Dosage and calculations

Dosage and Calculations: Desired over Have

Safe Dose Identify the nurse’s legal responsibility of

med administration Identify the six rights of safe administration Use the nursing process to administer med

safely to clients of all ages Identify components of a med prescription Describe strategies to minimize medication

errors Identify strategies to deliver traumatic care

to pediatric clients when administering med Recognize risks for adverse med reactions

Administration

Nurse are responsible for Preparing, administering, and evaluating client responses to

meds Developing and maintaining an up to date knowledge base of

meds administered, including uses, mechanisms of action, routes of administration, safe dosage range, side/adverse/toxic responses, precautions, and contraindications

Skill competency Knowledge of acceptable practice Determining accuracy of med orders Reporting all med errors Safeguarding and storing medications

6 Rights of Administration

Right client Right med Right route Right time Right dose Right documentation

The Right Client

The right client by the Joint commission requires two client identifiers to be used when administering meds. Acceptable identifiers include the client’s name, an assigned identification number, telephone number, birth date, or other person-specific identifier

The Right Medication

The right medication should be sure this is the medication prescribed by the primary care provider

Check the med label to ensure it matches the MARverify the medication’s expiration date

Consult a med guide or pharmacist if unfamiliar with the medication prescribed

The Right Route

The right route compare the route instruction written on the med label with t he route instruction written by the primary care provider

Clarify any discrepancies with the primary care provider or supervisor

The Right Time

The right time ensure it is the correct time for administration

Check the health care facility’s guideline for acceptable med administration time variations. Acceptable practice may include safely administering meds 30 mins. before or after the prescribed time

The Right Dose

The right dose ensure the dose is what has been prescribed

Perform any necessary conversions or calculations

Check before cutting or crushing any meds. (A complete list is available at http://www.ismp.org/Tools/DoNotCrush.pdf

The Right Documentation

Do not record any medications before administration

Document on the MAR immediately after giving the medication

Indicate on the MAR any medications not given. Document in the nurse’s notes the medication omitted and the reason it was not given

Only document meds that you have given

Types of Medication Prescriptions Routine order/standard order May or may not have a termination

date Without a specified termination date,

the order will be the effect until the primary care provider discontinues it or the client is discharged

Certain meds (opioids, antibiotics) must be reordered within a specified amount of time or will automatically be discontinued

Types of Medication Prescriptions Single/one time order A single/one time order is to be given

at a specified time or as soon as possible

For example: furosemide (Lasix) 40 mg PO at 1000

Types of Medication Prescriptions PRN order A PRN order stipulates at what dosage,

what frequency, and under what conditions a medication may be give. The health care professional uses clinical judgment to determine the client's need for the med

For example: acetaminophen (Tylenol) 325 mg PO every 3 hr. PRN

Types of Medication Prescriptions Standing orders Standing orders may be written for

specific circumstances and/or for specific units

For example: the critical care unit has standing orders to treat a client with asystole

Components of a Medication Prescription Name of client Date of order Time of order Name of med Dosage Route of administration Time and frequency: exact times or

number of times per day Signature of prescribing provider

Medication Errors

Common med errors include Wrong medication or IV fluid Incorrect dose or IV rate Wrong client, route, or time Administration of known allergic

medications Omission of dose Incorrect discontinuation of meds or IV

fluids

Using the Nursing Process Using the nursing process to administer meds

safely Assessment data collection Obtain information regarding the client's condition relevant to

med administration Obtain necessary pre-administration data (heart rate, blood

pressure) Omit or delay doses as indicated by client’s condition identify

client allergies Determine if the medication prescription is complete – to

include name of client, date and time, name of medication, dosage, route of administration, time and frequency, and signature of prescribing provider

Interpret the med prescription accurately Question the provider if the prescription is unclear or seems

inappropriate for the client’s condition

Using the Nursing Process

Planning using the nursing process in medication administration:

Calculate and measure doses accurately Be sure the medication is the correct

strength For example: Heparin is available in

strengths of 10 units, 100 units, 1000 units or 10,000 units per 1 mL

Verify high alert medications with a colleague if necessary

Avoid distractions during medication preparation


Implementing: Always use the six right medication administration Only administer medications that you have

prepared Follow correct procedures for all routes of

administration Use verbal orders only for emergencies Follow agency protocol for telephone prescriptions Follow all laws and regulations when administering

controlled substances Omit or delay a dose if client questions size of dose

or appearance of medication


Evaluation: Evaluate client response to a

medication, and document and report appropriately

Recognize side/adverse effects, and document and repost appropriately

Report all errors and take corrective measures immediately

Medication Error If an error occurs: Assess the client for any signs of an adverse

reaction Notify the client’s primary care provider and the

supervisor Document the event, along with the actions taken

in response to the event to treat or prevent adverse reactions

Document the event on an incident report according to agency policy

Evaluate the cause of the error in order to prevent a reoccurrence

Tools for Safe Medication Practice The institute for safe medication for

practice is a nonprofit organization working to educate health care providers and consumers regarding safe medication practices. Tools have been developed to decrease the risk of medication errors. Go to http://www.ismp.org for a complete list

http://www.ismp.org/

Tools for Safe Administration Practice Error-Prone Abbreviation List Certain abbreviation have been

associated with a high number of medication errors

IU International Units

Medication Errors

Confused medication Name List The names of some medications look

and sound alike, which can lead to medication errors

For example: Actos confused with Actonel

Medication Errors

High-Alert Medication List Some medications, if given in error,

have a high risk for resulting in significant patient harm

For example: adrenergic agonist IV (epinephrine) – Insulin, subcutaneous/IV

Medication Errors

Tall Man Letters Tall Man Letters are recommended for

differentiating between look-alike medications names

acetoHEXADINE (Dimelor) & acetaZOLAMIDE (Acetazolam)

Medication Errors

A high number of medication errors have been associated wit the inappropriate placement of zeros

The universal guideline is to always use a leading zero before a decimal, but never a trailing one

For example this prescription reads five tenths of a milliliter .5 mL

It could easily be mistaken as 5 milliliter, or 10 times the intended dose. A leading zero is placed before the decimal point to ensure that the dose is read correctly

0.5 mL: Always use a zero before a decimal point when the dose is less than one

5.0 mL reads five milliliters it could easily be mistaken as 50 milliliters. The trailing zero should not be placed following the decimal point to ensure that the dosage is read correctly

5 mL: never use a trailing zero following a decimal point

Medication Errors Sound-alike medications be careful with: Common medication suffixes – the use of med

suffixes has the potential for causing med errors. There is no standardized nomenclature or definition. Suffixes may be confused with medical abbreviations, acronyms, dosing intervals, etc.

For example: ER, XL, and SR all indicate some type of delayed response. This response may be delayed until the medication has passed through the stomach or the medication may be delivered over a longer interval than a similar med that has immediate release

Safe and Atraumatic Care

Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminates or minimizes the psychological and physical distress experienced by children and their families in the health care system

Safe and Autraumatic Care Prevent or minimize physical stressors: Educate on environment, diagnosis, treatment Use non-threatening models (dolls) Make environments less threatening; provide ”safe

areas” Keep a neutral thermal environment Explain all noises, including alarms Close doors to room when possible to allow privacy Allow rest periods between invasive procedures Allow transitional items at bedside, such as

blankets and dolls

Safe and Autraumatic Care

Prevent or minimize child/parent separation

Ask parents about interventions that are comforting for the child if they choose to be together

Always accompany the parents to the bedside on the first visit

Allow parents to hold their child, providing accommodation for equipment such as ventilators and monitors

Safe and Autraumatic Care Promote autonomy Orient parents to the environment as well as time

limitations related to visitation Allow parents and children time to be alone

together when possible Encourage parents to take time for themselves to

eat and sleep Ask children and parents if they wish to be together

for procedures Respect their decision Use time structuring to maintain a consistent and

normal schedule


When administering medications to pediatric clients, use the same six rights of medication administration that are used for adult clients


Developmental approach for infants (birth to 1 year)

Place in a semi-reclining position for oral medication

Expect that the infant may spit or drool and be ready to collect as much of the discarded medication as possible

Use an appropriate dosing device (such as an oral syringe, a hollow spoon, or a dropper) to deliver a precise dose

Allow the parent to give the medication with a health care professional observing


Developmental approach for toddlers (1-2 years)

Allow the child to touch and become familiar with the dosing device

Give simple choices (i.e. a cup or a spoon, but the medication must be taken now)

Follow home routines Disguise the taste of the medication if

necessary

Safe and Autraumatic Care Developmental approach for preschoolers (3-5

years) Check with the child or the child’s parent about the

child’s ability to swallow pills. Crush tablets and capsules if necessary

Allow the child to participate in decisions regarding how the medication will be administered: when, from whom, and where. The child’s parent may be the best person to administer the medication

Explain to the child what the medication will do Use therapeutic play with dolls or stuffed animals

Safe and Autraumatic Care Developmental approach for school-aged

children (6-12 years) Check with the child or the child’s parent

about the child’s ability to swallow pills. Crush tablets and capsules if necessary

Allow the child to have a sense of control by participating in decision making regarding how the medication will be administered

Explain the purpose of the medication to enhance cooperation

Praise the child after administration


Development approach for adolescents (12-20 years)

Give clients in this age group detailed information about medications, including the purpose, effects, side effects, availability of an alternative, etc.

Provide honest information regarding the medication

Encourage questions


Selecting the appropriate size equipment to safely administer pediatric meds

When using a calibrated syringe, be sure to choose the appropriate size to get the most precise measure of med

These syringes are commonly used to administer precise pediatric meds. They do not accommodate a needle are also available for home use


Liquids: Liquids must be measured accurately especially

when small doses (less than 1 m: or less than 1 tsp) are prescribed. Many devices such as standard medicine cups are not accurate for measuring small doses, and the household tsp comes in many different sizes and shapes

Liquid meds should be measured in specifically marked droppers or hollow-handled medicine spoons, or drawn into needleless syringes if the volume prescribed is less than 5 mL

Prescriptions for liquid meds should be written in mg, mL or mg/mL, not in tsp.

Safe and Autraumatic Care Pills, tablets, and capsules are not

recommended for young children because these items may be difficult to swallow, become lodged in the throat or esophagus, or be aspirated by a crying child

Chewable tablets are available for some preparations, primarily vitamins. Check before crushing or allowing the child to chew any pill, tablet or caplet, because crushing or dilution may alter the action of the medication. Some pills may be crushed and the contents placed in food such as applesauce or ice cream


Using the principles of atraumatic care medication administration

Oral medication administration Give a popsicle or ice to number the

mouth before giving the child medication Mix medication with a pleasant-tasting

substance such as cherry syrup Have a pleasant-tasting substance ready

to eliminate the unpleasant taste of the medication

Safe and Autraumatic Care Using the principles of atraumatic care for med administration IM/SBQ med administration Apply transdermal anesthetic eutectic mixture of lidocaine

and prilocain (EMLA cream) Use the smallest size needle that permits free flow of

medication Bring medication to room temperature Use distraction; talk with child through procedure Cover with bandage (if age-appropriate) Hold and cuddle post-injection (if age-appropriate) or allow

parents to do so Praise the child

Safe and Autraumatic Care Administering IM injectable med to children The size, wt., developmental level, and condition of

the child will determine the most appropriate injection site and the size of needle to be used

Infants and young children have small, underdeveloped muscles, which limits the available sites and dictates the length of needles to be used

Neonate 5/8 inch length Children < 1 year 5/8 to 1” length Children > 1 year 1” length Adolescent 1 ½ -2” for gluteal site


IM injection sites The vastus lateralis located at the

anterolateral thigh, is the most preferred site for IM injections in infants and children of all ages

The deltoid muscle may also be used to inject small volumes of nonirritating fluid in older children


SBQ injections Use 5/8”, 23-25 gauge needle Pinch the skin to avoid muscle tissue Infants: use the fatty region of the

anterolateral thigh Toddlers: use the fatty region of the

anterolateral thigh or posterior area of upper arm

Children: use the fatty region of the anterolateral thigh or posterior area of upper arm


IV delivery A soluset is an IV delivery device

between the IV fluid bag and the IV catheter

Many institutions require a volume control device for delivery of IV meds as well as an infusion pump

Solusets allow the provider to give medications using the maximum amount of fuid and allows for the maximum concentration


Equipment for IV insertion Choose the appropriate size needle for

the size of vein selected and the type of infusion require

Newborn – 1yr 22 – 24 gauge 1 – 8 years 20 – 22 gauge More than 8 years 18 – 22 gauge


Injection sites Preferred (upper extremity) Forearm veins Veins on the dorsum of the hand Other less well known are saphenous vein or small veins on

ventral surface of wrist or larger one on inner aspect of wrist proximal to thumb

The veins in children in crisis are difficult to assess and cannulate. Insertion of an intraosseous needle in the lateral aspect of the tibia bone allows administration of all meds, fluids, and blood products that could be given intraosseously ( within the bone marrow) it takes approximately 60 seconds to insert.


Endotracheal tube The ET can be used to administer

resuscitation medication if IV access is unobtainable. The following medications can be given via the ET tube

LEAN Lidocaine, Epinephrine, Atropine,

Naloxone Vascular access is preferred because

absorption via the ET tube is inconsistent

Adverse Reactions to Meds Reporting adverse reactions all serious adverse reactions to

medications must be reported to the Food and Drug Administration so that other health care professionals may be alerted to potential problems

FDA defines a serious medication reaction as one that is life-threatening, causes death, leads to hospitalization or prolonged rehabilitation, results in serious or permanent disability

The Joint Commission requires each hospital to create a process to report adverse medication reactions

Most health care facility establish internal committees that review all adverse med reactions. These committees must review the events associated with adverse medication reactions, including: the med suspected of causing the adverse reaction, the treatment administered and the client’s response to treatment and any increase in length of stay in the facility

Step to Improve Client Safety

Follow these steps to reduce the risk of an adverse reaction to a med Document a complete med history, including

meds, food, or environmental agent allergies Eliminate excessive or duplicate medications Understand the indications, intended effects, and

possible adverse reactions of each medication Anticipate adverse reactions when therapy is

started or stopped Regularly monitor liver and kidney function Suspect adverse medication reaction if

unexpected complications develop

Dosage and calculations

Health & Medicine

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