DRUG CALCULATION COMPETENCY TEST
EXAM OF PRACTICAL SKILLS I
A nurse has to be able to calculate drip rates, know the metric conversion and how much oral medication to dispense. Most nursing students have to take a medication dosage calculation test (med dose) before each semester begins. A score of at least 90%-95% has to be obtained in order to move on to the next semester. That means you can only miss 1-2 questions on your math test. Most nurses are not comfortable with taking these math tests. In this day and age, the are automatic IV pumps that control drip rates and pharmacists that determine the volume of a medications based upon weight. If you conquer these few rules that this article mentions, then passing the med dose test every semester should not be a problem.
Dimensional analysis (also known as the factor-label method or unit-factor method) is by far the most useful math trick you’ll ever learn. Maybe you’ve learned some algebra, but will you use it? For many people the answer is, “not after the final exam.”
For a fraction of the effort needed to learn algebra, you too can learn “dimensional analysis.” First off, however, let’s get rid of the big words. What this is all about is just conversion—converting one thing to another. This is something you will have occasion to do in real life. This is seriously useful stuff.
This trick is about applied math, not about numbers in the abstract. We’re talking about measurable stuff, stuff you can count. Anything you measure will have a number with some sort of “unit of measure” (the dimension) attached. A unit could be miles, gallons, miles per second, peas per pod, or pizza slices per person.
Example 1
How many seconds are in a day?
First, don’t panic. If you have no idea what the answer is or how to come up with an answer, that’s fine—you’re not supposed to know. You’re not going to solve THE PROBLEM. What you are going to do is break the problem down into several small problems that you can solve.
Here’s your first problem:
1. Ask yourself, “What units of measure do I want to know or have in the answer?” In this problem you want to know “seconds in a day.” After you figure out what units you want to know, translate the English into Math. Math is a sort of shorthand language for writing about numbers of things. If you can rephrase what you want to know using the word “per,” which means “divided by,” then that’s a step in the right direction, so rephrase “seconds in a day” to “seconds per day.” In math terms, what you want to know is:
2. Ask, “What do I know?” What do you know about how “seconds” or “days” relate to other units of time measure? You know that there are 60 seconds in a minute. You also know that in 1 minute there are 60 seconds. These are two ways of saying the same thing. You know that there are 24 hours in a day (and in one day there are 24 hours). If you could now connect “hours” and “minutes” together you would have a sort of bridge that would connect “seconds” to “days” (seconds to minutes to hours to days). The connection you need, of course, is that there are 60 minutes in an hour (and in one hour there are 60 minutes). When you have this kind of connection between units, then you know enough to solve the problem–but first translate what you know into math terms that you can use when solving the problem. If in doubt, write it out:
All of these statements, or conversion factors, are true or equivalent (60 seconds = 1 minute). All you need to do now is pick from these statements the ones that you actually need for this problem, so….
3. Ask, “From all the factors I know, what do I need to know?”
Remember that you want to know:
So pick from the things you know a factor that has seconds on top or day(s) on the bottom. You could pick either of the following two factors as your “starting factor:”
Write down your starting factor (say you pick 60 seconds per 1 minute):
Now the trick is to pick from the other things you know another factor that will cancel out the unit you don’t want. You start with “seconds” on top. You want “seconds” on top in your answer, so forget about the seconds—they’re okay. The problem is you have “minutes” on the bottom but you want “days.” You need to get rid of the minutes. You cancel minutes out by picking a factor that has minutes on top. With minutes on top and bottom, the minutes will cancel out. So you need to pick 60 minutes per 1 hour as the next factor because it has minutes on top:
You now have seconds per hour, since the minutes have cancelled out, but you want seconds per day, so you need to pick a factor that cancels out hours:
4. Solve it. When you have cancelled out the units you don’t want and are left only with the units you do want, then you know it’s time to multiply all the top numbers together, and divide by all the bottom numbers.
In this case you just need to multiple 60x60x24 to get the answer: There are 86,400 seconds in a day.
Here’s how this problem might look if it were written on a chalkboard:
Remember that you don’t need to worry about the actual numbers until the very end. Just focus on the units. Plug in conversion factors that cancel out the units you don’t want until you end up with the units you do want. Only then do you need to worry about doing the arithmetic. If you set up the bridge so the units work out, then, unless you push the wrong button on your calculator, you WILL get the right answer every time.
Example 2
How many hours are in a year?
Let’s go through the steps:
Don’t panic
What do you want to know? This one’s easy: hours in a year, or better, hours per year
Translate into math terms:
What do you know that you might need to use? You know that there are 24 hours in a day, 7 days in a week, 4 weeks in a month, 12 months in a year, and about 365 days in a year. The converse, of course, is also true: In one day there are 24 hours, in one week there are 7 days, in one month there are 4 weeks, in one year there are 12 months, and in one year there is about 365 days (actually closer to 365.25 days).
Translate into math terms—writing them all down can’t hurt:
Pick a starting factor. Since you want hours on top (or years on the bottom), you could start with 24 hours per day:
Now pick whatever factors you need to cancel out day(s):
Keep picking factors that cancel out what you don’t want until you end up with the units you do want:
Do the math. You have all the units cancelled out except hours per year, which is what you want, so when you do the math, you know you’ll get the right answer:
But wait, why not go from “hours” to “year” using the fact that there are 365 days per year?
Oh no! There is a 696-hour difference between the two answers! How can this be? Exact answers can only be obtained if you use conversion factors that are exactly correct. In this case there are actually more than 4 weeks in a month (about 4.35 weeks per month). Since there is a bit more than 365 days in a year (365.25 days), a more accurate answer still, to the nearest hour, would be that there are 8766 hours in a year. The point of this example is that your answer can only be as accurate as the conversion factors you use.
Example 3
Sometimes both the top and bottom units need to be converted:
If you are going 50 miles per hour, how many feet per second are you traveling?
If you were to do this one on the blackboard, it might look something like this:
You want your answer to be in feet per second. You are given 50 miles per hour. Notice that both are in distance per time. Normally you can use any value given by the problem as your starting factor. One thing you know, then, is given. The other things you just know or have to look up in a conversion table. Although every conversion factor can be written two ways, you really only need to write each one way. That’s because you know you can always just flip it over and then use it. If you have written 60 min/1 hr, then to solve this problem you would just flip the 60 min/hour factor over. With practice you won’t eveeed to write down what you know, you’ll just pull it out of your head and write down the last part, do the math, and get the right answer.
Example 4
How much bleach would you need to make a quart of 5 percent bleach solution?
You’re not told what answer unit to use, but ounces would work since there are 32 oz in a quart. If the only thing you had to measure bleach with was in milliliters, then you would pick “mL” as your answer unit.
When you are given something like “5 percent” or “5%” by a problem, you need to translate it into math terms you can use. “5%” means 5 per 100 or 5/100, but 5 what? per 100 what? You need to label the numbers appropriately. In this example you write down “5 oz bleach/100 oz bleach solution” or just “5 oz B/100 oz BS” as a factor you are given. If you were going for milliliters, then you would use “5 mL B/100 mL BS.” The top and bottom units must be the same or equivalent, but otherwise can be any units you may need. If you had 5 gal. bleach/100 gal. bleach solution, then you would still have a 5% bleach solution.
Setting up and solving this problem is now easy:
So you would add 1.6 oz bleach to a quart measuring cup, then add water (30.4 oz) to make 32 ounces of 5% bleach solution.
Example 5
Your little sister’s hamster is slowly dying a horrable death from multiple tumors and has stopped eatting. The vet wants $75 to put it to sleep. It is Friday night and even if Mom was willing to spend $75 the hamster and your sister would have to suffer until Monday. You look online and find information about small animal euthanasia. It says you need some vinegar or other 5% acid solution. There is no vinegar in the house, only some muraitic swimming pool acid in the garage. Instead of waiting until tomorrow to go to town and buy vinegar, you want to do something now. According to the label it is 31.45% hydrochloric acid (HCl). Realizing it is dangerous to mess with hydrodhloric acid, you take precautions you learned in chemistry class. Also from chemisty class you recall there is a formula, something about V2 times C2 over C1 but this is not a test, this is for real, and getting the wrong answer is not an option. Fortunately, also in chemistry, you learned dimentional analysis and know that if the formula (and answer) is correct, the units of measure will cancel out leaving you with only the ones appropriate for the answer. So you stop trying to recall the formula and decide to use DA. You have told your sister you can help Fuzzy go to sleep and stop thrashing about. She is crying and won’t go to bed. She stares hopefully at you. She trusts you. You realize it is up to you now to not mess up.
So what you want to know is the number of ounces of concentrated (32%) HCl you need to use to make, say, a quart of 5% dilute acid solution. In the previous example involving bleach, the assumption was that the initial bleach solution was 100% bleach. But HCl doesn’t come in a 100% acid form and what you have is about 32% acid. This means that in 100 oz. of concentrated HCl solution there are 31.45 oz. of actual HCl. You also know that in a 5% dilute solution there are 5 oz. actual pure HCl in 100 oz. of dilute solution. Since you want to end up with a quart of solution, you’ll need to know that there are 32 oz/qt.
So how much of the concentrated acid do you need to use to make a quart of dilute 5% acid? In your answer you want concentrated on top and dilute on bottom, so start with dilute on bottom or concentrated on top:
If the volume of concentrated acid is V1 and its concentration is C1, and V2 is the dilute volume and C2 is the concentration of the dilute acid, then V1 = (V2xC2)/C1. You might remember this formula for a test, but don’t expect to remember it when you need it. With dimensional analysis you can always think your way to the right answer. But knowing the right answer is not enough. You should also know not to ever add water to concentrated acid. So to make a quart of dilute acid you measure out 27 oz of water and add 5 oz concentrated acid to it. Following the instructions of the euthanasia site, Fuzzy goes quietly to sleep. This example is a real world one. Knowing some math can make all the difference.
Example 6
Your car’s gas tank holds 18.6 gallons and is one quarter full. Your car gets 16 miles/gal. You see a sign saying, “Next gas 73 miles.” Your often-wrong brother, who is driving, is sure you’ll make it without running out of gas. You’re not so sure and do some quick figuring:
“Ah! I knew I was right,” declares your brother on glancing at your calculator,
“your calculations prove it!” Is this a good time to be assertive and demand that he turn around to get gas, or do you conclude that your brother is right for once?
Unless the next stop is Las Vegas and you’re feeling really lucky, you should turn around and get some more gas. Your calculator reads “74.4” exactly, but if you believe what it says, then you believe that when the car runs out of gas, it will have gone some where between 74.35 miles and 74.45 miles or 74.4 + 0.05 miles. Obviously the “point four” is meaningless, so you round to 74. Is 74 the right answer? If you think it is, then you think your car will go some where between 73.5 miles and 74.5 miles before running out of gas. When you run out of gas, what chance do you think you’ll have of having gone 74 + 0.5 miles? A proverbial “fat chance” would be a good guess.
When you’re given something like a “quarter tank” you should wonder just how accurate such a measurement is. Can you really divide 18.6 by 4 and conclude that there really is 4.65 gallons of gas in the tank? The last time you figured mileage you came up with 16 miles/gallon, but is the engine still operating as efficiently? Are the tires still properly inflated? Will the next 73 miles be uphill? Do you have a head wind? Surely a calculated estimate of 74 miles is overly precise. A realistic answer, then, might be 74 + 10 miles. You realize you could run out of gas anywhere between 66 and 84 miles, so you finally and correctly conclude that you have a slightly less than a 50/50 chance of running out of gas before reaching the next gas station.
The point of this example is to remind you that dimensional analysis is applied math, not abstract math. The numbers used should describe the real world in so far as possible and indicate no more accuracy than is appropriate. If you overlook this point, you might have a five-mile walk to the next gas station.
Example 7
You’re throwing a pizza party for 15 and figure each person might eat 4 slices. How much is the pizza going to cost you? You call up the pizza place and learn that each pizza will cost you $14.78 and will be cut into 12 slices. You tell them you’ll call back. Do you have enough money? Here’s how you figure it out, step by step.
1. Ask yourself, “What do I want to know?” In this case, how much money is the pizza going to cost you, which in math terms is: cost (in dollars) per party, or just $/party. This is your “answer unit.” This is what you are looking for.
2. Ask, “What do I know?” Write it all down, everything you know: one pizza will cost you $14.78 (in math terms 1 pizza/$14.78). You also know that for $14.78 you can buy one pizza ($14.78/1 pizza). It can be important to realize that every conversion factor you know can be written two ways. One of these ways may be needed to solve the problem and the other won’t, but in the beginning you don’t know which, so just write them both ways. Continue writing down other things you know. You know, or hope, that only 15 people will be eating pizza (15 persons/1 party), or for this one party, 15 people will come (1 party/15 persons). You also know there will be 12 slices per pizza (12 slices/1 pizza), or that each pizza has 12 slices (1 pizza/12 slices). The last thing you know is that each person gets 4 slices (1 person/4 slices), or that you are buying 4 slices per person (4 slices/person). Math is a language that is much briefer and clearer than English, so writing every thing you know in math terms, here’s what you might have written down:
3. Ask, “From all the things above I know, what do I actually need to know to figure out the problem?”
Remember that you want to know $/party, so pick one of the things you know that has either dollars on top, or “party” on the bottom. Let’s start with $14.78/pizza as the starting factor. Great, you got dollars on top, but “pizza” on the bottom where you want “party.” To get rid of “pizza” pick one of the things you know that has “pizza” on the top. “Pizza” over “pizza” cancels out, so you get rid of the “pizza:”
Okay, you now have dollars per slice, but you want dollars per party, so now what? Easy, just keep picking from the things you know whatever cancels out the units you don’t want. The numbers go with the units, but don’t worry about numbers, just pay attention to the units. So you pick 4 slices/1 person to get rid of “slices,” then 15 persons/1 party to get rid of “person(s):”
Now multiply all the top numbers, and then divide by any bottom numbers to get the right number. Finally add the units that are left over to the number to get the answer you wanted. Using this method, you can hardly go wrong unless you push the wrong button on your calculator.
By the way, how many pizzas should you order? Figuring this out should be as easy as….
Example 8
Chemists often use dimensional analysis. Here’s a chemistry problem. To solve it you need to know that, as always, there are 6.02 x 1023 molecules (or atoms) of whatever in a mole.
A sample of calcium nitrate, Ca(NO3)2, with a formula weight of 164 g/mol, has 5.00 x 1025 atoms of oxygen. How many kilograms of Ca(NO3)2 are present?
This may look like a some sort of horribly complex nightmare problem, but don’t panic, just take it step by step. Since you want kilograms (kg) in your answer, pick a starting factor with weight (g=grams) on top. Note that in each molecule of calcium nitrate there are two nitrate ions each having three atoms of oxygen (for a total of 6).
Example 9
You have come down with a bad case of the geebies, but fortunately your grandmother knows how to cure the geebies. She sends you an eyedropper bottle labeled:
Take 1 drop per 10 lbs. of body weight per day divided into 4 doses until the geebies are gone.
This problem is a bit more challenging, but don’t panic. Break the problem down into a bunch of small problems, and tackle each one by one.
What do you want to know? In order to take one dose 4 times a day you need to know how many drops to take per dose.
Translated into math terms you want the answer to be in:
What do you know? Well, you know you weigh 160 pounds. You know that you need to take 4 doses per day (implied). You know that you need to take 1 drop per 10-lbs. body weight per day.
Translate this into math terms:
The problem now is the last factor. What can you do with such an odd factor? You rewrite it so it is in a different form that you can use. What you do is multiply the middle term by the bottom term:
So whenever you have a triple-decker, use this trick to rewrite the factor.
Now you should be able to solve the problem. The one thing you know that isn’t a conversion factor is that you weigh 160 lbs., so use that as your starting factor:
If you had wanted to know how many drops per day to take, you would have just left off the last conversion factor, which would give you an answer of 16 drops/day.
Example 10
Okay, enough easy problems, let’s try something harder. Well, not really harder, just longer. The point of this example is that no matter how ridiculously long your conversion might be, long problems are not really more difficult. If you get the point, then skip this example; otherwise read on.
At the pizza party you and two friends decide to go to Mexico City from El Paso, TX where y’all live. You volunteer your car if everyone chips in for gas. Someone asks how much the gas will cost per person on a round trip. Your first step is to call your smarter brother to see if he’ll figure it out for you. Naturally he’s too busy to bother, but he does tell you that it is 2015 km to Mexico City, there’s 11 cents to the peso, and gas costs 5.8 pesos per liter in Mexico. You know your car gets 21 miles to the gallon, but we still don’t have a clue as to how much the trip is going to cost (in dollars) each person in gas ($/person).
1. What do you want to know? $/person round trip—the answer unit(s).
2. What do you know so far? There will be 3 persons going on a round trip (3 persons/1 round trip), or in the planned round trip 3 persons will be going (1 round trip/3 persons), it will be a 2015 km trip one-way (2015 km/one-way trip), or one-way is 2015 km (one-way trip/2015 km), there are 2 one-way trips per round trip (2 one-way/round trip), there is 11 cents per peso (11 cents/1 peso), or one peso is worth 11 cents (1 peso/11 cents). Finally you know that one liter of gas costs 5.8 pesos (1 liter/ 5.8 pesos), or 5.8 pesos will buy you 1 liter (5.8 pesos/1 liter).
You know a lot, but still not enough. Knowing the number of miles in a kilometer, or liters in a gallon would be nice, but one of your friends recalls that there is 39.37 inches in a meter and the other is sure that there is 4.9 ml in a teaspoon. This still isn’t enough. You might need to know that there are 1000 meters in a kilometer, 1000 ml in a liter, 100 cents per dollar, 12 inches to the foot, and 5,280 feet to the mile, but then you already knew that.
Almost enough, but how can you get from teaspoons to gallons? Simple, call your mom. She knows that there are 3 teaspoons in a tablespoon, 16 tablespoons in a cup, 2 cups in a pint, 2 pints in a quart, and 4 quarts in a gallon. Wow, that’s a lot of things to know, but it should be enough. Write it all down in math terms and see what you have:
3. What do you need to know from the above? If any of the above are upside down from what you end up needing, just turn them over, then use them. This problem looks harder than it is. Since we want to end up with $/person, let’s start with:
Even with 18 factors to plug in to get your answer, it’s still pretty much a no-brainer whether you have two or 30 factors. If you know enough conversion factors and set the “bridge” up correctly to cancel out all unwanted units, then you get the correct answer. You may have to look up a few conversion factors you don’t know, but once you do, you’re home free. Looking up the number of liters per gallon or miles in a kilometer would have saved quite a few steps, but if you can remember any relationship you can still figure out your answer. It takes a little longer, but really adds nothing to the inherent difficulty.
Example 11
Now this one is a bit hard if you haven’t paid close attention to the previous examples.
You have come down with a bad case of the geebies, but fortunately your grandmother has a sure cure. She gives you an eyedropper bottle labeled:
Take 1 drop per 15 lb of body weight per dose four times a day until the geebies are gone. Contains gr 8 heebie bark per dr 100 solvent. 60 drops=1 tsp.
You weigh 128 lb, and the 4-oz bottle is half-full. You test the eyedropper and find there are actually 64 drops in a teaspoon. You are going on a three-week trip and are deeply concerned that you might run out of granny’s geebie tonic. Do you need to see her before leaving to get a refill?
Try working this one out before reading further.
First, what do you want to know? You want to know how long the bottle will last. You could figure out days/bottle or weeks/bottle and see if the bottle will last longer than 3 weeks or 21 days. So you write down “days/bottle” as the units you want in your answer.
What do you know to start off with that you might need to know? You write down the following:
You realize that if a 4-oz bottle is half-full, then there is 2 oz of tonic in it, but you could figure it out dimensionally if you wanted to:
You would then end up with “days/half-bottle” in your answer, but it’s easier to just go with 2 oz/bottle as you’re given.
What should you use as a starting factor? You pick 128 lb because it’s something you’re given and it seems lonely. You set the problem up:
Houston, we have a problem. You ended up with units reversed from what you wanted. You figured out how much of the bottle you would use in one day. What to do? You could hit the 1/x button on your calculator if it had one, or invert the answer by dividing 1 by 0.044, or start over with 128 lb on the bottom. What? Can you do that? Sure you can. You could even put 128 lb on the end and on the bottom, or put it in the middle somewhere. You decide to start over, this time picking a starting factor that already has “day” or “bottle” in the right place.
So, it looks like you’ll have enough. At some point you need to know how many drops per dose you will need to take, so you figure it out:
As a practical matter, you can’t take 8.533 drops per dose; you have to round off. At this point you realize that when you calculated 22.5 days/bottle, you were not figuring on 9 drops/dose. You decide to recalculate to see if rounding up to 9 makes a significant difference.
You note a small difference, but conclude that you have just enough geebie tonic. Concluding that you have enough, however, and having enough may not be the same thing. The story continues:
You leave on your trip and on the 19th day you run out of geebie juice. You didn’t spill any, and no one took any. You sit in a stunned stupor trying to figure out where you went wrong in your calculations.
You finally realize there might not have been 2.0 oz of tonic in the bottle to begin with. A measurement like “half a bottle” should not inspire great certainty. You wish you had measured the amount and found that the bottle contained 2.0 + 0.05 oz of tonic, but what you were given, more or less, was that you had 2 + 0.5 oz of tonic. There could be anything from 1.5 to 2.5 oz in the bottle. Recalculating using the low and high values, you find you had enough tonic to last somewhere between 16 and 26 days. If you had figured out the correct answer of 21 + 5 days the first time, you would have realized you had only slightly less than a 50/50 chance of running out, and would have gone to see Granny for a refill.
Summary
Don’t panic.
Figure out what answer unit(s) you want to end up with. This is usually easy.
Write down, in math terms, everything you know that relates to the problem. You may need to read the problem several times, rephrasing parts of it, so you can translate everything into math terms. You may need to look up a few conversion factors, but that’s inconvenient, not difficult.
Pick a starting factor. If possible pick one that already has one of the units you want in the right place. Otherwise start with something you are given that is not a conversion factor.
Plug in conversion factors that allow you to cancel out any units you don’t want until you are left with only the units you do want (your answer units).
If you can’t solve the problem, pick a different starting factor and start over.
Do the math. You may be less apt to make an error if you first multiply all the top numbers, then divide by all the bottom numbers. Now double-check your calculations. If you make a mistake it will probably be in hitting the wrong key on the calculator.
Ask yourself if the answer seems right or reasonable. If not, recheck everything.
A Step by Step Guide to Dimensional Analysis
The following summary can be used as a guide for doing DA. Some familiarity with DA is assumed. See above for an introduction to DA. While not all steps listed below will be needed to solve all problems, I have found that any problem that can be solved using DA will yield its answer if the following steps are followed. I would not suggest memorizing the sequence of steps, but rather understanding and practicing them. Understanding is more durable than memory.
1. Determine what you want to know. Read the problem and identify what you’re being asked to figure
out, e.g. “how many milligrams are in a liter of solution.”
a. Rephrase if necessary using “per.” Example: You want to know “milligrams per liter.”
b. Translate into “math terms” using appropriate abbreviations to end up with “mg/L” as your answer
unit (AU). Write this down, e.g. “AU= mg/L”
2. Determine what you already know.
a. What are you given by the problem, if anything? Example: “In one minute, you counted 45 drops.”
• Rephrase if necessary. Think: “Drip rate is 45 drops per minute.”
• Translate into math terms using abbreviations, e.g. “45 gtt/min”
— If a given is in the form mg/kg/day, rewrite as mg/kg x day (see example 8)
— If a percentage is given, e.g. 25%, rewrite as 25/100 with appropriate labels (see example 4)
b. Determine conversion factors that may be needed and write them in a form you can use, such as
“60 min/1 hour.” You will need enough to form a “bridge” to your answer unit(s). See example 1.
• Factors known from memory: You may know that 1 kg = 2.2 lb, so write down “1 kg/2.2 lb”
and/or “2.2 lb/1 kg” as conversion factors you may need.
• Factors from a conversion table: If the table says “to convert from lb to kg multiply by 2.2,” then
write down “2.2 lb/1 kg”
3. Setup the problem using only what you need to know.
a. Pick a starting factor.
• If possible, pick from what you know a factor having one of the units that’s also in your answer
unit and that’s in the right place. See example 1.
• Or pick a factor that is given, such as what the physician ordered.
• Note that the starting factor will always have at least one unit not in the desired answer unit(s) that
will need to be changed by canceling it out.
b. Pick from what you know a conversion factor that cancels out a unit in the starting factor that you
don’t want. See example 1.
c. Keep picking from what you know factors that cancel out units you don’t want until you end up with
only the units (answer units) you do want.
d. If you can’t get to what you want, try picking a different starting factor, or checking for a needed
conversion factor.
e. If an intermediate result must be rounded to a whole number, such as drops/dose which can only be
administered in whole drops, setup as a separate sub-problem, solve, then use the rounded off
answer as a new starting factor. See example 10.
4. Solve: Make sure all the units other than the answer units cancel out, then do the math.
a. Simplify the numbers by cancellation. If the same number is on the top and bottom, cancel them out.
b. Multiply all the top numbers together, then divide into that number all the bottom numbers.
c. Double check to make sure you didn’t press a wrong calculator key by dividing the first top number
by the first bottom number, alternating until finished, then comparing the answer to the first one.
Miskeying is a significant source of error, so always double check.
d. Round off the calculated answer.
• Be realistic. If you round off 74.733333 to 74.73 mL that implies that all measurements were of
an extreme accuracy and that the answer is known to fall between 74.725 and 74.735, or 74.73
+ 0.005 mL. A more realistic answer would probably be 74.7 mL or 75 mL. See example 6.
• If you round to a whole number that implies a greater accuracy than is appropriate, write your
answer to indicate a range, such as 75 + 5 mL. See example 10.
e. Add labels (the answer unit) to the appropriately rounded number to get your answer. Compare
units in answer to answer units recorded from first step.
5. Take a few seconds and ask yourself if the answer you came up with makes sense. If it doesn’t,
start over.
This is a fairly bare outline. The steps are best taught, rather than read, and so would serve better as a guide to tutoring students than as a self-teaching guide.
The steps for doing dimensional analysis are:
1. Determine the starting factor and answer unit.
2. Formulate a conversion equation.
3. Solve the conversion equation.
Determining the answer unit or units is crucial; they are not always obvious and can be challenging to determine. For some problems, reading the problem correctly is the only challenge. Students need to be able to translate sometimes convoluted English descriptions of a problem into clear, properly labeled factors they can later use to solve the problem. This skill is not emphasized in the textbook. If the answer unit is always given in the examples used, then this is because the examples have been contrived to be more simple and consistent than actual problems tend to be.
In some real-world problems no starting factor is given, or several possible starting factors are given with no way to decide, initially, which to use. It is preferable, in such cases, to determine everything you know that might be relevant to solving the problem, then decide, after the answer unit is determined, which of the factors you know would make an appropriate starting factor.
All examples used throughout the text use only numbers having a single unit attached for starting factors. Apparently “1 hour” is an acceptable starting unit, but “250 mL/hour” is not. This is not correct as starting factors are often in the form of “something per something.” Indeed, some problems cannot be solved if they have a single unit starting factor (see example 3 in Appendix A).
While many conversion factors are approximations, and fraction of a percent errors are unimportant in medication math, 10 percent errors are a bit worrisome. Equating 1 grain with 60 milligrams when the actual equivalency is closer to 64.8 mg, is questionable, as is equating liters and quarts, or 1 mL to 15 minims (actually 1 mL = 16.23 minims). It is possible to solve a problem and come up with answers that differ by as much as 10% depending on which approximate conversion factors you decide to use. If + 5% errors are acceptable, then, as an aside, any answer to a test question that is within 5% of the correct answer should be counted as correct. It is oddly inconsistent to insist on carrying out calculations to two decimals, rounding to the nearest tenth, when far greater errors can be introduced by using loose approximations.
When, in chapter 6, a problem involving amount/body weigh/day comes up, the solution is presented in an unorthodox way. The problem (p. 49) gives 25 mg/kg/24 hr. When doing dimensional analysis it is essential that all the units given should be used and accounted for. Ignoring a given unit, then pulling it out of thin air at the end is poor technique, yet this is what the textbook does. The solution is given as:
The problem is that the correct answer units should be how many mL should be administered per day, or “mL/day.” Omitting the “per day” part doesn’t alter the fact that that is what you want to know—not per hour, not per dose, but per day. There is actually a simple rule that applies here. For example, when acceleration is measured in feet per second per second, it is not written as ft/sec/sec, but as ft/sec 2 because ft/sec/sec is equal to ft/sec x sec. So if you’re given mg/kg/day, the preferred way to deal with such a “triple decker” is to rewrite it as mg/kg x day. In this form it can be used, all undesired units cancel, and you end up with the desired answer with the right units attached:
If the problem called for “mL/dose” given 4 doses per day, then the solution is straightforward:
If “day” were omitted, however, this problem would become more difficult to solve. The textbook method is to calculate “mL,” then divide by 4 to get “mL/dose.” Students must remember to perform this final “critically important” step which would not exist if better technique were used. As the text acknowledges, “it is easy to forget to divide the total daily dose into the prescribed number of doses, thus greatly increasing the risk of administering an overdosage (sic).”
Problems of this sort are common, and it is unfortunate that the authors neglect to show students how to logically deal with them. The risk of confusing some students by introducing a new rule can hardly be worth the risk of error introduced by teaching a flawed technique.
In Chapter 10, page 184, an example is shown, as a model for students to follow, to determine how many mcg/min must be administered to a 215 lb patient at 3 mcg/kg/min:
In this example, at least, minutes are not omitted then added at the end, and the technique is not even erroneous, but merely confusing to many students and visually awkward. A student might try to logically extend this technique to determine mL/hr:
The student who notices that the answer doesn’t make sense might wonder what went wrong. Would they realize that when “mcg” was cancelled that “3 1/min” was left requiring the use of 60 min/1 hr instead of 1 hr/60 min? Trying to explain how to work around the poor technique employed by this example only digs a deeper hole. The better response to student confusion would be to have them put a big X mark over this section of the textbook and show them a sensible way to set it up:
Another case of flawed technique arises in Chapter 10. Students are given problems that require converting from mL/hr to gtt/min, and are shown conversion equations like the following:
The problem, again, is that the correct answer unit is “gtt/min” and not “gtt” as it appears. The correct answer is just pulled out of nowhere and declared to be “33 gtt/min.” The initial starting factor of “1 min” is spurious. It is not a given, and it means absolutely nothing to say that you know “1 min” or “1 hour” or “1 cabbage.” If such meaningless starting factors are simply omitted from such examples, the problems are perfectly setup to yield the correct answers with the correct answer units. It seems that the pseudo-starting factor is used to avoid having a starting factor with more than one unit attached. As mentioned, however, there is no such requirement when doing dimension analysis. In the above example “90 mL/1 hr” would make a logical and perfectly good starting factor.
Students should be told to just ignore the nonsensical “1 min” and “1 hour” starting factors. If you were to introduce “1 hour” as a starting factor in example 3 in Appendix A, you would be committing mathematical suicide as the problem would be rendered unsolvable once “hour” is cancelled out.
Here’s an actual example from chapter 10:
Calculation of IV Flow Rate When Total Infusion Time is Specified
Order: 1000 mL of D5W (5% Dextrose in water) IV to infuse over a period of 5 hr
Drop Factor: 10 gtt/mL
Starting Factor Answer Unit
1 min gtt (drops)
Equivalents: 1000 mL = 5 hr, 10 gtt = 1 mL, 60 min = 1 hr
Conversion Equation:
1 min x 1 hr x 1000 mL x 10 gtt = 33.3 = 33 gtt
60 min 5 hr 1 mL
Flow Rate: 33 gtt/min
For review, let’s go over this problem.
1. There are two errors relating to the starting factor. One is procedural—there is no logical way to pick a starting factor as the first step. The other is that “1 min” is a meaningless factor. I can meaningfully say that I know there are 10 drops per mL, but it means nothing to say that I know “1 min” in the context of this problem.
2. The answer unit is wrong. I want to know a rate of flow in drops per some unit of time. Just “gtt” doesn’t cut it.
3. Factors are expressed as equalities. It should read “something per something” and not “something equals something” which leads to absurd statements like “25 mg = 1 kg”
4. By introducing a spurious starting factor the setup is in error, as is the resultant answer. The number is correct, but the answer unit is not.
5. The final statement, that the flow rate is 33 gtt/min, is the only part of the example that is correct, but it is logically disconnected from everything that precedes it.
So, let’s see, the text manages to state an incorrect answer unit, then introduces a spurious starting factor, which makes the setup wrong, which yields 33 gtt for an answer, which is also wrong. But through some sort of mental slight-of-mind, they finally come up with the correct answer, which they simply declare to be 33 gtt/min.
Is there a better way to do this problem? First ask, what do I want to know? The flow rate in gtt/min, which is my answer unit, not just gtt (drops). What do I know? I’m given that there are 10 gtt/mL and that the infusion rate is 1000 mL/5 hr. Since I want gtt on top and 10 gtt/mL has gtt in the right place, 10 gtt/mL makes a perfectly good starting factor—I just need to get from mL to min. My set up then:
10 gtt x 1000 mL x 1 hr = 33 gtt
1 mL 5 hr 60 min min
Just omitting the “1 min” from the textbook’s setup would also work.
As to what the authors might be thinking, the only clue to their reasoning was given in the following paragraph that preceded this example:
“In calculating the flow rate for drops per minute , one minute becomes the labeled value that must be converted to an equivalent value: number of drops. One minute , therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship.”
On page 9 is the following table:
Table 1-2 Conversion Equation
This table reveals how the authors think about dimensional analysis. They see the starting factor as something given; there can be only one starting factor; it has only one unit associated with it, and it forms a special “equivalent relationship” with the answer unit, which, being equivalent, must also have only a single unit associated with it. In between are conversion factors that are fundamentally different from the starting factor.
All of these assumptions are incorrect as generalizations about dimensional analysis. The only equivalent relationship is between what is on the left side of the equal sign and what is on the right side. One could speak of an equivalent relationship between the “numerator” and “denominator” of a conversion factor (2.2 lb/1 kg means 2.2 lb = 1 kg), but otherwise there is no necessary “equivalent relationship” implied.
There is a particular type of DA problem, the simple conversion problem, that does involve going from one unit of measure to another equivalent measure (such as converting from feet to meters). In this subtype of problem you have only one logical starting factor, which can be said to be equivalent to your answer (10 inches x 2.54 cm/1 inch = 25.4 cm), but such problems should not be taken as a model for all DA problems, which appears to be what has happened.
By the Commutative Law of Multiplication, it doesn’t matter what order the factors on the left side are multiplied in. Therefore any factor could be first, and thus be the starting factor, although usually only one or two factors qualify to be thought of as logical starting factors. Both starting factors and answer units are often in the form of something per something. You could start with miles/hour and end up with seconds in your answer, for example, without any equivalence between starting factor and answer unit.
It appears that such fundamental misunderstandings underlie the errors in the textbook. Problems that do not conform to their notions are tortured into compliance by introducing spurious starting factors and using obviously incorrect answer units. I don’t think it is going too far to suggest that the poor technique exhibited by the textbook makes it difficult for students to master med-math. Indeed, those who do must do so in spite of the textbook and not because of it.
Recommended Corrections to:
Clinical Calculations: A unified approach (4th ed.)
A Google search shows that only this textbook and a few nursing sites associate “label factor” with dimensional analysis (DA). Likewise “unit conversion” is not a synonym for DA. The only synonym commonly used is “factor-label method.” While this point is nit-picky, I would expect the authors to use the same terminology as everyone else by the 4th edition.
At the bottom, “Step I: Determining the Starting Factor and Answer Unit,” should read, “Step I: Determining the Answer Unit.” Determining the starting factor should come after Step II, since the starting factor is not always given, there can be more than one possible starting factor, and the best starting factor to use may be one of the factors determined in Step II. Picking a starting factor from what you are given or know is the first step of Step III—setting up/solving the conversion equation.
In the box is the statement: “When the conversion equation is solved, it will be seen that the starting factor and the labeled answer have formed an equivalent relationship.” The belief that this is true leads to serious error and confusion in Chapter 10. If true, the collorilary would be that if the starting factor has one unit of measure associated with it, then the answer unit can have only one unit of measure associated with it and vice versa .
Emphasize that several of the equivalents in the table are fairly rough approximations. Give the actual equivalents—some students will want to know. Also, if the value of an equivalent can be 5% off, then, to be consistent, any test answer that is within + 5% of the correct value should be counted correct. In some (unlikely) cases answers could be as much as 10% off when several approximate equivalents are used to compound the error.
In the example at the bottom of the page you are given 25 mg/kg/24-hr (or day). The third unit given should not be dropped. There is a way to deal with problems of this type (25 mg/kg/day = 25 mg/kg-day) that can be consistently applied to all problems of this type. Triple unit factors are common and the difficulty they pose should be dealt with head on. All the various ad hoc attempts to get around these problems result in endless trouble in the long run. In this example the answer unit is given as “mL,” whereas the correct answer unit is “mL/day.” The problem should be setup as:
Whatever initial difficulty this technique may present for students not already familiar with it, it is still the technique of choice and will save a lot of grief later on. Some of the techniques contrived to deal with these problems work on some problems, but not others. The technique used above has the virtue of working with all problems involving triple unit factors.
In the two examples on this page the Answer Unit is incorrectly given as “cap” whereas “cap/dose” is what is really desired. In the first example, you are given 50 mg/kg/day and 4 doses/day, but not knowing what to do with “mg/kg/day” the problem is broken into two problems. The “day” is initially ignored, then brought back in the second part of the problem, thus paving the way for confusion and error. The logically consistent one-step setup would be:
For the second example the setup should be:
In the box at the bottom on the page are several warnings (“critically important,” “easy to forget”) that do not apply when the problems are done in a single step.
Avoid the two-step technique, and ignore the two examples at the bottom of the page. Work out as above.
Cross out the second paragraph: “In calculating the flow rate for drops per minute , one minute becomes the labeled value that must be converted to an equivalent value: number of drops. One minute , therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship.”
Ignore examples. Omit the spurious “1 min” Starting Factors. Note that Answer Units are also wrong (should be “gtt/min,” not just “gtt”). All that needs to be done is to cross out the “1 min” at the beginning of each example and add “/min” to “gtt” (to get the correct answer unit).
Another ad hoc variation in technique is introduced without comment in step 1 of the first example. Students will get into trouble if they try to extend this example to other problems. Also, what if the desired answer units were “mcg/hr?” Would students have trouble canceling out “min” with “min” apparently on top? Putting “mcg/min” on top invites confusion. A better setup for step 1 would be:
For step 2:
For steps 3 and 4, just omit the “1 min.” and “1 gtt”
Cross out the meaningless Starting Factors in examples 1, 3, 4, 5, and 6. In example 2, change “mcg/min” over “kg” to “mcg” over “kg x min.”
In Example a., the setup is in error due to a failure to fully label units. The 10 mL is “10 mL water.” You have to ask, “10 mL of what?” Your answer unit is “mL Chloromycetin sol” and not just “mL.” You can’t use “mL water” and end up with “mL Chlor. sol.” When you add 10 mL water to reconstitute you will end up with somewhat more than 10 mL Chlor. solution. Since you want “mL Chlor. sol” in your answer, pick a factor that has “mL Chlor. sol” in it and in the right place. You are given “100 mg/mL” which should be more completely written as “100 mg Chlor./mL Chlor. sol” and “10 mL/g” should be “10 mL water/1 g Chlor.” which is quite an unnecessary bit of information for solving this problem, though the text incorrectly uses it (and by luck gets away with it). The correct setup should be:
Omit spurious Starting Factors from example.
The first example asks, “How many mL should the child receive per dose?” The answer unit, therefore, should be “mL/dose” and not “mL.” You are given 15 mcg/kg/dose, so solve as shown above for examples on pages 49 and 50—likewise with the second example on page 221.
Page 225: Again, example gives 50,000 U/kg/day and 4 doses/day, so a one-step setup would be:
That’s about it. The other 96% of the text is okay.
Textbook Guide to Dimensional Analysis
(as compiled from various pages throughout the textbook)
Determine the starting factor* and answer unit.
Initially, it is essential to determine exactly what information is sought: the known quantity called the starting factor , and the desired unit to which the starting factor will be converted, the answer unit.
When the conversion equation is solved, it will be seen that the starting factor and the labeled answer have formed an equivalent relationship.
In calculating the flow rate for drops per minute (or mL per hour) one minute (or one hour) becomes the labeled value that must be converted to an equivalent value: number of drops (or mL). One minute , therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship.
Formulate a conversion equation consisting of a sequence of labeled factors, in which successive units can be cancelled until the desired answer unit is reached.
If a given is in the form mg/kg/day, ignore the third unit, do the conversion, then remember to factor the omitted unit back in. If in the form mcg/kg/min, change to mcg/min over kg if mcg/min is the answer unit.
If a percentage is given, e.g. 25%, rewrite as 25/100 with appropriate labels.
Determine conversion factors that may be needed. You will need enough to form a “bridge” to your answer unit(s).
Use only conversion factors that have a 1:1 relationship
It is desirable that conversion factors be arranged in a sequence so that identical units are placed diagonally.
In setting up the conversion factors, it is helpful to write the denominator first, as this contains the unit of the preceding numerator and facilitates cancellation of successive units.
Solve the conversion equation by use of cancellation and simple arithmetic.
Cancel units first
Reduce numbers to lowest terms.
Multiply/divide to solve the equation.
Reduce answer to lowest terms, convert to decimal, and/or round off.
Take a few seconds and ask yourself if the answer you came up with makes sense. If it doesn’t, start over.
* The text in red represents weak or erroneous technique. Errors of omission are not indicated.
Conclusions
This may be a case of a book being the worst textbook on dimensional analysis available—with the exception of all the others. I’ve heard that it is much better than its predecessor. Several medication math textbook titles are currently available, but not having reviewed them, I can’t assume any do a better job, but I think other titles should be looked into.
There are errors of omission where students are not given a complete enough understanding of dimensional analysis to do all problems that could crop up. There are errors of commission where students are taught flawed or even erroneous technique. Throughout the textbook, overly simplified examples are used that fail to show the range of problems that students may encounter. A wider range of problems, however, would have illustrated the shortcomings of the techniques as taught, and may have been omitted for that reason.
Overall, however, I would say that this book is quite useable provided its shortcomings and flaws are amended. A better rounded, more robust presentation of dimensional analysis is definitely needed. Students should not only do well solving test problems, but come away feeling confident in their ability to handle any problems that may come their way in the future.
DRUG DOSE CALCULATIONS
FINDING THE ORDERED DOSE
The ordered dose is the most simple dosage calculation for the prehospital care provider. In this type of problem, the paramedic is given an order to administer to a patient.
There are five (5) components to locate in this type of problem: the desired dose, the concentration of the drug, volume on hand, is a weight conversioeeded, and what unit to administer. Let’s take a look at each of the five components and what each means.
1. THE DESIRED DOSE
The desired dose is an order from the doctor and includes the amount of the medication and should also include the route of administration. The route of administration may be subcutaneous, intramuscular, intravenous (IV), endotracheal, sublingual, intraosseous, transdermal, oral, and rectal. Orders can be verbal or written as a standing orders in your protocol. The desired dose in the example that follows is known as a basic doctor’s order. ? (2.5 mg of medication)
2 CONCENTRATION
The second item to identify is the concentration. The paramedic is given the concentration of a vial, an ampule, a prefilled syringe, or a tablet. Concentration can be listed as common fractions, percentages solutions, or by mass (e.g., grams and milligrams). Example: 10 mg/ml
3. VOLUME ON HAND
The volume on hand refers to the amount of liquid that the drug is in. In the example: 10 mg/ml, there is a 10 mg concentration of drug in 1 ml of liquid.
Look at the Doctor’s basic order. Is it directly tied to the patient’s weight?
Example: Give 5 mg/kg of drug X, Patient weights
5. UNIT TO ADMINISTER
It is essential to look at the doctor’s order and identify the unit of measurement that will be administered to the patient. Some texts refer to the unit to administer as “what you are looking for.” Example: How many ml will you administer?
Desired Dose:
Concentration:
Volume on Hand:
Lb to Kg:
Looking for:
EXAMPLE PROBLEM
1. Doctor orders 2.5 mg of morphine to be administered IV to a patient with substernal chest pain. You have 1 ml vial that contains 10mg of morphine (10 mg/ml). How many milliliters are you going to have to draw up into a syringe and push IV into your patient’s IV line port?
NOTE: Some problems may not ask, “How many milliliters?” You will have to deduce “milliliters” from the context of the problem.
The KEY to solving dosage calculation problems consistently and accurately, you must be ORGANIZED. Developing the habit of organization early will make drug dosage problems much-MUCH easier. So, before starting any calculations, organize all of the key components to the problem.
Desired Dose: 2.5 mg of morphine IV
Concentration: 10 mg
Volume on Hand: 1 ml
Lb to Kg: None
Looking for: ml to be given
Now that you have identified the components of the doctor’s order, you caow fill-in the formula and solve the problem. There are several books and methods used to calculate drug dosages and this is what confuses most Paramedic Student, (Multiple Methods). For the purpose of this class, we will be using the Formula Method.
TOP
Cancel any like units (g, mg) and/or (zeros): BOTTOM
Formula #1
Desired Dose X Volume on Hand = ___ml to be given
Concentration
2.5 mg X 1 ml = 2.5 ml or ( 2.5 ÷ 10 ) = 0.25 ml to be given
10 mg 10
FINDING THE UNITS PER KILOGRAM
Finding the units per kilogram adds a new dimension to the previous problem. Instead of the basic order, the doctor will order a certaiumber of units (e.g., gram, milligrams, micrograms) of the drug to be administered based on the patients weight, almost always given in kilograms. This is referred to as an order based on patient’s weight. Look at the following example.
The Doctor orders 5 mg/kg of Bretylium IV to be administered to your patient. You have premixed syringes with 500 mg/10ml. Your patient weights
Look at the Doctor’s order again. It is directly tied to the patient’s weight
(5 mg/kg). Put another way, the order is saying, “For every kilogram of patient, give 5 mg of Bretylium.”
First Things First!!! Convert lb to kg and then apply kg to the basic order to obtain the Desired Dose. Now, organize the other key components in the order.
Desired Dose: 400 mg (
Concentration: 500 mg
Volume on Hand: 10 ml
Lbs to Kg: (Yes) 176lb =
Looking for: ml to be given
**USE THE SAME FORMULA AS BEFORE**
TOP
Cancel any like units (g, mg) and/or (zeros): BOTTOM
Formula #1
Desired Dose X Volume on Hand = ___ml to be given
Concentration
400 mg X 10 ml = 40 ml = 8 ml to be given
500 mg 5
CALCULATE AN IV DRIP INFUSION
In many cases, patients require medication to be infused on a continual base. Paramedics will receive orders to administer a certaiumber of units (usually milligrams or micrograms) of a medication per minute to a patient through an IV. Known as an infusion, it is also referred to as an IV drip because it involves calculating the number of drops that “drip” and are delivered intravenously each minute to deliver the amount of drug the doctor is ordering. Even though most of these IV infusions are commercially available already premixed, paramedics will be tested on mixing the medication and starting the infusion correctly without the medication being premixed.
Formula #2 The Doctor orders 2 mg/min of Lidocaine to be infused to a patient who is experiencing an arrhythmia. Your ambulance carries only 250 ml bags of D5W. You have a 60 gtt/mL microdrip setup. How many drops per minute will you adjust your administration set to drip?
Before starting any drug calculation, organize the key information just as you’ve been doing, but, there will be a couple of new categories in this formula and set up a little differently.
Desired Dose: 2 mg Lidocaine IV
Concentration:
IV Bag in ml: 250 ml D5W
Lbs to Kg: None
Admin. Setup: 60 gtt/ml
Looking for: gtt/min
IV bag volume (ml) Desired Dose Admin. Setup (gtt)
———————- X ————— X ———————- = gtt/min
Concentration of Drug 1 min 1ml
250 ml 2 mg 60 gtt
——- X ——– X ———- = gtt/min
Note: Convert the grams you mixed in the bag to match the milligrams in the Doctor’s order:
250 ml 2 mg 60 gtt 25 2 6 gtt
——- X ——– X ———- = —- X —- X —- = 300 ÷ 10 = 30 gtt/min
1000 mg 1 min 1 ml 10 1 min 1
MILLILITERS PER HOUR for IV Fluids
Often, doctor’s order or protocols state that you are to run an IV in milliliters per hour of over a specific period of time. To set an IV’s administration set, the mL must be converted to drops per minute. This section shows how to convert that type of order. This may sound confusing but a simple conversion formula is all that is needed.
EXAMPLE PROBLEM
The Doctor orders you to start an IV of normal saline to run at 100 ml/hr. You have a macrodrip set of 15 gtt/ml. How many drops per minute will you set your administration set to drip?
Formula #3:
volume to be infused drip rate
X = gtt/min
infusion time in minute 1ml
100 ml X 15 gtt =____ gtt/min 100 ml X 15 gtt =____ gtt/min
1 hr 1 ml 60 min 1 ml
10 X 15 gtt = 150 gtt = 150 ÷ 6 = 25 gtt/min
Formula #1 Used for calculating IV push medications, (draw up into syringe)
Desired Dose X Volume on Hand = ___ml to be given
Concentration
Organize The Info: Desired Dose:
Concentration:
Volume on Hand:
Lb to Kg:
Looking for:
__________________________________________________________________
Formula #2 Used for calculating infusions/piggyback type drips
IV Bag Volume (mL) X Desired Dose X IV Drip Set (gtt) = ____ gtt/min
Concentration of Drug Time in (min) 1 ML
Organize The Info: Desired Dose:
Concentration:
IV Bag in ml:
Lbs to Kg:
IV Drip Setup:
Looking for:
__________________________________________________________________
Formula #3 Used for simple IV fluid flow rates, (no medications involved)
Volume to be infused X IV Drip Set (gtt) = ____ gtt/min
Time in (min) 1ml
STUDENTS MUST BE ABLE TO PERFORM FOLLOWING PRACTICAL SKILLS:
PHYSICAL ASSESSMENT
1. Taking a temperature
2. Taking a pulse
3. Counting respirations
4. Taking blood pressure
MEDICATION ADMINISTRATION
5. Administering oral, sublingual, and buccal medications
6. Administering eye and ear medications
7. Administering skin/topical medications
8. Administering nasal medications
9. Administering rectal medications
10. Administering vaginal medications
11. Administering nebulized medications
12. Administering an intradermal injection
13. Administering a subcutaneous injection
14. Administering an intramuscular injection
15. Administering medication via z-track injection
16. Withdrawing medication from a vial
17. Withdrawing medication from an ampoule
18. Mixing medications from two vials into one syringe
19. Preparing an IV solution
20. Adding medications to an iv solution
21. Administering medications via secondary administration sets (piggyback)
22. Administering medications via iv bolus or iv push
23. Managing controlled substances
PROCEDURE CHECKLISTS
Assessing Body Temperature
PROCEDURE STEPS
1. Selects appropriate site and thermometer type.
2. “Zeroes” or shakes down glass thermometer as needed.
3. Inserts thermometer in sheath or uses thermometer designated only for the patient.
4. Inserts in chosen route/site.
a. Oral: Places thermometer tip under the tongue in the posterior sublingual pocket (right or left of frenulum). Asks patient to keep lips closed.
b. Rectal: Lubricates thermometer; uses rectal thermometer; inserts 1 to
c. Axillary: Dries axilla; Places thermometer tip in the middle of the axilla; lowers patient’s arm.
Tympanic membrane:
Positions the patient’s head to one side and straighten the ear canal.
1) For an adult, pulls the pinna up and back.
2) For a child, pull the pinna down and back
5. Leaves glass thermometer recommended time (oral 3–5 min, rectal 2 min, axillary 6–8 min).
6. Holds rectal thermometer securely in places; does not leave patient unattended.
7. Leaves electronic thermometer until it beeps.
8. Reads temperature. Holds glass thermometer at eye level to read.
9. Shakes down (as needed) and cleans or stores thermometer.
ASSESSING PERIPHERAL PULSES
PROCEDURE STEPS
NOTE: You can use this checklist to evaluate one peripheral pulse, or to evaluate the student’s ability to locate all the peripheral pulses.
Used sites:
ü radial,
ü brachial,
ü carotid,
ü temporal,
ü popliteal,
ü femoral,
ü posterior tibial,
ü dorsalis pedis
1. Selects, correctly locates, and palpates site.
2. Uses fingers (not thumb) to palpate.
3. Counts for 30 sec. if regular; 60 sec. if irregular.
4. Notes rate, rhythm, and quality.
5. Compares bilaterally.
6. Carotid pulse: Palpates only on one side at a time.
7. Correctly locates the following sites:
a. radial
b. brachial
c. carotid
d. temporal
e. popliteal
f. femoral
g. posterior tibial
h. dorsalis pedis
ASSESSING RESPIRATIONS
PROCEDURE STEPS
1. Flexes patient’s arm and places patient’s forearm across chest, or otherwise counts unobtrusively.
2. Counts for 30 seconds if respirations regular; 60 seconds if irregular.
3. Observes rate, rhythm, and depth.
ASSESSING THE APICAL PULSE
PROCEDURE STEPS
1. Selects, correctly locates, and palpates apical site (5th intercostal space at the midclavicular line).
2. Uses diaphragm of stethoscope.
3. Counts for 60 seconds.
4. Notes rate, rhythm, and quality.
5. Identifies S1 and S2 heart sounds.
MEASURING BLOOD PRESSURE
PROCEDURE STEPS
1. If possible, positions patient sitting, feet on floor, legs uncrossed; alternatively, lying down.
2. Measures BP after patient has been inactive for 5 min.
3. Exposes arm (does not auscultate through clothing).
4. Supports patient’s arm at the level of the heart.
5. Uses appropriately sized cuff. (The width of the bladder of a properly fitting cuff will cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child. Alternatively, the length of the bladder encircles 80% to 100% of the arm in adults.)
6. Positions cuff correctly; wraps snugly.
7. Palpates radial artery, closes sphygmomanometer valve, and inflates cuff to determine mm Hg at which radial artery cao longer be felt.
8. Places stethoscope on brachial artery and continues to inflate cuff rapidly to
9. Ensures that stethoscope tubing is not touching anything.
10. Releases pressure at 2–3 mm Hg/second.
11. Reads mercury manometer at eye level
12. Records at least systolic/diastolic (first and last sounds heard—e.g., 110/80). Records level of muffling, if possible.
13. If necessary to remeasure, waits at least 2 minutes.
ADMINISTERING ORAL MEDICATIONS
PROCEDURE STEPS
1. *Wash hands.
2. Gather equipment: medication administration sheet (MAR), client’s container of medications, calculator, and medication cups.
3. *While noting for any allergies remove ordered medication from supply while comparing the label on the medication with the ordered medication on the MAR.
4. *Prepare medication using the five rights of medication administration: right medication, right client, right dose, right time and right route.
5. Place packaged medication in the cups without unwrapping. Place tablets from a multidose bottle into bottle cap and then transfer into cup. Pour liquid medications by holding label against palm of hand, remove cap and place countertop inside up and fill medicine cup until bottom of meniscus is at desired level. Dispose of any excess liquid into sink.
6. Take medication and MAR to client’s room.
7. * Compare name on MAR with name on client’s identification bracelet. Use one other identifier found both on bracelet and MAR such as medical record number or date of birth.
8. Complete any pre-administration assessment such as blood pressure or pulse.
9. *Using the five rights recheck each medication with the MAR while unwrapping the unit-dose medications.
10. Allow client to sitting position and provide with a glass of water to assess swallowing ability.
11. Explain the purpose of the medications and assist client as needed in taking tablets from cup. Stay with client until all of medication is swallowed.
12. *Dispose of soiled supplies and wash hands.
INTRAMUSCULAR INJECTION
PROCEDURE STEPS
1. Gather supplies: MAR, alcohol swabs, vial or ampule of medication, clean gloves and 3 ml syringe, #20 to #22 gauge 1″ to 1 1/2» inch needle.
2. *Calculate the correct amount of medication to administer.
3. *Wash hands.
4. *Using five rights of medications check against MAR and note any allergies.
4. Withdraw correct medication from vial or ampule and recap using one-handed method. Use filter needle to withdraw medication from an ampule, replace with injectioeedle after drawing up medication.
5. Label syringe with the name of the drug using tape or preprinted medication labels.
6. *Identify client using two identifiers found on MAR and ID bracelet. Recheck medication against MAR.
7. Explain procedure and reason for medication to client.
SC INJECTION
PROCEDURE STEPS
1. Gather supplies: MAR (medication administration record), alcohol wipes, clean gloves, 1-3ml syringe, 3/8 – 5/8 inch and 25-27 guage needle, and medication to be administered.
2. *Wash hands.
3. *Calculate the correct amount of drug to be administered.
4. *Using the five rights and three checks prepare the correct dose of medication to be administered.
5. *identify client using two identifiers. Explain procedure and provide for privacy.
6. Apply clean gloves and select an injection site.
7. Cleanse site with alcohol swab in circular motion starting from center outward. Allow to dry.
8. Remove needle guard and hold syringe in dominant hand. Use nondominant hand to pinch subcutaneous tissue to be injected.
9. While holding syringe between thumb and forefinger inject in a dart like fashion at a 45-90 degree angle.
10. Release bunched skin and use nondominant hand to stabilize syringe while using dominant hand to aspirate gently on plunger. If blood appears in syringe withdraw needle and prepare new injection.
Do not aspirate when injecting anticoagulants, (Ex: heparin, lovenox),or insulin.
11. Slowly inject medication and remove needle while applying pressure over site with alcohol swab.
12. Gently massage site with alcohol swab.
Do not massage site when injecting anticoagulants as this may cause bleeding at the injection site. It is appropriate to massage following insulin injections.
13. Do not recap needle. Dispose of needle and syringe in sharps container.
14. *Wash hands.
15. Using the sixth right of medication administration document medication administration on MAR according to agency policy.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATIONS: EYE OINTMENT
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the assigned medication(s).
4. Check that the label on the medication container corresponds with the medication listed on the medication sheet three times:
5. when taken from the individual’s supply;
6. when placed on medication tray or table, etc.;
7. when instilled in the individual’s eye.
8. Check for expiration date to be sure the medication is current.
9. Identify the individual prior to administration of the medication.
10. Explain the procedure to the individual.
11. Have the individual sit or lie down.
12. Put on gloves.
13. Observe the affected eye(s) for any unusual condition which should be reported to the clinic or the nurse prior to the medication application.
14. Position individual with head back and looking upward.
15. Retract the lower lid of the eye to be medicated.
16. Approach eye from below, outside the individual’s field of vision, using due care to avoid contact with the eye.
17. Apply prescribed ointment in a thin layer along inside lower lid.
18. Hold lid open a few seconds.
19. Close eyes gently. Ask individual to keep eyes closed for a few minutes. Wipe excess medication with a clean wipe.
20. Dispose of gloves.
21. Position individual comfortably.
22. Check label on the container when returning to the individual’s supply.
23. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
24. Wash hands.
25. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATION: EYE DROPS
1. Wash hands.
2. Assemble equipment.
3. State purpose for use, side effects and warnings of prescribed medication.
4. Check that the label on the medication container corresponds with the medication listed on the medication sheet 3 times:
a. When taken from the individual’s supply.
b. When placed on the medication tray or table, etc.
c. Prior to instilling in the individual’s eye.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Put on gloves.
9. Cleanse eye with a clean wipe, wiping from inner corner outward once. When drops are instilled into both eyes, cleanse each eye with a clean wipe.
10. Have individual sit or lie down.
11. Observe affected eye(s) for any unusual condition which should be reported to the clinic or the nurse prior to administration.
12. Draw up the correct ordered amount of medication into dropper (if applicable).
13. Position individual with head back and looking upward.
14. a. Separate lids of the affected eye by raising upper lid with forefinger and lower lid with thumb. Approach eye with dropper or bottle from below the eye, outside the individual’s field of vision. Avoid contact with the eye. OR
b. Gently draw lower lid down with forefinger; steady hand on forehead, and hold dropper or bottle, avoiding contact with eye.
15. Apply drop(s) gently near center of lower lid not allowing drop(s) to fall more than one inch before striking eye.
16. Close eyes gently. Ask individual to close their eyes for a few minutes.
17. Wipe excess medication with a clean wipe using a separate clean wipe for each eye.
18. Remove gloves.
19. Position individual comfortably.
20. Wash hands.
21. Check the label when returning the medication to the individual’s supply.
22. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
23. Observe individual for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATIONS: EAR DROPS
1. Wash hands.
2. Assemble equipment.
3. State the purpose, side effects, and warnings of prescribed medication.
4. Remove the medication from the individual’s supply checking that the label on the container corresponds with the medication listed on the medication sheet.
5. Place the medication on the medication tray, table, etc. Include a dropper, if one is required.
6. Identify individual prior to administration of medication.
7. Explain procedure to the individual.
8. Put on gloves.
9. Position the individual: a. if lying in bed, have individual turn head to opposite side; b. if sitting in a chair, tilt head sideways until ear is as horizontal as possible.
10. Clean entry to ear canal with clean cotton ball.
11. Observe affected ear for any unusual condition prior to ear drop instillation which should be reported to the clinic or the nurse.
12. Draw up the medication ordered into the dropper, (if applicable) checking that the label on the medication container corresponds with the medication sheet.
13. Administer the ear drops by gently pulling the ear backward and upward and instilling the number of drops ordered into the ear canal. Do not contaminate the dropper by touching any part of the ear canal.
14. If individual desires a cotton ball, place a clean cotton ball loosely in the ear.
15. Instruct individual to maintain the required position for 2-3 minutes.
16. If drops are ordered for both ears, wait at least 5 minutes before putting drops in second ear; repeat same procedure.
17. Remove gloves.
18. Leave individual comfortably positioned.
19. Return medication to individual’s supply checking that the label on the medication container corresponds with the medication sheet.
20. Wash hands.
21. Clean and replace equipment.
22. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
23. Observe individual for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF TOPICAL MEDICATIONS: SKIN MEDICATIONS
1. Wash hands.
2. Assemble necessary equipment.
3. State purpose for use, side effects, and warnings of prescribed medications.
4. Remove the medication from the individual’s supply, checking that the label on the medication container corresponds with the medication sheet.
5. Check for expiration date to be sure the medication is current.
6. Identify the individual prior to administration of medication by verifying his/her name.
7. Explain procedure to the individual.
8. Position the individual as necessary.
9. Put on gloves.
10. Observe any unusual conditions of the affected area of the body prior to medication administration which should be reported to the clinic or the nurse.
11. Cleanse affected area as indicated.
12. Check that the label on the medication container corresponds with the medication listed on the medication sheet.
13. Administer the correct medication according to prescribed directions.
14. Leave individual in a comfortable position.
15. Remove gloves.
16. Wash hands.
17. Check that the label on the medication container corresponds with the medication listed on the medication sheet and return medication to the individual’s supply.
18. Clean and replace (or discard) equipment.
19. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
20. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF RECTAL MEDICATIONS
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the assigned medication(s).
4. Check the label on the medication container to see that it corresponds with the medicine listed on the medication sheet three times.
a. When taken from the individual’s supply.
b. When removed from the container.
c. When returning the remaining suppositories to the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Follow directions as to whether medication should be chilled before using.
7. Identify individual prior to administration of the medication by verifying his/her name.
8. Explain procedure to the individual.
9. Provide privacy, as necessary.
10. Position individual on side with top leg flexed.
11. Put on rubber glove or finger cot.
12. Check for correct medication and remove suppository from the wrapper.
13. Lubricate tip of suppository unless contraindicated.
14. Encourage the individual to relax by instructing to breathe through the mouth or take deep breaths.
15. Insert suppository, pointed end, along the wall of the rectum beyond the sphincter, pushing it gently with gloved finger.
16. Administer prescribed medication and dose.
17. Slowly withdraw finger, press tissue against anus until urge to expel subsides.
18. Remove and discard glove or finger cot.
19. Position individual comfortably.
20. Give individual any specific instructions.
21. Wash hands.
22. Clean and replace equipment.
23. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
24. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF NEBULIZER MEDICATION
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Identify the individual prior to administration of medication.
6. Empty vial/bottle into nebulizer cup, checking label.
7. Assemble nebulizer machine and plug into outlet.
8. Place facemask over individual’s mouth and nose or insert mouthpiece into individual’s mouth.
9. Turn oebulizer machine.
10. Instruct individual to take deep breaths for entire treatment (usually lasts approximately 10 minutes).
11. Wash parts in hot soapy water and allow to air dry.
12. Wash hands.
13. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
14. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF NASAL MEDICATION
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Position the individual in a sitting position with head tilted backward, or to the side if the medicatioeeds to reach one or the other sinuses. If the individual is unable to sit, place a rolled towel or pillow beneath the neck.
9. Remove the cap from the nasal medication and check the label.
10. Drop form: Aim the tip of the dropper toward the nasal passage and squeeze the rubber portion of the cap to administer the number of prescribed drops. Instruct the individual to breathe through the mouth as the drops are instilled.
11. For Spray form: Place the tip of the container just inside the nostril. Occlude the opposite nostril. Instruct the individual to inhale as the container is squeezed. Repeat in the opposite nostril.
12. Advise the individual to remain in position for approximately 5 minutes.
13. Recap the container and replace where medication is stored and check the label.
14. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
15. Wash hands.
16. After 5 minutes, position the individual as necessary.
17. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF INHALANT MEDICATION
1. Wash hands.
2. Assemble necessary equipment.
3. State purpose, side effects, and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Check the label and attach the stem of the canister into the hole of the mouthpiece so that the inhaler looks like an “L”.
9. Shake the canister to distribute the drug within the pressurized chamber.
10. Instruct the individual to slowly exhale through pursed lips.
11. Instruct the individual to seal lips around the mouthpiece.
12. Compress the canister between thumb and fingers and instruct the individual to inhale at the same time.
13. Release pressure on the canister, but instruct the individual to continue inhaling as much as possible.
14. Withdraw mouthpiece.
15. Instruct the individual to hold breath for a few seconds.
16. Instruct the individual to exhale slowly, through nose.
17. Recap the canister and replace where medication is stored and check the label.
18. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
19. Wash hands.
20. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF VAGINAL MEDICATION
1. Assemble equipment necessary for administration.
2. State purpose, side effects, and warnings of the prescribed medication.
3. Have individual empty bladder prior to medication application.
4. Wash hands.
5. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
6. Check for expiration date to be sure it is current.
7. Know the individual prior to administration of the medication.
8. Explain procedure to individual.
9. Provide necessary privacy.
10. Check label, put on gloves, remove suppository or tablet from wrapper, or uncap cream. Insert suppository, cream into applicator, lubricate tip, as necessary.
11. Position individual on back with knees bent and legs spread.
12. Encourage the individual to relax by instructing to breathe through the mouth or take deep breaths.
13. Separate the labia and insert the applicator into vagina as far as it will go comfortably without using force. (2-
14. Slowly push in plunger of applicator until it stops automatically, inserting the medication.
15. Carefully remove applicator from vagina, holding the barrel (outer cylinder). Discard if disposable.
16. Apply a sanitary pad, to prevent staining.
17. Wash applicator with warm, soapy water (do not boil). For easy cleaning it may be disassembled by pulling the plunger from the barrel. Rinse and dry.
18. Keep the individual on their back for at least 10 to 30 minutes.
19. Discard rubber gloves and wash hands.
20. Check the medication label when returning medication to individual’s medication tray.
21. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
PROCEDURE CHECKLIST
Mixing Medications in One Syringe, Using Two Vials
PROCEDURE STEPS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Checks compatibility of medications.
3. Before beginning, determines total volume of all medications to be put in the syringe and whether that volume is appropriate for the administration site.
4. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique).
5. Maintains sterility of needles and medication throughout the procedure.
6. Avoids contaminating a multi-dose vial with a second medication.
7. Cleanses tops of vials with alcohol prep pad (according to agency procedure).
8. Places needle cap on opened, sterile alcohol wipe.
9. Draws up same amount of air into syringe as the total medication doses for both vials (e.g., if the order is for 0.5 mL for Vial A and 1 mL for Vial B, draws up 1.5 mL of air).
10. Maintaining sterility, inserts needle or vial access cannula into vial without coring (or uses a filter needle):
a. Places the tip of the needle or vial access cannula in the middle of the rubber top of the vial with the bevel up at a 45°–60° angle.
b. While pushing the needle or vial cannula device into the rubber top, gradually brings the needle upright to a 90° angle.
11. Keeping the tip of the needle (or vial access device) above the medication, injects amount of air equal to the volume of drug to be withdrawn from the first vial (e.g., 0.5 mL for Vial A in step 9; then injects the rest of the air into the second vial.
NOTE: If one vial is a multi-dose vial, injects air into the multiple-dose vial first.
NOTE: If mixing two types of insulin, puts air into the regular insulin last. Refer to Technique 23-
12a. Without removing the needle (or access device) from the second vial, inverts the vial and withdraws the ordered amount of medication.
12b. Using correct technique expels any air bubbles and measures dose at eye level. (See Procedure Checklist Chapter 23: Preparing and Drawing Up Medications from Vials.)
12 c. Removes needle from vial and pulls back on the plunger enough to pull all medication out of the needle (or access device) into the syringe.
12d. Reads dose at eye level; holds syringe vertically to eject all air; tips syringe horizontally if any medication must be ejected.
13a. Inserts needle into first vial, inverts, and withdraws the exact ordered amount of medication, holding syringe vertical (when finished, the plunger should be at the line for the total/combined dose.
13b. Keeps index finger on the flange of the syringe to prevent it being forced back by pressure. Does not draw excess medication into the syringe.
13c. If excess medication is inadvertently drawn into syringe, recognizes error, discards the medication in the syringe, and starts over. (The “total” amount calculated initially should be in the syringe.)
14. If a filter needle or VAD was used, draws air into syringe to clear medication from needle and proceeds according to Technique 23-
15. Removes needle from vial and recaps needle, using needle capping device or approved one-handed scoop method.
16. Places a new sterile needle on the syringe to be used to give the injection.
17. Next holds syringe vertically and re-checks the dosage at eye level.
PROCEDURE CHECKLIST
Preparing and Drawing Up Medications from Ampules
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique).
3. Flicks or taps the top of the ampule to remove medication trapped in the top of the ampule. Alternatively, shakes the ampule by quickly turning and “snapping” the wrist.
4. Uses ampule snapper, or wraps 2×2 gauze pad or unwrapped alcohol wipe around neck of the ampule; using dominant hand, snaps off the top.
5. Breaks ampule top away from the body.
6. Attaches filter needle (or filter straw) to a syringe. If syringe has a needle in place, removes both the needle and the cap and places on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), then attaches filter needle.
7. Does not touch the neck of the ampule with the needle while withdrawing medication.
8. Uses one of the following techniques to withdraw medication:
a. Inverts ampule, places needle tip in liquid, and withdraws all of medication. Does not insert needle through the medication into the air at the top of the inverted ampule.
b. Alternatively, tips ampule, places needle in liquid, and withdraws all medication. Repositions ampule so that needle tip remains in the liquid.
9. Draws up exact amount of medication.
10. If necessary to eject medication after ejecting air, tips the syringe horizontal to do so.
11. Holds syringe vertically and draws 0.2 mL of air into the syringe. Measures exact medication dose (draws back plunger to the “dose + 0.2 mL” line).
12. Removes filter needle and reattaches the “saved” (or other sterile) needle for administration.
13. Ejects the 0.2 mL of air, and checks the dose again.
(If giving an irritating medication such as parenteral iron, omit this step.)
14. Disposes of top and bottom of ampule and filter needle in a sharps container.
INITIATING INTRAVENOUS FLUIDS INTO AN EXISTING IV SITE
1. *Verify order and gather equipment: IV solution, IV tubing (micro tubing if hourly rate 50ml/hr. or less), alcohol wipes, clean gloves, saline flush, 3ml syringe, blunt cannula, tape and watch with second hand.
2. *Wash hands.
3. *Correctly interpret IV math for ml/hour and gtts./min.
4. *Using three checks and the five rights to compare solution with the physician’s order on the MAR
5. Remove outer wrapper from IV bag and assess the expiration date and check for any leaks or impurities in the bag.
6. Label the bag with client’s name, solution type, date, time and your initials. Label IV tubing with date and time. Place time strip on side of bag with hourly rate.
7. Prepare the IV tubing for spiking into bag by sliding roller clamp to the top of the tubing and closing it completely.
8. Invert IV bag and remove outer cap. Remove cap off IV tubing spike and insert spike into the IV bag while keeping tips sterile.
9. Place bag on IV pole and squeeze drip chamber to fill half full.
10. Remove IV tubing cap, place adapter on IV tubing end and while holding IV tubing at waist level slowly open roller clamp to prime IV tubing until all air is removed. Recap tubing and hang on IV pole while you prepare IV flush.
11. To prepare IV flush cleanse saline vial with alcohol. Draw up 2 ml of air into 3ml syringe and inject into saline vial. Invert vial and draw up 2 ml of saline flush. Recap and label syringe.
12.*If you have prepared IV in the medication room then gather your supplies and at client’s bedside use two identifiers to validate the correct patient against the MAR.
13.Apply clean gloves. Assess site for signs of infiltration and phlebitis.
14. After cleansing IV site with alcohol slowly inject saline flush. Set syringe aside and connect IV tubing to site.
15. Open roller clamp slowly and assess patency of IV flow rate.
16. Secure IV tubing with tape. Lower bed and using second hand timer set IV to ordered rate.
17. *Wash hands and document.
ADMINISTERING IVP MEDICATIONS VIA INT/PRN ADAPTER/LOCK DEVICE
1. Gather supplies: MAR, vial or ampule of ordered medication, watch with second hand, clean gloves, alcohol swabs, saline flush, 2-3ml syringes with blunt cannulas and appropriate size syringe to withdraw medication.
2. *Check for any allergies. Calculate the correct amount of drug to be given. Wash hands.
3. *Using the five rights check medication against MAR. Complete three checks of medication, as you retrieve medication, after preparing medication and prior to medication administration.
4. Prepare a pre and post flush of saline by withdrawing 2 ml of saline in each syringe. Label syringes.
5. Prepare medication according to dosage and administration section of drug reference. Label medication.
6. *Identify client by using two identifiers found on MAR and ID bracelet. Recheck five rights.
7. *Apply clean gloves and assess IV site patency by observing for any redness or swelling at site. (Note: Some institution’s policy requires aspirating on syringe and assessing for a blood return to ensure IV patency.)
8. Cleanse INT with alcohol swab and slowly flush with normal saline solution. Assess INT patency by noting if any discomfort or resistance while flushing.
9. Remove flush, cleanse site with alcohol and connect medication syringe. Using second hand on watch administer medication at recommended rate.
10. Remove medication syringe, cleanse site with alcohol and administer post-saline flush at the same rate at which medication was administered.
11. Dispose of syringe in sharps and container and remove gloves.
12. *Wash hands and document medication administration.
