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

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

Dosage calculation formulas and common conversions

Dosage calculation formulas

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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