unit is one thousandth of a micro unit. To
change from a milli unit to a micro unit, multiply by 1000, or move the decimal place three spaces to the
right. Changing micro units to nano units involves the same procedure, multiplying by 1000 or moving
the decimal place three spaces to the right.

EXAMPLES PROBLEM 1: Change 2 grams (g) to milligrams (mg).

2 g ​3 ​1000 ​5 ​2000 mg
or
2 g ​5 ​2.000 mg (2000 mg)
N

PROBLEM 2: Change 10 milligrams (mg) to micrograms (mcg).

10 mg ​3 ​1000 ​5 ​10,000 mcg
or
10 mg ​5 ​10.000 mcg (10,000 mcg)
N

PROBLEM 3: Change 4 liters (L) to milliliters (mL).

4 L ​3 ​1000 ​5 ​4000 mL
or
4 L ​5 ​4.000 mL (4000 mL)
N

PROBLEM 4: Change 2 kilometers (km) to hectometers (hm).

2 km ​3 ​10 ​5 ​20 hm
or
2 km ​5 ​2.0 hm (20 hm)
N

Method B (Smaller to Larger)

To change from a smaller unit to a larger unit, divide by 10 for each unit increased, or move the decimal
point one space to the left for each unit changed.

When changing three units from smaller to larger, divide by 1000, or move the decimal point three
spaces to the left.
Change 1500 milliliters (mL) to liters (L):
a. 1500 mL ​4 ​1000 ​5 ​1.5 L
     or
b. 1500 mL ​5 ​1 ​
500. L (1.5 L)

When changing two units from smaller to larger, divide by 100, or move the decimal point two spaces
to the left.
Change 400 centimeters (cm) to meters (m):
a. 400 cm ​4 ​100 ​5 ​4 m
     or
b. 400 cm ​5 ​4
 ​00. m (4 m)
20 PART II Systems, Conversion, and Methods of Drug Calculation

When changing one unit from smaller to larger, divide by 10, or move the decimal point one space to
the left.
Change 150 decigrams (dg) to grams (g):
a. 150 dg ​4 ​10 ​5 ​15 g
     or
b. 150 dg ​5 ​15 ​0. g (15 g)
N

EXAMPLES PROBLEM 1: Change 8 grams (g) to kilograms (kg).

8 g ​4 ​1000 ​5 ​0.008 kg
or
8 g ​5 ​
008. kg (0.008 kg)

PROBLEM 2: Change 1500 milligrams (mg) to decigrams (dg).

1500 mg ​4 ​100 ​5 ​15 dg
or
1500 mg ​5 ​15 ​
00. dg (15 dg)

PROBLEM 3: Change 750 micrograms (mcg) to milligrams (mg).

750 mcg ​4 ​1000 ​5 ​0.75 mg
or
750 mcg ​5 ​7
50. mg (0.75 mg)

PROBLEM 4: Change 2400 milliliters (mL) to liters (L).

2400 mL ​4 ​1000 ​5 ​2.4 L
or
2400 mL ​5 ​2 ​4
00. L (2.4 L)

PRACTICE PROBLEMS u
​ ​I METRIC SYSTEM (CONVERSION WITHIN THE METRIC SYSTEM)
Answers can be found on page 24.

1. C
 onversion from larger units to smaller units: Multiply by 10 for each unit changed (multiply by 10,
100, 1000), or move the decimal point one space to the right for each unit changed (move one, two, or
three spaces), Method A.
a. 7.5 grams to milligrams

b. 10 milligrams to micrograms

c. 35 kilograms to grams

d. 2.5 liters to milliliters

 CHAPTER 1 Systems Used for Drug Administration and Temperature Conversion 21

e. 1.25 liters to milliliters

f. 20 centiliters to milliliters

g. 18 decigrams to milligrams

h. 0.5 kilograms to grams

2. C
 onversion from smaller units to larger units: Divide by 10 for each unit changed (divide by 10, 100,
1000), or move the decimal point one space to the left for each unit changed (move one, two, or three
spaces), Method B.
a. 500 milligrams to grams

b. 7500 micrograms to milligrams

c. 250 grams to kilograms

d. 4000 milliliters to liters

e. 325 milligrams to grams

f. 100 milliliters to deciliters

g. 2800 milliliters to liters

h. 75 millimeters to centimeters

APOTHECARY SYSTEM

The apothecary system was started in England in the early seventeenth century. It was a system of
­measurement commonly used before the universal acceptance of the International Metric System. Now, all
pharmaceuticals are manufactured using the metric system, and the apothecary system is no longer included
on most drug labels. All medication should be prescribed and calculated using metric measures.
Occasionally the drug may be prescribed in grains or fluid ounces (apothecary system). Examples of
those drugs include aspirin grain (gr) v or x (325 or 650 mg), nitroglycerin tablets gr 1/150 (0.4 mg),
codeine gr 1/2 or 1 (30 or 60 mg), and morphine gr 1/6 (10 mg). Table 2-1 (page 28) is the conversion
table for the Approximate Metric, Apothecary, and Household Equivalents. The table can be used if a
drug is ordered in the apothecary system but needs to be converted into the metric system. With the
apothecary system, Roman numerals are written in lowercase letters, e.g., gr x (10 grains).
22 PART II Systems, Conversion, and Methods of Drug Calculation

Figure 1-1 This label for nitroglycerin tablets shows the strength of the drug using both the metric system (0.6 mg) and
apothecary system (1/100 gr).

An example of a drug that includes both metric and apothecary measurements on the label is nitro-
glycerin, 0.6 mg (metric) and 1/100 (apothecary) (see Figure 1-1).

HOUSEHOLD SYSTEM

The use of household measurements is on the increase because more patients/clients are being cared for
in the home. The household system of measurement is less accurate than the metric system because of a
lack of standardization of spoons, cups, and glasses. A teaspoon (t) is considered 5 mL, although it could
represent anywhere from 4 to 6 mL. Three household teaspoons are equal to one tablespoon (T). A drop
size can vary with the size of the lumen of the dropper. Basically, a drop and a minim are considered
equal. Again, household measurements must be considered approximate measurements. Some of the
household units are the same as the apothecary units because there is a blend of these two systems.
The community health nurse may use and teach the household units of measurements to patients/
clients.
Table 1-3 gives the commonly used units of measurement in the household system. You might want
to memorize the equivalents in Table 1-3 or refer to the table as needed.

Conversion Within the Household System

For changing larger units to smaller units and smaller units to larger units within the household system,
the same methods that applied to the apothecary system can be used. With household measurements, a
fluid ounce is usually indicated as an ounce.

Method C
To change a larger unit to a smaller unit, multiply the constant value found in Table 1-3 by the number
of the larger unit.

EXAMPLES PROBLEM 1: 2 medium-size glasses ​5 ​ ounces (oz).

1 medium glass ​5 ​8 fl oz (8 is the constant value)
2 ​3 ​8 ​5 ​16 oz

TABLE 1-3 Units of Measurement in the Household System

1 drop (gt) (gtt) 5 ​1 minim (m) 1 coffee cup (c) 5 ​6 to 8 ounces (oz)
1 teaspoon (t) 5 ​60 drops (gtt) 5 ​5 mL 1 medium-size glass 5 ​8 ounces (oz)
1 tablespoon (T) 5 ​3 teaspoons (t) 1 measuring cup 5 ​8 ounces (oz)
1 ounce (oz) 5 ​2 tablespoons (T)
 CHAPTER 1 Systems Used for Drug Administration and Temperature Conversion 23

PROBLEM 2: 3 tablespoons (T) ​5 teaspoons (t).

1 T ​5 ​3 t (3 is the constant value)
3 ​3 ​3 ​5 ​9 t

PROBLEM 3: 5 ounces (oz) ​5 tablespoons (T).

1 oz ​5 ​2 T (2 is the constant value)
5 ​3 ​2 ​5 ​10 T

PROBLEM 4: 2 teaspoons (t) ​5 drops (gtt).

1 t ​5 ​60 gtt (60 is the constant value)
2 ​3 ​60 ​5 ​120 gtt

Method D
To change a smaller unit to a larger unit, divide the constant value found in Table 1-3 into the number
of the larger unit.

N OTE
The constant values are the numbers of the smaller units in Table 1-3.

EXAMPLES PROBLEM 1: PROBLEM 3:

120 drops (gtt) ​5 teaspoons (t). 18 ounces (oz) ​5 coffee cups (c).
1 t ​5 ​60 gtt (60 is the constant value) 1 c ​5 ​6 oz (6 is the constant value)
120 ​4 ​60 ​5 ​2 t 18 ​4 ​6 ​5 ​3 c
If it is a large coffee cup, use 8 oz.

PROBLEM 2: PROBLEM 4:

6 teaspoons (t) ​5 tablespoons (T). 4 tablespoons (T) ​5 ounces (oz).

1 T ​5 ​3 t (3 is the constant value) 1 oz ​5 ​2 T (2 is the constant value)
6 ​4 ​3 ​5 ​2 T 4 ​4 ​2 ​5 ​2 oz

PRACTICE PROBLEMS u
​ ​II HOUSEHOLD SYSTEM (CONVERSION WITHIN THE HOUSEHOLD)
Answers can be found on page 25.

1. Give the equivalents using Method C, changing larger units to smaller units.
a. 2 glasses ​5 oz
b. 3 ounces ​5 T
c. 4 tablespoons ​5 t
d. 11⁄2 coffee c (cups) ​5 oz
e. ⁄2 teaspoon ​5
1
gtt
24 PART II Systems, Conversion, and Methods of Drug Calculation

2. Give the equivalents using Method D, changing smaller units to larger units.
a. 9 teaspoons ​5 T
b. 6 tablespoons ​5 oz
c. 90 drops ​5 t
d. 12 ounces ​5 coffee c (cups)
e. 24 ounces ​5 medium-size glasses

Temperature Conversion
Temperature is commonly measured by two scales, Celsius and Fahrenheit. Celsius (C), or centigrade,
describes temperature with 0° C as the freezing point of water and 100°C as the boiling point of water.
The Celsius scale is widely used around the world. Medical devices and scientific equipment often use the
Celsius scale because it is a base-10 system like the metric system. The Fahrenheit (F) scale describes
temperature with the freezing point of water as 32° F and the boiling point of water as 212° F. The Fahr-
enheit scale is primarily used in the United States and its territories.
To convert from Fahrenheit to Celsius the formula is:

3 C 4 5 1 3 ° F 4 2 322 3 5/9

To convert from Celsius to Fahrenheit the formula is:

3 F 4 5 1 3 ° C 4 3 9/52 1 32

PRACTICE PROBLEMS u
​ ​IIII TEMPERATURE CONVERSION
Answers can be found on page 25.

a. Change 98.6° F to Celsius d. Change 22° C to Fahrenheit

b. Change 101° F to Celsius e. Change 30° C to Fahrenheit
c. Change 104° F to Celsius

ANSWERS
I Metric System

1. a. 7.5 g to mg 2. a. 500 mg to g
7.5 g ​3 ​1000 ​5 ​7500 mg 500 ​4 ​1000 ​5 ​0.5 g
or or
7.500 mg (7500 mg) 500 mg ​5 ​
500. g (0.5 g)
N
b. 10,000 mcg b. 7.5 mg
c. 35,000 g c. 0.25 kg
d. 2500 mL d. 4L
e. 1250 mL e. 0.325 g
f. 200 mL f. 1 dL
g. 1800 mg g. 2.8 L
h. 500 g h. 7.5 cm
 CHAPTER 1 Systems Used for Drug Administration and Temperature Conversion 25

II Household System

1. a. 2 glasses ​5 ​ oz 2. a. 9 teaspoons ​5 T
2 ​3 ​8 ​5 ​16 oz 9 ​4 ​3 ​5 ​3 T
b. 6T b. 3 oz
c. 12 t c. 11⁄2 t
d. 9 or 12 oz d. 11⁄2 or 2 c
e. 30 gtt e. 3 medium-size glasses

III Temperature Conversion

a. ° C 5 1 3 98.6° F 4 2 322 3 5/9 d. ° F 5 1 3 22° C 4 3 9/52 1 32

° C 5 66.6 3 5/9 5 198/5 1 32
5 333/9 5 39.6 1 32
° C 5 37 ° F 5 71.6
b. ° C 5 1 3 101° F 4 2 322 3 5/9 e. ° F 5 1 3 30° C 4 3 9/52 1 32
5 69 3 5/9 5 270/5 1 32
5 345/9 5 54 1 32
° C 5 38.3 ° F 5 86
c. ° C 5 1 3 104° F 4 2 322 3 5/9
5 72 3 5/9
5 360/9
° C 5 40

SUMMARY ​PRACTICE PROBLEMS
Answers can be found on page 26.
Make conversions within the two systems.
1. Metric system 2. Household system
a. 30 mg ​5 mcg a. 12 t ​5 T
b. 3 g ​5 ​ mg b. 5 medium-size glasses ​5 oz
c. 6 L ​5 ​ mL c. 3 T ​5 t
d. 1.5 kg ​5 g d. ​2 coffee c (cups) ​5 oz
e. 10,000 mcg ​5 mg e. 24 oz ​5 coffee c (cups)
f. 500 mg ​5 g f. 4 oz ​5 T
g. 2500 mL ​5 L
h. 125 g ​5 kg
i. 120 mm ​5 cm
j. 5 m ​5 cm
26 PART II Systems, Conversion, and Methods of Drug Calculation

ANSWERS ​ ​SUMMARY PRACTICE PROBLEMS

1. a. 30,000 mcg 2. a. 4T
b. 3000 mg b. 40 oz
c. 6000 mL c. 9t
d. 1500 g d. 12 oz or 16 oz
e. 10 mg e. 3-4 coffee c (cups)
f. 0.5 g f. 8T
g. 2.5 L
h. 0.125 kg
i. 12 cm
j. 500 cm

Additional information is available in the Introducing Drug Measures section of Drug

Calculations Companion, version 5, on Evolve.
CHAPTER 2
Conversion Within the Metric,
Apothecary, and Household Systems

Objectives • Convert grams to milligrams and milligrams to grams.

• Convert drug dosage by weight from one system to another system by using the ratio method.
• Utilize the conversion table for metric, apothecary, and household systems.
• Convert liters/milliliters to ounces and milliliters to tablespoons and teaspoons.

Outline UNITS, MILLIEQUIVALENTS, AND PERCENTS

METRIC, APOTHECARY, AND HOUSEHOLD EQUIVALENTS
CONVERSION IN METRIC AND HOUSEHOLD SYSTEMS BY LIQUID VOLUME
CONVERSION IN METRIC AND HOUSEHOLD SYSTEMS BY LENGTH

Today, conversion within the metric system is more common than conversion within the metric-­
apothecary systems. Although the apothecary system is being phased out, some physicians still order
drug dosages by apothecary units. If the faculty find that the apothecary system is not being used in their
institutions, they may wish to omit the apothecary equivalents and conversion shown in Table 2-1.
Drug doses are usually ordered in metric units (grams, milligrams, liters, and milliliters). To calculate
a drug dosage, the same unit of measurement must be used. Therefore, you must memorize the metric
equivalents. After the conversion is made, the dosage problem can be solved. Some authorities state that
it is easier to convert to the unit used on the container (bottle).
Dosage conversion tables are available in many institutions; however, when you need a conversion
table, one might not be available. Nurses should memorize metric equivalents or should be able to con-
vert within the system.

UNITS, MILLIEQUIVALENTS, AND PERCENTS

Units, milliequivalents, and percents are measurements and are used to indicate the strength or potency of
certain drugs. When a drug is developed, its strength is based on chemical assay or biological assay. Chemical
assay denotes strength by weight, e.g., milligrams or grains. Biological assays are used for drugs in which the
chemical composition is difficult to determine. Biological assays assess potency by determining the effect that
one unit of the drug can have on a laboratory animal. Units mainly measure the potency of hormones, vita-
mins, anticoagulants, and some antibiotics. Drugs that were once standardized by units and were later syn-
thesized to their chemical composition may still retain units as an indication of potency, e.g., insulin.
Milliequivalents measure the strength of an ion concentration. Ions are given primarily for electrolyte
replacement. They are measured in milliequivalents (mEq), one of which is 1⁄1000 of the equivalent weight of
an ion. Potassium chloride (KCl) is a common electrolyte replacement and is ordered in milliequivalents.

27
28 PART II Systems, Conversion, and Methods of Drug Calculation

Percents, the concentrations of weight dissolved in a volume, are always expressed as units of mass per
units of volume. Common concentrations are g/mL, g/L, and mg/mL. These concentrations, expressed as
percentages, are based on the definition of a 1% solution as 1 g of a drug in 100 mL of solution. ­Dextrose
50% in a 50-mL pre-filled syringe is a concentration of 50 g of dextrose in 100 mL of water. Calcium glu-
conate 10% in a 30-mL bottle is a concentration of 10 g of calcium gluconate in 100 mL of solution. Pro-
portions can also express concentrations. A solution that is 1;100 has the same concentration as a 1%
solution. Epinephrine 1;1000 means that 1 g of epinephrine was dissolved in a 1000-mL solution.
Units, milliequivalents, and percents cannot be directly converted into the metric, apothecary, or
household system.

METRIC, APOTHECARY, AND HOUSEHOLD EQUIVALENTS

Knowing how to convert drug doses among the systems of measurement is essential in the clinical set-
ting. In discharge teaching for individuals receiving liquid medication, converting metric to household
measurement may be important.
Table 2-1 gives the metric and apothecary equivalents by weight and the metric, apothecary, and
household equivalents by volume.

TABLE 2-1 Approximate Metric, Apothecary, and Household Equivalents

Metric System Apothecary System Household System

Weight 1 kg; 1000 g 2.2 lb 2.2 lb

30 g 1 oz
15 g 4 dr
1 g; 1000 mg* 15 (16) gr
0.5 g; 500 mg 71⁄2 gr
0.3 g; 300 mg 5 gr
0.1 g; 100 mg 11⁄2 gr
0.06 g; 60 (65) mg* 1 gr
1
0.03 g; 30 (32) mg ⁄2 gr
1
0.01 g; 10 mg ⁄6 gr
1
0.6 mg ⁄100 gr
1
0.4 mg ⁄150 gr
1
0.3 mg ⁄200 gr
1 mg = 1000 mcg
Volume 1 L; 1000 mL 1 qt; 32 fl oz 1 qt; 32 fl oz
0.5 L; 500 mL 1 pt; 16 fl oz 1 pt; 16 fl oz
0.24 L; 240 mL 8 fl oz 1 glass or 8 oz
0.18 L; 180 mL 6 fl oz 1 c or 6 oz
30 mL 1 oz or 8 dr 2 T or 6 t or 1 oz
1
15 mL ⁄2 oz or 4 dr 1 T or 1⁄2 oz
4-5 mL 1t
4 mL 1 dr or 60 minims (m) 1t
1 mL 15 (16) m 15-16 gtt
(drops)
Height 2.54 cm 1 inch 1 inch
Length 0.0254 m 1 inch —
Distance 25.4 mm 1 inch 1 inch

*Equivalents commonly used for computing conversion problems by ratio.

Note: 1⁄2 may be written as ss.
 CHAPTER 2 Conversion Within the Metric, Apothecary, and Household Systems 29

Remember, conversion from one system to another is an approximation. Though the apothecary sys-
tem is not or infrequently used, the table is included as a reference for approximate metric, apothecary,
and household equivalents.

MEMORIZE
Metric Equivalence
1 gram (g) = 1000 milligrams (mg)
1 milligram (mg) = 1000 micrograms (mcg)

PRACTICE PROBLEMS u
​ ​I CONVERSION BY WEIGHT
Answers can be found on page 32.

Ratio and Proportion: Grams and Milligrams

1. 2.5 g ​5 ​ mg 3. 500 mg ​5 ​ g
2. 100 mg ​5 ​ g

CONVERSION IN METRIC AND HOUSEHOLD SYSTEMS BY LIQUID VOLUME

MEMORIZE
Metric and Household Equivalents
1000 mL ​5 ​1 L ​5 ​1 qt ​5 ​32 oz
1 ounce (oz) 5 30 mL

Liters and Ounces: 1 L ​5 ​32 oz

a. To convert liters and quarts to ounces, multiply the number of liters by 32, the constant value.
b. To convert ounces to liters or quarts, divide the number of ounces by 32, the constant value.

EXAMPLES PROBLEM 1: Change 3 liters to ounces.

3 L ​3 ​32 ​5 ​96 oz

PROBLEM 2: Change 64 ounces to liters.

64 oz ​4 ​32 ​5 ​2 L (liters)

Ounces and Milliliters: 1 oz ​5 ​30 mL

a. To convert ounces to milliliters, multiply the number of ounces by 30, the constant value.
b. To convert milliliters to ounces, divide the number of milliliters by 30, the constant value.
30 PART II Systems, Conversion, and Methods of Drug Calculation

EXAMPLES PROBLEM 1: Change 5 ounces to milliliters (mL).

5 oz ​3 ​30 ​5 ​150 mL

PROBLEM 2: Change 120 milliliters to ounces.

120 mL ​4 ​30 ​5 ​4 oz

Ratio and Proportion

The ratio method is useful when smaller units are converted within the two systems.
If it is difficult for you to recall these methods, then use the ratio and proportion method to convert
from one system to the other.

MEMORIZE
30 mL ​5 ​1 oz ​5 ​2 T ​5 ​6t

These are equivalent values.

EXAMPLES PROBLEM 1: Change 20 mL to teaspoons.

Known Desired
mL;t < mL;t
30;6 < 20 ;X

30 X 5 120
X 5 4 t 1teaspoons2

PROBLEM 2: Change 15 mL to tablespoons.

Known Desired
mL;T < mL;T
30;2 < 15 ;X
30 X 5 30
X 5 1 T 1tablespoon2

PROBLEM 3: Change 5 oz to tablespoons.

Known Desired
oz;T < oz;T
1;2 < 5 ;X
X 5 10 T 1tablespoons2
 CHAPTER 2 Conversion Within the Metric, Apothecary, and Household Systems 31

PRACTICE PROBLEMS u
​ ​II CONVERSION BY LIQUID VOLUME
Answers can be found on page 32.

Liters and Ounces (Round to the nearest tenths.)

1. 2.5 L ​5 oz
2. 0.25 L ​5 ​ oz
3. 40 oz ​5 L
4. 24 oz ​5 ​ L

Ounces and Milliliters

1. 4 oz (fl oz) ​5 ​ mL
2. 61⁄2 oz ​5 ​ mL
3. 1⁄2 oz ​5 ​ mL
4. 45 mL ​5 ​ oz
5. 150 mL ​5 ​ oz
6. 15 mL ​5 ​ oz

CONVERSION IN METRIC AND HOUSEHOLD SYSTEMS BY LENGTH

Inches and Meters: 1 inch 5 0.0254 meter (constant value)

a. To convert inches to meters, multiply the number of inches by 0.0254, the constant value.
b. To convert meters to inches, divide the number of meters by 0.0254, the constant value.

EXAMPLES PROBLEM 1: Change 12 inches to meters (m).

12 inches 3 0.0254 5 0.3048 or 0.305 meter or 0.3 meter

PROBLEM 2: Change 0.6 meter to inches.

0.6 meter 4 0.0254 5 23.6 inches

Inches and Centimeters: 1 inch 5 2.54 centimeters (constant value)

a. To convert inches to centimeters, multiply the number of inches by 2.54, the constant value.
b. To convert centimeters to inches, divide the numbers of centimeters by 2.54, the constant value.

EXAMPLES PROBLEM 1: Change 12 inches to centimeters (cm).

12 inches 3 2.54 5 30.48 cm (centimeters) or 30.5 cm

PROBLEM 2: Change 60 cm to inches.

60 cm 4 2.54 5 23.6 inches

32 PART II Systems, Conversion, and Methods of Drug Calculation

PRACTICE PROBLEMS u
​ ​III CONVERSION BY LENGTH
Answers can be found on pages 32 and 33.

Inches to Meters (Change feet to inches [e.g., 6 ft 2 inches 5 74 inches])

1. 6 ft 2 inches 5 m 4. 2 ft 10 inches 5 m
2. 5 ft 2 inches 5 m 5. 4 ft 7 inches 5 m
3. 6 ft 5 inches 5 m

Inches to Centimeters
1. 2 inches 5 cm 4. 6 inches 5 cm
2. 3 inches 5 cm 5. 8 inches 5 cm
3. ⁄2 inch 5
1
cm

ANSWERS
I Conversion by Weight

Ratio and Proportion: Grams and Milligrams

1. g;mg < g;mg 2. mg;g< mg;g

1;1000<2.5;X 1000;1<100;X
    X ​ 5 ​2500 mg 1000 X ​5 ​100
       or X ​5 ​0.1 g
Move decimal point three spaces to the right 3. mg;g< mg;g
(conversion within the metric system). 1000;1<500;X
2.5 g ​5 ​2.500 mg 1000 X ​5 ​500
N
     X ​5 ​0.5 g

II Conversion by Liquid Volume

Liters and Ounces

1. 2.5 L ​3 ​32 ​5 ​80 oz 3. 40 oz ​4 ​32 ​5 ​1.25 L or 1.3 L

2. 0.25 L ​3 ​32 ​5 ​8 oz 4. 24 oz ​4 ​32 ​5 ​0.75 L or 0.8 L

Ounces and Milliliters

1. 4 oz ​3 ​30 ​5 ​120 mL 4. 45 mL ​4 ​30 ​5 ​11⁄2 oz or 1.5 oz

2. 6.5 oz ​3 ​30 ​5 ​195 mL 5. 150 mL ​4 ​30 ​5 ​5 oz
3. 0.5 oz ​3 ​30 ​5 ​15 mL 6. 15 mL ​4 ​30 ​5 ​1⁄2 oz or 0.5 oz

III Conversion by Length

Inches to Meters

1. 74 inches 3 0.0254 5 1.879 or 1.880 m 4. 34 inches 3 0.0254 5 0.864 m

2. 62 inches 3 0.0254 5 1.575 m 5. 55 inches 3 0.0254 5 1.397 m
3. 77 inches 3 0.0254 5 1.956 m
 CHAPTER 2 Conversion Within the Metric, Apothecary, and Household Systems 33

Inches to Centimeters

1. 2 inches 3 2.54 5 5.08 cm 4. 6 inches 3 2.54 5 15.24 cm

2. 3 inches 3 2.54 5 7.62 cm 5. 8 inches 3 2.54 5 20.32 cm
3. 1⁄2 inch 3 2.54 5 1.27 cm

SUMMARY PRACTICE PROBLEMS

Answers can be found on page 35.

Metric Conversion
Before the drug dosage problems can be solved, the nurse must convert to one drug unit, either from
grams to milligrams or milligrams to grams. This will be explained in more detail in Chapter 8.

YOU MUST REMEMBER

Multiply when converting from larger to smaller units, and divide when converting from smaller to larger
units.

Weight: Metric System: Conversion Within

1. To convert grams to milligrams, move the decimal point three spaces to the right.
a. 1.0 g 5 mg c. 0.3 g 5 mg
b. 0.8 g 5 mg d. 0.1 g 5 mg
2. To convert milligrams to grams, move the decimal point three spaces to the left.
a. 750 mg 5 g c. 1200 mg 5 g
b. 250 mg 5 g d. 400 mg 5 g

Volume: Metric and Household Conversion

3. To convert liters and quarts to ounces, (multiply/divide) the number of liters by ;
to convert ounces to liters and quarts, (multiply/divide) the number of ounces by .
a. 3 L ​5 ​ oz d. 1⁄2 L ​5 ​ oz
b. 1 ⁄2 qt ​5 ​
1
oz e. 8 oz ​5 L or qt
c. 64 fl oz ​5 ​ qt f. 24 oz ​5 ​ qt
4. To convert ounces to milliliters, (multiply/divide) the number of ounces by ;
to convert milliliters to ounces, (multiply/divide) the number of milliliters by .
a. 1 ⁄2 oz ​5 ​
1
mL d. 75 mL ​5 ​ oz
b. 15 mL ​5 ​ oz e. 3 fl oz ​5 ​ mL
c. 60 mL ​5 ​ oz f. 8 oz ​5 mL
34 PART II Systems, Conversion, and Methods of Drug Calculation

5. To convert milliliters to drops, (multiply/divide) the number of milliliters by ;

to convert drops to milliliters (multiply/divide) the number of drops by .
a. 15 mL ​5 ​ gtt
b. 10 gtt ​5 ​ mL
c. 18 gtt ​5 ​ mL
d. 4 mL ​5 ​ gtt
e. 30 gtt ​5 ​ mL
f. 1⁄2 mL ​5 ​ gtt
6. Ratio and proportion.

YOU MUST REMEMBER

30 mL ​5 ​1 oz ​5 ​ 2 T ​5 ​6 t (fl oz and oz have been used interchangeably with liquids)

a. Change 16 oz to L or qt

b. Change 11⁄2 oz to T

c. Change 1 T to t

d. Change 20 mL to t

e. Change 21⁄2 oz to mL

f. ​Change 4 oz to mL

7. P
 atient intake for lunch included a carton of milk (8 oz), cup of coffee (6 oz), small glass of apple
juice (4 oz), and gelatin (4 oz). How many milliliters (mL) did the patient consume for lunch?

8. A
 dd 8-hour intake: IV: 30 mL/hr, 230 mL in IV medications. PO intake: juice 4 oz, tea 6 oz, water
3 oz, gelatin 4 oz, ginger ale 5 oz, and milk 8 oz. What was the patient’s intake (IV and PO) in
8 hours? mL
9. A
 dd 8-hour intake: IV: 60 mL/hr; 250 mL in IV medications. PO intake: juice 4 oz; water 3 oz;
gelatin 2 oz; and broth 4 oz. What was the patient’s intake (IV and PO) in 8 hours?
mL
 CHAPTER 2 Conversion Within the Metric, Apothecary, and Household Systems 35

ANSWERS ​ ​SUMMARY PRACTICE PROBLEMS

Weight

1. a. 1000 mg c. 300 mg
b. 800 mg d. 100 mg
2. a. 0.750 or 0.75 g c. 1.200 or 1.2 g
b. 0.250 or 0.25 g d. 0.400 or 0.4 g

Volume

3. multiply, 32; divide, 32

a. 3 L ​3 ​32 ​5 ​96 oz d. 0.5 L ​3 ​32 ​5 ​16 oz
b. 1.5 qt ​3 ​32 ​5 ​48 oz e. 8 oz ​4 ​32 ​5 ​8⁄32 ​5 ​1⁄4 L or 1⁄4 qt or 0.25 or 0.3 qt
c. 64 oz ​4 ​32 ​5 ​2 qt f. 24 oz ​4 ​32 ​5 ​24⁄32 ​5 ​3⁄4 qt or 0.75 or 0.8 qt
4. multiply, 30; divide, 30
a. 11⁄2 oz ​3 ​30 ​5 ​45 mL d. 75 mL ​4 ​30 ​5 ​21⁄2 oz or 2.5 oz
b. 15 mL ​4 ​30 ​5 ​15⁄30 ​5 ​1⁄2 oz or 0.5 oz e. 3 oz ​3 ​30 ​5 ​90 mL
c. 60 mL ​4 ​30 ​5 ​2 oz f. 8 oz ​3 ​30 ​5 ​240 mL
5. multiply, 15; divide, 15
a. 15 mL 3 ​15 ​5 ​225 gtt d. 4 mL ​3 ​15 ​5 ​60 gtt
b. 10 gtt ​4 ​15 ​5 ​10⁄15 ​5 ​2⁄3 ml or 0.67 or 0.7 mL e. 30 gtt ​4 ​15 ​5 ​2 mL
c. 18 gtt ​4 ​15 ​5 ​11⁄5 ml or 1.2 mL f. 1⁄2 mL ​3 ​15 ​5 ​7.5 gtt or 8 gtt
6. Ratio and proportion 7. 11 ounce 5 30 mL2
Known Desired Milk 5 240 mL
a. L;oz<L;oz Coffee 5 180 mL
1;32<X;16 Apple juice 5 120 mL
32 X ​5 ​16 Gelatin 5 120 mL
   X ​5 ​1⁄2 L 660 mL
b. oz;T<oz;T The patient’s intake for lunch is 660 mL.
1;2<11⁄2;X 8. IV;30 mL 3 8 hr 5 240 mL
   X ​5 ​3 T IV medications 5 230 mL
c. T;t<T;t Juice 14 oz 3 30 mL2 5 120 mL
2;6<1;X Tea 5 180 mL
2 X ​5 ​6 Water 5 90 mL
   X ​ 5 ​3 t Gelatin 5 120 mL
d. mL;t<mL;t Ginger ale 5 150 mL
30;6<20;X Milk 5 240 mL
30 X ​5 ​120 1370 mL
   X ​5 ​4 t The patient’s intake in 8 hours (IV and PO) is 1370 mL.
e. oz;mL<oz;mL
1;30<21⁄2;X 9. IV;60 mL/hr 3 8 hr 5 480 mL
   X ​5 ​75 mL IV medications 5 250 mL
f. oz;mL<oz;mL Juice 5 120 mL
1;30<4;X Water 5 90 mL
   X ​5 ​120 mL Gelatin 5 60 mL
Broth 5 120 mL
1120 mL
The patient’s intake in 8 hours (IV and PO) is 1120 mL.

Additional information is available in the Introducing Drug Measures section of

Drug Calculations Companion, version 5, on Evolve.
CHAPTER 3
Interpretation of Drug Labels,
Drug Orders, Bar Codes, MAR and eMAR,
Automation of Medication Dispensing
Administration, and Abbreviations

Objectives • Identify brand names, generic names, drug forms, dosages, expiration dates, and lot numbers on
drug labels.
• Explain difference between military and traditional time.
• Give examples of drugs with “look-alike” drug names.
• Name the components of a drug order.
• Explain the computer-based medication administration system.
• Explain the use of the bar code for unit dose drug.
• Identify drug information for charting.
• Provide meanings of abbreviations: drug form, drug measurement, and routes and times of drug
administration.

Outline INTERPRETATION OF DRUG LABELS

Military (International) Time versus Traditional Time
DRUG DIFFERENTIATION
Drug Orders
UNIT-DOSE DISPENSING SYSTEM (UDDS)
COMPUTER-BASED DRUG ADMINISTRATION (CBDA)
COMPUTERIZED PRESCRIBER ORDER SYSTEM (CPOS)
Bar Code Medication Administration
Automation of Medication Dispensing Administration
Medication Administration Record (MAR and eMAR)
ABBREVIATIONS
Drug Measurements and Drug Forms
Routes of Drug Administration
Times of Administration
“Do Not Use” Abbreviations
The “Do Not Use” Abbreviation List

36
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 37

INTERPRETATION OF DRUG LABELS

Pharmaceutical companies label drugs with their brand name of the drug in large letters and the generic
name in smaller letters. The form of the drug (tablet, capsule, liquid, or powder) and dosage are printed
on the drug label.
Many of the calculation problems in this book use drug labels. By using drug labels, the student can
practice solving drug problems that are applicable to clinical practice. The student should know what infor-
mation is on a drug label and how this information is used in drug calculations. All drug labels provide eight
basic items of data: (1) brand (trade) name, (2) generic name, (3) dosage, (4) form of the drug, (5) expiration
date, (6) lot number, (7) name of the manufacturer, and (8) drug information and directions.

EXAMPLE DRUG LABEL

c. Dosage
b. Generic name
a. Brand (trade) name
d. Drug form and NDC number

h. Drug information
and directions
3/15/20
2345–T

g. Manufacturer

f. Lot number
e. Expiration date
i. Bar code

a. The brand (trade) name is the commercial name given by the pharmaceutical company (manufacturer
of the drug). It is printed in large, bold letters.
b. The generic name is the chemical name given to the drug, regardless of the drug manufacturer. It is printed
in smaller letters, usually under the brand name. Drugs are usually referred to by their generic name.
c. The dosage strength is the drug dose per drug form (tablet, capsule, liquid) as stated on the label.
d. The National Drug Code number (NDC) is the universal product identifier required by the U.S. Food
and Drug Administration. The numbers identify the manufacturer, distributor, strength, dosage, for-
mulation (tablets, capsules, liquids), and package size.
e. The expiration date refers to the length of time the drug can be used before it loses its potency. Drugs
should not be administered after the expiration date. The nurse must check the expiration date of all
drugs that he or she administers.
f. The lot number identifies the drug batch in which the medication was produced. Occasionally, a drug
is recalled according to the lot number.
g. The manufacturer is the pharmaceutical company that produces the brand-name drug.
h. Specific drug-related information and directions. This information along with more detail can be
found in the package insert.
i. The bar code contains all drug identifiers, such as control lot, batch number, NDC number, and expi-
ration date. This is on all prescription and nonprescription medications.
Examples of drug labels are given, and practice problems for reading drug labels follow the examples.
38 PART II Systems, Conversion, and Methods of Drug Calculation

EXAMPLE ORAL DRUG (SOLID FORM)

h d a

764–RT–321
c

4/22/18
b

i g
e
f

a. Brand (trade) name is Compazine.

b. Generic name is prochlorperazine.
c. Drug form is a sustained-release capsule (SR capsule).
d. Dosage is 10 mg per capsule.
e. Expiration date is 4/22/18 (after this date, the drug should be discarded).
f. Lot number is 764-RT-321.
g. Manufacturer name is SmithKline Beecham Pharmaceuticals.
h. Drug information includes dosages, storage, and safety measures.
i. Bar code.

EXAMPLE ORAL DRUG (LIQUID FORM)

a
b

359–PR–246
5/15/20

i
c d h e f
g

a. Brand (trade) name is Duricef.

b. Generic name is cefadroxil monohydrate.
c. Drug form is oral suspension.
d. Dosage is 500 mg per 5 mL.
e. Manufacturer is Bristol-Myers Squibb Company.
f. Expiration date is 5/15/20.
g. Lot number is 359-PR-246.
h. See package insert for more information.
i. Bar code.
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 39

EXAMPLE INJECTABLE DRUG

f

a. Brand name is Mandol.

b. Generic name is cefamandole nafate.
c. Drug form is drug powder that must be reconstituted in sterile water for use.
d. Dosage is 500 mg drug powder.
e. Drug container is vial.
f. Directions for drug reconstitution. For IV use: Add 5 mL of sterile water into the vial. Shake the vial
well to completely dissolve the drug powder. For IM use: Add 2 mL of sterile water into the vial and
shake thoroughly. The total volume of sterile water in the vial will equal 2.2 mL. The powder will
increase the total volume by 0.2 mL.

Refer to Chapter 9 for more information on medication reconstitution.

PRACTICE PROBLEMS u
​ ​I INTERPRETATION OF DRUG LABELS
Answers can be found on page 55.

1.

a. Brand (trade) name

b. Generic name
c. Drug form
d. Dosage
e. Manufacturer
40 PART II Systems, Conversion, and Methods of Drug Calculation

2.

T54325

11/15/16

a. Brand (trade) name e. Lot number

b. Generic name f. Expiration date
c. Drug form g. Manufacturer
d. Dosage
3.

a. Brand (trade) name d. Type of drug container

b. Generic name e. Dosage
c. Drug form f. Methods of administration

4.

a. Brand (trade) name

b. Generic name
c. Drug form
d. Dosage
e. Expiration date
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 41

5.

a. Brand name
b. Generic name
c. Drug form
d. How many mL in vial
e. Dosage 1 mL 5 mg
f. Manufacturer
g. Drug label suggests storing

Military (International) Time versus Traditional Time

Understanding the difference between military time and traditional time is essential in the health care field
because almost all nursing settings use military time for documentation, medication administration, and for
scheduling routine care and treatments. Military time uses a 24-hour clock, preventing potential documen-
tation and medication errors as each time occurs only once a day. Military time requires 4 digits, the first
two representing the hour and the second two digits representing the minutes. Unlike traditional time, mili-
tary time does not separate the hours and minutes with a colon. Also, am and pm are omitted because a
12-hour clock is not used in military time. Example: 5:43 am 5 0543. Example: 11:07 pm 5 2307.
Use Figure 3-1 to solve conversion problems.

PRACTICE PROBLEMS u
​ ​II MILITARY TIME AND TRADITIONAL TIME CONVERSIONS
Answers can be found on page 55.
12
11 1 Convert traditional times to military time.
24
23 13 1. 9:30 am 5
2. 10:05 pm 5
10 2 3. 4:55 pm 5
22 Outer # = AM 14
Inner # = PM
Convert military times to traditional time.
9 21 15 3 4. 0245 5
5. 1515 5
6. 0001 5
20 16
8 4
19 17
7 18 5
6

Figure 3-1 24-hour clock. In military time, midnight is

considered 2400; however, midnight is referred to and
written as 0000 in the medical field.
42 PART II Systems, Conversion, and Methods of Drug Calculation

DRUG DIFFERENTIATION

Some drugs with similar names, such as quinine and quinidine, have different chemical drug structures.
Extreme care must be exercised when administering drugs that “look alike” or have similar spellings.

EXAMPLES PERCOCET

Exp:
Lot:
PERCOCET
(oxycodone and acetaminophen)

Each tablet contains:

Oxycodone hydrochloride………5 mg
WARNING: May be habit forming
Acetaminophen………………325 mg
CAUTION: Federal law prohibits
dispensing without prescription.
DOSAGE: For dosage and full prescrib-
ing information, read accompanying
product information.
DEA ORDER FORM REQUIRED
100 TABLETS

PERCODAN
Exp:
Lot:

PERCODAN
(oxycodone and aspirin)

Each tablet contains:

Oxycodone hydrochloride……4.50 mg
WARNING: May be habit forming
Aspirin…………………………325 mg
CAUTION: Federal law prohibits
dispensing without prescription.
DOSAGE: For dosage and full prescrib-
ing information, read accompanying
product information.
DEA ORDER FORM REQUIRED
100 TABLETS

Percocet contains oxycodone and acetaminophen, whereas Percodan contains oxycodone and aspirin. A
patient may be allergic to aspirin or should not take aspirin; therefore it is important that the patient be
given Percocet. Read the drug labels carefully and check patient for an allergy band.

EXAMPLES HYDROXYZINE AND HYDRALAZINE

Hydroxyzine is an antianxiety drug, and hydralazine is an antihypertensive drug.

EXAMPLES QUINIDINE AND QUININE

Quinidine sulfate is an antidysrhythmic drug, and quinine sulfate is an antimalarial drug.

Drug Orders
Medication orders may be prescribed and written by a licensed health care provider (HCP) with pre-
scriptive authority, which includes physicians (MD), osteopathic physicians (DO), dentists (DDS), podi-
atrists (DPM), nurse practitioners (NP), and physician assistants (PA). Drug prescriptions in private
practice or in clinics are written on a small prescription pad and are filled by a pharmacist at a drugstore
or hospital (Figure 3-2). Some facilities have moved to computerized prescriptions. The physician enters
the patient’s drug order into a prescription template on a computer. The prescription then can be printed
out for the patient or sent electronically over a secure network directly to the patient’s chosen pharmacy.
For hospitalized patients, the drug orders may be written on a doctor’s order sheet and signed by the
prescribing licensed HCP (Figure 3-3), or a computerized drug order system may be used. If the order is
given by telephone (TO), the order must be cosigned by the physician within 24 hours. Most health care
institutions have policies concerning verbal or telephone drug orders. The nurse must know and follow
the institution’s policy.
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 43

Roger J. Smith, Jr., M.D.

678 Apple Street
Wilmington, Delaware 19810

(123) 456-7891

Name Age
Address Date

Rx

Generic permitted
Label M.D.
Safety cap
Refill times

Figure 3-2 ​Prescription pad medication order.

Figure 3-3 ​Patient’s order sheet.

44 PART II Systems, Conversion, and Methods of Drug Calculation

The basic components of a drug order are (1) date and time the order was written, (2) drug name,
(3) drug dosage, (4) route of administration, (5) frequency of administration, and (6) physician’s or HCP’s
signature. It is the nurse’s responsibility to follow the physician’s or HCP’s order, but if any one of these
components is missing, the drug order is incomplete and cannot be carried out. If the order is illegible, is
missing a component, or calls for an inappropriate drug or dosage, clarification from the provider who
wrote the order must be obtained before the order is carried out. It is the nurse’s responsibility to know
what medication he or she is giving and why the patient is receiving it.
Examples of drug orders and their interpretations are as follows:

6/3/16   0900   Digoxin 0.25 mg, po, daily

(give 0.25 mg of digoxin by mouth daily)
Ibuprofen 400 mg, po, q4h, PRN
(give 400 mg of ibuprofen by mouth every 4 hours as needed)
Cefadyl 500 mg, IM, q6h
(give 500 mg of Cefadyl intramuscularly every 6 hours)
Prednisone 5 mg, po, q8h 3 5 days
(give 5 mg of prednisone by mouth every 8 hours for 5 days)

PRACTICE PROBLEMS u
​ ​III INTERPRETATION OF DRUG ORDERS
Answers can be found on page 55.

Interpret these drug orders. For abbreviations that you do not know, see the section on abbreviations
later in this chapter.
1. Procrit 40,000 units, SC, weekly

2. Furosemide 40 mg, IV, bid

3. Meperidine 50 mg, IM, q3-4h, PRN

4. Prednisone 10 mg, po, tid 3 ​5 days

List what is missing in the following drug orders.

5. Codeine 30 mg, po, PRN for pain
6. Digoxin 0.25 mg, daily
7. TheoDur 200 mg
8. Penicillin V K 200,000 units, for days

 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 45

TABLE 3-1 Types of Drug Orders

Types/Description Examples

Standing orders:
A standing order may be typed or written on the patient’s Erythromycin 250 mg, po, q6h, 5 days
order sheet. It may be an order that is given for a number Demerol 50 mg, IM, q3-4h, PRN, pain
of days, or it may be a routine order that is part of an Colace 100 mg, po, hs, PRN
order set that applies to all patients who have had the
same type of procedure. Standing orders may include
PRN orders.
One-time (single) orders:
One-time orders are given once, usually at a specified time. Preoperative orders:
One-time orders can include STAT orders.  ​ ​Meperidine 75 mg, IM, 0730
 ​ ​Atropine SO4 0.4 mg, IM, 0730
PRN orders:
PRN orders are given at the patient’s request and at the Acetaminophen 1000 mg IV q6h PRN 3
nurse’s discretion concerning safety and need. Narcotics 24 hr for fevers . 38° C
are time-framed and renewed every 48-72 hours. Ondansetron HCl (Zofran), 4 mg, q4-8h, PRN
for nausea
STAT orders:
A STAT order is for a one-time dose of drug to be given Regular insulin 10 units, subQ, STAT
immediately.

There are four types of drug orders: (1) standing order, (2) one-time (single) order, (3) PRN (whenever
necessary) order, and (4) STAT (immediate) order (Table 3-1). Many of the drugs ordered for nonhos-
pitalized patients are normally standing orders that can be renewed (refilled) for 6 to 12 months. Narcotic
orders are not automatically refilled; if the narcotic use is extended, the physician writes another prescrip-
tion or calls the pharmacy.

UNIT-DOSE DISPENSING SYSTEM (UDDS)

The unit-dose drug dispensing system (UDDS) was developed to decrease medication errors, reduce the
waste of medication, and improve the efficiency of the nurse when administering medication. The UDDS
has almost replaced the ward stock system (Table 3-2). In the ward stock system, bulk drug supplies were
delivered to the medication room in each patient area. In the medication room, the nurse would prepare
the patient’s dose from the large multidose containers or multiple-dose vials; the correct dosage of medi-
cation must be taken from the container each time and labeled. In unit-dose dispensing, the pharmacy
can provide individual doses in packets or containers for each patient. The pharmacy buys the drugs in
bulk and repackages the medication in individual dose packets labeled with the drug name, dosage, and
usually a bar code. Many variations are seen in how drugs are stored and delivered to patient care areas.
Unit-dose cart cabinets (Figure 3-4) with individualized drawers labeled with the patient’s name, room
number, and bed number are most common. Each drawer is filled with 24 hours of medication as pre-
scribed by the physician and filled and verified by the pharmacist. The drawers may be refilled or exchanged
every 24 hours. When the nurse administers medication, the patient’s drawer is accessed, and the appro-
priate drug is withdrawn.
46 PART II Systems, Conversion, and Methods of Drug Calculation

TABLE 3-2 Methods of Drug Distribution

Stock Drug Method Unit-Dose Method

Description Drug is stored in a large container on Drug is packaged in single doses by the
the floor and is dispensed from the pharmacy for 24-hour dosing.
­container for all patients.
Advantages Drug is always available, which eliminates Fewer drug errors are made.
time spent waiting for drug to arrive Packaging saves the nurse time otherwise
from the pharmacy. spent in preparing the drug dose.
Cost efficiency is enhanced by having large Correct dose is provided with no calculation
quantities of the drug. needed.
Drug is billed for specific number of doses.
Disadvan- Drug error is more prevalent because the Time delay is seen in receipt of drug from
tages drug is “poured” by many persons. the pharmacy.
More drugs are available to choose from; If doses are contaminated or damaged, they
this may cause errors. are not immediately replaceable.
Drug expiration date on the container may
be missed.

Figure 3-4 ​Unit-dose cabinet. (From Clayton, B. D., Willihnganz, M. J. [2013]. ​Basic pharmacology for nurses. 16th ed.
St. Louis: Mosby.)

Unit-dose dispensing has eliminated the need for many drug calculations that were essential with the
ward stock system. Drug manufacturers are working to develop single doses for all medications but extra
packaging is costly. In addition, not all medications that are prescribed for a patient are dosed in the exact
amount manufactured. Therefore the nurse must master manual calculations and must have working
knowledge of the process and formulas needed for medications to be given safely.
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 47

COMPUTER-BASED DRUG ADMINISTRATION (CBDA)

Computer-based drug administration (CBDA) is a technological software system that is designed to

prevent medication errors. The concept began when the Centers for Disease Control and Prevention
(CDC) reported a rise in the number of medication-related deaths between 1983 and 1993. Since that
time, the National Coordinating Council for Medication Error Reporting and Prevention has made
several recommendations regarding the causes of medication errors; one example of its changes is the bar
coding of medications. The federal government through the Department of Veterans Affairs hospitals
has developed a software program that automates the medication administration process to improve
accuracy and efficiency in documentation. Currently, this system is composed of the computerized
prescriber order system (CPOS), the bar-code medication administration (BCMA) system, the elec-
tronic medication administration record (eMAR), and the pharmacy information system (PIS). Future
software will be expanded to track medications in all forms and to include the whole process of prescrib-
ing, administering, monitoring, and documenting.

COMPUTERIZED PRESCRIBER ORDER SYSTEM (CPOS)

The process begins with the computerized prescriber order (entry) system (CPOS), by which the physi-
cian or HCP can search for and select medications from a scrolling list (Figure 3-5). Once the medica-
tion is selected, the next screen displays all the possible doses, routes, and schedules (Figure 3-6). Once
the physician selects those components of the order, he or she can view the screen and make changes. If
the screen information is correct, the physician signs the order with his or her personal electronic code,
and the order is sent through the PIS, where the order is processed.

VistA CPRS in use by: Marshall,Sally

File Edit View Action Tools Help
0-NHCU NH-E1-A TEAM E / Remote Postings

Office
Jan 04,1925 (91) Provider: MARSHALL,SALLY Attending: Data AD
Action Outpatient Medications Expires Status Last Filled Refills Rem...
Medication Order
RANITIDINE TAB
(No quick orders available)

RANITIDINE TAB
RAPAMUNE <SIROLIMUS SOLN,ORAL> NF
RAPAMUNE <SIROLIMUS TAB> NF
READI-CAT <BARIUM SULFATE SUSP>
READICAT <BARIUM SULFATE SUSP>
REAGENT STRIP (COMFORT CURVE) TEST STRIP
REAGENT STRIP (TEST TAPE) TEST STRIP NF
REBETOL <RIBAVIRIN 200MG CAP,ORAL>
REBETROL <RIBAVIRIN 200MG CAP,ORAL>
RECOMBIVAX-HB <HEPATITIS B VACCINE (RECOMBIVAX) INJ,SUSP>
REDI-CAT <BARIUM SULFATE SUSP>
REFLUDAN <LEPIRUDIN (RECOMBINANT) 50MG VIAL INJ,PWDR>
REFRESH 0.3ML <REFRESH O.3ML DOSETTE SOLN,OPH> NF
REFRESH 0.3ML DOSETTE SOLN,OPH NF
REGITENE <PHENTOLAMINE 5MG INJ,CONC,W/BUF>
REGITINE <PHENTOLAMINE 5MG INJ,CONC,W/BUF>
REGLAN <METOCLOPRAMIDE 10MG TAB>
REGLAN <METOCLOPRAMIDE 5MG/5ML ORAL SYRUP>
REGLAN <METOCLOPRAMIDE 5MG/ML INJ,>
RANITIDINE TAB OK
PO Quit
Microsoft

Cover Sheet Problems Meds Orders Notes Consults D/C Summ Labs Reports

LOCK

Start CPRS-Patient Chart 3:51 PM

Figure 3-5 ​CPOS screen for medication selection.

48 PART II Systems, Conversion, and Methods of Drug Calculation

VistA CPRS in use by: Marshall,Sally

File Edit View Action Tools Help
0-NHCU NH-E1-A TEAM E / Remote Postings
Jan 04,1925 (91) Provider: MARSHALL,SALLY Attending Data AD
Action Outpatient Medications Expires Status Last Filled Refills Rem...
RANITIDINE HCL 150MG TAV (CMOP) Qty: 11 for 6 days Nov 27,16 Expired Nov 21,16 0
SIG: TAKE ONE TABLET BY MOUTH TWO TIMES DAILY
METFORMIN HCL 500MG TAB Qty: 6 for 6 days Nov 27,16 Expired Nov 21,16 0
SIG: TAKE ONE TABLET BY MOUTH EVERY EVENING WITH DINNER FOR
Action Inpatient Medications Stop Date Status
*ACETAMINOPHEN TAB Mar 12,16 Active
Give: 1000MG PO Q6H PRN
TRAZODONE TAB Mar 09,16 Active
Give: 100MG PO At Bedtime
FOSINOPRIL TAB Feb 21,16 Active
Give: 20MG PO Daily
PAROXETINE TAB Feb 13,16 Active
Give: 20MG PO Daily
FELODIPINE TAB, SA Feb 06,16 Active
Give: 10MG PO Daily
METFORMIN TAB,ORAL Jan 10,16 Active
Give: 1000MG PO QAM GLY/MET
*METFORMIN TAB,ORAL Jan 09,16 Active
Give: 500MG PO QPM GLY/MET
RANITIDINE TAB Jan 02,16 Active
Give: 150MG PO BID

Cover Sheet Problems Meds Orders Notes Consults D/C Summ Labs Reports

Figure 3-6 ​CPOS medication selection screen.

Bar Code Medication Administration

Bar codes are mandatory on medication packaging produced by drug suppliers. Pharmacies can buy drugs in
bulk and repackage the medication individually in cellophane envelopes or packets for the unit dose, with
each drug and dose having a specific bar-code number. The pharmacy delivers bar-coded drugs to hospital
units at specified times, and drugs are kept in special carts within designated areas in patient care locations.
When the nurse is ready to administer the medications, she or he accesses the BCMA system, which
displays the medication record screen, and uses the bar-code reader to scan the patient’s wristband and
the bar code on the drug (Figures 3-7 and 3-8).
The software validates the correct patient, drug, and dosage, along with the right route and time. The
software is intended to enhance patient safety by clarifying orders, improving communication, and aug-
menting clinical judgment.

Figure 3-7 ​Bar code for unit drug dose.

 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 49

Figure 3-8 ​Bar-code reader. It is used to scan the patient’s wristband.

Automation of Medication Dispensing Administration

Automated dispensing cabinets (ADCs) are medication cabinets that store, dispense, and track drugs in
patient areas. They were developed to reduce medication errors, increase pharmacy and nursing efficiency,
increase security, support efforts to maintain The Joint Commission and regulatory compliance, and
control costs. ADCs permit nurses to access the system with a user ID, personal password, or biometric
fingerprint scan to obtain medication in the patient area without having to wait for medication to come
from a centralized pharmacy. The three most common dispensing systems are the Pyxis MedStation
system (Figure 3-9), Omnicell OmniRx, and the AcuDose-Rx. These systems support storage of vials,
ampules, unit-dose packages, prefilled syringes, liquid cups, pre-mixed IVs, large-volume IVs, and other
forms of packing. Now almost 90% of all ADCs are linked to the pharmacy information system’s patient
medication profile; this ensures that the nurse accesses only medication for a specific patient.

Figure 3-9 ​Pyxis MedStation system. (From Cardinal Health, San Diego, Calif.)
50 PART II Systems, Conversion, and Methods of Drug Calculation

HOPE HOSPITAL Patient’s Name

Age:
Medication Administration Record (MAR)
Room#
Nurse’s signature/Title Initial

Allergies:

DATE STOP Medication Date, Initial, HT Rate, BP

ORDER DATE Dose – Route – Frequency TIME

Hold if HR < 60

Hold if SBP < 100

One-Time/PRN/STAT Medications
Medication/Dose Time/
Date Route/Frequency Initial Reason Result
Left knee pain 5 of 10
knee pain has
improved
1 of 10

Figure 3-10 ​Medication administration record (MAR).

 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 51

Medication Administration Record (MAR and eMAR)

Documentation for the MAR should be completed immediately after medications are given. Failing to
do so may result in (1) forgetting to chart/document, or (2) administration of drugs by another nurse who
thought that the drugs were not given. Although the MAR may vary among health care facilities, all
include basic information, such as the patient’s name, identification number, date of birth, location,
weight, allergies, sex, and date of admission. Drug information on the MAR that is common to all
records includes the following: (1) date the drug was ordered, (2) drug name, (3) dosage, (4) route of
administration, (5) frequency of administration, (6) date and time the drug was given, and (7) the nurse’s
signature and initials. Handwritten MARs (Figure 3-10) should be avoided because of the high risk of
transcription error.
The electronic medication administration record (eMAR) (Figure 3-11) is the counterpart to BCMA.
It is a paperless system that displays on the computer screen the medications to be administered and the
appropriate times for each. The nurse uses his or her own specific code to log on to the system, and when
the drug is scanned, it is documented as given.

FRIDAY 10/12/16 - 0700 thru SATURDAY 10/13/16 - 0659 ST ANNE HOSPITAL

Meyer, Lois M. Unit#: MEDICATION ADMINISTRATION RECORD
WESOF W303-2 Admitted: 10/12/16 Acct#: Page: 1
Age: 87 Sex: F Ht: 152.40 cm Wt: 49.8 kg Attending Dr: Benjamin Simmons, MD
Primary Dx: Chest pain Run Date/Time: 10/12/16 - 2237
DOB: 12/28/1928

Drug: PCN, ERYTHROMYCIN, IV DYE

ALLERGIES: Other: NO ALLERGIES RECORDED
Pharmacy: IODINE (INCLUDES RADIOPAQUE AGENTS W/IODINE). MACROLIDE ANTIBIOTICS, PENICILLINS

Init IV Flushes: Routine 0700-1459 1500-2259 2300-0659

Sodium Chloride 0.9% IV Time Time Time
Flush peripheral IV lines with 5 mls 0.9 NS q 8 hours Init Init Init
and central lines per protocol. # Flushed # Flushed # Flushed

Init SCHED MEDS DOSE 0700-1459 1500-2259 2300-0659

DOCUSATE SODIUM (DOCUSATE SODIUM) 100 MG PO Q12
START: 10/12 D/C: 11/11/16 AT 2244 RX 002306792

PRAVACHOL (PRAVASTATIN SODIUM) 80 MG PO

Give at: BEDTIME
START: 10/12 D/C: 11/11/16 AT 2244 RX 002306793

METOPROLOL TARTRATE (METOPROLOL TARTRATE) 50 MG PO Q12

HOLD FOR SBP110 OR HR55
Check apical rate and BP before drug admin.
START: 10/12 D/C: 11/11/16 AT 2244 RX 002306794

ACCUPRIL (QUINAPRIL HCL) 40 MG PO Q12

HOLD FOR SBP120
START: 10/12 D/C: 11/11/16 AT 2244 RX 002306795

NITROGLYCERIN 2% (NITROGLYCERIN 2%) 1 INCH TP Q6 0000

0600
HOLD FOR SBP100
START: 10/12 D/C: 11/11/16 AT 2244 RX 002306796

ALPRAZOLAM (ALPRAZOLAM) 0.25 MG PO Q8 0000

START: 10/12 D/C: 10/14/16 AT 1601 RX 002306791

Init PRN MEDS DOSE 0700-1459 1500-2259 2300-0659

NITROSTAT 25 TABS/BOTTLE (NITROGLYCERIN) 0.4 MG SL STAT

Chest discomfort. May repeat q 5 min x 3. If no relief
after 3 doses. Stat ECG & call Physician.
START: 10/12 D/C: 11/11/16 at 1833 RX 002306718 PRN

Figure 3-11 ​Electronic medication administration record (eMAR).

Note all medication hold parameters before administering any medication.

52 PART II Systems, Conversion, and Methods of Drug Calculation

ABBREVIATIONS

Drug Measurements and Drug Forms

Many abbreviations, symbols, acronyms, and dose designations in health care developed over time from
the need to communicate and document care. The nurse must learn these and properly interpret them
when administering drug therapy. Here are lists of acceptable abbreviations used in three categories: (1)
drug measurements and drug forms, (2) routes of drug administration, and (3) times of administration.
Not all abbreviations are used in every institution. The nurse should follow the institution’s policies for
documentation and communication.
Abbreviation Meaning
cap capsule
elix elixir
g, gm, G, GM gram
gtt drops
kg kilogram
l, L liter
m2 square meter
mcg microgram
mEq milliequivalent
mg milligram
mL, ml milliliter
m, min minim
oz ounce
pt pint
qt quart
SR sustained release
supp suppository
susp suspension
T.O. telephone order
T, tbsp tablespoon
t, tsp teaspoon
V.O. verbal order

Routes of Drug Administration

Abbreviation Meaning
ID intradermal
IM intramuscular
IV intravenous
IVPB intravenous piggyback
KVO keep vein open
L left
NGT nasogastric tube
PO, po, os by mouth
R, R right
SC, subc, sc, SQ , subQ subcutaneous
SL, sl, subl sublingual
TKO to keep open
Vag vaginal
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 53

Times of Administration
Abbreviation Meaning
AC, ac before meals
ad lib as desired
B.i.d., b.i.d., bid twice a day
c with
NPO nothing by mouth
PC, pc after meals
PRN, p.r.n. whenever necessary, as needed
q every
qam every morning
qh every hour
q2h every 2 hours
q4h every 4 hours
q6h every 6 hours
q8h every 8 hours
Q.i.d., q.i.d., qid four times a day
s without
SOS once if necessary; if there is a need
STAT immediately
T.i.d., t.i.d., tid three times a day

“Do Not Use” Abbreviations

Misconstrued and misinterpreted abbreviations can result in harmful outcomes. Two organizations, The
Joint Commission (TJC), formerly known as The Joint Commission on Accreditation of Healthcare
Organizations, and the Institute for Safe Medication Practices (ISMP), whose purpose is to improve
quality of care and promote patient safety, have issued “Do Not Use” lists of error-prone abbreviations,
symbols, acronyms, and dose designations with suggestions for alternatives to avoid mistakes and patient
harm. The nurse must be alert and recognize drug orders with abbreviations or symbols that could cause
potential problems.
The following is a combined list from TJC and ISMP of abbreviations and symbols that have been
frequently misinterpreted and that have caused harmful errors.

The “Do Not Use” Abbreviation List

Abbreviation Meaning Use Instead
A.D., ad Right ear Right ear
& and and
A.S., as Left ear Left ear
@ at at
A.U., au Both ears Both ears
cc cubic centimeter mL (milliliter)
D/C Discharge or discontinue Discharge or discontinue
Drug name abbreviations Write out the full name of the drug
hs At bedtime Bedtime
HS Half-strength Half-strength or at bedtime
i/d One daily 1 daily
IJ Injection Injection
IN Intranasal Intranasal or NAS
IU International unit International unit
, and . Less than and greater than Less than and greater than
54 PART II Systems, Conversion, and Methods of Drug Calculation

Abbreviation Meaning Use Instead

o.d. or OD Once daily Daily
O.D., od Right eye Right eye
OJ Orange juice Orange juice
O.S., os Left eye Left eye
O.U., ou Both eyes Both eyes
Per os By mouth, orally PO, by mouth, or orally
q.d. or QD Every day Daily
qhs or qHS Nightly at bedtime Nightly
qn Nightly or at bedtime Nightly or at bedtime
q.o.d. or QOD Every other day Every other day
q1d Daily Daily
q6pm Every evening at 6 pm 6 pm daily
/ (slash mark) Separates doses or means per per
ss Sliding scale or 1/2 Sliding scale
SSI Sliding scale insulin Sliding scale insulin
SSRI Sliding scale regular insulin Sliding scale insulin
tiw or TIW Three times a week Three times weekly
U or u Unit Unit
UD ut dictum or as directed As directed
Ug microgram mcg (microgram)

Please refer to TJC website at www.jointcommission.org and to the Institute for Safe Medication Prac-
tices at www.ismp.org for more detailed safety information.

PRACTICE PROBLEMS u
​ I​ V ABBREVIATIONS
Answers can be found on page 55.

If you have more than three incorrect answers, review the abbreviations and meanings. Then quiz
yourself again.
1. cap 14. IV
2. SR 15. KVO or TKO
3. fl oz 16. subcut
4. g, G, gm, GM 17. c
5. gtt 18. A.C., ac
6. L 19. NPO
7. mL 20. PC, pc
8. mcg 21. q4h
9. mg 22. Q.i.d., q.i.d., qid
10. oz 23. T.i.d., t.i.d., tid
11. T, tbsp 24. B.i.d., b.i.d., bid
12. t, tsp 25. STAT
13. IM
 CHAPTER 3 Labels, Orders, Codes, MAR, Abbreviations 55

ANSWERS
I Interpretation of Drug Labels

1. a. Sinequan 3. a. quinidine gluconate 5. a. Aquamephyton

b. doxepin b. quinidine gluconate (same as b. phytonadione
c. capsule brand name) c. Aqueous colloidal solution,
d. 10 mg per capsule c. liquid for injection injectable
e. Pfizer/Roerig d. vial (multiple-dose vial), total d. 2.5 mL
amount is 10 mL per vial e. 10 mg
2. a. Amoxil e. 80 mg per mL f. Merck & Co.
b. amoxicillin f. IM or IV g. In a dark place
c. liquid for oral suspension
when reconstituted 4. a. Adalat
d. 200 mg/5 mL b. nifedipine
e. Lot #T54325 c. tablet
f. Expiration date: 11/15/20 d. 30 mg
g. SmithKline Beecham e. 3/15/20

II Military Time and Traditional Time Conversions

1. 0930 3. 1655 5. 3:15 pm

2. 2205 4. 2:45 am 6. 12:01 am

III Interpretation of Drug Orders

1. Give 40,000 units of Procrit subcutaneously, once a week

2. Give 40 mg of furosemide intravenously, two times per day
3. Give 50 mg of meperidine intramuscularly every 3 to 4 hours whenever necessary
4. Give 10 mg of prednisone by mouth three times a day for 5 days
5. frequency of administration
6. route of administration
7. route and frequency of administration
8. route and frequency of administration and stop date

IV Abbreviations

  1. capsule 10. ounce 18. before meals

  2. sustained release 11. tablespoon 19. nothing by mouth
  3. fluid ounce 12. teaspoon 20. after meals
  4. gram 13. intramuscular 21. every 4 hours
  5. drop 14. intravenous 22. four times a day
  6. liter 15. keep vein open 23. three times a day
  7. milliliter 16. subcutaneous 24. two times a day
  8. microgram 17. with 25. immediately
  9. milligram

Additional information is available in the Safety in Medication Administration section of

Drug Calculations Companion, version 5.
CHAPTER 4
Prevention of Medication Errors

Objectives • Know the organizations that are monitoring medication errors.

• Identify high-alert drugs.
• Discuss some of the causes of medication errors (MEs).
• Explain ways that medication errors can be prevented.
• Describe the Rights in drug administration.

Outline PREVENTING MEDICATION ERRORS

THE RIGHTS IN DRUG ADMINISTRATION

PREVENTING MEDICATION ERRORS

The purpose of drug therapy is to improve the patient’s quality of life while minimizing the risk. There
are risks, some known and some unknown, associated with every medication. An adverse drug event/
reaction (ADE/ADR) is an incident that causes physical, mental, or functional harm associated with a
medication or the delivery of that medication. One type of adverse drug event/reaction is a medication
error (ME), which is a mistake made in prescribing, dispensing, administering, and/or patient monitor-
ing. Although medication errors are considered preventable, over 100,000 MEs were reported by hospi-
tals nationwide in 2001, according to a study conducted by the Institute for Safe Medication Practices
(ISMP). As a result of these medication errors, at least 7,000 deaths occurred per year at a cost of $2
billion. However, the reporting of MEs is voluntary, not mandatory. So the actual figures of MEs are
probably much higher.
Currently there are 40 health care groups—private, governmental, and professional—that are working
together to report, understand, and prevent medication errors. These stakeholders include: the ISMP,
National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Food and
Drug Administration (FDA), American Hospital Association, American Medical Association, American
Nurses Association, United States Pharmacopeia (USP), the National Academy of Medicine (formerly
Institute of Medicine, IOM), American Society of Health-System Pharmacists, The Joint Commission
(TJC), and AARP. The NC-MERP has developed tools for reporting and categorizing medication errors.
The FDA rules state that a bar code and the national drug code, which identifies the drug strength and its
dosage form, are required for human drug products and blood. The ISMP has identified lists of high-alert
drugs that should be carefully monitored to prevent adverse drug reactions. Nurse educators have resources
through the Quality and Safety Education for Nurses (QSEN) Institute to assist students to learn the
complexities of safe practice in drug administration.
Of the MEs reported in 2001, about half are intercepted, and of those, 86% were intercepted by
nurses. With so many drugs in use today, the nurse should have access to drug reference books and
online resources, such as Micromedex, DailyMed (can be obtained from the National Institutes of

56
 CHAPTER 4 Prevention of Medication Errors 57

Health, www.Dailymed.nlm.nih.gov), and Lexicomp, on the unit for prompt information about the
drug to be given, especially if it is a high-alert drug. Some examples of high-alert drugs are: potassium
chloride, insulin, heparin, opiates, and anticancer agents. Refer to Chapter 13.

YOU MUST REMEMBER

The person who administers the medication, usually the nurse, is responsible if an ME occurs.

Here are some examples of the types of medication errors (MEs):

1. The physician or health care provider makes a prescribing error and/or the written drug order is
NOT legible.
2. Transcription errors occur because the medications have similar names; the decimals and zeros
are not correctly written; or numbers are transposed.
3. Telephone and verbal orders are misinterpreted.
4. Interruptions occur when preparing medications.
5. Drug labels look similar (names and color), and packing obscures print on the label.
6. Trade names and generic names for drugs are used interchangeably, which causes confusion.
7. Oral dosages and intravenous dosages are different for the same drug.
8. Subcutaneous insulin is given in a tuberculin syringe and NOT in an insulin syringe.
9. The pharmacy delivers the wrong drug.
10. Intravenous medication is given too fast or too concentrated.
11. The amount of the drug is incorrectly calculated.
12. The drug is given intramuscularly or subcutaneously and should be given intravenously OR the
drug is given intravenously and should be given intramuscularly.
13. Two incompatible drugs are given intravenously, which can cause crystallization of the drugs.
14. Two or three patients with the same names are on the same unit and their identification wrist-
bands are hard to read. One patient receives another’s medication.
15. Medication is given and not monitored, and an overdose occurs.
16. An infusion pump malfunctions or is incorrectly programmed.

Ways to prevent medication errors (MEs):

1. Ask the physician or health care provider to rewrite or clarify medication order.
2. Use only approved abbreviations from The Joint Commission (TJC) list for medication dosages.
Do not use “u” for unit; it should be spelled out. Avoid use of a slash mark (/), which could be
interpreted as a one (1).
3. Do not use abbreviations for medication names (e.g., MSO4 for morphine sulfate).
4. Use leading zeros for doses less than a unit (e.g., 0.1 mg; NOT .1 mg). Do not use a zero follow-
ing a whole number (e.g., 5 mg; NOT 5.0 mg). The decimal point after 5 may not be noticed and
would look like 50 mg.
5. Check medication orders with written order and MAR/eMAR.
6. Check the drug dose sent from the pharmacy with the MAR/eMAR.
7. Prepare medications in a clean, distraction-free environment.
8. Never administer a medication that has been prepared by another nurse.
9. Have another nurse check the dosage preparation, especially if in doubt. Recalculate drug dosage
as needed.
10. Check if the patient is allergic to any specific drugs. If an ­allergy exists, report the type of reaction
the patient experiences.
11. Check the patient’s identification band with the eMAR and bar code.
12. Do not leave medication at the bedside. Stay with the patient until the medications are swallowed.
58 PART II Systems, Conversion, and Methods of Drug Calculation

13. Know whether the medication the patient is to receive would be contraindicated because of the
­patient’s health (liver disease and Tylenol [acetaminophen]) or because of a possible drug interac-
tion with another drug the patient is taking.
14. Assess physical parameters (e.g., apical pulse, respiration, BP, INR, and electrolyte values) before
administering the medication that could affect these parameters.
15. Monitor the effects of the administered drug, the rate of IV flow, and the patient’s response to the
medication.
16. Check when to administer medication for a patient whose status is nothing by mouth (NPO).
When in doubt, check with the health care provider (HCP) or nurse manager.
17. Record medications that are given immediately after their administration.
18. Report MEs immediately to the HCP.
19. Educate the patient and family about the drug and its action.
20. Know the compatibility of drugs that are being given. Report any contraindications.
Nurses often work in busy environments with constant distractions. When giving medications, it is
important to concentrate fully on the task and know the usual drug dosage of the medication you are
giving. If your facility does not have a current drug reference book that is easily accessible, then a drug
reference text should be obtained. If a nurse is unsure about a drug order or dosage, then consultation is
required with the pharmacy, physician, HCP, or nurse manager before administering the medication.
Keeping the patient safe is the nurse’s responsibility. The nurse is the licensed practitioner who adminis-
ters the medication and monitors the medication’s response. Nurses are the final line of defense. Be a
patient advocate, and always ask if you are unsure.

THE RIGHTS IN DRUG ADMINISTRATION

To provide safe drug administration, the nurse should practice the “10 Rights”: the right patient, the right
drug, the right dose, the right time, the right route, the right documentation, the right to refuse the medi-
cation, the right assessment, the right education (patient), and the right evaluation (see Box 4-1).

Right Patient
The patient’s identification band should always be checked before a medication is given. The nurse should
do the following:
• Verify the patient’s identity by checking his or her identification bracelet/wristband.
• Ask the patient his or her name and birth date. Do not call the patient by name. Some individuals
answer to any name. The patient may have difficulty in hearing.
• Check the name on the patient’s medication label.
• Check if the patient has allergies (check chart and ask the patient).

Right Drug
To avoid error, the nurse should do the following:
• Check the drug label three times: (1) first contact with the drug bottle or drug pack, (2) before
pouring/preparing the drug, and (3) after preparation of the drug.
• Check that the drug order is complete and legible. If it is not, contact the physician, HCP, or
charge nurse.
• Know the drug action.
• Check the expiration date. Discard an outdated drug or return the drug to the pharmacy.
• If the patient questions the drug, recheck the drug and drug dose. If in doubt, seek another
HCP’s advice, i.e., pharmacist, physician, licensed HCP. Some generic drugs differ in shape
or color.
 CHAPTER 4 Prevention of Medication Errors 59

Right Dose
Stock drugs and unit doses are the two methods frequently used for drug distribution. Not all health care
institutions use the unit-dose method (drugs prepared by dose in the pharmacy or by the pharmaceutical
company). If the institution uses the unit-dose method, drugs in bottles should not be administered
without the consent of the physician or pharmacist. The nurse should:
• Be able to calculate drug dose using the ratio and proportion, basic formula, fractional equation,
or dimensional analysis methods.
• Know how to calculate drug dose by body weight (kg) or by body surface (BSA; m2). Doses of
potent drugs (e.g., anticancer agents) and doses for children are frequently determined by body
weight or BSA.
• Know the recommended dosage range for the drug. Check the Physicians’ Desk Reference, the
American Hospital Formulary Service (AHFS) Drug Information, nursing drug reference books,
computerized drug reference programs, or other drug references. If the nurse believes that the dose
is incorrect or is not within the therapeutic drug range, he or she should notify the charge nurse,
physician, or pharmacist and should document all communications.
• Recalculate the drug dose if in doubt, or have a colleague recheck the dose and calculation.
• Question drug doses that appear incorrect.
• Have a colleague check the drug dose of potent or specified drugs, such as insulin, digoxin, narcot-
ics, and anticancer agents. This procedure is required by some facilities.

Right Time
The drug dose should be given at a specified time to maintain a therapeutic drug serum level. Too-­frequent
dosing can cause drug toxicity, and missed doses can nullify the drug action and its effect. The nurse should:
• Administer the drug at the specified time(s). Usually, drugs can be given 30 minutes before or
after the time prescribed.
• Omit or delay a drug dose according to specific circumstance, e.g., laboratory or diagnostic tests
may be necessary. Notify the appropriate personnel of the reason.
• Administer drugs that are affected by food (e.g., tetracycline) 1 hour before or 2 hours after meals.
• Administer drugs that can irritate the gastric mucosa (e.g., potassium or aspirin) with food.
• Give some medications promptly or at a specified time (e.g., STAT drugs for pain or nausea drugs).
• Know that drugs with a long half-life (t1/2) (e.g., 20 to 36 hours) are usually given once per day.
Drugs with a short half-life, e.g., 1 to 6 hours, are given several times a day.
• Administer antibiotics at even intervals (e.g., q8h: 8 am, 4 pm, midnight), rather than tid (8 am,
noon, 4 pm); q6h (6, 12, 6, 12), rather than qid (8-12-4-8) to maintain therapeutic drug serum
level. If the patient is to receive a diuretic twice a day, q12h, 8 am and 8 pm, the evening dose may
be given at 4 pm (e.g., bid) because of the diuretic effect. If dose is given in the evening, it could
cause urination late at night.

Right Route
The right route is necessary for the appropriate absorption of the medication. The more common routes
of absorption are: (1) oral (by mouth, po) tablet, capsule, pill, liquid, or suspension; (2) sublingual (under
the tongue for venous absorption, not to be swallowed); (3) buccal (between gum and cheek, not to be
swallowed); (4) topical (applied to the skin); (5) inhalation (aerosol sprays); (6) instillation (in nose, eye,
ear, rectum, or vagina); and (7) four parenteral routes: intradermal, subcutaneous, intramuscular, and
intravenous. The nurse should:
• Know the drug route. If in doubt, check with the pharmacy. Ointment for the eye should have
“ophthalmic” written on the tube. Drugs given sublingually (e.g., nitroglycerin tablet) should not
be swallowed, because the effect of the drug would be lost.
60 PART II Systems, Conversion, and Methods of Drug Calculation

• Administer injectables (subcutaneous and intramuscular) at appropriate sites (see Chapter 9).
• Use aseptic technique when administering drugs. Sterile technique is required with parenteral
routes.
• Document the injection site used on the patient’s paper chart (MAR) or eMAR.

Right Documentation
Document on the MAR or eMAR (computer), the time the drug was administered and the nurse’s ini-
tials. To avoid overdosing or underdosing of drug, administration of medication should be recorded
immediately.
• Put your initials on the MAR sheet or eMAR at the proper space immediately after administering
the drug. With eMAR, click the mark as given, and the system will automatically sign the medi-
cation off with your initials.
• Refused drug: Circle your initials and document on the nurse’s notes or on the MAR or
eMAR.
• Omitted drug: Circle your initials and document on the nurse’s notes or the MAR/eMAR.
Document why the drug was omitted, such as the patient was NPO because of a laboratory or
diagnostic test. The charge nurse or HCP should be notified.
• Delay in administering drug should be documented on the nurse’s notes, MAR sheet, or eMAR.
If the drug is to be administered once a day and is delayed, document the time the drug is given.
Medications can be retimed on eMAR.
• High-alert medications must be cosigned whenever a dose changes or a new IV bag is hung.
Check with your institution.

Right to Refuse Medication

The patient has a right to refuse medication. However,
• Explain to the patient the therapeutic effect of the drug. This will often diminish the patient’s
refusal.
• Document the medication and time the patient refused the drug and the reason for the patient’s
refusal.
• Notify the physician, HCP, and/or charge nurse that the patient refused the drug and why.
• If the refusal is due to the mental status of the patient, it should be reported.

Right Assessment
• Assess whether the ordered medication is safe to administer.
• Assess the patient’s vital signs (VS) to determine medication safety. For example, a patient may be
ordered Dilaudid 0.5 mg, IV. The patient’s VS are BP 95/60, pulse 60, and respirations 8. After
assessing VS, the Dilaudid IV would be determined to be unsafe to administer.
• Know that opioids can decrease blood pressure, pulse, and respirations.
• Assess the effects of the medication being administered.

Right Education
• Educate the patient about the purpose(s) for the ordered medications.
• Answer patient’s questions about the medication he or she is taking. The patient will most likely
comply in taking the medication if the patient understands the purpose and effects of the
drug(s).
• Educate the patient about the possible effects of the medication, including side effects, especially
with potent drugs.
 CHAPTER 4 Prevention of Medication Errors 61

Right Evaluation
• Evaluate the effects of the medication, particularly whether it was effective or not.
• Record on the MAR or eMAR the positive or negative effects of the medication(s).
• Report to the health care provider (HCP) if the medication was ineffective.
• Evaluate whether the medication is causing adverse reactions. Report immediately any adverse
reactions.

BOX 4-1 CHECKLIST FOR THE “10 RIGHTS” IN DRUG

ADMINISTRATION
Right Patient
• Check patient’s identification bracelet.
• Ask the patient his or her name and birth date.
• Check the name on the patient’s medication label.

Right Drug
• Check that the drug order is complete and legible.
• Check the drug label three times.
• Check the expiration date.
• Know the drug action.

Right Dose
• Calculate the drug dosage.
• Know the recommended dosage range for the drug.
• Recalculate the drug dosage with another nurse if in doubt.

Right Time
• Administer drug at the specified time(s).
• Document any delay or omitted drug dose.
• Administer drugs that irritate gastric mucosa with food.
• Administer drugs that cannot be administered with food 1 hour before or 2 hours after meals.
• Administer antibiotics at even intervals (q6h or q8h).

Right Route
• Know the route for administration of the drug.
• Use aseptic techniques when administering a drug.
• Document the injection site on the MAR/eMAR.

Right Documentation
• Place nurse’s initials on the MAR sheet or eMAR.
• Document the reason for a patient not taking the drug.
• Indicate on the MAR sheet or eMAR whether the drug dose was delayed and the time it was given.

Right to Refuse Medication

• Document the time and date the patient refused the drug and the refusal reason.
• Notify the charge nurse and physician that the patient refused the drug.
• Explain the purpose and therapeutic effect of the drug to the patient.
• Record if the refusal could be due to the patient’s mental status.

Continued
62 PART II Systems, Conversion, and Methods of Drug Calculation

BOX 4-1 CHECKLIST FOR THE “10 RIGHTS” IN DRUG

ADMINISTRATION—cont’d
Right Assessment
• Assess if the ordered medication is safe to administer.
• Assess the patient’s vital signs and determine whether they are safe for the drug.
• Know that opioids can decrease vital signs.
• Assess the effects of the medication(s) being administered.

Right Education
• Educate the patient about the purpose(s) for the medication.
• Answer the patient’s questions about the medication he or she is receiving.
• Educate the patient about possible side effects of the medication.

Right Evaluation
• Evaluate the effects of the medication.
• Record on the MAR or eMAR the effects of the medication(s).
• Report to the HCP if the medication was ineffective.
• Evaluate whether the medication caused adverse reactions.

Additional information is available in the Safety in Medication Administration section of

Drug Calculations Companion, version 5.
CHAPTER 5
Alternative Methods
for Drug Administration

Objectives • Explain the correct method of applying a transdermal patch.

• Describe the administration nasal and ophthalmic medications.
• Explain the techniques for administering ear drops to adults and children.
• Recognize when intraosseous or intraspinal access should be utilized in the clinical setting.

Outline TRANSDERMAL PATCH

TYPES OF INHALERS AND NEBULIZERS
NASAL SPRAY AND DROPS
EYE DROPS AND OINTMENT
EAR DROPS
PHARYNGEAL SPRAY, MOUTHWASH, AND LOZENGE
TOPICAL PREPARATIONS: LOTION, CREAM, AND OINTMENT
RECTAL SUPPOSITORY
VAGINAL SUPPOSITORY, CREAM, AND OINTMENT
INTRAOSSEOUS ACCESS
INTRASPINAL ACCESS

63
64 PART II Systems, Conversion, and Methods of Drug Calculation

The properties of a medication significantly influence its route of administration, which determines how
it will be absorbed into the body. The two major routes of administration are enteral and parenteral.
Drugs taken orally or sublingually are using an enteral route of administration. The parenteral route
directly delivers the medication into the patient’s systemic circulation (i.e., intravenous, intramuscular,
intraosseous, and subcutaneous). Other methods of administration may be less common but are still
important alternatives for medication delivery. Some other forms of medication administration include
transdermal, inhalation, pharyngeal, topical, rectal, vaginal, nasal, eye, or ear drops, and intraspinal. The
general nursing procedure for any drug administration is to wash hands, apply clean gloves, then proceed
to administer the medication.

TRANSDERMAL PATCH

Purpose
The transdermal patch contains medication (Figure 5-1); the patch is applied to the skin for slow, sys-
temic absorption, usually over 24 hours. Use of the transdermal route avoids the gastrointestinal prob-
lems associated with some oral medications and provides a more consistent drug level in the patient’s
blood.

Method
Transdermal Patch
1. Wear gloves to remove existing patch if present, then cleanse and dry the area of skin where the new
patch will be applied. Commonly used areas are the chest, abdomen, arms, or thighs. Avoid areas that
have hair.
2. Label the patch with date, time, and nurse’s initials.
3. Remove the transparent cover (inside) of the patch. Do not touch the inside of the patch.
4. Apply the patch to the chosen area with the dull plastic side up.
5. Document location of transdermal patch on medication administration record or chart.
Note: There are some transdermal patches that absorb over 3 days (e.g., durgesic), some over 7 days (e.g.,
Catapres), and some over 1 month (e.g., contraceptive agents).

Skin

Drug in
patch

Epidermis
Dermis

Subcutaneous tissue Muscle

Figure 5-1 A, Transdermal nitroglycerin patch. (In Lilley, L. L., Collins, S. R., Harrington, S., Snyder, J. S. [2011]. Pharmacology
and the nursing process, 6th ed., St. Louis: Mosby. From Rick Brady, Riva, MD.) B, Interior of the transdermal patch.
 CHAPTER 5 Alternative Methods for Drug Administration 65
TYPES OF INHALERS AND NEBULIZERS

Purpose
The drug inhaler delivers a prescribed dose to be absorbed rapidly by the mucosal lining of the respiratory
tract (Figure 5-2). The drug categories for respiratory inhalation are bronchodilators, which dilate bron-
chial tubes; glucocorticoids, which are anti-inflammatory agents; and mucolytics, which liquefy bronchial
secretions.

Types
Inhalers can be divided into four groups: metered-dose inhalers (MDIs), MDI inhalers with spacers, dry
powder inhalers, and nebulizers. Standard MDIs use a pressurized gas that expels the medication. The
user must press the canister and inhale fully at the same time. Breath-activated MDIs are another type,
in which the dose is triggered by inhaling through the mouthpiece; they require less coordination.
Spacer devices are used with MDIs and act as a reservoir to hold the medication until it is inhaled.
These devices have a one-way valve that prevents the aerosol from escaping. Good coordination is not
needed to use a spacer device.
Dry powder inhalers contain small amounts of medications that have to be strongly inhaled if the
powder is to get into the lungs. This method is difficult for children younger than 6 years.
Nebulizers are devices that convert medication into a fine mist. The medication is usually prescribed
in a prefilled dosette, which is placed in a nebulizer connected to a small compressor that aerosolizes the
medication. The medication is inhaled via mouthpiece or face mask. Nebulizers are the choice for the
weak, elderly, and small children and infants because no coordination is needed for this type of delivery.

Metal canister

Insertion tip

Plastic holder

Mouthpiece

Cap

Upright position
Figure 5-2 ​Technique for using the aerosol inhaler. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2012]. Pharmacology:
a nursing process approach, 7th ed., Philadelphia: Saunders.)
66 PART II Systems, Conversion, and Methods of Drug Calculation

Without Spacer With Spacer

10% Inhaler Device 57%

81% Mouth/Throat 22%

9% Lungs 21%

Figure 5-3 ​Distribution of medication with and without a spacer.

Method
Metered-Dose Inhaler
1. Insert the medication canister into the plastic holder. If the inhaler has not been used recently or if it
is being used for the first time, test spray before administering the metered dose.
2. Shake the inhaler well before using. Remove the cap from the mouthpiece.
3. Instruct the patient to breathe out through the mouth, expelling air. Place the mouthpiece into the
patient’s mouth, holding the inhaler upright (see Figure 5-2).
4. Instruct the patient to keep his or her lips securely around the mouthpiece and inhale. While the
patient is inhaling, push the top of the medication canister once.
5. Instruct the patient to hold his or her breath for a few seconds. Remove the mouthpiece and take your
finger off the canister. Tell the patient to exhale slowly.
6. If a second dose is required, wait 1 to 2 minutes, and repeat steps 3 to 5.
7. Cleanse the mouthpiece.

Method
Metered-Dose Inhaler with Spacer
This method is similar to an MDI with the following additions; see Figure 5-3.
1. Start to inhale as soon as the canister is depressed.
2. Check that the valve opens and closes with each breath.
3. Wash spacer as directed by manufacturer.
Note: For steroid inhalers, rinsing and gargling are necessary to remove residual steroid medication, thus
preventing a sore throat or fungal overgrowth and infection.

NASAL SPRAY AND DROPS

Purpose
Most drugs in nasal spray and drop containers are intended to relieve nasal congestion typically caused
by upper respiratory tract infections by shrinking swollen nasal membranes. Types of drugs given by this
method are vasoconstrictors and glucocorticoids.
 CHAPTER 5 Alternative Methods for Drug Administration 67

Figure 5-4 ​Administering nasal spray. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a nursing
process approach, 8th ed., Philadelphia: Saunders.)

Method
Nasal Spray
1. Instruct the patient to sit with his or her head tilted slightly back or slightly forward, according to the
directions on the spray container.
2. Insert the tip of the container into one nostril and occlude the other nostril (Figure 5-4).
3. Instruct the patient to inhale as you squeeze the drug spray container. Repeat with the same nostril or
other nostril if ordered.
4. Encourage the patient to keep his or her head tilted back for several minutes to promote absorption
of the medication. The nose should not be blown until the head is upright.
5. Drink plenty of fluids after using a steroid nasal spray to avoid microbial overgrowth.

Method
Nasal Drops
1. Instruct the patient to sit with his or her head tilted back.
2. Insert the dropper into the nostril without touching the nasal membranes (Figure 5-5).
3. Instill the number of drops prescribed.
4. Instruct the patient to keep his or her head tilted back for 5 minutes and to breathe through the
mouth.
5. Cleanse the dropper.
6. For the medication to reach the frontal and maxillary sinuses, the patient should slowly alternate turn-
ing his or her head from side to side while in the supine position. For the medication to reach the
ethmoidal and sphenoidal sinuses, the patient will need to lean forward, bringing his or her head
toward the knees.
68 PART II Systems, Conversion, and Methods of Drug Calculation

Figure 5-5 ​Administering nasal drops. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a nursing
process approach, 8th ed., Philadelphia: Saunders.)

EYE DROPS AND OINTMENT

Purpose
Eye medications are prescribed for various eye disorders, such as glaucoma, infection, and allergies, and
for eye examination and eye surgery.

Method
Eye Drops
1. Instruct the patient to lie or sit with his or her head tilted back.
2. Instruct the patient to look up toward the ceiling and away from the dropper. Pull down the lower lid
of the affected eye (Figure 5-6). Place the number of drops prescribed into the lower conjunctival sac.
This prevents the drug from dropping onto the cornea. To prevent contamination DO NOT touch the
end of the dropper on the eye or eyelashes.
3. Press gently on the medial nasolacrimal canthus (side closer to the nose) with a tissue to prevent sys-
temic drug absorption.
4. If the other eye is affected, repeat the procedure in the other eye.
5. Instruct patient to blink once or twice and then to keep his or her eyes closed for several minutes. Use
a tissue to blot away excess drug fluid.
6. When administering two or more different types of eye drops, wait 5 minutes between medications.

Method
Eye Ointment
1. Instruct the patient to lie or sit with his or her head tilted back.
2. Pull down the lower lid to expose the conjunctival sac of the affected eye (Figure 5-7).
 CHAPTER 5 Alternative Methods for Drug Administration 69

3. Squeeze a strip of ointment about 1⁄4-inch long (unless otherwise indicated) onto the conjunctival sac.
Medication placed directly onto the cornea can cause discomfort or damage.
4. If the other eye is affected, repeat the procedure.
5. Instruct the patient to close his or her eyes for 2 to 3 minutes. Teach the patient to expect blurred
vision for a short time after the application of the ointment.

Conjunctival sac

Figure 5-6 ​To administer eye drops, gently pull down the skin below the eye to expose the conjunctival sac. (From
Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a nursing process approach, 8th ed., Philadelphia:
Saunders.)

Cornea

Ointment

Figure 5-7 ​To administer eye ointment, squeeze a 1⁄4-inch–long strip of ointment onto the conjunctival sac. (From Kee, J. L.,
Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a nursing process approach, 8th ed., Philadelphia: Saunders.)
70 PART II Systems, Conversion, and Methods of Drug Calculation

EAR DROPS

Purpose
Ear medication is frequently prescribed to soften and loosen the cerumen (wax) in the ear canal, for
anesthetic effect, to immobilize insects in the ear canal, and to treat infection such as fungal infections.

Method
Ear Drops
1. Instruct the patient to lie on the unaffected side or to sit upright with his or her head tilted toward the
unaffected side.
2. Straighten the external ear canal (Figure 5-8) as follows: Adult: Pull the auricle of the ear up and back.
Child: Pull the auricle of the ear down and back until age 3.
3. Instill the prescribed number of drops. Avoid contaminating the dropper.
4. Instruct the patient to remain in this position for 2 to 5 minutes to prevent the medication from leak-
ing out of the ear.

B
Figure 5-8 ​To administer ear drops, straighten the external ear canal by (A) pulling down and back on the auricle in children
until age 3, and (B) pulling up and back on the auricle in adults. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015].
Pharmacology: a nursing process approach, 8th ed., Philadelphia: Saunders.)
 CHAPTER 5 Alternative Methods for Drug Administration 71

PHARYNGEAL SPRAY, MOUTHWASH, AND LOZENGE

Purpose
Sprays, mouthwashes, and lozenges can be prescribed to reduce throat irritation and for antiseptic and
anesthetic effects. These methods are prescribed for a local effect on the throat and not for systemic use.

Method
Pharyngeal Spray
1. Instruct the patient to sit upright.
2. Place a tongue blade over the patient’s tongue to improve visualization of the mouth and to prevent
the tongue from becoming numb if an anesthetic is being administered.
3. Hold the spray pump nozzle outside the patient’s mouth, and direct the spray to the back of the
throat.

Method
Pharyngeal Mouthwash
1. Instruct the patient to sit upright.
2. Instruct the patient to swish the solution around the mouth, but not to swallow the solution, and then
to spit it into an emesis basin or sink.

Method
Pharyngeal Lozenge
1. Instruct the patient to sit upright.
2. Instruct the patient to place the lozenge into his or her mouth and suck until it is fully dissolved. The
lozenge should not be chewed or swallowed whole.

TOPICAL PREPARATIONS: LOTION, CREAM, AND OINTMENT

Purpose
Topical lotions, creams, and ointments are used to protect skin areas, prevent skin dryness, treat itching
of skin areas, and relieve pain.

Method
Topical Lotion
1. Cleanse skin area with soap and water. Allow time for the area to air-dry, or gently pat it dry.
2. Shake the lotion container. Rub the lotion thoroughly into the skin unless otherwise indicated.
72 PART II Systems, Conversion, and Methods of Drug Calculation

Method A
Topical Cream or Ointment
1. Cleanse the skin area. Allow time for the area to air-dry, or gently pat it dry.
2. Use a sterile tongue blade or gauze to apply the cream or ointment to the affected skin area. Use long,
smooth strokes. A piece of sterile gauze may be placed over the medicated area after application to
prevent soiling of clothing.

Method B
Topical Cream or Ointment
1. Cleanse the skin area. Allow time for the area to air-dry, or gently pat it dry.
2. Squeeze a line of ointment from the tube onto your gloved finger from the tip to the first skin crease;
this is known as a fingertip unit (FTU) (Figure 5-9).
One FTU weighs about 0.5 g.
3. Use the guidelines shown in Figure 5-10 to determine the number of FTUs to apply to various body
areas.
4. Apply the medication to the affected area.

Figure 5-9 ​Fingertip unit: ointment squeezed from the tip of the finger to the first skin crease.

Face and neck: 21/2 FTUs

Trunk: 14 FTUs
(front and back)

Arm: 3 FTUs

Hand: 1 FTU

Groin: 1 FTU

Leg: 6 FTUs

Foot: 2 FTUs
Figure 5-10 ​Number of fingertip units for various body areas.
 CHAPTER 5 Alternative Methods for Drug Administration 73

RECTAL SUPPOSITORY

Purpose
Rectal medications are used to relieve vomiting when the client is unable to take oral medication, to
relieve pain or anxiety, to promote defecation, and to administer drugs that could be destroyed by diges-
tive enzymes.

Method
Rectal Suppository
1. Place the patient on his or her left side in the Sims position.
2. Expose the anus by lifting the upper portion of the buttock. Check that the anus/rectum is not full of
stool.
3. Lightly lubricate the suppository with water-soluble lubricant, and insert the narrow (pointed) end of
the suppository into the anus, past the anal sphincter and into the rectum, approximately 3 inches or
7 to 8 centimeters (Figure 5-11).
4. Instruct the patient to remain in a supine or left lateral Sims position for 5 to 10 minutes.

Rectal anal ridge

Suppository Rectum

Anal sphincter

Anus

Figure 5-11 ​Inserting a rectal suppository. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology:
a nursing process approach, 8th ed., Philadelphia: Saunders.)
74 PART II Systems, Conversion, and Methods of Drug Calculation

VAGINAL SUPPOSITORY, CREAM, AND OINTMENT

Purpose
Vaginal medications are used to treat vaginal infection or inflammation.

Method
Vaginal Suppository, Cream, and Ointment
1. Place the patient in the lithotomy position (knees bent with feet on the table or bed).
2. Place the vaginal suppository at the tip of the applicator.
or
Connect the top of the vaginal cream or ointment tube with the tip of the applicator. Squeeze the tube
to fill the applicator.
3. Lubricate the applicator with water-soluble lubricant if necessary.
4. Insert applicator downward first, then upward and backward 3 to 4 inches or 8 to 10 centimeters
(Figure 5-12).
5. Instruct patient to remain lying down for at least 5 to 15 minutes after the application. The patient
may use a light pad in her underwear to prevent soiling of clothing. Bedtime is the suggested time for
vaginal drug administration.
6. Instruct the patient to avoid using tampons after insertion of the vaginal medication.

Figure 5-12 ​Inserting a vaginal suppository. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a nursing
process approach, 8th ed., Philadelphia: Saunders.)
 CHAPTER 5 Alternative Methods for Drug Administration 75

INTRAOSSEOUS ACCESS

Purpose
Intraosseous (IO) infusions are used for patients in emergent, urgent, and medically necessary situations
when intravenous access is difficult or unobtainable (Figure 5-13). The IO catheters are injected directly
through the bone cortex into the soft marrow interior, either manually or with a driver/drill device. Once
the IO catheter is placed, there is immediate access to the venous system for fluid and medication infu-
sion. Common sites for IO catheter placement are the proximal or distal tibia, proximal or distal humerus,
and the sternum. The distal femur is also a common insertion site in pediatric patients. The dwell time for
the IO device is 24 to 48 hours, after which an alternative route of access should be obtained.

Method
1. Monitor according to organizational policy, procedures, and practice guidelines.
2. Document response to therapy, i.e., vital signs improvement, urine output, site pain.
3. Maintain IO device placement, care, and maintenance.

Stages of powered intraosseous needle insertion

A B

C D

Reproduced from product information with permission of Vidacare Corp

Figure 5-13 Intraosseous catheter insertion. A, Site is palpated. B, Catheter placed with drill device. C, Stylet is removed.
D, Medication is infused. (Image courtesy Teleflex Incorporated. (c) 2015 Teleflex Incorporated. All rights reserved.)
76 PART II Systems, Conversion, and Methods of Drug Calculation

INTRASPINAL ACCESS

Purpose
Intraspinal access devices are catheters and infusion pumps used for the delivery of narcotics, anesthetic
agents, or antispasmodic medications to relieve pain or to control severe muscle spasms. The two access
areas for intraspinal medication are the epidural space and the intrathecal space of the spine (Figure 5-14).
The anesthesia provider inserts a needle in the subarachnoid space of the spine between the pia mater and
the arachnoid mater for the intrathecal or spinal access and threads a catheter through the needle. For
the epidural, the needle is placed between the dura mater and the flavum ligament, and a catheter is
threaded into that area. Once the catheter is secured, medication is administered through the catheter via
infusion pumps. Epidurals are given frequently for pain management in the labor and delivery setting,
and both intrathecal and epidural procedures are used for surgical pain management.
Small implantable pumps can be surgically placed under the skin of the abdomen to deliver medica-
tion through an intrathecal catheter for chronic conditions (Figure 5-15). Medications such as baclofen,
morphine, or ziconotide may be delivered in this manner to minimize the side effects often associated
with the higher doses used in oral or intravenous delivery of these drugs. The goal of a drug pump is to
better control symptoms and to reduce oral medications, thus reducing their associated side effects.

Method
1. Monitor according to the institution’s policy, procedures, and practice guidelines.
2. Document responses to therapy (i.e., pain scale, sedation level, head or neck pain).
3. Maintain infusions according to physician orders and established policy and procedures.
4. Identify and label intraspinal access devices and administration sets to differentiate from other infu-
sion administration systems.

Figure 5-14 Intrathecal and epidural insertion sites.

 CHAPTER 5 Alternative Methods for Drug Administration 77

Silastic anchor
Catheter Pocket
Costal margin Anterior iliac creast

A Secure catheter with Silastic anchor and sutures B Create pocket for pump

Coil of catheter in pocket

Additional incision

Extend tunneling device through subcutaneous Coil catheter into pocket, place
C tissues and then tunnel catheter through device D pump inside, and suture closed
Figure 5-15 Intrathecal pump implant. (From Brown, D. L. [2010]. Atlas of regional anesthesia, 4th ed. Philadelphia: Saunders.)
CHAPTER 6
Methods of Calculation

Objectives • Determine the amount of drug needed for a specified time.

• Select a dosage formula, such as basic formula, ratio and proportion, fraction equation, or
dimensional analysis, for solving drug dosage problems.
• Convert units of measurement to the same system and unit of measurement before calculating
drug dosage.
• Calculate the dosage amount of tablets, capsules, and liquid volume (oral or parenteral) needed
to administer the prescribed drug.

Outline DRUG CALCULATION

Method 1: Basic Formula
Method 2: Ratio and Proportion
Method 3: Fractional Equation
Method 4: Dimensional Analysis

Before drug dosage can be calculated, units of measurement must be converted to one system. If the drug
is ordered in grams and comes in milligrams, then grams are converted to milligrams or milligrams are
converted to grams.
Four methods for calculating drug dosages include basic formula, ratio and proportion, fractional
equation, and dimensional analysis. The ratio and proportion and fractional equation methods are similar.
For drugs that require individualized dosing, body weight and body surface area are used. When body
weight and body surface area calculations are used, one of the first four methods for calculation is neces-
sary to determine the amount of drug needed from the container.
At some institutions, the nurse orders enough medication doses for a designated period. If the
order requires 2 tablets, qid (4 times a day) for 5 days, then the number of tablets needed would be
2 tablets 3 4 times a day 3 5 days 5 40 tablets.

DRUG CALCULATION

The four methods as mentioned for drug calculations are (1) basic formula, (2) ratio and proportion,
(3) fractional equation, and (4) dimensional analysis (factor labeling).

78
 CHAPTER 6 Methods of Calculation 79

Method 1: ​Basic Formula

The following formula is often used to calculate drug dosages. The basic formula (BF) is the most commonly
used method, and it is easy to remember.

D
3 V 5 Amount to give
H

D or desired dose: drug dose ordered by physician or health care providers (HCPs)
H or on-hand dose: drug dose on label of container (bottle, vial, ampule)
V or vehicle: form and amount in which the drug comes (tablet, capsule, liquid)

EXAMPLES PROBLEM 1: Order: erythromycin (ERY-TAB) 0.5 g, po, q8h.

Drug available:

a. Both the dosage of the drug ordered and the dosage on the bottle are in the metric
system; however, the units of measurement are different. Conversion is needed. To
convert grams to milligrams, move the decimal point three spaces to the right (see
Chapter 1: Systems Used for Drug Administration and Temperature Conversion):
0.5 g 5 0.500 mg 5 500 mg
N
2
D 500 mg
b. BF: 3V5 3 1 tab 5 2 tablets
H 250 mg
1

Answer: erythromycin 0.5 g 5 2 tablets

PROBLEM 2: Order: loracarbef (Lorabid) 0.5 g, po, q12h for 7 days.

Drug available:
80 PART II Systems, Conversion, and Methods of Drug Calculation

a. The unit of measurement ordered and the unit given on the bottle are in the same sys-
tem but in different units; therefore conversion of units within the same system must
be done first. To convert grams to milligrams, move the decimal point three spaces to
the right (see Chapter 1).
0.5 g 5 0.500 mg 5 500 mg
N
5
D 500 5 25
b. 3V5 3 5 mL 5 3 5 5 5 12.5 mL
H 200 2 2
2

Answer: Lorabid 0.5 g per dose 5 12.5 mL

PROBLEM 3: Order: phenobarbital 120 mg, STAT.

Drug available: phenobarbital 30 mg per tablet.
a. Conversion of unit of measurement is NOT needed because both are of the same unit,
milligrams.
D 120 120
b. BF: 3V5 315 5 4 tablets
H 30 30

Answer: phenobarbital 120 mg 5 4 tablets

PROBLEM 4: Order: meperidine (Demerol) 35 mg, IM, STAT

Drug available:

a. Conversion is not needed, because both are of the same unit of measurement.
D 35 35
b. BF: 3V5 3 1 mL 5 5 0.7 mL
H 50 50

Answer: meperidine (Demerol) 35 mg 5 0.7 mL

Method 2: Ratio and Proportion

Ratio and proportion (RP) is the oldest method used for calculating dosage problems:

Known Desired
H : V :: D : X
on hand ​vehicle ​ ​desired dose ​amount to give
means
extremes

H and V: On the left side of the equation are the known quantities, which are dose on hand and vehicle.
D and X: On the right side of the equation are the desired dose and the unknown amount to give.
Multiply the means and the extremes. Solve for X.
 CHAPTER 6 Methods of Calculation 81

EXAMPLES PROBLEM 1: Order: erythromycin (ERY-TAB) 0.5 g, po, q8h.

Drug available:

a. To convert grams to milligrams, move the decimal point three spaces to the right (see
Chapter 1):
0.5 g 5 0.500 mg 5 500 mg
N
b. RP: H ; V < D ; X
250 mg;1 tab<500 mg;X tab

250 X 5 500
   X 5 2 tablets

Answer: erythromycin 0.5 g 5 2 tablets

Note: With RP, the ratio on the left (milligrams to tablets) has the same relation as the ratio
on the right (milligrams to tablets); the only difference is values.

PROBLEM 2: Order: aspirin (ASA) 650 mg, PRN.

Drug available: aspirin 325 mg per tablet.

RP; H ; V < D ; X
325 mg;1 tablet<650 mg;X tablet
325 X 5 650
X 5 2 tablets

Answer: aspirin 650 mg 5 2 tablets

PROBLEM 3: Order: amoxicillin 75 mg, po, qid.

Drug available:
82 PART II Systems, Conversion, and Methods of Drug Calculation

a. Conversion is not needed because both use the same unit of measurement.
b. RP; H ; V < D ; X
125 mg;5 mL<75 mg;X mL
125 X 5 375
X 5 3 mL

Answer: amoxicillin 75 mg 5 3 mL

PROBLEM 4: Order: meperidine (Demerol) 60 mg, IM, STAT.

Drug available:

a. Conversion is not needed; the same unit of measurement is used.

b. RP; H ; V < D ; X
100 mg;1 mL<60 mg;X mL
100 X 5 60
X 5 0.6 mL

Answer: meperidine (Demerol) 60 mg 5 0.6 mL

Method 3: Fractional Equation

The fractional equation (FE) method is similar to RP, except it is written as a fraction.
H D
5
V X
H: the dosage on hand or in the container
V: the vehicle or the form in which the drug comes (tablet, capsule, liquid)
D: the desired dosage
X: the unknown amount to give
Cross multiply and solve for X.

EXAMPLES PROBLEM 1: Order: erythromycin (ERY-TAB) 750 mg, po, q8h.

Drug available:
 CHAPTER 6 Methods of Calculation 83

a. How many tablet(s) should the patient receive per dose?

H D 250 mg 750 mg
FE: 5 5 5
V X 1 tab X
(Cross multiply) 250 X 5 750
X 5 3 tablets per dose
b. How many tablet(s) should the patient receive per day?
3 tablets per dose 3 3 times per day 5 9 tablets per day

Answer: erythromycin: 9 tablets per day

PROBLEM 2: Order: valproic acid (Depakene) 100 mg, po, tid.

Drug available: valproic acid (Depakene) 250 mg/5 mL suspension.
a. No unit conversion is needed.
H D 250 100
b. FE: 5 5
V X 5 X
(Cross multiply) 250 X 5 500
X 5 2 mL

Answer: valproic acid (Depakene) 100 mg 5 2 mL

PROBLEM 3: Order: atropine 0.6 mg, IM, STAT.

Drug available:

H D 0.4 mg 0.6 mg
FE: 5 5
V X 1 mL X
(Cross multiply) 0.4 X 5 0.6
X 5 1.5 mL

Answer: atropine 0.6 mg 5 1.5 mL

Method 4: Dimensional Analysis

Dimensional analysis (DA) is a calculation method known as units and conversions. The advantage
of DA is that it decreases the number of steps required to calculate a drug dosage. It is set up as one long
equation to answer a desired unit (e.g., mL, tab, or cap).
1. Identify the unit/form (tablet, capsule, mL) of the drug to be calculated. If the drug comes in tablet
(unit), then tablet 5 (equal sign).
84 PART II Systems, Conversion, and Methods of Drug Calculation

2. The known dose and unit/form from the drug label follow the equal sign.
Example order: Amoxicillin 500 mg. On the drug label: 250 mg per 1 capsule.
1 cap
capsule 5 1unit2
250 mg
(drug label)
3. The milligram value (250 mg) is the denominator and it must match the NEXT numerator, which
is 500 mg (desired dose or order). The NEXT denominator would be 1 (one) or blank.
2
1 cap 3 500 mg
capsule 5 5
250 mg 3 1
1

4. Cancel out the mg, and reduce the 250 and 500. What remains is the capsule and 2. Answer:
2 capsules.
When conversion is needed between milligrams (drug label) and grams (order), then a conversion factor
is needed, which appears between the drug dose on hand (drug label) and the desired dose (order). You
should REMEMBER the following:
Metric Equivalent
1 g 5 1000 mg
1 mg 5 1000 mcg
Also use Table 6-1 for metric and household conversions.

EXAMPLE Order: Amoxicillin 0.5 g.

Available: 250 mg 5 1 capsule (drug label). A conversion is needed between grams and milligrams.
Remember, 250 mg is the denominator; therefore 1000 mg (conversion factor, which is 1000 mg 5
1 g) is the NEXT numerator and 1 g becomes the NEXT denominator. The third numerator is 0.5 g
(desired dose), and the denominator is 1 (one) or blank.
4
1 cap 3 1000 mg 3 0.5 g
capsule 5 5 2 capsules
250 mg 3 1g 3 1 1or blank2
1
(drug label) (conversion) (drug order)
If conversion from grams to milligrams is not needed, then the middle step can be omitted. The following
are formulas for DA:
V 1drug form2 3 D 1desired dose2
V 1form of drug2 5
H 1on hand2 1drug label2 3 1 or blank 1drug order2
For conversion: V 1form of drug2 5
V 1drug form2 3 C 1H2 3 D 1desired dose2
H 1on hand2 3 C 1D2 3 1 1or blank2
(drug label) (conversion (drug order)
factor)
As with other methods for calculation, the three components are D, H, and V. With DA, the conver-
sion factor is built into the equation and is included when the units of measurement of the drug order
and the drug container differ. If the two are of the same units of measurement, the conversion factor is
eliminated from the equation.
 CHAPTER 6 Methods of Calculation 85

TABLE 6-1 Metric and Household Conversions*

METRIC
Grams (g) Milligrams (mg)

1 1000
0.5 500
0.3 300 (325)
0.1 100
0.06    60 (64 or 65)
0.03    30 (32)
0.015    15 (16)
0.010    10
0.0006     0.6
0.0004     0.4
0.0003     0.3

Liquid (Approximate)

   30 mL 5 1 oz 5 2 tbsp (T) 5 6 tsp (t)

   15 mL 5 1⁄2 oz 5 1 T 5 3 t
1000 mL 5 1 quart (qt) 5 1 liter (L)
500 mL 5 1 pint (pt)
    5 mL 5 1 tsp (t)

EXAMPLES PROBLEM 1: Order: erythromycin (ERY-TAB) 1 g, po, q12h.

Drug available:

Drug label: 250 mg 5 1 tablet

Drug order: 1 g
Conversion factor: 1 g 5 1000 mg
a. How many tablets should the patient receive per dose?
4
1 tablet 3 1000 mg 3 1g
DA: tab 5 5 4 tablets
250 mg 3 1g 3 1
1
(drug label) (conversion factor) (drug order)
(cancel units and numbers from numerator and denominator)

Answer: erythromycin 1 g 5 4 tablets

Give 4 tablets every 12 hours.
86 PART II Systems, Conversion, and Methods of Drug Calculation

PROBLEM 2: Order: acetaminophen (Tylenol) 1 g, po, PRN.

Drug available:

Drug label: 325 mg 5 1 tablet

Conversion factor: 1000 mg 5 1 g
How many tablet(s) would you give?
1 tab 3 1000 mg 3 1 g 1000
DA: tab 5 5 5 3.07 tab or 3 tab (cannot round
325 mg 3 1 g 3 1 325 off in tenths for tablets)

Answer: acetaminophen 1 g 5 3 tablets

Tylenol is also available in 500-mg (extra-strength) tablets.

PROBLEM 3: Order: ciprofloxacin (Cipro) 500 mg, po, q12h.

Drug available:

No conversion factor is needed because both are stated in milligrams (mg).

2
1 tab 3 500 mg
DA: tab 5 5 2 tablets
250 mg 3 1
1

Answer: Cipro 500 mg 5 2 tablets

SUMMARY ​PRACTICE PROBLEMS
Answers can be found on pages 94 to 96.

Solve the following calculation problems using Method 1, 2, 3, or 4. To convert units within the metric
system (grams to milligrams), refer to Chapter 1. To convert apothecary to metric units and vice versa,
refer to Chapter 2, Table 2-1. For reading drug labels, refer to Chapter 3. Several of the calculation prob-
lems have drug labels. Drug dosage and drug form are printed on the drug label.
 CHAPTER 6 Methods of Calculation 87

Extra practice problems are available in the chapters on oral drugs, injectable drugs, and pediatric drug
administration.
1. Order: doxycycline hyclate (Vibra-Tabs), po, initially 200 mg; then 50 mg, po, bid.
Drug available: Use one of the four methods to calculate dosage.

a. How many tablet(s) would you give as the initial dose?

b. How many tablets would you give for each dose after the initial dose?
2. Order: sulfisoxazole (Gantrisin) 1 g.
Drug available: sulfisoxazole (Gantrisin) 250 mg per tablet.

How many tablet(s) would you give?
3. Order: erythromycin 500 mg, po, q8h, for 7 days.
Drug available:

a. How many tablets would you order for 7 days?

b. How many tablets would you give every 8 hours?
4. Order: clarithromycin (Biaxin) 100 mg, po, q6h.
Drug available:

How many milliliters should the patient receive per dose?
88 PART II Systems, Conversion, and Methods of Drug Calculation

5. Order: phenytoin (Dilantin) 50 mg, po, bid.

Drug available:

a. Which Dilantin container would you select?

b. How many Dilantin capsules would you give per dose?
6. Order: indomethacin (Indocin) 30 mg, po, tid.
Drug available:

a. How many milliliters would you give per dose?

b. How many milligrams would the patient receive per day?
 CHAPTER 6 Methods of Calculation 89

7. Order: dexamethasone (Decadron) 0.5 mg, po, qid.

Drug available:

a. How many tablets would you give per dose?

b. How many milligrams would the patient receive per day?
8. Order: diltiazem (Cardizem) SR 120 mg, po, bid for hypertension.
Drugs available:

a. Which drug bottle should be selected?

b. How many tablet(s) should the patient receive per dose?
90 PART II Systems, Conversion, and Methods of Drug Calculation

9. Order: cimetidine (Tagamet) 0.2 g, po, qid.

Drug available:

How many tablet(s) would you give per dose?
10. O
 rder: bisoprolol (Zebeta) 5 mg, po, daily for the first week. Increase Zebeta to 15 mg, po, daily
starting with the second week.
Drug available:

a. W hich drug bottle(s) would you select the first week and how many tablet(s) would you give?

b. Th
 e dose is increased to 15 mg the second week. Explain which drug bottle(s) you would select
and how many tablets you would give?
 CHAPTER 6 Methods of Calculation 91

11. O
 rder: fluoxetine (Prozac) 25 mg, po, in the am.
Drug available:

How many milliliters (mL) should the patient receive in the am?
12. Order: methylprednisolone (Medrol) 75 mg, IM.
Drug available: Medrol 125 mg per 2 mL per ampule.

How many milliliters would you give?
13. Order: atropine sulfate 0.3 mg, IM, STAT.
Drug available:

How many milliliters should the patient receive?
14. O
 rder: Cefobid (cefoperazone NA) 1 g, IM, q12h.
Drug available:

According to the drug administration instructions, 3.4 mL of sterile water should be added to drug to
yield 4 mL of drug solution. How many milliliters (mL) would you administer per dose?
92 PART II Systems, Conversion, and Methods of Drug Calculation

Additional Dimensional Analysis (Factor Labeling)

15. Order: aminocaproic acid 1.5 g, po, STAT.
Drug available: aminocaproic acid 500-mg tablet.
Drug label: 500 mg 5 tablet
Conversion factor: 1 g 5 1000 mg

How many tablet(s) would you give?
16. Order: ampicillin (Principen) 50 mg/kg/day, po, in 4 divided doses (q6h).
Patient weighs 88 pounds, or 40 kg (88 4 2.2 5 40 kg).
Drug available:

Drug label: 250 mg 5 5 mL

Conversion factor: none (both are in milligrams)
a. How many milligrams per day should the patient receive?
b. How many milligrams per dose should the patient receive?
c. How many milliliters should the patient receive per dose (q6h)?
17. Order: cimetidine (Tagamet) 0.8 g, po, bedtime.
Drug available:

Drug label: 400 mg 5 1 tablet
0.8 g (drug order)

Conversion factor: 1 g 5 1000 mg (units of measurements are not the same; conversion factor is
needed)

How many tablet(s) would you give?
 CHAPTER 6 Methods of Calculation 93

18. Order: Xanax (alprazolam) 0.25 mg, po, tid.

Drug available:

Xanax tablet is scored.
a. How many tablet(s) should the patient receive per dose?
b. How many tablet(s) should the patient receive per day?
19. Order: codeine gr i (1), po, STAT.
Drug available:

Drug label: 30 mg 5 1 tablet
gr 1 (drug order) (apothecary problem). See Table 2-1 if needed.

Conversion factor: 1 gr 5 60 mg

How many tablet(s) would you give?
20. Order: Lasix (furosemide) 15 mg, IM, STAT.
Drug available:

How many milliliters (mL) would you give?
94 PART II Systems, Conversion, and Methods of Drug Calculation

ANSWERS ​ ​SUMMARY PRACTICE PROBLEMS

1. a. Initially: or
RP: H ;V< D ;X
D 200
BF: 3V5 315 100 mg; 1 <200 mg;X
H 100
100 X 5 200
2 tablets X 5 2 tablets
or or
100 200
FE 5 5 DA: No conversion factor
1 X 2
1 tab 3 200 mg
100 X 5 200 Tablet 1s2 5 5 2 tablets
X 5 2 tablets 100 mg 3 1
1

b. Daily: or
RP: H ;V< D ;X
D 50
BF: 3V5 315 100 mg; 1 <50 mg;X
H 100
100 X 5 50
1
⁄2 tablet X 5 1⁄2 tablet
or or
100 50
FE 5 5 5 DA: No conversion factor
1 X 1
1 tab 3 50 mg
1Cross multiply2 100 X 5 50 Tablet 1s2 5 5 1⁄2 tablet
X 5 1⁄2 tablet 100 mg 3 1
2
2. 4 tablets
3. a. 2 tablets 3 3 doses per day 3 7 days 5 42 tablets
b. 2 tablets every 8 hours
D 100 1 100 or
4. BF: 3V5 355 5 4 mL RP: H ;V< D ;X
H 125 25
25 125; 5 < 100;X
125 X 5 500
500
X5 5 4 mL
125
or 4 or
5 mL 3 100 mg 20 125 100
DA: mL 5 5 5 4 mL FE: 5 5
125 mg 3 1 5 5 X
5
1Cross multiply2 125 X 5 500
X 5 4 mL
5. a. The nurse could not use either of the Dilantins.
b. A capsule cannot be cut in half. The physician should be notified. Dilantin dose should be changed.

D 30 mg H D 25 mg 30 mg
6. a. BF: 3V5 3 5 mL 5 6 mL FE: 5 5 5
H 25 mg V X 5 mL X
1
25 X 5 150
5 mL 3 30 mg 30
DA: mL 5 5 5 6 mL X 5 6 mL
25 mg 3 1 5
5
RP: H ; V < D ; X
25 mg ; 5 mL 5 30 mg ; X
25 X 5 150
X 5 6 mL
b. 30 mg 3 3 5 90 mg per day
 CHAPTER 6 Methods of Calculation 95

or
D 0.5
7. a. BF: 3V5 31 RP: H ; V < D ; X
H 0.25 0.25; 1 tablet<0.5;X tablets
2. 0.25 X 5 0.5
0.25q0.50 5 2 tablets X 5 2 tablets
N N
b. 2 mg
8. a. Cardizem SR 60 mg
b. 2 SR capsules per dose
9. Change grams to milligrams by moving the decimal three spaces to the right (see Chapter 1).
0.2 g 5 0.200 mg 5 200 mg
N
or
D 200
BF: 3V5 3 1 tablet RP: H ; V < D ; X
H 400 400 mg;1 tablet< 200 mg; X tablet
200
5 5 1⁄2 tablet 400 X 5 200
400 200
X5 5 0.5 or 1⁄2 tablet
or 400
DA: With conversion factor
10
1 tab 3 1000 mg 3 0.2 g 2.0
Tablets 5 5 5 1⁄2 tablet
400 mg 3 1g 3 1 4
4

10. a. Select Zebeta 5-mg bottle.

D 5 mg
BF: 3V5 3 1 5 1 tablet of Zebeta 5-mg bottle
H 5 mg
RP; H ; V < D ; X
5 ; 1 < 5 ; X
5X55
X 5 1 tablet of Zebeta
b. Select either Zebeta 5-mg bottle OR Zebeta 5-mg and Zebeta 10-mg bottles
FE: using Zebeta 5-mg bottle
H D 5 mg 15 mg
5 5 5
V X 1 X
(Cross multiply) 5 X 5 15
X 5 3 tablets of Zebeta
If only the Zebeta 10-mg bottle was available, then give 11⁄2 tablets.
5
D 25 mg 25
11. BF: 3V5 3 5 mL 5 5 6.25 or 6.3 mL of Prozac
H 20 mg 4
4

H D 20 mg 25 mg
FE: 5 5 5
V X 5 mL X
(Cross multiply) 20 X 5 125
X 5 6.25 OR 6.3 mL of Prozac
96 PART II Systems, Conversion, and Methods of Drug Calculation
or
D 75
12. BF: 3V5 32 RP: H ; V < D; X
H 125 125 ; 2 < 75 ; X
150
5 1.2 mL 125 X 5 150
125 X 5 1.2 mL
or 125 or
75
FE: 5 DA: No conversion factor needed
2 X 3
125 X 5 150 2 mL 3 75 mg 6
mL 5 5 5 1.2 mL
X 5 1.2 mL 125 mg 3 1 5
5

D 0.3 mg or
13. BF: 3V5 3 1 mL 5 RP: H ; V < D ; X
H 0.4 mg
0.4 mg ; 1 mL < 0.3 mg ; X
0.75 mL
0.4 mg X 5 0.3 mg
X 5 0.75 mL
or 0.4 mg 0.3 mg
FE: 5 5 or
1 X 1 mL 3 0.3 mg 0.3
DA: mL 5 5 5 0.75 mL
0.4 mg X 5 0.3 mg 0.4 mg 3 1 0.4
X 5 0.75 mL
14. RP; H ; V < D ; X
2 g ; 4 mL < 1 g ; X
2X54
X 5 2 mL of Cefobid per dose

Additional Dimensional Analysis (Factor Labeling)

2
1 tablet 3 1000 mg 3 1.5 g 3.0
15. Tablets 5 5 5 3 tablets
500 mg 3 1g 3 1 1
1
16. a. 50 mg/kg/day
50 3 40 5 2000 mg
b. 2000 mg 4 4 5 500 mg per dose
2
5 mL 3 500 mg 10
c. mL 5 5 5 10 mL
250 mg 3 1 1
1
10
1 tablet 3 1000 mg 3 0.8 g 10 3 0.8 8
17. Tablets 5 5 5 5 2 tablets
400 mg 3 1g 3 1 4 4
4

1 tab 3 0.25 mg 0.25

18. a. DA: tab 5 5 5 1⁄2 tablet of Xanax
0.5 mg 3 1 0.5
b. 1⁄2 tablet 3 3 (tid) 5 11⁄2 tablets per day
2
1 tablet 3 60 mg 3 1 gr
19. Tablets 5 5 2 tablets
30 mg 3 1 gr 3 1
1
3
1 mL 3 15 mg 3
20. DA: mL 5 5 5 1.5 mL of furosemide 1Lasix2
10 mg 3 1 2
2

Additional practice problems are available in the Methods of Calculating Dosages section
of Drug Calculations Companion, version 5, on Evolve.
CHAPTER 7
Methods of Calculation for
Individualized Drug Dosing

Objectives • State the differences between the weight formulas used for drug calculations.
• Calculate drug dosages according to body surface area.
• Calculate drug dosages according to body weight.
• List indications for use of ideal body weight, adjusted body weight, and lean body weight
formulas.

Outline CALCULATION FOR INDIVIDUALIZED DRUG DOSING

Body Weight (BW)
Body Surface Area (BSA or m2)
Ideal Body Weight (IBW)
Adjusted Body Weight (ABW)
Lean Body Weight (LBW)

CALCULATION FOR INDIVIDUALIZED DRUG DOSING

The two methods for individualizing drug dosing are body weight (BW) and body surface area (BSA).
Other formulas that are associated with drug dosing, especially in bariatrics, are ideal body weight (IBW)
and lean body weight (LBW).

Body Weight (BW)

Drug dosing by actual BW is the primary way medication is individualized for adults and children.
Manufacturers supply dosing information in the package insert. The insert data provide the dosage based
on the patient’s weight in kilograms (kg). The first step is to convert pounds to kilograms (if necessary).
The second step is to determine the drug dose per BW by multiplying drug dose 3 body weight
(BW) 3 frequency (day or per day in divided doses). The third step is to choose one of the four methods
of drug calculation for the amount of drug to be given.

EXAMPLES PROBLEM 1: Order: fluorouracil (5-FU), 12 mg/kg/day IV, not to exceed 800 mg/day. The adult weighs
140 pounds.
a. Convert pounds to kilograms. Divide number of pounds by 2.2.
Remember: 1 kg 5 2.2 lb
140 lb 4 2.2 lb/kg 5 64 kg

97
98 PART II Systems, Conversion, and Methods of Drug Calculation

b. Dosage /BW: mg 3 kg 3 1 day 5

12 3 64 3 1 5 768 mg IV per day

Answer: fluorouracil (5-FU), 12 mg/kg/day 5 768 mg or 770 mg

PROBLEM 2: Give cefaclor (Ceclor), 20 mg/kg/day in three divided doses. The child weighs 20 pounds.
Drug available:

a. Convert pounds to kilograms.

20 lbs 4 2.2 lb/kg 5 9 kg
b. Dosage/BW: 20 mg 3 9 kg 3 1 day 5 180 mg per day.
180 mg 4 3 divided doses 5 60 mg
D 60 mg or
BF: 3V5 3 5 mL 5 RP: H ; V < D ;X
H 125 mg
125 mg; 5 mL<60 mg;X mL
300 125 X 5 300
5 2.4 mL
125 X 5 2.4 mL
1 12
or 125 mg 60 mg or 5 mL 3 60 mg 12
FE: 5 DA: mL 5 5 5 2.4 mL
5 mL X 125 mg 3 1 5
25
125 X 5 300 5
X 5 2.4 mL

Answer: cefaclor (Ceclor) 20 mg/kg/day 5 2.4 mL per dose three times per day

Body Surface Area (BSA or m2)

Body surface area is an estimated mathematical function of height and weight. BSA is considered to be
the most accurate way to calculate drug dosages in that the correct dosage is more proportional to the
surface area. BSA ​is commonly used in chemotherapy and some drug dosages used for infants and chil-
dren. There are two methods for calculating BSA. The first is the square root formula and the second is a
nomogram derived from the square root formula.

YOU MUST REMEMBER

Rounding Off Rule: ​Since calculators are used for working problems, round off at the final answer and not
the steps in between. For BSA ​problems, round off answers to the nearest hundredth.
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 99

BSA ​With the Square Root

BSA can be calculated by using the square root and a fractional formula of height and weight divided
by a constant, one for the metric system and another for inches and pounds. Now that calculators are
readily available, the square root formula is easier to calculate than the longhand version. But errors
can be made with calculators too; therefore a BSA nomogram can prove useful to verify answers. Fol-
low institutional policy regarding BSA methods of calculation. When solving BSA problems, it is
necessary to convert weight and height to the same system of measure.

BSA: ​Inch and Pound (lb) ​Formula

ht 1in2 3 wt 1lb2
BSA 5
Å 3131

BSA: Metric Formula by Centimeters (cm) and Kilograms (kg)

ht 1cm2 3 wt 1kg2
BSA 5
Å 3600

EXAMPLES PROBLEM 1: Order: melphalon (Alkeran) 16 mg/m2 q 2 weeks. Patient is 68 inches tall and weighs
172 pounds. Use the BSA inches and pounds formula.
68 in 3 172 lb
a. BSA 5
Å 3131
11696
BSA 5
Å 3131
BSA 5 "3.73
BSA 5 1.9 m2
b. 16 mg 3 1.9 m2 5 30.4 mg/m2 or 30 mg/m2

PROBLEM 2: Order: cisplatin (Platinol) 50 mg/m2/cycle IV. Patient weighs 84.5 kg and is 168 cm tall.
Use the BSA metric formula.
168 cm 3 84.5 kg
a. BSA 5
Å 3600
14196
BSA 5
Å 3600
BSA 5 "3.94
BSA 5 1.99 m2
b. 50 mg 3 1.99 m2 5 99.5 mg/m2, or 100 mg/m2

BSA With a Nomogram

The BSA in square meters (m2) is determined by the person’s height and weight and where these points
intersect on the nomogram scale (Figures 7-1 and 7-2). The nomogram charts were developed from the
square root formula and were correlated with heights and weights to provide a quick and simple method
for drug dosing before calculators were readily available. There are separate nomograms for infants, chil-
dren, and adults. When a nomogram is used, points on the scale must be carefully plotted. An error in
plotting points or drawing intersecting lines can lead to reading of the incorrect BSA, resulting in dosing
errors. Although there are slight discrepancies between the nomogram and square root method, the trend
in medication safety is to use the nomogram to verify the calculator-generated square root.
100 PART II Systems, Conversion, and Methods of Drug Calculation

Figure 7-1 ​ ​Body surface area (BSA) nomogram for adults. Directions: (1) find height, (2) find weight, (3) draw a straight line
connecting the height and weight. Where the line intersects on the BSA column is the body surface area (m2). (From Deglin, H.,
Vallerand, A. H., & Russin, M. M. [1991]. Davis’ drug guide for nurses, 2nd ed. Philadelphia: ​F. A. Davis, p. 1218. Used with permis-
sion from Lentner, C. [1991]. Geigy scientific tables, 8th ed., vol. 1, Basel, Switzerland: Ciba-Geigy, pp. 226-227.)
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 101

m2 lb kg

Figure 7-2 ​ ​West nomogram for infants and children. Directions: (1) find height, (2) find weight, (3) draw a straight line
connecting the height and weight. Where the line intersects on the SA column is the body surface area (m2). (From Behrman,
R. E., Kliegman, R. M., & Jenson, H. B., editors. [2004]. Nelson textbook of pediatrics, 17th ed. Philadelphia: Saunders.)
102 PART II Systems, Conversion, and Methods of Drug Calculation

To calculate the dosage by BSA obtained with nomogram, multiply the drug dose 3 m2, e.g.,
100 mg 3 1.6 m2 5 160 mg/m2. The advantage of using the nomogram is that no conversions from
pounds to kilograms or inches to centimeters are needed.

EXAMPLES PROBLEM 1: Order: cyclophosphamide (Cytoxan) 100 mg/m2/day, po. Patient weighs 150 pounds and is
5980 (68 inches) tall.
a. 68 inches and 150 pounds intersect the nomogram scale at 1.88 m2 (BSA) (Figure 7-3).
b. BSA: 100 mg 3 1.9 m2 5 190 mg/m2/day of Cytoxan
1.88 m2 5 ​188 mg/m2/day or 190 mg/m2/day

PROBLEM 2: Order: cytarabine (cytosine arabinoside) 200 mg/m2/day IV 3 5 days for a patient with
myelocytic leukemia. The patient is 64 inches tall and weighs 130 pounds.
a. 64 inches and 130 pounds intersect the nomogram scale at 1.69 m2 (BSA), or 1.7 m2
(BSA) rounded off to the nearest tenth.
b. BSA: 200 mg 3 1.69 m2 5 340 mg/m2 IV daily for 5 days
1.69 m2 5 ​338 mg/m2 or 340 mg/m2

Ideal Body Weight (IBW)

Drug dosing by ideal body weight (IBW) or lean body weight/mass (LBW)/(LBM) formulas is used for
medications that are poorly absorbed and distributed throughout the body fat. The ideal body weight
formula is based on height and can be adjusted for weight and is used for nutritional assessment. The lean
body weight/mass formula is based upon height and weight but is less frequently used because it may
predict insufficient doses in obese patients.

IBW Formula
Male: 50 kg 1 2.3 kg for EACH inch over 5 feet
Female: 45.5 kg 1 2.3 kg for EACH inch over 5 feet

EXAMPLE Female is 5 feet 2 inches (2 inches 3 2.3 kg)

IBW: 45.5 kg 1 2 (2.3 kg) 5 45.5 kg 1 4.6 kg 5 50.1 kg

Adjusted Body Weight (ABW)

Adjusted body weight (ABW) is used for dosing some medication for obese individuals or pregnant
women. ABW is better for nutritional assessment of obese individuals because it prevents overfeeding.
The ABW formula uses both the IBW and the actual body weight with adjustments for male and ­female.

ABW Formula
Male: IBW 1 0.4 (Actual Body Weight [kg] 2 IBW [kg]) 5 ABW
Female: ​IBW 1 0.4 (Actual Body Weight [kg] 2 IBW [kg]) 5 ABW

EXAMPLE Female is 5 feet 2 inches and weighs 100.5 kg

50.1 kg 1 0.4 (100.5 2 50.1 kg) 5
50.1 kg 1 0.4 (50.4 kg) 5
50.1 kg 1 20.16 kg 5 70.26 kg or 70.3 kg
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 103

Figure 7-3 Body surface area (BSA) nomogram for adults. Example Problem 1: a. 68 inches and 150
pounds intersect the nomogram scale at 1.88 m2 (BSA).
104 PART II Systems, Conversion, and Methods of Drug Calculation

Lean Body Weight (LBW)

Lean body weight (LBW) is the weight of bone, muscle, and organs without any fat. LBW is used for
the dosing of some medications and can be used as an indicator of overall health for patients with chronic
diseases.

LBW Formula
Lean body weight in kilograms (males over 16 years of age) 5 (0.32810 3 [body weight in kg] 1
0.33929 3 [height in centimeters]) 2 29.5336
Lean body weight in kilograms (women over 30) 5 (0.29569 3 [body weight in kg] 1 0.41813 3
[height in centimeters]) 2 43.2933

EXAMPLE Female is 5 feet 2 inches, weighs 100.5 kg, and is 55 years old.
(0.29569 3 [100.5 kg] 1 ([0.41813 3 (620 3 2.54 cm)]) 2 43.2933 5
29.71 1 (0.41813 3 157.48) 2 43.2933 5
29.71 1 65.84 2 43.2933 5
 ​ ​ ​ ​ ​ ​ ​95.55 2 43.2933 5 52.26 kg

SUMMARY PRACTICE PROBLEMS

Answers can be found on pages 108 to 111.

Body Weight
1. Order: trimethoprim-sulfamethoxazole 6 mg/kg/day, po, q12h.
Patient weighs 44 pounds.
How many milligrams should the patient receive per dose?

2. Order: azithromycin (Zithromax), po. First day: 10 mg/kg/day; next 4 days: 5 mg/kg/day. Patient
weighs 44 pounds.
Drug available:

a. How much does the child weigh in kilograms?

b. How many milliliters should the child receive for the first day?
c. How many milliliters should the child receive each day for the next 4 days (second to fifth
days)?
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 105

3. Order: ticarcillin disodium (Ticar), 200 mg/kg/day in 4 divided doses, IV. Patient weighs
176 pounds.
Max dose: 24 g every day
Drug available:

a. How many kilograms does the patient weigh?

b. How many milligrams per day should the patient receive? How many milligrams per dose? ​
 ​mg, q6h. Or how many grams per dose?  ​g, q6h

4. Order: tobramycin 5.1 mg/kg/day in 3 divided doses (q8h), IV. The patient weighs 180 pounds.
Drug available:

a. How many kilograms does the patient weigh?

b. How many milligrams should the patient receive per day?
c. How many milliliters should the patient receive per dose?

5. Order: sulfisoxazole (Gantrisin) 2 g/m2 daily in 4 divided doses (q6h). The patient weighs 110 pounds
and is 60 inches tall. Use nomogram.
How many milligrams should the patient receive per dose?

6. Order: doxorubicin (Adriamycin) 60 mg/m2 IV per month. Patient weighs 120 pounds and is 5920
(62 inches) tall. Use nomogram.
How many milligrams should the patient receive?
106 PART II Systems, Conversion, and Methods of Drug Calculation

7. Order: etoposide (VePesid) 100 mg/m2/day 3 5 days. Patient weighs 180 pounds and is 70 inches
tall. Use nomogram.
Drug available:

a. What is the BSA?

b. How many milligrams should the patient receive?
c. How many milliliters are needed?

BSA ​by Square Root

8. Order: vinblastine sulfate (Velban) 7.4 mg/m2 IV 3 1. Patient’s height is 115 cm and weight is
52 kg. Use the BSA metric formula to determine dosage.
Drug available:

How many milligrams should the patient receive?

9. Order: etoposide (VePesid) 50 mg/m2 day IV. Patient’s height is 72 inches and weight is 180 pounds.
How many milligrams should the patient receive?

10. Patient with advanced colorectal cancer

Order: Fluorouracil 250 mg/m2/day 3 7 days
Patient’s height and weight: 6920, 218 lb
a. What is patient’s BSA in square meters? (use square root)
b. What is the daily dose?
c. What is the total dosage for 7 days?

11. Order: docetaxel (Taxotene) 60 mg/m2/dose in 200 mL of normal saline solution over 60 minutes.
Patient’s height and weight: 5980, 136 lb.
a. What is patient’s BSA in square meters?
b. What is the total dosage of docetaxel?
c. What is the concentration per milliliter?
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 107

12. Order: gemcitabine (Gemzar) 800 mg/m2/dose in 100 mL of normal saline solution over 30 minutes.
Patient’s height and weight: 6960, 150 lb.
Drug available: 1 g/25 mL

a. What is patient’s BSA in square meters?

b. What is the total dose of gemcitabine?
c. How many milliliters should you prepare?

13. Order: Liposomal doxorubicin 20 mg/m2 in 250 mL D5W IV over 30 minutes. Patient’s height and
weight: 69, 129 lb.
Drug available: Doxorubicin 20 mg/10 mL

a. What is patient’s BSA in square meters?

b. What is the total dose of doxorubicin?
c. How many milliliters should you prepare?

14. Order: irinotecan (Camptosar) 60 mg/m2 in 500 mL D5 1⁄2NS IV over 90 minutes. Patient’s height
and weight: 69, 202 lb.
Drug available: Irinotecan 20 mg/mL

a. What is patient’s BSA in square meters?

b. What is the total dose of irinotecan?
c. How many milliliters should you prepare?

15. Order: Cisplatin 80 mg/m2 in 500 mL normal saline solution over 90 minutes. Patient’s height and
weight: 69, 200 lb.
Drug available: Cisplatin 1 mg/mL

a. What is patient’s BSA in square meters?

b. What is the total dose of cisplatin?

16. Order: Adriamycin 50 mg/m2 in 3 individual doses mixed with 1000 mL normal saline solution per
dose continuous infusion over 24 hr. Patient’s height and weight: 5980, 139 lb.
Drug available: Adriamycin 10 mg/5 mL

a. What is patient’s BSA in square meters?

b. What is the total dosage?
c. What is the divided dose?

Ideal Body Weight (IBW) and Adjusted Body Weight (ABW)

17. What is the IBW and ABW for a male weighing 385 lb and 5980 tall?

18. What is the IBW and ABW for a female weighing 370 lb and 5920 tall?

19. What is the IBW and ABW for a female weighing 290 lb and 5930 tall?

20. What is the IBW and ABW for a male weighing 310 lb and 59100 tall?
108 PART II Systems, Conversion, and Methods of Drug Calculation

Lean Body Weight (LBW)

21. What is the LBW for a 50-year-old male weighing 385 lb and 5980 tall?

22. What is the LBW for a 60-year-old female weighing 385 lb and 5920 tall?

23. What is the LBW for a 30-year-old male weighing 134 lb and 69 tall?

24. What is the LBW for a 65-year-old female weighing 99 lb and 5920 tall?

ANSWERS ​ ​SUMMARY PRACTICE PROBLEMS

Body Weight

1. 44 lb 4 2.2 lb/kg 5 20 kg
20 kg 3 6 mg/kg/day 5 120 mg 4 2 doses 5 60 mg/dose trimethoprim-sulfamethoxazole
2. a. 20 kg
b. First day: 10 mg 3 20 kg 5 200 mg
1
D 200 mg or
BF: 3V5 3 5 mL 5 5 mL RP: H ; V < D ;X
H 200 mg
1 200 mg;5 mL<200 mg;X
200 X 5 1000
X 5 5 mL
1
5 mL 3 200 mg or 200 mg 200 mg
DA: mL 5 5 5 mL FE 5 5 5 200 X 5 1000
200 mg 3 1 5 mL X
1
X 5 5 mL
First day give 5 mL
c. Second to fifth days (next 4 days): 5 mg 3 20 kg 5 100 mg
Give 2.5 mL/day.
3. a. Client weighs 80 kg
b. 200 mg 3 80 5 16,000 mg per day; 4000 mg per dose or 4 g per dose (q6h)
4. Tobramycin: 1.2 g 5 1200 mg
a. 180 lbs 4 2.2 kg 5 81.8 kg
5.1 mg 3 81.8 kg 5 417.2 mg/day
b. 417.2 mg 4 3 doses/day 5 139 mg/dose or 140 mg/dose
D 140 mg 4200 or
c. BF: 3V5 3 30 mL 5 5 3.5 mL RP: H ; V < D ;X
H 1200 mg 1200
1200 mg;30 mL<140 mg;X
1200 X 5 4200
30 mL 3 140 mg 4200 X 5 3.5 mL of tobramycin
DA: mL 5 5 5 3.5 mL of tobramycin
1200 mg 3 1 1200
5. 60 inches and 110 pounds intersect the nomogram scale at 1.5 m2.
BSA: 2 g 3 1.5 m2 5 3 g or 3000 mg per day
3000 mg 4 4 times per day 5 750 mg
6. 62 inches and 120 pounds intersect the nomogram scale at 1.6 m2.
BSA: 60 mg 3 1.6 m2 5 96 mg of Adriamycin
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 109

7. a. With the use of the nomogram, the BSA is 2.06

b. 100 mg 3 2.06 5 206 mg or 200 mg.
c. The amount of VePesid administered should be 10 mL.
or
D 200 mg
BF: 3V5 3 5 mL 5 10 mL RP: 100 mg;5 mL<200 mg;X
H 100 mg 100 X 5 1000
X 5 10 mL
2
or 5 mL 3 200 mg
DA: mL 5 5 10 mL
100 mg 3 1
1

BSA by Square Root

115 cm 3 52 kg
8. BSA 5
Å 3600
5980
BSA 5
Å 3600
BSA 5 "1.66
BSA 5 1.29 m2
7.4 mg 3 1.29 m2 5 9.5 mg/m2

72 in 3 180 lb
9. BSA 5
Å 3131
12960
BSA 5
Å 3131
BSA 5 "4.13
BSA 5 2.0 m2
50 mg/m2 3 2 m2 5 100 mg

74 3 218
10. a. 5 2.27 m2
Å 3131
b. 250 mg 3 ​2.27 m2 5 ​567.5 or 568 mg
c. 568 mg 3 7 5 3976 mg
68 3 136
11. a. 5 1.7 m2
Å 3131
b. 60 mg/m2 3 1.7 m2 5 102 mg
102 mg
c. 5 0.51 mg /mL
200 mL
110 PART II Systems, Conversion, and Methods of Drug Calculation

78 3 150
12. a. 5 1.9 m2
Å 3131
b. 800 mg/m2 3 1.9 m2 5 1520 mg
c. 1 g 5 1000 mg or
RP: 1000 mg;25 mL<1520 mg;X
D 1520 mg 25 mL
BF: 3V5 3 5 1000 X 5 38000
H 1000 mg 1 X 5 38 mL
38000
5 38 mL
1000
or or 1000 mg 1520 mg
25 mL 3 1520 mg
DA: mL 5 5 38 mL FE: 5
1000 mg 3 1 25 mL X
1000 X 5 3800
X 5 38 mL
72 3 129
13. a. 5 1.72 m2
Å 3131
b. 20 mg/m2 3 1.72 m2 5 34 mg
or
D 34 mg
c. BF: 3V5 3 10 mL RP: 20 mg;10 mL<34 mg;X
H 20 mg 20 X 5 340
340 X 5 17 mL
5 17 mL
20
or or 20 mg 34 mg
10 mL 3 34 mg
DA: mL 5 5 17 mL FE: 5 5 20x 5 340
20 mg 3 1 10 mL X
X 5 17 mL
72 3 202
14. a. 5 2.15 m2
Å 3131
b. 60 mg 3 2.15 m2 5 129 mg or 130 mg/m2
or
D 130 mg
c. BF: 3V5 3 1 mL 5 RP: 20 mg;1 mL<130 mg;X
H 20 mg 20 X 5 130
130 X 5 6.5 mL
5 6.5 mL
20
or or 20 mg 130 mg
1 mL 3 130 mg
DA: mL 5 5 6.5 mL FE: 5
20 mg 3 1 1 mL X
20 X 5 130
X 5 6.5 mL
72 3 200
15. a. 5 2.14 m2 b. 80 mg/m2 3 2.14 m2 5 171 mg or 170 mg
Å 3131

68 3 139
16. a. 5 1.73 m2 b. 50 mg/m2 3 1.73 m2 5 86.5 mg
Å 3131
c. 86.5 mg/3 doses 5 28.8 mg
 CHAPTER 7 Methods of Calculation for Individualized Drug Dosing 111

Ideal Body Weight (IBW) and Adjusted Body Weight (ABW)

17. 385 lb 4 2.2 5 175 kg

IBW 5 50 kg 1 2.3 kg (8 inches) 5
50 kg 1 18.4 kg 5 68.4 kg
Adjusted Body Weight 68.4 kg 1 0.4 (175 kg 2 68.4) 5
68.4 kg 1 0.4 (106.6 kg) 5
68.4 kg 1 42.64 kg 5 111.04 kg
18. 370 lb 4 2.2 5 168.2 kg
IBW 5 45.5 kg 1 2.3 (2 inches) 5
45.5 kg 1 4.6 kg 5 50.1 kg
Adjusted Body Weight 50.1 kg 1 0.4 (168.2 kg 2 50.1) 5
50.1 kg 1 0.4 (118.1 kg) 5
50.1 kg 1 47.24 kg 5 97.34 kg
19. 290 lb 4 2.2 5 131.8 kg
IBW 5 45.5 kg 1 2.3 (3 inches) 5
45.5 kg 1 6.9 kg 5 52.4 kg
Adjusted Body Weight 52.4 kg 1 0.4 (131.8 kg 2 52.4) 5
52.4 kg 1 0.4 (79.4 kg) 5
52.4 kg 1 31.76 5 84.16 or 84.2 kg
20. 310 lb 4 2.2 5 141 kg
IBW 5 50 kg 1 2.3 kg (10 inches) 5
50 kg 1 23 kg 5 73 kg
Adjusted Body Weight 73 kg 1 0.4 (141 kg 2 73) 5
73 kg 1 0.4 (68) 5
73 kg 1 27.2 5 100.2 kg

Lean Body Weight (LBW)

21. 0.32810 3 (385 lb 4 2.2) 1 0.33929 3 (680 3 2.54) 2 29.5336 5

0.32810 3 (175 kg) 1 0.33929 3 (172.72 cm) 2 29.5336 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​57.4 1 58.6 2 29.5336 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​116 2 29.5336 5 86.46 kg
22. 0.29569 3 (385 lb 4 2.2) 1 0.41813 3 (620 3 2.54) 2 43.2933 5
0.29569 3 (175 kg) 1 0.41813 3 (157.48 cm) 2 43.2933 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​51.7 1 65.84 2 43.2933 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​ ​ ​ ​ ​117.54 2 43.2933 5 74.246, or 74.25 kg
23. (0.32810 3 [135 lb 4 2.2] 1 0.33929 3 [720 3 2.54]) 2 29.5336 5
0.32810 3 (61.3 kg) 1 0.33929 3 (182.9 cm) 2 29.5336 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​20.11253 1 62.05614 2 29.5336 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​ ​ ​ ​ ​82.16867 2 29.5336 5 52.63507 kg or 52.64 kg
24. (0.29569 3 [99 lb 4 2.2] 1 0.41813 3 [600 3 2.54]) 2 43.2933 5
0.29569 3 (45 kg) 1 0.41813 3 (152.4 cm) 2 43.2933 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​13.306 1 63.7230 2 43.2933 5
 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ ​ ​ ​ ​ ​77.0290 2 43.2933 5 33.7357 kg or 33.74 kg
This page intentionally left blank
PART III
CALCULATIONS FOR
ORAL, INJECTABLE, AND
INTRAVENOUS DRUGS

113
CHAPTER 8
Oral and Enteral Preparations
With Clinical Applications

Objectives • State the advantages and disadvantages of administering oral medications.

• Calculate oral dosages from tablets, capsules, and liquids using given formulas.
• Give the rationale for diluting and not diluting oral liquid medications.
• Explain the method for administering sublingual medication.
• Calculate the amount of oral drug to be given per day in divided doses.

Outline TABLETS, CAPSULES, FLUID, AND FILM STRIPS

Pill/Tablet Cutter and Crusher
Calculation of Tablets and Capsules
LIQUIDS
Calculation of Liquid Medications
BUCCAL TABLETS
SUBLINGUAL TABLETS
Calculation of Sublingual Medications
ENTERAL NUTRITION AND DRUG ADMINISTRATION
Enteral Feedings
Enteral Medications

Oral administration of drugs is considered a convenient, less invasive, and economical method of giv-
ing medications. Oral drugs are available as tablets, capsules, powders, and liquids. Oral medications
are referred to as po (per os, or by mouth) drugs and are absorbed by the gastrointestinal tract, mainly
from the small intestine.
There are some disadvantages in administering oral medications, such as (1) variation in absorption rate
caused by gastric and intestinal pH and food consumption within the gastrointestinal tract; (2) irritation
of the gastric mucosa causing nausea, vomiting, or ulceration (e.g., with oral potassium chloride); (3) reten-
tion or inactivation of the drug in the body because of reduced liver function; (4) destruction of drugs by
digestive enzymes; (5) aspiration of drugs into the lungs by seriously ill or confused patients; and (6) dis-
coloration of tooth enamel (e.g., with a saturated solution of potassium iodide [SSKI]). Oral administra-
tion is an effective way to give medications in many instances, and at times it is the route of choice.

114
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 115

Body weight and body surface area are discussed in Chapter 7. When solving drug problems that
require body weight or body surface area, refer to Chapter 7.
Enteral nutrition and enteral medication are discussed toward the end of the chapter.

TABLETS, CAPSULES, FLUID, AND FILM STRIPS

Most tablets are scored and can be broken in halves and sometimes in quarters (Figure 8-1). Half of a
tablet may be indicated when the drug does not come in a lesser strength. If a half-tablet is not broken
equally, the patient may receive less than or more than the required dose. Also, crushing a drug tablet
does not ensure that the patient will receive the entire drug dose. Some of the crushed tablet could be
lost. Instead of halving or crushing a drug tablet, use the liquid form of the drug, if available, to ensure
proper drug dosage. If a tablet or pill is not scored, then it should NOT be broken or altered.
Capsules are gelatin shells containing powder or time pellets. Caplets (solid-looking capsules) are
hard-shell capsules. Sprinkle capsules have small granules inside that may be opened and sprinkled on
food. They may also be swallowed whole. Time-release capsules should remain intact and not be divided
in any way. Many drugs that come in capsules also come in liquid form. When a smaller dose is indicated
and is not available in tablet or capsule form, the liquid form of the drug is used (Figure 8-2).
Drug films are strips of medication that dissolve in seconds when in contact with wet mucosa. They
were originally designed for children and the elderly or for anyone who has difficulty swallowing. Films
are convenient, have a high dosage accuracy, and improve compliance. Strips are not to be cut or torn.
Examples of drugs that come in film form are Benadryl and Klonopin.

A B

C D
Figure 8-1 ​A and B, Some shapes of tablets. C and D, Shapes of capsules. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E.
[2015]. Pharmacology: a patient-centered nursing process approach, 8th ed. Philadelphia: Elsevier.)

8 dr 2T
1 oz 30 mL

4 dr 1T
1/2
oz 15 mL

10 mL
2 dr
1t 5 mL
1 dr 4 mL

Figure 8-2 ​Medicine cup for liquid measurement. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a
patient-centered nursing process approach, 8th ed. Philadelphia: Elsevier.)
116 PART III Calculations for Oral, Injectable, and Intravenous Drugs

A B
Figure 8-3 ​A, Pill/tablet cutter. B, Silent Knight tablet crushing system. (B, Used with permission from
Links Medical Products, Inc., Irvine, California.)

Pill/Tablet Cutter and Crusher

A pill or tablet cutter can be used to evenly split or divide a scored or unscored tablet. The pill cutter can-
not be used to cut/divide enteric-coated tablets or capsules, time-released, sustained-released, or con-
trolled-released capsules. Pill/tablet cutters can be purchased at a drug-store (Figure 8-3). If the patient
cannot swallow pills or tablets, best practice is to consult with the prescriber or pharmacist to find if a
liquid form of the drug is available. If the medication is not manufactured in liquid form, then a pill
crusher (Figure 8-3, B) can be used to reduce tablets to a powdered form that can be mixed with water,
juice, fruit sauce, or ice cream. Not all pills can be crushed; see Caution below.

C AUT I O N
• Enteric-coated tablets have a special coating that allows them to move through the stomach and be
dissolved in the small intestine so that the medication doesn’t irritate the gastric mucosa.
• Time-released, sustained-release, or controlled-release tablets slowly release drug over a period of time.
• Layered tablets have medications that may be released at different times. The outer coating dissolves
quickly, and the tablet core will dissolve slowly.

Calculation of Tablets and Capsules

The following steps should be taken to determine the drug dose:
1. Check the drug order.
2. Determine the drug available (generic name, brand name, and dosage per drug form).
3. Set up the method for drug calculation (basic formula, ratio and proportion, fraction equation, or
dimensional analysis).
4. Convert to like units of measurement within the same system before solving the problem. Use the
unit of measure on the drug container to calculate the drug dose.
5. Solve for the unknown (X).
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 117

Decide which of the methods of calculation you wish to use, and then use that same method for cal-
culating all dosages. In the following examples, the basic formula, the ratio and proportion, fraction
equation, and dimensional analysis methods are used (see Chapter 6).

Basic Formula (BF) Fraction Equation (FE)

D 1desired dose2 H 1on hand2 D 1desired dose2
3 V 1vehicle2 5 X 5
H 1on-hand dose2 V 1Vehicle2 X 1unknown2
(Cross multiply)

Ratio and Proportion (RP) Dimensional Analysis (DA)

H : V :: D :X V 3 C 1H2 3 D
V5
on hand ​vehicle ​ ​desired dose ​X H 3 C 1D2 3 1
Note: C 5 ​conversion factor if needed.

EXAMPLES PROBLEM 1: Order: pravastatin sodium (Pravachol) 20 mg, daily.

Drug available:

D or
Methods: BF: 3V
H RP:  H ; V < D ; X
20 mg 10 mg;1 tab<20 mg;X tab
3 1 tab 5 2 tablets 10 X 5 ​20
10 mg
X 5 ​2 tablets
or or
H D DA: no conversion factor
FE: 5 5 2
V X
1 tab 3 20 mg
10 mg 20 mg tab 5 5 2 tablets
5 5 10 mg 3 1
1 ta b X 1

10 X 5 20
X 5 2 tablets

Answer: Pravachol 20 mg 5 2 tablets, daily.

118 PART III Calculations for Oral, Injectable, and Intravenous Drugs

PROBLEM 2: Order: erythromycin (ERY-TAB) 0.5 g, qid (four times a day).

Drug available:

Note: Grams (g) and milligrams (mg) are units in the metric system. Remember: When
changing grams (larger unit) to milligrams (smaller unit), move the decimal point three
spaces to the right. Refer to Chapter 1, Table 1-2. Because the drug dose on the drug label
is in milligrams, conversion should be from grams to milligrams.
Methods: 0.5 g 5 ​0.500 mg or 500 mg
N
D 500 mg or
BF: 3V5 3 1 tab
H 250 mg RP: H ; V < D ; X
500 250 mg;1 tab<500 mg;X tab
5 5 2 tablets 250 X 5 500
250
X 5 2 tablets
4
or 250 mg 500 mg or 1 tab 3 1000 mg 3 0.5 g
FE: 5 DA: tablet 5
1 tab X 250 mg 3 1g 3 1
1
250 X 5 500 4 3 0.5 5 2 tablets
X 5 2 tablets

Answer: ERY-TAB 0.5 g 5 2 tablets

PROBLEM 3: Order: aspirin 650 mg, po, STAT.

Drug available: aspirin 325 mg per tablet.
Methods: 2
D 650 mg 2
BF: 3V5 3 1 5 5 2 tablets
H 325 mg 1
1
or or
H D
RP: H ; V < D ; X FE: 5 5
325 mg;1 tab<650 mg;X tab V X
325 X 5 650 325 mg 650 mg
X 5 2 tablets 5 5
1 X
325X 5 650
X 5 2 tablets
2
or 1 tab 3 650 mg
DA: tablet 5 5 2 tablets
325 mg 3 1
1

Answer: Aspirin 650 mg 5 2 tablets.

 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 119

LIQUIDS

Liquid medications come as tinctures, extracts, elixirs, suspensions, and syrups. Some liquid medications
are irritating to the gastric mucosa and must be well diluted before being given (e.g., potassium chloride
[KCl]). Medications in tincture form are always diluted or should be diluted. Liquid medication can be
poured into a calibrated measuring cup or drawn up into a syringe when greater accuracy is required (i.e.,
liquid narcotics).
Liquids are designed to be taken orally or through an enteral tube and are made palatable by the addi-
tion of sweeteners such as suctrose, aspartame, saccharin, fructose, and sorbitol. Unpalatable liquid drugs
can be mixed with 30 to 60 mL of fruit juice. Grapefruit juice interacts with many medications. Check
with the pharmacist before choosing which juice to mix with the drug.

C AUT I O N
• Concentrated liquid medication that can irritate the gastric mucosa should be diluted in at least
6 ounces of fluid, preferably 8 ounces of fluid.
• Liquid medication that can discolor the teeth should be well diluted and taken through a drinking straw.

Figure 8-4 ​Liquid medication drawn up into a syringe.

120 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Calculation of Liquid Medications

EXAMPLES PROBLEM 1: Order: potassium chloride (KCl) 20 mEq, po, bid.
Drug available: liquid potassium chloride 10 mEq per 5 mL.
D 20 mEq 100
Methods: BF: 3V5 3 5 mL 5 5 10 mL
H 10 mEq 10
or or H D
RP: H ; V < D ; X FE: 5 5
10 mEq;5 mL<20 mEq;X mL V X
10 mEq 20 mEq
10 X 5 100 5
X 5 10 mL 5 mL X
10 X 5 100
X 5 10 mL
or
DA: no conversion factor
2
5 mL 3 20 mEq
mL 5 5 10 mL
10 mEq 3 1
1

Answer: Potassium chloride 20 mEq 5 10 mL

PROBLEM 2: Order: amoxicillin (Amoxil) 0.25 g, po, tid.

Drug available:

Change grams to milligrams: 0.25 g 5 0.250 mg or 250 mg

N
D 250 mg 1250
Methods: BF: 3V5 35 5 5 10 mL
H 125 mg 125
or or
RP: H ; V < D ; X H D
125 mg;5 mL<250 mg;X mL FE: 5 5
V X
125 X 5 1250 125 mg 250 mg
X 5 10 mL 5 5
5 X
125X 5 1250
X 5 10 mL
8 1
or 5 mL 3 1000 mg 3 0.25 g 40
DA: mL 5 5 5 10 mL
125 mg 3 1g 3 1 4
1 4

Answer: Amoxil 0.25 g 5 10 mL

 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 121

PROBLEM 3: Give SSKI 300 mg, q6h, diluted in water.

Drug available: saturated solution of potassium iodide, 50 mg per drop (gt).

D 300 mg 300
Methods: BF: 3V5 3 1 drop 5 5 6 drops
H 50 mg 50
or or
RP: H ; V < D ;X H D
50 mg;1 drop<300 mg;X drop FE: 5 5
V X
50 X 5 300 50 mg 300 mg
X 5 6 drops 5 5
1 drop X
50 X 5 300
X 5 6 drops
6
or 1 gt 3 300 mg
DA: gtt 5 5 6 drops
50 mg 3 1
1

Answer: SSKI 300 mg 5 6 drops (gtt)

BUCCAL TABLETS

Buccal tablets are dissolved when held between the cheek and gum, permitting direct absorption of the
active ingredient through the oral mucosa. The buccal tablet should be placed in the buccal cavity, above
the rear molar between the upper cheek and gum.

C AUT I O N
The patient should not split, crush, or chew the tablet.

EXAMPLE PROBLEM 1: Order: fentanyl buccal tablet, 100 mcg, STAT.

Drug available: 4 fentanyl, 100-mcg tablet each in a blister package. Dissolve 1 tablet in the buccal cavity
over 30 minutes; then swallow any remaining pieces.

SUBLINGUAL TABLETS

Few drugs are administered sublingually (tablet placed under the tongue). Sublingual tablets are small
and soluble and are quickly absorbed by the numerous capillaries on the underside of the tongue. Sublin-
gual tablet may be called “orally disintegrating” tablet. Today some sublingual medications may include
steroids, enzymes, antipsychotics, and cardiovascular drugs.

C AUT I O N
• A sublingual tablet (e.g., nitroglycerin [NTG]) should not be swallowed. If the drug is swallowed, the
desired immediate action of the drug is decreased or lost.
• Fluids should not be taken until the drug has dissolved.
122 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Calculation of Sublingual Medications

EXAMPLES PROBLEM 1: Order: nitroglycerin (Nitrostat) 0.6 mg, sublingually (SL).
Drug available:

D 0.6 mg 0.6
Methods: BF: 3V5 3 1 tab 5 5 1 SL tablet
H 0.6 mg 0.6
or or
DA: no conversion factor RP: H ; V < D ;X
1
0.6 mg;1 tab<0.6 mg;X
1 tab 3 0.6 mg
SL tab 5 5 1 SL tablet 0.6 X 5 0.6
0.6 mg 3 1 X 5 1 tab
1
or H D
FE: 5
V X
0.6 mg 0.6 mg
5
1 tab X
0.6 X 5 0.6
X 5 1 tab
Answer: nitroglycerin (Nitrostat) 0.6 mg 5 1 SL tablet

PROBLEM 2: Order: isosorbide dinitrate (Isordil) 5 mg, SL.

Drug available: Isordil 2.5 mg per tablet.
D 5 mg
Methods: BF: 3V5 3 1 5 2 SL tablets
H 2.5 mg
or or
RP: H ; V < D ; X H D 2.5 mg 5 mg
2.5 mg;1 tab<5 mg;X tab FE: 5 5 5
V X 1 X
2.5 X 5 5 2.5 X 5 5
X 5 2 SL tablets X 5 2 tablets
or
DA: no conversion factor
2
1 SL tab 3 5 mg
SL tablets 5 5 2 SL tablets
2.5 mg 3 1
1

Answer: Isordil 5 mg 5 2 SL tablets

PROBLEM 3: Order: olanzapine (Zyprexa, Zydis) 5 mg, SL daily.

Drug available: olanzapine 2.5-, 5-, 7.5-, 10-, 20-mg orally disintegrating blister packet.
a. Which tablet in the blister pack of olanzapine would you select?
b. Explain how the orally disintegrating (SL) olanzapine tablet is administered.
Answer
a. Select 5-mg tablet from the olanzapine blister pack.
b. Have the patient place the sublingual tablet under the tongue, where it will be dissolved
and absorbed by the oral mucosa.
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 123

PRACTICE PROBLEMS u
​ ​ORAL MEDICATIONS
Answers can be found on pages 142 to 147.

Note: Tablets: Round off tenths to whole numbers; Liquid: Round off to hundredths and then to tenths.

For each question, calculate the correct dosage that should be administered.
1. Order: doxycycline hyclate (Vibra-Tabs) 50 mg, po, q12h.
Drug available:

How many tablets(s) would you give for each dose?
2. Order: trimethoprim/sulfamethexazole (Septra) 40 mg/200 mg, po, bid.
Drug available:

a. The drug label states that each tablet is .

b. How many tablet(s) would you give?
3. Order: digoxin (Lanoxin) 0.5 mg.
Drug available:

How many tablets should the patient receive?
124 PART III Calculations for Oral, Injectable, and Intravenous Drugs

4. Order: furosemide (Lasix) 20 mg, po, daily.

Drug available: Drug is scored.

How many tablet(s) would you give?
5. Order: Diovan HCT (valsartan and hydrochlorothiazide) 160 mg/25 mg, po, daily.
Drug available:

How many tablets would you give?
6. Order: potassium chloride 20 mEq, po.
Drug available:

How many milliliters should the patient receive?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 125

7. Order: cefaclor (Ceclor) 250 mg, q8h.

Drug available:

a. Which Ceclor bottle would you select? ​W hy?

b. How many milliliters per dose should the patient receive?
8. Order: ProSom (estazolam) 2 mg, po, at bedtime.

Drug available: 1-mg tablet.

How many tablet(s) should be given?
126 PART III Calculations for Oral, Injectable, and Intravenous Drugs

9. Order: cefuroxime axetil (Ceftin) 400 mg, po, q12h.

Drug available:

a. How many milliliters should the patient receive?

b. Which drug bottle would you use?
Why?
10. Order: zidovudine (Retrovir) 300 mg, po, q12h.
Drug available:

a. How many milligrams would you give per day?

b. How many milliliters would you give per dose?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 127

11. Order: Depakene 750 mg, po, daily.

Drug available:

How many milliliters would the patient receive?
12. Order: HydroDiuril 50 mg, po, daily.
Drug available:

a. Which drug bottle would you use?

b. How many tablet(s) would you give, if the tablet(s) are not scored?

Explain.
128 PART III Calculations for Oral, Injectable, and Intravenous Drugs

13. Order: simvastatin (Zocor) 30 mg, po, daily.

Drug available:

a. Which bottle(s) of Zocor would you select? Why?

b. How many tablet(s) should the patient receive?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 129

14. Order: oxycodone hydrochloride, 15 mg, po, q6h, PRN for pain.
Drug available:

How many milliliters (mL) should the patient receive?
15. Order: phenobarbital gr 1⁄2 (apothecary system). See Table 2-1.
Drug available: phenobarbital 15 mg per tablet.

How many tablet(s) should the patient receive?
16. Order: cefprozil (Cefzil) 100 mg, po, q12h.
Drug available:

How many milliliters should the patient receive per dose?
130 PART III Calculations for Oral, Injectable, and Intravenous Drugs

17. Order: Crestor 20 mg, po, daily.

Drug available:

  

a. Which Crestor bottle(s) would you select?

b. How many tablet(s) would you give?
18. Order: nitroglycerin 0.4 mg SL, STAT.
Drug available:

Which Nitrostat SL tablet would you give?
19. Order: cefixime 0.4 g, po, daily.
Drug available:

How many milliliters would the patient receive?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 131

20. Order: digoxin (Lanoxin) 0.25 mg, po, daily.

Drug available:

  

a. Which Lanoxin bottle would you select?

b. How many tablet(s) would you give?
21. Order: diazepam (Valium) 21⁄2 mg.
Drug available: Valium 5-mg scored tablet.

How many tablet(s) would you give?
22. Order: ondansetron HCl (Zofran) 6 mg, po, 30 min before chemotherapy, then q8h 3 2 more
doses.
Drug available:

How many milliliters would you give per dose?
23. Order: allopurinol 450 mg, po, daily.

Drug available: allopurinol 300 mg scored tablet.

How many tablet(s) would you give?
132 PART III Calculations for Oral, Injectable, and Intravenous Drugs

24. Order: captopril (Capoten) 25 mg, po, bid, for an elderly patient with heart failure.
Drug available:

a. How many milligrams should the patient receive per day?

b. How many tablet(s) would you give?
25. Order: Cogentin 1.5 mg, initially (first day); then 1 mg, po, daily starting second day.
Drug available:

a. How many tablet(s) should the patient receive initially (first day)?
b. How many tablet(s) should the patient receive the second day?
26. Order: fluconazole (Diflucan) 120 mg, po, daily for 4 weeks.
Drug available:

How many milliliters should the patient receive per dose?

 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 133

27. Order: lithium carbonate 600 mg, po, tid.

Drug available:

a. D
 rug label states that 8 mEq per 5 mL of lithium citrate is equivalent to of
lithium carbonate.
b. How many milliliters per dose should the patient receive?
c. How many milligrams should the patient receive per day?
28. Order: furosemide 100 mg, po, as a loading dose, then furosemide 20 mg, po, q12h.
Drug available:

a. How many milliliters would be given as the loading dose?

b. How many milliliters would be given for the next scheduled dose?
134 PART III Calculations for Oral, Injectable, and Intravenous Drugs

29. Order: amoxicillin/clavulanate potassium (Augmentin) 0.5 g, po, q8h.

Drug available:

How many milliliters should the patient receive per dose?
30. Order: Prozac 30 mg, po, daily.
Drug available:

How many milliliters should the client receive?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 135

Solve questions 31 to 39 with Additional Dimensional Analysis (factor labeling). Refer to Chapter 6 as
necessary.
31. Order: Ativan 1.5 mg, po, bid.
Drug available:

How many milligrams should the patient receive per dose?
32. Order: Vasotec 5 mg, po, bid.
Drug available:

Factors: 2.5 mg 5 1 tablet (drug label); 5 mg/1 (drug order)

Conversion factor: none.

How many tablet(s) should the patient receive?
136 PART III Calculations for Oral, Injectable, and Intravenous Drugs

33. Order: fluoxetine (Prozac) 60 mg, po, daily in the am for bulimia nervosa.
Drug available:

Conversion factor: None

How many milliliters of fluoxetine should the patient receive per day?
34. Order: cephalexin (Keflex) 1 g, po, 1 hour before dental cleaning.
Drug available:

a. Conversion factor: 1 g 5 1000 mg

b. How many capsules would you give 1 hour before dental cleaning?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 137

35. Order: metoprolol (Lopressor) 0.1 g, po, daily.

Drug available:

Conversion factor: 1 g 5 1000 mg

How many tablet(s) would you give?
36. Order: amoxicillin (Amoxil) 0.4 g, po, q6h.
Drug available:

Factors: 250 mg/5 mL (drug label); 0.4 g/1 (drug order)

Conversion factor: 1 g 5 1000 mg

How many milliliters would you give?
138 PART III Calculations for Oral, Injectable, and Intravenous Drugs

37. Order: acetaminophen (Tylenol) 650 mg, po.

Drug available:

How many acetaminophen tablets would you give?
38. Order: atenolol (Tenormin) 50 mg, po, daily for the first 2 weeks and then increase to 100 mg, po,
daily starting the third week.
Drug available:

Conversion factor: None
a. How many tablet(s) should the patient receive for the first 2 weeks?
b. How many tablet(s) should the patient receive after the second week?
39. Order: lactulose 25 g, po 3 1 dose.
Drug available:

How many milliliters would the patient receive?
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 139

Questions 40 to 44 relate to body weight and body surface area. Refer to Chapter 7 as necessary.
40.  Order: valproic acid (Depakene) 10 mg/kg/day in three divided doses (tid), po. Patient weighs
165 pounds. How much Depakene should be administered tid?
41. Order: cyclophosphamide (Cytoxan) 4 mg/kg/day, po. Patient weighs 154 pounds. How much
Cytoxan would you give per day?
42. Order: mercaptopurine 2.5 mg/kg/day po or 100 mg/m2 body surface area po. The patient weighs
132 pounds and is 64 inches tall. The estimated body surface area according to the nomogram is
1.7 m2. The amount of drug the patient should receive according to body weight is
and according to body surface area is ​ .
43. Order: ethosuximide (Zarontin) 20 mg/kg/day in 2 divided doses (q12h). Patient weighs
110 pounds (110 4 2.2 5 50 kg).
Drug available:

a. How many milligrams should the patient receive per day?

b. How many tablet(s) should the patient receive per dose?
44. Order: minocycline HCl (Minocin) 4 mg/kg/day in 2 divided doses (q12h). Patient weighs
132 pounds (132 4 2.2 5 60 kg).

Drug available: Minocin 50 mg/5 mL.

a. How many milligrams should the patient receive per day?

b. How many milliliters should the patient receive per dose?
45. Order: Pradaxa 150 mg, po, q12h.

Drug available: Pradaxa 75-mg tablet.

How many tablets should the patient receive?
46. Order: Xarelto 10 mg, po, daily.

Drug available: Xarelto 20-mg tablet.

How many tablets should the patient receive?
140 PART III Calculations for Oral, Injectable, and Intravenous Drugs

ENTERAL NUTRITION AND DRUG ADMINISTRATION

When the patient is unable to take nourishment by mouth, enteral feeding (tube feeding) is usually pre-
ferred over parenteral (intravenous) nutrition. Candidates for enteral feedings include patients who suffer
from neurological deficits and have swallowing problems; patients who are debilitated; have burns; suffer
from malnutrition disorders; and those who have undergone radical head and neck surgery. The cost of
enteral nutrition is much less than the use of intravenous therapy. Enteral nutrition also carries consider-
ably less risk of infection.
Drugs that can be administered orally (with the exception of sustained-release and extended-release
drugs) can also be given through the enteral feeding tube. The drug must be in liquid form or dissolved
into a liquid.

A Nasogastric Nasoduodenal/nasojejunal B

C Gastrostomy Jejunostomy D
Figure 8-5 ​Types of gastrointestinal tubes for enteral feedings. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015].
Pharmacology: a nursing process approach, 8th ed. Philadelphia: Saunders.)
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 141

Figure 8-6 Kangaroo pump.

Enteral Feedings
Enteral nutrition may be provided by a gastric, jejunal, or nasogastric tube. Enteral feeding tubes can be
identified by their anatomical insertion site and the location of the tip. Gastrostomy and jejunostomy routes
are used for long-term feeding and require a surgical procedure for insertion. There are two types of nasogas-
tric tubes: the flexible small-bore tube that has a small diameter (4-8 Fr), and the rigid large bore tube with
a larger diameter (10-18 Fr). All tubes inserted orally or nasally are primarily for short-term use and may
cause nasal or pharyngeal irritation if the use is prolonged. Large-bore tubes are less likely to clog than small-
bore tubes. It is essential to flush any feeding tube before and after feedings and between medications.
Enteral feedings may be given as a bolus (intermittent) or as a continuous drip feeding over a specific
time period. Continuous feedings can be given by gravity flow from a bag or by infusion pump. With
bolus feedings, the amount of solution administered is approximately 200 mL or less and feeding times
per day are more frequent.
Although enteral feeding solutions are formulated to be given at full strength, this may not be toler-
ated. Solutions that are highly concentrated (hyperosmolar or hypertonic) when given in full strength can
cause vomiting, cramping, or excessive diarrhea. In many situations, clients have better gastrointestinal
tolerance when the strength of the solution is gradually increased. Continuous feedings are usually started
slowly and advanced as tolerated by approximately 10 mL/hr to the goal feeding rate.
If diarrhea continues, changing to a fiber-containing formula may decrease or eliminate it. With some
patients, hypoalbuminemia could be a cause of diarrhea, which can lead to malabsorption in the intestines.
The prealbumin level is a better indicator of hypoalbuminemia than is the serum albumin test. Other causes
of diarrhea may include fecal impaction, Clostridium difficile, pseudomembranous colitis, and gut atrophy.
Blood sugar levels should be monitored during enteral therapy. This is important for patients who are
acutely ill, have septic conditions, are recovering from acute trauma, or who are receiving steroids. If
hyperglycemia occurs, decreasing the tube feeding rate or concentration may help.

TABLE 8-1 Common Enteral Formulations

Ensure Isocal Nephro
Ensure Plus Sustacal Ultracal
Ensure HN Sustacal HC Jevity
Osmolite Vital Criticare
Osmolite HN Pulmocare Promote
142 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Enteral Medications
Oral medications in liquid, tablet, or capsule form may be administered through a feeding tube when
diluted with 30 to 60 mL of water. Tablets or capsules than can be crushed should be pulverized into a
fine powder and then mixed in enough water to form a slurry. The slurry can be given through a large-
bore feeding tube with a catheter-tip syringe; 30 to 60 mL of water is flushed through the feeding tube
between medications. Some new feeding pumps are designed to include a flush bag that periodically
clears the feeding tube and prevents clogging.

C AUT I O N
• Use caution with crushing devices, such as a mortar and pestle, to avoid cross-contamination and pos-
sible allergic reactions, which may occur if the device is not cleaned or if the medication being crushed
is not shielded.

C AUT I O N
• Medications in time-released, enteric-coated, or sublingual form and bulk-forming laxatives cannot be
crushed or administered enterally.

ANSWERS
Oral Medications
D 50 mg H D 100 mg 50 mg
1. BF: 3V5 3 1 tab 5 0.5 5 1⁄2 tablet FE: 5 5 5
H 100 mg V X 1 X
100 X 5 50
X 5 0.5 or 1⁄2 tablet
or or
RP: H ; V < D ; X DA: no conversion factor
100 mg;1 tab<50 mg;X tab 1
1 tab 3 50 mg
100 X 5 50 tab 5 5 1⁄2 tablet
X 5 0.5 or 1⁄2 tablet 100 mg 3 1
2
2. a. scored
b. 1⁄2 tablet
3. 2 tablets
1
D 20 mg
4. BF: 3V5 3 1 5 1⁄2 tablet of Lasix
H 40 mg
2
RP: H ; V < D ; X
40 mg;1 tab<20 mg;X
40 X 5 20
X 5 1⁄2 tablet of Lasix
H D 40 mg 20 mg
FE: 5 5 5
V X 1 X
40 X 5 20
X 5 1⁄2 tablet of Lasix
5. 2 tablets daily
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 143

6. 7.5 mL
7. a. Select the 125-mg/5-mL bottle. It is a fractional dosage with the 375-mg/5-mL bottle (3.3 mL).
D 250 mg 1250
b. BF: 3V5 3 5 mL 5 5 10 mL of Ceclor
H 125 mg 125
or
RP: H ; V < D ;X
125 mg; 5 mL<250 mg;X
125 X 5 1250
X 5 10 mL of Ceclor
2
or 5 mL 3 250 mg
DA: mL 5 5 10 mL of Ceclor
125 mg 3 1
1
8. 2 tablets of ProSom
D 400 mg 2000
9. a. BF: 3V5 3 5 mL 5 5 16 mL of Ceftin
H 125 mg 125
or 400 mg
D 2000
BF: 3V5 3 5 mL 5 5 8 mL of Ceftin
H 250 mg 250
b. Either Ceftin bottle could be used. For fewer milliliters, select the 250-mg/5-mL bottle.
10. a. 600 mg per day
D 300 mg or
b. BF: 3V5 3 5 mL RP: H ; V < D ; X
H 50 mg
50 mg; 5 mL<300 mg; X mL
5 30 mL per dose
50 X 5 1500
X 5 30 mL
6
or H 50 mg 300 mg or
D 5 mL 3 300 mg
FE: 5 5 5 5 DA: mL 5 5 30 mL per dose
V X 5 mL X 50 mg 3 1
1
50 X 5 1500
X 5 30 mL per dose
D 750 mg or
11. BF: 3V5 3 5 mL 5 15 mL RP: H ; V< D ; X
H 250 mg
250; 5<750; X
250 X 5 3750
X 5 15 mL
or H 250 mg 750 mg or 5 mL 3 750 mg
D
FE: 5 5 5 DA: mL 5 5 15 mg
V H 5 mL X 250 mg 3 1
250 X 5 3750
X 5 15 mL
12. a. The HydroDiuril 25-mg tablet bottle is preferred. A half-tablet from the HydroDiuril 100-mg tablet bottle
can be used; however, breaking or cutting the 100-mg tablet can result in an inaccurate dose.
b. From the HydroDiuril 25-mg bottle, give 2 tablets. From the HydroDiuril 100-mg bottle, give 1⁄2 tablet (if
the tablet is scored).
13. a. Select a 10-mg and 20-mg Zocor bottle. The 40-mg tablet would not be selected because breaking or cut-
ting the tablet can result in an inaccurate dose.
b. Give 1 tablet from each bottle.
144 PART III Calculations for Oral, Injectable, and Intravenous Drugs

D 15 mg or
14. BF: 3V5 3 1 mL 5 0.75 mL  
H 20 mg RP: H ;V< D ;X
20 mg; 1<15 mg;X
20 X 5 15
X 5 0.75 mL
or H 20 mg 15 mg or
D 1 mL 3 15 mg
FE: 5 5 5 DA: mL 5 5 0.75 mL
V X 1 X 20 mg 3 1
20 X 5 15
X 5 0.75 mL
15. Use the metric system. Give 2 tablets (gr 1⁄2 5 30 mg).
D 100 500 or
16. BF: 3V5 3 5 mL 5 5 4 mL
H 125 125 RP: H ; V < D ;X
125 mg;5 mL<100 mg;X
125 X 5 500
X 5 4 mL
or 125 mg 100 mg or
FE: 5 5 125X 5 500 DA: no conversion factor
5 mL X 4
X 5 4 mL 5 mL 3 100 mg 20
mL 5 5 5 4 mL
125 mg 3 1 5
5
17. a. Preferred the selection of Crestor 10-mg bottle. Could select Crestor 5-mg bottle; however, the number of
tablets given would have to be increased.
b. 2 tablets from Crestor 10-mg bottle. If Crestor 5-mg bottle was selected, then 4 tablets.
18. Nitrostat 0.4 mg
19. Change grams to milligrams: 0.400 g 5 400 mg
N
D 400 mg or
BF: 3V5 3 5 mL 5 20 mL RP: H : V :: D : X
H 100 mg
100 : 5 :: 400 : X
100 X 5 2000
X 5 20 mL
or H 100 mg 400 mg or
D 5 mL 3 400 mg
FE: 5 5 5 DA: mL 5 5 20 mL
V X 5 mL X 100 mg 3 1
100 X 5 2000
X 5 20 mL

20. a. Preferred: the selection of Lanoxin 0.125-mg (125-mcg) bottle. Could select Lanoxin 0.5-mg (500-mcg)
bottle because the tablets are scored.
b. 2 tablets from the Lanoxin 0.125-mg bottle or 1⁄2 tablet from the Lanoxin 0.5-mg bottle.
21. 1⁄2 tablet
D 6 mg 30
22. BF: 3V5 3 5 mL 5 5 7.5 mL of Zofran
H 4 mg 4
23. 11⁄2 tablets
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 145

24. a. 50 mg per day

D 25 mg or
b. BF: 3V5 3 1 tab 5 2 tablets RP: H : V :: D : X
H 12.5 mg
12.5 mg : 1 tab :: 25 mg : X tab
12.5 mg X 5 25 mg
X 5 2 tablets
2
or H 12.5 mg 25 mg or
D 1 tab 3 25 mg
FE: 5 5 5 5 DA: tablets 5 5 2 tablets
V X 1 tablet X 12.5 mg 3 1
1
12.5 X 5 25
X 5 2 tablets
25. a. Initially, first day
3
D 1.5 mg
BF: 3V5 3 1 5 3 tablets
H 0.5 mg
1
or
RP: H : V :: D : X
0.5 mg : 1 tab :: 1.5 mg : X
0.5 X 5 1.5
X 5 3 tablets of Cogentin
b. Second day and ON
H D 0.5 mg 1 mg
FE: 5 5 5
V X 1 X
0.5 X 5 1
X 5 2 tablets
2
or 1 tab 3 1 mg
DA: tablet 5 5 2 tablets of Cogentin
0.5 mg 3 1
1
26. 12 mL of Diflucan
27. a. 300 mg per 5 mL
2
D 600 mg or
b. BF: 3V5 3 5 mL 5 10 mL of lithium RP: H ; V < D ;X
H 300 mg
1 300 mg;5 mL<600 mg;X
or H 300 X 5 3000
D 300 mg 600 mg
FE: 5 5 5 X 5 10 mL
V X 5 mL X or 2
300 X 5 3000 5 mL 3 600 mg
X 5 10 mL of lithium DA: mL 5 5 10 mL
300 mg 3 1
c. 600 mg 3 3 (tid) 5 1800 mg per day 1

28. a. Loading dose

D 100 mg or
BF: 3V5 3 4 mL 5 RP: H : V :: D : X
H 40 mg
40 mg : 4 mL :: 100 mg : X
400
5 10 mL of furosemide 40 X 5 400
40 X 5 10 mL
1
b. Per dose or 4 mL 3 20 mg 4
H D 40 mg 20 mg DA: mL 5 5 5 2 mL of furosemide
FE: 5 5 5 40 mg 3 1 2
V X 4 mL X 2
40 X 5 80
X 5 2 mL
146 PART III Calculations for Oral, Injectable, and Intravenous Drugs

29. 10 mL 3
30 mg or
D 5 mL 3 30 mg 15
30. BF: 3V5 3 5 mL 5 DA: mL 5 5 5 7.5 mL of Prozac
H 20 mg 20 mg 3 1 2
2
150
5 7.5 mL of Prozac
20
Additional Dimensional Analysis
1 tab 3 1.5 mg 1.5
31. DA: tab 5 5 5 3 tablets of Ativan
0.5 mg 3 1 0.5
2
1 3 5.0 mg
32. tablets 5 5 2 tablets of Vasotec
2.5 mg 3 1
1
3
5 mL 3 60 mg
33. DA: mL 5 5 15 mL of Prozac
20 mg 3 1
1
4
1 cap 3 1000 mg 3 1 g
34. DA: cap 5 5 4 capsules of Keflex
250 mg 3 1g 3 1
1
20
1 tab 3 1000 mg 3 0.1 g 20 3 0.1
35. DA: tab 5 5 5 2 tablets of Lopressor
50 mg 3 1g 3 1 1
1
4
5 mL 3 1000 mg 3 0.4 g
36. mL 5 5 8 mL
250 mg 3 1g 3 1
1
Give 8 mL per dose of amoxicillin.
37. Drug label: 325 mg 5 1 tablet
2
1 tab 3 650 mg
DA: tablet 5 5 2 tablets
325 mg 3 1
1
38. a. 1 tablet of Tenormin
2
1 tablet 3 100 mg
b. DA: tablet 5 5 2 tablets of Tenormin
50 mg 3 1
1
D 25 g or
39. BF: 3V5 3 15 mL 5 37.5 mL  
H 10 g RP: H ; V < D ;X
10 g; 15 mL<25 g;X
10 X 5 375
X 5 37.5 mL
or H 10 g 25 g or
D 15 mL 3 25 mg
FE: 5 5 5 DA: mL 5 5 37.5 mL
V X 15 mL X 10 mg 3 1
1Cross multiply2 10 X 5 375
X 5 37.5 mL
40. 165 lb 5 75 kg (change pounds to kilograms by dividing by 2.2 into 165 pounds, or 165 4 2.2)
10 mg/kg/day 3 75 5 750 mg/day
750 4 3 5 250 mg, tid
41. 154 lb 5 70 kg
4 mg/kg/day 3 70 kg 5 280 mg/day
 CHAPTER 8 Oral and Enteral Preparations With Clinical Applications 147

42. 132 lb 5 60 kg
2.5 mg/kg/day 3 60 kg 5 150 mg or 100 mg/m2 3 1.7 m2 5 170 mg
43. a. 20 mg/50 kg/day 5 20 3 50 5 1000 mg per day
b. 2 tablets of Zarontin per dose (500 mg per dose)
44. a. 4 mg/60 kg/day 5 4 3 60 5 240 mg per day or 120 mg, q12h
D 120 mg 1 120
b. BF: 3V5 3 5 mL 5 5 12 mL
H 50 mg 10
10
or
RP: H ; V < D ;X
50 mg; 5 mL<120 mg;X
50 X 5 600
600
X5 5 12 mL
50
12
or 5 mL 3 120 mg 60
DA: mL 5 5 5 12 mL
50 mg 3 1 5
5
Give 12 mL per dose of minocycline.
D 150 mg or
45. BF: 3V5 3 1 tab 5 2 tablets  
H 75 mg H ; V < D ;X
75 mg; 1 tab<150 mg;X
75 X 5 150
X 5 2 tablets
D 10 mg or
46. BF: 3V5 3 1 tab 5 0.5 or 1⁄2 tablet  
H 20 mg H ; V < D ;X
20 mg; 1 tab<10 mg;X
20 X 5 10
X 5 0.5 or 1⁄2 tablet

Additional practice problems are available in the Basic Calculations section of Drug
Calculations Companion, version 5 on Evolve.
CHAPTER 9
Injectable Preparations
With Clinical Applications

Objectives • Select the correct syringe and needle for a prescribed injectable drug.
• Calculate dosages of drugs for subcutaneous and intramuscular routes from solutions in vials
and ampules.
• Explain the procedure for preparing and calculating medications in powder form for injectable
use.
• State the various sites for intramuscular injection.
• Explain how to administer intradermal, subcutaneous, and intramuscular injections.

Outline INJECTABLE PREPARATIONS

Vials and Ampules
Syringes
Needles
INTRADERMAL INJECTIONS
SUBCUTANEOUS INJECTIONS
Calculations for Subcutaneous Injections
INTRAMUSCULAR INJECTIONS
Drug Solutions for Injection
Reconstitution of Powdered Drugs
MIXING OF INJECTABLE DRUGS

Medications administered by injection are given through four routes. In the first method, intradermal,
the needle is inserted just under the epidermis in the dermal layer of the skin. In the second route, sub-
cutaneous, the needle is placed farther into the fatty tissue. In the third route, intramuscular, the injection
goes directly into the muscle. In the fourth route, intravenous, the medication is directly injected into a
vein. (Intravenous injectables are discussed in Chapter 11.) Because these routes are commonly used in
drug orders they are frequently abbreviated: intradermal as ID; subcutaneous as subcut, subQ, SC, and
SQ; intramuscular as IM; and intravenous as IV. It is essential that injectable drugs be given by the cor-
rect route. Any use of abbreviations should follow institutional policies and protocols.
Injectable drugs are ordered in grams, milligrams, micrograms, or international units. The drug man-
ufacturer prepares the medication as either a liquid or a powder according to the stability of the

148
 CHAPTER 9 Injectable Preparations With Clinical Applications 149

compound. The nurse’s responsibility is to have working knowledge of all types of injectable prepara-
tions, the equipment for injections, and the routes of administration.

INJECTABLE PREPARATIONS

Vials and Ampules

Drugs are packaged in vials (sealed rubber-top containers) for single and multiple doses and in ampules
(sealed glass containers) for a single dose. Multiple-dose vials can be used more than once because of
their self-sealing rubber top; however, ampules are used only once after the glass-necked container is
opened. A 15-gauge filtered needle should be used with a glass ampule to prevent aspiration of small
glass particles. The drug is available in either liquid or powder form in vials and ampules. When drugs in
solution deteriorate rapidly, they are packaged in dry form, and solvent (diluent) is added before admin-
istration. If the drug is in powdered form, mixing instructions and dose equivalents such as milligrams
(mg) per milliliter (mL) are usually given; if not, check the drug information insert. After the dry form
of the drug is reconstituted with sterile water, bacteriostatic water (sterile water with a small amount of
benzyl alcohol to prevent bacterial growth), or saline solution, the drug must be used immediately or
refrigerated. Usually, the reconstituted drug in the vial is used within 48 hours to 1 week; check the drug
information insert. A Mix-O-Vial has two containers, one holding a diluent and the other holding a
powdered drug. When pressure is applied to the top of the vial, the liquid is released, which dissolves the
powdered drug. A vial, a Mix-O-Vial and an ampule are shown in Figure 9-1.
The route by which the injectable drug can be given, such as subcut or SQ, IM, or IV, is printed on
the drug label.

Syringes
Types of syringes used for injection include 3-mL and 5-mL calibrated syringes, metal and plastic
syringes for pre-filled cartridges, and tuberculin syringes. Insulin syringes are discussed in detail in
­Chapter 10. There are 10-mL, 20-mL, and 50-mL syringes that are used mostly for drug preparations.
A syringe is composed of a barrel (outer shell), a plunger (inner part), and the tip, where the needle joins
the syringe (Figure 9-2).

Vial Ampule Mix-O-Vial

A B C
Figure 9-1 ​A, Vial. B, Ampule. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered
nursing process approach, 8th ed., Philadelphia: Elsevier.) C, Mix-o-vial. (From Clayton B. D., & Willihnganz M. J. [2013]: Basic
pharmacology for nurses, 16th ed., St Louis: Elsevier.)
150 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Tip Read from

(Hub) Barrel this point Plunger

Rubber
stopper
Figure 9-2 ​Parts of a syringe.

Three-Milliliter Syringe
The 3-mL syringe is calibrated in tenths (0.1 mL). The amount of fluid in the syringe is determined by
the rubber end of the plunger that is closer to the tip of the syringe (Figure 9-3). An advance in safety
needle technology is the SafetyGlide shielding hypodermic needle (Figure 9-4). The purpose of this type
of needle is to reduce needlestick injuries. Needles should never be recapped by hand and should always
be disposed of in a sharps container (Figure 9-5).

Figure 9-3 ​Three-milliliter syringes: A, 3-mL syringe with 0.1-mL markings. B, 3-mL syringe with a needle cover.
C, 3-mL syringe with a protective cover over the needle after injection. (B and C from Kee, J. L., Hayes, E. R., &
McCuistion, L. E. [2015]. Pharmacology: a patient-centered nursing process approach. 8th ed., Philadelphia: Elsevier.)

Figure 9-5 ​Sharps container. (From Clayton, B. D.,

Figure 9-4 ​BD SafetyGlide™ needle. (From Becton, & Willihnganz, M. J. [2013]. Basic pharmacology for
Dickinson and Company, Franklin ​Lakes, N.J.) nurses, 16th ed., St. Louis: Elsevier.)
 CHAPTER 9 Injectable Preparations With Clinical Applications 151

B
Figure 9-6 ​Five-milliliter syringes. A, 5-mL syringe with 0.2-mL markings. B, Needleless 5-mL syringe that can penetrate a
rubber-top vial. (B from Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered nursing process
approach. 8th ed., Philadelphia: Elsevier.)

Five-Milliliter Syringe
The 5-mL syringe is calibrated in 0.2 mL increments. A 5-mL syringe usually is used when the fluid
needed is more than 21⁄2 mL. This syringe is frequently used to draw up appropriate solution to dilute the
dry form of a drug in a vial because the volume needed for reconstitution is generally more than 21/2 mL.
Figure 9-6 shows the 5-mL syringe and its markings and the 5-mL needleless syringe.

Tuberculin Syringe
The tuberculin syringe is a 1-mL slender syringe that is calibrated in tenths (0.1 mL), hundredths
(0.01 mL), and minims (Figure 9-7). This syringe is used when the amount of drug solution to be admin-
istered is less than 1 mL and for pediatric and heparin dosages. The tuberculin syringe is also available in
a 1/2-milliliter (mL) syringe. Figure 9-8 shows the 1⁄2-mL and the 1-mL tuberculin syringes.

Pre-filled Drug Cartridge and Syringe

Many injectable drugs are packaged in pre-filled disposable cartridges. The disposable cartridge is placed
into a reusable metal or plastic holder. A pre-filled cartridge usually contains 0.1 to 0.2 mL of excess drug
solution. On the basis of the amount of drug to be administered, the excess solution must be expelled
before administration. Injectables are also supplied by pharmaceutical companies in ready-to-use

4m 8m 12 m 16 m

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Figure 9-7 ​Tuberculin syringe.

A B
Figure 9-8 ​Two types of tuberculin syringes: A, 1⁄2-mL tuberculin syringe with a permanently attached needle. B, 1-mL tuber-
culin syringe with a detachable needle. (From Becton, Dickinson and Company, Franklin Lakes, ​N.J.)
152 PART III Calculations for Oral, Injectable, and Intravenous Drugs

C
Figure 9-9 ​A, Carpuject syringe. B, Tubex syringe. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a
patient-centered nursing process approach. 8th ed., Elsevier: ​Saunders.) C, Lovenox syringe.

pre-filled syringes that do not require a holder. Figure 9-9, A, shows a Carpuject syringe. Figure 9-9, B,
shows a Tubex syringe. Figure 9-9, C, shows a pre-filled Lovenox syringe.

Needles
A needle consists of (1) a hub (large metal or plastic part attached to the tip of the syringe), (2) a shaft
(thin needle length), and (3) a bevel (end of the needle). Figure 9-10 shows the parts of a needle.
Needle size is determined by gauge (diameter of the shaft) and by length. The larger the gauge num-
ber, the smaller the diameter of the lumen. The smaller the gauge number, the larger the diameter of the
lumen. The usual range of needle gauges is from 18 to 26. Needle length varies from 3⁄8 inch to
2 inches. Table 9-1 lists the sizes and lengths of needles used in intradermal, subcutaneous, and intramus-
cular injections.
When choosing the needle length for an intramuscular injection, the nurse must consider the size of the
patient and the amount of fatty tissue. A patient with minimal fatty tissue may need a needle length of
1 inch. For an obese patient, the length of the needle for an intramuscular injection may be 11⁄2 to 2 inches.

Figure 9-10 ​Parts of a needle. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered
nursing process approach. 8th ed., Philadelphia: Elsevier.)
 CHAPTER 9 Injectable Preparations With Clinical Applications 153

TABLE 9-1 Needle Size and Length

Type of Injection Needle Gauge Needle Lengths (inch)
3
Intradermal 25, 26 ⁄8, 1⁄2, 5⁄8
3
Subcutaneous 23, 25, 26 ⁄8, 1⁄2, 5⁄8
Intramuscular 19, 20, 21, 22 1, 11⁄2, 2

Figure 9-11 ​Two combinations of needle gauge and length.

Pre-filled cartridges have permanently attached needles. With other syringes, needle sizes can be
changed. Needle gauge and length are indicated on the syringe package or on the top cover of the syringe.
These values appear as gauge/length, such as 21 g/11⁄2 inch. Figure 9-11 shows two types of needle gauge
and length.
Research has shown that after an injection, medication remains in the hub of the syringe, where the
needle joins the syringe. This volume can be as much as 0.2 mL. There is controversy as to whether air
should be added to the syringe before administration to ensure that the total volume is given. The best
practice is to follow the institution’s policy.

Angles for Injection

For injections, the needle enters the skin at different angles. Intradermal injections are given at a 10- to
15-degree angle; subcutaneous injections, at a 45- to 90-degree angle; and intramuscular injections, at a
90-degree angle. Figure 9-12 shows the angles for intradermal, subcutaneous, and intramuscular injections.

Bleb Intradermal

10°–15°
Epidermis
Skin
Dermis

Subcutaneous
tissue

Muscle

Intramuscular
Subcutaneous

Skin 90°
45°
Subcutaneous
tissue 90°
Muscle

Figure 9-12 ​Angles of injection. (From Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered
nursing process approach.. 8th ed., Philadelphia: Elsevier.)
154 PART III Calculations for Oral, Injectable, and Intravenous Drugs

PRACTICE PROBLEMS u
​ ​I NEEDLES
Answers can be found on page 179.
1. Which would have the larger needle lumen: a 21-gauge needle or a 25-gauge needle?

2. Which would have the smaller needle lumen: an 18-gauge needle or a 26-gauge needle?

3. Which needle would have a length of 11⁄2 inches: a 20-gauge needle or a 25-gauge needle?

4. Which needle would have a length of 5⁄8 inch: a 21-gauge needle or a 25-gauge needle?

5. W
 hich needle would be used for an intramuscular injection: a 21-gauge needle with a 11⁄2-inch
length or a 25-gauge needle with a 5⁄8-inch length?

INTRADERMAL INJECTIONS

Intradermal injections are shallow and designed to deliver medication between the dermis and epidermis.
Usually, an intradermal injection is used for skin testing. Primary uses are for tuberculin and allergy test-
ing. The tuberculin syringe (25 g/1⁄2 inch) holds 1 mL (16 minims) and is calibrated in 0.1 to 0.01 mL.
The inner aspect of the forearm is often used for diagnostic testing because there is less hair in the area
and the test results are easily seen. The upper back can also be used as a testing site. The needle is inserted
with the bevel upward at a 10- to 15-degree angle. Do not aspirate. The injected fluid creates a wheal or
bleb that is slowly absorbed. For allergy testing, results are usually read in minutes to 24 hours after the
injection. For tuberculin testing, results are read 48 to 72 hours after the injection. A reddened or raised
hardened area, called the area of induration, indicates a positive reaction.

SUBCUTANEOUS INJECTIONS

Drugs injected into the subcutaneous (fatty) tissue are absorbed slowly because there are fewer blood
vessels in the fatty tissue. The amount of drug solution administered subcutaneously is generally 0.5 to
1 mL at a 45-, 60-, or 90-degree angle. Irritating drug solutions are given intramuscularly because they
could cause sloughing of the subcutaneous tissue.
The two types of syringes used for subcutaneous injection are the tuberculin syringe (1 mL), which is
calibrated in 0.1 and 0.01 mL, and the 3-mL syringe, which is calibrated in 0.1 mL (Figure 9-13). The
needle gauge commonly used is 25 or 26 gauge, and the length is usually 3⁄8 to 5⁄8 inch. Insulin is also
administered subcutaneously and is discussed in Chapter 10.

Figure 9-13 ​Syringes used for subcutaneous injections.

 CHAPTER 9 Injectable Preparations With Clinical Applications 155

Calculations for Subcutaneous Injections

Types of formulas for calculating small dosages include the following: (1) basic formula, (2) ratio and
proportion, (3) fractional equation, and (4) dimensional analysis (see Chapter 6).
EXAMPLES PROBLEM 1: Order: heparin 5000 units, subcut.
Drug available:

Methods:
Basic formula (BF)
D 5000 units 5
3V5 3 1 mL 5 5 0.5 mL
H 10,000 units 10
or
Ratio and proportion (RP)
H ; V < D ; X
10,000 units;1 mL<5000 units;X mL

10,000 X 5 5000
5000 5
X5 5 5 0.5 mL
10,000 10
or
Fractional equation ​(FE)
H D 10,000 units 5000 units
FE: 5 5 5 5
V X 1 mL X
1Cross multiply2 10,000 X 5 5000
X 5 0.5 mL
or
Dimensional analysis (DA)
V 3 C 1H2 3 D
V5
H 3 C 1D2 3 1
1
1 mL 3 5000 units 1
mL 5 5 or 0.5 mL
10,000 units 3 1 2
2

Answer: heparin 5000 units 5 0.5 mL

PROBLEM 2: Order: morphine 10 mg, subcut.

Drug available:

See label with approximate equivalents.

156 PART III Calculations for Oral, Injectable, and Intravenous Drugs

D 10 mg 2
Methods: BF: 3V5 3 1 mL 5 5 0.67 mL or 0.7 mL (round off in tenths)
H 15 mg 3
or or H 15 mg 10 mg
D
RP: H ; V < D ; X FE: 5 5 5 5
15 mg;1 mL<10 mg;X mL V X 1 mL X
1Cross multiply2 15 X 5 10
10 2
15 X 5 10 ​ X5 5 5
2 15 3
10 2 0.67 or 0.7 mL
X5 5 5 0.67 mL or 0.7 mL
15 3
3
or
DA: no conversion factor
2
1 mL 3 10 mg 2
mL 5 5 or 0.7 mL
15 mg 3 1 3
3

Answer: morphine 10 mg 5 0.67 or 0.7 mL (use a tuberculin syringe or a 3-mL syringe).

(Round off in tenths.)

PRACTICE PROBLEMS u
​ ​ II ​SUBCUTANEOUS INJECTIONS
Answers can be found on pages 179 to 181.

Use the formula you chose for calculating oral drug dosages in Chapter 8.
Note: Answers should be rounded off in tenths or whole numbers.

1. Which needle gauge and length should be used for a subcutaneous injection:
a. 25 g/5⁄8 inch or 26 g/3⁄8 inch?
2. Order: heparin 4000 units, subcut.
Drug available:

a. How many milliliters of heparin would you give?

b. At what angle would you administer the drug?
3. Order: heparin 7500 units, subcut.
Drug available:

How many milliliters of heparin would you give?
 CHAPTER 9 Injectable Preparations With Clinical Applications 157

4. Order: Lovenox (enoxaparin sodium) 30 mg, subcut, q12h. Lovenox is a low-molecular-weight

heparin (LMWH).
Drug available:

How many mililiters would you give?
5. Order: atropine sulfate 0.6 mg, subcut.
Drug available:

How many milliliters of atropine would you give?
6. Order: epoetin alfa (Epogen) 50 units/kg, subcut.
Drug available: Epogen 10,000 units/mL.
Patient weighs 65 kg.
a. What is the correct dosage?
b. How many milliliters would you give?
7. Order: filgrastim (Neupogen) 6 mcg/kg, subcut, bid.
Drug available:

Patient weighs 198 pounds.
a. How many kilograms does the patient weigh?
b. How many micrograms (mcg) would you give?
c. How many milliliters would you give?
d. Explain how the drug should be drawn up.
158 PART III Calculations for Oral, Injectable, and Intravenous Drugs

8. Order: enoxaparin (Lovenox) 1 mg/kg, subcut, q12h, for 3 days (treatment of deep vein thrombo-
sis [DVT]).
 rug available: Lovenox in pre-filled syringes: 40 mg per 0.4 mL; 60 mg per 0.6 mL; 80 mg per
D
0.8 mL.
Patient weighs: 70 kg
a. Which Lovenox dosage would you select?
b. How many milliliters should the patient receive?
9. Order: morphine 8 mg, subcut, 3 1 dose.
Drug available:

How many milliliters would the patient receive?
10. Order: Fragmin 120 units/kg, subcut, q12h.
Drug available:

Patient weighs 165 kg.
a. How many international units (IU) would the patient receive per dose?
b. How many milliliters would the patient receive per dose?

INTRAMUSCULAR INJECTIONS

The IM injection is a common method of administering injectable drugs. The muscle has many blood
vessels (more than fatty tissue), so medications given by IM injection are absorbed more rapidly than
those given by subcutaneous injection. The volume of solution for an IM injection is 0.5 to 3.0 mL, with
the average being 1 to 2 mL. A volume of drug solution greater than 3 mL causes increased muscle tissue
displacement and possible tissue damage. Occasionally, 5 mL of certain drugs, such as magnesium sulfate,
may be injected into a large muscle, such as the ventrogluteal. Dosages greater than 3 mL are usually
divided and are given at two different sites.
Needle gauges for IM injections containing thick solutions are 19 gauge and 20 gauge, and for thin
solutions, 20 gauge to 21 gauge. IM injections are administered at a 90-degree angle. The needle length
depends on the amount of adipose (fat) and muscle tissue; the average needle length is 11⁄2 inches.
 CHAPTER 9 Injectable Preparations With Clinical Applications 159

The Z-track injection technique delivers medication intramuscularly in a method that prevents the
drug from leaking back into the subcutaneous tissue (Figure 9-14). This method is ordered for medica-
tions that could cause irritation to the subcutaneous tissue or discoloration to the skin. When preparing
the medication, a needle change is made after the drug has been drawn up into the syringe and before it
is injected into the patient. The large gluteal muscle is frequently used for Z-track injections.
Common sites for IM injections are the deltoid, dorsogluteal, ventrogluteal, and vastus lateralis mus-
cles. Figure 9-15 displays the sites for each muscle used with IM injection. Table 9-2 gives the volume
for drug administration, common needle size, patient’s position, and angle of injection for the four IM
injection sites.

Note: Some institutions may prohibit using the dorsogluteal for intramuscular injections due to the
close proximity of the sciatic nerve to the injection site. Always check institutional policy and
procedures.

Drug Solutions for Injection

Commercially premixed drug solutions are stored in vials and ampules for immediate use. At times,
enough drug solution may be left in a vial for another dose, and the vial may be saved. The balance of a
drug solution in an ampule is always discarded after the ampule has been opened and used.

Skin

Subcutaneous
tissue

Muscle

B C
Figure 9-14 ​Z-track injection. A, Pull the skin to one side and hold; insert needle. B, Holding skin to the side, inject medica-
tion. C, Withdraw needle and release skin. This technique prevents medication from entering subcutaneous tissue. (From
Kee, J. L., Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered nursing process approach., 8th ed.,
Philadelphia:Elsevier).
160 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Deltoid
Injection site
muscle
Landmarks
Acromion Iliac crest
Clavicle
Head of
humerus Gluteus minimus
muscle
Deep radial
artery Injection site Greater trochanter
Radial Landmarks of femur
nerve
Gluteus maximus
muscle
A B

Tubercle Greater
of Iliac crest trochanter
of femur
Injection site
Injection site
Landmarks
Landmarks

Greater
trochanter
of femur
Gluteus
maximus
muscle Vastus
lateralis Patella
muscle

C D
Figure 9-15 Intramuscular injection sites. A, Deltoid. B, Dorsogluteal. C, Ventrogluteal. D, Vastus lateralis. (From Kee, J. L.,
Hayes, E. R., & McCuistion, L. E. [2015]. Pharmacology: a patient-centered nursing process approach., 8th ed., Philadelphia:
Elsevier).

TABLE 9-2 Intramuscular Injection Sites in the Adult

Deltoid Dorsogluteal Ventrogluteal Vastus Lateralis

Volume for drug Usual: 0.5 to Usual: 1.0 to 3 mL Usual: 1 to 3 mL Usual: 1 to 3 mL

administration 1 mL Maximum: 3 mL; 5 mL gamma Maximum: 3 to Maximum: 3 to 4 mL
Maximum: 2.0 mL globulin 4 mL
Common needle 23 to 25 gauge; 18 to 23 gauge; 11⁄4 to 20 to 23 gauge; 20 to 23 gauge;
5
size ⁄8 to 11⁄2 inches 3 inches 11⁄4 to 21⁄2 inches 11⁄4 to 11⁄2 inches
Patient’s position Sitting; supine; Prone Supine; lateral Sitting (dorsiflex foot);
prone supine
Angle of injection 90-degree angle, 90-degree angle to flat surface; 80- to 90-degree 80- to 90-degree
angled slightly upper outer quadrant of the angle; angle the angle
toward the buttock or outer aspect of line needle slightly For thin person:
acromion from the posterior iliac crest toward the iliac 60- to 75-degree
to the greater trochanter of crest angle
the femur
 CHAPTER 9 Injectable Preparations With Clinical Applications 161

EXAMPLES Here are two problems for calculating IM dosage, using all four methods and rounded to the nearest tenths.
PROBLEM 1: Order: gentamycin (Garamycin) 60 mg, IM, q12h.
Drug available:

D 60 mg 3
Methods: BF: 3V5 3 1 mL 5 or RP: H ; V < D ; X
H 40 mg 2 40 mg;1 mL<60 mg;X mL
5 1.5 mL of gentamycin 40 X 5 60
X 5 1.5 mL
3
or H 40 mg 60 mg 1 mL 3 60 mg 3
D
FE: 5 5 5 5 or DA: mL 5 5
V X 1 mL X 40 mg 3 1 2
2
1Cross multiply2 40 X 5 60 5 1.5 mL of gentamycin
X 5 1.5 mL of gentamycin

Answer: gentamycin 60 mg 5 1.5 mL

PROBLEM 2: Order: Naloxone 0.5 mg, IM, STAT.

Drug available:

D 0.5 mg H D
Methods: BF: 3V5 3 1 mL 5 1.25 mL or FE: 5
H 0.4 mg V X
or 0.4 mg 0.5 mg
5
RP: H ; V < D ;X 1 mL X
0.4 mg;1 mL<0.5 mg;X
0.4 X 5 0.5
X 5 1.25 mL
0.4 X 5 0.5
X 5 1.25 mL
10
or 1 mL 3 1000 mcg 3 0.5 mg 10 3 0.5 5
DA: mL 5 5 5 5 1.25 mL
400 mcg 3 1 mg 3 1 4 4
4

Answer: Naloxone 0.5 mg 5 1.25 mL

162 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Reconstitution of Powdered Drugs

Certain drugs lose their potency in liquid form. Therefore manufacturers package these drugs in powdered
form, and they are reconstituted before administration. To reconstitute a drug, look on the drug label or in
the drug information insert (circular or pamphlet) for the type and amount of diluent to use. Sterile water,
bacteriostatic water, and normal saline solution are the primary diluents. If the type and amount of diluent
are not specified on the drug label or in the drug information insert, call the pharmacy.
The powdered drug occupies space and therefore increases the volume of drug solution. Usually, man-
ufacturers determine the amount of diluent to mix with the drug powder to yield 1 to 2 mL per desired
dose. After the powdered drug has been reconstituted, the unused drug solution should be dated, ini-
tialed, and refrigerated. Most drugs retain their potency for 48 hours to 1 week when refrigerated. Check
the drug information insert or drug label to see how long the reconstituted drug may be used.

EXAMPLES PROBLEM 1: Order: Tazicef 500 mg, IM, q8h.

Drug available:
RECONSTITUTION
Single Dose Vials:
For I.M. injection, I.V. direct (bolus) injection, or I.V. infusion,
reconstitute with Sterile Water for injection according to the
following table. The vacuum may assist entry of the diluent.
SHAKE WELL.
Table 5
Vial Diluent to Approx. Avail. Approx. Avg.
Size Be Added Volume Concentration
Intramuscular or Intravenous Direct (bolus) Injection
1 gram 3.0 ml. 3.6 ml. 280 mg./ml.
Intravenous Infusion
1 gram 10 ml. 10.6 ml. 95 mg./ml.
2 gram 10 ml. 11.2 ml. 180 mg./ml.
Withdraw the total volume of solution into the syringe (the
pressure in the vial may aid withdrawal). The withdrawn solu-
tion may contain some bubbles of carbon dioxide.
NOTE: As with the administration of all parenteral
products, accumulated gases should be ex-
pressed from the syringe immediately before
injection of ‘Tazicef’.
These solutions of ‘Tazicef’ are stable for 18 hours at room
temperature or seven days if refrigerated (5C.). Slight yel-
lowing does not affect potency.
For I.V. infusion, dilute reconstituted solution in 50 to 100 ml.
of one of the parenteral fluids listed under COMPATIBILITY
AND STABILITY.

According to the label, the amount of powdered drug is 1 g. The drug label states for IM injection add
3 mL of sterile water (diluent) to the vial to yield a volume of 1 g/3.6 mL or 280 mg/mL.

Note: the diluent amount is different for IM versus IV formulation.

Milligrams
D 500 mg
BF: 3V5 3 1 mL 5 1.78 mL or RP: H ; V < D ;X
H 280 mg
280 mg;1 mL<500 mg;X
or 1.8 mL 280 X 5 500
X 5 1.78 mL or 1.8 mL
Grams
1
3 .6 m L 3 1 g 3 500 mg 3 .6 H D 280 mg 500 mg
DA: m L 5 5 or FE: 5 5 5
1 g 3 1000 mg 3 1 2 V X 1 mL X
2
5 1 .8 m L (Cross multiply)
280 X 5 500
X 5 1.78 mL
or 1.8 mL
Answer: Tazicef 500 mg 5 ​1.8 mL
 CHAPTER 9 Injectable Preparations With Clinical Applications 163

PROBLEM 2: Order: methylprednisolone 250 mg IM 3 1 dose.

Drug available:

The drug label says to add 16 mL bacteriostatic water to reconstitute 1 g of methyl­­

prednisolone.

Change grams to milligrams (1 g 5 1000 mg).

D 250 mg
BF: 3V5 3 16 mL 5 4 mL or RP: H ; V < D ;X
H 1000 mg
1000 mg;16 mg<250 mg;X
1000 X 5 4000
X 5 4 mL
1
H D 16 mL 3 1g 3 250 mg 16
FE: 5 or DA: mL 5 5 5 4 mL
V X 1 g 3 1000 mg 3 1 4
4
1000 mg 250 mg
5
16 mL X
1000 X 5 4000
X 5 4 mL

Answer: methylprednisolone 250 mg 5 4 mL. Since the volume of the ordered drug is
greater than 3 mL, the dose should be divided into 2 mL per injection site.

MIXING OF INJECTABLE DRUGS

Drugs mixed together in the same syringe must be compatible to prevent precipitation. To determine
drug compatibility, check drug references or check with a pharmacist. When in doubt about compatibil-
ity, do not mix drugs.
The three methods of drug mixing are (1) mixing two drugs in the same syringe from two vials,
(2) mixing two drugs in the same syringe from one vial and one ampule, and (3) mixing two drugs in a
pre-filled cartridge from a vial.

u Method 1
Mixing Two Drugs in the Same Syringe From Two Vials
1. Draw air into the syringe to equal the amount of solution to be withdrawn from the first vial, and
inject the air into the first vial. Do not allow the needle to come into contact with the solution.
Remove the needle.
2. Draw air into the syringe to equal the amount of solution to be withdrawn from the second vial.
Invert the second vial and inject the air.
3. Withdraw the desired amount of solution from the second vial.
4. Change the needle unless you will use the entire volume in the first vial.
5. Invert the first vial and withdraw the desired amount of solution.
164 PART III Calculations for Oral, Injectable, and Intravenous Drugs

or
1. Draw air into the syringe to equal the amount of solution to be withdrawn, and inject the air into
the first vial. Withdraw the desired drug dose.
2. Insert a 25-gauge needle into the rubber top (not in the center) of the second vial. This acts as an air
vent. Injecting air into the second vial is not necessary.
3. Insert the needle in the center of the rubber-top vial (beside the 25-g needle–air vent), invert the
second vial, and withdraw the desired drug dose.

u Method 2
Mixing Two Drugs in the Same Syringe From One Vial and One Ampule (same “prep” as Method 1).
1. Remove the amount of desired solution from the vial.
2. Aspirate the amount of desired solution from the ampule.

u Method 3
Mixing Two Drugs in a Pre-filled Cartridge From a Vial
1. Check the drug dose and the amount of solution in the pre-filled cartridge. If a smaller dose is
needed, expel the excess solution.
2. Draw air into the cartridge to equal the amount of solution to be withdrawn from the vial. Invert the
vial and inject the air.
3. Withdraw the desired amount of solution from the vial. Make sure the needle remains in the fluid
and do not take more solution than needed.

EXAMPLES Mixing drugs in the same syringe.

PROBLEM 1: Order: meperidine (Demerol) 60 mg and atropine sulfate 0.4 mg IM.

The two drugs are compatible.
Drugs available:

Note: Meperidine is in an ampule and atropine sulfate is in a vial.

How many milliliters of each drug would you give? Explain how to mix the two drugs.
 CHAPTER 9 Injectable Preparations With Clinical Applications 165

Methods: meperidine

D 60 mg
BF: 3V5 3 1 mL 5 0.6 mL
H 100 mg
or or H 100 mg 60 mg
D
RP: H ; V < D ; X FE: 5 5 5
100 mg;1 mL<60 mg;X mL V X 1 mL X
100 X 5 60 1Cross multiply2 100 X 5 60
X 5 0.6 mL X 5 0.6 mL
or
DA: no conversion factor
1 mL 3 60 mg 60
mL 5 5 5 0.6 mL
100 mg 3 1 100
atropine SO4 5 0.4 mg

Answer: meperidine (Demerol) 60 mg 5 0.6 mL

atropine 0.4 mg 5 1 mL

Procedure: Mix two drugs in a syringe for IM injection:

1. Remove 1 mL of atropine solution from the vial.
2. Withdraw 0.6 mL of meperidine (Demerol) from the ampule into the syringe contain-
ing atropine solution.
3. Syringe contains atropine 1 mL and meperidine 0.6 mL 5 ​total 1.6 mL.

PROBLEM 2: Order: meperidine 25 mg, Vistaril 25 mg, and Robinul 0.1 mg, IM. All three drugs are
compatible.
Drugs available: meperidine (Demerol) is in a 2-mL Tubex cartridge labeled 50 mg/mL.
Hydroxyzine (Vistaril) is in a 50-mg/mL ampule. Glycopyrrolate (Robinul) is available in
a 0.2-mg/mL vial.
How many milliliters of each drug would you give?
Explain how the drugs could be mixed together.
Methods:
a. meperidine 25 mg. Label: 50 mg/mL.
D 25 mg
BF: 3V5 3 1 mL 5 0.5 mL
H 50 mg
or or H 50 mg 25 mg
D
RP: H ; V < D ; X FE: 5 5 5
50 mg;1 mL<25 mg;X mL V X 1 mL X
50 X 5 25 1Cross multiply2 50 X 5 25
X 5 1⁄2 mL or 0.5 mL X 5 0.5 mL
1
or 1 mL 3 25 mg 1
DA: mL 5 5 mL or 0.5 mL meperidine
50 mg 3 1 2
2

b. Vistaril 25 mg. Label: 50 mg/mL ampule.

D 25 mg
BF: 3V5 3 1 mL 5 0.5 mL
H 50 mg
166 PART III Calculations for Oral, Injectable, and Intravenous Drugs

or or H 50 mg 25 mg
D
RP: H ; V < D ; X FE: 5 5 5
50 mg;1 mL<25 mg;X mL V X 1 mL X
50 X 5 25 50 X 5 25
X 5 1⁄2 mL or 0.5 mL X 5 0.5 mL

c. Robinul 0.1 mg. Label: 0.2 mg/mL.

D 0.1 mg or H 0.2 mg 0.1 mg
D
BF: 3V5 3 1 mL 5 0.5 mL Robinul FE: 5 5 5
H 0.2 mg V X 1 mL X
0.2 X 5 0.1
X 5 0.5 mL
or or
1 mL 3 0.1 mg 0.1 1
RP: H ; V < D ; X DA: mL 5 5 5 or 0.5 mL
0.2 mg;1 mL<0.1 mg;X mL 0.2 mg 3 1 0.2 2
0.2 X 5 0.1
X 5 0.5 mL

Answer: meperidine (Demerol) 25 mg 5 0.5 mL; Vistaril 25 mg 5 0.5 mL; Robinul

0.1 mg 5 0.5 mL

Procedure: Mix three drugs in the cartridge:

1. Check drug dose and volume on pre-filled cartridge. Expel 0.5 mL of meperidine and
any excess of drug solution from cartridge.
2. Draw 0.5 mL of air into the cartridge and inject into the vial containing the Robinul.
3. Withdraw 0.5 mL of Robinul from the vial into the pre-filled cartridge containing
meperidine.
4. Withdraw 0.5 mL of Vistaril from the ampule into the cartridge.

PRACTICE PROBLEMS u
​ ​ III ​INTRAMUSCULAR INJECTIONS
Answers can be found on pages 181 to 187.

Round off to the nearest tenths.

1. Order: tobramycin (Nebcin) 50 mg, IM, q8h.
Drug available:

How many milliliters of tobramycin would you give?
 CHAPTER 9 Injectable Preparations With Clinical Applications 167

2. Order: methylprednisolone (Solu-Medrol) 75 mg, IM, daily.

Drug available: 125 mg/2 mL in vial.

How many milliliters would you give?
3. Order: vitamin B12 (cyanocobalamin) 300 mcg, IM, daily.
Drug available:

How many milliliters of cyanocobalamin would you give?
4. Order: naloxone 0.2 mg, IM, STAT.
Drug available:

How many milliliters would you give?
5. Order: diazepam 4 mg, IM, q6h.
Drug available:

How many milliliters would you give?
168 PART III Calculations for Oral, Injectable, and Intravenous Drugs

6. Order: cefepime HCl (Maxipime) 500 mg, IM, q12h.

Drug available:

a. Which single-dose vial of Maxipime would you select?

Explain.
b. How many milliliters (mL) of diluent should you use for reconstitution of the drug?

Note: The drug label does not indicate the amount of diluent to use. This may be found in the
drug information insert. Usually, if you inject 2.6 mL of diluent, the amount of drug solution
may be 3.0 mL. If you inject 3.4 or 3.5 mL of diluent, the amount of drug solution should
be 4.0 mL.

c. How many milliliters of drug solution should the patient receive?

7. Order: prochlorperazine (Compazine) 4 mg, IM, q8h, as needed.
Drug available:

How many milliliters should the patient receive?
8. Order: secobarbital (Seconal) 125 mg, IM, 1 hour before surgery.
Drug available: Seconal 50 mg/mL.

How many milliliters would you give?
 CHAPTER 9 Injectable Preparations With Clinical Applications 169

9. Order: thiamine HCl 75 mg, IM, daily.

Drug available: 100 and 200 mg/mL vials.

a. Which vial would you use?

b. How many milliliters would you give?
10. Order: hydroxyzine (Vistaril) 25 mg, deep IM, STAT.
Drug available: Vistaril 100 mg/2 mL in a vial.

How many milliliters would you give?
11. Order: loxapine HCl (Loxitane) 25 mg, IM, q6h until desired response and then 50 mg.
Drug available:

How many milliliters would you administer intramuscularly for the initial dose?
12. Order: penicillin G potassium (Pfizerpen) 250,000 units, IM, q6h.
Drug available:

a. S
 elect the appropriate dilution for the ordered dose. How many milliliters of diluent would
you add?
b. How many milliliters should the patient receive per dose?
13. Order: cefonicid (Monocid) 750 mg, IM, daily.
Drug available:

Change grams to milligrams (3 spaces to the right) or milligrams to gram (3 spaces to the left).
1.000 g 5 1000 mg or 1000 mg 5 1 g
N N
a. How many gram(s) is 750 mg, IM, daily?
b. How many milliliters of diluent should be injected into the vial (see drug label)?
c. How many milliliters of cefonicid (Monocid) should the patient receive per day?
170 PART III Calculations for Oral, Injectable, and Intravenous Drugs

14. Order: meperidine (Demerol) 35 mg and promethazine (Phenergan) 10 mg, IM.

Drugs available: meperidine 50 mg/mL in an ampule; promethazine 25 mg/mL in an ampule.

a. How many milliliters of meperidine would you give?

b. How many milliliters of promethazine would you give?
c. Explain how the two drugs should be mixed.

15. Order: meperidine (Demerol) 50 mg and atropine sulfate 0.3 mg, IM.
Drugs available:

  
a. How many milliliters of meperidine would you give?
b. How many milliliters of atropine would you give?
c. Explain how the two drugs should be mixed.

16. Order: codeine phosphate 20 mg IM 3 1 dose.
Drug available:

How many milliliters would the patient receive?
 CHAPTER 9 Injectable Preparations With Clinical Applications 171

17. Order: heparin 2500 units, subcut, q6h.

Drug available:

  
a. Which drug vial would you use?
b. How many milliliters of heparin would you give?
18. Order: chlordiazepoxide HCl (Librium) 50 mg, IM, STAT.
Drug available: Librium (100 mg) powder in ampule.
Add 2 mL of special intramuscular diluent to the ampule. When diluted, the powder content may
increase the volume.

How many milliliters would be equivalent to 50 mg?

Explain.
19. Order: cefamandole (Mandol) 500 mg, IM, q6h.
Drug available:

a. Change milligrams to grams (see Chapter 1).

b. How many milliliters of diluent would you add (see drug label)?
c. What size syringe would you use?
d. How many milliliters should the patient receive?
172 PART III Calculations for Oral, Injectable, and Intravenous Drugs

20. Order: ticarcillin (Ticar), 400 mg, IM, q6h.

Drug available:

a. Drug label reads to add 2 mL of diluent. Total volume of solution is

b. How many milliliters of ticarcillin should be withdrawn?
21. Order: morphine 10 mg IM, STAT.
Drug available:

How many milliliters of morphine would you give?
22. Order: hydroxyzine (Vistaril) 25 mg, deep IM, q4–6h, PRN for nausea.
Drug available:

How many milliliters should the patient receive per dose?
 CHAPTER 9 Injectable Preparations With Clinical Applications 173

23. Order: Decadron (dexamethasone) 2 mg, IM, q6h.

Adult parameters: 0.75–9 mg/day in 2 to 4 divided doses.
Drug available:

a. Is the dose according to adult parameters?

b. How many milliliters would you give?
c. What type of syringe could be used?
d. Can the Decadron vial be used again? Explain.
24. Order: ceftazidime (Fortaz) 500 mg, IM, q8h.
Add 2 mL of diluent 5 2.6 mL drug solution. Check the drug information insert.
Drug available:

a. How many gram(s) of ceftazidime (Fortaz) should the patient receive per day?

b. How many milliliters of ceftazidime would you give per dose?

25. Order: streptomycin sulfate 1500 mg IM 3 1 dose.
Drug available:

Change milligrams to grams or change grams to milligrams

1500 mg 5 1.5 g or 5 g 5 5000 mg
a. How many milliliters of diluent would you add to the vial?
b. How many milliliters would the patient receive?
174 PART III Calculations for Oral, Injectable, and Intravenous Drugs

26. Order: diazepam 8 mg, IM, STAT and repeat in 4 hours if necessary.
Drug available:

  
a. Which ampule or vial of diazepam would you select?
b. How many milliliters (mL) of diazepam should the patient receive?
27. Order: benztropine mesylate (Cogentin) 1.5 mg, IM, daily.
Drug available:

How many milliliters (mL) of Cogentin should the patient receive?
28. Order: cefotaxime Na (Claforan) 750 mg, IM, bid.
Drug available: Pamphlet states to add 3 mL of diluent equal 3.4 mL.

a. 1 g 5 mg
b. How many milligrams should the patient receive per day?
c. How many milliliters would you give per dose?
29. Order: diphenhydramine HCl 30 mg, IM, STAT.
Drug available:

How many milliliters should the patient receive?
 CHAPTER 9 Injectable Preparations With Clinical Applications 175

30. Order: interferon alfa-2b (Intron A) 10 million international units IM 3 3 week.

Drug available: interferon alfa-2b (Intron A) 25 million international units/5 mL vials.

How many milliliters would you give per dose?
31. Order: vitamin K (AquaMEPHYTON) 2.5 mg IM 3 1.
Drug available:

How many milliliters would you give?
32. Order: ampicillin/sulbactam (Unasyn) 1 g, IM, q8h.
Drug available:
(add 3.6 mL of diluent to the vial; drug and diluent equals 4 mL)

a. Unasyn 3 g vial equals .

b. How many milliliters of Unasyn would you give every 8 hours? .
Questions 33 through 38 relate to additional dimensional analysis. Refer to Chapter 6.
33. Order: droperidol 2 mg, IM, STAT.
Drug available: droperidol 5 mg/2 mL.
Factors: 5 mg/2 mL; 2 mg/1
Conversion factor: none; order and drug are both available in milligrams.

How many milliliters of droperidol should be given?
34. Order: dexamethasone 5 mg, IM, daily.
Drug available:

How many milliliters should be administered daily?
176 PART III Calculations for Oral, Injectable, and Intravenous Drugs

35. Order: levothyroxine (Synthroid) 100 mcg, IM, STAT then 0.025 mg, po, daily.
Drug available: levothyroxine 200 mcg/mL for IM; levothyroxine 12.5 mcg/tablet, po

a. How many milliliters would you give IM?

b. How many tablets would you give per dose?
36. Order: cefobid 500 mg, IM, q6h.
Add 2 mL of diluent to equal 2.4 mL solution.
Drug available:

a. Cefobid 1 g 5 __________ mL; 500 mg 5 __________ mL

Conversion factor: 1 g 5 1000 mg
b. How many milliliters of Cefobid would you give?
37. Order: ceftriaxone 1000 mg, IM, daily.
Drug available:

a. How many milliliters diluent would you add to the vial?

b. What is the reconstituted concentration for IM use?
c. How many milliliters of ceftriaxone would you give?
 CHAPTER 9 Injectable Preparations With Clinical Applications 177

38. Order: cefazolin (Ancef ) 0.25 g, IM, q12h.

Drug available: 2.0 mL of diluent = 2.2 mL

Note: Change grams to milligrams; drug label is in milligrams.

How many milliliters of Ancef would you give?
Questions 39 through 42 relate to drug dosage per body weight.
39. Order: amikacin (Amikin) 15 mg/kg/day, q8h, IM.
Drug available:

Patient weighs 140 pounds.
a. How many kilograms does the patient weigh?
b. How many milligrams should the patient receive daily?
c. How many milligrams should the patient receive q8h (three divided doses)?

d. How many milliliters should the patient receive q8h?
40. Order: netilmicin sulfate (Netromycin) 2 mg/kg, q8h, IM.
Patient weighs 174 pounds.
Drug available: netilmicin 100 mg/mL.

a. How many kilograms does the patient weigh?

b. How many milligrams should the patient receive daily?
c. How many milligrams should the patient receive q8h?
d. How many milliliters should the patient receive q8h?
178 PART III Calculations for Oral, Injectable, and Intravenous Drugs

41. Order: midazolam HCl (Versed) 0.07 mg/kg, IM before general anesthesia.
Patient weights: 156 pounds.
Drug available:

a. How many kilograms does the patient weigh?

b. How many milligrams should the patient receive?
c. How should midazolam be administered?
42. Order: Robinul 4 mcg/kg, IM 3 1 dose.
Drug available:

Patient weighs 72 kilograms.
a. How many milligrams should the patient receive?
b. How many milliliters should the patient receive?
 CHAPTER 9 Injectable Preparations With Clinical Applications 179

43. Order: Lasix 0.5 mg/kg, IM, bid.

Drug available:

Patient weighs 130 pounds.
a. How many kilograms does the patient weigh?
b. How many milligrams should the patient receive per day?
c. How many milligrams should the patient receive every 12 hours?
d. How many milliliters per dose should the patient receive?

ANSWERS
I Needles

1. The 21-gauge needle because it is the smaller gauge number.

2. The 26-gauge needle because it is the larger gauge number.
3. The 20-gauge needle because it has the larger lumen (smaller gauge). A needle with a 20-gauge and 11⁄2-inch
length is used for IM injection.
4. The 25-gauge needle, because it has the smaller lumen (larger gauge). It is used for subcutaneous injections. The
needle is not long enough for an IM injection.
5. The 21-gauge needle with 11⁄2-inch length (21 g/11⁄2 inch). Muscle is under subcutaneous or fatty tissue, so a
longer needle is needed.

II Subcutaneous Injections

1. Both needle gauge and length combinations could be used.

2. a. 0.4 mL
b. 45- to 90-degree angle. The angle depends on the amount of fatty tissue in the patient.
3. 3⁄4 mL or 0.75 mL
3
D 30 mg 1.2 or
4. BF: 3V5 3 0.4 mL 5 RP: H ; V < D ; X
H 40 mg 4
4
5 0.3 mL of Lovenox 40 mg;0.4 mL<30 mg;X mL
H D 40 mg 30 40 X 5 12
FE: 5 5 5 5 X 5 0.3 mL
V X 0.4 mg X
1Cross multiply2 40 X 5 12 or 0.4 mL 3 30 mg 12
X 5 0.3 mL of Lovenox DA mL 5 5 5 0.3 mL
40 mg 3 1 40
180 PART III Calculations for Oral, Injectable, and Intravenous Drugs

D 0.6 mg 0.6
5. BF: 3V5 3 1 mL 5 5 1.5 mL
H 0.4 mg 0.4
or
RP: H ; V < D ; X
0.4 mg;1 mL<0.6 mg;X mL
0.4 X 5 0.6
0.6
X5 5 1.5 mL
0.4
or 1 mL 3 0.6 mg 0.6
DA: mL 5 5 5 1.5 mL
0.4 mg 3 1 0.4
6. a. 50 units/kg 3 65 kg 5 3250 units
D 3250 units
b. 3V5 3 1 5 0.325 mL
H 10,000 units
or
H ; V < D ;X
10,000 units;1 mL<3250 units;X
10,000 X 5 3250
X 5 0.325 mL
Answer: Epogen 3250 units 5 0.325 mL or
0.33 mL
7. a. 198 lb 4 2.2 kg 5 90 kg
b. 90 kg 3 6 mcg/kg 5 540 mcg
D 540 mcg
c. 3V5 3 1 mL 5 1.8 mL
H 300 mcg
Answer: Neupogen 540 mcg 5 1.8 mL
d. Drug can be prepared in two syringes, one with 1 mL, and the other with 0.8 mL. With subcutaneous
injections, one (1) mL is given per site unless the person weighs more than 200 lb or the dose has been
approved by the health care provider.
8. a. Select 80 mg per 0.8 mL Lovenox.
7
D 70 mg 5.6
b. BF: 3V5 3 0.8 mL 5 5 0.7 mL of Lovenox
H 80 mg 8
8
or H 80 mg 70 mg
D
FE: 5 5 5
V X 0.8 mL X
1Cross multiply2 80 X 5 56
X 5 0.7 mL of Lovenox
7
or 0.8 mL 3 70 mg 5.6
DA: mL 5 5 5 0.7 mL of Lovenox
80 mg 3 1 8
8

D 8 mg or
9. BF: 3V5 3 1 mL 5 0.53 mL or 0.5 mL RP: H ; V < D ;X
H 15 mg
15 mg ; 1 mL < 8 mg ; X
or H 15 X 5 8
D 15 mg 8 mg
FE: 5 5 5 X 5 0.53 mL or 0.5 mL
V X 1 mL X
1Cross multiply2 15 X 5 8
X 5 0.53 mL or 0.5 mL
 CHAPTER 9 Injectable Preparations With Clinical Applications 181

10. a. 120 units 3 65 kilograms 5 7800 units

D 7800 Iunits 3120
b. BF: 3V5 3 0.4 mL 5 5 0.3 mL subcut
H 10,000 Iunits 10,000
or
RP: H ; V < D ;X
10,000 Iunits;0.4 mL<7800 Iunits;X
10,000 X 5 3120
X 5 0.3 mL

III Intramuscular Injections (Round off in tenths)

D 50 mg 100
1. BF: 3V5 3 2 mL 5 5 1.25 mL or 1.3 mL
H 80 mg 80
or or H 80 mg 50 mg
D
RP: H ; V < D ; X FE: 5 5 5 5
80 mg;2 mL<50 mg;X mL V X 2 mL X
80 X 5 100 1Cross multiply2 80 X 5 100
100 X 5 1.25 or 1.3 mL
X5 5 1.25 mL or 1.3 mL
80
or
DA: no conversion factor
5
2 mL 3 50 mg 10
mL 5 5 5 1.25 mL or 1.3 mL
80 mg 3 1 8
8
Answer: tobramycin 50 mg 5 1.25 mL or 1.3 mL
3
D 75 mg 6
2. BF: 3V5 3 2 mL 5 5 1.2 mL
H 125 mg 5
5
or
RP:  H ; V < D ; X
125 mg;2 mL<75 mg;X mL
125 X 5 150
X 5 1.2 mL
Answer: methylprednisolone 75 mg 5 ​1.2 mL
3. 0.3 mL of vitamin B12 (cyanocobalamin)
4. 0.5 mL of naloxone (Narcan)
4 mg or H 10 mg 4 mg
D 8 D
5. BF: 3V5 3 2 mL 5 5 0.8 mL diazepam FE: 5 5 5
H 10 mg 10 V X 2 mL X
RP: H ; V < D ;X 1Cross multiply2 10 X 5 8
10 mg;2 mL<4 mg;X X 5 0.8 mL of diazepam
10 X 5 8 or
X 5 0.8 mL of diazepam DA: no conversion factor
2
2 mL 3 4 mg 4
mL 5 5 5 0.8 mL of diazepam
10 mg 3 1 5
5
182 PART III Calculations for Oral, Injectable, and Intravenous Drugs

6. a. Select the Maxipime 1-g vial. The Maxipime 2-g vial is for intravenous use according to the drug label and
cannot be used for intramuscular injection.
b. Using 2.6 mL diluent 5 3.0 mL of solution
c. Change 500 mg to 0.5 g or 1 g to 1000 mg
D 0.5 g
BF: 3V5 3 3 mL 5 1.5 mL of cefepime twice a day
H 1g
D 4 mg 4
7. BF: 3V5 3 1 mL 5 5 0.8 mL of compazine
H 5 mg 5
or or H 5 mg 4 mg
D
RP:  H ; V < D ; X FE: 5 5 5 55X54
V X 1 mL X
5 mg;1 mL<4 mg;X
1Cross multiply2 X 5 0.8 mL
5 X 5 4
or
X 5 0.8 mL 1 mL 3 4 mg 4
DA: mL 5 5 5 0.8 mL
5 mg 3 1 5
8. 2.5 mL of secobarbital
9. a. 100-mg vial
b. 0.75 mL of thiamine
10. 1⁄2 or 0.5 mL of hydroxyzine
11. 0.5 mL (1⁄2 mL) of Loxitane
12. a. 4.0 mL of diluent 5 1,000,000 units (drug label)
1
D 250,000 units 4
b. BF: 3V5 3 4 mL 5 5 1 mL Pfizerpen
H 1,000,000 units 4
4
DA: 1 million units 5 1,000,000 units
1
4 mL 3 250,000 units 4
mL 5 5 5 1 mL of Pfizerpen
1,000,000 units 3 1 4
4
13. a. 750 mg of cefonicid (Monocid) is equivalent to 0.75 g.
b. Drug label indicates that 2.5 mL of diluent should be added to the drug powder, which yields 3.1 mL of
drug solution.
D 0.75 g
c. 3V5 3 3.1 mL
H 1g
5 2.33 mL or 2.3 mL of cefonicid solution
14. a. meperidine 35 mg 5 0.7 mL
b. promethazine 10 mg 5 0.4 mL
c. Procedure: 1. Obtain 0.7 mL of meperidine from the ampule and 0.4 mL of promethazine from the ampule.
2. ​Discard the remaining solutions within the ampules.
15. a. meperidine 50 mg 5 1⁄2 or 0.5 mL
b. atropine 0.3 mg 5 0.75 or 0.8 mL (Round off in tenths)
Atropine
D 0.3 mg
BF: 3V5 3 1 mL 5 0.75 or 0.8 mL
H 0.4 mg
 CHAPTER 9 Injectable Preparations With Clinical Applications 183

or or
Atropine Atropine
RP: H ; V < D ; X H D 0.4 mg 0.3 mg
0.4 mg;1 mL<0.3 mg;X mL FE: 5 5 5 5
V X 1 mL X
0.4 X 5 0.3 0.4 X 5 0.3
0.3 X 5 0.75 or 0.8 mL
X5 5 0.75 or 0.8 mL
0.4
Meperidine
1
1 mL 3 50 mg 1
DA: mL 5 5 or 0.5 mL
100 mg 3 1 2
2
c. 1. ​The two drugs are compatible.
2. ​Inject 0.75 (0.8) mL of air into the atropine vial.
3. ​Inject 0.5 mL of air into the meperidine vial and withdraw 0.5 mL of meperidine.
4. ​Withdraw 0.8 mL of atropine from the atropine vial. Discard both vials.
D 20 mg or
16. BF: 3V5 3 1 mL 5 0.66 or 0.7 mL RP: H ; V < D ; X
H 30 mg
30 mg ; 1 mL < 20 mg ; X
or 30 X 5 20
RP: H ; V < D ; X X 5 0.66 or 0.7 mL
30 mg;1 mL<20 mg;X
30 X 5 20
X 5 0.66 or 0.7 mL
17. a. Use either heparin vial; 5000 units/mL or 10,000 units/mL
b. 0.5 mL of heparin (units 5000); 0.25 mL of heparin (units 10,000)
18. Librium 50 mg 5 1 mL (100 mg 5 2 mL)
After adding 2 mL of diluent, withdraw the entire drug solution to determine the total volume of drug solu-
tion. Expel half of the solution; the remaining drug solution is equivalent to chlordiazepoxide (Librium) 50 mg.
19. a. Change milligrams to grams by moving the decimal point three spaces to the left: 500. mg 5 0.5 g.
N
Because the drug weight on the label is in grams, the conversion is to grams. However, the drug can be con-
verted to milligrams by changing grams to milligrams (moving the decimal point three spaces to the right):
1 g 5 1.000 mg 5 1000 mg.
N
b. Drug label states to add 3 mL of diluent and, after it is reconstituted, the drug solution will be 3.5 mL.
Mandol 1 g 5 3.5 mL.
c. A 5-mL syringe is preferred: however, a 3-mL syringe can be used because less than 3 mL of the drug solu-
tion is needed.
D 0.5 g
d. BF: 3V5 3 3.5 mL 5 1.75 or 1.8 mL
H 1g
or
RP: H ; V < D ; X
1000 mg;3.5 mL<500 mg;X mL
1000 X 5 1750
X 5 1.75 or 1.8 mL
or 3.5 mL 3 0.5 g
DA: mL 5 5 1.75 or 1.8 mL
1g 3 1
Answer: cefamandole (Mandol) 500 mg 5 1.8 mL
184 PART III Calculations for Oral, Injectable, and Intravenous Drugs

20. Change 400 milligrams to grams

400 mg 5 0.400 g or 0.4 g
N
a. Total volume of drug solution is 2.6 mL; see drug label.
D 0.4 g
b. BF: 3V5 3 2.6 5 1 mL
H 1g
or or H 1g 0.4 g
D
RP: H ; V < D ; X FE: 5 5 5 5
1 g;2.6 mL<0.4 g;X mL V X 2.6 mL X
1Cross multiply2 X 5 1.04 mL or 1 mL
X 5 2.6 3 0.4
X 5 1 mL or 2.6 mL 3 0.4 g
ticarcillin 400 mg or 0.4 g 5 1 mL DA 5 5 1.04 mL or 1 mL
1g31
2
D 10 mg 2
21. BF: 3V5 3 1 mL 5 5 0.66 or 0.7 mL
H 15 mg 3
3
or
FE:  H ; V < D ; X
15 mg;1 mL<10 mg;X mL
15 X 5 10
X 5 0.66 or 0.7 mL
22. 0.5 mL of Vistaril
23. a. Yes, 8 mg per day
1 1
D 2 mg or 1 mL 3 2 mg
b. BF: 3V5 3 1 mL 5 1⁄2 or 0.5 mL DA: mL 5 5 1⁄2 or 0.5 mL
H 4 mg 4 mg 3 1
2 2
c. 3-mL syringe
d. Yes, the vial has a rubber top that is self-sealing.
24. a. Change milligrams to grams; move the decimal point three spaces to the left: 500. mg 5 0.5 g
N
0.5 g 3 3 (q8h) 5 1.5 g per day
b. Add 2 mL of diluent to yield 2.6 mL (check drug information insert):
D 0.5 g
BF: 3V5 3 2.6 mL 5 1.3 mL per dose
H 1g
25. a. Add 9 mL of diluent to yield 10 mL after dilution
3
D 1500 mg 30
b. BF: 3V5 3 10 mL 5 5 3 mL
H 5000 mg 10
10
or H D 5000 mg 1500 mg
FE:
5 5 5
V X 10 mL X
1Cross multiply2 5000 X 5 15,000


X 5 3 mL
26. a. Either the ampule or the vial could be used. The diazepam 5 mg/mL is a multiple-dose vial that contains 10
mL of drug solution.
8 mg 8 mg
b. BF: Ampule: 3 2 mL 5 1.6 mL of diazepam BF: Vial: 3 1 mL 5 1.6 mL of diazepam
10 mg 5 mg
4
or or
2 mL 3 8 mg 8 1 mL 3 8 mg 8
DA: Ampule: mL 5 5 5 1.6 mL DA: Vial: mL 5 5 5 1.6 mL
10 mg 3 1 5 5 mg 3 1 5
5
 CHAPTER 9 Injectable Preparations With Clinical Applications 185

D 1.5 mg 1
27. 3V5 3 2 mL 5 1.5 mL of Cogentin
H 2 mg
1
28. a. 1 g 5 1000 mg
b. 750 mg 3 2 5 1500 mg of cefotaxime Na per day
3
D 750 mg 10.2
c. BF: 3V5 3 3.4 mL 5 5 2.55 mL or 2.6 mL of cefotazime Na 1rounded off in tenths2
H 1000 mg 4
4
3
3.4 mL 3 750 mg 10.2
DA: mL 5 5 5 2.55 mL or 2.6 mL of cefotazime Na 1rounded off in tenths2
1000 mg 3 1 4
4
29. RP: H ; V < D ; X
50 mg;1 mL<30 mg;X
50 X 5 30
X 5 0.6 mL of diphenhydramine HCl
H D 50 mg 30 mg
FE: 5 5 5
V X 1 mL X
1Cross multiply2 50 X 5 30
X 5 0.6 mL of diphenhydramine HCl
D 10 50 or
30. BF: 3V5 355 5 2 mL RP: H ; V < D ; X
H 25 25
25 million units;5 mL<10 million units;X mL
25 X 5 50
X 5 2 mL
Answer: Intron A 2 mL three times a week
D 2.5 mg
31. BF: 3V5 3 1 mL 5 0.25 mL or 0.3 mL
H 10 mg
or or H 10 mg 2.5 mg
D
RP: H ; V < D ;X FE: 5 5 5 5
10 mg;1 mL<2.5 mg;X V X 1 mL X
10 X 5 2.5 10 X 5 2.5
X 5 0.25 mL or 0.3 mL
or X 5 0.25 mL or 0.3 mL
DA: no conversion factor
1
1 mL 3 2.5 mg 1
mL 5 5 or 0.25 mL
10 mg 3 1 4
4
Answer: AquaMEPHYTON 2.5 mg 5 0.25 mL or 0.3 mL
32. a. 4 mL 5 3 g
D 1g 4 or
b. BF: 3V5 3 4 mL 5 5 1.3 mL of Unasyn RP: H : V :: D : X
H 3g 3
3 g : 4 mL :: 1 g : X mL
3X54
X 5 1.3 mL of Unasyn
2 mL 3 2 mg 4
33. DA: mL 5 5 5 0.8 mL of droperidol
5 mg 3 1 5

1 mL 3 5 mg 5
34. DA: mL 5 5 5 1.25 mL or 1.3 mL of dexamethasone 1rounded off in tenths2
4 mg 3 1 4
186 PART III Calculations for Oral, Injectable, and Intravenous Drugs

1
1 mL 3 100 mcg
35. DA: a: mL 5 5 0.5 or 1⁄2 mL of levothyroxine
200 mcg 3 1
2
DA: b: Conversion factor: 1 mg 5 1000 mcg
80
1 tablet 3 1000 mcg 3 0.025 mg
Tablet 5 5 80 3 0.025 5 2 tablets of levothyroxine
12.5 mcg 3 1 mg 3 1
1
36. a. 1 g 5 2.4; 500 mg 5 1.2 mL
1
2.4 mL 3 1g 3 500 mg 2.4
b. DA: mL 5 5 5 1.2 mL
1 g 3 1000 mg 3 1 2
2
Give 1.2 mL of Cefobid
37. a. 4.2 mL
b. 350 mg/mL
D 1000 mg or
c. BF: 3V5 3 1 mL 5 2.85 mL or 2.9 mL RP: H ; V < D ;X
H 350 mg
350 mg ; 1 mL < 1000 mg ; X
350 X 5 1000
X 5 2.85 mL or 2.9 mL
or H 350 mg 1000 mg or
D 1 mL 3 1000 mg
FE: 5 5 5 DA: mL 5 5 2.85 mL or 2.9 mL
V X 1 mL X 350 mg 3 1
1Cross multiply2 350 X 5 1000
X 5 2.85 mL or 2.9 mL
38. 0.25 g 5 0.250 mg (250 mg)
N
a. Give 1.1 mL of Ancef.
39. a. 140 4 2.2 5 63.6 kg
b. 15 mg 3 63.6 3 1 5 954 mg daily
c. 954 4 3 5 318 mg of amikacin q8h
D 318 mg 636 or H
d. BF: 3V5 325 5 1.27 or 1.3 mL D 500 mg 318 mg
H 500 mg 500 FE: 5 5 5 5
V X 2 mL X mL
or 1Cross multiply2 500 X 5 636
RP: H ; V < D ; X
X 5 1.27 or 1.3 mL
500 mg;2 mL<318 mg;X mL
500 X 5 636
X 5 1.27 or 1.3 mL 1tenths2
or
2 mL 3 318 mg 636
DA: mL 5 5 5 1.3 mL per dose
500 mg 3 1 500
Answer: give 1.27 or 1.3 mL of amikacin q8h (three times a day)
 CHAPTER 9 Injectable Preparations With Clinical Applications 187

40. a. 174 4 2.2 5 79.1 kg

b. 2 mg 3 79.1 5 158.2 or 158 mg daily
c. 158 4 3 5 52.6 mg or 50 mg q8h (Round off to a number that can be administered; check with your
institution)
5
D 50 mg 5
d. BF: 3V5 3 1 mL 5 5 0.5 mL
H 100 mg 10
10
or or H 100 mg 50 mg
D
RP: H ; V < D ; X FE: 5 5 5 5
100 mg;1 mL<50 mg;X mL V X 1 mL X mL
100 X 5 50 100 X 5 50
X 5 0.5 mL
or X 5 0.5 mL
1
1 mL 3 50 mg 1
DA: mL 5 5 or 0.5 mL
100 mg 3 1 2
2
Answer: netilmicin 50 mg 5 0.5 mL
41. a. 156 pounds = 70.9 or 71 kg
b. 0.07 mg 3 71 kg = 4.97 mg or 5 mg (rounded off )
c. Administered IM in two syringes at two sites, 2.5 mL in each syringe unless otherwise instructed
42. a. 4 mcg 3 72 kg 5 288 mcg or 0.288 mg or 0.3 mg
Move the decimal place three places to the left to convert mcg to mg.
D 0.3 mg 0.6 or H
b. BF: 3V5 3 2 mL 5 5 1.5 mL of Robinul D 0.4 mg 0.3 mg
H 0.4 mg 0.4 FE: 5 5 5
V X 2 mL X
1Cross multiply2 0.4 X 5 0.6
X 5 1.5 mL
43. a. 130 lb 5 59 kg
b. 59 milligrams per day
c. 29.5 milligrams per dose
D 29.5 mg or
d. BF: 3V5 3 4 mL 5 2.95 mL or 3 mL RP: H ; V < D ;X
H 40 mg
350 mg ; 4 mL < 29.5 mg ; X
40 X 5 118
X 5 2.95 mL or 3 mL
or H 40 mg 29.5 mg or
D 4 mL 3 29.5 mg
FE: 5 5 5 DA: mL 5 5 2.95 mL or 3 mL
V X 4 mL X 40 mg 3 1
1Cross multiply2 40 X 5 118
X 5 2.95 mL or 3 mL

Additional practice problems are available in the Basic Calculations and Advanced
Calculations sections of Drug Calculations Companion, version 5 on Evolve.
CHAPTER 10
Insulin Administration

Objectives • Identify the different types of insulin.

• Determine prescribed insulin dosage in units using an insulin syringe.
• Describe the sites and angle for administering insulin.
• Explain the methods for mixing two insulin solutions in one insulin syringe.
• Explain the various methods of insulin administration, such as insulin pens, insulin pump.

Outline INSULIN SYRINGES

INSULIN BOTTLES
SITES AND ANGLES FOR INSULIN INJECTIONS
TYPES OF INSULIN
MIXING INSULINS
INSULIN PEN DEVICES
INSULIN PUMPS

Insulin is secreted from pancreatic beta cells to help regulate blood glucose levels. Diabetes mellitus rep-
resents an insulin deficiency, and is characterized as either type 1 or type 2. The pancreatic beta cells in
patients with type 1 do not secrete insulin, requiring patients to subcutaneously administer insulin to
regulate glucose metabolism. Patients with type 2 secrete an insufficient amount of insulin to match
glucose load, often necessitating the use of oral antidiabetic medications and/or subcutaneous insulin.
Insulin was obtained from beef and pork pancreases when it first became available in 1925. Synthetic
human insulin (Humulin) first became available in the 1980s, and largely replaced beef and pork insulin
in the United States. Beef insulin has not been available since 1998 due to allergy concerns. Although
pork and human insulin are similar, pork insulin has not been available in the United States since Decem-
ber 2005 but may still be imported. The development of insulin analogs with different onsets and dura-
tions of action provides more options for patients today.

INSULIN SYRINGES

Insulin syringes have a capacity of 0.5 to 1 mL. Insulin is measured in units, using an insulin syringe.
Insulin dosage must NOT be calculated in milliliters. The insulin syringe is calibrated as 2 units and 100
units equal 1 mL syringe. The insulin syringe is usually marked on one side in even units (10, 20, 30) and
on the other side in odd units (5, 15, 25) (Figure 10-1).
Insulin syringes are available in 3⁄10-, 1⁄2-, and 1-mL sizes. The 1-mL insulin syringe may be purchased
with a permanently attached needle or a detachable needle (Figure 10-2).

188
 CHAPTER 10 Insulin Administration 189

Figure 10-1 ​Insulin syringe.

D
Figure 10-2 ​Four types of insulin syringes: A, 3⁄10-mL insulin syringe with a permanently attached needle. B, 1⁄2-mL insulin
syringe with a permanently attached needle. C, 1-mL insulin syringe with a permanently attached needle. D, 1-mL insulin
syringe with a detachable needle. (From Becton, Dickinson and Company, Franklin Lakes, N.J.)

INSULIN BOTTLES

Insulin is prescribed and measured according to U.S. Pharmacopeia (USP) units. Most insulins are pro-
duced in concentrations of 100 units/mL. Insulin should be administered with an insulin syringe that is
calibrated to correspond with the 100 units of insulin bottle. DO NOT use a tuberculin syringe. The
insulin bottle and syringe are color-coded “orange” to avoid medication errors.
Insulin is ordered in units. For example, if the prescribed insulin dosage is 30 units, withdraw 30 units
from the bottle of 100 units of insulin usig a 100-unit calibrated insulin syringe (Figure 10-3).
190 PART III Calculations for Oral, Injectable, and Intravenous Drugs

0
10 ITS
90 UN
U 100 80
NPH 70
Insulin 60 95
50 85
40 75
30 65
20 55
10 45
35
25
15
5

Figure 10-3 ​Unit-100 insulin bottle and unit-100 insulin syringe.

SITES AND ANGLES FOR INSULIN INJECTIONS

Insulin is a protein that can be given only by injection. Gastrointestinal (GI) secretions destroy the insu-
lin structure. Figure 10-4 indicates the sites for insulin injection. People who inject their insulin usually
use sites 3, 4, 5, or 6. Caregivers or health care workers who administer insulin usually use sites 1 or 2
(upper arm or the deltoid area).

C AUT I O N
• DO NOT administer insulin with a tuberculin syringe.

Figure 10-4 Sites for insulin injection. (From Kee, J. L., Hayes, E. R.,
& McCuistion, L. E. [2015]. Pharmacology: a patient-centered nurs-
ing process approach. 8th ed., Philadelphia: Elsevier.)
 CHAPTER 10 Insulin Administration 191

Insulin is administered at a 45- or 90-degree angle into the subcutaneous tissue. The subcutaneous
absorption rate of insulin is slower because there are fewer blood vessels in the fatty tissue than in the
muscular tissue. For an obese person, the angle may be 90 degrees, and for a very thin person the angle
may be 45 degrees.

TYPES OF INSULIN

Insulin is categorized as rapid-acting, fast-acting, intermediate-acting, long-acting, and as commercial

premixed insulin. The following drug labels (Figure 10-5) are arranged according to insulin action.

Rapid-Acting Insulins

Rapid-Acting Insulins

(From Novo (Product images and trademarks are the

Nordisk, Inc., property of and used with the permission
Princeton, N.J.) of sanofi-aventis U.S. LLC, Bridgewater,
Fast-Acting InsulinsN.J. as of September, 2015.)

Fast-Acting Insulins

Intermediate-Acting Insulins

Intermediate-Acting Insulins

Figure 10-5 Types of insulins. (From Novo Nordisk Inc., Princeton, N.J.)
192 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Long-Acting Insulins Long-Acting Insulins

Long-Acting Insulins

(From Novo (Product images and trademarks are the property

Nordisk, Inc., of and used with the permission of sanofi-aventis
Princeton, N.J.) U.S. LLC, Bridgewater, N.J. as of September, 2015.)
Combinations: Rapid- and Intermediate-Acting
Combinations: Rapid-
Insulins
and Intermediate-Acting Insulins
Combinations: Rapid- and Intermediate-Acting Insulins

Fast- and Intermediate-Acting Fast-

Insulins
and Intermediate-Acting Insulins
Fast- and Intermediate-Acting Insulins

Figure 10-5 (cont’d) Types of insulins. (Lantus from sanofi-aventis U.S. Inc., Bridgewater, N.J.)
 CHAPTER 10 Insulin Administration 193

Insulins have various descriptions, including color, action, source, and manufacturer. They are either
clear (regular or crystalline insulin) or cloudy (NPH) because of the substance, protamine, used to
prolong the action of insulin in the body. Only clear (regular) insulin can be given IV as well as
subcutaneously.
Insulin action is broken down into onset, peak, and duration. Onset is how long it takes the insulin
to begin working. Peak is when the insulin is working most effectively, and duration is how long the
insulin remains effective. Additionally, insulins are either DNA recombinant or analogs. Since 2005
only human insulin has been available in the United States. Human insulin is DNA recombinant and
is manufactured; it does not come from cadavers. Analog insulin is human insulin that has been manip-
ulated to change the action. The three insulin manufacturers are Eli Lilly, NovoNordisk, and Sanofi-
Aventis. Humulin and Novolin are examples of brand names of insulins.
Insulin is categorized as rapid-acting, fast-acting, intermediate-acting, long-acting, and commercial
premixed insulin (see Figure 10-5). Insulin is prescribed in units and administered in units. The first
rapid-acting insulin, Humalog (lispro insulin), was approved for use in 1996. Lispro (Humalog) and
the new rapid-acting insulins, aspart and glulisine, act faster than regular insulin and thus can be
administered 5 to 15 minutes before mealtime, whereas regular insulin is given 30 minutes before
meals. Rapid-acting insulins can become effective within 5 to 15 minutes of injection and last 3 to
5 hours. Lispro insulin (Humalog) is formed by reversing two amino acids in human regular insulin
(Humulin R). Aspart insulin (NovoLog) is an analog of human insulin with a rapid onset. It is struc-
tured identically to human insulin except for one amino acid. Glulisine insulin (Apidra), like aspart
insulin, is a synthetic analog of natural human insulin (see Table 10-1 and Figure 10-5). Rapid-acting
(Aspart, Apidra, and Humalog) and fast-acting (regular) insulins can be given intravenously as
well as subcutaneously. Intermediate-acting and long-acting insulins can ONLY be administered
subcutaneously.
Fast-acting insulin (regular insulin) is also clear but takes longer to start working compared with
rapid-acting insulins. It is administered 30 minutes before meals and is effective for 6 to 8 hours. If it
is given during or after the meal, the patient may experience low blood sugars. Fast-acting insulin is
known as regular or R insulin. Humulin R and Novolin R are brand names of fast-acting human
insulin.
Intermediate-acting insulin (NPH, Humulin N, Novolin N) is administered 30 minutes before meals
(breakfast) and becomes effective in 1 to 2 hours. Its duration of action in the body is 12 to 18 hours. This
type of insulin contains protamine, which prolongs the action in the body. It is cloudy because of the
protamine added to the regular insulin. It can ONLY be given subcutaneously. Humulin N can be mixed
with Humulin R (regular insulin) or rapid-acting insulin in the same syringe.
The long-acting insulins are insulin detemir (Levemir), an analog of human insulin, and insulin glargine
(Lantus). Lantus is the first long-acting recombinant DNA (rDNA) human insulin for patients with type
1 and 2 diabetes mellitus. Lantus and Levemir are clear, colorless insulins that are to be given ONLY sub-
cutaneously and NOT intravenously. Lantus and Levemir CANNOT be mixed with other insulins or
given intravenously. The long-acting insulin acts within 1 to 2 hours and lasts in the body for 18 to
24 hours. The Levemir vial is tall and has a green top. The Lantus vial is taller and narrower than the other
types of insulin. It has a purple top and purple print on the label. Levemir is usually administered in the
evening or at bedtime; however, it can be administered once or twice a day subcutaneously. Lantus is usually
administered at bedtime; thus, the incidence of nocturnal hypoglycemia is not common. Some patients
report more pain at the injection site with long-acting insulins than with Humulin N (NPH).
The use of commercially premixed combination insulins has become popular for patients with diabe-
tes mellitus who mix fast-acting and intermediate-acting insulins. Examples are two groups: the rapid-
and intermediate-acting insulin and the fast- and intermediate-acting insulins. The two rapid- and
intermediate-acting insulins are Novolog mix 70/30 and Humalog mix 75/25. The fast- and intermediate-
acting insulins are Humulin 70/30, Novolin 70/30, and Humulin 50/50 (see Table 10-1). They are avail-
able in vials or pens that resemble a fountain pen. Some patients need less than 30% Humulin R and
more Humulin N, so these combinations of insulins cannot be used. They must mix their insulins accord-
ing to the prescribed units of insulin.
194 PART III Calculations for Oral, Injectable, and Intravenous Drugs

The onset, peak, and duration times are given in Table 10-1 for four groups of insulins: rapid-acting,
fast-acting, intermediate-acting, and long-acting. The table includes the peak and return times after the
insulins are administered.

TABLE 10-1 Types of Insulin

ACTION

Pregnancy Time to Duration

Generic (Brand) Route Color Category Administer Onset Peak (Dose-Related)
Rapid-Acting Insulin (Short Duration)
aspart (NovoLog) A: subcut, IV Clear B 5-15 min before 5-15 min 1-3 h 3-5 h
meals
glulisine (Apidra) A: subcut, IV Clear B 5-15 min before 5-15 min 1-2 h 3-4.5 h
meals
lispro (Humalog) A: subcut, IV Clear B 5-15 min before 5-15 min 0.5-2 h 3-5 h
meals
Fast-Acting Insulin (Slower Duration)
regular insulin (Humulin A,C: subcut, Clear B 15-30 min 0.5-1 h 2-4 h 6-8 h
R, Novolin R) IV before meals
Intermediate-Acting Insulin
NPH Insulin, Humulin N, A,C: subcut Cloudy B 30 min before 1-2 h 6-12 h 12-18 h
Novolin N meals
Long-Acting Insulin
determir (Levemir) A: subcut Clear C Dinner or 1-2 h 6-8 h 14-24 h (dose
bedtime related)
glargine (Lantus) A: subcut Clear C Bedtime 1.5-2 h No peak 24 h
COMBINATIONS
Rapid- and Intermediate-Acting Insulin
70% aspart protamine/ A: subcut Cloudy B 15 min before 15 min 1-4 h 12-18 h
30% aspart insulin meals
(NovoLog mix 70/30)
75% lispro protamine/ A: subcut Cloudy B 15 min before 15 min-2h 2-6 h 14-18 h
25% lispro insulin meals
(Humalog mix 75/25)

Fast- and Intermediate-Acting Insulin

70% NPH/30% regular A: subcut Cloudy B 15 min before 30-60 min 2-8 h 10-18 h
insulin (Humulin meals
70/30, Novolin 70/30)
50% NPH/50% regular A: subcut Cloudy B 15 min before 15-60 min 2-6 h 10-18 h
insulin (Humulin 50/50) meals

A, adult; C, child; h, hour; min, minute; subcut; subcutaneous; IV, intravenous, ,, less than.
CAUTION: Levemir and Lantus should NOT be mixed with other insulins and should NEVER be given intravenously.
 CHAPTER 10 Insulin Administration 195

With severe hyperglycemia (high blood sugar), Humulin R units 500 may be ordered. This unit type
of insulin is of high potency and NOT for ordinary use. It is a high-risk drug. It is given with caution.

When the blood sugar level becomes extremely low (less than 40 mg/mL) and/or the patient is unc-
oncious, glucagon injection is given. It increases the blood sugar level. Many diabetic patients have glu-
cagon emergency kits in their homes for use if this occurs (Figure 10-6).
Figure 10-7 compares the action-time and rapid-acting, fast-acting, intermediate-acting, and long-
acting insulins.

A
Figure 10-6 Glucagon emergency kit for home use. (From Eli Lilly and Company. All rights reserved. Used with
permission.)

7
Insulin lispro aspart, glulisine
6
Glucose infusion rate (mg/kg/min)

Regular
5

NPH
3

Insulin detemir
2

Insulin glargine
1

0 3 6 9 12 15 18 21 24
Time (hours)
Figure 10-7 ​Activity profiles of different types of insulin. NPH, Neutral protamine Hagedorn. (Adapted from Rosenstock, J.,
Wyne, K. [2003]. Insulin treatment in type 2 diabetes. In Goldstein BJ, Müller-Wieland D, editors: Textbook of type 2 diabetes,
London, Martin Dunitz, Ltd.; Plank J, Bodenlenz, M., Sinner, F., et al. [2005]. A double-blind, randomized, dose-response study
investigating the pharmacodynamic and pharmacokinetic properties of the long-acting insulin analog detemir, Diabetes Care
28:1107-1112. Rave, K., Bott, S., Heinemann, L., et al. [2005]. Time-action profile of inhaled insulin in comparison with sub-
cutaneously injected insulin lispro and regular human insulin, Diabetes Care 28:1077-1082.)
196 PART III Calculations for Oral, Injectable, and Intravenous Drugs

MIXING INSULINS

Regular insulin is frequently mixed with insulins containing protamine, such as Humulin N.
REMEMBER: Insulin is prescribed in units and administered in units. Lantus and Levemir insulins can
NOT be mixed with regular (rapid- or fast-acting) insulin.

EXAMPLE Problem and method for mixing insulin.

PROBLEM: Order: Humulin R insulin units 10 and Humulin N insulin units 40, subcut.
Drug available: Humulin R insulin units 100 and Humulin N insulin units 100, both in
multidose vials. The insulin syringe is marked units 100.

Method:
1. Gently roll insulin bottles between palms to evenly distribute the insulin solution. DO
NOT shake insulin. Cleanse the rubber tops with alcohol.
2. Draw up 40 units of air* and inject into the Humulin N insulin bottle. Do not allow the
needle to come into contact with the Humulin N insulin solution. Withdraw the needle.
3. Draw up 10 units of air and inject into the Humulin R insulin bottle.
4. Withdraw 10 units of Humulin R insulin. Humulin R insulin is withdrawn before
Humulin N insulin.
5. Withdraw 40 units of Humulin N insulin.
6. Administer the two insulins immediately after mixing. Do not allow the insulin mixture
to stand, because unpredicted physical changes might occur.

*You may draw up 50 units of air; inject 40 units into the NPH bottle and 10 units into the regular insulin bottle.
 CHAPTER 10 Insulin Administration 197

PRACTICE PROBLEMS u
​ ​ I ​INSULIN
Answers can be found on pages 202 to 203.

1. Order: Humulin N insulin 35 units, subcut.

Drug available: Humulin N insulin units 100 and units 100 insulin syringe.
Indicate on the insulin syringe the amount of insulin that should be withdrawn.

2. Order: Apidra (insulin glulisine) 10 units, subcut, STAT.

Drug available: The syringe is units-100 insulin syringe.

(Product images and trademarks are the property

of and used with the permission of sanofi-aventis
U.S. LLC, Bridgewater, N.J. as of September, 2015.)

Indicate on the insulin syringe the amount of insulin that should be withdrawn.

3. Order: Humalog insulin units 8 and Humulin N insulin units 52.

Drug available: Humalog insulin units 100 and Humulin N insulin units 100.
The insulin syringe is units 100.
Explain the method for mixing the two insulins.

Indicate on the units-100 insulin syringe how much Humalog insulin should be withdrawn and
how much Humulin N insulin should be withdrawn.
198 PART III Calculations for Oral, Injectable, and Intravenous Drugs

4. Order: Humulin R insulin units 15 and Humulin N insulin units 45.

Drug available: Humulin R insulin units-100 and Humulin N insulin units 100.
The insulin syringe is units 100.
Explain the method for mixing the two insulins.

Indicate on the units-100 insulin syringe how much Humulin R insulin and how much Humulin N
insulin should be withdrawn.

5. Order: Insulin detemir (Levemir) 40 units, subcut, at bedtime/hour of sleep.

Drug available: The syringe is units-100 insulin syringe.

(From Norvo Nordisk, Inc., Princeton, N.J.)

Indicate on the insulin syringe the amount of insulin that should be given.

a. Can Levemir be mixed with regular insulin?

 CHAPTER 10 Insulin Administration 199

6. Order: Novolin N insulin, 38 units, subcut, 30 minutes before breakfast.

Drug available: The insulin syringe is 100 units.

Indicate on the insulin syringe the amount of Novolin N insulin that should be given.

7. Order: Lantus insulin, 35 units, subcut, at bedtime.

Drug available: The insulin syringe is 100 units.

(Product images and trademarks are the property

of and used with the permission of sanofi-aventis
U.S. LLC, Bridgewater, N.J. as of September, 2015.)

Indicate on the insulin syringe the amount of Lantus insulin that should be given.
200 PART III Calculations for Oral, Injectable, and Intravenous Drugs

INSULIN PEN DEVICES

There are two types of insulin pen devices: pre-filled and reusable. Both types require insulin pen needles
to dispense the insulin.
Pre-filled insulin pen devices are filled with 300 units or 3 mL of units-100 insulin. Before each insulin
dose, a small disposable needle is placed on the end of the insulin pen device and then the insulin dose is
dialed in. As the dose is dialed in, the plunger comes out. After the dose is dialed, the needle is placed sub-
cutaneously and the plunger pushed down.
In some hospitals or medical institutions, the insulin pen is primed with 2 units of insulin before admin-
istration. Check with the institution’s policy for priming the insulin pen with 2 units of insulin before
administering the insulin dose. After the insulin is delivered, the dose indicator returns to zero and the
needle is removed from the skin. The needle is discarded. A new needle is placed on the prefilled pen before
each injection. The pre-filled pen device is reused for multiple injections until all the insulin is dispensed.
Once the insulin is completely dispensed, the pen is thrown away (Figure 10-8).

Figure 10-8 ​Prefilled insulin pens. A, Humulin 70/30 short- and intermediate-acting. B, Humulin N intermediate-acting.
C, Novolog® rapid-acting. D, Novolog® 70/30 short- and intermediate-acting. E, Levemir® long-acting. (A and B, Copyright
Eli Lilly and Company. All rights reserved. Used with permission. C to E, From Novo Nordisk Inc., Princeton, N.J.)
 CHAPTER 10 Insulin Administration 201

Reusable insulin pen devices are filled with disposable insulin cartridges. The cartridges are filled with
150 units (1.5 mL) or 300 units (3 mL) of units-100 insulin. The cartridge is placed in the pen device. Before
each insulin dose, a small disposable needle is placed on the end of the insulin pen device and then the insulin
dose is dialed in. As the dose is dialed in, the plunger comes out. After the dose is dialed, the needle is placed
subcutaneously and the plunger pushed down. Following the insulin delivery, the dose indicator returns to
zero and the needle is removed from the skin. The needle is removed from the pen device. The pre-filled pen
device is reused for multiple injections until all the insulin is dispensed from the cartridge. Once the cartridge
is empty, the cartridge is thrown away and a new cartridge placed in the reusable pen device.

PRACTICE PROBLEMS u
​ ​II ​INSULIN PEN DEVICES
Answers can be found on page 204.
1. Your patient receives 25 units of units-100 Levemir insulin by FlexPen twice a day. The pen holds
300 units. How many days will one pen last?

2. L
 antus SoloStar Pens are dispensed in boxes of five pens. Each pen holds 300 units. If your patient
receives 75 units of units-100 Lantus insulin once a day at bedtime, how many doses can the patient
get from the box of five pens?

INSULIN PUMPS

There are two types of insulin pumps—the implantable and the external (portable). The implantable
insulin pump is surgically implanted in the abdomen and delivers a basal insulin infusion and bolus doses
with meals either intravenously or intraperitoneally. With implantable insulin pumps, there are fewer
hypoglycemic reactions, and blood glucose levels are mostly controlled.
External (portable) insulin pumps, also called continuous subcutaneous insulin infusion or CSII, have
been available since 1983. CSII mimics the body’s normal delivery of insulin. The external insulin pump
keeps blood glucose (sugar) levels as close to normal as possible. The continuous delivery of insulin is
called the basal rate and the larger pre-meal doses are called bolus doses. The insulin delivery setting
is programmed by a diabetes expert and adjusted by the patient. Before the patient eats, the pump is
programmed to dispense a large dose through the catheter. The patient then (1) programs insulin infu-
sion at a basal rate of units per hour (a rate that can be adjusted), (2) delivers bolus infusions to cover
meals (the patient pushes a button to deliver a bolus dose during meals), (3) changes delivery rates at
specific times of the day (e.g., from 3 am to 9 am) to avoid early-morning hyperglycemia, and (4) over-
rides the set basal rate to allow for unexpected changes in activity such as early-morning exercise.
Most insulin pump systems consist of the insulin pump, an insulin reservoir, plastic tubing, and inser-
tion set. The insulin reservoir holds 150 to 300 units of rapid- or fast-acting insulin, which is held in the
insulin pump. The plastic tubing is attached to a metal or plastic needle and placed subcutaneously by the
patient. The needle can be inserted into the abdomen, upper thigh, or upper arm. Only regular insulin is
used because protamine insulin, such as Humulin N, can cause unpredictable blood glucose levels. The
pump can deliver small amounts of insulin such as 0.1 or 0.2 units much more accurately than a tradi-
tional insulin syringe. Again, these pumps used a remote control to program the basal rates and bolus
doses. The patient usually changes the insertion site every 3 days.
A glucose sensor device is available to check the fluid glucose level. The sensor is separate from the
insulin pump and is attached to the body surface area. Radio-like wave sounds are transmitted to the
pump, which records the glucose level on the pump every 5 minutes. An alarm warns of low or high
glucose levels.
202 PART III Calculations for Oral, Injectable, and Intravenous Drugs

A B
Figure 10-9 ​A, Medtronic Paradigm REAL-Time System. B, Insert the reservoir into the top of the pump case. (From
Medtronic, Inc., Minneapolis, Minn.)

The use of the insulin pump helps to decrease the risk of severe hypoglycemic reactions and maintains
glucose control. However, glucose levels should still be monitored at least daily with or without an insulin
pump. The person with type 1 diabetes mellitus has the greatest benefit from use of an insulin pump. This
method should reduce the number of long-term diabetic complications compared with the use of mul-
tiple injections of regular and modified types of insulins. Figure 10-9 shows an example of an insulin
pump.

PRACTICE PROBLEMS u
​ ​ III ​INSULIN PUMP
Answers can be found on page 204.

1. Y
 our patient receives 50 units of basal insulin in a 24-hour period. His basal rate is the same for all
24 hours. How much insulin does your patient receive each hour?
unit/hour/24 hours
2. Your patient’s pump setting are:
Midnight to 3 am 1.4 units/hr 5 units for 3 hours
3 am to 7 am 2.6 units/hr 5 units for 4 hours
7 am to 5 pm 1.2 units/hr 5 units for 10 hours
5 pm to midnight 1.4 units/hr 5 units for 7 hours
How much basal insulin would your patient receive in 24 hours?
3. Y
 our patient’s insulin reservoir holds 180 units of insulin. The patient uses 2.5 units per hour. How
often does the patient need to refill the insulin reservoir?

ANSWERS
I Insulin

1. W
 ithdraw 35 units of Humulin N insulin to the 35 mark on the insulin syringe. Both the insulin and the syringe
have the same concentration: units 100.
 CHAPTER 10 Insulin Administration 203

2. Withdraw 10 units of Apidra insulin.

3. I nject 52 units of air into the Humulin N insulin bottle. Do not allow the needle to touch the insulin solution.
Inject 8 units of air into the Humalog insulin bottle and withdraw 8 units of Humalog insulin. Withdraw
52 units of Humulin N insulin. Total amount of insulin should be 60 units. Do not allow the insulin mixture to
stand. Administer immediately because Humulin N contains protamine, and unpredicted physical changes could
occur with a delay in administration.

Humalog Humulin N

4. I nject 45 units of air into the Humulin N insulin bottle. Inject 15 units of air into the Humulin R insulin bottle
and withdraw 15 units of Humulin R insulin. Withdraw 45 units of Humulin N insulin. Total amount of insulin
should be 60 units.

Humulin R Humulin N

5. Withdraw 40 units of Levemir insulin.

a. No. CANNOT BE MIXED WITH REGULAR INSULIN.

6. Withdraw 38 units of Novolin N insulin.

7. Withdraw 35 units of Lantus insulin.

204 PART III Calculations for Oral, Injectable, and Intravenous Drugs

II Insulin Pen Devices

1. 300 units per pen 4 by 25 units 5 12 doses per pen

12 4 2 doses per day 5 6 days
2. 300 units per pen 3 5 pens 5 1500 units per box
1500 units (5 pens) 4 75 units per day 5 20 doses per box

III Insulin Pumps

1. 50 units per 24 hours 4 24 hours per day 5 2.08 units of basal insulin per hour
2. Patient receives 36.4 units of insulin (basal) in 24 hours
Midnight to 3 am: 1.4 units/hr, 3 hours 3 1.4 units 5 4.2 units in 3 hours
3 am to 7 am: 2.6 units/hr, 4 hours 3 2.6 units 5 10.4 units in 4 hours
7 am to 5 pm: 1.2 units/hr, 10 hours 3 1.2 units 5 12.0 units in 10 hours
5 pm to midnight: 1.4 units/hr, 7 hours 3 1.4 units 5 9.8 units in 7 hours
3. 2.5 units per hours 3 24 hours 5 60 units per 24 hours or per day
180 units per reservoir 4 60 units per day 5 3 days
Patient must refill insulin reservoir every 3 days.

Additional practice problems are available in the Basic Calculations and Advanced
Calculations sections of Drug Calculations Companion, version 5 on Evolve.
CHAPTER 11
Intravenous Preparations
With Clinical Applications

Objectives • Identify catheter types and sites for intravenous (IV) access.
• Examine the three methods for calculating IV flow rate and select one of the methods for IV
calculation.
• Calculate drops per minute of prescribed IV solutions for IV therapy.
• Determine the drop factor according to the manufacturer’s product specification.
• Calculate the drug dosage for IV medications.
• Calculate the flow rate for IV drugs being administered in a prescribed amount of solution.
• Explain the types and uses of electronic IV infusion devices.
• Calculate the rate of direct IV injection.

Outline INTRAVENOUS SITES AND DEVICES

Intermittent Infusion Add-On Devices
DIRECT INTRAVENOUS INJECTIONS
CONTINUOUS INTRAVENOUS ADMINISTRATION
Intravenous Infusion Sets
CALCULATION OF INTRAVENOUS FLOW RATE
Safety Considerations
Adding Drugs Used for Continuous Intravenous Administration
Types of Solutions
Tonicity of IV ​Solutions
INTERMITTENT INTRAVENOUS ADMINISTRATION
Secondary Intravenous Sets
Adding Drugs Used for Intermittent Intravenous Administration
ADD-Vantage ​System
Electronic Intravenous Infusion Pumps
FLOW RATES FOR INFUSION PUMPS AND SECONDARY SETS

205
206 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Intravenous (IV) therapy is used for administering fluids containing water, dextrose, fat emulsions, vita-
mins, electrolytes, and drugs. Approximately 90% of all hospitalized patients, some outpatients, and some
home-care patients receive IV therapy. Many drugs cannot be absorbed through the gastrointestinal tract
and must be administered intravenously to provide bioavailability with direct absorption and fast action.
Certain drugs that need to be absorbed immediately are administered by direct IV injection, sometimes
over several minutes. However, many drugs administered intravenously are irritating to the veins because
of the drug’s pH or osmolality and must be diluted and administered slowly.
Advantages of IV drug therapy are (1) rapid drug distribution into the bloodstream, (2) rapid onset of
action, and (3) no drug loss to tissues. There are many complications of IV therapy, some of which are
sepsis, thrombosis, phlebitis, air emboli, infiltration, and extravasation. The nurse must monitor for signs
of these complications during the course of IV therapy.
Three methods are used to administer IV fluid and drugs: (1) direct IV drug injection, (2) continuous
IV infusion, and (3) intermittent IV infusion. Continuous IV administration replaces fluid loss, main-
tains fluid balance, and is a vehicle for drug administration. Intermittent IV administration is primarily
used for giving IV drugs at prescribed intervals.
Nurses play an important role in preparing and administering IV solutions and drugs. Nursing func-
tions and responsibilities include (1) knowledge of IV sets and their drop factors, (2) calculating IV flow
rates, (3) verifying compatibility of the IV solution and the drug, (4) mixing and diluting drugs in IV
solution, (5) regulating IV infusion devices, (6) maintaining patency of IV accesses, and (7) monitoring
for signs and symptoms of infiltration or other potential complications.

INTRAVENOUS SITES AND DEVICES

The successful administration of IV drugs and fluids depends on patent vascular access. The most com-
mon site for short-term (less than 1 week) IV therapy is the peripheral short site, which uses the dorsal
and ventral surfaces of the upper extremities. Catheter length is normally 1 to 3 inches (Figure 11-1, A
and B).
The peripheral midline site for IV therapy uses the veins in the area of the antecubital fossa—the
basilic, brachial, cephalic, cubital, or medial. Midline peripheral catheters are between 3 and 8 inches in
length and can stay in place 2 to 4 weeks.
The peripherally inserted central catheter (PICC) (Figure 11-2) can be used for IV therapy for up to
1 year. The catheter length is 21 inches. The insertion site is the region of the antecubital fossa that uses
the same veins as the peripheral midline. The catheter is advanced through the vein in the upper arm until
the tip rests in the lower third of the superior vena cava. Because the tip of the PICC line rests in the
superior vena cava, it is considered a central line. Compared to other types of access, the multilumen
PICC is more dependable and cost-effective. It is also versatile because it can be used for medication, IV
fluids, blood products, total parenteral nutrition (TPN), and blood sampling. Infection rates are also very
low with PICC lines. Another benefit of the PICC line is that it can be maintained on an outpatient
basis, therefore patients can be discharged earlier from the hospital. In some states registered nurses certi-
fied in IV therapy can insert PICC lines.
Central venous access is used for patients who need long-term continuous infusions of fluids, medica-
tion, or nutritional support that cannot be sustained with a peripheral site. Central venous access is also
used for patients who have poor peripheral veins, require a large amount of IV fluid or blood products in
a short amount of time, or are receiving medication that is known to be too caustic for peripheral vessels.
Central venous catheters (CVC) provide access to the superior vena cava and the inferior vena cava. A
CVC placed in the internal jugular vein or the right or left subclavian vein is commonly used to access
the superior vena cava. The inferior vena cava can be accessed through the femoral vein (Figure 11-3).
Length of the CVC can vary from 6 to 28 inches. Insertion requires a competent provider to perform a
sterile procedure involving the cannulation of the selected percutaneous vein with a single- or multi­
lumen catheter. An x-ray is taken at the end of the procedure to confirm placement of the tip of the
catheter in the superior vena cava just above the right atrium.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 207

Figure 11-1 ​A, BD Nexiva IV catheter system has a single port with cap adapter. B, Various types of Becton Dickinson (BD)
catheters.

Figure 11-2 ​Bard PowerPICC triple-lumen catheter.

208 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Subclavian Catheter Site Peripherally Inserted

A Central Catheter (PICC) B

C Femoral Catheter Site Hickman (Tunneled) Catheter Site D

Self-sealing
Skin line septum

Suture

Fluid flow
Catheter

Subclavian Catheter Implantable

with Implantable Vascular Access Port
E Vascular Access Port F
Figure 11-3 ​Central venous access sites. A, Subclavian catheter. B, Peripherally inserted central catheter (PICC). C, Femoral
catheter. D, Hickman (tunneled) catheter. E, Subclavian catheter with implantable vascular access port. F, Implantable vascular
access port. (F, from Perry, A. G., & Potter, P. A. [2006]. Clinical nursing skills and techniques. 6th ed. St. Louis: Mosby.)

Patients who need vascular access for long-term use, such as chemotherapy, antibiotic therapy, or
nutritional support, are given much longer catheters, which are tunneled under the skin after the vein is
cannulated. The catheter and its drug infusion port exit from the subcutaneous tissue to a site on the
chest. Examples of these devices are the Hickman, Groshong, NeoStar, and Cook catheters.
Another type of catheter for long-term use has an implantable infusion port that is inserted in the
subcutaneous tissue under the skin. These devices are called vascular access ports, also known as Port-a-
caths, and they have a larger drug port or septum than other catheters. Care must be taken to use a non-
coring needle that slices the port instead of making holes, so that the septum will close instead of leaking
after the needle has been removed (Figure 11-3).
 CHAPTER 11 Intravenous Preparations With Clinical Applications 209

Intermittent Infusion Add-On Devices

When IV access sites are used for intermittent therapy instead of continuous infusion, they must be
flushed periodically to maintain patency. An intermittent infusion add-on device can be attached to the
end of the vascular access device, catheter, or needle to close the connection that was attached to the IV
tubing. There are many types of add-on devices, such as extension loops, solid cannula caps, and injection
access caps. All add-on devices should use a needleless Luer-Lok design as a safety measure. Use of add-
on devices should be included as part of the protocol of the institution (Figure 11-4). These devices have
ports (stoppers) where needleless syringes can be inserted when drug therapy is resumed. This practice
can eliminate the need for a constant low-rate infusion to keep the vein open (KVO) and reduce exces-
sive fluid intake. The use of intermittent infusion devices can allow the patient greater mobility and can
be cost-effective because less IV tubing, IV solution, and regulating equipment are needed.
IV sites should be flushed every 8 to 12 hours or before and after each drug infusion, depending on
institutional policy, to maintain patency. Table 11-1 gives suggested flushing times. Prefilled single-use
syringes of saline solution are available to flush infusion devices (Figure 11-5, A and B). The intent of
prefilled single-use syringes is to prevent the cross-contamination that can occur with a multidose vial.
The volume of the flush used for vascular access devices is twice the volume of the catheter plus any con-
nected devices such as a three-way stopcock or an extension set.

TABLE 11-1 Venous Access Devices: Flushing for Peripheral and Central Venous
Catheters*
Flush Before
Catheter Type Length (inches) Drug Use Flush After Drug Use Volume/mL

Peripheral 1-2 NS NS 1-3

Central venous
 ​ ​Single-lumen  ​8 NS HS 1-3
 ​ ​Multilumen  ​8 NS HS 1-3
External tunneled 35 NS HS or NS 10
 ​ ​Hickman, Cook, Flush q12h if not used
 ​ ​or Groshong
Peripherally inserted 20 NS NS 10
 ​ ​central catheter (PICC) Flush q12h if not used
Implanted vascular 35 NS HS or NS 10
 ​ ​access device Flush q12h if not used

*If the adapter/cap is pressurized, then normal saline is used, not a heparin solution. Follow the institution policy procedure
and manufacturer’s guidelines.
HS, Heparinized saline; NS, normal saline.

Figure 11-4 ​Needleless infusion devices. Medication in a needleless syringe can be inserted into a needleless infusion device.
210 PART III Calculations for Oral, Injectable, and Intravenous Drugs

A B
Figure 11-5 A, BD 3-mL and I0-mL prefilled, single-use syringe of sterile saline is used for IV catheter flush. B, IV catheter
flush. The prefilled, single-use syringe is attached to the port of the IV tubing. (B, From Perry, A. G., & Potter, P. A. [2010].
­Clinical nursing skills and techniques. 7th ed. St Louis: Mosby.)

DIRECT INTRAVENOUS INJECTIONS

Medications that are given by the IV injection route are calculated in the same manner as medications
for intramuscular (IM) injection. This route is often referred to as IV push. Clinically, it is the preferred
route for patients with poor muscle mass or decreased circulation, or for a drug that is poorly absorbed
from the tissues. Medications administered by this route have a rapid onset of action, and calculation
errors can have serious, even fatal, consequences. Drug information inserts must be read carefully, and
attention must be paid to the amount of drug that can be given per minute. If the drug is pushed into the
bloodstream at a faster rate than is specified in the drug literature, adverse reactions to the medication are
likely to occur.
Calculating the amount of time needed to infuse a drug given by direct IV infusion can be done using
the ratio and proportion method.

YOU MUST REMEMBER

When giving drugs by direct IV infusion, always verify the compatibility of the IV solution and the drug, or
precipitation may result. Precipitation is a crystallization or suspension of particles in a solution, causing an
occlusion of the intravenous line. Incompatibility can be avoided if the IV tubing is flushed with a compat-
ible solution of normal saline before and after administration.

EXAMPLES S
 et up a ratio and proportion using the recommended amount of drug per minute on one side of the
equation; these are the known variables. On the other side of the equation are the desired amount of
the drug and the unknown desired minutes: a. amount in milliliters (mL); b. number of minutes.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 211

PROBLEM 1: Order: Dilantin 200 mg, IV, STAT.

Drug available: Dilantin 250 mg/5 mL. IV infusion not to exceed 50 mg/min.
4
D 200 mg 20
a. BF: 3V5 3 5 mL 5 5 4 mL
H 250 mg 5
5
or or H 250 mg 200 mg
D
RP: H ; V < D ; X FE: 5 5 5
V X 5 mL X
250 mg;5 mL<200 mg;X mL
250 X 5 1000 (Cross multiply) 250 X 5 1000
X 5 4 mL X 5 4 mL
4
or 5 mL 3 200 mg 20
DA: mL 5 5 5 4 mL
250 mg 3 1 5
5
200 mg 5 4 mL (discard 1 mL of the 5 mL)
b. known drug;known minutes<desired drug;desired minutes
50 mg ; 1 min < 200 mg ; X min
50 X 5 200
X 5 4 min

PROBLEM 2: Order: Lasix 120 mg, IV, STAT.

Drug available: Lasix 10 mg/mL. IV ​infusion not to exceed 40 mg/min.
a. RP; H ; V < D ; X
10 mg;1 mL<120 mg;X mL
10 X 5 120
X 5 12 mL of Lasix
12
or 1 mL 3 120 mg
DA: mL 5 5 12 mL of Lasix
10 mg 3 1
1
b. known drug;known minutes<desired drug;desired minutes
40 mg ; 1 min < 120 mg ; X min
40 X 5 120
X 5 3 min
When dosing instructions give the amount of drug and specify infusion time, the amount of drug can
be divided by the number of minutes to attain the per-minute amount to be infused.

PROBLEM 3: Order: inamrinone (Inocor) 65 mg, IV bolus over 3 minutes.

Drug available: Inocor 100 mg/20 mL.
a. RP: H ; V < D ; X
100 mg;20 mL<65 mg;X mL
100 X 5 1300
X 5 13 mL
1
or 20 mL 3 65 mg 65
DA: mL 5 5 5 13 mL
100 mg 3 1 5
5
13 mL
b. 5 4.3 mL/min
3 min
212 PART III Calculations for Oral, Injectable, and Intravenous Drugs

PRACTICE PROBLEMS u
​ ​I ​DIRECT IV INJECTION
Answers can be found on pages 239 to 240.

A. Determine the amount in milliliters of drug solution to administer.

B. Determine the number of minutes that is required for the direct IV drug dose to be administered
for each of the practice problems.
1. Order: protamine sulfate 50 mg, IV, STAT.
Drug available:

IV infusion not to exceed 5 mg/min.

a. Amount in milliliters
b. Number of minutes to administer
2. Order: dextrose 50% in 50 mL, IV, STAT.
Drug available: dextrose 50% in 50 mL.
IV infusion not to exceed 10 mL/min.

Number of minutes to administer 50% of 50 mL
3. Order: calcium gluconate 4.65 mEq, IV, STAT.
Drug available:

IV infusion not to exceed 1.5 mL/min. Note: 4.65 mEq/10 mL.

a. Amount in milliliters
b. Number of minutes
4. Order: fentanyl 12.5 mcg, IV, q4h, PRN for pain.
Drug available: fentanyl 100 mcg in 2 mL.
IV infusion not to exceed 10 mcg/min.
a. Amount in milliliters
b. Number of minutes
 CHAPTER 11 Intravenous Preparations With Clinical Applications 213

5. Order: morphine sulfate 6 mg, IV, q3h, PRN.

Drug available:

Infusion not to exceed 10 mg/4 min.

a. Amount in milliliters
b. Number of minutes
6. Order: digoxin 0.25 mg, IV, daily.
Drug available:

Infuse slowly over 5 minutes.

a. Amount in milliliters
b. How many mL/min should be infused?
7. Order: Haldol 2 mg, IV, q4h, PRN.
Drug available: Haldol 5 mg/mL.
IV infusion not to exceed 1 mg/min.
a. Amount in milliliters
b. Number of minutes
8. Order: Ativan 6 mg, IV, q6h, PRN.
Drug available: Ativan 4 mg/mL.
IV infusion not to exceed 2 mg/min.
a. Amount in milliliters
b. Number of minutes
214 PART III Calculations for Oral, Injectable, and Intravenous Drugs

9. Order: diltiazem (Cardizem) 20 mg IV over 2 minutes.

Drug available:

a. How many milliliters (mL) would you give?

b. How many milliliters (mL) would you infuse per minute?
10. Order: granisetron (Kytril) 10 mcg/kg, 30 minutes before chemotherapy.
Infuse 1 mg over 60 seconds.
Patient weighs 140 pounds.
Drug available:

a. How many kilograms (kg) does the patient weigh?

b. How many milligrams (mg) should the patient receive?
c. For how many seconds should the drug dose be infused?

YOU MUST REMEMBER

Consider the length of the injection port on the tubing from the patient’s IV site. If the IV rate is very low,
(e.g., 30 mL/hr), the IV medication may take a long time to reach the patient. The drug dose is not com-
plete until all of the drug has entered the patient. Therefore, the tubing will have to be flushed to ensure
that the dose reaches the patient in a timely manner.

CONTINUOUS INTRAVENOUS ADMINISTRATION

When IV fluids are required, the health care provider orders the amount of solution per liter or milliliter to
be administered for a specific time, such as for 24 hours. The nurse calculates the IV flow rate according to
the drop factor, the amount of fluid to be administered, and the infusion time.

Intravenous Infusion Sets

All infusion sets have the same components: a sterile spike for entry into the IV bag or bottle, a drip cham-
ber for counting drops and managing flow, a roller clamp that controls flow through the tubing, tubing
length from drip chamber to IV site, Y-site for adding a secondary set or giving IV drugs, and the
 CHAPTER 11 Intravenous Preparations With Clinical Applications 215

needleless adapter (which attaches to the IV catheter in the vessel) (Figure 11-6). Often a filter is added
to the IV line to remove bacteria, particles, and air. Figure 11-7 shows two types of IV containers.
IV sets are either vented or unvented. Vented sets are used for IV bottles that have no vents and need
a vent for air to enter the bottle so that the fluid will flow out. Unvented sets are for bottles or bags that
either have their own venting system or do not need a venting system. Glass bottles are primarily used
when the medication is not compatible with plastic because the drug either adheres to the plastic or is
absorbed by the plastic.
If the IV infusion is not placed on a flow control device but instead is delivered by gravity, then the
hourly rate will have to be adjusted manually. It is necessary to know the drop factor of the IV set to
calculate the hourly infusion rate. The drop factor, or the number of drops per milliliter (mL), is printed
on the package of the infusion set and found on top of the drip chamber. Sets that deliver large drops per
milliliter (10, 15, or 20 gtt/mL) are referred to as macrodrip sets, and those that deliver small drops per
milliliter (60 gtt/mL) are called microdrip or minidrip sets (Figure 11-8).
Drip rates are adjusted by counting the drops coming into the drip chamber. While looking at the
second hand of your watch, adjust the roller clamp to determine the correct number of drops in one
minute. It is more difficult to count when the drops are smaller and the drop rate is faster. One advantage
of the microdrip set is that the number of milliliters per hour is the same as the drops per minute (e.g., if
the infusion rate is 50 mL/hr, the drip rate is 50 gtt/min). When the IV rate is 100 mL/hr or higher, the
macrodrip set generally is used. Slow drip rates (less than 100 mL/hr) make macrodrip adjustments too
difficult (e.g., at 50 mL/hr, the macrodrip rate would be 8 gtt/min). Therefore if the IV rate is 100 mL/
hr or lower, the microdrip is preferred.

Spike end for

IV bag or bottle

Drop chamber
Adapter end of
tubing to needle
or catheter

Filter

Roller clamp
for manual flow
control Y-site

Figure 11-6 ​Intravenous tubing set.

216 PART III Calculations for Oral, Injectable, and Intravenous Drugs

1000 mL 1000 mL

500 mL 500 mL

100 mL 100 mL

Injection
port

IV bag IV bottle

Air vent

Figure 11-7 Intravenous bag and bottle.

Macrodrip Microdrip
10, 15, or 20 gtt/mL 60 gtt/mL

Figure 11-8 Macrodrop and microdrip sizes.

 CHAPTER 11 Intravenous Preparations With Clinical Applications 217

At times, IV fluids are given at a slow rate to keep vein open (KVO), also called to keep open (TKO).
Reasons for ordering KVO include (1) a suspected or potential emergency situation requiring rapid
administration of fluids and drugs, and (2) the need to maintain an open line to give IV drugs at specified
hours. For KVO, a microdrip set (60 gtt/mL) and a 250-mL IV bag can be used. KVO should have a
specific infusion rate, such as 10 to 20 mL/hr, or should be given according to the institution’s protocol.

CALCULATION OF INTRAVENOUS FLOW RATE

Three different methods can be used to calculate IV flow rate (drops per minute or gtt/min). The nurse
should select one of these methods, memorize it, and use it to calculate dosages.*

u THREE-STEP METHOD
Amount of solution
a. 5 mL/hr
Hours to administer
mL per hour
b. 5 mL/min
60 minutes
c. mL per minute 3 gtt per mL of IV set 5 gtt/min

u TWO-STEP METHOD
a. Amount of fluid 4 Hours to administer 5 mL/hr
mL per hour 3 gtt /mL 1IV set2
b. 5 gtt /min
60 minutes

u ONE-STEP METHOD
Amount of fluid 3 gtt /mL 1IV set2
5 gtt /min
Hours to administer 3 Minutes per hour 1602

Safety Considerations
All IV infusions should be checked every half-hour or hour, according to the policy of the institution, to ensure
the appropriate rate of infusion and to assess for potential problems, especially when manual flow control is
used. Common problems associated with IV infusions are kinked tubing, infiltration, and “free-flow” IV rates.
If IV tubing kinks and the flow is interrupted, the prescribed amount of fluid will not be given, and the access
site can clot. When IV infiltration occurs, fluid leaks into the tissues around the IV site, causing redness, swell-
ing, and discomfort. A more serious complication is extravasation, which occurs when the infiltrated medica-
tion damages the tissues at the IV site, resulting in sloughing and necrosis of exposed tissue.
Again, in this situation the prescribed amount of IV fluid is not infused. Free-flow IV rate refers to a
rapid infusion of IV fluids, faster than prescribed, causing fluid overload, or too much fluid in the intra-
vascular space, which can cause hypertension, pulmonary edema, and/or dyspnea. Medications that are
administered faster than prescribed also can result in toxicity. A free-flow IV rate is the most prevalent
drug error and has led to the use of electronic infusion devices.
Electronic infusion devices are not without flaws; mechanical problems occur and these devices can be
incorrectly programmed, resulting in the wrong infusion rate. Fluid overload, thrombus formation, infiltra-
tion, and extravasation are complications of IV therapy that can be avoided with frequent monitoring of IV
infusions. See Appendix A for more detailed information on safe practice for IV drug administration.

*The two-step method is the most commonly used method of calculating IV flow rate.
218 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Adding Drugs Used for Continuous Intravenous Administration

Nurses may need to prepare medications from vials and add the medication into the patient’s IV solu-
tion bag for some continuous infusions. This process of mixing or compounding an IV solution should
be completed before the IV bag or bottle is hung. The medication is prepared using sterile technique
and is added through the injection port to the bag or bottle that is to be rotated, or gently agitated, to
ensure that the drug is dispersed. Failure to adequately disperse the medication can result in a higher
concentration of medication close to the bottom of the bag or bottle. This would deliver a higher con-
centration of the added medication, potentially causing harm to the patient. Medication labels must
be placed on the IV bag or bottle, clearly stating the patient’s name and any other identifiers as speci-
fied by policy, such as name of the drug, amount, concentration, and strength of all ingredients without
abbreviation; also, date, nurse’s initials, time, and the time the IV should be completed should be
provided. It is important to follow institutional policies and procedures when adding medication to
continuous IV fluid.

N OTE
DO NOT add the drug while the infusion is running unless the bag is rotated. A drug solution injected into
an upright infusing IV solution causes the drug to concentrate into the lower portion of the IV bag and not
be dispersed. The patient will receive a concentrated drug solution, and this can be harmful (e.g., if the drug
is potassium chloride).

Types of Solutions
All IV solutions contain various solutes and electrolytes that are added for specific therapies. Common
solutes include dextrose (D) and sodium chloride (NaCl). The strength of the solution is expressed in
percent (%), such as 0.45%, which means 0.45 g in 100 mL. Common commercially prepared IV solu-
tions are dextrose in water (D5W), dextrose with one-half normal saline solution (D5 0.45%), normal
saline solution (0.9% NaCl), one-half normal saline solution (0.45% NaCl), and lactated Ringer’s solu-
tion (LR). Lactated Ringer’s solution contains sodium, chloride, potassium, calcium, and lactate.

Tonicity of IV Solutions
The terms tonicity and osmolality have been used interchangeably, but tonicity refers to the concentration
of IV solution, whereas osmolality is the concentration of body fluids (e.g., blood, serum). IV solutions
produce tonicity in the cells of the body; this is the movement of water molecules into and out of the cells
because of their surrounding aqueous environment. IV solutions are divided into three categories: hyper-
tonic, hypotonic, and isotonic. The range of tonicity is measured in milliosmoles, and the normal range is
240 to 340 mOsm: 150 mOsm and/or 250 mOsm of 290 mOsm. Hypertonic solutions cause water
molecules to diffuse out of the cells and exert a hyperosmolar effect. For example, a hypertonic solution
is D5 0.9% normal saline (NaCl) because it has an osmolarity of 560 mOsm. Hypotonic solutions cause
water molecules to diffuse into the cells and exert a hypo-osmolar effect. A solution of 0.45% normal
saline (NaCl) is hypo-osmolar and has an osmolarity of 154 mOsm. D5W is iso-osmolar with an osmo-
lality of 250 mOsm; however, the dextrose is metabolized quickly, leaving only water, thus making the
solution hypotonic. Isotonic solutions maintain the same concentration of water molecules on both sides
of the cell, so no net movement occurs. The osmolarity of isotonic solutions is 240 to 340 mOsm, similar
to blood, lactated Ringer’s (LR), and 0.9% normal saline (NaCl) solution. Table 11-2 lists the names of
selected IV solutions, their tonicity, and their osmolarity, as well as the abbreviations for these solutions.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 219

TABLE 11-2 Abbreviations for IV Solutions with Tonicity and Osmolarity

IV Solution Tonicity mOsm Abbreviation(s)

5% dextrose in water Iso 250 D5W, 5% D/W

10% dextrose in water Hyper 500 D10W, 10% D/W
0.9% sodium chloride, normal saline solution Iso 310 0.9% NaCl, NS
0.45% sodium chloride, 1⁄2 normal saline solution Hypo 154 0.45% NaCl, 1⁄2 NS
5% dextrose in 0.9% sodium chloride Hyper 560 D5NS, 5% D/NS, 5%
D/0.9% NaCl, D5 PSS
Dextrose 5%/0.2% sodium chloride Iso 326 D5/0.2% NaCl
5% dextrose in 0.45% sodium chloride, 5% Hyper 410 D51⁄2 NS, 5% D/1⁄2, NSS
dextrose in 1⁄2 normal saline solution
Lactated Ringer’s solution Iso 274 LR

EXAMPLES T
 wo problems in determining IV flow rate are given. Each problem is solved with each of the three
methods for calculating IV flow rate.

PROBLEM 1: Order: 1000 mL of D51⁄2 NS (5% dextrose in 1⁄2 normal saline solution) in 6 hours.
Available: 1 L (1000 mL) of D51⁄2 NS solution bag: IV set labeled 10 gtt/mL.
How many drops per minute (gtt/min) should the patient receive?
1000 mL
Three-Step Method: a. 5 166.6 or 167 mL/hr
6 hr
167 mL
b. 5 2.7 or 2.8 mL/min
60 min
c. 2.8 mL/min 3 10 gtt/mL 5 28 gtt/min
Two-Step Method: a. 1000 mL 4 6 hr 5 167 mL/hr
1
167 mL/hr 3 10 gtt /mL 167
b. 5 5 28 gtt /min
60 min 6
6

10 and 60 cancel to 1 and 6.

If mL/hr is given, use only part b of the two-step method for
calculating IV flow rate.
1
1000 mL 3 10 gtt /mL 1000
One-Step Method: 5 5 28 gtt /min
6 hr 3 60 min 36
6

10 and 60 cancel to 1 and 6.

 or the purpose of avoiding errors, the use of a hand calculator is
F
strongly suggested.

Answer: 28 gtt/min.
220 PART III Calculations for Oral, Injectable, and Intravenous Drugs

PROBLEM 2: Order: 1000 mL of D5W (5% dextrose in water), 1 vial of MVI (multiple vitamin), and
20 mEq of KCl (potassium chloride) every 8 hours.
Available: 1000 mL D5W solution bag
1 vial of MVI 5 5 mL
40 mEq/20 mL of KCl in an ampule
IV set labeled 15 gtt/mL
How many milliliters (mL) of KCl would you withdraw as equivalent to 20 mEq of KCl?
How would you mix KCl in the IV bag?
How many drops per minute should the patient receive?

Procedure: MVI: Inject 5 mL of MVI into the rubber stopper on the IV bag.
KCl: Calculate the prescribed dosage for KCl by using the basic formula, ratio
and proportion, fractional equation (FE) method, or dimensional analysis.
D 20 mEq 400
BF: 3V5 3 20 mL 5 5 10 mL
H 40 mEq 40
or or H 40 mEq 20 mEq
D
RP: H ; V < D ; X FE: 5 5 5
V X 20 mL X
40 mEq;20 mL<20 mEq;X mL
40 X 5 400 (Cross multiply) 40 X 5 400
X 5 10 mL X 5 10 mL
or
V3D
DA: mL 5
H31
1
20 mL 3 20 mEq 20
mL 5 5 5 10 mL
40 mEq 3 1 2
2

Withdraw 10 mL of KCl and inject it into the rubber stopper on the IV bag. Make sure
the KCl solution and MVI ​additives are dispersed throughout the IV solution by rotating
the IV bag.
1000 mL
Three-Step Method: a. 5 125 mL/hr
8 hr
125 mL
b. 5 2.0–2.1 mL/min
60 min
c. 2.1 3 15 5 31 (31.25 gtt/min)
Two-Step Method: a. 1000 4 8 5 125 mL/hr
1
125 mL/hr 3 15 gtt /mL 125
b. 5 5 31 131.25 gtt /min2
60 min 4
4

15 and 60 cancel to 1 and 4.

IV flow rate should be 31.
1
1000 mL 3 15 gtt /mL 1000
One-Step Method: ​ 5 5 31 gtt /min 131.25 gtt /min2
8 hr 3 60 min 32
4

15 and 60 cancel to 1 and 4.

IV flow rate should be 31 gtt/min.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 221

N OTE
Medication volume can be added to the total volume if strict intake and output are recorded. In general, an
IV bag contains more fluid than is labeled on the bag; some estimates are as high as 50 mL. Count all
volume added to bag, 1 mL or greater. If an electronic infusion device is used, the patient will receive the
amount programmed into the device.

PRACTICE PROBLEMS u
​ ​II ​CONTINUOUS INTRAVENOUS ADMINISTRATION
Answers can be found on pages 240 and 241.

Select one of the three methods for calculating IV flow rate. The two-step method is preferred by most nurses.
1. Order: 1000 mL of D5W to run for 12 hours.
a. Would you use a macrodrip or microdrip IV ​set?
b. Calculate the drops per minute (gtt/min) using one of the three methods.

2. Order: 3 L of IV solutions for 24 hours: 2 L of 5% D/1⁄2 NS and 1 L of D5W.
a. One liter is equal to mL.
b. Each liter should run for hours.
c. The institution uses an IV set with a drop factor of 15 gtt/mL. How many drops per minute
(gtt/min) should the patient receive?
3. Order: 250 mL of D5W for KVO.
a. What type of IV set would you use?
Why?
b. How many drops per minute should the patient receive?
4. Order: 1000 mL of 5% D/0.2% NaCl with 10 mEq of KCl for 10 hours.
Available: Macrodrip IV set with a drop factor of 20 gtt/mL and microdrip set;
KCl 20 mEq/20 mL vial.
a. How many milliliters (mL) of KCl should be injected into the IV bag?

b. How is KCl mixed in the IV solution?
c. How many drops per minute (gtt/min) should the patient receive with both the macrodrip set
and the microdrip set?
5. A
 liter (1000 mL) of IV fluid was started at 9 am and was to run for 8 hours. The IV set delivers
15 gtt/mL. Four hours later, only 300 mL has been absorbed.
a. How much IV fluid is left?
b. Recalculate the flow rate for the remaining IV fluids.
222 PART III Calculations for Oral, Injectable, and Intravenous Drugs

6. The patient is to receive D5W, 100 mL/hr.

Available: Microdrip set (60 gtt/mL).
How many drops per minute should the patient receive?
7. Order: 1000 D5W with 40 mEq KCl at 125 mL/hr.
Drug available:

a. Which concentration of KCl would you choose?

b. How many milliliters of KCl should be injected into the IV bag?

c. How many hours will the IV infusion last?
8. Order: 1000 D5/1⁄2 NS with 20 mEq KCl at 100 mL/hr.
Available: Macrodrip set (10 gtt/mL).
Drug available:

a. Which concentration of KCl would you choose?

b. How many milliliters of KCl should be injected into the IV bag?
c. How many hours will the IV infusion last?
d. How many drops per minute should the patient receive?

INTERMITTENT INTRAVENOUS ADMINISTRATION

Giving drugs via the intermittent IV route has many advantages. The IV route allows for rapid therapeutic
concentration of the drug and control over the onset of action and peak concentrations. Blood serum con-
centrations can be achieved via the IV route if the oral route is unavailable because of the patient’s condi-
tion, such as gastrointestinal malabsorption or neurological deficits that prevent swallowing. The intermittent
IV route can be used on an outpatient basis and can ensure compliance with drug therapy. The IV route also
allows for the rapid correction of electrolyte imbalances. IV medications can be given at intervals within a
24-hour period for days or weeks. These medications are administered in a small volume of fluid (50 to
250 mL of D5W or saline solution). The drug solution usually is delivered to the patient in 15 minutes to
 CHAPTER 11 Intravenous Preparations With Clinical Applications 223

2 hours, depending on the medication. A separate delivery set or secondary set is used for intermittent
therapy if the patient is also receiving continuous infusion through the same IV site.

Secondary Intravenous Sets

Secondary IV sets are used to infuse small fluid volumes such as, 50, 100, 250, and 500 mL in bags or
bottles. Three types of tubing can be used. The first is similar to a regular IV set but with shorter tubing
that is inserted or piggybacked into the primary IV line port. The second is a calibrated cylinder or cham-
ber, which holds 150 mL, with brand names such as Buretrol, Volutrol, and SoluSet, also inserted into
the primary set port. The third type is the regular set used with the infusion pump and piggybacked into
the primary set at a port closer to the patient (Figure 11-9).
Medication is prepared and injected into a bag or a cylinder. If the cylinder is used, the drug is diluted with
a measured amount of IV solution. After infusion, the cylinder is rinsed with 15 to 30 mL of the IV solution
to clear the medication from the tubing. If the bag is used, the infusion runs until the bag is emptied.
If the fluid is delivered by gravity flow, the medication bag or cylinder needs to be raised higher than
the primary set for the medication to infuse. Be aware that the drip chamber of the primary set must be
observed to see that the medication is infusing properly from the secondary set and is not flowing into
the primary set instead of the patient. If the secondary set is not flowing properly, then the IV site must
be checked for patency.

Adding Drugs Used for Intermittent Intravenous Administration

Drugs that are given by intermittent infusion must be diluted and infused over a specific period of time.
The pH and the osmolarity determine the dilution. A slower infusion time allows for the medication to
be diluted in the blood vessel, thereby preventing phlebitis and high concentrations in the plasma and

Secondary
IV bag
with drug

Drug port

Primary
Air vent bag

150
140
130
120
110
100
90
80
70
60
50
40
30
20
10

Calibrated cylinder Secondary bag with

(Buretrol) medication
Figure 11-9 ​Equipment for secondary intravenous sets.
224 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Figure 11-10 ​Medication mixed and attached to an IV bag.

tissues, which might cause time-related overdose, toxic effects, or allergic reaction. Drug-dosing instruc-
tions indicate the amount and type of solution and the length of infusion time. If the medication is not
premixed from the pharmacy, the nurse must calculate the drug dose from the physician’s order, then
calculate the flow rate from the drug-dosing information.
Clinical agencies frequently have their own protocols for dilutions; if not, the drug information insert
should provide infusion guidelines. If the information is not available, the hospital’s pharmacy should be
contacted. It is recommended that one set be used for the same drug to prevent admixture. Every set
should be dated and labeled because one set can be used multiple times for the same drug in a 24-hour
period. Guidelines and protocols help prevent drug and fluid incompatibilities.
Drugs administered by Buretrol, Volutrol, or SoluSet may be prepared by the nurse. Powdered drugs
must be reconstituted with sterile water or normal saline solution following manufacturers’ guidelines.
Once the medication is added to the Buretrol, then the appropriate amount and type of IV fluid is added
to the medication, and the infusion rate is adjusted. For medication diluted in bags or bottles, the pow-
dered drug can be reconstituted the same way, or a spike adaptor can be used that can be attached to the
vial and the bag. Fluid from the IV bag is flushed into the vial, reconstituting the powder, and then is
flushed back into the bag. This process decreases contamination and is cost-effective. Mixing may be
done by either the pharmacy or by the nurse (Figure 11-10).
The current trend in IV administration is the use of premixed or “ready to use” IV drugs in 50-mL to
1000-mL bags. These premixed IV medications can be prepared by the manufacturer or by the hospital’s
pharmacy. Problems of contamination and drug errors are decreased with the use of premixed IV medica-
tion. Each IV drug bag has separate tubing to prevent admixture. The actual cost of premixed medication is
lower because there is less risk and less waste; it also saves nurses time. Because not all hospitals have admix-
ture pharmacy systems in place, nurses will continue to prepare some drugs for IV administration.

N OTE
Sometimes the medication volume that is added to a bag or bottle adds a significant amount of volume. In
those situations the 10% guideline applies. If the volume of medication for IV infusion exceeds 10% of the
IV solution volume in the bag or bottle, then the amount of the medication volume should be withdrawn
from the IV bag/bottle and replaced with the medication. For example, if the medication volume is 10 mL
and a 100-mL bag is used, 10 mL should be aspirated from the IV bag injection port and replaced with the
medication so that the total volume will still be 100 mL. If the medication’s volume is less than 10%, then
add the volume of medication to the volume of the bag or bottle. For example, 7 mL of medication is less
than 10% of a 100-mL bag, so the total volume will be 107 mL. Follow your institution’s protocol.

ADD-Vantage System
This system is similar to a secondary IV infusion or a piggyback system in which the nurse or pharmacist
prepares the IV drugs. Figure 11-11 shows steps that the nurse takes in preparing the ADD-Vantage
drug for IV administration.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 225

Figure 11-11 ​Hospira ADD-Vantage system. (From Hospira, Inc., Lake Forest, Ill.)
226 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Electronic Intravenous Infusion Pumps

Infusion pumps are used for accurate fluid and drug administration (Figure 11-12). The peristaltic, volu-
metric, and syringe are three basic types of infusion pumps and all use a motor mechanism to create posi-
tive pressure to infuse fluid. The first is the linear peristaltic pump that uses a specially designed IV
administration set that when placed in the pump, allows for ridges in the pump to move in a wavelike
motion against the tubing to propel fluid along. The volumetric pump also has a specifically designed
administration set with a reservoir that fills and empties every cycle to deliver the programmed fluid rate.
The increments of fluid delivered with volumetric pumps can be as small as one tenth to one hundredth
of a milliliter. The volumetric pump is considered more accurate than the peristaltic pump and the volu-
metric design is more widely manufactured.
The syringe pump uses a gear and screw mechanism to push fluid through IV tubing. One advantage
of the syringe pump is that it does not require special tubing. A major disadvantage is that the syringe
pump can hold only 2-mL to 100-mL syringes. The syringe pump is ideal for infusion of very small
increments and some brands of pumps can infuse in nanograms. Syringe pumps are commonly used in
pediatrics, oncology, obstetrics, and anesthesia (Figure 11-13, A).
The general-purpose pumps have safety features such as air-in-line, occlusion and infusion-complete
alarms, as well as low-battery or low-power alerts (Figure 11-13, B and C). Pumps deliver a specific vol-
ume of fluid at a specific rate, measured in milliliters per hour (mL/hr). The general-purpose pump deliv-
ers at the rate of 0.1 to 999.9 mL/hr. The tubing for infusion pumps includes a safety feature called a flow
regulator to prevent “free flow” when the tubing is removed from the pump. These regulators can be
adjusted similarly to the roller clamp but are to be used only temporarily until the tubing can be placed
back in the pump. Sensors in the pumps detect full or partial occlusion, especially at low flow rates.
Another design feature is an alarm that notifies the nurse of an empty fluid container or any upstream
occlusion, such as a clamp, that has not been released.
Programmable infusion pumps are now available that have important safety features that help in pre-
venting IV drug errors. Programmable pumps, often referred to as “smart” pumps, have customized software
that contains a library of medications and the maximum and minimum rates, known as guardrail limit, at
which the medications should safely infuse (Figure 11-13, E). Hospitals can develop dosing parameters for
each IV drug used in each patient area and update as needed. Once the IV medication solution is prepared,
the nurse chooses the drug from the pump’s library, then selects the dose to be given, the amount of solution
in which the drug is diluted, and the time of the infusion. The pump calculates the infusion rate and will

Secondary IV

Primary IV

Clamp

Clamp

Y port

Infusion pump

Clamp

Figure 11-12 Typical IV setup with infusion pump.

 CHAPTER 11 Intravenous Preparations With Clinical Applications 227

infuse the drug at the correct rate. If the software recognizes an incorrect concentration or infusion time, the
pump will alarm to alert the nurse so that the problem can be evaluated and corrected.

Multichannel Pumps
Multichannel smart pumps have a main software module or platform that houses the drug library.
The infusion channel where the IV tubing is placed is docked or added to the platform. The platform
controls infusion rates through the channel, and extra channels (up to four) can be added to handle mul-
tiple drug infusions at different infusion rates (Figure 11-13, F).

Ambulatory Pumps
Ambulatory pumps are volumetric and used primarily for outpatients because of their small size and light
weight. This type of programmable pump is used for intermittent and continuous infusion or demand
dosing. Ambulatory pumps can accommodate high volume rates, such as 125 mL/hr, and low dosing
rates, such as 0.02 to 1 mL.

Patient-Controlled Analgesia
Patient-controlled analgesia (PCA) pumps are computerized devices that are programmed so patients
can self-administer IV analgesics (Figure 11-13, D). These battery-operated infuser pumps latch onto a
cassette or bag of a narcotic that can be infused into a patient with the use of PCA-compatible tubing. A
continuous rate, demand dose, and frequency of administration can be programmed into the pump. These

E
A C

D
Figure 11-13 ​Multichannel infusion pump. A, Syringe pump. B, Single-infusion pump. C, Dual-channel infusion pump. D, Patient-controlled
analgesia (PCA) pump. E, Alaris System Large Volume Pump with PCA. F, Example of the Medley pump module attached to the Medley program-
ming module. (From ALARIS Medical Systems, Inc., San Diego, Calif. E and F, Copyright 2011 CareFusion Corporation; used with permission.)
228 PART III Calculations for Oral, Injectable, and Intravenous Drugs

set limits are ordered by the prescriber and prevent overdosage. The patient is able to administer a dose
of pain medication using a control button attached to the PCA pump. The pump keeps a record of how
much pain medication was delivered and how frequently the pain button was used. Each patient’s pain
should be assessed and PCA therapy should be documented per your institution’s policy. Commonly used
narcotics administered on a PCA pump are morphine, fentanyl, and hydromorphone.
The use of infusion pumps is becoming the standard of care for IV medication delivery. IV pumps
with programmable software allow for the precise and accurate delivery of medication, especially com-
pared to the roller clamp adjustment and visual drop counting method. Remember, every model of pump
has different features and capabilities. It is essential that the nurse has a working knowledge and under-
standing of the equipment to deliver safe patient care.

FLOW RATES FOR INFUSION PUMPS AND SECONDARY SETS

When medication is given via the infusion pump, the primary IV flow is halted while the medication is
infused. Once the secondary infusion is complete, the primary IV fluid can be restarted (see Figure
11-12). If a smart pump is used, the drug is selected from the library with the prescribed concentration,
and the rate per hour is determined by the calculations from the pump. However, if a general-purpose
pump is used, the nurse must calculate the rate per hour. If pumps are not available for infusion, then the
nurse must calculate the secondary set IV rate in drops per minute.

u ONE-STEP METHOD FOR IV DRUG CALCULATION WITH SECONDARY SET

Amount of solution 3 gtt /mL of the set
5 gtt /minute
Minutes to administer
Minutes to administer
Amount of solution 4 5 mL/hour
60 minutes /hour

N OTE
Medication volume that exceeds 1 mL should be added to the dilution volume in intermittent drug therapy.
Because smaller volumes of fluid are used for IV infusion, drug dosage may be decreased if the volume of
medication is not included in the dilution volume. The amount of solution in the formula should include
both volumes.

EXAMPLES PROBLEM 1: Order: Tagamet 200 mg, IV, q6h.

Drug available:

Set and solution: Buretrol set with drop factor of 60 gtt/mL; 500 mL of D5W.
Instructions: Dilute drug in 100 mL of D5W and infuse over 20 minutes.
Drug calculation:
D 200 mg 400
BF: 3V5 3 2 mL 5 5 1.3 mL of Tagamet
H 300 mg 300
 CHAPTER 11 Intravenous Preparations With Clinical Applications 229

or or H D 300 mg 200 mg
RP: H ; V < D ; X FE: 5 5 5 5
V X 2 mL X
300 mg;2 mL<200 mg;X mL
300 X 5 400 1Cross multiply2 300 X 5 400
400 X 5 1.3 mL
X5
300
X 5 1.3 mL of Tagamet
2
or 2 mL 3 200 mg 4
DA: mL 5 5 5 1.3 mL
300 mg 3 1 3
3

Flow rate calculation: 100 mL 1 1.3 mL 5 101.3 mL or 101 mL

3
Amount of solution 3 gtt /mL 101 mL 3 60 gtt
5 5 303 gtt /min
Minutes to administer 20 min
1

Answer: Inject 1.3 mL of Tagamet into 100 mL of D5W in the Buretrol chamber.
Regulate IV flow rate to 303 gtt/min.
It would be impossible to count 303 gtt/min. Instead of using the Buretrol, the nurse could
use a secondary set with a larger drop factor or a regulator.

PROBLEM 2: Order: Mandol 500 mg, IV, q6h.

Drug available:

Label: Add 20 mL of diluent.

Set and solution: Secondary set with 100 mL D5W and a drop factor of 15 gtt/mL.
Instructions: Dilute in 100 mL of D5W and infuse over 30 minutes.
Drug calculation: (2.0 g 5 2.000 mg).
N
D 500 mg 10,000
BF: 3V5 3 20 mL 5 5 5 mL of Mandol
H 2000 mg 2000
or or H D 2000 mg 500 mg
RP: H ; V < D ; X FE: 5 5 5 5
2000 mg;20 mL<500 mg;X mL V X 20 mL X
2000 X 5 10,000 1Cross multiply2 2000 X 5 10,000
X 5 5 mL of Mandol X 5 5 mL of Mandol

or 10 1
20 mL 3 1g 3 500 mg 10
DA: mL 5 5 5 5 mL of Mandol
2 g 3 1000 mg 3 1 2
1 2
230 PART III Calculations for Oral, Injectable, and Intravenous Drugs

Flow rate calculation: 100 mL 1 5 mL 5 105 mL

1
Amount of solution 3 gtt /mL 105 mL 3 15 gtt /mL 105
5 5 5 52.5 or 53 gtt /min
Minutes to administer 30 min 2
2

Answer: Inject 5 mL of Mandol into the 100 mL D5W bag.

Regulate IV flow rate to 53 gtt/min.

PROBLEM 3: Order: Zithromax 500 mg IV daily for 2 days.

Drug available:

Label: Add 4.8 mL of sterile water to reconstitute to 100 mg/mL 5 5 mL

Set and solution: Use an infusion pump.
Instructions: Dilute in 250 mL D5W and infuse over 3 hours.
Flow rate calculation: 250 mL D5W 1 5 mL of medication 5 255 mL
3
Minutes to administer 180 min 1
Amount of solution 4 5 255 mL 4 5 255 3 5 85 mL/hr
60 minutes /hr 60 min/hr 3
1

Answer: Infusion rate should be set at 85 mL/hr.

PROBLEM 4: Order: albumin 25 g, IV, now.

Available: albumin 25 g in 50 mL.
Set: Use an infusion pump.
Instructions: Administer over 25 minutes, or 2 mL/min.
Drug calculation: Not applicable.
Infusion pump rate:
25 min 60 3000
50 mL 4 5 50 3 5 5 120 mL/hr
60 min 25 25

Answer: Infusion rate should be set at 120 mL/hr.

 CHAPTER 11 Intravenous Preparations With Clinical Applications 231

PROBLEM 5: Order: potassium phosphate 10 mM IV in 100 mL NS over 90 minutes.

Drug available:

Set: Use an infusion pump.

Drug calculation:
D 10 mM 50
BF: 3V5 3 5 mL 5 5 3.3 mL of potassium phosphate
H 15 mM 15
or or H D 15 mM 10 mM
RP: H ; V < D ; X FE: 5 5 5
V X 5 mL X mL
15 mM;5 mL<10 mM;X mL
15 X 5 50 1Cross multiply2 15 X 5 50
X 5 3.3 mL of
X 5 3.3 mL of potassium phosphate
potassium
phosphate
2
or 5 mL 3 10 mM 10
DA: mL 5 5 5 3.3 mL
15 mM 3 1 3
3

Minutes to administer
Infusion pump rate: Amount of solution 4 5 mL/hr
60 minutes
90 min 60
103 mL 4 5 103 3 5 68.6 or 69 mL/hr
60 min 90

Answer: Rate on the infusion pump should be 69 mL/hr to deliver potassium phosphate
10 mM in 90 minutes.

N OTE
When the electrolyte potassium is administered peripherally, the maximum infusion rate is 10 mEq/hr.

PRACTICE PROBLEMS u
​ ​III ​INTERMITTENT INTRAVENOUS ADMINISTRATION
Answers can be found on pages 241 to 245.

Calculate the fluid rate by using a calibrated cylinder (Buretrol), a secondary set, or an infusion pump, as
indicated in each question.
1. Order: Cefazolin 250 mg, IV, q6h.
Drug available: Cefazolin 1 g vial to be diluted with 2.5 mL.

Set solution: Set Buretrol for a drop factor of 60 gtt/mL.

Instructions: Dilute drug in 75 mL of NS and infuse over 30 minutes in Buretrol.
a. 250 mg 5 grams
b. Drug calculation:
c. Flow rate calculation:
232 PART III Calculations for Oral, Injectable, and Intravenous Drugs

2. Order: acetaminophen 500 mg, IV, q6h PRN for fever .38° C.
Patient’s temperature is currently 38.5° C.
Drug available: Ofirmev 1000 mg/100 mL.

Set: secondary set with a drop factor of 6 gtt/mL.

Instructions: Infuse over 15 minutes.
a. Drug calculation:

b. Flow rate calculation:

3. Order: ticarcillin (Ticar) 500 mg, IV, q6h.
Drug available:

Set and solution: Buretrol set with a drop factor of 60 gtt/mL; infusion pump; 500 mL of D5W.

Instructions: Dilute drug in 75 mL of D5W and infuse over 40 minutes.
a. Drug calculation: Add mL to ticarcillin vial (see drug label).

b. Flow rate calculation (gtt/min):
How many drops per minute should the patient receive with use of the Buretrol set?

c. Infusion pump rate calculation (mL/hr):
With an infusion pump, how many mL/hr should be administered?

 CHAPTER 11 Intravenous Preparations With Clinical Applications 233

4. Order: piperacillin 2.5 g, IV, q6h.

 Drug available: piperacillin 4 g vial in powdered form; add 7.8 mL of diluent to yield 10 mL of
drug solution (4 g 5 10 mL).

Set and solution: Buretrol set with a drop factor of 60 gtt/mL; infusion pump; 500 mL of D5W.

Instructions: Dilute drug in 100 mL of D5W and infuse over 30 minutes.
a. Drug calculation:

b. Flow rate calculation (gtt/min):
How many drops per minute should the patient receive with use of the Buretrol set?

c. Infusion pump rate calculation (mL/hr):
With an infusion pump, how many mL/hr should be administered?

5. Order: methicillin (Staphcillin) 1 g, IV, q6h.
Drug available: Staphcillin 4 g in powdered form in vial; add 5.7 mL of diluent to yield 8 mL
(1 g 5 2 mL).

Set and solution: secondary set with a drop factor of 15 gtt/mL; 100-mL bag of D5W; infusion
pump.

Instructions: Dilute drug in 100 mL of D5W and infuse over 40 minutes.
a. Drug calculation:
Explain the procedure for diluting the drug and adding it to the IV bag.

b. Flow rate calculation (gtt/min):
How many drops per minute should the patient receive with use of a secondary set?

c. Infusion pump rate calculation (mL/hr):
With an infusion pump, how many mL/hr should be administered?

234 PART III Calculations for Oral, Injectable, and Intravenous Drugs

6. Order: ciprofloxacin 250 mg, IV, q12h.

Drug available:

Set and solution: Secondary set with drip factor 15 gtt/mL; 250 mL of D5W.

Instructions: ​Add ciprofloxin 250 mg to 250 mL D5W and infuse over 60 minutes.
a. Drug calculation:

b. Flow rate calculation (gtt/min):
How many drops per minute should the patient receive?

7. Order: doxycycline (Vibramycin), 100 mg, IV, q12h.
Drug available:

Set and solution: 100 mL of D5W; secondary set with drop factor 15 gtt/mL; infusion pump.

Instructions: Mix Vibramycin vial with 10 mL of diluent; dilute in 100 mL of D5W and infuse in
40 minutes.
a. Flow rate calculation (gtt/min):

b. Infusion pump rate calculation (mL/hr):

 CHAPTER 11 Intravenous Preparations With Clinical Applications 235

8. Order: ranitidine (Zantac) 50 mg, IV, q6h.

Set: infusion pump.
Drug available: premixed drug in bag (Zantac 50 mg in 0.45% NaCl [1⁄2 NSS]).

Instructions: Infuse over 15 minutes.

a. Infusion pump rate calculation:
9. Order: cefepime (Maxipime) 750 mg, IV, q12h.
Set and solution: infusion pump; 100 mL D5W.
Drug available:

Instructions: Add 8.7 mL of diluent to Maxipime to yield 10 mL of drug solution. Dilute in

100 mL of D5W; infuse over 30 minutes.
a. Drug calculation:

b. Infusion pump rate calculation (mL/hr):
236 PART III Calculations for Oral, Injectable, and Intravenous Drugs

10. Order: rifampin (Rifadin) 600 mg, IV, daily.

Set and solution: infusion pump; 500 mL D5W.
Drug available: Rifadin, 600 mg sterile powder.

Instructions: Add 10 mL of diluent to the rifampin vial. Dilute rifampin in 500 mL of D5W;
infuse over 3 hours.
a. Infusion pump rate calculation (mL/hr):
11. Order: cefoxitin (Mefoxin) 2 g, IV, q8h.
Drug available: ADD-Vantage vial.

Set and solution: 100 mL of 0.9% NaCl diluent bag for ADD-Vantage; Mefoxin vial for
ADD-Vantage.

Instructions: Dilute Mefoxin in 100 mL of NS (0.9% NaCl) and infuse in 30 minutes.
a. How would you prepare Mefoxin 2 g powdered vial with the diluent bag? (See page 225 as
needed.)
b. Infusion pump rate calculation (mL/hr):
12. Order: Hycamtin (topotecan HCl) 1.5 mg/m2/day, IV, daily for 5 days.
Adult weight and height: 140 lb, 66 inches.
Drug available:

Set and solution: 100 mL of D5W; infusion pump.

Instructions: Mix Hycamtin with 5.6 mL of diluent, equals 6 mL of Hycamtin; dilute in 100 mL
of D5W and infuse over 30 minutes.
a. What is the patient’s m2 (BSA)? See Figure 7-1 on page 100.
b. Drug calculation:
c. Infusion pump rate calculation (mL/hr):
 CHAPTER 11 Intravenous Preparations With Clinical Applications 237

13. Order: Velban (vinblastine): initially 3.7 mg/m2 as a single dose.

Adult weight and height: 180 lb, 70 inches.
Drug available:

Set and solution: 250 mL of D5W; infusion pump.

Instructions: Mix vinblastine powdered vial with 10 mL of diluent and inject solution into
250 mL of D5W. Infuse over 1 hour.
a. What is the patient’s m2 (BSA)?
b. Drug calculation:
c. Infusion pump rate calculation (mL/hr):
14. Order: potassium chloride 20 mEq in 150 mL D5W infused over 2 hours.
Drug available:

Set and solution: secondary set with drop factor of 15 gtt/mL; 150-mL bottle D5W; infusion
pump.
a. Drug calculation:

b. Infusion pump rate calculation (mL/hr):
238 PART III Calculations for Oral, Injectable, and Intravenous Drugs

15. Order: magnesium sulfate 5 g in 100 mL D5W infused over 3 hours.

Drug available:

Set and solution: secondary set with drip factor of 15 gtt/mL; 100-mL bag D5W; infusion
pump.

Drug calculation:
a. 1 mL 5 mg (see drug label)
b. 5 g 5 mL
c. Infusion pump rate calculation (mL/hr):

16. Order: calcium gluconate 10%, 16 mEq in 100 mL D5W, infused over 30 minutes.
Drug available:

Set and solution: secondary set with a drip factor of 15 gtt/mL; 100-mL bag D5W; infusion
pump.
a. Drug calculation:

b. Infusion pump rate calculation (mL/hr):

 CHAPTER 11 Intravenous Preparations With Clinical Applications 239

ANSWERS
I Direct IV Injection

1. a. 5-mL drug solution

b. known drug;known minutes<desired drug;desired minutes
5 mg ; 1 min < 50 mg ; X min
5 X 5 50
X 5 10 minutes
2. known drug;known minutes<desired drug;desired minutes
10 mL ; 1 min < 50 mL ; X min
10 X 5 50
X 5 5 minutes
3. a. 10 mL
b. known drug;known minutes<desired drug;desired minutes
1.5 mL ; 1 min < 10 mL ; X min
1.5 X 5 10
X 5 6.6 minutes or 7 minutes
4. a. 0.25 mL fentanyl
b. known drug;known minutes<desired drug;desired minutes
10 mcg ; 1 min < 12.5 mcg ; X min
10 X 5 12.5
X 5 1.25 minutes
5. a. RP: H ; V < D ; X or H 10 mg 6 mg
D
10 mg;1 mL<6 mg;X FE: 5 5 5
10 X 5 6 V X 1 mL X
X 5 0.6 mL morphine 10 X 5 6
b. known drug;known minutes<desired drug;desired minutes X 5 0.6 mL
10 mg ; 4 min < 6 mg ; X min
10 X 5 24
X 5 2.4 minutes
6. a. 1 mL
b. known drug;known minutes<desired drug;desired minutes
1 mL ; 5 min < X mL ; 1 min
5X51
X 5 0.2 mL/minute
1 mL 3 2 mg 2
7. a. DA: mL 5 5 5 0.4 mL of Haldol
5 mg 3 1 5
b. known drug;known minutes<desired drug;desired minutes
1 mg ; 1 min < 2 mg ; X min
X 5 2 minutes
D 6 mg
8. a. BF: 3V5 3 1 5 1.5 mL of Ativan
H 4 mg
b. known drug;known minutes<desired drug;desired minutes
2 mg ; 1 min < 6 mg ; X min
2X56
X 5 3 minutes
240 PART III Calculations for Oral, Injectable, and Intravenous Drugs

9. a. RP: H ; V < D ; V or H 25 mg 20 mg
D
25 mg;5 mL<20 mg;X mL FE: 5 5 5
25 X 5 100 V X 5 mL X mL
X 5 4 mL 1Cross multiply2 25 X 5 100
or X 5 4 mL
V3D
DA: V 5
H31
4
5 mL 3 20 mg 20
mL 5 5 5 4 mL
25 mg 3 1 5
5
Amount of drug 4 mL
b. 5 5 2 mL/min
Number of minutes 2 min
Answer: Infuse 2 mL of cardizem per minute.
10. a. 140 lb 4 2.2 5 64 kg
b. 10 mcg 3 64 kg 5 640 mcg
Change micrograms (mcg) to milligrams by moving the decimal point three spaces to the left: 640 mcg 5
0.640 mg or 0.6 mg. N
c. Known drug;known seconds<desired drug;desired seconds
1 mg ; 60 seconds < 0.6 mg ; X sec
X 5 36 seconds
Answer: Infuse 0.6 mg of granisetron (Kytril) over 36 seconds.

II Continuous Intravenous Administration

1. a. Microdrip set because the patient is to receive 83 mL/hr

1000 mL
b. Three-step method: (a) 5 83 mL/hr
12 hr
83 mL/hr
(b) 5 1.38 mL/min or 1.4 mL
60 min
(c) 1.4 mL/min 3 60 gtt/mL 5 84 gtt/min
Using a microdrip set (60 gtt/mL), IV should run at 84 gtt/min.
2. a. 1 L 5 1000 mL
b. Each liter should run for 8 hours.
c. Two-step method: 1000 4 8 5 125 mL/hr
1
125 mL 3 15 gtt /min 125
5 5 31–32 gtt /min
60 min 4
4
With a 15-gtt/mL drop set, IV should run at 31 to 32 gtt/min.
3. a. Microdrip set with drop factor of 60 gtt/mL is used because the hourly rate is low and would make drops
easier to count.
1
250 mL 3 60 gtt /min
b. One-step method: 5 10 gtt /min
24 hr 3 60 min/hr
1
With a microdrip set, IV should run at 10 gtt/min. KVO usually means 24 hours.
4. a. 10 mL of KCl
b. Use a 10-mL syringe; withdraw 10 mL of KCl and inject into the rubber stopper part of the IV bag.
c. Microdrip set: 100 gtt/min
Macrodrip set: drop factor of 20 gtt/mL; 33 gtt/min (33.3 gtt/min)
 CHAPTER 11 Intravenous Preparations With Clinical Applications 241

5. a. 700 mL of IV fluid is left and 4 hours are left.

b. Recalculate using 700 mL and 4 hours to run.
700 mL
Three-step method: (a) 5 175 mL/hr
4 hr
175 mL/hr
(b) 5 2.9 mL/min
60 min
(c) 2.9 mL/min 3 15 gtt/mL 5 43.5 gtt/min or 44 gtt/min
6. 100 gtt/min
1
100 3 60 gtt /mL
Two-step method: 5 100 gtt /min
60 min
1
7. a. KCl 40 mEq/20 mL
b. 20 mL
1000 mL
c. 5 8 hours
125 mL/hr
8. a. KCl 20 mEq/10 mL
b. 10 mL
1000 mL
c. 5 10 hours
100 mL/hr
1
100 mL 3 10 gtt /mL 100
d. 5 5 16.6 gtt /min or 17 gtt /min
60 min 6
6
or 1
1000 mL 3 10 gtt /mL 1000
5 5 16.6 gtt /min or 17 gtt /min
10 hr 3 60 min 60
1

III Intermittent Intravenous Administration

1. a. 250 mg 5 0.25 g
b. Drug calculation:
or
D 0.25 g
BF: 3V5 3 2.5 mL 5 0.6 mL RP: H; V < D ; X
H 1g 1 g;2.5 mL<0.25 g;X mL
1 X 5 2.5 3 0.25
X 5 0.6 mL
or 2.5 mL 3 1g 3 250 mg or H 1g 0.25 g
D
DA: mL 5 5 0.6 mL FE: 5 5 5 5 X 5 0.6 mL
1 g 3 1000 mg 3 1 V X 2.5 mL X
c. Flow rate calculation: Amount of solution: 75 mL 1 0.6 mL 5 75.6 or 76 mL
Amount of solution 3 gtt /mL 76 mL 3 60 gtt /mL
5 5 152 gtt /min
Minutes to administer 30 min
Regulate flow rate for 152 gtt/min.
242 PART III Calculations for Oral, Injectable, and Intravenous Drugs

2. a. Drug calculation:
500 g or
D
BF: 3V5 3 100 mL 5 50 mL RP: H ; V < D ; X
H 1000 mg 1000 g;100 mL<500 mg;X mL
1000 X 5 50,000
X 5 50 mL
or 100 mL 3 500 mg or H 1000 mg 500 mg
D
DA: mL 5 5 50 mL FE: 5 5 5
1000 mg 3 1 V X 100 mL X
1000 X 5 50,000
1Cross multiply2 X 5 50 mL
b. Flow rate calculation:
Amount of solution 3 gtt /mL 100 mL 3 6 gtt /mL
5 5 40 gtt /min
Minutes to administer 15 minutes
Regulate flow rate of secondary tubing for 40 gtt/min.
3. a. Drug calculation:
D 500 mg 2000
BF: 3V5 3 4 mL 5 5 2 mL is the dose for 500 mg of ticarcillin.
H 1000 mg 1000
b. Flow rate calculation: Amount of solution: 75 mL D5W 1 2 mL of drug solution 5 77 mL
For Buretrol set:
3
77 mL 3 60 gtt /mL 1set2 231
5 5 115.5 or 116 gtt /min
40 minutes 2
2
c. Infusion pump rate calculation:
Minutes to administer
Amount of solution 4 5 mL/hr
60 min/hr
2
40 min to administer 3 231
77 mL 4 5 77 3 5 5 116 mL/hr
60 min/hr 2 2
3
Set pump rate at 116 mL/hr to deliver Ticar 500 mg in 40 minutes.
4. a. Drug calculation:
D 2.5 g 5 12.5 or H
BF: 3V5 3 10 mL 5 5 6.25 mL D 4g 2.5 g
H 4g 2 FE: 5 5 5
2 V X 10 mL X mL
or 1Cross multiply2 4 X 5 25
RP: H ; V < D ; X
X 5 6.25 mL
4 g;10 mL<2.5 g;X mL
or
4 X 5 25 10 mL 3 2.5 g 25
DA: mL 5 5 5 6.25 mL
X 5 6.25 mL 4g 3 1 4
piperacillin 2.5 g 5 6.25 mL
b. Flow rate calculation for Buretrol set: amount of solution: 6.25 mL 1 100 mL 5 106.25 mL
2
106 mL 3 60 gtt /mL
5 212 gtt /min
30 min/hr
1
c. Infusion pump rate calculation: 100 mL 1 6 mL medication 5 106 mL
1
30 min to administer 2
106 mL 4 5 106 3 5 212 mL/hr
60 min/hr 1
2
Set pump rate at 212 mL/hr to deliver piperacillin 2.5 g in 30 minutes.
 CHAPTER 11 Intravenous Preparations With Clinical Applications 243

5. a. Drug calculation: Staphcillin 4 g 5 8 mL

D 1g 8
BF: 3V5 3 8 mL 5 5 2 mL dose of Staphcillin
H 4g 4
Amount of solution: 2 mL 1 100 mL 5 102 mL
b. Flow rate calculation for secondary set:
102 mL 3 15 gtt /mL 1set2 1530
5 5 38.25 or 38 gtt /min
40 minutes 40
c. Infusion pump rate calculation: amount of solution: 100 mL 1 2 mL 5 102 mL
2
40 min to administer 3 306
102 mL 3 5 102 3 5 5 153 mL/hr
60 min/hr 2 2
3
Set pump rate at 153 mL/hr to deliver Staphcillin 1 g in 40 minutes.
6. a. Drug calculation:
250 mg or
D 1 250
BF: 3V5 3 40 mL 5 5 25 mL RP: H ; V < D ; X
H 400 mg 10 400 mg;40 mL<250 mg;X mL
10
400 X 5 10,000
X 5 25 mL
1
or H or
D 400 250 40 mL 3 250 mg
FE: 5 5 5 5 DA: mL 5 5
V X 40 X 400 mg 3 1
10
1Cross multiply2 400 X 5 10,000 25 mL of ciprofloxacin
X 5 25 mL of ciprofloxacin
b. Flow rate calculation (gtt/min):
Amount of solution: 25 mL 1 250 mL 5 275 mL
275 mL 3 15 gtt /mL 4125
5 5 68.75 or 69 gtt /min
60 min/hr 60
7. a. Flow rate calculation (gtt/min):
Amount of solution: 10 mL 1 100 mL 5 110 mL
3
110 mL 3 15 gtt /mL 330
5 5 41.25 or 41 gtt /min
40 min to admin 8
8
b. Infusion pump rate calculation (mL/hr):
6
40 min 60 660
110 mL 4 5 110 mL 3 5 5 165 mL/hr
60 min 40 4
4
8. a. Amount of solution:
4
Min to administer 15 min 60 min
5 50 mL 4 5 50 mL 3 5 200 mL/hr
60 mL/hr 60 min 15 min
1
Infusion pump rate calculation: 200 mL/hr
9. 1 g 5 1000 mg (use conversion table as needed) of Maxipime
a. Drug calculation:
3
D 750 mg 30
3 V 5 3 10 mL 5 5 7.5 mL drug solution
H 1000 mg 4
4
Amount of solution: 7.5 mL 1 100 mL 5 107.5 mL
244 PART III Calculations for Oral, Injectable, and Intravenous Drugs

b. Infusion pump rate calculation:

2
30 min to administer 60
107.5 mL 4 5 107.5 mL 3 5 215 mL/hr pump rate
60 min/hr 30
1
10. Amount of solution: 10 mL 1 500 mL 5 510 mL
1
180 min 60 510
a. Infusion pump rate calculation: 510 mL 4 5 510 mL 3 5 5 170 mL/hr
60 min/hr 180 3
3
11. a. See page 225 for mixing ADD-Vantage drugs. Mix 2 g of cefoxitin (Mefoxin) using ADD-Vantage vial
with ADD-Vantage 100 mL diluent bag.
b. Infusion pump rate calculation (mL/hr):
30 min to administer
100 mL 4 5
60 min/hr
2
60
100 mL 3 5 200 mL/hr
30
1

12. a. BSA: 1.74 m2; see Figure 7-1, page 100.

b. Drug calculation:
1.5 mg 3 1.74 m2 5 2.61 or 2.6 mg/m2/day
D 2.6 mg 3 7.8
BF: 3V5 3 6 mL 5 5 3.9 mL or 4 mL
H 4 mg 2
2
Amount of solution: 4 mL 1 100 mL 5 104 mL
c. Infusion pump rate calculation (mL/hr):
2
30 min to administer 60
104 mL 4 5 104 3 5 208 mL/hr
60 min/hr 30
1
13. a. 2.05 m2 (BSA)
b. Drug calculation:
3.7 mg 3 2.05 m2 5 7.58 or 7.6 mg/m2
Velban 10 mg diluted in 10 mL
Each mg 5 1 mL; 7.6 mg 5 7.6 mL
Amount of solution: 7.6 mL 1 250 mL 5 257.6 mL
c. Infusion pump rate calculation (mL/hr):
1
60 60
257.6 mL 4 5 257.6 3 5 257.6 or 258 mL/hr
60 60
1
14. a. Drug calculation:
20 mEq or
D 400
BF: 3V5 3 20 mL 5 5 10 mL KCl RP: H ; V < D ;X
H 40 mEq 40 40 mEq;20 mL<20 mEq;X
or H 40 X 5 400
D 40 mEq 20 mEq
FE: 5 5 5 X 5 10 mL KCl
V X 20 mL X mL
1
or
1Cross multiply2 40 X 5 400 20 mL 3 20 mEq 20
DA: mL 5 5 5 10 mL
X 5 10 mL 40 mEq 3 1 2
2
Amount of solution: 150 mL 1 10 mL 5 160 mL
 CHAPTER 11 Intravenous Preparations With Clinical Applications 245

b. Infusion pump rate calculation:

120 min to administer 1
160 mL 4 5 160 3 5 80 mL/hr
60 min/hr 2
Set pump rate at 80 mL/hr to deliver KCl 20 mEq in 2 hours.
15. Drug calculation:
a. 1 mL 5 500 mg and 2 mL 5 1 g
D 5g or
b. BF: 3V5 3 2 5 10 mL RP: H; V <D; X
H 1g
1 ; 2 < 5 ;X
X 5 10
X 5 10 mL KCl magnesium sulfate
2
or H 1g 5g or
D 1 mL 3 1000 mg 3 5 g
FE: 5 5 5 DA: mL 5 5 10 mL
V X 2 mL X mL 500 mg 3 1g 3 1
1
1Cross multiply2 X 5 10 mL of magnesium sulfate
Amount of solution: 10 mL 1 100 mL 5 110 mL
c. Infusion pump rate calculation:
3
180 min to administer 1
110 mL 4 5 110 3 5 36.6 or 37 mL/hr
60 min/hr 3
1
Set pump rate at 37 mL/hr to deliver magnesium sulfate 5 g in 3 hours.
16. a. Drug calculation:
D 16 mEq or
BF: 3V5 3 10 mL 5 34.4 mL RP: H ; V < D ; X
H 4.65 mEq
4.65 mEq;10 mL<16 mEq;X mL
or H 4.65 X 5 160
D 4.65 16
FE: 5 5 5 X 5 34.4 mL
V X 10 X
4.65 X 5 160
X 5 34.4 mL
or 10 mL 3 16 mEq
DA: mL 5 5 34.4 mL
4.65 mEq 3 1
Amount of solution: 34.4 mL 1 100 mL 5 134.4 mL
b. Infusion pump rate calculation:
1
30 min to administer 2
134.4 mL 4 5 134.4 3 5 268.8 or 269 mL/hr
60 min/hr 1
2

Additional practice problems are available in the Intravenous Calculations and Advanced
Calculations sections of Drug Calculations Companion, version 5, on Evolve.
PART IV
CALCULATIONS FOR
SPECIALTY AREAS

247
CHAPTER 12
Pediatrics

Objectives • Use the two primary methods of determining pediatric drug dosages.
• State the reason for checking pediatric dosages before administration.
• Describe the dosage inaccuracies that can occur with pediatric drug formulas.
• Identify the steps in determining body surface area from a pediatric nomogram and with the
square root method.

Outline FACTORS INFLUENCING PEDIATRIC DRUG ADMINISTRATION

Oral
Intramuscular
Intravenous
PEDIATRIC DRUG CALCULATIONS
Dosage per Kilogram Body Weight
Dosage per Body Surface Area
PEDIATRIC DOSAGE FROM ADULT DOSAGE
Body Surface Area Formula
Age Rules

FACTORS INFLUENCING PEDIATRIC DRUG ADMINISTRATION

Drug dosages for children differ greatly from those for adults because of the physiological differences
between the two groups. Neonates and infants have immature kidney and liver function, which delays
metabolism and elimination of many drugs. Drug absorption in neonates is different as a result of slow
gastric emptying. Decreased gastric acid secretion in children younger than 3 years contributes to altered
drug absorption. Neonates and infants have a lower concentration of plasma proteins, which can cause
toxic effects with drugs that are highly bound to proteins. They have less total body fat and more total
body water. Therefore lipid-soluble drugs require smaller doses because less than normal fat is present,
and water-soluble drugs can require larger doses because of a greater percentage of body water. As chil-
dren grow, changes in fat, muscle, body water, and organ maturity can alter the pharmacokinetic effects
of drugs. Most drugs are dosed according to weight, and doses are specifically calculated for each child.
For example, a dose of cefazolin for a 34-kg, 12-year-old child is larger than a dose for a 7-kg, 8-month-
old infant. It is the nurse’s responsibility to ensure that a safe drug dosage is given and to closely monitor
signs and symptoms of adverse reactions to drugs. The purpose of learning how to calculate pediatric
drug doses is to ensure that each child receives the correct dose within the therapeutic range.

248
 CHAPTER 12 Pediatrics 249

Oral
Oral pediatric drug delivery often requires the use of a metric dosing device because most drugs for small
children are provided in liquid form. The metric measuring device can be a small plastic cup, an oral dropper,
a measuring spoon, an oral syringe, or a specially designed pediatric medication dispenser such as the medi-
bottle (Figure 12-1). The medibottle is a specially designed pediatric medication dispenser that provides
optimum drug delivery by allowing small volumes of medication to be swallowed with oral fluids. Some
liquid medications come with their own calibrated droppers. The type of measuring device chosen depends
on the developmental level of the child. For infants and toddlers, the oral syringe, dropper, and medibottle
provide better drug delivery than is provided by a small cup. A young child who is cooperative is able to use
a small cup or measuring spoon. All liquid medications can be drawn up with an oral syringe to ensure accu-
racy and then are transferred to a small cup or measuring spoon. It may be necessary to refill the cup or spoon
with water or juice and to have the child drink that as well to ensure that all prescribed medication has been
administered. Medicine should not be mixed in the infant’s or toddler’s bottle because the full dose will not
be administered if the child doesn’t finish the bottle. Any medication with a strong taste should not be mixed
in formula because the infant could begin to refuse formula. Avoid giving oral medications to a crying child
or infant, who could easily aspirate the medication. Some chewable medications are available for administra-
tion to the older child. Because many drugs are enteric-coated or are provided in timed-release form, the
child must be told which medications are to be swallowed and not chewed.

Intramuscular
Intramuscular sites are chosen on the basis of the age and muscle development of the child (Table 12-1).
All injections should be given in a manner that minimizes physical and psychosocial trauma. The child
must be adequately restrained, if necessary, and provided with a momentary distraction. The procedure
must be performed quickly, with comfort measures immediately following.

30mL 30mL
25mL 25mL
20mL 20mL
15mL 15mL
10mL 10mL
5mL 5mL
4mL 4mL

L
5m 3m
L
4m L
L 2m
3m L
L 1m
2m
L
0.5
1m
L
10m
8.75
7.5m
6.25

L
mL
5mL
3.75

L
mL
2.5m
1.25

mL
L
mL

A
Figure 12-1 A, Calibrated measuring devices. Continued
250 PART IV Calculations for Specialty Areas

B
Figure 12-1, cont’d B, Medibottle. (B, from The Medicine Bottle Company, Inc.)

TABLE 12-1 Pediatric Guidelines for Intramuscular Injections According to Muscle Group*
AMOUNT BY MUSCLE GROUP (mL)

Vastus Lateralis Rectus Femoris Ventro-gluteal Dorsal Gluteal Deltoid

Neonates 0.5 mL Not safe Not safe Not safe Not safe
Infants
 ​ ​1-12 months 0.5-1 mL Not safe Not safe Not safe Not safe
Toddlers
 ​ ​1-2 years 0.5-2 mL 0.5-1 mL Not safe Not safe 0.5-1 mL
Preschool
 ​ ​3-5 years 0.5-2 mL 0.5-1 mL 0.5-1 mL Not safe 0.5-1 mL
School age
 ​ ​6-12 years 2 mL 2 mL 0.5-3 mL 0.5-2 mL 0.5-1 mL
Adolescent
 ​ ​12-18 years 2 mL 2 mL 2-3 mL 2-3 mL 1-1.5 mL

*The safe use of all sites is based on normal muscle development and size of the child. Follow institutional policies and procedures.
 CHAPTER 12 Pediatrics 251

TABLE 12-2 Pediatric Guidelines for 24-Hour Intravenous Fluid Therapy

100 mL/kg for first 10 kg body weight
 ​50 mL/kg for the next 10 kg body weight
 ​20 mL/kg after 20 kg body weight

Example: Child’s weight 25 kg

100 mL/kg 3 ​10 kg 5 ​1000 mL
 ​50 mL/kg 3 ​10 kg 5 ​  500 mL
 ​20 mL/kg 3 ​ ​5 kg 5 ​  100 mL
1600 mL for 24 hours, or 66.6 mL/hr, or 67 mL

N OTE
The usual needle length and gauge for pediatric clients are 5⁄8 of an inch to 1 inch long and 22 to 27 gauge.
Another method of estimating needle length is to grasp the muscle for injection between the thumb and
the forefinger; half the distance would be the needle length.

Intravenous
For children, the maximum amount of intravenous (IV) fluid varies with body weight. Their 24-hour
fluid status must be monitored closely to prevent overhydration. The amount of fluid given with IV ​medi-
cation must be considered in the planning of their 24-hour intake (Table 12-2). After the correct dosage
of drug is obtained, it may need further dilution and to be given over a specified time, as mentioned in
Chapter 11. Usually, the drug is diluted with 5 to 60 mL of IV fluid, depending on the drug or dosage,
placed in a calibrated cylinder or syringe pump, and infused over 20 to 60 minutes, depending on the type
of drug. After the drug has been infused, the cylinder is flushed with 3 to 20 mL of IV fluid to ensure
that the child has received all of the medication and to prevent admixture. All fluid volume is considered
intake. Refer to Chapter 11 for methods of calculating IV infusion rates.
The safety factors that must be considered when medications are administered to children are similar
to those for adults. See Appendix A for more detailed information on safe nursing practice for drug
administration.

PEDIATRIC DRUG CALCULATIONS

The two main methods of determining drug dosages for pediatric drug administration are body weight
and body surface area (BSA). For both, a current weight is essential. The first method uses a specific
number of milligrams, micrograms, or units for each kilogram of body weight (mg/kg, mcg/kg, unit/kg).
Usually, drug data for pediatric dosage (mg/kg) are supplied by manufacturers in a drug information
insert. BSA, measured in square meters (m2), is considered a more accurate method than body weight.
BSA takes into consideration the relation between basal metabolic rate and surface area, which correlates
with blood volume, cardiac output, and organ growth and development. Although BSA has been used
primarily to calculate the dosage of antineoplastic agents, BSA is used when there is a narrow margin
between therapeutic and toxic doses. Pharmaceutical manufacturers are including BSA parameters
(mg/m2, mcg/m2, units/m2) in the drug information.
If the manufacturer does not supply data for pediatric dosing, the child’s dosage can be determined
from the adult dose. The BSA formula is used to calculate the pediatric dose. The BSA formula is con-
sidered more accurate than previously used formulas, such as Clark’s, Young’s, and Fried’s rules. Drug
calculations performed according to the BSA formula are safer than those done with formulas that rely
252 PART IV Calculations for Specialty Areas

solely on the child’s age or weight. The West nomogram for infants and children (Figure 12-2) can also
be used to determine BSA or to verify BSA results. It is important to follow institutional policies regard-
ing the calculation of BSA (see Chapter 7). Although the BSA formula has improved the accuracy of
drug dosing in infants and children, calculation of drug doses for neonates and preterm infants are weight
based because BSA does not guarantee complete accuracy.

Figure 12-2 West nomogram for infants and children. Directions: (1) Find height; (2) find weight; (3) draw a straight line
connecting the height and weight. Where the line intersects on the S.A. (surface area) column is the body surface area in
square meters (m2). (Modified from data by E. Boyd & C. D. West. In Kliegman, R. M., Stanton, B. F., St. Geme, J. W., et al
[2011]: Nelson textbook of pediatrics, ed. 19, Philadelphia: Saunders.)
 CHAPTER 12 Pediatrics 253

N OTE
If the manufacturer states in the drug information insert that the medication is not for pediatric use, the
alternative formulas should NOT be used for dosage calculation.

Dosage per Kilogram Body Weight

The following information is needed to calculate the dosage:
a. Physician’s order with the name of the drug, the dosage, and the frequency of administration.
b. The child’s age and weight in kilograms:
1 kg 5 ​2.2 lb
c. The pediatric dosage as listed by the manufacturer or hospital formulary.
d. Information on how the drug is supplied.

EXAMPLES PROBLEM 1
a. Order: amoxicillin (Amoxil) 60 mg, po, tid.
Child’s age and weight: 4 months, 12.5 lb.
b. Change pounds to kilograms.
12.5 lb /kg
5 5.7 kg
2.2 kg
c. Pediatric dosage for children older than 3 months old: 20-40 mg/kg/day in three equal doses.

Step 1: Check dosing parameters by multiplying the child’s weight by the minimum and maximum
daily dose of the drug.
20 mg/kg/day 3 ​5.7 kg 5 ​114 mg/day
40 mg/kg/day ​3 ​5.7 kg 5 ​228 mg/day

Step 2: Multiply the dosage by the frequency to determine the daily dose.
The order for amoxicillin 60 mg, po, tid means that three doses will be given per day.
60 mg ​3 ​3 5 ​180 mg

Because the daily dose of amoxicillin 180 mg falls within the recommended range, it is considered a
safe dose.
254 PART IV Calculations for Specialty Areas

d. Drug preparation:
Use the basic formula (BF), ratio and proportion (RP), fractional equation (FE) method, or dimen-
sional analysis (DA).
Basic Formula
D 60 mg
BF: 3V5 3 5 mL 5 2.4 mL
H 125 mg
or or
RP: Ratio and Proportion FE: Fractional Equation
125 mg;5 mL<60 mg;X mL H D 125 mg 60 mg
5 5 5
125 X 5 300 V X 5 mL X
X 5 2.4 mL
or 1Cross multiply2 125 X 5 300
5 mL 3 60 mg 300 X 5 2.4 mL
DA: mL 5 5 5 2.4 mL
125 mg 3 1 125
Answer: amoxicillin 60 mg, po 5 ​2.4 mL

PROBLEM 2
a. Order: ampicillin 350 mg, IV, q6h.
Child’s weight and age: 61.5 lb and 9 years old.
Dilution instructions: Mix with 20 mL of D5/1/4 NS; infuse over 20 minutes.
Flush with 15 mL at same infusion rate.
b. Change pounds to kilograms.
61.5
5 27.95 or 28 kg ​
2.2
c. Pediatric dose is 25 to 50 mg/kg/day in divided doses.
Step 1: Multiply weight by minimum and maximum daily dose:
25 mg 3 ​28 kg 5 ​700 mg/day
50 mg 3 ​28 kg 5 ​1400 mg/day

Step 2: Multiply the dose by the frequency:
350 mg 3 ​4 5 ​1400 mg/day
The dose is considered safe because it does not exceed the therapeutic range.
d. Drug available: When diluted, 500 mg 5 ​2 mL. Use your selected formula to calculate the dosage.

D 350 mg

BF: 3V5 3 2 mL 5 1.4 mL
H 500 mg
 CHAPTER 12 Pediatrics 255

or or H 500 mg 350 mg
D

RP: 500 mg;2 mL<350 mg; X mL FE: 5 5 5
V X 2 mL X
500 X 5 700
X 5 1.4 mL 500 X 5 700

or X 5 1.4 mL

DA: no conversion factor
7
2 mL 3 350 mg 14

mL 5 5 5 1.4 mL
500 mg 3 1 10
10

Answer: Each dose is 1.4 mL.

e. Amount of fluid to infuse medication:
1.4 mL 1 ​20 mL (dilution) 5 ​21.4 mL
f. Flow rate calculation (60 gtt/mL set):
Amount of solution 3 gtt /mL 1set2
5 gtt /min
Minutes to administer
3
21.4 mL 3 60 gtt /mL
5 64.2 gtt /min or 64 gtt /min
20 min
1

g. Infusion pump setting

Minutes to administer 20 min
Amount of solution 4 5 21.4 mL 4 5​
60 min/hr 60 min
60
21.4 3 5 64.2 mL/hr or 64 mL 1round off to whole number2 .
20

YOU MUST REMEMBER

• The IV flush (3-20 mL) is part of the total IV ​fluids necessary for medication administration and must be
included in patient intake. The flush is started after IV ​medication infusion is completed, and it is infused
at the same rate.
• For a 60-gtt/mL set, the drop per minute rate is the same as the milliliter per minute rate.

Dosage per Body Surface Area

The following information is needed to calculate the dosage:
a. Physician’s order with name of drug, dosage, and time frame or frequency.
b. Child’s height, weight in kilograms, and age.
c. Information on how the drug is supplied.
d. Pediatric dosage (in m2) as listed by manufacturer or hospital formulary.
e. BSA with square root.
f. BSA nomogram for children (Figure 12-2).
256 PART IV Calculations for Specialty Areas

EXAMPLES PROBLEM 1
a. Order: methotrexate 50 mg, IV, ​3 ​1.
b. Child’s height, weight, age: 134 cm, 32.5 kg, 9 years.
c. Pediatric dose: 25-75 mg/m2 per week.
d. Drug preparation: 25 mg/mL.
e. BSA with square root (see BSA metric formula on p. 99)
134 3 32.5
5 1.09 m2
Å 3600
25 mg/m2 3 ​1.09 m2 5 ​27.25 or 27 mg
75 mg/m2 3 ​1.09 m2 5 ​81.75 or 82 mg
Compare answer with nomogram.
f. BSA nomogram for children: The child’s height (134 cm) and weight (32.5 kg) intersect at 1.11 m2
BSA.
Multiply the BSA, 1.11 m2, by the minimum and maximum dose. (Substitute BSA for weight.)

25 mg/m2 3 ​1.11 m2 5 ​28.0 mg

75 mg/m2 3 ​1.11 m2 5 ​83.0 mg
This dose is considered safe because it is within the therapeutic range for the child’s BSA.
g. Calculate drug dose: For determination of the amount of drug to be administered, either formula can
be used:
50 mg or H 25 mg 50 mg
D D
BF: 3V5 3 1 mL 5 2 mL FE: 5 5 5
H 25 mg V X 1 mL X mL
1Cross multiply2 25 X 5 50
X 5 2 mL
2

or or 1 mL 3 50 mg

RP: 25 mg;1 mL<50 mg;X mL DA: mL 5 5 2 mL
25 mg 3 1
25 X 5 50 1
X 5 2 mL

Answer: methotrexate 50 mg 5 ​2 mL

SUMMARY ​PRACTICE PROBLEMS
Answers can be found on pages 269 to 277.

In the following dosage problems for oral, IM, and IV administration, determine whether the ordered
drug is a safe pediatric dose, and calculate the dose.

I Oral

1. Child with a streptococcal soft tissue infection.

Order: clindamycin 90 mg, po, qid.
Child’s weight and age: 68 lb, 6 years.
Pediatric dose: 4-6 mg/lb/day in 3 doses.
 CHAPTER 12 Pediatrics 257

Drug available: clindamycin 75 mg/5 mL.

2. Child with seizures.

Order: phenobarbital 25 mg, po, bid.
Child’s weight and age: 7.2 kg, 9 months.
Pediatric dose: 5-7 mg/kg/day.
Drug available: phenobarbital 20 mg/5 mL.

3. Child with lower respiratory tract infection.

Order: cefprozil (Cefzil) 100 mg, po, q12h.
Child’s weight and age: 17 lb, 6 months.
Pediatric dose greater than 6 months: 15 mg/kg/q12h.
Drug available:
258 PART IV Calculations for Specialty Areas

4. Child with pain.

Order: codeine 7.5 mg, po, q4h, prn 3 ​6 doses/day.
Child’s height, weight, and age: 43 inches, 50 lb; 5 years.
Pediatric dose: 100 mg/m2/day (see Figure 12-2), or solve by square root.
Drug available: codeine 15-mg tablets.

5. Child with seizures.

Order: Zarontin 125 mg, po, bid.
Child’s weight and age: 13 kg, 36 months.
Pediatric dose: 15-40 mg/kg/day.
Drug available:

6. Child with seizures.

Order: Dilantin 40 mg, po, bid.
Child’s weight and age: 6.7 kg, 3 months.
Pediatric dose: 5-7 mg/kg/day.
Drug available: Dilantin 125 mg/5 mL.

7. Child with acute urinary tract infection.

Order: Bactrim 600 mg/120 mg, po, bid.
Child’s weight and age: 66 lb, 9 years.
Pediatric dose: Bactrim 40 mg/kg/day sulfamethoxazole and 6-10 mg/kg/day trimethoprim.
Drug available: Bactrim 400 mg/80 mg. For this drug, calculate the trimethoprim only.
 CHAPTER 12 Pediatrics 259

8. Infant with upper respiratory tract infection.

Order: Augmentin oral suspension 75 mg, po, q8h.
Child’s weight and age: 8 kg, 7 months.
Pediatric dose: 20-40 mg/kg/day.
Drug available:

9. Child with poison ivy.

Order: Benadryl 25 mg, po, q6h.
Child’s weight and age: 25 kg, 7 years.
Pediatric dose: 5 mg/kg/day.
Drug available: Benadryl 12.5 mg/5 mL.

10. Child with cystic fibrosis exposed to influenza A.

Order: oseltamivir (Tamiflu) 45 mg, po, bid 3 5 days.
Child’s weight and age: 16 kg, 4 years.
Pediatric dose: 90 mg/day for 16-23 kg.
Drug available: oseltamivir 12 mg/mL.

11. Order: cefaclor (Ceclor) 50 mg, qid.

Child’s weight and age: 15 lb, age 4 months.
Pediatric dose: 20-40 mg/kg/day in three or four divided doses.
Drug available:
260 PART IV Calculations for Specialty Areas

12. Child with nausea and vomiting from chemotherapy.

Order: ondansetron (Zofran) 2 mg, po 30 minutes before administration, q8h, prn.
Child’s weight and age: 80 lb, 10 years.
Pediatric dose: 0.04-0.87 mg/kg/day.
Drug available:

13. Child, 7 years old, with pinworms.

Order: Pyrantel pamoate suspension 250 mg.
Child’s weight: 50 lbs.
Pediatric dose: 11 mg/kg.
Drug available: Pyrantel pamoate 50 mg/mL.

II Intramuscular

Determine whether dose is safe and calculate dose.

14. Child with pain after surgery.
Order: morphine 4.5 mg, IM 3 1.
Child’s weight and age: 45 kg, 14 years.
Pediatric dose: 0.1 mg/kg.
Drug available: morphine 10 mg/mL.

15. Child has strep throat (streptococcal pharyngitis).

Order: Bicillin C-R, 1,000,000 units, IM ​3 ​1.
Child’s weight: 44 lb.
Pediatric dose: 30-60 lb: 900,000-1,200,000 units daily.
Drug available: Bicillin C-R, 1,200,000 units/2 mL.

16. Child receiving preoperative medication (may solve by nomogram or square root).
Order: hydroxyzine (Vistaril) 25 mg, IM.
Child’s height and weight: 47 inches, 45 lb.
Pediatric dose: 30 mg/m2.
Drug available:
 CHAPTER 12 Pediatrics 261

17. Child receiving preoperative medication.

Order: atropine 0.2 mg, IM.
Child’s weight and age: 12 kg, 7 months.
Pediatric dose: 0.01-0.02 mg/kg/dose, not to exceed 0.4 mg/dose.
Drug available:

18. Child with cancer.

Order: methotrexate 40 mg, IM, weekly (may solve by nomogram or square root).
Child’s height and weight: 56 inches, 100 lb.
Pediatric dose: 7.5-30 mg/m2/wk.
Drug available: methotrexate 2.5 mg/mL; 25 mg/mL; 100 mg/mL.

19. Order: A newborn is to receive AquaMEPHYTON (vitamin K) 0.5 mg IM immediately after

delivery.
Pediatric dose: 0.5-1 mg.
Drug available:

a. Which AquaMEPHYTON container would you select?

b. How many milliliters (mL) should the newborn receive?
c. Is drug dose within the safe range?
262 PART IV Calculations for Specialty Areas

20. Child with severe croup.

Order: Dexamethasone 6 mg, IM ​3 ​1.
Child’s height, weight, and age: 42 inches, 44 lb, 4 years.
Pediatric dose: 0.6 mg/m2 to 9 mg/m2
Drug available:
a. Determine if dosage is safe.
b. Calculate dose.

III Intravenous

21. Adolescent with progressive hip pain secondary to rheumatoid arthritis.

Order: morphine sulfate 2.5 mg, IV ​piggyback, in 10 mL NS ​over 5 minutes. Flush with 5 mL.
Child’s weight and age: 50 kg, 16 years.
Pediatric dose: 50-100 mcg/kg/dose for IV.
Drug available:

a. Determine if dosage is safe. d. How many gtt/min should infuse?

b. Calculate dose. e. What is the total amount of fluid given?
c. How many mL should infuse?
 CHAPTER 12 Pediatrics 263

22. Treatment to reverse postoperative narcotic depression.

Order: Narcan (naloxone) 1.8 mg IV push.
Child’s weight and age: 18 kg, 3 years.
Pediatric dose: 0.1 mg/kg
Drug available:

a. Determine if dosage is safe. b. Calculate dose.

23. Infant with sepsis.
Order: Amikin 40 mg, IV, q12h, in D5W 5 mL, over 20 minutes. Flush with 3 mL.
Child’s weight and age: 5.3 kg, 1 year.
Pediatric dose: 15 mg/kg/day.
Drug available:

a. Determine if dosage is safe. d. How many gtt/min should infuse?

b. Calculate dose. e. What is the total amount of fluid given?
c. How many mL should infuse?
24. Treatment for child with cerebral palsy having spasticity after spinal fusion.
Order: lorazepam 3 mg IV q6h.
Child’s weight and age: 47 kg, 17 years.
Pediatric dose: 0.05-0.1 mg/kg.
Drug available: lorazepam 4 mg/mL.
a. Determine if dosage is safe.
b. Calculate dose.
264 PART IV Calculations for Specialty Areas

25. Child with pneumonia.

Order: cefazolin ​(Ancef ) 500 mg, IV, q6h, in D5W 20 mL, over 30 minutes.
Flush with 10 mL.
Child’s weight and age: 5.6 kg, 2 months.
Pediatric dose: 25-100 mg/kg/day in four divided doses.
Drug available:

a. Determine if dosage is safe. d. How many gtt/min should infuse?

b. Calculate dose. e. What is the total amount of fluid given?
c. How many mL should infuse?
26. Child with sepsis.
Order: gentamicin 10 mg, IV, q8h, in D5W, 4 mL, over 30 minutes. Flush with 3 mL.
Child’s height, weight, and age: 21 inches, 4 kg, 1 month.
Pediatric dose: more than 7 days old: 5-7.5 mg/kg/day in three divided doses.
Drug available: gentamicin 10 mg/mL.
a. Determine if dosage is safe. d. How many gtt/min should infuse?
b. Calculate dose. e. What is the total amount of fluid given?
c. How many mL should infuse?
27. Child with postoperative wound infection.
Order: cefazolin 185 mg, IV, q6h, in D5W 20 mL, over 20 minutes. Flush with 15 mL.
Child’s weight: 15 kg.
Pediatric dose: 25-50 mg/kg/day.
Drug available:

a. Determine if dosage is safe. d. How many gtt/min should infuse?

b. Calculate dose. e. What is the total amount of fluid given?
c. How many mL should infuse?
 CHAPTER 12 Pediatrics 265

28. Child with staphylococcus scalded skin syndrome.

Order: clindamycin 50 mg IV q8h.
Dilution instructions: mix in 10 mL NS over 15 min via syringe pump.
Child’s weight and age: 7.5 kg, 5 months.
Pediatric dose: 16-20 mg/kg/day.
Drug available: clindamycin 150 mg/mL.
a. Determine if dosage is safe.
b. Calculate dose.
29. Child with congestive heart failure.
Order: digoxin 40 mcg, IV, bid, in NS 2 mL, over 1 minute.
Child’s weight and age: 6 lb, 1 month.
Pediatric dose: 2 weeks to 2 years: 25-50 mcg/kg.
Drug available: digoxin 0.1 mg/mL.
a. Determine if dosage is safe.
b. Calculate dose.
30. Child with lymphoma.
Order: Cytoxan 125 mg, IV, in D51⁄2 NS, 300 mL, over 3 hours, no flush to follow.
Child’s weight and height: 16 kg, 75 cm (may solve by nomogram or square root).
Pediatric dose: 60-250 mg/m2/day.
Drug available:

a. Determine if dosage is safe.

b. Calculate dose.
31. Child with pertussis.
Order: azithromycin (Zithromax) 300 mg/day.
Child’s weight and age: 55 lb, 8 years.
Pediatric dose: 10 mg/kg/day ​3 ​5 days.
Drug available: azithromycin 200 mg/5 mL.

a. Determine if dosage is safe.

b. Calculate dose.
266 PART IV Calculations for Specialty Areas

32. Child with severe systemic infection.

Order: tobramycin (Nebcin) 15 mg, IV, q6h.
Child’s weight and age: 10 kg, 18 months.
Pediatric dose parameters: 6-7.5 mg/kg/day in four divided doses.
Drug available:

a. Determine if dosage is safe.

b. Calculate dose.
33. Child with acute lymphocytic leukemia.
Order: daunorubicin HCl 40 mg, IV, daily.
Pediatric dose parameters: more than 2 yr: 25-45 mg/m2/day.
Child’s age, weight, and height: 10 years, 72 lb, 60 inches.
Drug available: daunorubicin 20 mg/4 mL.
Instructions: Mix in 100 mL D5W; infuse in 45 minutes via pump.
a. The BSA is
b. How many milliliters should be mixed in the D5W?
c. Is the drug dose within the safe range?
d. How many milliliters per hour should infuse?
34. Child with a serious fungal infection.
Order: fluconazole (Diflucan) 200 mg, IV, per day for 10 days.
Child’s weight and age: 55 lb, 7 years.
Pediatric dose: 6-12 mg/kg/day.
Drug available: fluconazole 400 mg/200 mL.

a. How many kilograms does the child weigh?

b. Is the dose safe?
c. How many milliliters should the child receive per dose?

IV Neonates

35. Neonate with bradycardia, heart rate ​less than 60 beats/min.

Order: epinephrine 0.25 mg IV now.
Pediatric dose: 0.1 mg/kg.
 CHAPTER 12 Pediatrics 267

Neonate weight: 2.5 kg.

Drug available:

a. Determine if dosage is safe.

b. Calculate dose.
36. Neonate with respiratory depression after delivery; mother received Stadol during labor.
Neonate weight: 8 lb 12 oz.
Order: naxolone 0.04 mg IM now.
Pediatric dose: 0.01 mg/kg.
Drug available: naxolone 0.4 mg/mL.
a. Determine if dosage is safe.
b. Calculate dose.
37. Neonate with bacterial meningitis.
Neonate weight: 2.5 kg.
Order: ampicillin 125 mg IV push over 2 minutes.
Pediatric dose parameters: 50-75 mg/kg/dose.
Drug available:

a. Determine if dosage is safe.

b. Calculate dose.
38. Neonate with IV ​fluids for sepsis.
Neonate weight: 2.5 kg.
Order: D5W 80 mL/kg for 24 hours.
a. How much D5W should be given in 24 hours?
b. How many milliliters per hour should be infused?
39. Neonate with sepsis.
Neonate weight: 2.5 kg.
Order: gentamicin 10 mg q24h.
Pediatric dosage parameters: 4-5 mg/kg.
Drug available: gentamicin 40 mg/mL.
a. Determine if dosage is safe.
b. Calculate dose.
268 PART IV Calculations for Specialty Areas

PEDIATRIC DOSAGE FROM ADULT DOSAGE

Body Surface Area Formula

The following information is needed to calculate the pediatric dosage with the BSA formula:
a. Physician’s order with the name of the drug, the dosage, and the time frame or frequency.
b. The child’s height and weight.
c. A BSA nomogram for children (p. 252).
d. The adult drug dosage.
e. The BSA formula:
BSA 1m22
3 Adult dose 5 Child dose
1.73 m2

EXAMPLE PROBLEM
a. Erythromycin 80 mg, po, qid.
b. Child’s height is 34 inches and weight is 28.5 lb.
Note: Height and weight do not have to be converted to the metric system.
c. Height (34 inches) and weight (28.5 lb) intersect the nomogram at 0.57 m2. See BSA nomogram,
Figure 12-2.
d. The adult drug dosage is 1000 mg/24 hr.
e. BSA formula:
BSA 1m22 0.57 m2
2 3 Adult dose 5 3 1000 mg
1.73 m 1.73 m2
5 0.33 3 1000 mg
5 330 mg /24 hr

Dose frequency: 330 mg 4 ​4 doses 5 ​82.5 or 80 mg/dose
80 mg 3 ​4 times per day 5 ​320 mg/day

Dosage is safe.

Age Rules
Fried’s rule and Young’s rule are two methods for determining pediatric drug doses based on the child’s
age. Fried’s rule is used primarily for children younger than 1 year of age, whereas Young’s rule is used for
children between 2 and 12 years of age. In current practice, these rules are infrequently used. Because the
maturational development of infants and children is variable, age cannot be an accurate basis for drug
dosing.

Fried’s Rule: Young’s Rule:

Age in months Child’s age in years
3 Adult dose 5 Infant dose 3 Adult dose 5 Child dose
150 Age in years 1 12

N OTE
The age rules should not be used if a pediatric dose is provided by the manufacturer.
 CHAPTER 12 Pediatrics 269

ANSWERS ​ ​Summary Practice Problems

I Oral

1. Dosage parameters: 4 mg 3 ​68 lb 5 ​272 mg

6 mg 3 ​68 lb 5 ​408 mg
Dosage frequency: 90 mg 3 ​4 5 ​360 mg/day
Dosage is safe.
D 90 mg or
V 3D 5 mL 3 90 mL 450
BF: 3V5 3 5 mL 5 6 mL DA: mL 5 5 5 5 6 mL
H 75 mg H3 X 75 mg 3 1 75
or or H 75 mg 90 mg
D
RP: H ; V < D ;X FE: 5 5 5
V X 5 mL X
75 mg;5 mL<90 mg;X
75 X 5 450 1Cross multiply2 75 X 5 450
X 5 6 mL X 5 6 mL ​
2. Dosage parameters: 5 mg/kg/day 3 ​7.2 kg 5 ​36 mg/day
7 mg/kg/day 3 ​7.2 kg 5 ​50.4 mg/day
Dose frequency: 25 mg 3 ​2 5 ​50 mg
Dosage is safe.
5
D 25 mg or 5 mL 3 25 mg 25
BF: 3V5 3 5 mL 5 6.25 mL/dose DA: mL 5 5 5 6.25 mL
H 20 mg 20 mg 3 1 4
4
3. Dosage parameters: 15 mg/kg, q12h 3 ​8 kg 5 ​120 mg, q12h
Dosage frequency: 100 mg, q12h
Dosage is safe.
or H 125 mg 100 mg
D 100 mg D
BF: 3V5 3 5 mL 5 4 mL/dose FE: 5 5 5
H 125 mg V X 5 mL X
1Cross multiply2 125 X 5 500
X 5 4 mL
4. Height and weight intersect at 0.84 m2 with nomogram.
Dosage parameters: 100 mg/0.84 m2/day 5 ​84 mg/day
Dose frequency: 84 mg/day 4 ​6 5 ​14 mg/dose
Dosage is safe.
BSA with the Square Root: BSA Pounds and Inches Formula, see p. 99.
43 3 50
5 "0.686 5 0.828 or 0.83 m2
Å 3131
Dosage parameters: 100 mg/0.83 m2 5 ​83 mg/day (compare with nomogram)
Dosage frequency: 83 mg/day/6 5 ​13.8 or 14 mg/dose
Dosage is safe.
D 7.5 mg or
BF: 3V5 3 1 5 0.50 or 1⁄2 tablet RP: H ; V < D ;X
H 15 mg
15 mg;1 tab < 7.5 mg;X
15 X 5 7.5
X 5 1⁄2 tablet
270 PART IV Calculations for Specialty Areas

5. Dosage parameters: 15 mg/kg/day 3 ​13 kg 5 ​195 mg/day

40 mg/day 3 ​13 kg 5 520 mg/day
Dose frequency: 125 mg 3 2 5 250 mg/day
Dosage is safe.
D 125 mg
BF: 3V5 3 5 mL 5 2.5 mL
H 250 mg
6. Dosage parameters: 5 mg/kg/day 3 ​6.7 kg 5 ​33.5 mg/day
7 mg/kg/day 3 ​6.7 kg 5 ​46.9 mg/day
Dose frequency: 40 mg 3 ​2 5 ​80 mg/day
Dosage exceeds the therapeutic range. Dosage is not safe.
7. Pounds to kilograms
66 lb
5 30 kg
2.2 lb /kg
Dosage parameters:   6 mg/kg/day 3 ​30 kg 5 ​180 mg/day
10 mg/kg/day 3 ​30 kg 5 ​300 mg/day
Dosage frequency: 2 times a day 3 ​120 mg 5 ​240 mg/day
Dosage is safe.
D 120 mg or
1 tab 3 120 mg 120
BF: 3 3 1 5 1.5 tablets DA: tab 5 5 5 1.5 tablets
H 80 mg 80 mg 3 1 80
or or H 80 mg 120 mg
D
RP: H ;V< D ;X FE: 5 5 5
V X 1 tab X
80 mg; 1<120 mg;X
80 X 5 120 80 X 5 120
X 5 1.5 tablets X 5 1.5 tablets​
8. Dosage parameters: 20 mg/kg/day 3 ​8 kg 5 ​160 mg/day
40 mg/kg/day 3 ​8 kg 5 ​320 mg/day
Dose frequency: 75 mg 3 ​3 5 ​225 mg
Dosage is safe.
75 mg or H 125 mg 75 mg
D D
BF: 3V5 3 5 mL 5 3 mL FE: 5 5 5 5
H 125 mg V X 5 mL X
or 125 X 5 375
RP: H ; V < D ;X X 5 3 mL
125 mg;5 mL<75 mg;X
125 X 5 375
X 5 3 mL
9. Dosage parameters: 5 mg/kg/day 3 ​25 kg 5 ​125 mg/day
Dose frequency: 25 mg 3 ​4 5 ​100 mg/day
Dosage is safe.
or H 12.5 mg 25 mg
D 25 mg D
BF: 3V5 3 5 mL 5 10 mL FE: 5 5 5
H 12.5 mg V X 5 mL X mL
2
or 12.5 X 5 125
5 mL 3 25 mg
DA: mL 5 5 10 mL X 5 10 mL
12.5 mg 3 1
1
 CHAPTER 12 Pediatrics 271

10. Dosing parameters: 90 mg/day

Dosing frequency: 45 mg 3 ​2 5 ​90 mg
Dosage is safe.
or
D 45 mg 1 mL 3 45 mg
BF: 3V5 3 1 mL 5 3.75 mL DA: mL 5 5 3.75 mL
H 12 mg 12 mg 3 1
11. 15 lb 4 ​2.2 5 ​6.8 kg
Dosage parameters: 20 mg 3 ​6.8 kg 5 ​136 mg/day
40 mg 3 ​6.8 kg 5 ​272 mg/day
Dose frequency: 50 mg 3 ​4 5 ​200 mg/day
Dosage is safe.
or H 125 mg 50 mg
D 50 250 D
BF: 3V5 355 5 2 mL FE: 5 5 5
H 125 125 V X 5 mL X
or 1Cross multiply2 125 X 5 250
RP: H ; V < D ; X X 5 2 mL
2
125 mg;5 mL<50 mg;X mL or 5 mL 3 50 mg 10
125 X 5 250 DA: mL 5 5 5 2 mL
125 mg 3 1 5
X 5 2 mL 5

12. Pounds to kilograms

80 lb
5 36.4 kg
2.2 lb /kg
Dosing parameters:
0.04 mg 3 36.4 kg/day 5 1.46 mg/kg/day
0.87 mg 3 36.4 kg/day 5 31.7 mg/kg/day
Dosage frequency: 3 times a day 3 2 mg 5 6 mg
Dosage is safe.
1
or
D 2 mg 5 mL 3 2 mg 5
BF: 3V5 3 5 mL 5 2.5 mL DA: mL 5 5 5 2.5 mL
H 4 mg 4 mg 3 1 2
2
13. a. Pounds to kilograms
50 lbs
5 22.7 kg
2.2 lbs /kg
b. 22.7 kg 3 ​11 mg/kg 5 ​249.9 or 250 mg
Dosage is safe.
D
c. BF: 3V or 50 mg 250 mg
H FE: 5 5
1 X
250 mg
3 1 mL 5 5 mL 50 X 5 250
50 mg
5 5
X 5 5 mL
or 1 mL 3 250 mg 250 or
DA: mL 5 5 5 5 mL RP: H ; V < D ;X
50 mg 3 1 50
1 1 50 mg;1 mL< 250 mg;X
50 X 5 250 mg
X 5 5 mL
272 PART IV Calculations for Specialty Areas

II Intramuscular

14. Dosing parameters: 0.1 mg/kg 3 45 kg 5 4.5 mg

Dosing frequency: one time.
Dosage is safe.
D 4.5 mg or 1 mL 3 4.5 mg 4.5
BF: 3V5 3 1 5 0.45 mL DA: mL 5 5 5 0.45 mL
H 10 mg 10 mg 10
15. Dosage parameters: Child’s weight is 44 lb, which falls in the 30- to 60-lb pediatric dosage range.
Dose frequency: The one-time dose of 1,000,000 units falls within the pediatric dosage range.
Dosage is safe.
D 1,000,000 Units
BF: 3V5 3 2 mL 5 1.666 or 1.7 mL 1round off to tenths2
H 1,200,000 Units
16. Height and weight intersect at 0.82 m2 with the nomogram.
BSA with Square Root (Pounds and Inches Formula)
47 inches 3 45 pounds
5 "0.675 5 0.82 m2 1same as the nomogram2
Å 3131
Dosage parameters: 30 mg/m2 3 ​0.82 m2 5 ​24.6 mg or 25 mg
Dose frequency: 25 mg IM/dose
Dosage is safe.
1
25 mg or
D 1 mL 3 25 mg
BF: 3V5 3 1 5 1.0 mL DA: mL 5 5 1 mL
H 25 mg 25 mg 3 1
1
17. Dosing parameters: 0.01 mg/kg/dose 3 12 kg 5 0.12 mg/dose
0.02 mg/kg/dose 3 12 kg 5 0.24 mg/dose
Dosage is safe.
D 0.2
BF: 3V5 3 1 5 0.5 mL
H 0.4
18. Height and weight intersect at 1.38 m2 with the nomogram.
Dosing parameters for nomogram: 7.5 mg 3 1.38 m2 5 10.35 mg/wk
30 mg 3 1.38 m2 5 41.4 mg/wk
BSA with Square Root (Pounds and Inches Formula)
56 inches 3 100 pounds
5 "1.788 5 1.34 m2
Å 3131
Dosing parameter for BSA formula: 7.5 mg 3 1.34 m2 5 10.05 mg/wk
30 mg 3 1.34 m2 5 40.2 mg/wk
Dose frequency: 40 mg/wk IM
Dosage is safe.
40 mg or 1 mL 3 40 mg
D 40
BF: 3V5 3 1 mL 5 0.4 mL DA: mL 5 5 5 0.4 mL
H 100 mg 100 mg 3 1 100
19. a. Preferred selection is AquaMEPHYTON 1 mg 5 ​0.5 mL
b. AquaMEPHYTON 1 mg 5 ​0.5 mL:
D 0.5 mg 0.25
BF: 3V5 3 0.5 mL 5 5 0.25 mL
H 1.0 mg 1.0
 CHAPTER 12 Pediatrics 273

or
RP: H ; V < D ; X
1 mg;0.5 mL<0.5 mg;X
X 5 ​0.25 mL
AquaMEPHYTON 10 mg 5 ​1 mL:
0.5 mg or H D 10 mg 0.5 mg
D 0.5
BF: 3V5 3 1.0 mL 5 5 0.05 mL FE: 5 5 5
H 10 mg 10 V X 1 mL X mL
10 X 5 0.5
X 5 0.05 mL
For AquaMEPHYTON 1 mg 5 ​0.5 mL, give 0.25 mL (use a tuberculin syringe).
For AquaMEPHYTON 10 mg 5 ​1 mL, give 0.05 mL (use a tuberculin syringe; however, it would be diffi-
cult to give this small amount).
c. Drug dose is within the safe range.
20. Height and weight intersect at 0.78 m2 with the nomogram.
Dosage parameters: 0.6 mg/m2 3 0.78 m2 5 0.46 mg
9 mg/m2 3 0.78 m2 5 7.02 mg
a. Dosage is safe.
6 mg or 6 mg
D 1 mL
b. BF: 3V5 3 1 mL 5 0.6 mL DA: mL 5 3 5 0.6 mL
H 10 mg 10 mg 1
or or H 10 mg 6 mg
D
RP: H ; V < D ;X FE: 5 5 5
10 mg;1 mL<6 mg;X V H 1 mL X
10 X 5 6 1Cross multiply2 10 X 5 6
X 5 0.6 mL X 5 0.6 mL

III Intravenous

21. Dosage parameters: 50 mcg/kg/dose 3 ​50 kg 5 ​2500 mcg/dose or 2.5 mg/dose
100 mcg/kg/dose 3 ​50 kg 5 ​5000 mcg/dose or 5 mg/dose
a. Dosage is safe.
D 2.5
b. BF: 3V5 3 1 5 0.5 mL
H 5
1
or 1 mL 3 2.5 mg 1
DA: mL 5 5 or 0.5 mL
5 mg 3 1 2
2
c. Amount of fluid to be infused: 0.5 mL 1 ​10 mL 5 ​10.5 mL
12
10.5 mL 3 60 gtt /mL
d. 5 126 gtt /min
5 minutes
1
e. Total fluid for medication infusion plus flush: 10.5 mL 1 ​5 mL 5 ​15.5 mL.
22. Dosing parameter: 0.1 mg/kg 3 18 kg 5 1.8 mg.
a. Dosage is safe.
D 1.8 mg
b. BF: 3V5 3 1 mL 5 4.5 mL by IV push
H 0.4 mg
274 PART IV Calculations for Specialty Areas

23. Dosage parameters: 15 mg/kg/day 3 ​5.3 5 ​79.5 mg/day.

Dose frequency: 40 mg IV 3 ​2 5 ​80 mg. 79.5 mg is rounded off to 80 mg.
a. Dosage is safe.
D 40 mg
b. BF: 3V5 3 2 5 0.8 mL
H 100 mg
or or H 100 mg 40 mg
D
RP: H ; V < D ;X FE: 5 5 5
100 mg;2 mL<40 mg;X V X 2 mL X
100 X 5 80 1Cross multiply2 100 X 5 80
X 5 0.8 mL X 5 0.8 mL
c. Amount of fluid to be infused: 0.8 mL 1 ​5 mL 5 ​5.8 mL
3
5.8 mL 3 60 gtt /mL
d. 5 17.4 gtt /min or 17 gtt /min
20 minutes
1
e. Total fluid for medication infusion plus flush: 5.8 mL 1 ​3 mL 5 ​8.8 mL.
24. Dosing parameters: 0.05 mg/kg 3 47 kg 5 2.35 mg
0.1 mg/kg 3 47 kg 5 4.7 mg
a. Dosage is safe.
D 3 mg or
b. BF: 3V5 3 1 mL 5 0.75 mL RP: H ; V < D ;X
H 4 mg
4 mg;1 mL<3 mg;X
or H 4X53
D 4 mg 3 mg
FE: 5 5 5 5 X 5 0.75 mL
V X 1 mL X
1Cross multiply2 4 X 5 3
X 5 0.75 mL
25. Dosage parameters: 25-100 mg/kg/day in four divided doses.
25 mg 3 ​5.6 kg 5 ​140 mg/day
100 mg 3 ​5.6 kg 5 ​560 mg/day
560 mg 4 ​4 5 ​140 mg/dose
Dose frequency: 500 mg 3 ​4 5 ​2000 mg/day
Dose exceeds therapeutic range of 560 mg/day. Dosage is not safe.
26. Dosage parameters: 5 mg/kg/day 3 ​4 kg 5 ​20 mg/day
7.5 mg/kg/day 3 ​4 kg 5 ​30 mg/day
Dose frequency: 10 mg 3 ​3 times/day 5 ​30 mg
a. Dosage is safe.
D 10 mg or
b. BF: 3V5 3 1 mL 5 1 mL RP: H ; V < D ; X
H 10 mg
10 mg;1 mL<10 mg;X mL
1
or 10 X 5 10
1 mL 3 10 mg
DA: mL 5 5 1 mL X 5 1 mL
10 mg 3 1 or H
1 D 10 mg 10 mg
c. Amount of fluid to be infused: 1 mL 1 ​4 mL 5 ​5 mL FE: 5 5 5
2
V X 1 mL X mL
5 mL 3 60 gtt /mL 1Cross multiply2 10 X 5 10
d. 5 10 gtt /min
30 minutes X 5 1 mL
1
e. Total fluid for medication infusion plus flush: 5 mL 1 ​3 mL 5 ​8 mL
 CHAPTER 12 Pediatrics 275

27. Dosage parameters: 25 mg/kg/day 3 ​15 kg 5 ​375 mg/day

50 mg/kg/day 3 ​15 kg 5 ​750 mg/day
Dose frequency: 185 mg 3 ​4 5 ​740 mg/day
a. Dosage is safe.
D 185 mg or
b. BF: 3V5 3 1 mL 5 1.48 or 1.5 mL RP:H ; V < D ;X
H 125 mg
125 mg;1 mL<185 mg;X
Reconstitution information: 125 mg 5 ​1 mL 125 X 5 185
X 5 1.5 mL
c. Amount of fluid to be infused: 1.5 mL 1 ​20 mL 5 ​21.5 mL
3
21.5 mL 3 60 gtt /mL
d. 5 64.5 gtt /min
20 minutes
1
e. Total fluid for medication infusion plus flush: 21.5 mL 1 ​15 mL 5 ​36.5 mL
28. Dosing parameter: 16 mg/kg/day 3 7.5 kg 5 120 mg/day
20 mg/kg/day 3 7.5 kg 5 150 mg/day
Dosing frequency: 50 mg 3 3 5 150 mg
a. Dosage is safe.
D 50 mg or
b. BF: 3V5 3 1 mL 5 0.33 mL or 0.3 mL RP: H ; V < D ;X
H 150 mg
150 mg;1 mL<50 mg;X mL
150 X 5 50
50
X5 5 0.3 mL
150
1
or 1 mL 3 50 mg or H 150 mg 50 mg
D
DA: mL 5 5 0.33 mL or 0.3 mL FE: 5 5 5 5
150 mg 3 1 V X 1 mL X mL
3
29. Dosage parameters: 25 mcg/kg/day 3 ​2.72 kg 5 ​68 mcg 1Cross multiply2 150 X 5 50
50 mcg/kg/day 3 ​2.72 kg 5 ​136 mcg 50
Dose frequency: 40 mcg 3 ​2 5 ​80 mcg X5
150
a. Dosage is safe. X 5 0.3 mL
D 40 mcg
b. BF: 3V5 3 1 5 0.4 mL
H 100 mcg
0.1 mg 5 ​100 mcg
30. Height and weight intersect at 0.6 m2 according to the nomogram.
Dosing parameters for nomogram: 60 mg/m2/day 3 0.6 m2 5 36 mg/day.
250 mg/m2/day 3 0.6 m2 5 150 mg/day.
BSA with the square root (metric formula)
"16 kg 3 75 cm
5 "0.333 5 0.58 m2
3600
Dosage parameters for BSA formula: 60 mg/m2/day 3 0.58 m2 5 ​34.8 mg/day
250 mg/m2/day 3 0.58 m2 5 145 mg/day
a. Dosage is safe.
5
125 mg or
D 10 mL 3 125 mg 50
b. BF: 3V5 3 10 mL 5 6.25 mL DA: mL 5 5 5 6.25 mL
H 200 mg 200 mg 3 1 8
8
276 PART IV Calculations for Specialty Areas

31. Dosage parameters: 55 lb 4 ​2.2 5 ​25 kg

25 kg 3 ​10 mg/kg 5 ​250 mg
25 kg 3 ​12 mg/kg 5 ​300 mg
a. Dosage is safe.
D 300 mg 5 mL or 300 mg 3 5 mL
b. BF: 3V5 3 5 7.5 mL DA: mL 5 5 7.5 mL
H 200 mg 1 200 mg 3 1
or
RP: H ; V < D ; X H D 200 mg 300 mg
FE: 5 5 5
200 mg;5 mL<300 mg;X mL V X 5 mL X
200 X 5 1500
X 5 7.5 mL 1Cross multiply2 200 X 5 1500
X 5 7.5 mL

32. Pediatric dosage parameters:   6 mg 3 10 kg/day 5 ​60 mg/day

7.5 mg 3 10 kg/day 5 ​75 mg/day
15 mg 3 ​4 (q6h) 5 ​60 mg/day
a. Drug dosage per day is within the safe range.
15 1 15 or
b. BF: 3 2 mL 5 5 1.5 mL of Nebcin RP: 20 mg : 2 mL :: 15 mg : X
20 10
10 20 X 5 30
X 5 1.5 of Nebcin
33. a. The BSA using inches and pound formula is 1.17.
b. 8 mL of daunorubicin HCl mixed in 100 mL D5W.
c. Dosage parameters: 25 mg 3 ​1.17 m2 5 ​29.3 mg/day
45 mg 3 ​1.17 m2 5 ​52.7 mg/day or 53 mg/day
Child is to receive 40 mg of daunorubicin HCl per day.
Drug dose is within the safe range.
4
45 min 60
d. 108 mL 4 5 108 3 5 144 mL
60 min 45
3
Pump setting: 144 mL/hr
34. a. 55 lb 4 2.2 lb/kg 5 25 kg
b. Yes. 6 mg/kg 3 25 kg 5 150 mg
12 mg/kg 3 25 kg 5 300 mg
Drug dosage is safe.
D 200 mg
c. BF: 3V5 3 200 mL 5 100 mL of Diflucan per dose
H 400 mg

IV Neonates

35. a. 0.1 mg/kg 3 ​2.5 kg 5 ​0.25 mg

Drug dosage is safe.
or H 0.1 mg 0.25 mg
0.25 mg D
b. BF: 3 1 mL 5 2.5 mL FE: 5 5 5 5
0.1 mg V X 1 mL X
or 1Cross multiply2 0.1 X 5 0.25
1 mL 3 0.25 mg 0.25
DA: mL 5 5 5 2.5 mL X 5 2.5 mL
0.1 mg 3 1 0.1
 CHAPTER 12 Pediatrics 277

8.75
36. a. 5 3.97 kg or 4 kg
2.2
0.01 mg/kg 3 ​4 kg 5 ​0.04 mg dose
Drug dosage is safe.
D 0.04 mg
b. BF: 3V5 3 1 mL 5 0.1 mL
H 0.4 mg
or
RP: H ; V < D ; X
0.4 mg;1 mL<0.04 mg;X mL
0.4 X 5 0.04
X 5 0.1 mL
37. Dosage parameters: 50 mg/kg 3 ​2.5 kg 5 ​125 mg
75 mg/kg 3 ​2.5 kg 5 ​187.5 mg
a. Drug dosage is within safe range.
125 mg or H 500 mg 125 mg
D
b. BF: 3 2 mL 5 0.5 mL FE: 5 5 5 5
500 mg V X 2 mL X
1
or 1Cross multiply2 500 X 5 250
2 mL 3 125 mg 2
DA: mL 5
​ 5 5 0.5 mL X 5 0.5 mL
500 mg 3 1 4
4
38. a. 80 mL/kg 3 ​2.5 kg 5 ​200 mL D5W in 24 hours
200 mL
b. 5 8.3 mL/hr
24 hr
39. Dosage parameters: 4 mg/kg 3 ​2.5 kg 5 ​10 mg
5 mg/kg 3 ​2.5 kg 5 ​12.5 mg
a. Drug dosage is safe.
D 10 mg
b. BF: 3V5 3 1 mL 5 0.25 mL
H 40 mg
or
RP: H ; V < D ; X
40 mg;1 mL<10 mg;X mL
40 X 5 10
X 5 0.25 mL

Additional practice problems are available in the Pediatric Calculations section of Drug
Calculations Companion, version 5, on Evolve.
CHAPTER 13
Critical Care

Objectives • Calculate the prescribed concentration of a drug in solution.

• Identify the units of measure designated for the amount of drug in solution.
• Describe the four determinants of infusion rates.
• Calculate the concentration of drug per unit of time for a specific body weight.
• Recognize the variables needed for the basic fractional formula.
• Describe how the titration factor is used when infusion rates are changed.
• Recognize the methods of determining the total amount of drug infused over time.

Outline CALCULATING AMOUNT OF DRUG OR CONCENTRATION OF A SOLUTION

Calculating Units per Milliliter
Calculating Milligrams per Milliliter
Calculating Micrograms per Milliliter
CALCULATING INFUSION RATE FOR CONCENTRATION AND VOLUME PER UNIT TIME
Concentration and Volume per Hour and Minute With a Drug in Units
Concentration and Volume per Hour and Minute With a Drug in Milligrams
Concentration and Volume per Hour and Minute With a Drug in Micrograms
CALCULATING INFUSION RATES OF A DRUG FOR SPECIFIC BODY WEIGHT
PER UNIT TIME
Micrograms per Kilogram Body Weight
BASIC FRACTIONAL FORMULA
Using Basic Formula to Find Volume per Hour or Drops per Minute
Using Basic Formula to Find Desired Concentration per Minute
Using Basic Formula to Find Concentration of Solution
TITRATION OF INFUSION RATE
Determine Titration Factor Using Infusion Pump
Increasing or Decreasing Infusion Rates Using Infusion Pump
Determine Titration Factor Using a Microdrip IV ​Set
Increasing or Decreasing Infusion ​Rates Using a Microdrip IV ​Set
TOTAL AMOUNT OF DRUG INFUSED OVER TIME

In critical care areas, medication is primarily given intravenously and therefore has an immediate sys-
temic effect on the patient. Drug dosages can be highly individualized, which necessitates close patient
monitoring for improvement or stabilization in parameters such as vital signs, urine output, cardiac index,
level of consciousness, or whatever is appropriate for the medication. Because intravenous (IV) medica-
tion can have immediate effects and have a narrow therapeutic range, the patient can be at great risk if

278
 CHAPTER 13 Critical Care 279

these medications are administered incorrectly. Therefore it is essential that the nurse understand the
drug’s mechanism of action and the calculations necessary for safe drug administration.
Administration of potent drugs—drugs that cause major physiological changes—may be delivered in
milligrams, micrograms, or units per body weight or unit time. The physician determines the drug dosage
and rate of infusion either per body weight or unit time, per hour or per minute. Depending on the medi-
cation, the physician may give the type of IV solution for the dilution. Most institutions have their own
pharmacy guidelines or protocols for preparation of drugs for continuous IV infusion in critical care
areas. Premixed, ready-to-use IV drugs in solution are also available from drug manufacturers with stan-
dardized dosages. The nurse is the last step in the administration process and must make sure that the
dosage is accurate and the infusion rate is correct.
National research has shown a high incidence of IV drug errors committed by pharmacists, physicians,
and nurses. Complete examination of medication processes is under way across the country in an effort
to eliminate adverse drug errors. One step in the process has been to identify drugs with the highest
potential to do harm when used in error. Now these drugs are referred to as “high-alert” drugs and identi-
fied in some facilities with special labeling (Table 13-1). Another effort under way is the increasing use
of programmable infusion pump technology or “smart pumps.” These pumps have drug menus called
“libraries” entered into their software with safe dosing limits called guardrails. The pump will alarm if the
limits are breached and prevent infusion of an unsafe dose. The smart pump’s technology allows a facility
to program the pump for specific areas, i.e., adult, pediatric, oncology, and anesthesia.
When the nurse uses the smart pump, she or he first selects the drug from the drug library. The library
list of drugs is distinguished by capitalized letters that emphasize spelling differences for drugs with
similar names. The nurse selects the amount of the drug and the amount of the prescribed soluton for
infusion, and the pump calculates the concentration of solution. If the drug is dosed based on patient
weight, the most current weight in kilograms is entered, allowing the smart pump to calculate the drug’s
dosage per kilogram of body weight per minute. Depending on the drug that is selected from the library,
the smart pump will use volume per hour or volume per minute to calculate the dosage.

TABLE 13-1 High-Alert Drug Examples

Drug Class Examples

Adrenergic agonists Epinephrine, norepinephrine, dopamine, dobutamine

Adrenergic antagonists Esmolol
Anesthetics Propofol
Antiarrhythmics Amiodarone, lidocaine
Anticoagulants Heparin, bivalirudin, argatroban, lepirudin
Antineoplastics
Dextrose, hypertonic, 20% or greater
Electrolyte solutions Potassium chloride, potassium phosphate, magnesium sulfate
Fibrinolytics Streptokinase, anistreplase, alteplase
Glycoprotein llb/llla inhibitors Eptifibatide
Inotropics Milrinone
Insulin
Liposomal forms of drugs Liposomal amphotericin
Moderate sedatives Midazolam, lorazepam, diazepam
Neuromuscular blockers Atracurium, vecuronium, cisatracurium
Opiates
Total parenteral nutrition solutions
Vasodilators Nitroglycerin, nitroprusside, nesiritide

Adapted from Dennison, Robin D. High-alert drugs: Strategies for some IV infusions. American Nurse Today, November,
2006. Retrieved from http://www.americannursetoday.com/high-alert-drugs-strategies-for-safe-i-v-infusions/.
280 PART IV Calculations for Specialty Areas

The smart pump is an effective tool for drug administration, but the nurse must know all the drug
calculation formulas used in the critical care setting and how they are applied to verify that the dose is
correct before it is given to the patient. Nurses working in these areas need to be able to calculate for:
1. Concentration of the solution.
2. Concentration per hour or per minute.
3. Volume per hour or minute.
4. Dosage per kilogram body weight per minute.
For high-alert drugs it is recommended that two nurses independently do the drug calculations and
verify the results. If any questions arise regarding dosing or infusion rates, the pharmacist and the physi-
cian should be consulted before the drug is administered to the patient.

CALCULATING AMOUNT OF DRUG OR CONCENTRATION OF A SOLUTION

The first step in administering a medication is to determine the concentration of the solution, which is
the amount of drug in each milliliter (mL) of solution. This is written as units per milliliter, milligrams
per milliliter, or micrograms per milliliter and must be calculated for individualized patient dosage. For
all problems, remember to convert to like units before solving.

Calculating Units per Milliliter

EXAMPLE I nfuse heparin 5000 units in D5W 250 mL at 30 mL/hr. What will be the concentration of heparin in
each milliliter of D5W?
Method: units/mL

Set up a ratio and proportion. Solve 5000 units;250 mL<X units;mL

for X.

250 X 5 5000
X 5 20 units

Answer: The D5W with heparin will have a concentration of 20 units/mL of solution.

Calculating Milligrams per Milliliter

EXAMPLE I nfuse lidocaine 2 g in 500 mL D5W at 2 mg/min. What will be the concentration of lidocaine in each
milliliter of D5W?
Method: mg/mL

Convert grams to milligrams. Set up a 2 g 5 2000 mg

ratio and proportion and solve for X. 2000 mg;500 mL<X mg;mL

500 X 5 2000
X 5 4 mg

Answer: The D5W with lidocaine has a concentration of 4 mg/mL of solution.

N OTE
At the beginning of his or her shift, the nurse must check the infusion pump to verify the medication and
concentration that are programmed in the device match the order on the MAR/eMAR.
 CHAPTER 13 Critical Care 281

Calculating Micrograms per Milliliter

EXAMPLE I nfuse dobutamine 250 mg in 500 mL D5W at 650 mcg/min. What is the concentration of dobutamine
in each milliliter of D5W?
Method: mcg/mL

Convert milligrams to micrograms. Set 250 mg 5 250,000 mcg

up a ratio and proportion and solve 250,000 mcg;500 mL<X mcg;mL
for X.

500 X 5 250,000
X 5 500 mcg /mL

Answer: The D5W with dobutamine will have a concentration of 500 mcg/mL of solution.

PRACTICE PROBLEMS: u I CALCULATING CONCENTRATION OF A SOLUTION

Answers can be found on pages 294 to 295.

1. Order: heparin 10,000 units in 250 mL D5W at 30 mL/hr.

2. Order: propofol 1000 mg in 100 mL at 30 mL/hr.
3. Order: regular insulin 100 units in 500 mL NS at 30 mL/hr.
4. Order: lidocaine 1 g in 1000 mL D5W at 30 mL/hr.
5. Order: norepinephrine 4 mg in 500 mL D5W at 15 mL/hr.
6. Order: dopamine 500 mg in 250 mL ​D5W at 10 mL/hr.
7. Order: dobutamine 400 mg in 250 mL D5W at 20 mL/hr.
8. Order: Isuprel 2 mg in 250 mL D5W at 10 mL/hr.
9. Order: streptokinase 750,000 units in 50 mL D5W over 30 minutes.
10. Order: nitroprusside 50 mg in 500 mL D5W at 50 mcg/min.
11. Order: aminophylline 1 g in 250 mL D5W at 20 mL/hr.
12. Order: Pronestyl 2 g in 250 mL D5W at 16 mL/hr.
13. Order: heparin 25,000 units in 250 mL D5W at 5 mL/hr.
14. Order: aminophylline 1 g in 500 mL D5W at 40 mL/hr.
15. Order: nitroglycerin 50 mg in 250 mL D5W at 50 mcg/min.
16. Order: alteplase 100 mg in NS 100 mL over 2 hours.
17. Order: theophylline 800 mg in D5W 500 mL at 0.5 mg/kg.
18. Order: milrinone 20 mg in D5W 100 mL at 0.50 mcg/kg/min.
19. Order: streptokinase 1.5 million units in D5W 100 mL over 60 minutes.
20. Order: amiodarone 150 mg in D5W 100 mL over 10 minutes.

CALCULATING INFUSION RATE FOR CONCENTRATION AND VOLUME

PER UNIT TIME

The second step for administering medication is to calculate the infusion rate of the drug per unit time.
Infusion rates can mean two things: the rate of volume (mL) given or the rate of concentration (units,
mg, mcg) administered. Unit time means per hour or per minute. For drugs administered by continuous
infusion, the four most important determinants are the concentration per hour and minute and the vol-
ume per hour and minute. Infusion rates are part of the physician’s continuous infusion order, and they
may be stated in concentration or volume per unit time.
282 PART IV Calculations for Specialty Areas

Today’s technology has produced smart pumps that are easily programmable, have built-in safety
features, and can calculate and deliver appropriate drug dosages. The smart pump’s conrol panel allows
the user to select or enter (1) the name of the drug, (2) the concentration of the drug, (3) the volume of
the solution, (4) the patient’s weight in kilograms, and (5) the drug’s dosage parameter per unit time (e.g.,
mg/min, units/hr, mcg/min) (Figure 13-1).
Not all facilities have infusion pumps with advanced technology; therefore the nurse must be able to
calculate the infusion rates. For general-purpose infusion pumps that deliver mL/hr, the volume per hour
of the drug must be known. Remember: If an infusion device is unavailable, a microdrip IV administration
set is the appropriate set to use because the drops per minute rate (gtt/min) corresponds to the volume
per hour rate (mL/hr).
Complete infusion rates for the volume and concentration are given in the examples and practice
problems. In clinical practice, not all of the data is needed or pertinent for each drug to infuse. For
example, when administering a heparin infusion, the concentration per minute is not as vital as the
concentration per hour. However, vasoactive drugs such as dobutamine focus heavily on the concen-
tration per minute and not the concentration per hour. Both of these drugs can use the same methods
of calculation in order to obtain the same information. The nurse must have knowledge of pharmacol-
ogy and clinical practice to determine the data that will be the most beneficial.

Concentration and Volume per Hour and Minute With a Drug in Units
EXAMPLES I nfuse heparin 5000 units in D5W 250 mL at 30 mL/hr. Concentration of solution is 20 units/mL. (Also
note that volume/hour is given.) How many milliliters will be infused per minute?

Find volume per minute:

Method: mL/min

Set up a ratio and proportion. 30 mL;60 min<X mL; min

Use
volume/hour, 30 mL/hr, or 60 X 5 30
30
mL/60 min as the known variable. X 5 0.5 mL

Answer: The infusion rate for volume per minute is 0.5 mL/min and the hourly rate is 30 mL/hr.

What is the concentration per minute and hour?

Find concentration per minute:
Method: units/min

Multiply the concentration of solution 20 units/mL 3 ​0.5 mL/min 5 ​10 units/min

by the volume per minute.

Find concentration per hour:

Method: units/hr

Multiply the volume per minute by 10 units/min 3 ​60 min/hr 5 ​600 units/hr
60 min/hr.

Answer: The concentration per minute of heparin is 10 units/min and the concentration per hour is
600 units/hr.
 CHAPTER 13 Critical Care 283

A Infusion Menu
A Guardrail Drugs
B Guardrail IV Fluids
Basic Infusion

Select Channel

A B
Select the pump channel Select the infusion option.
providing the dosage.

A Guardrail Drugs A Guardrail Drugs

diltiazem DOPamine
diphenhydrAMINE 200mg/100mL
DOBUTamine 400mg/250mL
DOPamine 800mg/200mL
doxyCYCLINE 800mg/250mL

C D
Select the drug. Select the concentration.

A Guardrail Drugs A Guardrail Drug Setup

DOPamine DOPamine
400mg/250mL YES Drug Amount 400 mg
was selected. Diluent Volume 250 mL
Is this correct? NO
Patient Weight ___kg
DOSING Time Units mcg/kg/min
UNITS mcg/kg/min
NOT BOLUSABLE [Conc]: 1600mcg/mL

E F
Verify correct dosage is selected. Enter patient weight

A Guardrail Drugs
Continuous Infusion
Rate 5mL/h
VTBI_250_mL
DOSE 1.07 mcg/kg/min
[Conc] 1600mcg/mL
Start

G
Verify information is correct and start infusion.
Figure 13-1 Examples of display screens of a dose rate calculator on an advanced infusion pump. (Modified from the Alaris
System with Guardrail, Suite MX software. CareFusion 2011, San Diego, Calif.)
284 PART IV Calculations for Specialty Areas

Concentration and Volume per Hour and Minute With a Drug in Milligrams
EXAMPLES I nfuse lidocaine 2 g in D5W 500 mL at 2 mg/min. Concentration of solution is 4 mg/mL. (Also note
that concentration/minute is given.) How many milligrams will be infused per hour?

Find concentration per hour:

Method: mg/hr

Find the concentration/minute. lidocaine 2 mg/min

Multiply concentration/minute 3 ​ 2 mg/min 3 ​60 min 5 ​120 mg/hr
60 min/hr.

Answer: The amount of lidocaine infused per hour is 120 mg/hr.

How many milliliters of lidocaine will be infused in 1 hour?

Find volume per hour:
Method: mL/hr

Calculate concentration of solution. lidocaine 4 mg/mL

Divide the concentration/hour by the 120 mg /hr
concentration of solution. 5 30 mL/hr
4 mg /mL

Answer: The infusion rate in milliliters for lidocaine 2 mg/min is 30 mL/hr.

How many milliliters of lidocaine will be infused in 1 minute?

Divide the concentration/minute by 2 mg /min

the concentration of the solution.
5 0.5 mL/min
4 mg /mL

Answer: The infusion rate for lidocaine 2 mg/min is 0.5 mL/min.

Concentration and Volume per Hour and Minute With a Drug in Micrograms
EXAMPLES I nfuse dobutamine 250 mg in D5W 500 mL at 650 mcg/min. Concentration of solution is 500 mcg/mL.
(Also note that concentration/minute is given in the order.) How many micrograms will be infused in
1 hour?

Find concentration per hour:

Method: mcg/hr

Find the concentration/minute. dobutamine 650 mcg/min

Multiply concentration/minute by 650 mcg/min 3 ​60 min/hr 5 ​39,000 mcg/hr
60 min/hr.

Answer: The concentration of dobutamine infused per hour is 39,000 mcg/hr.

 CHAPTER 13 Critical Care 285

How many milliliters of dobutamine will be infused in 1 hour?

Find volume per hour:
Method: mL/hr

Calculate concentration of solution. dobutamine 500 mcg/mL

Divide the concentration/hour by the 39,000 mcg /hr
concentration of solution. 5 78 mL/hr
500 mcg /mL

Answer: The infusion rate for dobutamine 650 mcg/min is 78 mL/hr.

How many milliliters of dobutamine should be infused in 1 minute?

Find volume per minute:
Method: mL/min

Divide concentration/minute by 650 mcg /min

concentration of solution.
5 1.3 mL/min
500 mcg /mL

Answer: The infusion rate for dobutamine is 1.3 mL/min.

PRACTICE PROBLEMS: u II CALCULATING INFUSION RATE

Answers can be found on pages 296 to 301.

Use the examples to find the following information:

• Concentration of the solution
• Infusion rates per unit time:
a. Volume per minute
b. Volume per hour
c. Concentration per minute
d. Concentration per hour
1. Order: heparin 1000 units in D5W 500 mL at 50 mL/hr.
2. Order: nitroprusside 100 mg in D5W 500 mL at 60 mL/hr.
3. Order: nitroprusside 25 mg in D5W 250 mL at 50 mcg/min.
4. Order: dopamine 800 mg in D5W 500 mL at 400 mcg/min.
5. Order: norepinephrine 2 mg in D5W 250 mL at 45 mL/hr.
6. Order: dobutamine 1000 mg in D5W 500 mL at 12 mL/hr.
7. Order: dobutamine 250 mg in D5W 250 mL at 10 mL/hr.
8. Order: lidocaine 2 g in D5W 500 mL at 4 mg/min.
9. Order: dopamine 400 mg in D5W 250 mL at 60 mL/hr.
10. Order: isoproterenol 4 mg in D5W 500 mL at 65 mL/hr.
11. Order: morphine sulfate 50 mg in 150 mL NS at 3 mg/hr.
12. Order: regular Humulin insulin 50 units in 250 mL NS at 4 ​units/hr.
13. Order: aminophylline 2 g in 250 mL D5W at 20 mL/hr.
14. Order: nitroglycerin 50 mg in 250 mL D5W at 24 mL/hr.
15. Order: heparin 25,000 units in 500 mL D5W at 10 mL/hr.
16. Order: amiodarone 900 mg in D5W 500 mL at 33.3 mL/hr.
17. Order: procainamide 1 g in D5W 250 mL at 4 mg/min.
18. Order: diltiazem 100 mg in 100 mL NS at 10 mg/hr.
19. Order: streptokinase 750,000 ​units in 250 mL NS at 100,000 units/hr.
20. Order: bretylium 1 g in 250 mL D5W at 1 mg/min.
286 PART IV Calculations for Specialty Areas

CALCULATING INFUSION RATES OF A DRUG FOR SPECIFIC BODY WEIGHT

PER UNIT TIME

The last method is calculating infusion rates for the amount of drug per unit time for a specific body
weight. The weight parameter is an accurate means of dosing for a therapeutic effect. The metric system
is used for all drug dosing, so pounds must be changed to kilograms. The physician orders the desired
dose per kilogram of body weight and the concentration of the solution. From this information, infusion rates
can be calculated for administering an individualized dose. Accurate daily weights are essential for the
correct dosage.
The previous methods for calculating concentration of solution and infusion rates for concentration and
volume are used, with one addition. The concentration per minute is obtained by multiplying the body
weight by the desired dose per kilogram per minute, which must be done before the other infusion rates can
be calculated. For many vasoactive drugs given as examples in this chapter, the most useful information
clinically is the concentration per minute for the specific body weight, volume per minute, and volume
per hour, because these parameters determine the infusion pump settings (see Figure 13-1).
New volumetric infusion pumps can now deliver fractional portions of a milliliter from tenths to
hundredths in addition to calculating dosages for infusion rates. If the infusion pumps available do not
have this feature and the volume per hour is a fractional amount, it must be rounded off to a whole num-
ber (1.8 mL/hr 5 ​2 mL/hr). When calculating concentration per minute and hour and volume per
minute, carry out the problem to three decimal places, if necessary, before rounding off. The volume per
hour, if fractional, can then be rounded off, making the volume per hour as accurate as possible. There are
two important factors to consider when rounding off fractional infusion rates:
1. If the patient’s condition is labile, the difference between 1 or 2 mL could be important.
2. The ordering physician should be consulted if rounding off would significantly change the drug
dosage.

Micrograms per Kilogram Body Weight

EXAMPLES I nfuse dobutamine 250 mg in 500 mL D5W at 10 mcg/kg/min. Patient weighs 143 lb. Concentration of
solution is 500 mcg/mL. How many micrograms of dobutamine would be infused per minute? Per hour?

Convert pounds to kilograms:

143 lb
Divide pounds by 2.2. 5 65 kg
2.2 lb /kg

Find concentration per minute:

Method: mcg/min

Multiply patient’s weight by the 65 kg 3 ​10 mcg/kg/min 5 ​650 mcg/min

desired dose of mcg/kg/min.

Find concentration per hour:

Method: mcg/hr

Multiply concentration/min by 650 mcg/min 3 ​60 min/hr 5 ​39,000 mcg/hr

60 min/hr.

Answer: The concentration of dobutamine infused per minute and per hour is 650 mcg/min and
39,000 mcg/hr for the patient’s body weight.
 CHAPTER 13 Critical Care 287

How many milliliters of dobutamine will be infused per minute? Per hour? Find volume per minute:
Method: mL/min

Divide the concentration/minute by 650 mcg /min

the concentration of the solution.
5 1.3 mL/min
500 mcg /mL

Find volume per hour:

Method: mL/hr

Multiply volume/minute by 1.3 mL/min 3 ​60 min/hr 5 ​78 mL/hr

60 min/hr.

Answer: The volume of dobutamine infused per minute is 1.3 mL/min, and the infusion rate is
78 mL/hr.

BASIC FRACTIONAL FORMULA

A fractional equation can create a basic formula that can be used as another quick method to determine
any one of the following quantities: concentration of solution, volume per hour, and desired concentra-
tion per minute (3 ​kilogram of body weight, if required). The equation has one constant, the drop rate of
the IV set, 60 gtt/mL. The unknown quantity can be represented by X. (See Chapter 6 for fractional
equations.) The basic formula is not accurate to the nearest hundredth, as are the other methods in this
section:
Concentration of solution 1units, mg, mcg /mL2 Desired concentration 3 kg body weight
5
Drop rate of set 160 gtt /mL2 Volume /hr 1mL/hr or gtt /min2

Using Basic Formula to Find Volume per Hour or Drops per Minute
EXAMPLE Infuse heparin 5000 units in 250 mL D5W at 0.15 units/kg/min.

Patient weighs 70 kg. The concentration of solution is 20 units/mL.

Desired concentration/minute: 0.15 units/kg/min 3 ​70 kg 5 ​10.5 units/min

20 units /mL 10.5 units /min
5
60 gtt /mL X 1mL/hr or gtt /min2
20 X 5 630
X 5 31 mL/hr or 31 gtt /min

Using Basic Formula to Find Desired Concentration per Minute

EXAMPLE Infuse lidocaine 2 g in 500 mL D5W at 30 mL/hr. The concentration of the solution is 4 mg/mL.
4 mg /mL X
5
60 gtt /mL 30 mL/hr
60 X 5 120
X 5 2 mg /min
288 PART IV Calculations for Specialty Areas

Using Basic Formula to Find Concentration of Solution

EXAMPLE I nfuse dobutamine 250 mg in D5W 500 mL at 10 mcg/kg/min with rate of 78 mL/hr. Patient weighs
65 kg.

Desired concentration per minute 5 10 mcg /kg /min 3 65 kg

5 650 mcg /min
X 650 mcg /min
5
60 gtt /mL 78 mL/hr
78 X 5 39,000
X 5 500 mcg /mL

PRACTICE PROBLEMS: u III CALCULATING INFUSION RATE FOR SPECIFIC BODY WEIGHT
Answers can be found on pages 301 to 304.

Determine the infusion rates for specific body weight by calculating the following:
• Concentration of the solution
• Weight in kilograms
• Infusion rates:
a. Concentration per minute
b. Concentration per hour (not always measured)
c. Volume per minute
d. Volume per hour
You can use the basic fractional formula and compare answers.
1. Infuse dobutamine 500 mg in 250 mL D5W at 5 mcg/kg/min. Patient weighs 182 lb.
2. Infuse amrinone 250 mg in 250 mL NS ​at 5 mcg/kg/min. Patient weighs 165 lb.
3. Infuse vecuronium 20 mg in 100 mL NS at 0.8 mcg/kg/min. Patient weighs 202 lb.
4. Infuse nitroprusside 100 mg in 500 mL D5W at 3 mcg/kg/min. Patient weighs 55 kg.
5. Infuse Precedex 200 mcg in 50 mL NS at 0.3 mcg/kg/hr. Patient weighs 158 lb. Hourly rate only.
6. Infuse propofol (Diprivan) 500 mg/50 mL infusion bottle at 10 mcg/kg/min. Patient weighs
187 lb.
7. Infuse alfentanil (Alfenta) 10,000 mcg in D5W 250 mL at 0.5 mcg/kg/min. Patient weighs
175 lb.
8. Infuse milrinone (Primacor) 20 mg in D5W 100 mL at 0.375 mcg/kg/min. Patient weighs 160 lb.
9. Infuse theophylline 400 mg in D5W 500 mL at 0.55 mg/kg/hr. Patient weighs 70 kg. Hourly
rate only.
10. Infuse esmolol 2.5 g in NS 250 mL at 150 mcg/kg/min. Patient weighs 148 lb.

TITRATION OF INFUSION RATE

High-alert drugs are given to improve a physiological function that is causing a life-threatening condi-
tion for the patient. Every high-alert drug produces a physiological response that should be closely moni-
tored and evaluated for effectiveness. For example, a patient receiving aminophylline should be monitored
for improved respiratory rate and breath sounds. Another example is nitroprusside, where a patient’s
decrease in blood pressure is the goal of therapy. Monitoring parameters should be a part of the physi-
cian’s order and followed closely by the nurse.
 CHAPTER 13 Critical Care 289

The purpose of titration in medication administration is to give the least amount of drug in the thera-
peutic range to elicit the appropriate targeted physiological response. With the smart pump, the thera-
peutic ranges are calculated. If a general-purpose infusion pump is used, the nurse should calculate the
upper and lower limits of the therapeutic range.
Titration of drugs administered by infusion is based on (1) concentration of solution, (2) infusion rates,
(3) specific concentration per kilogram of body weight, and (4) titration factor. The titration factor is the con-
centration of drug per drop in units (units/gtt), milligrams (mg/gtt), or micrograms (mcg/gtt). For the
programmable volumetric infusion pump, the titration factor is the increment of increase or decrease in
units, micrograms, or milligrams. If the only IV equipment available has the mL/hr feature, the titration
factor of concentration per drop can be used. Smart pumps can infuse medication volume in increments
of 0.01 mL/hr. Other pump features include a drug-specific dose calculator that allows the nurse to select
a drug name and input the dosage, the concentration of the drug, and the weight of the patient (see
Figure 13-1). These infusion pumps make drug delivery and titration easier for the nurse and safer for the
patient. Any dose changes can be easily reprogrammed by the pump’s drug-specific dose calculator. The
smart pump’s safety features help to decrease medication errors. Many drug manufacturers are recom-
mending smart pumps for the delivery of all vasoactive medications used in the critical care setting.
Calculating the titration factor is necessary when the technology of the advanced infusion pump is
unavailable. The titration factor can be added to or subtracted from the baseline infusion rate to deter-
mine the exact concentration of an infusion. Because the titration method of drug administration is
primarily used when a patient’s condition is labile, calculating the titration factor gives the nurse the
means of determining the exact amount of drug to be infused.
Medication protocols of the institution or drug infusion charts (developed by the drug manufacturer
or the hospital’s pharmacy) can be used to adjust infusion rates at the appropriate increments when titrat-
ing medications via the physician’s order. It is imperative that critical care nurses are knowledgeable on
the expected effects of a given medication, its titration factor, and its minimum and maximum dosage
when titrating. Often, the amount of drug being infused falls between calibrations on the charts. When
this occurs, the titration factor can be used to determine the exact concentration of drug being adminis-
tered. The titration factor can also be used to verify the correct selection from the chart.

EXAMPLE Infuse isuprel 2 mg in 250 mL D5W. Titrate 1 to 3 mcg/min to maintain heart rate greater than
50 beats/min and less than 130 beats/min and blood pressure greater than 90 mm Hg systolic.
a. Find concentration of solution:

2 mg 5 2000 mcg
Convert mg to mcg. Set up ratio and
proportion.
2000 mcg;250 mL<X mcg;mL
250 X 5 2000
X 5 8 mcg
8 mcg /mL

b. Infusion rate by volume per unit time:

Desired infusion rate by concentration is stated in the problem.
Note that the upper dosage and lower dosage must be determined.

Find volume rate per minute: mL/min:

Divide concentration/minute by con- Lower Upper

centration of solution. 1 mcg /min 3 mcg /min
8 mcg /mL 8 mcg /mL
5 0.125 mL/min 5 0.375 mL/min
290 PART IV Calculations for Specialty Areas

Find volume rate per hour: mL/hr (equivalent to gtt/min):

Multiply volume rate/minute by Lower

60 min. 0.125 mL/min 3 ​60 min/hr
5 ​7.5 mL/hr
Upper
0.375 mL/hr 3 ​60 min/hr
5 ​22.5 mL/hr

Dosage range is 7.5 mL/hr at 1 mcg/min, the lowest dose ordered, to 22.5 mL/hr at 3 mcg/min, the
highest dose ordered.

Determine Titration ​Factor Using Infusion Pump

When the amount of fluid being titrated is 1 mL or greater (0.1 mL/hr lowest increment of infusion),
the concentration of the solution multiplied by the volume per hour will give the total concentration
to be given in 1 hour. ​The total volume in 1 hour divided by 60 min/hr will yield the concentration
per minute.

EXAMPLE Increase isuprel from 7.5 mL/hr to 9 mL/hr.

Multiply concentration of solution by 9 mL/hr 3 8 mcg/mL 5 72 mcg/hr

volume/hr. Then divide by 60 min/hr. 72 mcg /hr
5 1.2 mcg /min
60 min/hr

When increments of less than 1 mL are being titrated, multiply the concentration by the lowest incre-
ment of infusion.

Multiply concentration of solution by 8 mcg/mL 3 0.1 mL/hr 5 0.8 mcg/hr

0.1 mL/hr to get the concentration/hr.

Find rate in mcg/min by dividing 0.8 mcg /hr

concentration/hr by 60 min/hr.
5 0.013 mcg /min
60 min/hr

Titration factor is 0.8 mcg/hr or 0.013 mcg/min for the solution of isuprel 2 mg in 250 mL D5W with
0.1 mL/hr as the lowest increment of infusion. If the baseline rate is 7.5 mL/hr and 1 mcg/min, increas-
ing the rate by 0.1 mL/hr to 7.6 mL/hr will increase the per minute dose to 1.013 mcg/min. Since isuprel
is ordered in mcg/min, using the titration factor in mcg/min would give a very accurate dose if increases
or decreases are needed.

Increasing or Decreasing Infusion ​Rates Using Infusion Pump

When increasing infusion rate (0.1 mL/hr lowest increment of infusion) from baseline, multiply the
titration factor by the number of increases and add to beginning rate.
 CHAPTER 13 Critical Care 291

EXAMPLE Baseline Data

Order isuprel 2 mg in 250 mL
Concentration of solution 8 mcg/mL
Beginning rate 1 mcg/min
Volume per hour 7.5 mL/hr
Lowest increment of infusion 0.1 mL/hr (lowest pump setting)
Titration factors 0.8 mcg/hr or 0.013 mcg/min

Since the order is given in mcg/min, the titration factor of mcg/min should be used. To increase infusion
rate from 7.5 mL/hr to 7.7 mL/hr, a 0.2-mL increase on the infusion pump, multiply titration factor by
2. Multiply 2 3 0.013 mcg/min 5 0.026 mcg/min, then add to baseline of 1 mcg/min and now the
concentration per minute is 1.026 mcg/min. Incremental increases can be easily calculated by multiply-
ing the titration factor by the number of increases, then adding to baseline.

EXAMPLE Hourly Rate Concentration/min

(mL/hr) Titration Factor (ADD)
7.5 mL/hr 0.013 mcg/min 1 mcg/min
7.6 mL/hr 0.013 mcg/min 3 1 5 0.013 1.013 mcg/min
7.7 mL/hr 0.013 mcg/min 3 2 5 0.026 1.026 mcg/min
7.8 mL/hr 0.013 mcg/min 3 3 5 0.039 1.039 mcg/min

To titrate downward, multiply titration factor by the number of decreases and subtract each decrease
from current infusion rate.

EXAMPLE Hourly Rate Concentration/min

(mL/hr) Titration Factor (SUBTRACT)
10 mL/hr 0.013 mcg/min 1.33 mcg/min
9.8 mL/hr 0.013 mcg/min 3 2 5 0.026 1.299 mcg/min
9.4 mL/hr 0.013 mcg/min 3 6 5 0.078 1.247 mcg/min

Determine Titration Factor Using a Microdrip IV Set

A microdrip IV set has a drop factor of 60 gtt/mL, so the number of drops per minute is the same as
the hourly rate. In a situation where infusion pumps are not available, a microdrip IV set should be
the only option to deliver small amounts of IV medication. Using the isuprel data, the mL/hr rate will
be 7.5 gtt counted per minute from the drip chamber. The titration factor is the amount of isuprel in
each drop.

Determine the titration factor:

Find rate in gtt/min. Divide 7.5 gtt/min

concentration/minute by gtt/min. 1 mcg /min
5 0.133 mcg /gtt
7.5 gtt /min

The titration factor is 0.133 mcg/gt in a solution of isuprel 2 mg in 250 mL D5W. In other words, changing
drops per minute results in a corresponding change in milliliters per hour. If the baseline infusion rates
are 1 mcg/min for concentration and 7.5 mL/hr for volume, increasing the infusion rate by 1 gt/min
changes the concentration/minute by 0.133 mcg and increases the hourly volume by 1 mL to give a rate
of 8.5 mL/hr.
292 PART IV Calculations for Specialty Areas

Increasing or Decreasing Infusion Rates Using a Microdrip IV ​Set

To increase the infusion rate by 5 gtt/min from a baseline rate of 1 mcg/min, set up a ratio and proportion
or multiply the titration factor (mcg/gt) by 5 to obtain the increment of increase.

EXAMPLES

Set up a ratio and proportion with 7.5 gtt;1 mcg<5 gtt;X mcg

rate in gtt/min as the known variable. 7.5 X 5 5
X 5 0.666 mcg
5 gtt /0.66 mcg

or

Multiply titration factor in mcg/gt 0.133 mcg/gt 3 ​5 gtt 5 ​0.665 mcg
by 5.

Adding 5 gtt/min increases the volume infusion rate by 5 mL/hr, from 7.5 to 12.5 mL/hr. The concentra-
tion of drug delivered is increased by 0.665 mcg/min to 1.665 mcg/min. For example,

1.000 mcg/min ​ ​ baseline rate

1 ​0.665 mcg/min ​ ​increment of rate increased
1.665 mcg/min ​ ​ adjusted infusion rate

Suppose the infusion rate was 3 mcg/min and a decrease was needed. To decrease the infusion rate by
10 gtt, set up another ratio and proportion or multiply the titration factor (mcg/gt) by 10.

EXAMPLES

Set up a ratio and proportion with 7.5 gtt;1 mcg<10 gtt;X mcg

rate in gtt/mcg as the known variable. 7.5 X 5 10
X 5 1.33 mcg
1.33 mcg /10 gtt

or

Multiply titration factor in mcg/gt 0.133 mcg/gt 3 ​10 gtt 5 ​1.33 mcg
by 10.

Subtracting 10 gtt/min decreases the infusion rate by 10 mL/hr, from 22.5 to 12.5 mL/hr. The amount
of drug delivered is decreased by 1.33 mcg/min to 1.67 mcg/min. For example,

3.00 mcg/min  baseline infusion rate

21.33 mcg/min   increment of rate decreased
1.67 mcg/min  adjusted infusion rate
 CHAPTER 13 Critical Care 293

PRACTICE PROBLEMS: u IV TITRATION OF INFUSION RATE

Answers can be found on pages 304 to 305.

1. What are the units of measure for the following terms?

a. Concentration of solution per minute for specific body weight
b. Concentration of solution
c. Volume per hour
d. Concentration per minute
e. Volume per minute
f. Concentration per minute
g. Titration factor
2. O
 rder: nitroprusside 50 mg in 250 mL D5W. Titrate 0.5 to 1.5 mcg/kg/min to maintain mean
systolic blood pressure at 100 mm Hg. Patient weighs 70 kg.

Find the following:
a. Concentration of solution
b. Concentration per minute
c. Volume per minute and hour
d. Titration factor for infusion pump; for microdrop set
e. Increase infusion rate of 10.5 mL/hr by 0.5 mL to 11 mL/hr with infusion pump. What is the
concentration per minute?
f. Increase infusion rate from 11 mL/hr to 20 mL/hr. What is the concentration per minute?
g. Increase the infusion rate of 11 gtt/min by 5 gtt. What is the concentration per minute? What
is the volume per hour?
h. Increase the infusion rate of 16 gtt/mL by 13 gtt. What is the concentration per minute?
What is the volume per hour?
3. O
 rder: dopamine 400 mg in 250 mL D5W. Titrate beginning at 4 mcg/kg/min to maintain a
mean systolic blood pressure of 100 to 120 mm Hg. Patient weighs 75 kg.

Find the following:
a. Concentration of solution
b. Concentration per minute
c. Volume per minute and hour
d. Titration factor for infusion pump; for microdrip set
e. W ith the infusion pump, increase infusion rate from 11.4 mL/hr to 12 mL/hr. What is the
concentration per minute?
f. W ith the infusion pump, increase the infusion rate to 12.5 mL/hr. What is the concentration
per minute?
g. Using a microdrip set, increase the infusion rate of 13 gtt/min by 7 gtt. What is the concentra-
tion per minute? What is the volume per hour?
h. Using a microdrip set, decrease the infusion rate of 20 mL/hr (20 gtt/min) by 5 gtt. What is
the concentration per minute? What is the volume per hour?

TOTAL AMOUNT OF DRUG INFUSED OVER TIME

Determining the total amount of drug infused over time is useful when changes in drug therapy occur. If
adverse effects, toxic levels, therapeutic failure, or discontinuance of a drug occurs, knowing the amount
that was administered can be important for charting and for determining future therapies.
294 PART IV Calculations for Specialty Areas

For this calculation, the concentration of the drug in its solution must be known, as well as the time
that the drug therapy began to the nearest minute. Again, with 60-gtt sets, the hourly rate is the same as
the drip rate per minute.

EXAMPLES Heparin 10,000 units in 250 mL D5W at 30 mL/hr has been infusing for 3 hours. The drug is discon­tinued.

How much heparin did the patient receive?

Find concentration of solution:

Set up a ratio and proportion. Solve 10,000 units;250 mL<X units;mL

for X. 250 X 5 10,000
X 5 40 units
40 units /mL

Find concentration per hour:

Multiply concentration of solution by 40 units/mL 3 ​30 mL/hr 5 ​1200 units/hr

volume/hour.

Calculate total amount of drug infused:

Multiply concentration/hour by length 1200 units/hr 3 ​3 hr 5 ​3600 units/hr

of administration.

Answer: The total amount of heparin infused over 3 hours was 3600 units.

PRACTICE PROBLEMS: u V TOTAL AMOUNT OF DRUG INFUSED OVER TIME

Answers can be found on page 306.

Solve for the amount of drug infused over time.

1. In 1 hour, a patient received two boluses of lidocaine 100 mg and an IV infusion of 4 mg/mL at
40 mL/hr for 30 minutes. How many milligrams have been infused?

Note: Do not exceed 300 mg/hr of lidocaine.

2. H
 eparin 20,000 units in 500 mL D5W at 50 mL/hr has been infused for 51⁄2 hours. The drug is dis-
continued. How much heparin has been given?

ANSWERS
I Calculating Concentration of a Solution

1. 10,000 units;250 mL<X units;mL

250 X 5 10,000 2. 1000 mg;100 mL<X mg; mL
X 5 40 units 100 X 5 1000 mg
The concentration of solution is 40 units/mL. X 5 10 mg
The concentration of solution is 10 mg/mL.
 CHAPTER 13 Critical Care 295

3. 100 units;500 mL<X units;mL 12. 2 g 5 2000 mg

500 X 5 100 2000 mg;250 mL<X mg;mL
X 5 0.2 units 250 X 5 2000
The concentration of solution is 0.2 units/mL. X 5 8 mg
The concentration of solution is 8 mg/mL.

4. 1 g 5 1000 mg 13. 25,000 units;250 mL<X mg;mL

1000 mg;1000 mL<X mg;mL 250 X 5 25,000
1000 X 5 1000 X 5 100 units
X 5 1 mg The concentration of solution is 100 units/mL.
The concentration of solution is 1 mg/mL.

5. 4 mg 5 4000 mcg 14. 1 g 5 1000 mg

4000 mcg;500 mL<X mcg;mL 1000 mg;500 mL<X mg;mL
500 X 5 4000 500 X 5 1000
X 5 8 mcg X 5 2 mg
The concentration of solution is 8 mcg/mL. The concentration of solution is 2 mg/mL.

6. 500 mg;250 mL<X mcg;mL 15. 50 mg 5 50,000 mcg

250 X 5 500 50,000 mcg;250 mL<X mcg;mL
X 5 2 mg 250 X 5 50,000
The concentration of solution is 2 mg/mL. X 5 200 mcg
The concentration of solution is 200 mcg/mL.

7. 400 mg;250 mL<X mg;mL 16. 100 mg;100 mL<X mg;mL

250 X 5 400 100 X 5 100
X 5 1.6 mg X 5 1 mg /mL
The concentration of solution is 1.6 mg/mL. The concentration of solution is 1 mg/mL.

8. 2 mg 5 2000 mcg 17. 800 mg;500 mL<X mg;mL

2000 mcg;250 mL<X mcg;mL 500 X 5 800
250 X 5 2000 X 5 1.6 mg /mL
X 5 8 mcg The concentration of solution is 1.6 mg/mL.
The concentration of solution is 8 mcg/mL.

9. 750,000 units;50 mL<X units;mL 18. 20 mg;100 mL<X mg;mL

50 X 5 750,000 100 X 5 20
X 5 15,000 units X 5 0.2 mg /mL
The concentration of solution is 15,000 units/mL. The concentration of solution is 0.2 mg/mL.

10. 50 mg 5 50,000 mcg 19. 1,500,000 units;100 mL<X mg;mL

50,000 mcg;500 mL<X mcg;mL 100 X 5 1,500,000
500 X 5 50,000 X 5 15,000 units /mL
X 5 100 mcg The concentration of solution is 15,000 units/mL.
The concentration of solution is 100 mcg/mL.

11. 1 g 5 1000 mg 20. 150 mg;100 mL<X mg;mL

1000 mg;250 mL<X mg;mL 100 X 5 150
250 X 5 1000 X 5 1.5 mg /mL
X 5 4 mg The concentration of solution is 1.5 mg/mL.
The concentration of solution is 4 mg/mL.
296 PART IV Calculations for Specialty Areas

II Calculating Infusion Rate

1. Concentration of solution:
1000 units;500 mL 5 ​X units;mL
500 X 5 1000
X 5 2 units
The concentration of solution is 2 units/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
50 mL;60 min<X mL;min 2 units/mL 3 ​0.8 mL/min 5 ​1.60 units/min
60 X 5 50
X 5 0.833 mL or 0.83 mL or 0.8 mL
0.8 mL/min
b. Volume/hr: d. Concentration/hr:
50 mL/hr 1.60 units/min 3 ​60 min/hr 5 ​96 units/hr
2. Concentration of solution.
100 mg;500 mL<X mg;mL
500 X 5 100
X 5 0.2 mg
The concentration of solution is 0.2 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
60 mL;60 min<X mL;min 0.2 mg/mL 3 ​1 mL/min 5 ​0.2 mg/min
60 X 5 60
X 5 1 mL
1 mL/min
b. Volume/hr: d. Concentration/hr:
60 mL/hr 0.2 mg/min 3 ​60 min/hr 5 ​12 mg/hr
3. Concentration of solution:
25 mg 5 25,000 mcg
25,000 mcg;250 mL<X mcg;mL
250 X 5 25,000
X 5 100 mcg
The concentration of solution is 100 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
50 mcg /min 50 mcg/min
5 0.5 mL/min
100 mcg /mL
b. Volume/hr: d. Concentration/hr:
0.5 mL/min 3 ​60 min/hr 5 ​30 mL/hr 50 mcg/min 3 ​60 min/hr 5 ​3000 mcg/hr
 CHAPTER 13 Critical Care 297

4. Concentration of solution:
800 mg 5 800,000 mcg
800,000 mcg;500 mL<X mcg;mL
500 X 5 800,000
X 5 1600 mcg
The concentration of solution is 1600 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
400 mcg /min 400 mcg/min
5 0.25 mL/min
1600 mcg /mL
b. Volume/hr: d. Concentration/hr:
0.25 mL/min 3 ​60 min/hr 5 ​15 mL/hr 400 mcg/min 3 ​60 min/hr 5 ​24,000 mcg/hr
5. Concentration of solution:
2 mg 5 2000 mcg
2000 mcg;250 mL<X mcg;mL
250 X 5 2000
X 5 8 mcg
The concentration of solution is 8 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
45 mL;60 min<X mL;min 8 mcg/mL 3 ​0.75 mL/min 5 ​6 mcg/min
60 X 5 45
X 5 0.75 mL/min
b. Volume/hr: d. Concentration/hr:
45 mL/hr 6 mcg/min 3 ​60 min/hr 5 ​360 mcg/hr
6. Concentration of solution:
1000 mg 5 1,000,000 mcg
1,000,000 mcg;500 mL<X mcg;mL
500 X 5 1,000,000
X 5 2000 mcg
The concentration of solution is 2000 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
12 mL;60 min<X mL;min 2000 mcg/mL 3 ​0.2 mL/min 5 ​400 mcg/min
60 X 5 12
X 5 0.2 mL
0.2 mL/min
b. Volume/hr: d. Concentration/hr:
12 mL/hr 400 mcg/min 3 ​60 min/hr 5 ​24,000 mcg/hr
7. Concentration of solution:
250 mg 5 250,000 mcg
250,000 mcg;250 mL<X mcg;mL
250 X 5 250,000
X 5 1000 mcg
The concentration of solution is 1000 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
10 mL;60 min<X mL;1 min 1000 mcg/mL 3 ​0.17 mL/min 5 ​170 mcg/min
60 X 5 10 mL
X 5 0.1666 mL or 0.17 mL
0.17 mL/min
b. Volume/hr: d. Concentration/hr:
10 mL/hr 170 mcg/min 3 ​60 min/hr 5 ​10,200 mcg/hr
298 PART IV Calculations for Specialty Areas

8. Concentration of solution:
2 g 5 2000 mg
2000 mg;500 mL<X mg;mL
500 X 5 2000
X 5 4 mg
The concentration of solution is 4 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
4 mg /min 4 mg/min
5 1 mL/min
4 mg /mL
b. Volume/hr: d. Concentration/hr:
1 mL/min 3 ​60 min/hr 5 ​60 mL/hr 4 mg/min 3 ​60 min/hr 5 ​240 mg/hr
9. Concentration of solution:
400 mg;250 mL<X mg;mL
250 X 5 400
X 5 1.6 mg
The concentration of solution is 1.6 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
60 mL;60 min<X mL;min 1.6 mg/mL 3 ​1 mL/min 5 ​1.6 mg/min
60 X 5 60
X 5 1 mL
1 mL/min
b. Volume/hr: d. Concentration/hr:
60 mL/hr 1.6 mg/min 3 ​60 min/hr 5 ​96 mg/hr
10. Concentration of solution:
4 mg 5 4000 mcg
4000 mcg;500 mL<X mcg;mL
500 X 5 4000
X 5 8 mcg
The concentration of solution is 8 mcg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
65 mL;60 min<X mL;min 8 mcg/mL 3 ​1.08 mL/min 5 ​8.64 mcg/min
60 X 5 65
X 5 1.083 mL or
1.08 mL/min
b. Volume/hr: d. Concentration/hr:
65 mL/hr 8.64 mcg/min 3 ​60 min/hr 5 ​518.4 mcg/hr or
518 mcg/hr
11. Concentration of solution:
50 mg;150 mL<X mg;mL
150 X 5 50
X 5 0.33 mg
The concentration of solution is 0.33 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/min:
0.05 mg /min 3 mg;60 min<X mg;min
5 0.15 mL/min 60 X 5 3
0.33 mg /mL
b. Volume/hr: X 5 0.05 mg /min
3 mg /hr
5 9.09 or 9 mL/hr
0.33 mg /mL
 CHAPTER 13 Critical Care 299

12. Concentration of solution:

50 units;250 mL<X mg;mL
250 X 5 50
X 5 0.2 units
The concentration of solution is 0.2 units/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
4 units;60 min<X units;min 0.066 units /min
5 0.33 mL/min
60 X 5 4 0.2 units /mL
X 5 0.066 units /min or 0.07 units/min
b. Concentration/hr: d. Volume/hr:
4 units/hr 4 units /hr
5 20 mL/hr
0.2 units /mL
13. Concentration of solution:
2 g 5 2000 mg
2000 mg;250 mL<X mg;mL
250 X 5 2000
X 5 8 mg
The concentration of solution is 8 mg/mL.
Infusion rates:
a. Volume/hr 5 ​20 mL/hr c. Concentration/min:
8 mg/mL 3 ​0.3 mL/min 5 ​2.4 mg/min
b. Volume/min: d. Concentration/hr:
20 mL;60 min<X mL;min 2.4 mg/min 3 ​60 min/hr 5 ​144 mg/hr
60 X 5 20
X 5 0.3 mL/min
14. Concentration of solution:
50 mg 5 50,000 mcg
50,000 mcg;250 mL<X mg;mL
250 X 5 50,000
X 5 200 mcg
The concentration of solution is 200 mcg/mL.
Infusion rates:
a. Volume/hr 5 ​24 mL/hr c. Concentration/min:
200 mcg/mL 3 ​0.4 mL/min 5 ​80 mcg/min
b. Volume/min: d. Concentration/hr:
24 mL/hr;60 min/hr<X mL;min 80 mcg/min 3 ​60 min 5 ​4800 mcg/hr
60 X 5 24
X 5 0.4 mL/min
15. Concentration of solution:
25,000 units;500 mL<X units;mL
500 X 5 25,000
X 5 50 units
The concentration of solution is 50 units/mL.
Infusion rates:
a. Volume/hr: c. Concentration/hr:
10 mL/hr 50 units/mL 3 ​10 mL/hr 5 ​500 units/hr
b. Volume/min: d. Concentration/min:
10 mL;60 min/hr<X mL;min 50 units/mL 3 ​0.166 mL/min 5 ​8.3 units/min
60 X 5 10
X 5 0.166 mL/min
300 PART IV Calculations for Specialty Areas

16. Concentration of solution:

900 mg;500 mL<X mg;mL
500 X 5 900
X 5 1.8 mg /mL
The concentration of solution is 1.8 mg/mL.
Infusion rates:
a. Volume/hr: c. Concentration/hr:
33.3 mL/hr 1.8 mg/mL 3 ​33.3 mL/hr 5 ​59.9 mg/hr
b. Volume/min: d. Concentration/min:
33.3 mL;60 min<X mL;min 1.8 mg/mL 3 ​0.55 mL/min 5 ​0.99 mg/mL or
60 X 5 33.3 1.0 mg/mL
X 5 0.55 mL/min
17. Concentration of solution:
1 g 5 1000 mg
1000 mg;250 mL<X mg;mL
250 X 5 1000
X 5 4 mg /mL
The concentration of solution is 4 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/hr:
4 mg /min 4 mg/min 3 ​60 min/hr 5 ​240 mg/hr
5 1 mL/min
4 mg /mL
b. Volume/hr: d. Concentration/min:
1 mL/min 3 ​60 min/hr 5 ​60 mL/hr 4 mg/min
18. Concentration of solution:
100 mg;100 mL<X mg;mL
100 X 5 100
X 5 1 mg /mL
The concentration of solution is 1 mg/mL.
Infusion rates:
a. Volume/hr: c. Concentration/hr:
10 mg /hr 10 mg/hr
5 10 mL/hr
1 mg /mL
b. Volume/min: d. Concentration/min:
10 mL/hr 1 mg/mL 3 ​0.166 mL/min 5 ​0.166 mg/min or
5 0.166 mL/min 0.17 mg/min
60 min/hr
19. Concentration of solution:
750,000 units;250 mL<X units;mL
250 X 5 750,000
X 5 3000 units /mL
The concentration of solution is 3000 units/mL.
Infusion rates:
a. Volume/hr: c. Concentration/hr:
100,000 units /hr 100,000 units/hr
5 33.3 mL/hr
3000 units /mL
b. Volume/min: d. Concentration/min:
33.3 mL/hr 100,000 units /hr
5 0.55 mL/min 5 1666.6 units /min or 1667 units /min
60 min/hr 60 min/hr
 CHAPTER 13 Critical Care 301

20. Concentration of solution:

1 g 5 1000 mg
1000 mg;250 mL<X mg;mL
250 X 5 1000
X 5 4 mg /mL
The concentration of solution is 4 mg/mL.
Infusion rates:
a. Volume/min: c. Concentration/hr:
1 mg /min 4 mg/mL 3 ​15 mL/hr 5 ​60 mg/hr
5 0.25 mL/min
4 mg /mL
b. Volume/hr: d. Concentration/min:
0.25 mL/min 3 ​60 min/hr 5 ​15 mL/hr 1 mg/min

III Calculating Infusion Rate for Specific Body Weight

1. Concentration of solution: Patient weight:

500 mg 5 500,000 mcg 182
lb to kg: 5 82.7 kg
500,000;250 mL<X mcg;mL 2.2
250 X 5 500,000
X 5 2000 mcg
The concentration of solution is 2000 mcg/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 413.5 mcg /min
5 0.206 mL/min or 0.2 mL/min
82.7 kg 3 5 mcg /kg /min 2000 mcg /mL
5 413.5 mcg /min
b. Concentration/hr: d. Volume/hr:
413.5 mcg/min 3 ​60 min/hr 5 ​24,810 mcg/hr 0.2 mL/min 3 ​60 min/hr 5 ​12 mL/hr
2. Concentration of solution: Patient weight:
250 mg 5 250,000 mcg 165
lb to kg: 5 75 kg
250,000 mcg;250 mL<X mcg;mL 2.2
250 X 5 250,000
X 5 1000 mcg
The concentration of solution is 1000 mcg/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 375 mcg /min
5 0.375 mL/min
75 kg 3 5 mcg /kg /min 5 375 mcg /min 1000 mcg /mL
b. Concentration/hr: d. Volume/hr:
375 mcg/min 3 ​60 min/hr 5 ​22,500 mcg/hr 0.375 mL/min 3 ​60 min/hr 5 ​22.5 mL/hr
302 PART IV Calculations for Specialty Areas

3. Concentration of solution: Patient weight:

20 mg 5 ​20,000 mcg 202
lb to kg: 5 92 kg
20,000 mcg;100 mL<X mcg;mL 2.2
100 X 5 20,000
X 5 200 mcg
The concentration of the solution is 200 mcg/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 73.6 mcg /min
92 kg 3 0.8 mcg /kg /min 5 0.368 mL/min
200 mcg /mL
5 73.6 mcg /min
b. Concentration/hr: d. Volume/hr:
73.6 mcg/min 3 ​60 min/hr 5 ​4,416 mcg/hr 0.368 mL/min 3 ​60 min/hr 5 ​22.08 or 22.1 mL/hr
4. Concentration of solution: Patient weight:
100 mg 5 100,000 mcg   55 kg
100,000 mcg;500 mL<X mg;mL
500 X 5 100,000
X 5 200 mcg
The concentration of solution is 200 mcg/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
3 mcg/kg/min 3 ​55 kg 5 ​165 mcg/min 165 mcg /min
5 0.825 mL/min
200 mcg /mL
b. Concentration/hr: d. Volume/hr:
165 mcg/min 3 ​60 min/hr 5 ​9900 mcg/hr 0.825 mL/min 3 ​60 min/hr 5 ​49.5 mL/hr

5. Concentration of solution: Patient weight:

200 mcg;50 mL<X mcg;mL 158 lb
lb to kg: 5 72 kg
50 X 5 200 2.2
X 5 4 mcg
The concentration of solution is 4 mcg/mL.
Infusion rates (hourly only, so no answers for a or c):
b. Concentration/hr: d. Volume/hr:
Body weight 3 Desired dose /kg /hr 21.6 mcg /hr
5 5.4 mL/hr
72 kg 3 0.3 mcg /kg /hr 4 mcg /mL
  5 21.6 mcg /hr
 CHAPTER 13 Critical Care 303

6. Concentration of solution: Patient weight:

500 mg;50 mL<X mg;mL   187
lb to kg: 5 85 kg
50 X 5 500 2.2
X 5 10 mg /mL
The concentration of solution is 10 mg/mL or 10,000 mcg/mL.
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 850 mcg /min
5 0.085 mL/min
85 kg 3 10 mcg /kg /min 10,000 mcg /mL
5 850 mcg /min
b. Concentration/hr: d. Volume/hr:
850 mcg/min 3 ​60 min/hr 5 ​51,000 mcg/hr 0.085 mL/min 3 ​60 min/hr 5 ​5.1 mL/hr
or 51 mg/hr
7. Concentration of solution: Patient weight:
10,000 mcg;250 mL<X mcg;mL 175
lb to kg: 5 79.5 kg
250 X 5 10,000 2.2
X 5 40 mcg /mL
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 39.75 mcg /min
5 0.99 mL/min or 1 mL/min
79.5 kg 3 0.5 mcg /kg /min 40 mcg /mL
5 39.75 mcg /min
b. Concentration/hr: d. Volume/hr:
39.75 mcg/min 3 ​60 min/hr 5 ​2385 mcg/hr 0.99 mL/min 3 ​60 min/hr 5 ​59.4 mL/hr
or 2.4 mg/hr
8. Concentration of solution: Patient weight:
20 mg;100 mL<X mg;mL 160
lb to kg: 5 72.7 kg
100 X 5 20 2.2
X 5 0.2 mg /mL
or 200 mcg /mL
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 27.2 mcg /min
5 0.136 mL/min
72.7 kg 3 0.375 mcg /kg /min 200 mcg /mL
5 27.2 mcg /min
b. Concentration/hr: d. Volume/hr:
27.2 mcg/min 3 ​60 min/hr 5 ​1632 mcg/hr or 0.136 mL/min 3 ​60 min/hr 5 ​8.16 mL/hr or
1.6 mg/hr 8.2 mL/hr
9. Concentration of solution: Patient weight:
400 mg;500 mL<X mg;mL   70 kg
500 X 5 400
X 5 0.8 mg /mL
Infusion rates: b. Volume/hr:
a. Concentration/hr: 38.5 mg /hr
Body weight 3 Desired dose /kg /min 5 48.125 mL/hr or 48 mL/hr
0.8 mg /mL
70 kg 3 0.55 mg /kg /min
5 38.5 mg /hr
304 PART IV Calculations for Specialty Areas

10. Concentration of solution: Weight:

2500 mg;250 mL<X mg;mL   148
lb to kg: 5 67.27 or 67.3 kg
250 X 5 2500 2.2
X 5 10 mg /mL
Infusion rates:
a. Concentration/min: c. Volume/min:
Body weight 3 Desired dose /kg /min 10 mg /min
5 1 mL/min
67.3 3 150 mcg /kg /min 10 mg /mL
5 10,095 mcg /min or 10 mg /min
b. Concentration/hr: d. Volume/hr:
10 mg/min 3 ​60 min/hr 5 ​600 mg/hr 1 mL/min 3 ​60 min/hr 5 ​60 mL/hr

IV Titration of Infusion Rate

1. a. (units, mg, mcg)/kg/min e. mL/min

b. (units, mg, mcg)/mL f. (units, mg, mcg)/min
c. mL/hr g. (units, mg, mcg)/min with infusion pump
d. (units, mg, mcg)/min (units, mg, mcg)/gtt with microdrip IV set
2. a. Concentration of solution:
50 mg 5 50,000 mcg
50,000 mcg;250 mL<X mcg;1 mL
250 X 5 50,000
X 5 200 mcg
The concentration of solution is 200 mcg/mL.
b. Concentration/min:
Lower: 0.5 mcg/kg/min 3 ​70 kg 5 ​35 mcg/min
Upper: 1.5 mcg/kg/min 3 ​70 kg 5 ​105 mcg/min
c. Volume/min and volume/hr:
Lower
35 mcg /min
5 0.175 mL/min 3 60 min /hr 5 10.5 or 11 mL/hr
200 mcg /mL
Upper
105 mcg /min
5 0.525 mL/min 3 60 min /hr 5 31.5 or 32 mL/hr
200 mcg /mL
d. Titration factor for infusion pump:
20 mcg /hr
200 mcg/mL 3 ​0.1 mL/hr 5 20 mcg/hr 5 0.333 or 0.3 mcg /min
60 min/hr
Titration factor for microdrip
35 mcg
11 mL/hr 5 11 gtt/min 5 3.18 or 3 mcg /gt
11 gtt /min
e. Base rate 10.5 mL/hr or 35 mcg/min.
5 3 0.33/min 5 1.65 mcg/min or 1.7 mcg/min
Add to base rate 35 mcg /min
1 1.7 mcg /min
36.7 mcg /min
 CHAPTER 13 Critical Care 305
4000 mcg /hr
f. 200 mcg/hr 3 20 mL/hr 5 4000 mcg/hr 5 66.6 mcg /min
60 min/hr
g. Concentration/min and volume/hr using a microdrip set:
5 gtt 3 3 mcg /gt 5 15 mcg
15 mcg 1 35 mcg /min 5 50 mcg /min
5 gtt 1 11 gtt /min 5 16 gtt /min or 16 mL/hr
h. Concentration/min and volume/hr using a microdrip set:
13 gtt 3 3 mcg /gt 5 39 mcg
39 mcg 1 50 mcg 5 89 mcg /min
13 gtt 1 16 gtt 5 29 gtt /mL or 29 mL/hr
3. a. Concentration of solution:
400 mg 5 400,000 mcg
400,000 mcg;250 mL<X mcg;1 mL
250 X 5 400,000 mcg
X 5 1600 mcg
The concentration of solution is 1600 mcg/mL.
b. Concentration/min:
4 mcg/kg/min 3 ​75 kg 5 ​300 mcg/min
c. Volume/min and volume/hr:
300 mcg /min
5 0.1875 mL/min 3 60 min /hr 5 11.25 or 11 mL/hr
1600 mcg /mL
d. Titration factor for infusion pump:
1600 mcg/mL 3 0.1 mL/hr 5 160 mcg/hr
160 mcg /hr
5 2.66 or 2.7 mcg /min
60 min/hr
Titration factor for microdrip:
300 mcg /min
11 mL/hr 5 ​11 gtt/min 5 27.2 or 27 mcg /gtt
11 gtt /min
e. Base rate 11 mL/hr or 300 mcg/min 300 mcg /min
6 3 2.7 mcg/min 5 16.2 mcg/min 116.25 mcg /min
316.2 mcg /min
f. 12.5 mL/hr 3 1600 mcg/mL 5 333 mcg/min
5 20,000 mcg/hr
20,000 mcg /hr
5 333 mcg /min
60 min/hr
g. Concentration/min and volume/hr using a microdrip set:
20 gtt /min 3 27 mcg /gt 5 540 mcg /min
7 gtt 1 13 gtt /min 5 20 gtt /min or 20 mL/hr
h. Concentration/min and volume/hr using a microdrip set:
15 gtt /min 3 27 mcg /gt 5 405 mcg /min
20 gtt /min 2 5 gtt 5 15 gtt /min or 15 mL/hr
306 PART IV Calculations for Specialty Areas

V Total Amount of Drug Infused Over Time

1. Lidocaine bolus:
100 mg
1100 mg
200 mg
Lidocaine IV infusion:
a. Concentration of solution: given as 4 mg/mL c. Concentration over 1⁄2 hour:
in problem. 30 min
160 mg /hr 3 5 80 mg over 30 min
60 min/hr
b. Concentration/hr: d. Amount of IV drug infused:
4 mg/mL 3 ​40 mL/hr 5 ​160 mg/hr Lidocaine per two boluses: 200 mg
Lidocaine per IV infusion: 180 mg
280 mg total amount infused over 1 hr
Note: The infusion rate is close to exceeding the maximum therapeutic range, which is 200 to 300 mg/hr.
2. Concentration of solution:
20,000 units;500 mL<X units;1 mL
500 X 5 20,000
X 5 40 units
a. The concentration of solution is 40 units/mL.
b. Concentration/hr:
40 units/mL 3 ​50 mL/hr 5 ​2000 units/hr
c. Amount of IV drug infused over 51⁄2 hours: 10,000 units
1
11,000 units
30 min
2000 units 3 5 1000 units over 1⁄2 hr 11,000 units over 51⁄2 hr
60 min/hr
2

2000 units 3 5 hr 5 10,000 units /5 hr

Additional practice problems are available in the Advanced Calculations section of Drug
Calculations Companion, version 5, on Evolve.
CHAPTER 14
Pediatric Critical Care

Objectives • Recognize factors that contribute to errors in drug and fluid administration.
• Identify the steps in calculating dilution parameters.
• Determine the accuracy of the dilution parameters in a drug order.

Outline FACTORS INFLUENCING INTRAVENOUS ADMINISTRATION

CALCULATING ACCURACY OF DILUTION PARAMETERS

In delivery of emergency drugs with complex dilution calculations, it is important for the nurse to evalu-
ate the accuracy of the physician’s order and to ensure that a child does not receive excessive fluids. Many
institutions are attempting to standardize the concentration of the solution for various pediatric intrave-
nous (IV) dosages to decrease the occurrence of miscalculations. National efforts are under way to stan-
dardize IV emergency drugs for infusion to eliminate medication errors.
As noted in Chapter 13, the concepts of concentration of the solution, infusion rates for concentration
and volume, and concentration of a drug for specific body weight per unit time that are used in adult
critical care are also used to prepare pediatric doses.

FACTORS INFLUENCING INTRAVENOUS ADMINISTRATION

Excess fluid can be given when the fluid volume of the emergency drug is not considered in the 24-hour
fluid intake. Long IV tubing can be another source of fluid excess and can cause errors in drug delivery.
When the priming or filling volume of the IV tubing is not considered, the child may receive extra fluid,
especially if medication is added to the primary IV set via a secondary IV set. IV medication may not
reach the child if the IV infusion rate is low, such as 1 mL/hr, or if the IV tubing has not been primed or
filled with the medication before infusion. Most pediatric departments are developing protocols for safe
and consistent IV drug delivery.

CALCULATING ACCURACY OF DILUTION PARAMETERS

The nurse may find it necessary to calculate the dilution parameters of a drug order that specifies the
concentration per kilogram per minute and the volume per hour infusion rate. The physician should
determine all drug dose parameters, including concentration per kilogram per minute, volume per hour,
and dilution parameters. The nurse should check the accuracy of the dilution parameters to ensure that
the correct drug dosage is given. These methods are also used to prepare the pediatric dose. In many

307
308 PART IV Calculations for Specialty Areas

pediatric critical care areas, IV fluids for drug administration are limited to prevent fluid overload. If the
physician changes the drug dosage, rather than increasing the volume (mL), the concentration of the
solution will be changed. It is important that all health care providers follow the policies and procedures
of their institution regarding medication administration.

EXAMPLES PROBLEM 1: A 5-year-old-child, weight 14 kg, with septic shock.

Order: dobutamine 10 mcg/kg/min at 2.1 mL/hr; titrate to keep SBP .90.
Dilute as follows: dobutamine 200 mg in D5W to make a total volume of 50 mL for a
syringe pump.
Pediatric dosage: 2-20 mcg/kg/min.
Drug available: dobutamine 250 mg/20 mL.

Here are the following checks that can determine whether the infusion rate and the dilu-
tion orders will result in the correct concentration delivered according to weight.
Step 1: Calculate infusion concentration rates per minute and hour.
a. Concentration per minute.
Child’s weight 3 ​concentration/kg/min 5 ​
14 kg 3 10 mcg/kg/min 5 ​140 mcg/min
b. Concentration per hour.
140 mcg/min 3 ​60 min/hr 5 ​8400 mcg/hr
Step 2: Calculate the concentration of the solution. Check order by dividing concentration
per hour by the ordered mL per hour. Results should match.
200 mg 5 200,000 mcg
8400 mcg /hr
200,000 mcg : 50 mL<X mcg : 1 mL and 5 4000 mcg /mL
2.1 mL/hr
50 X 5 200,000
X 5 4000 mcg /mL
The concentration solution matches.
Step 3: Calculate the infusion rate, volume per hour. Divide concentration per hour by
concentration of solution. Results should confirm the infusion rate in order.
8400 mcg /hr
5 2.1 mL/hr
4000 mcg /mL
Infusion rate is correct.
Step 4: Calculate drug order.
H ; V < D ; V
D 200 20 4000
250 mg;20 mL<200 mg;X mL or 3V5 3 5 5 16 mL
H 250 1 250
250 X 5 4000
X 5 16 mL
Dobutamine 200 mg is 16 mL. Find the amount of D5W by subtracting 16 mL of dobu-
tamine drug volume from 50 mL; 34 mL of D5W is needed to fill the 50-mL syringe.

PROBLEM 2: A 3-week-old premature infant, weight 1.6 kg, in shock.

Order: dopamine 2.5 mcg/kg/min at 0.6 mL/hr.
Dilute as follows: dopamine 20 mg in D5W to make a total of 50 mL for syringe pump.
 CHAPTER 14 Pediatric Critical Care 309

Dosage range: 2 to 20 mg/kg/min.

Drug available: dopamine 200 mg/5 mL.

Check to determine whether the infusion rate and the dilution orders will result in the cor-
rect concentration delivered according to weight.
Step 1: Calculate the concentration per minute and per hour, based on weight.
a. Concentration rate per minute
Infant’s weight 1.6 kg 3 2.5 mcg/kg/min 5 4 mcg/min
b. Concentration rate per hour
4 mcg/min 3 60 min/hr 5 240 mcg/hr
Step 2: Calculate the concentration of the solution. Check order by dividing concentration
per hour by the ordered mL per hour. Results should match.
20 mg 5 20,000 mcg
240 mcg /hr
20,000 mcg;50 mL<X mcg;mL  and   5 400 mcg /mL
0.6 mL/hr
50 X 5 20,000
X 5 400 mcg /mL
The concentration of solution matches.
Step 3: Calculate the infusion rate, volume per hour. Divide concentration per hour by
concentration solution. Results should confirm the infusion rate in order.
240 mcg /hr
5 0.6 mL/hr
400 mcg /mL
Infusion rate is correct.
Step 4: Calculate dilution orders.
H ; V < D ; V
D 20 mg
3V5 3 5 mL 5 0.5 mL  or  200 mg;5 mL<20 mg;X mL
H 200 mg
200 X 5 100
X 5 0.5 mL
Dopamine 20 mg is 0.5 mL. Find the amount of D5W needed by subtracting 0.5 mL of dopamine drug
volume from 50 mL; 49.5 mL of D5W is needed to fill the 50-mL syringe.

PROBLEM 3: For the same infant, the physician increases the dose of dopamine.
Order: dopamine 15 mcg/kg/min at 1.8 mL/hr.
Dilution: Same, dopamine 20 mg in 50 mL with a syringe pump.
Pediatric dosage range: 2-20 mcg/kg/min.
Drug available: dopamine 200 mg/5 mL.

Check to determine whether the infusion rate and the dilution orders will result in the cor-
rect concentration delivered according to weight.
Step 1: Calculate the concentration per minute and per hour based on weight.
a. Concentration rate per minute
Infant’s weight 1.6 kg 3 15 mcg/kg/min 5 24 mcg/min
b. Concentration rate per hour
24 mcg/min 3 60 min/hr 5 1440 mcg/hr
310 PART IV Calculations for Specialty Areas

Step 2: Calculate the concentration of the solution. Check order by dividing concentration
per hour by the ordered mL per hour.
1440 mcg /hr
400 mcg/mL (same as previous problem)   and   5 800 mcg /mL
1.8 mL/hr
Concentrations do not match. Physician must be consulted.
Step 3: Calculate the correct infusion rate per hour. Divide concentration per hour by con-
centration of solution.
1440 mcg /hr
5 3.6 mL/hr
400 mcg /mL

SUMMARY ​PRACTICE PROBLEMS
Answers can be found on pages 311 to 314.

Determine whether dilution orders will yield the correct concentration of solution.
1. A 5-year-old child with acute status asthmaticus.
Child weighs 21 kg.
O
 rder: terbutaline 0.1 mcg/kg/min. Dilute 25 mg terbutaline in 25 mL D5W to make a total volume
of 50 mL. Infuse at 0.25 mL/hr with syringe pump.
Pediatric dosage range: 0.02-0.25 mcg/kg/min.
Drug available: terbutaline 1 mg/mL.
2. A 9-year-old child who is intubated postoperatively.
Child weighs 30 kg.
O
 rder: fentanyl 0.03 mcg/kg/min. Dilute 2.5 mg fentanyl in 30 mL 0.9% saline to make a total vol-
ume of 50 mL. Infuse at 1 mL/hr with syringe pump.
Pediatric dosage range: 0.01-0.05 mcg/kg/min.
Drug available: fentanyl 2.5 mg/20 mL.
3. A 1-year-old child with septic shock.
Child weighs 9 kg.
O
 rder: dopamine 5 mcg/kg/min. Dilute 40 mg dopamine in 49.5 mL D5W to make a total volume
of 50 mL. Infuse at 3.4 mL/hr with syringe pump.
Pediatric dosage range: 2-20 mcg/kg/min.
Drug available: dopamine 400 mg/5 mL.
4. A 3-year-old child with hypertension related to a tumor.
Child weighs 16 kg.
O
 rder: sodium nitroprusside 2 mcg/kg/min. Dilute 50 mg nitroprusside in 45 mL D5W to make a
total volume of 50 mL. Infuse at 3 mL/hr with syringe pump.
Pediatric dosage range: 200-500 mcg/kg/hr.
Drug available: sodium nitroprusside 50 mg/5 mL.
5. A 10-year-old child with diabetic ketoacidosis.
Child weighs 32 kg.
O rder: regular insulin 0.1 units/kg/hr.
Dilute: regular insulin 50 units in 49.5 mL 0.9% saline, total volume 50 mL at 6.4 mL/hr with syringe
pump.
Pediatric dosage: 0.1 units/kg/hr.
Drug available: regular insulin 100 units/mL.
 CHAPTER 14 Pediatric Critical Care 311

6. A 2-day-old child with patent ductus arteriosus.

Child weighs 3.4 kg.
O
 rder: alprostadil 0.1 mcg/kg/min.
Dilute 0.1 mg of alprostadil in 50 mL D5W to run at 2 mL/hr with syringe pump.
Pediatric dosage range: 0.05-0.1 mcg/kg/min.
Drug available: alprostadil 500 mcg/mL.
7. A 7-year-old child with pulmonary embolism.
Child weighs 20 kg.
O
 rder: heparin 25 units/kg/hr using a premixed bag with a standard concentration of
200 units/mL. Run at 2.5 mL/hr with IV pump.
Pediatric dosage range: 15-25 units/kg/hr.
Drug available: heparin 50,000 units/250 mL.

ANSWERS SUMMARY PRACTICE PROBLEMS

1. Step 1: Calculate the concentration per minute and hour based on weight.
a. Concentration per minute.
21 kg 3 0.1 mcg/kg/min 5 2.1 mcg/min
b. Concentration per hour.
2.1 mcg/min 3 60 min/hr 5 126 mcg/hr 5 0.126 mg/hr
Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.
126 mcg /hr
25 mg;50 mL<X mg;1 mL   and   5 504 mcg /mL 5 0.5 mg /mL
0.25 mL/hr
50 X 5 25
X 5 0.5 mg/1 mL
The concentration of solution matches.
Step 3: Calculate the infusion rate, volume per hour. Divide concentration per hour by concentration of solution.
0.126 mg /hr
5 0.25 mL/hr
0.5 mg /mL
Step 4: Calculate the drug order.
D 25 mg 25
BF: 3V5 3 1 mL 5 5 25 mL  or  RP: 1 mg;1 mL<25 mg;X mL
H 1 mg 1
X 5 25 mL
Drug order is correct.
2. Step 1: Calculate the concentration per minute and hour based on weight.
a. Concentration per minute.
30 kg 3 ​0.03 mcg/kg/min 5 ​0.9 mcg/min
b. Concentration per hour.
0.9 mcg/min 3 ​60 min/hr 5 ​54 mcg/hr 5 0.054 mg/hr
312 PART IV Calculations for Specialty Areas

Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.
54 mcg /hr
2.5 mg;50 mL<X mg;1 mL   and   5 54 mcg /mL 5 0.05 mg /mL
1 mL/hr
50 X 5 2.5
X 5 0.05 mg/mL
The concentration of solution matches.
Step 3: Calculate the infusion rate, volume per hour. Divide concentration per hour by concentration of solution.
0.054 mg /hr
5 1 mL/hr
0.05 mg /mL
Step 4: Calculate the drug order.
D 2.5 mg 1
BF: 3V5 3 20 mL 5 3 20 mL 5 20 mL or RP: 2.5 mg;20 mL<2.5 mg;X mL
H 2.5 mg 1
2.5 X 5 50
Drug order is correct. X 5 20 mL
3. Step 1: Calculate the concentration per minute and hour based on weight.
a. Concentration per minute.
9 kg 3 ​5 mcg/kg/min 5 ​45 mcg/min
b. Concentration per hour.
45 mcg/min 3 ​60 min/hr 5 ​2700 mcg/hr 5 ​2.7 mg/hr
Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.
2700 mcg /hr
40 mg;50 mL<X mg;1 mL   and    5 794 mcg /mL   or   0.8 mg/mL
3.4 mL/hr
50 X 5 40
X 5 0.8 mg/mL or 800 mcg/mL
The concentration of solution matches.
Step 3: Calculate the infusion rate, volume per hour. Divide concentration per hour by concentration of solution.
2.7 mg /hr
5 3.4 mL/hr 13.375 mL/hr before rounding2
0.8 mg /mL
Step 4: Calculate the drug order.
D 40 mg 200
BF: 3V5 3 5 mL 5 5 0.5 mL  or  RP: 400 mg;5 mL<40 mg;X mL
H 400 mg 400
400 X 5 200 mL
Drug order is correct. X 5 0.5 mL
4. Step 1: Calculate the concentration per minute and hour based on weight.
a. Concentration per minute.
16 kg 3 ​2 mcg/kg/min 5 ​32 mcg/min
b. Concentration per hour.
32 mcg/min 3 ​60 min/hr 5 ​1920 mcg/hr 5 1.92 mg/hr
 CHAPTER 14 Pediatric Critical Care 313

Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.
1920 mcg /hr
50 mg;50 mL<X mg;1 mL   and   5 640 mcg /mL
3 mL/hr
50 X 5 50
X 5 1 mg/mL or 1000 mcg/mL
The concentration of solution does not match and the order is incorrect. The physician must be consulted.
Step 3: Calculate the correct infusion rate, volume per hour. Divide concentration per hour by concentration of
solution.
1920 mcg /hr
5 1.9 mL/hr
1000 mcg /mL
The concentration of solution is incorrect, and infusion rate cannot be confirmed until concentration of
solution is clarified.
Step 4: Calculate the drug order.

D 50 mg 250
BF: 3V5 3 5 mL 5 5 5 mL  or  RP: 50 mg;5 mL<50 mg;X mL
H 50 mg 50
50 X 5 250
  X 5 5 mL
Drug order is correct.
5. Step 1: Calculate the concentration per hour based on weight.
32 kg 3 ​0.1 units/kg/hr 5 ​3.2 units/hr
Step 2: Calculate the concentration of the solution. Check order by dividing the concentration per hour by the
order per mL per hour.
3.2 units /hr
50 units;50 mL<X units;1 mL   and   5 0.5 units /mL
6.4 mL/hr
50 X 5 50
X 5 1 unit/mL
The concentration of solution does not match. The physician must be consulted.
Step 3: C
 alculate the correct infusion rate, volume per hour. Divide concentration per hour by concentration of
solution.
3.2 units /hr
5 3.2 mL/hr
1 unit /mL
The concentration of solution is incorrect and infusion rate cannot be confirmed.
Step 4: Calculate the drug order.
D 50 units
5 3 1 mL 5 0.5 mL  or  RP: 100 units;1 mL<50 units;X mL
H 100 units
100 X 5 50
X 5 0.5 mL
Drug order is correct.
6. Step 1: Calculate the concentration per minute and hour based on weight.
a. Concentration per minute.
3.4 kg 3 ​0.1 mcg/kg/min 5 ​0.34 mcg/min
b. Concentration per hour.
0.34 mcg/min 3 60 min 5 20.4 mcg/hr
314 PART IV Calculations for Specialty Areas

Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.

0.1 mg 5 100 mcg

20.4 mcg /hr
100 mcg;50 mL<X mcg;mL  and   5 10.2 mcg /mL
2 mL/hr
50 X 5 100
  X 5 2 mcg/mL
The concentration of solution does not match. The physician must be consulted.
Step 3: Calculate
 the correct infusion rate, volume per hour. Divide the concentration per hour by the
concentration of solution.
20.4 mcg /hr
5 10.2 mL/hr
2 mcg /mL
The concentration of solution is incorrect and infusion rate cannot be confirmed.
Step 4: Calculate the drug order.
D 0.1 mg
BF: 5 3 1 mL 5 0.2 mL  or  RP: 0.5 mg;1 mL<0.1 mg;X mL
H 0.5 mg
0.5 X 5 0.1
X 5 0.2 mL
Drug order is correct.
7. Step 1: Calculate the concentration per hour based on weight.
Concentration per hour.
20 kg 3 ​25 units/kg/hr 5 ​500 units/hr
Step 2: Calculate the concentration of solution. Check order by dividing concentration per hour by the order mL
per hour.
500 units /hr
50,000 units;250 mL<X units;mL  and   5 200 units /mL
2.5 mL/hr
250 X 5 50,000
X 5 200 units /mL
The concentration of solution matches.
Step 3: C
 alculate infusion rate, volume per hour. Divide concentration per hour by concentration of solution.
500 units /hr
5 2.5 mL/hr
200 units /mL
Step 4: Calculate the drug order.
Premixed bag of heparin 50,000 units/250 mL.

Additional practice problems are available in the Intravenous Calculations and Advanced
Calculations sections of Drug Calculations Companion, version 5, on Evolve.
CHAPTER 15
Labor and Delivery

Objectives • State the complication related to intravenous fluid administration in the high-risk mother.
• Recognize the different types of fluid administration used in cases of high-risk labor.
• Determine the infusion rates of a drug in solution when the drug is prescribed by concentration
or volume.

Outline FACTORS INFLUENCING INTRAVENOUS FLUID AND DRUG MANAGEMENT

TITRATION OF MEDICATIONS WITH MAINTENANCE INTRAVENOUS FLUIDS
Administration by Concentration
Administration by Volume
INTRAVENOUS LOADING DOSE
INTRAVENOUS FLUID BOLUS

Drug calculations for labor and delivery are the same as those used in critical care. Determinations of the
concentration of the solution, infusion rates, and titration factors are the primary calculation skills used.
Accurate calculations are essential, as is the monitoring of intravenous (IV) fluid intake for medications
and anesthetic procedures. Impaired renal filtration in patients with preeclampsia and the antidiuretic
effect of tocolytic drugs make the monitoring of fluid intake vital. Accurate measurement of IV fluid
intake along with pulmonary assessment can decrease the risk of fluid overload and the sequelae of acute
pulmonary edema in women at high risk for complications.
Physicians’ orders and hospital protocols give specific guidelines for administering IV drugs. Careful
labeling of all IV fluids, IV medications, and IV lines is essential in preventing drug errors. The nurse is
responsible for managing the IV drug therapy, monitoring the patient’s fluid balance, and assessing the
patient’s response to drug therapy.

FACTORS INFLUENCING INTRAVENOUS FLUID AND DRUG MANAGEMENT

The most important concept in labor and delivery is that the drugs given to the mother also affect the
unborn baby. Therefore the responses of both the mother and the unborn baby must be closely monitored.
Vital signs and laboratory results, such as platelet counts, liver function studies, renal function, magne-
sium levels, reflexes, and contraction patterns, are the main indicators of the mother’s status. For the fetus,
the fetal heart pattern is the primary guide.

315
316 PART IV Calculations for Specialty Areas

TITRATION OF MEDICATIONS WITH MAINTENANCE INTRAVENOUS FLUIDS

Women in labor receive IV fluids to prevent dehydration when oral intake is contraindicated. IV drugs
are given to stimulate labor, treat preeclampsia, or inhibit preterm labor. Normally, 500 to 1000 mL of IV
fluids may be given to initially hydrate the mother, especially in preterm labor or before administration
of regional anesthesia. Any IV medications that are given by titration are a part of the hourly IV rate. The
patient has a primary IV line and a secondary IV line for medications. All IV medications should be
delivered by a volumetric pump, which ensures that the specified volume and correct dosage are
delivered.
Titration of drugs is frequently done for women with preeclampsia and women experiencing preterm
labor. The most common use of titration is for the induction or augmentation of labor. In the following
example, an oxytocic drug is given, and the primary IV rate is adjusted with the secondary IV drug line
to achieve a therapeutic effect and maintain adequate maternal hydration. Note that the drug is ordered
to be given by concentration and that the infusion rates for volume per minute and hour must be
determined.

Administration by Concentration
EXAMPLES 1. Give IV fluids at 100 mL/hr with lactated Ringer’s solution (LR).
2. Mix 10 units of oxytocin in 1000 mL normal saline solution (NS). Start at 1 milliunit/min, increase
by 1 or 2 milliunits/min, every 15-30 min, until uterine contractions are 2 to 3 minutes apart. Do not
exceed 40 milliunits/min.
Note: ​1 unit 5 ​1000 milliunits

Available: Secondary set:

 ​oxytocin 10 units/mL
  1000 mL NS
 ​IV set drop factor 20 gtt/mL
 ​infusion pump
Primary set:
 ​1000 mL LR
 ​IV set drop factor 20 gtt/mL
 ​infusion pump
For the secondary IV set, the following calculations must be made:
1. Concentration of solution.
2. Infusion rates: volume per minute and volume per hour.
3. Titration factor in concentration per minute (milliunits/min).
For the primary IV set, the following calculations must be made:
1. Pump is used; set the rate at mL/hr.
2. Balance primary IV flow with secondary IV rate to achieve 100 mL/hr.

Secondary IV (see Chapter 8 for formulas)

1. Concentration of solution:
10 units;1000 mL<X;1 mL
1000 X 5 10
X 5 0.01 unit or 10 milliunits
The concentration of solution is 10 milliunits/mL.
 CHAPTER 15 Labor and Delivery 317

2. Infusion rates for volume:

Concentration/minute
5 Volume /min 3 60 min 5 Volume /hr
Concentration of solution
Volume per minute Volume per hour
1 milliunit /min
5 0.1 mL/min 3 60 min 5 6 mL/hr
10 milliunits /mL
2 milliunits /min
5 0.2 mL/min 3 60 min 5 12 mL/hr
10 milliunits /mL
5 milliunits /min
5 0.5 mL/min 3 60 min 5 30 mL/hr
10 milliunits /mL
3. Titration factor (see Chapter 12): To increase the concentration by increments of 1 milliunit/min,
the hourly rate on the pump must be increased by 6 mL/hr. The titration factor for this problem is
6 mL/hr. To increase the concentration to a higher rate, multiply the rate of increase times 6 mL/hr.
(Example: To increase infusion to 5 milliunits/min, multiply 5 by 6 mL ​5 ​30 mL/hr.)
For the secondary IV line, the concentration of the solution is 10 milliunits/mL of oxytocin, with the
infusion rate of 6 mL/hr to be increased in increments of 1 to 2 milliunits every 15 to 30 minutes until
contractions are 2 to 3 minutes apart.

Primary IV
The secondary IV rate will start at 6 mL/hr; therefore the primary rate will be 94 mL/hr. (A balance is
needed to achieve 100 mL/hr.)
For every increase in rate from the secondary line, a corresponding decrease must be made with the
primary IV line. If the rate of the secondary line exceeds the ordered hourly rate, the primary IV line may
be shut off completely. The concentration of the solution may be changed by the physician if the mother
is receiving too much fluid.

Administration by Volume
In the previous example, the oxytocin was ordered to be infused by concentration (milliunits/min), which
is the recommended method for patient safety. Sometimes in clinical practice, the infusion rate may be
ordered by volume (mL/hr).

EXAMPLES M
 ix 30 units of oxytocin in 500 mL NS. Start at 1 mL/hr and increase by 1 to 2 mL every 15-30 min
until uterine contractions are 2 to 3 minutes apart. Notify physician before exceeding 40 milliunits/min.
To determine the concentration per hour of infusion, multiply concentration of the solution by
volume/hr.
60 milliunits/mL ​3 ​1 mL/hr ​5 ​60 milliunits/hr
To determine the concentration of the infusion per minute, divide:
Concentration/hr
5 Concentration/min
60 min/hr
60 milliunits /hr
5 1 milliunit /min
60 min/hr
Therefore an oxytocin solution with a concentration of 60 milliunits/mL infused at 1 mL/hr will admin-
ister 1 milliunit of the drug per minute.
318 PART IV Calculations for Specialty Areas

INTRAVENOUS LOADING DOSE

Some situations require IV medications to be infused over a short period to obtain a serum level for a
therapeutic effect. This type of IV drug administration is called a loading dose.
In the following example, a patient with preeclampsia receives a loading dose of magnesium sulfate,
followed by a maintenance dose of magnesium sulfate via the secondary IV line. A primary IV line is also
maintained after the loading dose is given. At the end of this example, the total IV intake is determined
for an 8-hour period.

EXAMPLES 1. Mix magnesium sulfate 40 g in 1000 mL of sterile NS.

2. Infuse 4 g over 20 minutes, then maintain at 2 g/hr.
3. Start LR at 75 mL/hr after magnesium sulfate loading dose.
Available: Secondary set:
  magnesium sulfate 50% (5 g in 10-mL ampules)
  1000 mL IV fluid
  IV set 20 gtt/mL
  infusion pump
Primary set:
  1000 mL LR
  IV set drop factor 20 gtt/mL
  infusion pump
For the secondary IV line, the following calculations must be made:
1. Dose of magnesium sulfate in IV.
2. Concentration of solution.
3. Volume of loading dose and flow rate for infusion pump (see Chapter 10).
4. Infusion rate: volume per hour of magnesium sulfate infusion.
For the primary IV line, the following calculation must be made:
1. Drop rate per minute.
For the total IV intake, the following solutions must be added:
1. Volume of loading dose.
2. Volume of secondary IV for 8 hours.
3. Volume of primary IV for 8 hours.

Secondary IV
D 40 g
1. 3V5 3 10 mL 5 80 mL of magnesium sulfate or 8 ampules
H 5g
2. Concentration of solution:
40 g 5 40,000 mg
40,000 mg;1000 mL<X;1 mL
1000 X 5 40,000
X 5 40 mg
The concentration of solution is 40 mg/mL.
3. Volume of loading dose:
4 g 5 4000 mg
40 mg;1 mL<4000 mg;X mL
40 X 5 4000
X 5 100 mL
 CHAPTER 15 Labor and Delivery 319

Flow rate for the pump:

3
20 min 60
100 mL 4 5 100 3 5 300 mL/hr
60 min/hr 20
1
The rate on the infusion pump for the 4-g infusion of magnesium sulfate over 20 minutes is
300 mL/hr. When the infusion rate is this high, it must be monitored closely, and the patient must be
observed for response to drug therapy.
4. Infusion rate: volume per hour:
2 g ​5 ​2000 mg
Concentration/hr 2000 mg /hr
5 Volume /hr 5 50 mL/hr
Concentration of solution 40 mg /mL
The rate on the pump for the 2-g/hr infusion is 50 mL/hr.

Primary IV
After the loading dose of magnesium sulfate, the primary IV will run at 75 mL/hr.

Total IV Intake Over 8 Hours

Volume of loading dose 100 mL
Volume of secondary IV 50 mL ​3 ​8 ​5 ​ 400 mL
Volume of primary IV 75 mL ​3 ​8 ​5 ​ 1 ​600 mL
 ​1100 mL
Because fluid overload is a potential problem for patients with preeclampsia, all IV fluids must be
calculated accurately and the use of infusion pumps is essential.

INTRAVENOUS FLUID BOLUS

An IV fluid bolus is a large volume, 500 to 1000 mL, of IV fluid infused over a short time (1 hour or less).
A bolus may be given before administration of regional anesthesia or to a patient experiencing preterm
labor.
In the next example, calculate the flow rate of an IV bolus from the primary IV followed by an infu-
sion of a tocolytic drug given by titration. At the end of this example, calculate the patient’s fluid intake
for 8 hours.

EXAMPLES
1. Start 1000 mL LR at 300 mL/10 min, then reduce to 125 mL/hr.
2. Mix terbutaline 7.5 mg in 500 mL of NS; start at 2.5 mcg/min; increase 2.5 mcg/min every 20 min
until contractions subside.
Available: Primary set:
  1000 mL LR
  IV set drop factor 20 gtt/mL
 ​infusion pump
Secondary set:
 ​terbutaline 1 mg/mL
 ​500 mL NS
  IV set 20 gtt/mL
 ​infusion pump
320 PART IV Calculations for Specialty Areas

For the secondary IV line, the following calculations must be made:

1. The dose of terbutaline in IV.
2. Concentration of solution.
3. Infusion rates: volume per minute and hour.
4. Titration factor for 2.5 mcg/mL.
For the primary IV line, determine the following:
1. Set pump to infuse 300 mL over 10 minutes and then 125 mL/hr.
2. Balance the primary IV with the secondary IV to achieve a rate of 125 mL/hr.
Total the IV fluids for 8 hours.

Secondary IV
D 7.5 mg
1. 3V5 3 1 mL 5 7.5 mL of terbutaline
H 1 mg
2. Concentration of solution:
7.5 mg 5 7500 mcg
7500 mcg;500 mL<X mcg;1 mL
500 X 5 7500
X 5 15 mcg
The concentration of solution is 15 mcg/mL.
3. Infusion rates: volume per minute and volume per hour.
2.5 mcg /min
5 0.166 mL/min 3 60 min /hr 5 9.96 mL/hr or 10 mL/hr
15 mcg /mL
4. Titration factor: To increase the concentration by increments of 2.5 mcg/min, the volume of the
increment of change must be calculated per minute and per hour:
Concentration/minute 2.5 mcg /min
5 mL/min 5 0.166 mL/min
Concentration of solution 15 mcg /mL
Volume /min 3 60 min/hr 5 Volume /hr
0.166 mL/min 3 60 min/hr 5 9.96 mL/hr or 10 mL
The titration factor is 0.166 mL/min or 10 mL/hr. Increasing or decreasing the infusion rate by
2.5 mcg/min will correspond to an increase or decrease in volume by 0.166 mL/min or 10 mL/hr.

Primary IV
1. Set infusion pump at 300 mL over 10 minutes, then reduce rate to 125 mL/hr.

Total IV Intake Over 8 Hours

Volume of loading dose 300 mL
Volume of primary set 115 mL ​3 ​8 ​5 ​ 920 mL
Volume of secondary set   10 mL ​3 ​8 ​5 ​ 1 ​  80 mL
 ​1300 mL
Assume that an average of 10 mL/hr of terbutaline was given.
 CHAPTER 15 Labor and Delivery 321

SUMMARY ​PRACTICE PROBLEMS
Answers can be found on pages 323 to 325.

1. Preeclamptic labor.
a. Mix magnesium sulfate 20 g in 500 mL NS.
b. Infuse 4 g over 30 minutes, then maintain at 2 g/hr.
c. Start LR 1000 mL at 75 mL/hr after loading dose of magnesium sulfate.
Available: Secondary set:
 ​ ​magnesium sulfate 50% (5 g in 10 mL)
 ​ ​1000 mL NS
 ​ ​IV set 20 gtt/mL
 ​ ​infusion pump
Primary set:
​  ​1000 mL LR
 ​ ​IV set 20 gtt/mL
Determine the following:
a. Secondary IV:
(1) ​Magnesium sulfate dosage.
(2) ​Concentration of solution.
(3) ​Volume of loading dose and infusion rate for pump.
(4) ​Infusion rate per hour of magnesium sulfate.
b. Primary IV: 75 mL/hr.
c. Total fluid intake for 8 hours.
2. Oxytocin/Pitocin for augmentation of labor.
a. Give LR 500 mL over 30 minutes, then infuse at 75 mL/hr.
b. Mix 15 units of oxytocin/Pitocin in 250 mL NS.
Start infusion at 2 milliunits/min, increase by 1 to 2 milliunits/min until labor pattern is established
and contractions are 2 to 3 minutes apart. Notify physician before exceeding 40 milliunits/min.
Available: Secondary set:
  ​oxytocin 10 units/mL
  ​250 mL NS
  ​IV set 20 gtt/mL
  ​infusion pump
Primary set:
  ​1000 mL LR
  ​IV set 20 gtt/mL
For secondary IV line, the following calculations must be made:
(1) Dose of oxytocin for IV.
(2) Concentration of solution.
(3) Infusion rate: volume per minute and volume per hour.
(4) Titration factor in milliunits per minute.
For primary IV line, the following calculation must be made:
(1) Infusion rate for 500 mL over 30 minutes.
322 PART IV Calculations for Specialty Areas

3. Preterm labor.
a. Mix terbutaline 5 mg in 250 mL NS.
Begin infusion at 15 mcg/min; increase by 2 mcg/min until contractions subside. Do not exceed
80 mcg/min.
b. Start NS 1 L at 100 mL/hr.
Available: Secondary set:
   terbutaline 1 mg/1 mL ampule
  ​250 mL NS
  ​IV set 20 gtt/mL
Primary set:
  ​1000 L NS
  ​IV set 20 gtt/mL
For secondary IV line, the following calculations must be made:
(1) Dose of terbutaline for IV.
(2) Concentration of solution.
(3) Infusion rate: volume per minute and volume per hour.
(4) Titration factor in micrograms per minute and hour.
For primary IV line, the following calculation must be made:
(1) Infusion rate for 100 mL/hr.
4. Oxytocin/Pitocin for augmentation of labor.
a. Mix 20 units of IV oxytocin in 1000 mL D5W.
Start infusion at 4 milliunits/min; increase by 3 milliunits/min until regular contractions begin.
b. Give 1000 mL D51⁄2NS over 2 hours.
Available: Secondary set:
  ​oxytocin 10 units/mL
  ​1000 mL D5W
  ​IV set 20 gtt/mL
  ​infusion pump
Primary set:
  ​1000 mL D51⁄2NS
  ​IV set 20 gtt/mL
For secondary IV line, the following calculations must be made:
(1) Dose of oxytocin for IV.
(2) Concentration of solution.
(3) Infusion rate: volume per minute and volume per hour.
(4) Titration factor in micrograms per minute.
For primary IV line, the following calculation must be made:
(1) Infusion rate for 1000 mL over 2 hours.
 CHAPTER 15 Labor and Delivery 323

ANSWERS ​ ​SUMMARY PRACTICE PROBLEMS

1. a. ​Secondary IV:
(1) ​Magnesium sulfate dosage:
D 20 g
3V5 3 10 mL 5 40 mL or 4 ampules of magnesium sulfate
H 5g
(2) ​Concentration of solution:
20 g 5 20,000 mg
20,000 mg;500 mL<X mg;1 mL
500 X 5 20,000
X 5 40 mg
The concentration of solution is 40 mg/mL.
(3) ​Volume of loading dose:
4 g 5 4000 mg
40 mg;1 mL<4000 mg;X mL
40 X 5 4000
X 5 100 mL
Infusion rate for 30 minutes:
2
30 min 60
100 mL 4 5 100 3 5 200 mL/hr
60 min/hr 30
1

(4) ​Infusion rate: volume per hour:

2 g 5 2000 mg
2000 mg /hr
5 50 mL/hr
40 mg /mL
b. Primary IV:
After the loading dose: Set IV rate at 75 mL/hr.
c. Total IV intake over 8 hours:
Volume of loading dose 100 mL
Volume of secondary IV 50 mL ​3 ​8 ​5 ​ 400 mL
Volume of primary IV 75 mL ​3 ​8 ​5 ​ 1600 mL
1100 mL
2. Augmentation of labor
a. Secondary IV:
D 15 units
(1) ​Oxytocin dosage: 3V5 3 1 mL 5 1.5 mL
H 10 units
Add 1.5 mL of oxytocin to 250 mL of NS.
(2) ​Concentration of solution
15 units 5 15,000 milliunits
15,000 milliunits;250 mL 5 X milliunits;1 mL
250 X 5 15,000
X 5 60 milliunits /mL
Concentration/minute 2 milliunits /min
(3) ​Infusion rate: 5
Concentration of solution 60 milliunits /mL
5 0.033 mL/min
5 19.8 mL/hr
324 PART IV Calculations for Specialty Areas

2 milliunits /min
(4) ​Titration factor: 5 0.033 mL/min 3 60 min /hr 5 1.9 mL/hr or 2 mL/hr
60 milliunits /mL
3 milliunits /min
5 0.05 mL/min 3 60 min /hr 5 3 mL/hr
60 milliunits /mL
4 milliunits /min
5 0.06 mL/min 3 60 min /hr 5 3.6 mL/hr or 4 mL/hr
60 milliunits /mL
5 milliunits /min
5 0.08 mL/min 3 60 min /hr 5 4.8 mL/hr or 5 mL/hr
60 milliunits /mL

Note: With this concentration of solution, there is a 1:1 relationship between milliunits/mL and mL/hr.

Minutes to administer 30 minutes

b. Primary IV: 500 mL LR 4 5 500 mL 4
60 min/hr 60 min/hr
60
5 500 3
30
5 1000 mL in 30 min
3. a. Secondary IV:
(1) Terbutaline dosage:
D 5 mg
3V5 3 1 mL 5 5 mL or 5 ampules of terbutaline
H 1 mg
Add 5 mL of terbutaline to 250 mL NS.
(2) ​Concentration of solution:
5 mg 5 5000 mcg
5000 mcg;250 mL<X mcg;1 mL
250 X 5 5000
X 5 20 mcg /mL
(3) ​Infusion rate:
Concentration/minute 15 mcg /min
5
Concentration of solution 20 mcg /mL
5 0.75 mL/min
5 0.75 3 60 5 45 mL/hr
(4) ​Titration factor:
20 mcg /min
5 0.1 mL/min
60 mcg /mL
0.1 mL/min 3 60 min/hr 5 6 mL/hr
b. Primary IV: Set infusion pump to deliver 100 mL/hr.
4. a. Secondary IV:
(1) ​Oxytocin dosage:
D 20 units
3V5 3 1 mL 5 2 mL
H 10 units
Add 2 mL of oxytocin to 1000 mL of D5W.
 CHAPTER 15 Labor and Delivery 325

(2) ​Concentration of solution:
20 units 5 20,000 milliunits
20,000 milliunits: 1000 mL<X milliunits;1 mL
1000 X 5 20,000
X 5 20 milliunits /mL
(3) ​Infusion rate:
Concentration/minute 4 milliunits /min
5
Concentration of solution 20 milliunits /mL
5 0.2 mL/min
5 0.2 3 60 5 12 mL/hr
(4) ​Titration factor:
7 milliunits /min
5 0.35 mL/min
20 milliunits /mL
10 milliunits /min
5 0.5 mL/min
20 milliunits /mL
13 milliunits /min
5 0.65 mL/min
20 milliunits /mL

Minutes to administer 120 minutes

b. Primary IV: 1000 mL D51⁄2NS 4 5 1000 mL 4
60 min/hr 60 min/hr
60
5 1000 3
120
5 500 mL/hr

Additional practice problems are available in the Basic Calculations and Advanced Calcula-
tions sections of Drug Calculations Companion, version 5, on Evolve.
CHAPTER 16
Community

Objectives • Identify the problems with conversion of metric to household measure.

• Name the components of a solution.
• List three methods of preparing a solution.
• Describe three ways solutions are labeled.
• State the formula used for calculating a solution of a desired concentration.
• State the formula used for calculating a weaker solution from a stronger solution.
• Identify the types of devices used for home infusion therapy.
• Determine daily fluid intake for an adult and a febrile adult.
• Describe the importance of body mass index (BMI) in health assessment.

Outline METRIC TO HOUSEHOLD CONVERSION

PREPARING A SOLUTION OF A DESIRED CONCENTRATION
Changing a Ratio to Fractions and Percentages
Calculating a Solution From a Ratio
Calculating a Solution From a Percentage
PREPARING A WEAKER SOLUTION FROM A STRONGER SOLUTION
Guidelines for Home Solutions
HYDRATION MANAGEMENT
Calculate Daily Fluid Intake for an Adult
Standard Formula for Daily Fluid Intake
Calculate Daily Fluid Intake for a Febrile Adult
BODY MASS INDEX (BMI)
Calculate Body Mass Index Using Two Formulas

Although the metric system is widespread in the clinical area, the home setting generally does not have
the devices of metric measure. This becomes a problem when liquid medication is prescribed in metric
measure for the home patient. Measuring spoons and syringes with metric measurements are available in
pharmacies, and families should be encouraged to purchase them. All pediatric liquid medication must
be measured using a metric measuring device. If metric devices are not available, the community nurse
should be able to assist the adult patient in converting metric to household measure.
Preparation of solutions in the home setting may involve conversion between the metric and house-
hold systems. Solutions used in the home setting can be used for oral fluid replacement, topical applica-
tion, irrigation, or disinfection. Although the majority of the solutions are available in stores, solutions
that can be prepared in the home can be effective and less costly than the commercially premixed items.
When commercially prepared drugs are too concentrated for the patient’s use and must be diluted, it
is necessary to calculate the strength of the solution to meet the therapeutic need as prescribed by the

326
 CHAPTER 16 Community 327

physician. Knowledge of solution preparation and of metric-household conversion can be useful skills for
the community nurse.

METRIC TO HOUSEHOLD CONVERSION

When changing from metric to household measure, use the ounce from the apothecary system as an
intermediary, because there is no clear conversion between the two systems.
The conversion factors for volume are:

Ounces to milliliters: multiply ounces ​3 ​29.57 or 30

Milliliters to ounces: multiply milliliters ​3 ​0.034

The conversion factors for weight are:

Ounces to grams: multiply ounces ​3 ​28.35

Grams to ounces: multiply grams ​3 ​0.035

Note that weight and volume measures differ in the metric system. The properties of crystals, powders,
and other solids account for the differences more so than the liquids. Also, as liquid measures increase in
volume, there are greater discrepancies between metric and standard household measure. Table 16-1 shows
the current approximate equivalents. Deciliters and liters are also included with the volume measurements.
These terms will be seen more commonly as the use of the metric system increases. Although conversion
charts are helpful guides, a metric measuring device would be optimal for drug administration. Standard
household measuring devices should be used instead of tableware if a metric device is not available.

N OTE
When a measuring device comes from the manufacturer with a drug, it should be used. If a liquid drug has
no measuring device, one should be purchased from the pharmacy, and the pharmacist can help choose
the correct device. If a measuring device cannot be obtained, then standard household measuring devices
can be used.

TABLE 16-1 Household to Metric Conversions (Approximate)

Standard Household Measure Apothecary Metric Volume Metric Weight
1
/8 teaspoon 7-8 gtt or 1/48 oz 0.6 mL 0.6 g
1
/4 teaspoon 15 gtt or 1/24 oz 1.25 mL 1.25 g
1
/2 teaspoon 30 gtt or 1/12 oz 2.5 mL 2.5 g
1 teaspoon 60 gtt or 1/6 oz 5 mL 5g
1
1 tablespoon or 3 teaspoons /2 oz 15 mL 15 g
1
2 tablespoons or 6 teaspoons 1 oz /4 dL or 30 mL 30 g
1 1
/4 cup or 4 tablespoons 2 oz /2 dL or 60 mL 60 g
1
/3 cup or 5 tablespoons 21/2 oz 3
/4 dL or 75 mL 75 g
1
/2 cup 4 oz 1 dL or 120 mL 120 g
1
1 cup 8 oz /4 L or 250 mL 230 g
1
1 pint 16 oz /2 L or 480-500 mL
1 quart 32 oz 1 L or 1000 mL
2 quarts or 1/2 gallon 64 oz 2 L or 2000 mL
1 gallon 128 oz 33/4 L or 3840-4000 mL
328 PART IV Calculations for Specialty Areas

PRACTICE PROBLEMS u
​ ​I ​METRIC TO HOUSEHOLD CONVERSION
Answers can be found on page 336.
Use Table 16-1 to convert metric to household measure.
1. Bismuth subsalicylate 15 mL every hour up to 120 mL in 24 hr.

2. Ceclor 5 mL four times per day.

3. Tylenol elixir 1.25 mL every 6 hours as necessary for temperature greater than 102° F.

4. Maalox 30 mL after meals and at bedtime.

5. Neo-Calglucon 7.5 mL three times per day.

6. Gani-Tuss NR liquid 10 mL, q6h, prn.

7. Castor oil 60 mL at bedtime.

Use Table 16-1 for conversions.

8. Metamucil 5 g in 1 glass of water every morning.

9. Dilantin-30 pediatric suspension 10 mL twice per day.

10. Homemade pediatric electrolyte solution:

H2O 1 L, boiled

Sugar 30 g

Salt 1.5 g

Lite salt 2.5 g

Baking soda 2.5 g
11. A nonalcoholic mouthwash:

H2O 500 mL boiled

Table salt 5 g

Baking soda 5 g
12. Magic mouthwash:

Benadryl 50 mg/10 mL

Maalox 10 mL
 CHAPTER 16 Community 329

13. Gastrointestinal cocktail for gastric upset:

Belladonna/phenobarbital elixir, 10 mL

Maalox, 30 mL

Viscous lidocaine, 10 mL

PREPARING A SOLUTION OF A DESIRED CONCENTRATION

All solutions contain a solute (drug) and a solvent (liquid). Solutions can be mixed three different ways:
1. Weight to weight: Involves mixing the weight of a given solute with the weight of a given liquid.

EXAMPLE 5 g sugar with 100 g H2O

This type of preparation is used in the pharmaceutical setting and is the most accurate. Scales for
weight to weight preparation are not usually found in the home setting.
2. Weight to volume: Uses the weight of a given solute with the volume of an appropriate amount of solvent.

EXAMPLE 10 g of salt in 1 L of H2O

or
1
⁄3 oz of salt in 1 qt of H2O

Again, a scale is needed for this preparation.

3. Volume to volume: Means that a given volume of solution is mixed with a given volume of solution.

EXAMPLE 30 mL of hydrogen peroxide 3% in 1 dL H2O

or
2 T of hydrogen peroxide 3% in 1/2 c H2O
Preparation of solutions volume to volume is commonly used in both clinical and home settings.
After a solution is prepared, the strength can be expressed numerically in three different ways:
1. A ratio—1;20 acetic acid
2. A fraction—5 g/100 mL acetic acid
3. A percentage—5% acetic acid
With a ratio, the first number is the solute and the second number is the solvent. In a fraction, the
numerator is the solid and the denominator is the liquid. A solution labeled by percentage indicates the
amount of solute in 100 mL of liquid. All pharmaceutically prepared solutions use the metric system, and
the ratio, fraction, and percentages are interpreted in grams per milliliter.

Changing a Ratio to Fractions and Percentages

Change a ratio to a percentage or a fraction by setting up a proportion using the following variables:
Known drug;Known volume<Desired drug;Desired volume
A proportion can also be set up like a fraction:
Known drug Desired drug
5
Known volume Desired volume

YOU MUST REMEMBER

Any variable in this formula can be found if the other three variables are known.
330 PART IV Calculations for Specialty Areas

EXAMPLE Change acetic acid 1;20 to a percentage

1 g;20 mL ​5 ​X g;100 mL

20 X ​5 ​100
X ​5 ​5 g
1 g;20 mL ​5 ​5 g;100 mL

Note: ​In percentage, the volume of liquid is 100 mL.

The ratio can be expressed as a fraction, 5 g/100 mL, or as a percentage, 5%. Another method of
changing a ratio to a percentage involves finding a multiple of 100 for volume (denominator), then mul-
tiplying both terms by that multiple.

PRACTICE PROBLEMS u
​ ​II ​PREPARING A SOLUTION OF A DESIRED CONCENTRATION
Answers can be found on pages 336 and 337.

Change the following ratios to fractions and percentages.

1. 4;1 6. 1;10,000
2. 2;1 7. 1;4
3. 1;50 8. 1;5000
4. 1;3 9. 1;200
5. 1;1000 10. 1;10
In the previous problems, grams per milliliter is the unit of measure used for preparing solutions. Scales
for measuring grams are rarely found in the clinical area or the home environment. Volume (in milliliters)
is the common measurement of drugs for administration. Drugs that are powders, crystals, or liquids are
measured in graduated measuring cups with metric, apothecary, or household units. The milliliter, although
a volume measure, can be substituted for a gram, a measure of mass, because at 4° C, 1 mL of water weighs
1 g. Mass and volume differ with the type of substance; thus grams and milliliters are not exact equivalents
in all instances, but they can be accepted as approximate values for preparation of solutions.

Calculating a Solution From a Ratio

To obtain a solution from a ratio, use the proportion or fraction method.

EXAMPLES PROBLEM 1: Prepare 500 mL of a 1;100 vinegar-water solution for a vaginal douche.

Known drug;Known volume<Desired drug;Desired volume

1 mL ; 100 mL < X mL ; 500 mL
100 X 5 500
X 5 5 mL
or
Known drug Desired drug
5
Known volume Desired volume
1 mL X
5
100 mL 500 mL
100 X 5 500
X 5 5 mL
 CHAPTER 16 Community 331

Answer: ​ 5 mL of vinegar added to 500 mL of water is a 1;100 vinegar-water solution.

Note: ​Five milliliters did not increase the volume of the solution by a large amount. When
volume and volume solutions are mixed, the total amount of desired volume should not be
exceeded. Therefore it is important to determine the volume of desired drug first, then
remove that volume from the appropriate amount of solvent (solution). When mixing the
solution, begin with the desired drug and add the premeasured solvent. This process ensures
that the solution has an accurate concentration.

PROBLEM 2: Prepare 100 mL of a 1;4 hydrogen peroxide 3% and normal saline mouthwash.

Known drug;Known volume<Desired drug;Desired volume

1 mL ; 4 mL < X mL ; 100 mL
4 X ​5 ​100 mL
  X ​5 ​25 mL

25 mL of hydrogen peroxide 3% is the amount of desired drug. To calculate the amount of

normal saline, use the following formula:

Desired volume ​2 ​Desired drug ​5 ​Desired solvent

100 mL 2 25 mL 5 75 mL

Answer: ​75 mL of saline and 25 mL of hydrogen peroxide 3% make 100 mL of a 1;4

mouthwash.

Calculating a Solution From a Percentage

To obtain a solution from a percentage, use the same formula with either the proportion or fraction
method.

EXAMPLE Prepare 1000 mL of a 0.9% NaCl solution.

Known drug;Known volume<Desired drug;Desired volume

0.9 g ; 100 mL < Xg ; 1000 mL
100 X ​5 ​900
    X ​ 5 ​9 g or 9 mL

9 g or 9 mL of NaCl in 1000 mL makes a 0.9% NaCl solution.

Answer: ​

PREPARING A WEAKER SOLUTION FROM A STRONGER SOLUTION

When a situation requires the preparation of a weaker solution from a stronger solution, the amount of
desired drug must be determined. The known variables are the desired solution, the available or on-hand
solution, and the desired volume. The formula can be set up with the strength of the solutions expressed
in either ratio or percentage. The proportion method or the fractional method can be used to solve the
problem. The first ratio or fraction, the desired solution (weaker solution), is the numerator, and the avail-
able or on-hand solution (stronger solution) is the denominator.

Desired solution;Available solution<Desired drug;Desired volume

or
Desired solution Desired drug
5
Available solution Desired volume
332 PART IV Calculations for Specialty Areas

EXAMPLES P
 repare 500 mL of a 2.5% aluminum acetate solution from a 5% aluminum acetate solution. Use water
as the solvent.

2.5% ; 5% < X ;500 mL

2.5 mL;5 mL<X;500 mL
5 X 5 1250
X 5 250 mL

Answer: ​Use 250 mL of 5% aluminum acetate to make 500 mL of 2.5% aluminum acetate solution.

Determine the amount of water needed.

Desired volume ​2 ​Desired drug ​5 ​Desired solvent

500 mL 2 250 mL 5 250 mL
or
Same problem using the fractional method:
2.5% X
3 5
5% 500 mL
5 X 5 1250
X 5 250 mL of 5% aluminum acetate
or
Same problem but stated as a ratio:
Prepare 500 mL of a 1;40 aluminum acetate solution from a 1;20 aluminum acetate solution with water
as the solvent.
1 1
: :: X : 500 mL
40 20
1 500
X5
20 40
1
500 20 500
X5 3 5
40 1 2
2

X 5 250 mL of 5% aluminum acetate solution

Guidelines for Home Solutions

For solutions prepared by patients in the home, directions need to be very specific and in written form, if
possible. People often think that more is better. Teach the patient that solutions can be dangerous if they
are too concentrated. Higher concentrations of solutions can irritate tissues and prevent the desired
effect. Recommend that standard measuring spoons and cups be used rather than tableware. Level mea-
sures rather than heaping measures of dry solutes should be used. Utensils and containers for solution
preparation should be clean or sterilized by boiling if used for infants. Mixing acidic solutions in aluminum
containers should be avoided, especially if the solution is for oral use. Although there is no evidence of
toxicity, a metallic taste is noticeable. Glass, enamel, or plastic containers can be used. Solutions should
be made fresh daily or just before use. Oral solutions, especially for infants, require refrigeration; topical
solutions do not.
 CHAPTER 16 Community 333

When preparing the solution, start with the desired drug and then add the solvent. This helps to dis-
perse the drug and ensures that the desired volume of solution is not exceeded. If the volume of solvent
is several liters, then it is not always practical to subtract a small volume of solute.
Solution problems are best calculated within the metric system. Fractional and percentage dosages are
difficult to determine within the household system.

PRACTICE PROBLEMS u
​ ​III ​PREPARING A WEAKER SOLUTION FROM A STRONGER ONE
Answers can be found on pages 337 to 339.

Identify the known variables and choose the appropriate formula. Perform calculations needed to
obtain the following solutions using the metric system. Use Table 16-1 to obtain the household
equivalent.
1. Prepare 250 mL of a 0.9% NaCl and sterile water solution for nose drops.

2. Prepare 250 mL of a 5% glucose and sterile water solution for an infant feeding.

3. Prepare 1000 mL of a 25% Betadine solution with sterile saline for a foot soak.

4. Prepare 2 L of a 2% Lysol solution for cleaning a changing area.

5. Prepare 20 L of a 2% sodium bicarbonate solution for a bath.

6. Prepare 100 mL of a 50% hydrogen peroxide 3% and water solution for a mouthwash.

7. P
 repare 500 mL of a modified Dakin’s solution 0.5% from a 5% sodium hypochlorite solution
with sterile water as the solvent.

8. Prepare 1500 mL of a 0.9% NaCl solution for an enema.

9. P
 repare 2 L of a 1;1000 Neosporin bladder irrigation with sterile saline. (Omit the household
conversion.)

10. D
 etermine how much alcohol is needed for a 3;1 alcohol and white vinegar solution for an exter-
nal ear irrigation. Vinegar 30 mL is used. Solve using the proportion method.

11. Prepare 1000 mL of a 1;10 sodium hypochlorite and water solution for cleaning.

12. Prepare 1000 mL of a 3% sodium hypochlorite and water solution.

334 PART IV Calculations for Specialty Areas

13. Prepare
​ 2000 L of a 1;9 Lysol solution to clean colorfast linens soiled with body fluids. (Omit the
household conversion.)

14. P
 repare 6 L of a 1;1200 bleach bath solution, using household bleach and water, for eczema. De-
termine how much bleach is needed.

15. Prepare
​ a 0.12% bleach bath solution, using household bleach and 20 gallons of water, to reduce
methicillin-resistant Staphylococcus aureus (MRSA) colonization. Determine how much bleach is
needed.

HYDRATION MANAGEMENT

Calculate Daily Fluid Intake for an Adult

Hydration problems normally increase with age as total body water is lost when muscle mass decreases.
With aging, the sensation of thirst diminishes and the physiological response to dehydration is not suf-
ficient to meet metabolic needs. Kidney function begins to decline in middle age, slowly decreasing the
ability of the kidney to concentrate urine, resulting in increasing water loss. Add health care problems,
such as dementia and diabetes, along with commonly used medication that increases fluid loss, such as
diuretics and laxatives, and dehydration is a real risk.
Dehydration can exacerbate problems such as urinary tract and respiratory tract infections but can
cause more subtle problems in the elderly, such as confusion, decreased cognitive function, incontinence,
constipation, and falls. All elderly adults, especially those over 85 years old, should be assessed for dehy-
dration on the basis of physical assessment, laboratory data, cognitive assessment, pattern of fluid intake,
and medical condition. Once daily fluid intake is established, nursing measures can be taken to maintain
an adequate hydration.

Standard Formula for Daily Fluid Intake*

100 mL/kg for the first 10 kg of weight
50 mL/kg for the next 10 kg of weight
15 mL/kg for the remaining kg

The standard formula includes fluid contained in foods. To determine how much liquid alone an adult
needs to consume, multiply the daily fluid intake by 75%.

EXAMPLE Adult weight is 94 kg

210 kg 3 100 mL 5 1000 mL

84 kg
210 kg 3 50 mL 5 500 mL
74 kg 3 15 mL 5 1110 mL
2610 mL
2610 mL 3 75% 5 2610 3 0.75 5 1957.5 or 1958 mL fluid/day

*Adapted from Skipper, A. (Ed.) (1998). Dietitian’s handbook of enteral and parenteral nutrition. Rockville, Maryland: Aspen
Publishers.
 CHAPTER 16 Community 335

Calculate Daily Fluid Intake for a Febrile Adult

When an adult is febrile, the need for fluids increases by 6% for each degree over normal temperature.
For example, a 94-kg adult with an oral temperature of 100.8° F, 2° above normal, needs a 12% increase
in fluid. To find the increase, multiply the fluid/day, 1958 mL, by the percent increase, 12%, and add that
to the total fluid/day.

1958 mL 3 12% 5 1958 3 0.12 5 234.9 or 235 mL

1958 mL 1 235 mL 5 2193 mL

PRACTICE PROBLEMS u
​ ​ IV ​HYDRATION MANAGEMENT
Answers can be found on pages 339 and 340.
1. Calculate the standard formula, then the fluid need of an adult weighing 84 kg.
2. Calculate the standard formula, then the fluid need of an adult weighing 63 kg.
3. Calculate the standard formula, then the fluid need of an adult weighing 70 kg.
4. Calculate the standard formula, then the fluid need of an adult weighing 100 kg.
5. C
 alculate the standard formula, then the fluid need of an adult weighing 69 kg with a fever
of 101° F.

BODY MASS INDEX (BMI)

The importance of weight for the determination of overall health status and drug therapy must be
emphasized. The current international standard is “body mass index” for adults and children as the crite-
ria for healthy weight, overweight, and obese persons.
Body mass index (BMI) is a weight-for-height index that takes the place of previously used height
and weight tables. BMI is a part of health assessments and is used as an indicator of risk factors for
chronic diseases.

Calculate Body Mass Index Using Two Formulas

a. BMI pounds and inches formula:
Weight in pounds
3 703
1Height in inches2 1Height in inches2

EXAMPLE A person who weighs 165 pounds and is 6 ft 1 inch (73 inches) has a BMI of:
165
3 703 5 21.8 BMI
73 3 73
b. BMI metric formula:
Weight in kg

1Height in meters2 1Height in meters2

EXAMPLE A person who weighs 165 pounds and is 6 ft 1 inch (73 inches) has a BMI of:

73 inches 3 0.0254 meters 5 1.854 meters

165 lb 4 2.2 kg 5 75 kg
75 75
5 5 21.8 BMI
11.8542 11.8542 3.437
336 PART IV Calculations for Specialty Areas

PRACTICE PROBLEMS u
​ ​V BODY MASS INDEX
Answers can be found on page 340.

1. What is the BMI for a female weighing 208 lb and who is 5 ft 2?

2. What is the BMI for a male weighing 198 lb and who is 5 ft 11?
3. What is the BMI for a female weighing 112 lb and who is 5 ft 4 inches tall?
4. What is the BMI for a male weighing 165 lb and who is 6 ft 1 inch tall?
5. What is the BMI for a male weighing 60 lb with a height of 3 ft 10 inches?

ANSWERS
I Metric to Household Conversion

  1. Bismuth subsalicylate 15 mL = 1 T; no more than 10. H2O 1 L ​5 ​1 qt

8 T in 24 hr Sugar 30 g ​5 ​2 T
  2. Ceclor 5 mL ​5 ​1 t Salt 1.25 g ​5 ​1/4 ​t
  3. Tylenol elixir 1.25 mL ​5 ​1/4 t Lite salt 2.5 g ​5 ​1/2 t
  4. Maalox 30 mL ​5 ​2 T Baking soda 2.5 g ​5 ​1/2 t
  5. Neo-Calglucon 7.5 mL ​5 ​11/2 t 11. H2O 500 mL ​5 ​1 pt
  6. Gani-Tuss NR 10 mL ​5 ​2 t Table salt 5 mL ​5 ​1 t
  7. Castor oil 60 mL ​5 ​4 T or 1/4 c Baking soda 5 mL ​5 ​1 t
  8. Metamucil 5 g ​5 ​1 t 12. Benadryl 50 mg/10 mL ​5 ​2 t
  9. Dilantin-30 pediatric suspension 10 mL ​5 ​2 t Maalox 10 mL ​5 ​2 t
13. Belladonna/phenobarbital elixir, 10 mL ​5 ​2 t
Maalox 30 mL ​5 ​2 T
Viscous lidocaine 10 mL ​5 ​2 t

II Preparing a Solution of a Desired Concentration

  1. 4;1 5 X;100   4. 1;3 5 X;100

X 5 400 3 X 5 100
400 X 5 33.3
, 400%
100 33.3
, 33.3%
  2. 2;1 5 X;100 100
X 5 200   5. 1;1000 5 X;100
200 1000 X 5 100
, 200%
100 X 5 0.1
  3. 1;50 5 X;100 0.1
, 0.1%
50 X 5 100 100
X52   6. 1;10,000 5 X;100
2 10,000 X 5 100
, 2%
100 X 5 0.01
1
, 0.01%
10,000
 CHAPTER 16 Community 337

  7. 1;4 5 X;100   9. 1;200 5 X;100

4 X 5 100 200 X 5 100
X 5 25 X 5 0.5
25 0.5
, 25% , 0.5%
100 100
  8. 1;5000 5 X;100 10. 1;10 5 X;100
5000 X 5 100 10 X 5 100
X 5 0.02 X 5 10
0.02 10
, 0.02% , 10%
100 100

III Preparing a Weaker Solution From a Stronger One

1. Known drug: 0.9% NaCl 0.9;100<X;250

Known volume: 100 mL 100 X 5 225
Desired drug: X X 5 2.25 mL
Desired volume: 250 mL
2.25 mL of NaCl in 250 mL of water yields a 0.9% NaCl solution. Household equivalents are approximately
1
/2 teaspoon salt and 1 cup sterile water.
2. Known drug: 5% glucose (sugar) 5;100<X;250
Known volume: 100 mL 100 X 5 1250
Desired drug: X X 5 12.5 mL
Desired volume: 250 mL
12.5 mL of sugar in 250 mL of water yields a 5% glucose solution. Household equivalents are approximately
1 tablespoon in 1 cup of sterile water.
3. Known drug: 25% Betadine 25;100<X;1000
Known volume: 100 mL 100 X 5 25,000
Desired drug: X X 5 250 mL
Desired volume: 1000 mL 1000 mL 2 250 mL 5 750 mL
250 mL of Betadine in 750 mL saline yields a 25% Betadine solution. Household equivalents are 1 cup Betadine
in 3 cups sterile saline.
4. Known drug: 2% Lysol 2;100<X;2000 mL
Known volume: 100 mL 100 X 5 4000
Desired drug: X X 5 40 mL
Desired volume: 2 L ​5 ​2000 mL
40 mL of Lysol in 2 L of water yields a 2% Lysol solution. Household equivalents are 2 tablespoons and
2 teaspoons (40 mL) of Lysol to 2 quarts or 1/2 gallon of water.
5. Known drug: 2% sodium bicarbonate 2;100<X;20,000 mL
Known volume: 100 mL 100 X 5 40,000
Desired drug: X X 5 400 mL or 400 g
Desired volume: 20,000 mL
400 mL or 400 g of sodium bicarbonate (baking soda) in 20,000 mL of water yields a 2% sodium bicarbonate
solution. Household equivalents are 11/2 cups and 2 tablespoons baking soda in 5 gallons of water.
338 PART IV Calculations for Specialty Areas

6. Known drug: 50% hydrogen peroxide 50;100<X;100

Known volume: 100 mL 100 X 5 5000
Desired drug: X X 5 50 mL
Desired volume: 100 mL 100 mL 2 50 mL 5 50 mL
50 mL of hydrogen peroxide 3% in 50 mL water yields a 50% solution. Household equivalents are approximately
3 tablespoons of hydrogen peroxide 3% in 3 tablespoons of water.
7. Known drug: 0.5% 0.5;5<X;500
Available solution: 5% 5 X 5 250
Desired drug: X X 5 50 mL
Desired volume: 500 mL 500 mL 2 50 mL 5 450 mL
50 mL of 5% sodium hypochlorite in 450 mL sterile water yields a 0.5% modified Dakin’s solution. Household
equivalents are 3 tablespoons and 1 teaspoon of Dakin’s solution in 1 pint minus 3 tablespoons of water.
8. Known drug: 0.9% 0.9;100<X;1500
Known volume: 100 mL 100 X 5 1350
Desired drug: X X 5 13.5 mL
Desired volume: 1500 mL
13.5 mL of NaCl in 1500 mL water yields a 0.9% NaCl solution. Household equivalents are 21/2 teaspoons of
salt in 11/2 quarts of water.
9. Known drug: 1 mL 1;1000<X;2000
Known volume: 1000 mL 1000 X 5 2000
Desired drug: X X 5 2 mL
Desired volume: 2000 mL
2 mL of Neosporin irrigant in 2000 mL of sterile saline yields a 1;1000 solution for continuous bladder
irrigation. This treatment is done primarily in the clinical setting.
10. Use ratio and proportion to solve this problem.
3;1<X;30 mL
X ​5 ​90 mL
Add 90 mL of alcohol to 30 mL of vinegar to yield a 3;1 solution for an external ear wash. Household
equivalents are 6 tablespoons of alcohol and 2 tablespoons of vinegar.
11. Known drug: 1 mL 1;10<X;1000
Known volume: 10 mL 10 X 5 1000
Desired drug: X X 5 100 mL
Desired volume: 1000 mL 1000 mL 2 100 mL 5 900 mL
100 mL of sodium hypochlorite (bleach) in 900 mL water yields a 1;10 sodium hypochlorite solution.
Household equivalents are 1/3 cup and 2 tablespoons sodium hypochlorite in approximately 1 quart minus
1
/3 cup and 2 tablespoons of water.
12. Known drug: 3 mL 3;100<X;1000
Known volume: 100 mL 100 X 5 3000
Desired drug: X X 5 30 mL
Desired volume: 1000 mL 1000 mL 2 30 mL 5 970 mL
30 mL of sodium hypochlorite (bleach) in 970 mL water yields a 3% sodium hypochlorite solution. Household
equivalents are 2 tablespoons in 1 quart minus 2 tablespoons of water.
 CHAPTER 16 Community 339

13. Use ratio and proportion to solve this problem.

1;9<X;2000 mL
9 X 5 2000 mL
X 5 222 mL
Desired volume 2 Desired drug 5 Desired solvent
2000 mL 2 222 mL 5 1778 mL
222 mL of Lysol in 1778 mL of water yields a 1;9 cleansing solution for colorfast linens soiled with body fluids.
14. Use ratio and proportion to solve this problem.
1;1200<X;6000 mL
1200 X 5 6000
X 5 5 mL
5 mL of household bleach in 6 L of water yields a 1;1200 bleach bath solution for eczema.
15. Convert gallons to liters.
1 gallon 5 4 liters
20 gallons 3 4 liters/gallon 5 80 liters
Use ratio and proportion to solve this problem.
0.12 mL;0.1 L<X;80 L
0.1 X 5 9.6
X 5 96 mL or 31⁄4 ounces
31⁄4 ounces of bleach in 20 gallons of water yields a 0.12% bleach bath solution for MRSA decolonization.

IV Hydration Management

1. Adult weight is 84 kg
210 kg 3 100 mL 5 1000 mL
74 kg
210 kg 3 50 mL 5 500 mL
64 kg 3 15 mL 5 960 mL
2460 mL
2460 mL 3 75% 5 2460 3 0.75 5 1845 mL
2. Adult weight is 63 kg
210 kg 3 100 mL 5 1000 mL
53 kg
210 kg 3 50 mL 5 500 mL
43 kg 3 15 mL 5 645 mL
2145 mL
2145 mL 3 75% 5 2145 3 0.75 5 1608.75 or 1609 mL
340 PART IV Calculations for Specialty Areas

3. Adult weight is 70 kg
210 kg 3 100 mL 5 1000 mL
60 kg
210 kg 3 50 mL 5 500 mL
50 kg 3 15 mL 5 750 mL
2250 mL
2250 mL 3 75% 5 2250 3 0.75 5 1687.5 or 1688 mL
4. Adult weight is 100 kg
210 kg 3 100 mL 5 1000 mL
90 kg
210 kg 3 50 mL 5 500 mL
80 kg 3 15 mL 5 1200 mL
2700 mL
2700 mL 3 75% 5 2700 3 0.75 5 2025 mL
5. Adult weight is 69 kg
210 kg 3 100 mL 5 1000 mL
59 kg
210 kg 3 50 mL 5 500 mL
49 kg 3 15 mL 5 735 mL
2235 mL
2235 mL 3 75% 5 2235 3 0.75 5 1676 mL
6% 3 3° 5 18% for increased temperature.
1676 mL 3 18% 5 1676 3 0.18 5 301.6 or 302 mL
1676 mL 1 302 mL 5 1978 mL

V Body Mass Index

1. 5 feet 2 inches 5 62 inches (12 3 5 5 60 inches 1 2 inches 5 62 inches)

208 208
3 703 5 3 703 5 0.054 3 703 5 38 BMI
1622 1622 3844
2. 5 feet 11 inches 5 71 inches
198 198
3 703 5 3 703 5 0.039 3 703 5 27.4 BMI
1712 1712 5041
3. 5 feet 4 inches 5 64 inches
112 112
3 703 5 3 703 5 0.027 3 703 5 19 BMI
1642 1642 4096
4. 6 feet 1 inch 5 73 inches
165 165
3 703 5 3 703 5 0.031 3 703 5 21.8 BMI
1732 1732 5329
5. 3 feet 10 inches 5 46 inches
60 60
3 703 5 3 703 5 0.028 3 703 5 19.7 BMI
1462 1462 2116
PART V
POST-TEST: ORAL
PREPARATIONS, INJECTABLES,
INTRAVENOUS, AND
PEDIATRICS

341
342 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

The post-test is for testing the content of Part III, Oral Preparations, Injectables (subcutaneous and
intramuscular), Insulin, Intravenous, and Chapter 14, Pediatric Critical Care. The test is divided into four
sections. There are 65 drug problems, which should take 1 to 11⁄2 hours to complete. You may use a con-
version table as needed. The minimum passing score is 57 correct, or 88%. If you have more than two drug
problems wrong in a section of the test, return to the chapter in the book for that test section and rework
the practice problems.

ORAL PREPARATIONS

Answers can be found on pages 368 to 370.

1. Order: nifedipine (Adalat CC) 60 mg, po, daily for 1 week; then 90 mg, po, daily.
Drug available:

a. Which Adalat CC container would you use for the first week?
b. Explain how you would give 90 mg.
2. Order: Crestor (rosuvastatin calcium)
10 mg, po, daily at bedtime.
Drug available:

a. How many tablet(s) would you give?

b. When is/are the tablet(s) given?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 343

3. Order: pravastatin sodium (Pravachol) 20 mg, po, at bedtime.

How many tablets of Pravachol should the patient receive?
4. Order: nitroglycerin (Nitrostat) gr 1/200, SL, STAT.
Drug available:

This drug dosage is ordered in the apothecary system, but the metric dosage is also on the drug
label.

The drug is available in three different strengths. Which drug label would you select? Why?

5. Order: clorazepate dipotassium (Tranxene) 7.5 mg in am and 15 mg, po, at bedtime.
Drug available:

a. How many tablet(s) should the patient receive in the am? .

b. How many tablets should the patient receive at bedtime? .
344 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

6. Order: clarithromycin (Biaxin) 0.5 g, bid ​3 ​10 days, po.

Drug available:

a. 0.5 gram is equivalent to milligrams.

b. How many tablets would you give per dose?
7. Order: acetaminophen (Tylenol) 650 mg, po, prn, for headache.
Drug available:

a. Which Tylenol bottle would you select?

b. How many tablets or caplets should the patient receive?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 345

8. Order: allopurinol (Zyloprim) 0.2 g, po, bid.

Drug available:

a. 0.2 g is equivalent to milligrams.

b. The patient should receive how many tablets of allopurinol per dose?
9. Order: prochlorperazine (Compazine) 10 mg, po, tid.
Drug available:

a. Which Compazine bottle would you select? Why?

b. How many milliliters would you give?
346 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

10. Order: olanzapine (Zyprexa) 10 mg, po, daily.

Drug available:

a. Which Zyprexa bottle would you select? Why?

b. How many tablet(s) would you give?
11. Order: Synthroid (levothyroxine) 0.0375 mg, po, daily.
Drug available:

a. The micrograms for 0.0375 mg would be?

b. Which Synthroid bottle would you select?
c. How many tablet(s) would you give per day?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 347

12. Order: cefuroxime axetil (Ceftin) 500 mg, po, q12h.

Drug available:

a. Which Ceftin bottle would you select? Explain.

b. Th
 e patient would receive how many grams or milligrams of
Ceftin per day?
c. How many milliliters should the patient receive per dose?
348 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

13. Order: cefaclor (Ceclor) 250 mg, po, q8h.

Drug available:

a. Which Ceclor bottle would you select?

b. How many milliliters should the patient receive per dose?
c. Is there another solution to this drug problem?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 349

14. Order: simvastatin (Zocor) 40 mg, po, daily.

Drug available:

a. Which Zocor bottle would you select? Why?

b. How many tablets should the patient receive?
15. Order: ziprasidone (Geodon) 40 mg, po, bid.
After a week (7 days later) 60 mg, po, bid.
Drug available:

a. Which Geodon bottle(s) would you select to give 40 mg?

b. How many Geodon capsule(s) would you give for 40 mg per dose per day?
c. Which Geodon bottle(s) would you select to give 60 mg per dose?
d. How many Geodon capsule(s) from which bottle would you give per dose?
Per day?
350 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

16. Order: Amoxil (amoxicillin) 0.4 g, po, q8h.

Drug available:

a. Change grams into milligrams: 0.4 grams 5 milligrams.

b. How many milligrams should the patient receive per dose?
c. How many milliliters should the patient receive?
17. Order: lamivudine (Epivir) 150 mg, po, q12h.
Drug available:

a. How many milligrams would you give per day?

b. How many milliliters would you give per dose?
18. Order: etretinate (Tegison) 0.75 mg/kg/day, po, in two divided doses. Patient weighs 150 pounds.
Drug available: Tegison 10-mg and 25-mg capsules.

a. How many kilograms does the patient weigh?

b. How many milligrams of Tegison should the patient receive per day?
c. Which bottle of Tegison would you select and how many capsules of Tegison per dose?

19. Order: theophylline 5 mg/kg/LD (loading dose), po. Patient weighs 70 kg.
Drug available: Oral solution 80 mg/15 mL and 150 mg/15 mL.

a. How milligrams should the patient receive?

b. Which oral solution bottle would you select?
c. How many milliliters of theophylline should the patient receive as a loading dose?

 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 351

20. Order: docusate sodium (Colace) 100 mg, po, bid per NG (nasogastric) tube.
Drug available: Colace 50 mg/5 mL. Osmolality of docusate sodium is 3900 mOsm. The desired
osmolality is 500 mOsm.
a. How many milliliters of Colace should the client receive?
b. How much water dilution is needed to obtain the desired osmolality?

INJECTABLES

Answers can be found on pages 370 to 372.

21. Order: hydroxyzine (Vistaril) 25 mg, deep IM, STAT.

Drug available: (50 mg 5 1 mL)

How many milliliters of Vistaril would you give?
22. Order: digoxin (Lanoxin) 0.25 mg, IM, daily.
Drug available:

How many milliliters of digoxin would you give per dose?
23. Order: meperidine (Demerol) 40 mg and atropine sulfate 0.5 mg, IM, STAT.
Drug available:

 ​ ​ ​
a. How many milliliters of meperidine and how many milliliters of atropine would you
administer?
b. Explain how the two drugs would be mixed.
352 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

24. Order: heparin 2500 units, subcut, q6h.

Drug available:

a. Which heparin would you use?

b. How many milliliters of heparin should the patient receive?
25. Order: Lovenox (enovaparin sodium) 20 mg, subcut, q12h.
Drug available:

How many milliliters would you give?
26. Order: naloxone (Narcan) 0.5 mg, IM, STAT.
Drug available:

How many milliliters of naloxone should the patient receive?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 353

27. Order: Humulin 70/30 insulin 35 units, subcut, in am.

Drug available:

Indicate on the unit-100 insulin syringe how many units of 70/30 insulin should be given.

28. Order: Humulin N insulin 45 units and Humulin R (regular) 10 units.

a. Explain the method for mixing the two insulins.

b. M
 ark on the unit-100 insulin syringe how much Humulin R insulin and Humulin N insulin
should be withdrawn.

29. Order: vitamin B12 500 mcg, IM, 3 times a week.

Drug available:

a. Which cyanocobalamin would you select? Why?

b. How many milliliters would you give?
354 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

30. Order: morphine 8 mg IM, STAT.

Drug available:

How many milliliters of morphine would you administer?
31. Order: phytonadione (AquaMEPHYTON) 5 mg, IM, STAT.
Drug available:

How many milliliters of AquaMEPHYTON would you administer?
32. Order: ranitidine HCl (Zantac) 35 mg, IM, q8h.
Drug available:

How many milliliters of Zantac should the patient receive per dose?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 355

33. Order: tobramycin (Nebcin) 3 mg/kg/day, IM, in three divided doses.

Patient weighs 145 pounds.
Drug available: (80 mg 5 2 mL)

a. How many kilograms does the patient weigh?

b. How many milligrams of Nebcin should the patient receive per day?
c. How many milligrams of Nebcin should the patient receive per dose?
d. How many milliliters of Nebcin would you administer per dose?
34. Order: bethanechol chloride (Urecholine) 2.5 mg, subcut, STAT and may repeat in 1 hour.
Drug available: (Note: 5.15 mg 5 5 mg or 5.15 mg 5 5.2 mg [tenths])

How many milliliters of Urecholine would you give?
35. Order: methotrexate 20 mg, IM, every other week.
Drug available:

How many milliliters should the nurse administer?
356 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

36. Order: Tazidime (ceftazidime) 250 mg, IM, q8h.

Drug available:

a. How much diluent would you add to the Tazidime vial? (See label.)
The diluent when mixed in the vial would equal .
b. How many milligrams should the patient receive per day?
c. How many milliliters would you give IM per dose?
d. What type of syringe would you use?
37. Order: cefamandole (Mandol) 500 mg, IM, q12h.
Drug available:

a. How much diluent would you mix with the Mandol powder? (See label for mixing.)

b. How many milliliters should be given per dose?

38. Order: cefazolin (Ancef ) 0.25 g, IM, q12h.
Mixing: Add 2.0 mL of diluent ​5 ​2.2 mL of drug solution.
Drug available:

a. Change grams in order to milligrams; drug label is in milligrams.

b. How many milliliters of Ancef should the patient receive per dose?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 357

39. Order: Rocephin (ceftriaxone) 500 mg, IM, q12h. Suggested dose: 1-2 g/day.
Drug available:

a. Is the dose per day within the suggested drug parameters?

Explain
b. How many milliliters of sterile water should be injected into the Rocephin 1-g vial?
c. After reconstitution, 1 mL of Rocephin solution would yield .
d. How many mL of the Rocephin solution would you give per dose?
40. Order: ceftazidime (Fortaz) 750 mg, IM, q12h.
Add 2.5 mL of diluent ​5 ​3 mL of drug solution.
Drug available:

How many milliliters of ceftazidime would you administer per dose?
41. Order: gentamicin sulfate 4 mg/kg/day, IM, in three divided doses.
Patient weighs 165 pounds.
Drug available: gentamicin 10 mg/mL and 40 mg/mL.

a. How many kilograms does the patient weigh?

b. How many milligrams of gentamicin per day should the patient receive?
c. How many milligrams of gentamicin per dose?
d. Which gentamicin bottle would you select? Explain.

e. How many milliliters of gentamicin per dose should the patient receive?
358 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

DIRECT IV ADMINISTRATION

Answers can be found on page 372.

42. Order: furosemide (Lasix) 30 mg, IV direct, STAT.

Drug available:

Instruction: Direct IV infusion not to exceed 10 mg/min.
a. How many milliliters should the patient receive?
b. Number of minutes to administer?
43. Order: diltiazem (Cardizem) 15 mg, IV direct, STAT.
Drug available:

Instruction: Direct IV infusion. Initial dose: 0.25 mg/kg over 2 minutes. Patient weights 60 kg.
a. How many milligrams should the patient receive?
b. Is the Cardizem dose ordered within the drug parameter?
c. Give the number of milliliters and number of minutes to administer.

INTRAVENOUS
Answers can be found on page 373 to 374.

44. Order: 1000 mL of 5% dextrose/0.45% NaCl in 8 hours.

Available: 1 liter of 5% D/1⁄2 NS; IV set labeled 10 gtt/mL.
How many drops per minute should the patient receive?

 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 359

45. Order: 500 mL of D5W in 2 hours.

Available: 500 mL of D5W; IV set labeled 15 gtt/mL.
How many drops per minute should the patient receive?

46. Order: potassium chloride 20 mEq in 1000 mL in D5W to run 8 hours.
Drug available:

a. H
 ow many milliliters should be mixed in 1000 mL of 5% dextrose in water to be given IV
over 8 hours?
b. How many drops per minute should the patient receive using a macrodrip IV set (10 gtt/mL)?

47. Order: ticarcillin disodium (Ticar) 600 mg, IV, q6h.

Available: Calibrated cylinder (Buretrol) set with drop factor 60 gtt/mL; 500 mL D5W.
Drug available: add 2 mL of diluent 5 2.6 mL drug solution

Instruction: Dilute drug in 60 mL of D5W and infuse in 30 minutes.
a. Drug calculation:

b. Flow rate calculation:

360 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

48. Order: cefazolin (Kefzol) 500 mg, IV, q6h.

Available: Secondary set: drop factor 15 gtt/mL; 100 mL D5W.
Add 2.5 mL of diluent to yield 3 mL of drug solution.
Drug available:

Instruction: Dilute drug in 100 mL D5W and infuse in 45 minutes.
a. Drug calculation:

b. Flow rate calculation:

49. Order: chlorpromazine HCl (Thorazine) 50 mg, IV, to run for 4 hours.
Available: Secondary set: drop factor 15 gtt/mL; 500 mL of NS (normal saline solution).
Drug available:

Instruction: Dilute Thorazine 50 mg in 500 mL of 0.9% NaCl (NS) to run for 4 hours.
a. Drug calculation:

b. Flow rate calculation:

 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 361

50. Order: cefoxitin (Mefoxin) 1 g, IV, q6h.

Drug available: ADD-Vantage vial

Set and solution: 50 mL of IV diluent bag for ADD-Vantage; Mefoxin 1 g vial for ADD-Vantage.
Instruction: Dilute Mefoxin in 50 mL of NaCl bag and infuse in 30 minutes.
a. How would you prepare Mefoxin 1 g powdered vial using the diluent bag? (See page 225.)

b. Infusion pump rate (mL/hr):

51. Order: cefepime HCl (Maxipime) 0.5 g, IV, q12h.
Available: Infusion pump.
Add 2.0 mL diluent ​5 ​2.5 mL.
Drug available:

Instruction: Dilute in 50 mL of D5W and infuse over 20 minutes.
a. Drug calculation:

b. Infusion pump rate:

362 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

52. Order: diltiazem (Cardizem) 10 mg/hr, IV for 5 hours.

Available: Infusion pump; 500 mL of D5W.
Drug available:

Instruction: Infuse diltiazem 10 mg/hr over 5 hours.

Drug parameter: 5–15 mg/hr for 24 hours.
a. Drug calculation: How many milligrams of Cardizem should the patient receive over 5 hours?

b. How many milliliters of Cardizem should be mixed in the 500 mL of D5W?
c. Infusion pump rate:

53. Order: ciprofloxacin (Cipro) 100 mg, IV, q6h.
Drug available:

Set and solution: Secondary set with drop factor 15 gtt/mL; 100 mL of D5W.

Instruction: Dilute drug in 100 mL of D5W and infuse in 30 minutes; also calculate rate for infu-
sion pump.
a. Drug calculation:
b. Flow rate calculation with secondary set (gtt/min):
c. Infusion pump rate (mL/hr):
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 363

54. Order: ifosfamide (Ifex) 1.2 g/m2/day for 5 consecutive days.

Patient: Weight: 150 pounds; height: 70 inches ​5 ​1.98 m2.
Available: Infusion pump; 5% dextrose solution.
Add 20 mL of diluent to 1 g of Ifex.
Drug available:

Instruction: Dilute Ifex in 50 mL of D5W; infuse over 30 minutes.
a. Drug calculation:

How many grams or milligrams of Ifex should the patient receive?

b. How much diluent would you add to 2.4 g of Ifex?
c. Infusion pump rate:

PEDIATRICS

Answers can be found on pages 374 to 376.

55. Child with cardiac disorder.
Order: Lanoxin pediatric elixir 0.4 mg, po, daily.
Drug available:

Child’s age and weight: 3 years, 12 kg.

Pediatric dose range: 0.03–0.04 mg/kg.
a. Is this drug dose within the safe range?
b. How many milliliters would you administer?
364 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

56. Child with high fever.

Order: ibuprofen (Motrin) 0.1 g, prn temperature greater than 102° F.
Child’s age and weight: 3 years, 15 kg.
Pediatric dose range: 100 mg, q6-8h, not to exceed 400 mg/day.
Drug available: (100 mg 5 5 mL)

a. Is this drug dose within the safe range?

b. How many milliliters should the child receive per dose?
57. Child with strep throat.
Order: penicillin V potassium (Veetids) 400,000 units, po, q6h.
Child’s age and weight: 8 years, 53 pounds.
Pediatric dose range: 25,000–90,000 units/kg/day in three to six divided doses.
Drug available:

a. Is the drug dose within the safe range?

b. How many milliliters of penicillin V would you give?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 365

58. Child with otitis media.

Order: amoxicillin (Amoxil) 250 mg, po, q6h.
Child’s age and weight: 5 years, 19 kg.
Pediatric dose range: 20-40 mg/kg/day in three divided doses.
Drug available:

a. Is the drug dose within the safe range?

b. How many milliliters would you give?
59. Child with pruritus.
Order: diphenhydramine HCl (Benadryl) 25 mg, po, tid.
Child’s age and weight: 2 years, 16 kg.
Pediatric dose: 5 mg/kg/day.
Drug available: Benadryl 12.5 mg/5 mL.

a. Is the drug dose within the safe range?

b. How many milliliters would you give?
366 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

60. Child with severe bacterial infection.

Order: clindamycin (Cleocin) 150 mg, po, q8h for 7 days.
Child’s weight: 45 pounds.
Pediatric dose range: 20-40 mg/kg/day in three divided doses.
Drug available:

a. How many kilograms does the child weigh?

b. What are the dosage parameters?
c. Is the dosage within drug parameters?
d. How many milligrams should the child receive per day?
e. How many milliliters should the child receive per dose?
61. Child with a lower respiratory tract infection.
Order: cefaclor (Ceclor) 100 mg, q8h.
Child’s age and weight: 4 years, 44 pounds.
Pediatric dose range: 20-40 mg/kg/day in three divided doses.
Drug available:

a. How many kilograms does the child weigh?

b. Is the drug dose within the safe range?
c. How many milliliters should the child receive?
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 367

62. Child with severe systemic infection.

Order: tobramycin (Nebcin) 15 mg, IV, q8h.
Child’s age and weight: 18 months, 10 kg.
Pediatric dose range: 3-5 mg/kg/day in three divided doses.
Drug available:

a. Is the drug dose within the safe range?

b. How many milliliters of tobramycin would you give per dose?
63. Child with a severe central nervous system (CNS) infection.
Order: ceftazidime (Fortaz) 250 mg, IV, q6h.
Child’s age and weight: 6 years, 27 kg.
Pediatric dose range: 30-50 mg/kg/day in three divided doses.
Add 2.0 mL of diluent ​5 ​2.4 mL of drug solution.
Drug available:

a. Is the drug dose within the safe range?

b. How many milliliters of Fortaz would be given?
368 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

64. Order: Cefazolin (Ancef ) 400 mg, IV, q8h.

Child weight: 49 pounds.
Parameters: 50-100 mg/kg/day in three divided doses.
Drug available:

Instruction: Mix Ancef with 1.8 mL to equal 2.0 mL = 500 mg. Buretrol: Dilute drug in 50 mL
of IV diluent; infuse in 30 minutes.
a. How many kg does the child weigh?
b. Is the drug dose within drug parameters?
c. How many mL of Ancef should be withdrawn from the vial?
d. Flow rate calculation (gtt/min):
65. Child with a severe respiratory tract infection.
Order: kanamycin (Kantrex) 60 mg, IV, q8h.
Child’s age and weight: 1 year, 26 pounds.
Pediatric dose range: 15 mg/kg/day, q8-12h.
Drug available:

a. How many milligrams of kanamycin will the child receive per day? Per dose?
b. How many milliliters of kanamycin will the child receive per dose?
c. Is the drug dose within the safe range?

ANSWERS
Oral Preparations

1. a. The Adalat CC, 60-mg tablet container

b. For 90 mg, remove 1 tablet from the 30-mg tablet container and 1 tablet from the 60-mg tablet container.
2. (a) 2 tablets; (b) in the evening or bedtime
3. 2 tablets of Pravachol
4. Nitrostat 0.3 mg (use conversion table as needed)
5. a. 1 tablet in the am
b. 2 tablets at bedtime
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 369

6. a. 0.5 gram ​5 ​500 mg
b. 2 tablets
7. a. 325-mg bottle
b. 2 tablets from the 325-mg bottle
8. a. 0.2 g ​5 ​200 mg
b. 2 tablets
9. a. Compazine 5 mg/5 mL; Compazine 5 mg/mL is for injection.
b. 10 mL
10. a. Select Zyprexa 2.5-mg tablets. The nurse could give 1 tablet of Zyprexa 7.5 mg and 1 tablet of Zyprexa
2.5 mg ​5 ​10 mg. If the nurse does not have the 2 strengths of Zyprexa, then the nurse should use the
2.5-mg tablets.
D 10 mg
b. BF: 3V5 3 1 tab 5 4 tablets
H 2.5 mg
or
RP: H ; V < D ;X
2.5 mg;1 tab < 10 mg;X
2.5 X 5 10
X 5 4 tablets
11. a. 37.5 mcg 5 0.0375 mg
b. 0.025-mg or 25-mcg bottle
D 0 .0 3 7 5 or
c. BF: 3V5 31 5
H 0 .0 2 5 RP: H ; V < D ; X
0.025 mg;1 tab < 0.0375 mg;X tab
11⁄2 tablets 0.025 X 5 0.0375
X5 11⁄2 tablets
or H 25 mcg 37.5 mcg or
D 1 tab 3 0.0375 mg
FE: 5 5 5 5 DA: tab 5 5 1 1⁄2 tablets
V X 1 tab X 0.025 mg 3 1
1Cross multiply2 25 X 5 37.5
X 5 11⁄2 tablets
12. a. Select 250-mg/5-mL bottle. However, either bottle could be used; 125 mg/5 mL ​5 ​20 mL.
b. 1 gram; 1000 mg
c. 500 mg ​5 ​10 mL of Ceftin 250 mg/5 mL
13. a. Either 187 mg/5 mL or 375 mg/5 mL.
b. With (preferred) 187-mg/5-mL bottle:
250 mg 1250
3 5 mL 5 5 6.68 or 7 mL per dose
187 mg 187
c. With the 375 mg/5 mL, 3.3 mL per dose.
14. a. Zocor 20-mg bottle. Either bottle; however, with the 10-mg Zocor bottle, more tablets would be taken
(Zocor 10-mg bottle ​5 ​4 tablets).
b. 2 tablets (Zocor 20-mg bottle)
15. a. Select Geodon 40-mg bottle.
b. 1 capsule of Geodon 40 mg per dose; 2 capsules per day.
c. Select both Geodon 40 mg and Geodon 20 mg to equal 60 mg.
d. Per dose, give 1 capsule from the 40-mg bottle and 1 capsule from the 20-mg bottle to equal 60 mg. You
can NOT cut a capsule in half, so both bottles of Geodon would be needed. Per day, give 2 capsules from
Geodon 40-mg bottle and 2 capsules from the Geodon 20-mg bottle.
370 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

16. a. Change 0.4 grams to milligrams 5 400 mg

b. 400 mg per dose.

D 400 mg or
c. BF: 3V5 3 5 mL 5
H 250 mg RP: H ; V < D ; X
8 mL of amoxicillin 250 mg;5 mL<400 mg;X mL
250 X 5 2000
X 5 8 mL
4
or H or
D 250 400 5 mL 3 1000 mg 3 0.4 g
FE: 5 5 5 5 DA: mL 5 5 8 mL
V X 5 X 250 mg 3 1g 3 1
1
1Cross multiply2 250 X 5 2000
X 5 8 mL of amoxicillin
17. a. 300 mg per day
15
D 150 mg or
b. BF: 3V5 3 1 mL 5 1 mL 3 150 mg
H 10 mg DA: mL 5 5 15 mL
10 mg 3 1
150
5 15 mL
10
18. a. 150 pounds ​5 ​68 kg
b. 0.75 ​3 ​68 ​5 ​51 mg or 50 mg per day
c. Select 25-mg capsule bottle. One capsule per dose.
19. a. 5 mg ​3 ​70 kg ​5 ​350-mg loading dose
b. Select the 150-mg/15-mL bottle.
7
D 350 mg 105
c. BF: 3 V 5 3 15 mL 5 5 35 mL theophylline
H 150 mg 3
3
7
or 15 mL 3 350 mg 105
DA: mL 5 5 5 35 mL theophylline
150 mg 3 1 3
3
20. a. 10 mL ​5 ​100 mg Colace
Known mOsm 139002 3 Volume of drug 110 mL2 39,000
b. 5 5 78 mL drug solution and water
desired mOsm 15002 500
78 mL of drug solution and water ​2 ​10 mL of drug solution 5 ​68 mL of water to dilute the osmolality of
the drug

Injectables

21. 1⁄2 mL or 0.5 mL

1
D 25 mg or
BF: 3V5 3 1 mL 5 1⁄2 mL
H 50 mg RP: ​H ; V < D ;X
2 50 mg;1 mL<25 mg;X
or 50 X 5 25
DA: no conversion factor needed X 5 1⁄2 mL or 0.5 mL
1
1 mL 3 25 mg
mL 5 5 1⁄2 mL or 0.5 mL
50 mg 3 1
2
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 371

22. 1 mL
23. a. Meperidine 0.8 mL; atropine 1.25 mL or 1.3 mL
b. (1) ​Draw 1.25 mL of air and insert into the atropine bottle.
(2) ​Withdraw 1.25 mL of atropine and 0.8 mL of meperidine from the ampule.
24. a. Could use either vial, units 5000/mL or units 10,000/mL.
b. 0.5 mL from the units 5000 vial or 0.25 mL from the units 10,000 vial.
25. 0.2 mL of Lovenox
26. 1.25 mL of Naloxone
27. Withdraw 35 units of Humulin 70/30.

28. a. Withdraw the regular Humulin R insulin first and then the Humulin N insulin.

b. Total of 55 units of Humulin R and Humulin N insulin (10 units regular, 45 units Humulin N).
29. a. Select 1000 mcg/mL. If you chose the 100-mcg/mL cartridge, you would need 5 cartridges to give 500 mcg.
b. 1⁄2 mL or 0.5 mL
30. RP: H : V < D :X
15 mg : 1 mL < 8 mg : X
15 X 5 8
X 5 0.533 or 0.5 mL of morphine 1round off to tenths2
or 1 mL 3 8 mg 8
DA: mL 5 5 5 0.533 or 0.5 mL of morphine 1round off to tenths2
15 mg 3 1 15
31. 1⁄2 mL or 0.5 mL
32. 1.4 mL
33. a. 145 ​4 ​2.2 ​5 ​65.9 kg or 66 kg
b. 3 mg ​3 ​66 kg ​5 ​198 mg/day
c. 198 ​4 ​3 ​5 ​66 mg per dose
66 mg 132
d. BF: 3 2 mL 5 5 1.65 or 1.7 mL per dose 1round off to tenths2
80 80
or 2 mL 3 66 mg 132
DA: mL 5 5 5 1.7 mL per dose
80 mg 3 1 80
34. 0.5 mL or 0.48 mL 5 0.5 mL (tenths)
35. RP: H ; V < D ;X or 1 mL 3 20 mg 20
25 mg;1 mL<20 mg;X DA: mL 5 5 5 0.8 mL
25 mg 3 1 25
25 X 5 20
X 5 0.8 mL of methotrexate
Give 0.8 mL of methotrexate.
372 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

36. a. Add 1.5 mL of diluent: 1.8 mL total

b. 750 mg per day
D 250 mg
c. BF: 3V5 3 1.8 mL 5 0.9 mL of Tazidime
H 500 mg
or
RP: H ; V < D ; X
500 mg;1.8 mL < 250 mg;X mL
500 X 5 450
X 5 0.9 mL of Tazidime
d. 3-mL syringe for mixing and administering; unable to mix the drug and diluent with a tuberculin syringe.
37. a. Add 3 mL diluent ​5 ​3.5 mL of drug solution; 1 g ​5 ​1000 mg.
500 mg 1750
b. BF: 3 3.5 mL 5 5 1.75 mL or 1.8 mL per dose 1round off to tenths2
1000 mg 1000
38. a. 0.25 g ​5 ​250 mg
250 mg 550
b. BF: 3 2.2 mL 5 5 1.1 mL per dose or 1 mL
500 500
or or
RP: H ; V < D ;X 2.2 mL 3 250 mg
500 mg;2.2 5 250;X DA: mL 5 5 1.1 mL or 1 mL of Ancef
500 mg 3 1
500 X 5 550
550
X5 5 1.1 mL or 1 mL
500
39. a. Yes, the total dose is 1000 mg daily (1 g ​5 1000 mg).
b. Inject 2.1 mL of sterile water into the vial.
c. After reconstitution, 1 mL of Rocephin solution would yield 350 mg.
D 500 mg
d. BF: 3V5 3 1 mL 5 1.4 mL of Rocephin
H 350 mg
40. 2.25 mL Fortaz
41. a. 165 lb ​4 ​2.2 ​5 ​75 kg
b. 4 mg ​3 ​75 kg ​5 ​300 mg/day
c. 100 mg per dose
d. Select 40-mg/mL bottle of gentamicin sulfate. (Normally less than 3 mL IM should be given at one site.)
e. 2.5 mL of gentamicin per dose

Direct IV Administration

42. a. 3 mL
b. Known drug;Known minutes<Desired drug;Desired minutes
10 mg ; 1 min < 30 mg ; X
X 5 3 min to administer 3 mg
43. a. 0.25 mg 3 60 kg 5 15 mg according to drug parameters of Cardizem IV direct (bolus) over 2 minutes
b. Yes, dose is within drug parameters.
c. Administer 3 mL of IV Cardizem over 2 minutes.
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 373

Intravenous

44. 125 mL per hour

125 mL 3 10 gtt /min 1250
5 5 20.8 gtt /min or 21 gtt /min
60 min/hr 60
1
250 mL/hr 3 15 gtt /mL 250
45. 5 5 62.5 or 63 gtt /min
60 min 4
4
2
D 20 mEq 30
46. a. BF: 3V5 3 15 mL 5 5 10 mL of KCl
H 30 mEq 3
3
Inject 10 mL of potassium chloride in 1000 mL D5W. The KCl should be injected into the IV bag and
mixed well before the IV is hung.
b. 1000 ​4 ​8 ​5 ​125 mL
125 mL 3 10 gtt 1250
5 5 21 gtt /min
60 min/hr 60
47. Add 2.0 mL diluent ​5 ​2.6 mL of drug solution; 1 g ​5 ​1000 mg.
600 mg 15.6
a. 3 2.6 mL 5 5 1.56 mL or 1.6 mL Ticar per dose 1round off to tenths2
1000 mg 10
2
Amount of solution 3 gtt /mL 60 mL 3 60 gtt /mL
b. 5 5 120 gtt /min
Minutes 30 min
1
48. a. 1.5 mL
1
100 mL 3 15 gtt /mL 100
b. 5 5 33.3 or 33 gtt /min
45 min 3
3
49. a. Add 2 mL Thorazine to 500 mL. For 4 hours: 500 mL ​4 ​4 ​5 ​125 mL/hr.

1
125 mL 3 15 gtt /mL 125
b. 5 5 31 gtt /min for 4 hours
60 min/1 hr 4
4
50. a. Use the Mefoxin 1-g vial for ADD-Vantage and mix drug in the 50 mL IV bag for ADD-Vantage.
Minutes to admin
b. Amount of sol 4 5 mL/hr
60 min/hr
2
30 min 60 min
50 mL 4 5 50 mL 3 5 100 mL/hr
60 min 30 min
1
51. a. 0.5 g ​5 ​500 mg; add 2.0 mL of diluent ​5 ​2.5 mL of drug solution; 500 mg ​5 ​2.5 mL
Min to admin
b. Amount of solution 4 5 mL/hr
60 min/hr
3
20 min 60
2.5 mL drug 1 50 mL 4 5 52.5 mL 3 5 157.5 mL/hr or 158 mL/hr
60 min/hr 20
1
Set pump to deliver in 20 minutes.
374 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

52. a. 10 mg/hr ​3 ​5 hr ​5 ​50 mg Cardizem

50 mg
b. 3 1 mL 5 10 mL Cardizem to add to 500 mL
5 1
300 min 15 hr2 60 min 510
c. 10 mL drug solution 1 500 mL 4 5 510 mL 3 5 5 102 mL/hr
60 min/hr 1
300 min 5 hr2 5
5
53. a. Drug calculation:
D 100 mg
BF: 3V5 3 20 mL 5 10 mL or RP: H ; V < D ; X
H 200 mg
200 mg;20 mL<100 mg;X mL
200 X 5 2000
X 5 10 mL
1
or H D 200 100 or 20 mL 3 100 mg
FE: 5 5 5 5 DA: mL 5 5 10 mL
V X 20 X 200 mg 3 1
2
1Cross multiply2 200X 5 2000
X 5 10 mL
b. Flow rate calculation (secondary set):
1
110 mL 1100 1 102 3 15 gtt /mL 1set2
5 55 gtt /min
30 min
2
c. Infusion pump rate:
2
30 min to admin 60
110 mL 4 5 110 3 5 220 mL/hr
60 min/hr 30
1
54. a. 1.2 g ​3 ​1.98 m2 ​5 ​2.37 g or 2.4 g or 2400 mg
b. 2.4 g ​3 ​20 mL ​5 ​48 mL diluent added to Ifex vials
2
30 min 60 min
c. 148 mL of drug solution 1 50 mL2 4 5 98 mL 3 5 196 mL/hr
60 min 30 min
1
Set pump to deliver in 30 minutes.

Pediatrics

55. a. Drug dose is within safe range.

0.03 mg 3 12 kg 5 0.36 mg
0.04 mg 3 12 kg 5 0.48 mg
D 0.4 mg
b. BF: 3V5 3 1 5 8 mL of digoxin 1Lanoxin2
H 0.05 mg
1 mL 3 0.4 mg 0.4 mg
DA: mL 5 5 5 8 mL of digoxin
0.05 mg 3 1 0.05 mg
56. a. Drug dose is within safe range.
b. 5 mL
 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics 375

57. a. Drug dose is within safe range; 53 pounds ​4 ​2.2 ​5 ​24 kg. 25,000 ​3 ​24 ​5 ​600,000 units;
90,000 ​3 ​24 ​5 ​2,160,000 units/day. Child receives 400,000 units ​3 ​4 (q6h) ​5 ​1,600,000 units/day.
b. RP: H ; V < D ;X
200,000 units;5 mL<400,000 units;X
200,000 X 5 2,000,000
X 5 10 mL of penicillin
400,000 units 5 ​10 mL per dose
58. a. No; the drug dose is NOT within safe range. Do NOT give. Contact the physician or health care provider.
Dosage parameters: 380 to 760 mg/day
Order 250 mg ​3 ​4 (q6h) ​5 ​1000 mg/day; not safe; exceeds parameters
b. Would not give medication.
59. a. Drug dose is within safe range.
5 mg ​3 ​16 kg ​5 ​80 mg; child receives 25 mg ​3 ​3 (tid) ​5 ​75 mg; SAFE
b. 10 mL
60. a. Child’s weight: 45 lb 4 2.2 5 20.45 or 20.5 kg.
b. Dosage parameters:
20 mg 3 20.5 kg/day 5 410 mg/day.
40 mg 3 20.5 kg/day 5 820 mg/day.
c. Drug dose is safe, within the parameters.
d. 150 mg 3 3 doses 5 450 mg.
The child should receive 450 mg of Cleocin per day.
2 2
D 150 5 mL 3 150 mg
e. BF: 3V5 3 5 mL 5 10 mL per dose   or  DA: mL 5 5 10 mL per dose
H 75 75 mg 3 1
1 1
61. a. 44 lb ​4 ​2.2 ​5 ​20 kg
b. Drug dose is less than pediatric drug range.
Check with the health care provider.
20 mg ​3 ​20 kg ​5 ​400 mg/day; 40 mg ​3 ​20 kg ​5 ​800 mg/day.
Child to receive 100 mg ​3 ​3 (q8h) ​5 ​300 mg/day; less than 400-800 mg/day.
D 100 mg 500
c. BF: 3V5 3 5 mL 5 5 2.67 or 2.7 mL of Ceclor 1round off to tenths2
H 187 mg 187
62. a. Drug dose is within safe range.
3 mg ​3 ​10 kg ​5 ​30 mg/day; 5 mg ​3 ​10 kg ​5 ​50 mg/day.
Child to receive 15 mg ​3 ​3 (q8h) ​5 ​45 mg/day.
b. 1.5 mL per dose
63. a. Drug dose is within the safe range.
30 mg ​3 ​27 kg ​5 ​810 mg/day; 50 mg ​3 ​27 kg ​5 ​1350 mg/day.
Child to receive 250 mg ​3 ​4 (q6h) ​5 ​1000 mg/day.
1
2.4 mL 3 250 mg
b. DA: mL 5 5 1.2 mL of Fortaz
500 mg 3 1
2
376 PART V Post-Test: Oral Preparations, Injectables, Intravenous, and Pediatrics

64. a. 22 kg (child’s weight in kg); 49 lb 4 2.2 5 22.2 or 22 kg

b. Yes, the daily dose is within the parameters; 50 3 22 5 1100 mg/day and 100 3 22 5 2200 mg/day.
c. Drug calculation: Child is to receive 400 mg 3 3 5 1200 mg/day or 400 mg q8h.
D 400 mg 8
BF: 3V5 3 2 mL 5 5 1.6 mL
H 500 mg 5
4
2 mL 3 400 mg 8
DA: mL 5 5 5 1.6 mL
500 mg 3 1 5
5
2
50 mL 3 60 gtt /mL
d. Flow rate calculation: 5 100 gtt /min
30 min
1
65. a. 180 mg/day; 60 mg/dose
60 120
b. BF: 3 2 mL 5 5 1.6 mL per dose
75 75
H D 75 mg 60 mg
FE: 5 5 5
V X 2 mL X
1Cross multiply2 75 X 5 120
X 5 1.6 mL of Kantrex
c. Drug dose is within safe range.
Child’s weight: 26 lb ​4 ​2.2 ​5 ​11.8 or 12 kg
15 mg ​3 ​12 kg ​5 ​180 mg/day; child to receive 180 mg/day or 60 mg per dose.

Additional practice problems are available in the Comprehensive Post-Test section of Drug
Calculations Companion, version 5, on Evolve.
APPENDIX A
Guidelines for Administration
of Medications

Outline GENERAL DRUG ADMINISTRATION

ORAL MEDICATIONS
INJECTABLE MEDICATIONS
INTRAVENOUS FLUID AND MEDICATIONS

GENERAL DRUG ADMINISTRATION

1. Wash hands and don gloves before preparing all medications.

2. All medication should be prepared in a clean, distraction-free environment.
3. Check medication order against physician’s orders in the MAR (medication administration record)
or eMAR (electronic medication administration record). Check for medication administration
parameters, such as heart rate, respiration, and blood pressure.
4. Check label of drug container against medication order and physician’s order. Verify 5 “rights”: that
you have the right patient, medication, dose, route of administration, and time of administration. If
something is amiss, ask another nurse to verify the medication reconciliation with you.
5. Check all drug labels for an expiration date. Notify the pharmacy of outdated drugs, and return
expired medication.
6. If a drug order is unclear, do not guess. Verify order with charge nurse, physician, and/or
pharmacist.
7. Nurses are patient advocates and have the right to question and clarify drug orders. Physicians are
responsible for medication orders. Nurses are responsible for administering medications correctly and
safely.
8. Do not give medications that are poured or drawn up by someone else unless you witness the drug
preparation. Dosages should be verified before administering them.
9. Do not leave medication sitting out unsupervised or out of your sight.
10. Identify patients by using their identification bracelets (ID bands) and by asking each patient to
state his or her name and birth date.
11. Check if patient has any allergies to the drug or drug class. Patient should be wearing an allergy
bracelet.
12. Explain to the patient what medication he or she is receiving and why.
13. Assist patient as necessary with taking medication (i.e., positioning or providing water). You must
stay with the patient to make sure the medication is taken. Manage time by giving medications last
to patients who need more assistance.

377
378 APPENDIX A Guidelines for Administration of Medications

14. Promptly document in patient’s MAR or eMAR that medication was given (especially STAT med-
ications). If patient did not receive medication, document why in MAR or eMAR.
15. Record the amount of fluid taken orally or intravascularly with each medication if client’s intake (I)
and output (O) are being recorded.
16. Immediately report any medication errors to the physician and charge nurse. Document incident
per your institution’s policy. Evaluate the patient’s condition immediately.
17. Nurses have a window of 30 minutes before and after the scheduled time to administer ordered
medications. Check hospital policy because some facilities vary on time allowed before and after the
scheduled administration time.
18. Patients have the right to refuse medications. Provide education for these patients. Notify physician
of patient’s refusal. Document refusal on patient’s MAR or eMAR.

ORAL MEDICATIONS

1. Wash hands and don gloves before preparing oral medications.

2. Pour tablet or capsule into medicine cup (not your hand or into another medication container).
Drugs prepared for unit dose can be opened at the time of administration in the patient’s room.
Discard drugs that are dropped on the floor and dispose of them per institutional policy.
3. Pour liquids into a container or cup placed on a flat surface and read measurement at eye level. Pour
liquid medication from the opposite side of the bottle’s label to avoid spilling on the label.
4. Do not mix liquid medications or tablets and liquid medications together. Ideally, medications
should be given one at a time. Patient may take more than one tablet or capsule at a time (except
oral narcotics, digoxin, and STAT medications) if they are comfortable doing so.
5. Evaluate patients’ swallowing abilities by first having them take a sip of water. For a larger pill (e.g.,
potassium), ask patients if they feel comfortable swallowing it. Instant coughing after swallowing
water may indicate that the patient is aspirating.
6. For the patient who has difficulty swallowing tablets and thin liquids, contact the physician and
pharmacy to evaluate whether the medication can be crushed and given in applesauce.
7. Do not return poured medication to its container. Discard poured medication if unused.
8. Dilute liquid medication that irritates gastric mucosa (e.g., potassium products) or that could dis-
color or damage tooth enamel (e.g., saturated solution of potassium iodide). Evaluate whether these
medications can be taken with meals.
9. Offer ice chips before administering bad-tasting medications to help numb patient’s taste buds.
10. Assist patient into an upright position when administering oral medications. Stay with patient until
medication is taken.
11. Give 50 to 100 mL of oral fluids with medications unless the patient has a fluid restriction.
12. Patients who have a nasogastric or gastric tube should receive their oral medications via this route.
Tablets should be thoroughly crushed and diluted in sterile water or normal saline (NS). Medica-
tions should be given one at a time and flushed with sterile water or NS between each medication.
Some medications cannot be crushed; therefore the form would need to be changed. Refer to your
institution’s policy. (See Chapter 8 for additional information.)
13. For drugs given by oral syringe, direct the syringe across the tongue and toward the side of the mouth.
14. If a patient spits out all of the liquid medication, repeat the dose. If the patient spits out half of the
medication, repeat half of the dose. Notify the physician if there is a question regarding repeated
doses. The physician may need to select another route of administration.
 APPENDIX A Guidelines for Administration of Medications 379

INJECTABLE MEDICATIONS

1. Wash hands and don gloves before preparing injectable medications.

2. Check medication order and medication label to determine method(s) for drug administration
(e.g., intramuscular [IM] or subcutaneous [subcut]).
3. Check for drug compatibility before mixing drugs in the same syringe. Check institution’s policy
before mixing compatible drugs in a syringe to administer.
4. Do not give medications that are cloudy, discolored, or that have precipitated.
5. Select the proper syringe and needle size for the route and type of medication to be administered.
6. Select the injection site according to the drug, patient’s age, and disease process.
7. Medication in ampules should be drawn up using a 15-micron filtered needle or filter straw. Once
opened, the ampule cannot be used again and the unused solution should be discarded.
8. Do not reuse vials, needles, or syringes between patients.
9. Avoid the use of multiple-dose vials. If multiple-dose vials must be used, each patient should have
his or her own vial, labeled with the date it was opened and stored according to manufacturer’s
directions.
10. Know alternative sites of administration. Do not administer injections into inflamed, edematous, or
infected tissue. Lesions (moles, birthmarks, and scar tissue) and surgical sites should also be avoided.
11. When administering IM medications, aspirate the plunger before injecting the medication. If blood
is aspirated, do not administer. Withdraw the needle and prepare a new solution. Check your insti-
tution’s policy about aspirate when giving IM injections.
12. Do not massage the injection site when using the Z-track method, intradermal injections, or any
anticoagulant solution.
13. Recognize that patients experiencing edema, shock, or poor circulation will have a slower tissue
absorption rate with IM injections.
14. The site of injection on the patient’s skin should be cleansed with an alcohol swab before
injection.
15. Do not administer IM medications subcutaneously. Poor medication absorption and sloughing of
the skin could occur.
16. Specific medications (e.g., narcotics) need to be discarded with a colleague and documented per
your institution’s policy.
17. Discard medication per your institution’s policy. Discard needles into the proper sharps container.

INTRAVENOUS FLUID AND MEDICATIONS

1. Wash hands and don gloves before preparing and priming IV drugs or fluids.
2. Use aseptic technique when inserting IV ​catheters, administering medications, and changing IV
tubing and fluids.
3. All products and medications for IV infusion should be clearly labeled with trade and generic
names, along with the dosage and concentration of the drug or fluid, route of administration, expi-
ration date, frequency, infusion rate, and sterility state.
4. Recognize signs of catheter-related infection, such as erythema, edema, induration or drainage at
vascular access site, fever, and chills. These changes should be reported immediately to the charge
nurse and physician.
5. Use peripheral access over central access when appropriate. Avoid placing an IV in areas of inflam-
mation, bruises, breakdown, or infection; in the lower extremities; at surgical sites; or in extremities
with neuromuscular or motor deficits.
6. IV tubing and fluid bags should be labeled with date, time, and initials of nurse. When multiple
catheters or lumens are being used, all lines should be labeled (at the sites where they connect to the
patient) with the name of the medication or fluid that is infusing.
380 APPENDIX A Guidelines for Administration of Medications

7. Check patency of IV catheter before using by flushing the IV catheter with 2 mL of normal saline
(NS). To clear IV tubing of a medication’s solution, flush tubing with 15 mL of NS.
8. Do not forcefully irrigate IV catheters. The IV catheter could be kinked, infiltrated, or the force
could dislodge a clot from the catheter site, leading to an embolus.
9. IV sites that are saline locked should be flushed at intervals that adhere to your institution’s
protocols.
10. Check for air bubbles in tubing. Remove air from tubing by repriming the tubing or by clamping
below the air bubble and removing the air by aspirating with a syringe. Use the method that is
indicated by unit policy.
11. Monitor all IV flow rates hourly or as needed. IV flow rates can be easily altered by the patient’s
position or by kinked tubing. Promptly address pump alarms.
12. Assess for signs of an allergic reaction to the IV drug. If signs of a reaction are noted, stop the
administration of the drug and notify the prescriber immediately.
13. Use an infusion pump for any high-risk medications with a narrow therapeutic range to prevent
medication errors. Every precaution should be taken to prevent “free flow” incidence of IV fluids.
Check that the pump is infusing accurately.
14. Check compatibility of IV medications before infusing them together. Stop infusion immediately
if precipitation is noted in the tubing.
15. Assess IV sites for signs of infiltration: swelling, coolness, leakage, and pain at insertion site. If these
symptoms are found, remove IV and elevate arm. Use an infiltration scale to grade severity of the
infiltration when documenting (see following page).
16. Monitor IV sites for signs of phlebitis, which is an inflammation of the vein, causing erythema and
pain along the vessel. Remove the IV catheter if signs are present. A phlebitis scale should be used
when documenting this site (see following page).
17. IV sites should be secured with tape or stat lock and stabilized to prevent the loss of IV access.
18. Change IV site dressing when soiled and per institution’s policy. Ensure that IV sites are labeled
with date and time of insertion, gauge size, and initials.
19. Change IV tubing every 24 to 48 hours. This includes all add-on devices, such as filters, extensions, ports,
stopcocks, access caps, and needleless systems. Change IV fluid every 24 hours. Follow institution’s
policy.
20. Vascular access sites should be flushed at intervals according to institutional policies and procedures
and manufacturer’s recommendations.
21. Choose the flow-control device that best meets the clinical application for patients. Base this choice
on factors such as severity of illness, type of therapy, clinical setting, age, and mobility.
 APPENDIX A Guidelines for Administration of Medications 381

Infiltration Scale
Grade Clinical Criteria

0 No symptoms
1 Skin blanched
Edema less than 1 inch in any direction
Cool to touch
With or without pain
2 Skin blanched
Edema 1–6 inches in any direction
Cool to touch
With or without pain
3 Skin blanched, translucent
Gross edema greater than 6 inches in any direction
Cool to touch
Mild to moderate pain
Possible numbness
4 Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema greater than 6 inches in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate to severe pain
Infiltration of any amount of blood product, irritant, or vesicant

From Infusion Nursing Standards of Practice. (2006). New York: Infusion Nurses Society, p. S60.

Phlebitis Scale
Grade Clinical Criteria

0 No symptoms
1 Erythema at access site with or without pain
2 Pain at access site with erythema and/or edema
3 Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord
4 Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord greater than 1 inch in length
Purulent drainage

From Infusion Nursing Standards of Practice. (2006). New York: Infusion Nurses Society, p. S59.
APPENDIX B
Nomograms

382
 APPENDIX B Nomograms 383

Body surface area (BSA) nomogram for adults. Directions: (1) Find height; (2) find weight; (3) draw a straight line connecting
the height and weight. Where the line intersects on the BSA column is the body surface area (m2). (From Deglin, J.H., Vallerand,
A.H., & Russin, M.M. [1991]. Davis’s Drug Guide for Nurses [2nd ed.]. Philadelphia: F.A. Davis, p. 1218. Used with permission
from Lentner C. [Ed.]. [1981]. Geigy Scientific Tables. [8th ed.] Vol. 1. Basel, Switzerland: Ciba-Geigy, pp. 226-227.)
384 APPENDIX B Nomograms

West nomogram for infants and children. Directions: (1) Find height; (2) find weight; (3) draw a straight line connecting the
height and weight. Where the line intersects on the S.A. (surface area) column is the body surface area in square meters (m2).
(Modified from data by E. Boyd & C. D. West. In Kliegman, R. M., Stanton, B. F., St. Geme, J. W., et al [2011]: Nelson textbook
of pediatrics, ed. 19, Philadelphia: Saunders.)
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guidelines released. Retrieved from www.nhlbi.nih.gov/new/press/ Vanderveen, T. (2005). Medication safety: averting high-risk errors is first
ober14f.htm. priority. Patient Safety & Quality Healthcare. Retrieved from www.
Neville, K., Galinkin J.I., Green, T.P., et al. (2015). Metric units and the psqh.com/mayjun05/averting.html.
preferred dosing of orally administered liquid medications. [elec- Wideman, M.V., Whittler, M.E., & Anderson, T.M. (n.d.). Barcode
tronic Version]. Pediatrics, 1359(4):784-787. medication administration: lessons learned from an intensive card unit
Niemi, K., Geary, S., Larrabee, M., & Brown, K.R. (2005). Standardized implementation. Columbia, Mo: Agency for Healthcare Research and
vasoactive medications: a unified system for every patient, every- Quality.
where. Hospital Pharmacy, 40(11): 984-993. Wyeth Laboratories. (1988). Intramuscular injections. Philadelphia:
Ogden, S.J. (2012). Calculation of drug dosages (9th ed.). St. Louis: Wyeth Laboratories.
Elsevier/Mosby. Youngberg Webb, P., & Chilamkurti, R. (2009). Formulations: RTU
Okeke, C. (2005). Pharmaceutical calculations in prescription com- drug products, the keys to RTU parenterals [electronic version].
pounding [electronic version]. Pharmacopeial Forum, 31(3):846. Pharmaceutical Formulation & Quality.
INDEX
A Body surface area (BSA)
Abbreviations for pediatric dosage from adult dosage, 33
“do not use,” 53–54 in pediatric drug calculations, 251–252, 252f, 255–256
for drug forms, 42 Body surface area (BSA), in drug calculation, 98–99, 100f,
for drug measurements, 42 101f, 102, 1034
for IV solutions, 219t inch and pound formula for, 99
for metric units, 17, 17t with metric formula, 99
practice problems, 54 with nomogram, 99, 100f, 101f, 102, 103f, 383
practice problems answers, 55 practice problems, 106–107
for routes of drug administration, 52 practice problems answers, 109–110
for times of administration, 53 by square root, 99
Absorption, drug Body weight
common routes of, 59 in calculating infusion rates, 286–287
in neonates, 248 in pediatric drug calculations, 251–252, 253–255
Add-on devices, for intermittent IV therapy, 209, 209f, 209t, Body weight, in drug calculation, 97–98, 108–109
210f practice problems, 104–106, 177–178
ADD-Vantage system, 224, 225f practice problems answers, 104–106
Adjusted body weight (ABW), in drug calculation, 102 Bolus, intravenous fluid
practice problems, 107 calculation of, 319–320
practice problems answers, 111 in labor and delivery, 319–320
Adverse drug event/reaction (ADE/ADR), 56 Buccal tablets, 121
Age rules, for pediatric dosage from adult dosage, 268 Buretrol, 223f
Aluminum containers, 332
Ambulatory infusion pumps, 227, 227f C
American Hospital Formulary Service (AHFS) Drug Calculation, drug dose, 78
Information, 59 individualized, 97
Ampules, 149, 149f adjusted body weight in, 102
Analgesia, patient-controlled, 227–228, 227f body surface in, 98–99, 100f, 101f, 102, 1034
Apothecary system, 16, 21–22, 29 body weight in, 97–98
household equivalents for, 28, 28t ideal body weight in, 102
on labels, 21, 22f lean body weight in, 104
metric equivalents for, 28, 28t practice problems, 104–108, 108–111
Arabic system, 2 practice problems answers, 108–111
Assessment, checking for right, 60, 62b methods for, 78
Automated dispensing cabinets (ADCs), 49, 49f basic formula, 79–80
dimensional analysis, 83–86, 85t
B fractional equation, 82–83
Bar-code medication administration (BCMA) system, 47, 48, ratio and proportion, 80–82
48f, 49f practice problems, 86–93
Basic formula (BF), for calculating drug dose, 78, 79–80 practice problems answers, 94
Basic fractional formula, 287 Capsules, 115, 115f, 116–118
for concentration of solution, 33, 288 Carpuject syringe, 152, 152f
for concentration per minute, 287 Catheters, IV, 206, 207f
for volume per hour, 287 Becton Dickinson (BD), 207f
for volume per minute, 287 central venous, 206, 208f
Basic math review, 1–14 PICC lines, 206, 208f
answers, 9–10 triple-lumen, 207f
post-math test, 11–14 Celsius (C) scale, 24
Biological assays, 27 Central venous access, 206, 208f
Body mass index (BMI), 335 Chemical assays, 27
formulas for, 335 Children. See also Pediatric critical care; Pediatric drug
practice problems, 32 administration
practice problems answers, 34 dosage calculation for, 248
West nomogram for, 252, 252f, 384
Page references with f indicate figures; those with t, tables. Community. See also Home; Household system

387
388 INDEX

Community nurse, 326–327 Drug administration (Continued)

Compatibility, checking for, 210 inhalation, 65–66, 65f, 66f
Computer-based drug administration (CBDA), 47 intraosseous access devices, 75, 75f
Computerized drug order system, 42 intraspinal access devices for, 76, 76f, 77f
Computerized prescriber order system (CPOS), 47–48, 47f, lozenges, 71
48f mouthwash, 71
automation of medication dispensing administration, 49, nasal spray and drops, 66–67, 67f, 68f
49f oral, 115
BCMA, 48, 48f, 49f pharyngeal spray, 71
Concentration. See Solutions, concentration of rectal suppositories, 73, 73f
Conversion rights in, 58–61, 62b–62b
practice problems, 33–34 routes of, 52
practice problems answers, 35 topical preparations, 71, 72f
Conversion, of number systems, 2 transdermal patch, 64, 64f
by length, 28t, 31 vaginal suppository, cream and ointment, 74, 74f
practice problems, 32 Drug distribution, methods of, 45, 46t
practice problems answers, 32 Drug films, 115
by liquid volume, 28t, 29–30 Drug forms, abbreviations for, 52
practice problems, 31 Drug measurements, abbreviations for, 52
practice problems answers, 32 Drug orders, 42
by weight, 28t basic components of, 44
practice problems, 29 for hospitalized patients, 42, 43f
practice problems answers, 32 prescriptions, 42, 43f
Cream types of, 45, 45t
FTUs for, 72f Drug orders, interpretation of
purpose of, 71 practice problems, 44
vaginal, 74, 74f practice problems answers, 55
Critical care. See also Pediatric critical care Drug therapy, 56. See also Intravenous (IV) therapy
basic fractional formula in, 287–288 Dry powder inhalers, 65
IV therapy in, 278–279
Crusher, pill/tablet, 116, 116f E
Cutter, pill/tablet, 116, 116f Ear drops, 70, 70f
Education, checking for right, 60, 62b
D Electronic medication administration record (eMAR), 47, 51, 51f
Decimals, 6, 16 Emergency kit, glucagon, 195, 195f
changing fractions to, 4–5 Enteral nutrition, 140–141
dividing, 7 feedings, 141
multiplying, 6 GI tubes for, 140f, 141
practice problems, 7, 12 infusion pump for, 141, 141f
practice problems answers, 10, 14 solutions for, 141, 141t
Denominator, in dimensional analysis, 84 Enteral therapy
Dentists (DDSs), 42 blood sugar levels during, 141
Diabetes mellitus, 188 cautions with, 142
Dilution parameters, in pediatric critical care, 307–310 medications in, 142
Dimensional analysis (DA), 83–86, 85t, 92 Epidural insertion sites, 76, 76f
practice problems, 175–177 Errors. See Medication errors
practice problems answers, 185–186 Evaluation, checking for right, 61, 62b
Discharge teaching, 28 Extravasation, 217
Documentation, checking for right, 60, 61b Eye drops, 68, 69f
“Do Not Use” abbreviation list, 53–54 Eye ointment, 68–69, 69f
Dosage conversion tables, 27. See also Conversion
Dose, checking for right, 59, 61b F
Drip rates, adjusting, 215. See also Macrodrop IV sets; Factor labeling, in dimensional analysis, 92
Microdrip IV sets Fahrenheit (F) scale, 24
Drug administration Film strips, 115
abbreviations for, 52, 60 Fingertip units (FTUs), 72
alternative methods for, 63–64 Flow regulator, for infusion pumps, 226
computer-based (CBDA), 47 Fluid ounces, in apothecary system, 21
ear drops, 70, 70f Fluid overload, with IV infusion, 217
enteral, 140, 141f, 142 Flushing
eye drops and ointment, 68–69, 69f intravenous, prefilled single-use, sterile syringe for, 209, 210f
guidelines for, 377–378 for venous access devices, 209, 209t
 INDEX 389

Fractional equation (FE) method, of dose calculation, Infants. See also Pediatric drug administration
82–83 drug doses for, 252
Fractional system, 16 oral solutions for, 332
Fractions, 3 West nomogram for, 384
changing ratio to, 329 Inferior vena cava, vascular access to, 206, 208f
decimal, 4–5 Infiltration scale, 381
dividing, 4 Infusion pumps. See also Smart pumps
improper, 3 ambulatory, 227, 227f
mixed, 3 calculating titration factor with, 289
multiplying, 4 checking, 280
practice problems, 5, 11–12 dose rate calculator on, 281f
practice problems answers, 9–10, 14 electronic, 226–228, 226f, 227f
proper, 3 flow rates for, 228–231
Free-flow IV rate, 217 general-purpose, 226
Fried’s rules, 268 IV setup with, 226, 226f
linear peristaltic, 226
G multichannel, 227, 227f
Gastrointestinal tubes, types of, 140f, 141 patient-controlled analgesia, 227–228, 227f
Gastrostomy, 140f, 141 programmable, 226–227, 279–280
Glucagon injection, 195, 195f syringe, 226, 228f
Glulisine insulin (Apidra), 193 volumetric, 226
Grains, in apothecary system, 21 Infusion rate
Gram, 17 titration of, 288–290
practice problems, 293
H practice problems answers, 304
Health care providers (HCPs), 42 and total amount of drug, 293–294
Hickman (tunneled) catheter, 208, 208f practice problems, 294
High-alert drugs, 57 practice problems answers, 306
definition of, 279 Infusion rate, calculating
examples of, 279t per unit time, 282–283
indications for, 288 with drug in micrograms, 284–285
High-risk drug, Humulin R units 500 as, 195 with drug in milligrams, 284
Home care. See Household system with drug in units, 283
Home setting, 326 practice problems, 285, 288
hydration management in, 334–335 practice problems answers, 296
solutions prepared by patients in, 332 for specific body weight, 286–287
Hospira ADD-Vantage system, 224, 225f practice problems, 288
Household conversions, 85 practice problems answers, 301–304
Household system, 16, 22–23 Inhalation administration of drugs, 65–66, 65f, 66f
apothecary equivalents for, 28, 28t Injectable medications
conversion within, 22 guidelines for, 379
converting metric to, 326–327 mixing of, 163–166
metric equivalents for, 28, 28t orders for, 148–149
practice problems, 23 post-test for, 351–357, 370–372
practice problems answers, 25 routes for, 148
units of measurement in, 22, 22t Injectable preparations
Humulin R units 500, as high-risk drug, 195 ampules, 149, 149f
Hydration management drug solutions for, 159
calculating daily fluid intake for adult, 334–335 intradermal, 154
daily fluid intake for febrile adult, 335 intramuscular, 158–163, 159f, 160f, 160t
practice problems, 335 needles for, 152–153, 152f, 153t
practice problems answers, 339–340 subcutaneous, 154–156, 154f
standard formula for daily fluid intake, 334–335 syringes for, 149
vials, 149
I Institute for Safe Medication Practices (ISMP), 53, 56
Ideal body weight (IBW), in drug calculation, Insulin analogs, 188, 193
102 Insulin bottles, 189–190, 190f
practice problems, 107 Insulin injections
practice problems answers, 111 angles for, 191
Identification band, checking patient’s, 58 cautions for, 191
Implantable vascular access port, 208, 208f sites for, 190, 190f
Inches, conversion of, 31–32 timing of, 193
390 INDEX

Insulin pen devices Intravenous (IV) drug administration, intermittent

examples of, 200f (Continued)
practice problems, 201 indications for, 222
practice problems answers, 204 and medication volume, 224
types of, 200–201 of potassium, 231
Insulin pumps, 201–202, 202f practice problems, 231–238
practice problems, 202 practice problems answers, 241–245
practice problems answers, 204 secondary IV sets for, 223
Insulins, 188 Intravenous (IV) drug therapy
action of, 191f, 192f, 193, 195f advantages of, 206
mixing, 196 indications for, 206
ordered in units, 190, 190f in labor and delivery, 315
practice problems, 197–199 methods of, 206
practice problems answers, 202–203 sites and devices for, 206, 207f, 208, 208f
types of, 191, 193, 194t systemic effect of, 278–279
combinations, 192, 192f, 193, 194t Intravenous (IV) drug therapy, pediatric, 251, 251t, 255
fast-acting, 191, 192f, 193, 194t and fluids, 251, 251t
fast- and intermediate-acting, 192, 192f guidelines for, 251t
intermediate-acting, 191, 192f, 193, 194t Intravenous (IV) flow rate
long-acting, 192, 192f, 193, 194t calculation of, 219–220
rapid-acting, 191, 192f, 193, 194t methods, 217
Insulin syringes and tonicity of IV solutions, 218, 219t
measured in units, 188–189, 189f and types of solutions, 218
types of, 189, 189f free, 217
Intake and output (I&O), and checking IV flow rate, 221 and intake and output, 221
International Metric System, 16 safety considerations with, 217
International System of Units, 16 Intravenous (IV) fluids, guidelines for, 379–380
Intradermal injections, 154 Intravenous (IV) injections, direct
Intradermal medications, 148 calculations for, 210–211
Intramuscular injections, 158 checking for incompatibility, 210–211
calculations for, 161 flushing for, 214
common sites for, 159, 160f, 160t post-test for, 358, 372
needle gauges for, 158 practice problems, 212–214
practice problems, 166–179 practice problems answers, 239–240
practice problems answers, 181–187 timing of, 210–211
reconstitution of powdered drugs for, 162–163 Intravenous (IV) medications, guidelines for, 379–380
volume of solutions for, 158 Intravenous (IV) sets, 214–215, 215f, 216f, 217
Z-track injection technique, 159, 159f bag vs. bottle, 216f
Intramuscular injections, pediatric, 249, 250t, 251 equipment for secondary, 223
guidelines for, 250t macro- vs. minidrip, 215, 216f
sites for, 250t vented vs. unvented, 215
Intramuscular medications, 148 Intravenous (IV) solutions, abbreviations for, 219t
Intraosseous access devices, 75, 75f Intravenous medications, 148
Intraosseous (IO) infusions, 75, 75f
Intraspinal access devices, 76, 76f, 77f J
Intrathecal insertion sites, 76, 76f Jejunostomy, 140f, 141
Intrathecal pump implant, 76, 77f The Joint Commission (TJC), 53
Intravenous (IV) drug administration
electronic infusion pumps for, 226–228, 226f, 227f K
free-flow rate for, 217 Kangaroo pump, 141, 141f
in pediatric critical care, 307 Keep vein open (KVO) rate, 217
post-test for, 358–363, 373–374
safe practice for, 217 L
Intravenous (IV) drug administration, continuous Labels, drug
adding drugs used for, 218 checking, 58
infusion sets for, 214–215, 215f, 216f, 217 in dimensional analysis, 84
practice problems, 221–222 drug differentiation for, 42
practice problems answers, 240–241 example of, 37
Intravenous (IV) drug administration, intermittent information on, 37
adding drugs used for, 223–224, 224f for injectable drugs, 39
add-on devices for, 209, 209f, 209t, 210f interpretation of, 37
ADD-Vantage system, 224, 225f for oral drugs, 38
 INDEX 391

Labels, drug (Continued) Metric equivalent, in dimensional analysis, 84

practice problems, 39–41 Metric system, 16, 17, 326
practice problems answers, 55 apothecary equivalents for, 28, 28t
Labor and delivery conversion within, 17–20, 17t, 18t
drug calculations for, 315 household equivalents for, 28, 28t
intravenous loading dose in, 318–319 practice conversion problems, 20–21
IV fluid and drug management in, 315 practice conversion problems answers, 24
practice problems, 321–322 prefixes in, 17
practice problems answers, 323–325 Metric to household conversion, 327, 327t
titration of medications in, 316 conversion factors, 327, 327t
by concentration, 316–317 measuring devices for, 327
by volume, 316–317 practice problems, 328–329
Lantus insulin, 193, 194t practice problems answers, 336
Lean body weight (LBW), in drug calculation, 104 Metric units, 27
practice problems, 108 abbreviations for, 17, 17T
practice problems answers, 111 prefixes for, 17, 18t
Lean body weight/mass (LBW/LBM) formula, 102 Microdrip IV sets, 215, 216f
Levemir insulin, 193, 194t determining titration factor with, 291
Lipid-soluble drugs, in children, 248 indication for, 283
Liquid medications Military (international) time, vs. traditional time, 41,
calculation of, 120–121 41f
caution with, 119 Millequivalents (mEqs), 27
forms of, 119 Milliliters, conversion of, 29–30
Liquid volume, conversion by, 29–30 Mix-O-Vial, 149
Liters, 17, 29 Monitoring parameters
Loading dose, in labor and delivery, 318–319 for high-alert drugs, 288
Lotion, 71, 72f in labor and delivery, 315
Lovenox syringes, 152, 152f Mouthwash, 71
Lozenges, 71
Luer-Lok design, needleless, 209, 209f N
Narcotics, administered on PCA pump, 228
M Nasal drops, 67, 68f
Macrodrop IV sets, 215, 216f Nasal spray, 66–67, 67f
Measurement systems, 16 Nasoduodenal/nasojejunal tube, 140f, 141
practice problems, 25 Nasogastric tube, 140f, 141
practice problems answers, 26 National Coordinating Council for Medication Error
for temperature, 24 Reporting and Prevention, 47
Medibottle, 249, 250f Nebulizers, 65
Medication administration Needleless infusion devices, 209, 209f
bar code, 47, 48, 48f, 49f Needles
titration in, 289 angles for injection for, 153, 153f
Medication administration record (MAR), 51 determining size and length for, 152–153, 153f
Medication errors (MEs), 56 filtered, 149
examples of, 57 parts of, 152, 152f
intercepted, 56–57 for pediatric injections, 251
intravenous, 279 practice problems, 154
preventing, 56–57, 57–58 practice problems answers, 179
reporting, 56 SafetyGlide shielding, 150, 150f
responsibility for, 57, 58 Neonates
Medication orders. See Drug orders drug absorption in, 248
Medications, chosen on CPOS, 47, 48f. See also Injectable drug administration for
medications practice problems, 266–267
Medications, intravenous (IV) practice problems answers, 276–277
dispersing, 218 drug doses for, 252
premixed, 224 Nomogram
Medicine cup, 115, 115f body surface area (BSA) on, 99, 100f, 101f, 102, 103f,
Meter, 17 383
Metered-dose inhalers (MDIs), 65, 65f for infants and children, 252, 252f, 384
Metered-dose inhalers (MDIs) with spacers, 65, 66f Number systems, 2–3
Meters, conversion of, 31–32 Numerator, in dimensional analysis, 84
Metric conversions, 85 Nurse practitioners (NPs), 42
Metric equivalence, 29 Nutrition, enteral, 140–141, 140f, 141f
392 INDEX

O Physicians (MDs), 42
Ointment, 71, 72f Podiatrists (DPMs), 42
eye, 68–69, 69f Port-a-caths, 208, 208f
vaginal, 74, 74f Post-test
One-time (single) orders, 45, 45t for direct IV administration, 358, 372
Oral medications for injectables, 351–357, 370–372
capsules, 115, 115f for IV administration, 358–363, 373–374
cautions with, 116 for oral preparations, 342–352, 368–369
disadvantages of, 114 for pediatric IV administration, 363–368, 374–376
film strips, 115 Potassium, IV administration of, 231
guidelines for, 378 Precipitation, checking for, 210
liquid form of, 115, 115f, 119–121, 119f Prescriptions, 42, 42f. See also Drug orders
pediatric, 249–250, 249f, 250f PRN orders, 45, 45t
practice problems, 123–139 Proportion, definition for, 7
practice problems answers, 142–147 Pumps, insulin, 201–202, 202f
tablets, 115, 115f Pyxis MedStation system, 49, 49f
Oral preparations, post-test for, 342–351, 368–369
Osmolality, 218, 219t Q
Osteopathic physicians (DOs), 42 Quality and Safety Education for Nurses (QSEN) Institute, 56
Ounces, conversion of, 29–30
R
P Ratio
Patient advocate, nurses as, 58 calculating solution from, 330–331
Patient-controlled analgesia (PCA), 227–228, 227f changing to fractions and percentages, 329–330
Pediatric critical care, 307 definition for, 7
dilution parameters in, 307–310 Ratio and proportion, 7–8
intravenous administration in, 307 for calculating drug dose, 80–82
practice problems, 310–311 for conversion by liquid volume, 30
practice problems answers, 311–314 for conversion by weight, 29
Pediatric drug administration, 248 practice problems, 8, 13
from adult dosage practice problems answers, 10, 14
age rules for, 268 Rectal suppositories, 73, 73f
body surface area formula for, 268 Refusal of medication, checking for right of, 60, 61b
calculations for, 251–252, 252f Rights, in drug administration, 58–61, 61b–62b
calibrated measuring devices for, 249f checklist for, 61b–62b
intramuscular, 249, 250t, 251 right assessment, 60, 62b
practice problems, 260–262 right documentation, 60, 61b
practice problems answers, 272–273 right dose, 59, 61b
intravenous, 251, 251t, 255 right drug, 58
practice problems, 262–266 right education, 60, 62b
practice problems answers, 273–276 right evaluation, 61, 62b
for neonates, 248 right patient, 58
practice problems, 266–267 right route, 59–60, 61b
practice problems answers, 276–277 right time, 59, 61b
oral, 249–250, 249f, 250f right to refuse medication, 60, 61b
practice problems, 256–260 Roman numerals, 2
practice problems answers, 269–271 practice problems, 3, 11
per body surface area, 252, 255–256 practice problems answers, 9, 13
per kilogram body weight, 253–255 Rounding off rule, in drug calculation, 98
post-test for, 363–368, 374–376 Route of drug administration, checking right, 59–69, 61b
Percentages, 8–9, 28
calculating solution from, 331 S
changing ratio to, 329 Scrolling list, for CPOS, 47, 47f
practice problems, 9, 13 Secondary sets
practice problems answers, 10, 14 drug calculation with, 228–231
Peripherally inserted central catheters (PICCs), 206 flow rates for, 228
Pharmacy information system (PIS), 47 Sharps container, 150, 150f
Pharyngeal spray, 71 SI units, 16
Phlebitis Smart pumps, 226
Phlebitis scale, 381 control panel of, 283
Physician assistants (PAs), 42 in critical care, 279
Physician’s Desk Reference, 59 dose rate calculator on, 281f
 INDEX 393

Software, for drug administration, 47 Tablets (Continued)

Solutions sublingual, 121–122
abbreviations for intravenous, 219t time-released, 116
calculating concentration of, 280 Telephone orders (TOs), 42
with micrograms per milliliter, 282 Temperature conversion, 24
with milligrams per milliliter, 280 practice problems, 24
from percentage, 331 practice problems answers, 25
practice problems, 282 Tenths, rounding off to, 6
practice problems answers, 294–295 Time conversions
from ratio, 330–331 military vs. traditional, 41, 41f
with units per milliliter, 280 practice problems, 41
guidelines for home, 332–333 practice problems answers, 55
preparing desired concentration for, 329–331 Timing, checking right, 59, 61b
practice problems, 330 Titration
practice problems answers, 336–337 basis for, 289
preparing weaker solution from, 331–332 calculation of, 289
practice problems, 333–334 increasing or decreasing infusion rates, 290–291
practice problems answers, 337–339 with infusion pump, 290
Spacer devics, 65, 66f with microdrop IV set, 291–292
Square meters (m2), BSA determined by, 99 practice problems, 293
Standing orders, 45, 45t practice problems answers, 304
STAT orders, 45, 45t purpose of, 289
Stock system, of drug distribution, 45, 46t To keep open (TKO) rate, 217
Subcutaneous injections Tonicity, 218, 219t
calculations for, 155–156 Topical administration, with transdermal patch, 64, 64f
practice problems, 156–158 Topical preparations, 71, 72f
practice problems answers, 179–181 Transdermal patch, 64, 64f
syringes used for, 154, 154f Tuberculin syringes, 151, 151f
Subcutaneous medications, 148 Tubex syringes, 152, 152f
Sublingual tablets, 121–122 Tubing, for infusion pumps, 226
calculation of, 122
caution with, 121 U
Superior vena cava, vascular access to, 206, Unit-dose cart cabinets, 45, 46f
208f Unit-dose drug dispensing system (UDDS), 45–46, 46f, 46t
Suppositories Units, 27
rectal, 73, 73f Unit time, 282
vaginal, 74, 74f
Syringe pumps, 226, 228f V
Syringes Vascular access
Carpuject, 152, 152f for IV drugs and fluids, 206
five-milliliter, 151, 151f for long-term use, 208
insulin, 188–189, 189f Vascular access port, implantable, 208, 208f
Lovenox, 152, 152f Venous access devices, flushing for, 209, 209t
needleless, 209, 209f Verbal drug orders, 42
parts of, 149, 150f Vials
with pre-filled drug cartridges, 151 drugs packaged in, 149, 149f
prefilled single-use, sterile, 209, 210f Mix-O-Vial, 149
tuberculin, 151, 151f multiple-dose, 149
Tubex, 152, 152f
types of, 149 W
Weights, daily, for calculating infusion rates, 286
T West nomogram, for infants and children, 101f, 252, 252f, 384
Tablets, 115, 115f
buccal, 121 Y
calculations for, 116–118 Young’s rules, 268
enteric-coated, 116
layered, 116 Z
“orally disintegrating,” 121 Z-track injection technique, 159, 159f
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 Drug Calculations Drug Calculations
Basic Formula Ratio and Proportion

D 1desired2 H : V :: D : X
3 1Vehicle, drug form2
H 1on hand2 On hand ​ ​​vehicle ​ ​desired ​ ​​unknown
means
extremes
Example:
Order: amoxicillin 100 mg, po, q6h Example:
Available: amoxicillin 250 mg/5 mL Order: amoxicillin 100 mg, po, q6h
100 mg Available: amoxicillin 250 mg/5 mL
D
3V5 3 5 mL 5 H : V :: D : X
H 250 mg
250 mg : 5 mL :: 100 mg : X mL
500
5 2 mL amoxicillin 250 X ​= ​500
250
X ​= ​2 mL amoxicillin

Body Weight (Kilograms) IV Flow Rate: Continuous Method II

To change pounds to kilograms divide by 2.2. a. amount of fluid ÷ hours to administer ​5 ​mL/hr
Example: mL/hr 3 gtt/mL 1IV set2
b. 5 gtt /min
Change 44 pounds to kg. 60 min/hr
44 ÷ 2.2 ​= ​20 kg Example:
dosage/kg/day ​= ​dosage/day Order: 1000 mL, D5/1⁄2 NSS over 8 hours
(dosage × kg ​= ​dose/day) IV set: macrodrip 10 gtt/m:

a. 1000 mL ÷ 8 hours ​5 ​125 mL/hr

1
125 mL/hr 3 10 gtt/mL
b. 5 21 gtt/min
60 min/hr
6

IV Flow Rate: Intermittent Secondary Sets IV Flow Rate: Intermittent Volumetric Pump

amount of solution 3 gtt/mL 1set2 minutes to administer

5 gtt/min amt of sol 4 5 mL/hr
minutes to administer 60 mL/hr

Order: administer 5 mL of drug solution in 50 mL Order: administer 5 mL of drug solution in 100 mL

of D5W over 30 minutes. of D5W over 45 minutes.
IV set: Buretrol (60 gtt/mL)
45 min
2 105 mL 4 1invert divisor and multiply2
55 mL 3 60 gtt 60 min/hr
5 110 gtt /min
30 minutes 4
1 60
5 105 3 5 140 mL/hr
45
3

Set volumetric pump at 140 mL/hr to deliver

105 mL over 45 minutes.