Safety related to Administration methods

1. Safety related to Administration methods UNRS 314 Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. 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

3. 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

4. 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.

5. Safe Medication Dose • Calculate daily dose ordered (Physician orders) • Calculate the low and high parameters of safe range (from drug book) • Compare the patient’s daily dose to the safe range to see if it falls within the safe zone

6. 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) < 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?

7. 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

8. 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

9. 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.

10. 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

11. Fluid overload • Know what the IV rate is. • Hourly recording of IV fluid intake • Don’t try and catch up on fluids • Calculate fluids used to administer IV medications into the hourly fluid calculations.

12. IV Buretrol

13. IV Buretrol • A buretrol or volutrol is an inline receptacle between the client’s 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.

14. 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.

15. 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

16. 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.

17. 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?

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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?

24. 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.

25. 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

26. 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 ml’s will you need to draw up to equal 750 mg?

27. 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?

28. 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

29. 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 > 7 days and > 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?

30. Remember the Basics • 1 teaspoon = 5 ml • 1 tablespoon = 15 ml • 1 ounce = 30 ml • 1 grain = 60 mg • mcg to mg to grams