Medications & I.V.s



Medications & I.V.s






Drug administration guidelines


Precautions for drug administration

Whenever you administer medication, observe these precautions to ensure that you’re giving the right drug in the right dose to the right patient at the right time by the right route.


Check the order

Check the order on the patient’s medication record against the practitioner’s order.


Check the label

Check the label on the medication three times before administering it to the patient to ensure that you’re administering the prescribed medication in the prescribed dose by the prescribed route. Check it when you take the container from the shelf or drawer, right before pouring the medication into the medication cup or drawing it into the syringe, and before returning the container to the shelf or drawer. If you’re administering a unit-dose medication, check the label for the third time immediately after pouring the medication and again before discarding the wrapper. Don’t open a unit-dose medication until you’re at the patient’s bedside.


Confirm the patient’s identity

Before giving the medication, confirm the patient’s identity by checking two patient identifiers. Then make sure that you have the correct medication.

Explain the procedure to the patient and provide privacy.


Have a written order

Make sure that you have a written order for every medication that’s to be given. If the order is verbal, make sure that the practitioner signs for it within the specified time according to your facility’s policy.


Give labeled medication

Don’t give medication from a poorly labeled, soiled, or unlabeled container. Furthermore, don’t attempt to label drugs or reinforce drug labels yourself; a pharmacist must do that.


Monitor medication

Never give a medication that someone else has poured or prepared. Never allow your medication cart or tray out of your sight. Never return unwrapped or prepared medications to stock containers. Instead, dispose of them and notify the pharmacy.


Respond to the patient’s questions

If the patient questions you about his medication or the dosage, check his medication record again. If the medication is correct, reassure him that it’s correct. Be sure to tell him about changes in his medication or dosage. Instruct him, as appropriate, about possible adverse reactions, and encourage him to report any that he experiences.



Identifying the most dangerous drugs

Almost any drug can cause an adverse reaction in some patients, but the following drugs cause about 90% of all reported reactions.


Anticoagulants



  • Heparin


  • Warfarin


Antimicrobials



  • Cephalosporins


  • Penicillins


  • Sulfonamides


Bronchodilators



  • Sympathomimetics


  • Theophylline


Cardiac drugs



  • Antihypertensives


  • Digoxin


  • Diuretics


  • Quinidine


Central nervous system drugs



  • Analgesics


  • Anticonvulsants


  • Neuroleptics


  • Sedative-hypnotics


Diagnostic agents

X-ray contrast media


Hormones



  • Corticosteroids


  • Estrogens


  • Insulin




Dangerous abbreviations

The Joint Commission has approved the following “minimum required list” of dangerous abbreviations, acronyms, and symbols that shouldn’t be used by accredited organizations. They have also provided a list of other abbreviations that medical personnel should consider not using. Avoiding use of all of these abbreviations, acronyms, and symbols should help protect patients from the effects of miscommunication in clinical documentation.























































Abbreviation


Potential problem


Preferred term


U (for unit)


Mistaken as zero, four, or cc


Write “unit.”


IU (for international unit)


Mistaken as IV (intravenous) or 10


Write “international unit.”


Q.D., Q.O.D. (Latin abbreviations for “once daily” and “every other day”)


Mistaken for each other; the period after the “Q” can be mistaken for an “I”; the “O” can also be mistaken for an “I”


Write “daily” and “every other day.”


Trailing zero (X.0 mg); lack of leading zero (.X mg)


Decimal point is missed


Never write a zero by itself after a decimal point (X mg); always use a zero before a decimal point (0.X mg).


MS, MSO4, MgSO4


Confused with each other


Write “morphine sulfate” or “magnesium sulfate.”


μg (for microgram)


Mistaken for mg (milligram), resulting in overdose


Write “mcg.”


H.S. (for half-strength or Latin abbreviation for “bedtime”)


Mistaken for either “half-strength” or “hour of sleep”; “q H.S.” mistaken for “every hour”


Write “half-strength” or “at bedtime.”


T.I.W. (for three times a week)


Mistaken for “three times a day” or “twice weekly”


Write “3 times weekly” or “three times weekly.”


S.C. or S.Q. (for subcutaneous)


Mistaken for “SL” (sublingual) or “5 every”


Write “sub-Q,” “subQ,” or “subcutaneously.”


D/C (for discharge)


Mistaken for discontinue whatever drugs follow


Write “discharge.”


c.c. (for cubic centimeter)


Mistaken for U (units) when written poorly


Write “ml” (milliliter).


A.S., A.D., A.U. (Latin abbreviations for “left ear,” “right ear,” and “both ears”)


Mistaken for OS, OD, OU


Write “left ear,” “right ear,” or “both ears.”




Body surface area nomogram





image


Reprinted with permission from Geigy Scientific Tables, 8th ed., vol. 5, p. 105. © Novartis, 1990.



Dosage calculation formulas and common conversions


Dosage calculation formulas





image



Common conversions























































1 kg


=


1,000 g


1 g


=


1,000 mg


1 mg


=


1,000 mcg


1″


=


2.54 cm


1 L


=


1,000 ml


1 ml


=


1,000 microliters


1 tsp


=


5 ml


1 tbs


=


15 ml


2 tbs


=


30 ml


8 oz


=


240 ml


1 oz


=


30 g


1 lb


=


454 g


2.2 lb


=


1 kg




Drip rate calculation

When calculating the flow rate of I.V. solutions, remember that the number of drops required to deliver 1 ml varies with the type of administration set. To calculate the drip rate, you must know the calibration of the drip rate for each manufacturer’s product. As a quick guide, refer to the chart below. Use this formula to calculate specific drip rates:































































































Ordered volume



500


1,000


1,000


1,000


1,000


1,000



ML/


ML/


ML/


ML/


ML/


ML/



24 HR


24 HR


20 HR


10 HR


8 HR


6 HR



OR


OR


OR


OR


OR


OR



21


42


50


100


125


167



ML/HR


ML/HR


ML/HR


ML/HR


ML/HR


ML/HR


Drops/ml


Drops/minute to infuse


Macrodrip


10


4


7


8


17


21


28


15


5


11


13


25


31


42


20


6


14


17


33


42


56


Microdrip


60


21


42


50


100


125


167




Tips for high-risk drips

Patient-controlled analgesia (PCA), heparin, and insulin infusions can be especially dangerous if administered incorrectly. If possible, have another nurse independently check the practitioner’s order, your calculations, and the pump settings for these drugs before starting them.


PCA

Be sure to note:

• strength of the drug solution in the syringe

• number of drug administrations during assessment period

• basal dose, if any

• amount of solution received (number of injections × volume of injections + basal doses)

• total amount of drug received (amount of solution × solution strength).


Heparin

Be sure to:

• determine the solution’s concentration (Divide the units of drug added by the amount of the solution in milliliters.)

• state as a fraction: the desired dose over the unknown flow rate

• cross-multiply to find the flow rate.


Insulin

Be sure to:

• remember that regular insulin is the only type given by I.V. route

• always use an infusion pump

• use concentrations of 1 unit/ml.



Infusion flow rates































































































Epinephrine infusion rates


Isoproterenol infusion rates


Mix 1 mg in 250 ml (4 mcg/ml).


Mix 1 mg in 250 ml (4 mcg/ml).


Dose


Infusion rate


Dose


Infusion rate


(MCG/MINUTE)


(ML/HOUR)


(MCG/MINUTE)


(ML/HOUR)


1


15


1


15


2


30


2


30


3


45


3


45


4


60


4


60


5


75


5


75


6


90


6


90


7


105


7


105


8


120


8


120


9


135


9


135


10


150


10


150


15


225


15


225


20


300


20


300


25


375


25


375


30


450


30


450


35


525


40


600




Nitroglycerin infusion rates

Determine the infusion rate in ml/hour using the ordered dose and the concentration of the drug solution.









































































Dose
(MCG/MINUTE)


25 mg/250 ml
(100 MCG/ML)


50 mg/250 ml
(200 MCG/ML)


100 mg/250 ml
(400 MCG/ML)


5


3


2


1


10


6


3


2


20


12


6


3


30


18


9


5


40


24


12


6


50


30


15


8


60


36


18


9


70


42


21


10


80


48


24


12


90


54


27


14


100


60


30


15


150


90


45


23


200


120


60


30





Dobutamine infusion rates

Mix 250 mg in 250 ml of D5W (1,000 mcg/ml). Determine the infusion rate in ml/hr using the ordered dose and the patient’s weight in pounds or kilograms.














































































































































































































































Dose (mcg/kg/min)


Patient’s weight


LB


88


99


110


121


132


143


154


165


176


187


198


209


220


231


242


KG


40


45


50


55


60


65


70


75


80


85


90


95


100


105


110


2.5



6


7


8


8


9


10


11


11


12


13


14


14


15


16


17


5



12


14


15


17


18


20


21


23


24


26


27


29


30


32


33


7.5



18


20


23


25


27


29


32


34


36


38


41


43


45


47


50


10



24


27


30


33


36


39


42


45


48


51


54


57


60


63


66


12.5



30


34


38


41


45


49


53


56


60


64


68


71


75


79


83


15



36


41


45


50


54


59


63


68


72


77


81


86


90


95


99


20



48


54


60


66


72


78


84


90


96


102


108


114


120


126


132


25



60


68


75


83


90


98


105


113


120


128


135


143


150


158


165


30



72


81


90


99


108


117


126


135


144


153


162


171


180


189


198


35



84


95


105


116


126


137


147


158


168


179


189


200


210


221


231


40



96


108


120


132


144


156


168


180


192


204


216


228


240


252


264





Dopamine infusion rates

Mix 400 mg in 250 ml of D5W (1,600 mcg/ml). Determine the infusion rate in ml/hour using the ordered dose and the patient’s weight in pounds or kilograms.



































































































































































































































































Dose (mcg/kg/min)


Patient’s weight


LB


88


99


110


121


132


143


154


165


176


187


198


209


220


231


KG


40


45


50


55


60


65


70


75


80


85


90


95


100


105


2.5



4


4


5


5


6


6


7


7


8


8


8


9


9


10


5



8


8


9


10


11


12


13


14


15


16


17


18


19


20


7.5



11


13


14


15


17


18


20


21


23


24


25


27


28


30


10



15


17


19


21


23


24


26


28


30


32


34


36


38


39


12.5



19


21


23


26


28


30


33


35


38


40


42


45


47


49


15



23


25


28


31


34


37


39


42


45


48


51


53


56


59


20



30


34


38


41


45


49


53


56


60


64


68


71


75


79


25



38


42


47


52


56


61


66


70


75


80


84


89


94


98


30



45


51


56


62


67


73


79


84


90


96


101


107


113


118


35



53


59


66


72


79


85


92


98


105


112


118


125


131


138


40



60


68


75


83


90


98


105


113


120


128


135


143


150


158


45



68


76


84


93


101


110


118


127


135


143


152


160


169


177


50



75


84


94


103


113


122


131


141


150


159


169


178


188


197





Nitroprusside infusion rates

Mix 50 mg in 250 ml of D5W (200 mcg/ml). Determine the infusion rate in ml/hour using the ordered dose and the patient’s weight in pounds or kilograms.


















































































































































































































































































Dose (mcg/kg/min)


Patient’s weight


LB


88


99


110


121


132


143


154


165


176


187


198


209


220


231


242


KG


40


45


50


55


60


65


70


75


80


85


90


95


100


105


110


0.3



4


4


5


5


5


6


6


7


7


8


8


9


9


9


10


0.5



6


7


8


8


9


10


11


11


12


13


14


14


15


16


17


1



12


14


15


17


18


20


21


23


24


26


27


29


30


32


33


1.5



18


20


23


25


27


29


32


34


36


38


41


43


45


47


50


2



24


27


30


33


36


39


42


45


48


51


54


57


60


63


66


3



36


41


45


50


54


59


63


68


72


77


81


86


90


95


99


4



48


54


60


66


72


78


84


90


96


102


108


114


120


126


132


5



60


68


75


83


90


98


105


113


120


128


135


143


150


158


165


6



72


81


90


99


108


117


126


135


144


153


162


171


180


189


198


7



84


95


105


116


126


137


147


158


168


179


189


200


210


221


231


8



96


108


120


132


144


156


168


180


192


204


216


228


240


252


264


9



108


122


135


149


162


176


189


203


216


230


243


257


270


284


297


10



120


135


150


165


180


195


210


225


240


255


270


285


300


315


330




Insulin overview



































































Insulin type


Onset


Peak (hours)


Usual effective duration (hours)


Usual maximum duration (hours)


Animal


Regular


0.5 to 2 hours


3 to 4


4 to 6


6 to 8


NPH


4 to 6 hours


8 to 14


16 to 20


20 to 24


Human


Insulin aspart


5 to 10 minutes


1 to 3


3 to 5


4 to 6


Insulin lispro


< 15 minutes


0.5 to 1.5


2 to 4


4 to 6


Regular


0.5 to 1 hour


2 to 3


3 to 6


6 to 10


NPH


2 to 4 hours


4 to 10


10 to 16


14 to 18


Lente


3 to 4 hours


4 to 12


12 to 18


16 to 20


Ultralente


6 to 10 hours



18 to 20


20 to 24


Insulin glargine


1 hour



24


24




Insulin infusion pumps

A subcutaneous (subQ) insulin infusion pump provides continuous, long-term insulin therapy for patients with type 1 diabetes mellitus. Complications include site infection, catheter clogging, and insulin loss from loose reservoir-catheter connections. Insulin pumps work on either an open-loop or a closed-loop system.


Open-loop system

• Is the most common.

• Infuses insulin but can’t respond to changes in the patient’s serum glucose levels.

• Delivers insulin in small (basal) doses every few minutes; large (bolus) doses are set by the patient.

• Consists of reservoir containing insulin syringe, small pump, infusion-rate selector that allows insulin release adjustments, battery, and plastic catheter with attached needle leading from syringe to subQ injection site.

• Needle is held in place with waterproof tape.

• Pump is worn on a belt or in a pocket.

• Infusion line must have clear path to injection site.

• Infusion-rate selector releases about one-half the total daily insulin.

• The patient releases the remainder in bolus doses before meals and snacks.

• The patient must change the syringe daily.

• The patient must change needle, catheter, and injection site every other day.


Closed-loop system

• Self-contained; detects and responds to changing serum glucose levels.

• Includes glucose sensor, programmable computer, power supply, pump, and insulin reservoir.

• The computer triggers continuous insulin delivery in appropriate amounts.


Nonneedle catheter system

• Uses tiny plastic catheter inserted into the skin over a needle using a special insertion device.

• The needle is withdrawn, leaving the catheter in place (in the abdomen, thigh, or flank).

• Catheter is changed every 2 to 3 days.







50 common critical care drugs

This table provides information on drugs commonly used in critical care nursing, along with their indications.




























































































































































Drug name


Indications


Abciximab (ReoPro)


• Adjunct to percutaneous transluminal coronary angioplasty or arterectomy
• Unstable angina not responding to conventional medical therapy in patients scheduled for percutaneous coronary intervention within 24 hours


Adenosine (Adenocard)


• To convert paroxysmal supraventricular tachycardia to sinus rhythm


Alprazolam (Xanax)


• Anxiety


Alteplase (tissue plasminogen activator, recombinant) (Activase)


• Lysis of thrombi in acute myocardial infarction (MI), pulmonary emboli, or central venous access devices


Amiodarone (Cordarone)


• Cardiac arrest, pulseless ventricular tachycardia, ventricular fibrillation
• Atrial fibrillation
• Heart failure


Amlodipine (Norvasc)


• Chronic stable angina
• Hypertension


Atenolol (Tenormin)


• Hypertension
• Angina pectoris
• Risk reduction of cardiovascularrelated death and reinfarction postacute MI


Atropine sulfate (Sal-Tropine)


• Symptomatic bradycardia, bradyarrhythmia
• Preoperatively to diminish secretions and block cardiac vagal reflexes


Bumetanide (Bumex)


• Heart failure


Calcium chloride


• Hypocalcemic emergency
• Hypocalcemic tetany
• Hyperphosphatemia
• Hyperkalemia with secondary cardiac toxicity


Clonidine (Catapres)


• Hypertension
• Migraine prophylaxis
• Opioid dependence
• Alcohol dependence


Dexamethasone (Decadron)


• Cerebral edema
• Inflammatory conditions, allergic reaction
• Shock
• Adrenocortical insufficiency


Diazepam (Valium)


• Anxiety
• Acute alcohol withdrawal
• Cardioversion
• Status epilepticus, severe recurrent seizures


Digoxin (Lanoxin)


• Heart failure
• Paroxysmal supraventricular tachycardia, atrial fibrillation and flutter


Diltiazem (Cardizem)


• Prinzmetal’s or chronic stable angina pectoris
• Hypertension
• Atrial fibrillation or flutter, paroxysmal supraventricular tachycardia


Diphenhydramine (Benadryl)


• Sedation
• Nighttime sleep aid
• Allergy symptoms


Dobutamine (Dobutrex)


• Heart failure
• Adjunctive therapy in cardiac surgery


Dopamine (Intropin)


• Shock
• Hypotension
• To increase organ perfusion


Drotrecogin alfa (Xigris)


• Sepsis


Enalaprilat (Vasotec)


• Hypertension
• Heart failure
• Asymptomatic left ventricular dysfunction


Enoxaparin (Lovenox)


• Pulmonary emboli (PE) and deep vein thrombosis (DVT) prophylaxis
• Prevention of ischemic complications of unstable angina and non-Q-wave MI
• DVT


Epinephrine (EpiPen)


• Bronchospasm, hypersensitivity reactions, anaphylaxis
• Cardiac arrest
• Acute asthma attack


Eptifibatide (Integrilin)


• Acute coronary syndrome


Furosemide (Lasix)


• Acute pulmonary edema
• Edema
• Hypertension


Heparin sodium (Heparin sodium injection)


• DVT
• MI
• PE
• Atrial fibrillation with embolism


Lorazepam (Ativan)


• Anxiety
• Status epilepticus


Magnesium sulfate


• Hypomagnesemia
• Seizures


Mannitol (Osmitrol)


• Oliguria
• Drug intoxication
• Increased intraocular pressure
• Increased intracranial pressure


Methylprednisolone (Solu-Medrol)


• Severe inflammation or immunosuppression
• Shock


Metoprolol (Lopressor)


• Hypertension
• Early intervention in acute MI
• Angina pectoris
• Stable, symptomatic heart failure resulting from ischemia, hypertension, or cardiomyopathy


Midazolam (Versed)


• Preoperative sedation
• Conscious sedation


Morphine sulfate (Duramorph)


• Pain


Naloxone (Narcan)


• Known or suspected opioid-induced respiratory depression


Nesiritide (Natrecor)


• Acute decompensated heart failure


Nitroglycerin (Nitrostat)


• Prophylaxis against chronic anginal attacks
• Acute angina pectoris
• Hypertension


Nitroprusside (Nipride)


• Hypertensive emergency
• Cardiogenic shock


Norepinephrine (Levophed)


• Hypotension


Pancuronium


• Adjunct to anesthesia to relax skeletal muscle, facilitate intubation, assist with mechanical ventilation


Phenobarbital (Solfoton)


• Seizures, status epilepticus
• Sedation


Phenylephrine (Neo-Synephrine)


• Hypotensive emergency
• Shock


Phenytoin (Dilantin)


• Seizures, status epilepticus


Potassium chloride (K-Lor)


• Hypokalemia


Propranolol (Inderal)


• Angina pectoris
• To decrease risk of death after MI
• Supraventricular, ventricular, and atrial arrhythmias; tachyarrhythmias caused by excessive catecholamine action
• Hypertension


Protamine sulfate


• Heparin overdose


Streptokinase (Streptase)


• Arteriovenous-cannula occlusion
• Venous thrombosis, PE, arterial thrombosis and embolism
• Lysis of coronary artery thrombi following acute MI


Vasopressin (Pitressin)


• Non-nephrogenic, non-psychogenic diabetes insipidus
• GI bleeding


Vecuronium


• Adjunct to general anesthesia to facilitate endotracheal intubation and relax skeletal muscles during surgery or mechanical ventilation


Verapamil (Calan)


• Vasospastic angina, classic chronic stable angina
• Chronic atrial fibrillation, supraventricular arrhythmias
• Hypertension


Vitamin K analogue (AquaMEPHYTON)


• Hypoprothrombinemia


Warfarin (Coumadin)


• PE with DVT
• MI
• Rheumatic heart disease with heart valve damage, prosthetic heart valves
• Chronic atrial fibrillation




Common antidotes
















































Drug or toxin


Antidote


Acetaminophen


Acetylcysteine (Mucomyst)


Anticholinergics


Physostigmine (Antilirium)


Benzodiazepines


Flumazenil (Romazicon)


Calcium channel blockers


Calcium chloride


Cyanide


Amyl nitrate, sodium nitrite, and sodium thiosulfate (Cyanide Antidote Kit); methylene blue


Digoxin, cardiac glycosides


Digoxin immune fab (Digibind)


Ethylene glycol


Ethanol


Heparin


Protamine sulfate


Insulin-induced hypoglycemia


Glucagon


Iron


Deferoxamine mesylate (Desferal)


Lead


Edetate calcium disodium (Calcium Disodium Versenate)


Opioids


Naloxone (Narcan), nalmefene (Revex), naltrexone (ReVia)


Organophosphates, anticholinesterases


Atropine, pralidoxime (Protopam)


Warfarin


Vitamin K




Antidotes for extravasation





























Antidote


Extravasated drug


Ascorbic acid injection


• dactinomycin


Edetate calcium disodium (calcium EDTA)


• cadmium
• copper
• manganese
• zinc


Hyaluronidase 15 units/ml


• aminophylline
• calcium solutions
• contrast media
• dextrose solutions (concentrations of 10% or more)
• nafcillin
• potassium solutions
• total parenteral nutrition solutions
• vinblastine
• vincristine
• vindesine


Hydrocortisone sodium succinate 100 mg/ml


• doxorubicin
• vincristine


Usually followed by topical application of hydrocortisone cream 1%


Phentolamine


• dobutamine
• dopamine
• epinephrine
• metaraminol bitartrate
• norepinephrine


Sodium bicarbonate 8.4%


• carmustine
• daunorubicin
• doxorubicin
• vinblastine
• vincristine


Sodium thiosulfate 10%


• cisplatin
• dactinomycin
• mechlorethamine
• mitomycin

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Jul 17, 2016 | Posted by in NURSING | Comments Off on Medications & I.V.s

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