Safety related to Administration methods

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Safety related to Administration methods

• UNRS 314
• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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Pediatric dosages calculated by weight

• Most drug books use weight in kilograms, patients
  are often weighed in pounds
• To convert pounds to kilograms 2.2 lb 1 kg.
• 2.2 x weight in lb
• Divide pounds by 2.2 to get weight in kg

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Calculation

• If a child weighs 88 lbs, what is the weight in
  kg?
• 88lb x kg
• 88 divided by 2.2 40 kg
• If a child weights 6 lbs what is the weight in
  kg?
• 6 lb divided by 2.2 2.72 kg

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Medication dosage

• For a dosage of medication to be safe, it must
  fall within the safe range as listed in a Drug
  Handbook, PDR or other reliable drug reference.

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Safe Medication Dose

• Calculate daily dose ordered (Physician orders)
• Calculate the low and high parameters of safe
  range (from drug book)
• Compare the patients daily dose to the safe
  range to see if it falls within the safe zone

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Calculation

• A child is 2 years and weighs 36 lbs is receiving
  Amoxicillin 215 mg po tid for a bilateral otitis
  media (ear infection).
• Patient weight in kg 16.36 kg
• Davis drug guide PO (children) lt 40 kg 6.7 to
  13.3 mg / kg q 8 hours.
• 16.36 x 6.7 109.6 mg q 8hours
• 16.36 x 13.3 217.5 mg q 8 hours
• Safe range 110 to 218 mg of Amoxicillin Q 8
  hours
• Is the dose safe?

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How much medication do you give?

• Amoxicillin suspension comes 250 mg per 5 ml.
• 250 mg / 5 ml 215 mg / x ml
• Give 4.3 cc po every 8 hours

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Safe Dose Ranges

• Read the medication ranges carefully
• Some are the dose range for 24 hours
• Some are the dose range for q 8 hours
• Some are the dose range for q 12 hours

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Fluid Control

• Crucial in the pediatric population
• Units often have policies that children under
  certain ages with IV fluids / IV medication be
  placed on an infusion pump.

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Key concepts

• Fluid overload must be avoided
• Time over which a medication should be
  administered is critical information
• Minimal dilution (end concentration of
  medication) is important for medications such as
  aminoglycosides.
• Collecting therapeutic blood levels

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Fluid overload

• Know what the IV rate is.
• Hourly recording of IV fluid intake
• Dont try and catch up on fluids
• Calculate fluids used to administer IV
  medications into the hourly fluid calculations.

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IV Buretrol
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IV Buretrol

• A buretrol or volutrol is an inline receptacle
  between the clients IV catheter set and the bag
  of fluids.
• Capacity is 100 to 120 mL
• Rationale the nurse can fill the buretrol to a
  certain level and if the IV pump malfunctions,
  only the volume in the buretrol will flow to the
  client.

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The Infusion Pump

• The ml / hour the doctor orders is set on the
  pump as the infusion rate.
• The amount of fluid in the buretrol or volutrol
  is the amount to be infused.
• This will need to be set every 2 hours or
  according to hospital policy.

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IV fluid calculations

• The maintenance dose for administration of IV
  fluids is based on the following formula
• 100 ml of fluid for the 1st 10 kg of weight
• 50 ml of fluid for the 2nd 10 kg of weight
• 20 ml of fluid for and additional kg
• You need to memorize this

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Practice problem

• Jose weighs 16 pounds
• Weight in kg 7.27 kg
• Using the formula provided how many mls of fluid
  would he need in 24 hours.

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Practice problem

• Kyisha is a 10 year old admitted to the unit in
  sickle cell crisis. She weighs 36 kg. What would
  her maintenance dose of fluids be?
• She is dehydrated so they physician orders the
  fluids to be double maintenance. What would her
  24 hour fluid needs be?

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IV bolus

• A 6 year old with dehydration is admitted to your
  unit. The referring hospital has an adult IV
  set-up. (drip factor of 15 gtt/ml) The physician
  order is to infuse 90 mL of normal saline over 1
  hour. At what rate will you set the IV rate?
• 90 ml x 15 gtts/ml divided by 60 minutes
• Drip rate will be ____ gtts/minute

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Safe administration of IV medications

• Vancomycin anti-infective
• For treatment of potentially life-threatening
  infections when less toxic anti-invectives are
  contraindicated.
• MRSA Methicillin resistant staph aureus
• Use with caution in patients with renal impairment

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Vancomycin

• IV (children) 10 mg / kg q 6 hours or 20 mg / kg
  q 12 hours.
• IV (neonates) 1 week to 1 month 15 mg / kg
  initially (loading dose) then 10 mg / kg q 8
  hours.
• IV (neonates) less than 1 week 15 mg / kg
  initially then 10 mg / kg q 12 hours.

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Nursing implications

• Assess for infection at beginning, during and end
  of therapy. (wbc, fever, lethargy, wound, lung
  sounds)
• Obtain any cultures ordered before administration
  of the medication.
• Vancomycin is irritating to tissue and causes
  necrosis and severe pain with extravasation.
• Evaluate 8th cranial nerve function by audiometry
  and serum Vancomycin levels throughout course of
  therapy.
• Monitor urine cloudy or pink urine may be signs
  of nephrotoxicity.

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Intermittent infusion

• Dilute each 500 mg vial with 10 ml of sterile
  water.
• Dilute further with 100 to 200 ml of IV solution
  (D5W)
• Infuse over 60 minutes Do not administer rapidly
  or as a bolus to minimize risk of
  thrombophlebitis, hypotension, or red neck
  syndrome.
• Thrombophlebitis can be minimized by using dilute
  solutions of 2.5 to 5 mg / ml.

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Neonate dosage

• Weight 3.25 kg / 5 days old
• How much Vancomycin for loading dosage?
• How much Vancomycin for maintenance dosage?
• How much fluid would you need to dilute
  medication in to administer safely?

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Calculations

• 3.25 x 15 mg 48.75 mg
• Vancomycin comes in 500 mg vial
• 500 mg diluted with 10 cc sterile water
• 500mg /10 cc 48.75/ X ml
• You will draw up .97 ml
• How much fluid do you have to further dilute
  medication in (2.5 to 5 mg / ml)?
• Dilute in approximately 20 ml and run in over 60
  minutes.

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What about the flush?

• If you put the medication and the 20 cc in the
  buretrol how fast will you have to set the IV
  pump to get the medication into the patient in 60
  minutes?
• Hint you will need 20 ml of additional fluid to
  flush the medication through the IV line.
• THE PHYSICIAN ORDER WILL NEVER STATE TO FLUSH THE
  LINE YOU MUST DO THIS WITH EACH IV MEDICATION

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Practice IV medications

• Jose is a 15 year old to receive 750 mg of Ancef
  (Cefazolin) pre-operatively for an ORIF
  orthopedic procedure. The pharmacy sends you 1
  gram of powdered Ancef. The direction are to
  dilute the powder with 10 ml of sterile water.
  You concentration is now 1 gram in 10 ml of
  sterile water. How many mls will you need to
  draw up to equal 750 mg?

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Ancef continued

• 750 mg of Ancef in 7.5 ml. Add the 7.5 ml of
  medication to 50 ml of IV fluid and infuse over
  30 minutes. How fast do you need to set your IV
  at (remember the 20 ml flush) to have the
  medication infused over 30 minutes?

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Practice problem

• John is receiving Cefuroxime 350 mg IV. The
  medication comes from the pharmacy 350 mg of
  Cefuroxime in 3.5 ml of fluid. The medication is
  to be further diluted with fluid to equal 20 ml
  in the buretrol. The medication is to infuse over
  30 minutes. Keeping in mind that you will have a
  20 ml flush. (total fluid to infuse over 30
  minutes is 40 ml)
• 20 ml of medication 20 ml rinse 40 ml

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Practice problem

• You are to administer 100 mg of Ampicillin q 12
  hours to a neonate with sepsis. (weight 3.45 kg).
  The range for ampicillin is
• Infants gt 7 days and gt 2000 grams 50 mg to 100
  mg / kg / day divided into doses q 12 hours.
• Is the dose a safe dose?
• The ampicillin comes as a powder 125 mg to be
  diluted with 1 ml of sterile water.
• How much ampicillin would you draw up from the
  vial to equal 100 mg?

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Remember the Basics

• 1 teaspoon 5 ml
• 1 tablespoon 15 ml
• 1 ounce 30 ml
• 1 grain 60 mg
• mcg to mg to grams