chapter 3

Pharmacology

Objectives

After studying this chapter, the student should be able to:

1 Verbalize the importance of using all aspects of the nursing process in the administration of medications.

2 Demonstrate correct technique in administering medication safely.

3 Correctly calculate appropriate doses of medications.

4 Describe a beginning understanding of major drug classifications, including actions, side effects, and nursing considerations.

5 Discuss the importance of continuing his or her education in the field of pharmacology.

http://evolve.elsevier.com/Mosby/comprehensivePN

This chapter covers two major areas: (1) administration of medications and (2) pharmacological aspects of nursing care. The nursing process as it applies to drugs and drug administration is explained and integrated throughout the text.

Calculation of dosage and intravenous (IV) infusion rate, principles of medication administration, procedures and sites for medication administration, blood transfusion administration, and pediatric drug administration are reviewed.

The major classifications of drugs are presented with their actions, adverse effects, and nursing process applications. Commonly used clinical drugs are listed with generic and brand names.

Today more than ever nurses have a responsibility to stay current with changes in pharmacology. Consumers have become more and more sophisticated and have a wide variety of resources available to them as well.

The role of the licensed practical/vocational nurse (LPN/LVN) in the administration of medications is determined by the state nurse practice acts and agency policy. However, knowledge of drugs has a significant impact on the quality of nursing care provided to each patient by the LPN/LVN. The LPN/LVN has a legal and moral responsibility to use the nursing process in the administration of medications.

Key drugs are identified by an asterisk (*).

PHARMACOLOGY AND THE NURSING PROCESS

A Assessment: a systematic collection of subjective and objective data about the patient, drug, and environment

B Planning: prioritizes the nursing diagnosis and specifies the goals and outcome criteria and the time in which these should be achieved

C Implementation: consists of initiation and completion of the nursing care plan as defined by the nursing diagnosis and outcome criteria

D Evaluation: an ongoing monitoring of the patient’s response to drug therapy

ASSESSMENT

A Assessing the patient

1. Variables

a. Growth and development related to age

b. Body build—many antibiotics (particularly IV antibiotics), narcotics, and vasoactive drugs are ordered based on patient’s weight and build

c. Past and present medical history

d. Nutritional practices

e. Allergies

f. Sociocultural beliefs—how this person’s culture views medication and the health care system

g. Knowledge of disease and drugs

h. Cognitive function—the person’s ability to understand the drug regimen

i. Physical challenges—eyesight, hearing, weakness in extremities

j. Physical assessment: vital signs, height, weight, laboratory results, results of diagnostic tests

    Additional detailed discussion of variables appears in the Pharmacokinetics section, p. 79.

2. Medication history

a. Over-the-counter (OTC) medications—an increasing number of medications have changed from prescription to OTC. The LPN/LVN has a responsibility to educate the patient on the dangers of self-medicating. Long-term use of OTC medications may mask symptoms of a more serious disorder.

b. Prescription medications

c. Substance abuse, including street drugs, smoking, alcohol, caffeine, food

d. Problems with drug therapy in the past (e.g., allergies, adverse effects, noncompliance)

e. Cultural variables—some medications have differing effects on individual groups. Some medications may not be allowed in certain cultures.

B Assessing the drug

1. Medication order

a. From a physician, dentist, or nurse practitioner (if permitted by state law)

b. Contains patient’s name, date order was written, name of medication, dosage (size, frequency, number of doses), route, signature of health care provider

c. Accuracy, legibility, need for clarification

d. Incorrect, inappropriate, or illegible orders must be clarified before administration.

2. Types of medication orders

a. Routine or standard

b. Pro re nata (p.r.n.) order: given on a “when necessary” basis

c. Single order: to be given only once

d. Stat order: to be given only once and immediately

e. Standing order: established for all patients with a specific condition

f. Verbal order: must be written and signed within a specified time limit

g. Telephone order—emergency situations only: follow hospital policy concerning who is allowed to accept. In many states LPN/LVNs have special restrictions. They are allowed to follow only physician orders that are co-signed by a registered nurse (RN)

h. To decrease medication errors, The Joint Commission (TJC) no longer recommends that a nurse use “q” or “qod” for “every day” or “every other day.”

C Institutional-level management: drug distribution systems

1. Floor stock

2. Individual patient medication system: a supply of medication that is dispensed and labeled for a particular patient

3. Unit dose: individual doses of each medication ordered

4. Computerized or automatic drug dispensing system

5. Pyxis is an automated system that uses barcodes to ensure adequate medication dispensing.

6. The nurse must be aware of federal and state agency policy regarding the storage and dispensing of controlled substances.

PLANNING

A Establish priorities: weigh the importance of one problem against another

B Set goals: objective, measurable, and realistic with an established time period for achievement of the outcome

C Outcome: should reflect expected changes through nursing care

D Outcome criteria: provide a standard of measure that can be used to move toward the goal

See Critical Thinking Challenge box.

Critical Thinking Challenge

A patient arrives at the walk-in clinic complaining of a headache, runny nose, and swollen glands. The patient is 54 years old and states that she never had allergies until she was 50 years old. While the nurse was taking a patient history, it was discovered that the patient had had no medical care since the birth of her last child at the age of 32. Before the patient is seen by a physician, what information would be essential for the nurse to obtain that would better assist the physician in meeting the needs of this patient?

Basic assessment data would include vital signs, height and weight, and questions concerning family history, any known allergies, including food allergies, over-the-counter medication history, including herbal supplements, and specific lifestyle questions specific to exercise and dietary patterns.

The patient should then be referred to the appropriate clinic physician and be encouraged to begin regular medical care. Patient responses to questions asked during the initial assessment help guide physician diagnosis as well as govern the choice of medication prescribed by the physician for this patient.

IMPLEMENTATION

A Requires constant communication with patient and health care team

B Requires proper administration of medication

1. Approach to patient

a. “Therapeutic use of self” attitude of nurse

b. Consistency of approach

c. Informed consent for patients

d. Compliance and right to refuse

2. Uses the six rights

a. Right drug

b. Right dose

c. Right time

d. Right route

e. Right patient

f. Right documentation

    Please note that it is required procedure in many institutions for the nurse to open the medication at the patient’s bedside.

3. Uses measures to support the therapeutic or desired effect—nursing actions can complement drug therapy or minimize unpleasant adverse reactions.

4. Observes for desired therapeutic effect

a. Establish baseline data for all medications.

b. Establish observational parameters (vital signs, diagnostic test results and laboratory data, pain assessment scales) to evaluate effectiveness of medications.

C Teaches patients

1. Explain drug, dose, side effects, food-drug interactions, time schedule, method of administration, and so on.

2. Identify need for teaching.

3. Establish realistic teaching goals.

4. Select teaching methods—the method chosen should be individualized to fit the patient’s needs.

5. Implement teaching.

6. Evaluate effectiveness.

D Document accurately (form is set by agency policy)—some institutions consider this right the sixth right.

1. Information must be complete and accurate.

2. Documentation must be done immediately after administration.

3. Legal implications—if drug administration is not documented, the assumption is that the drug has not been administered.

4. Data should include:

a. Observations relevant to therapeutic effects.

b. Actions taken to prevent or treat adverse reactions.

c. Time when a drug is discontinued.

d. Reason or reasons for discontinuation of drug.

e. Reasons for refusal or noncompliance of patient.

f. It is no longer recommended that drugs be disposed of in the sink or the toilet.

(1) At home, patients should crush oral forms of medications, place in original containers, black out information, place in another container in a brown bag, and place in the trash.

(2) Syringes should be placed in a glass jar until full and then placed in a paper bag and disposed of in the trash. Nurses should follow agency policy.

(3) Patients should contact health care providers if they have any questions.

E Dosage forms

1. Factors influencing route of administration

a. Specific chemical and physical properties of the drug

b. Pathological condition of the patient

c. Adequacy of medication compliance

2. Dose: amount of drug to be given at one time

3. Dosage: regulation of the frequency, size, number of doses

4. Dosage form: final product administered to the patient

a. Preparations for oral use

(1) Liquids

(a) Aqueous solutions: substances dissolved in water and syrups

(b) Aqueous suspensions: solid particles suspended in liquid

(c) Syrup: medication dissolved in a concentrated solution of a sugar to which flavors may have been added

(d) Emulsions: fats or oils suspended in liquid with an emulsifier

(e) Spirits: alcohol solution

(f) Elixir: aromatic sweetened alcoholic and water solution

(g) Tincture: alcoholic extract of plant or water solution

(h) Fluid extract: concentrated alcoholic extract of plant or vegetables

(i) Extract: syrup or dried form of pharmacologically active drug

(2) Solids

(a) Capsules—soluble case (usually gelatin) that contains liquid, dry, or beaded particles. Capsules may be timed release or sustained action (slow, continuous dissolution for an extended period).

(b) Tablets: compressed powdered drug or drugs in small disks

• Enteric-coated tablets: coated with a second layer of material to prevent dissolution in stomach; disintegrate in small intestine to prevent stomach irritation

• Press-coated or layered tablets: contain a second layer of material pressed on or around them, which allows incompatible ingredients to be separated and to dissolve at different rates

• Troches or lozenges: medicated tablets that dissolve slowly in the mouth

(c) Powders or granules: loose or molded drug substances for drug administration with or without liquids

b. Preparations for parenteral use

(1) Ampules: sealed glass containers for liquid injectable medications; for single-dose use

(2) Vials: glass containers with a rubber stopper, usually for multiple doses; contain liquid or powdered medications

(3) Cartridge or Tubex: a single-dose unit of parenteral medication to be used with a specific injecting device

(4) Patients with specific conditions (e.g., diabetes or chronic pain) may self-administer regulated doses of medication.

(5) IV solutions: must be sterile and particle free

(a) Continuous infusion may be used for fluid replacement with or without medication.

(b) Intermittent—runs as a secondary administration set (piggyback) hung separately from the primary set by means of a secondary tubing

(c) Heparin lock (PRN lock) or angiocatheter: a port site for direct administration of intermittent IV medications without the need for a primary IV solute

(6) Certain medications (i.e., lidocaine) may be used subcutaneously to provide local anesthesia

c. Preparations for topical use

(1) Lotions: liquid suspensions that can be protective, emollient, cooling, astringent, pain relieving, antipruritic, cleansing, and so on

(2) Ointments: semisolid medicines in a base for local use—protective, soothing, astringent, topical pain relieving

(3) Paste: thick ointments used primarily for skin protection

(4) Creams: emulsions that contain aqueous and oily bases

(5) Aerosols: fine powders or solutions in volatile liquids that contain a propellant

(6) Transdermal patches: patches containing medication that is absorbed continuously through the skin and acts systemically (primarily pain relief and the relief of vasoconstriction)

(7) Powders: finely ground drugs or combinations of drugs

d. Preparations for use on mucous membranes

(1) Drops are aqueous solutions with or without a gelling agent (to increase retention time in the eye). Drops can be used for eyes, ears, or nose.

(2) An aqueous solution of medications is topically administered, usually for topical action but occasionally used for systemic effects, including enemas, douches, mouthwashes, throat sprays, gargles.

(3) Aerosol sprays, nebulizers, and inhalers deliver aqueous solutions of medication in droplet form to the target membrane such as the bronchial tree (bronchodilators).

(4) Foams such as vaginal foams for contraception are powders or solutions of medication in volatile liquids with a propellant.

(5) Suppositories usually contain medicinal substances mixed in a firm but malleable base to facilitate insertion into a body cavity (e.g., rectal, vaginal); can be used for local or systemic effects.

e. Miscellaneous drug delivery systems

(1) Intradermal implants are pellets containing a small deposit of medication that are inserted in a dermal pocket; usually used to administer hormones such as testosterone or estradiol.

(2) Micropump system is a small external pump, attached by belt or implanted, that delivers medication by way of a needle in a continuous, steady dose. Examples include insulin, anticancer chemotherapy, opioids.

F Dosage route: means of access to the site of action or systemic circulation; divided into three classifications

1. Enteral: drug is administered directly into gastrointestinal (GI) tract.

a. Oral: Drug is ingested and absorbed from stomach or small intestine. Route is convenient and economical. Drug can irritate stomach; it may be destroyed by digestive juices.

b. Rectal: Drug is inserted into rectum and absorbed through mucous membrane. Route may be used in unconscious or vomiting patient.

2. Parenteral: In practice, parenteral means administration by means of a needle; drugs must be sterile, and aseptic technique must be used.

a. Intradermal: Drug is injected directly under the skin. Amount of drug is small, and absorption is slow. Examples of use include allergy testing, tuberculosis (TB) testing, administering small amounts of anesthesia.

b. Subcutaneous: Drug is injected under the skin into subcutaneous fascia. Ideally solutions are limited to no more than 1 mL of solution. Examples of use include insulin, heparin, and morphine.

c. Intramuscular: Drug is injected into muscle mass. Relatively rapid absorption is the result of good blood supply. Larger volumes up to 5 mL can be given.

d. Intravenous: Drug is injected into the vein for immediate effect. Route permits direct control of blood drug concentrations. It is used when an immediate effect is desired; can be given by injection or infusion; and is useful in emergency situations. Precautions must be taken to avoid infiltration. Follow institution policy for the time required to stay with a patient after the initiation of a transfusion.

e. Epidural (administration by this route is performed by a physician; however, the nurse is responsible for assisting and monitoring sites and effects): A catheter is implanted beneath the skin with its tip in the epidural space; the drug diffuses into the central spinal fluid, bypassing the blood-brain barrier; route is frequently used in the management of acute and chronic pain.

f. Intraarterial (administration by this route is performed by a physician; however, the nurse is responsible for assisting and monitoring sites and effects): Drug is injected directly into an artery.

g. Intraarticular (administration by this route is performed by a physician; however, the nurse is responsible for assisting and monitoring sites and effects): Drug is injected directly into a joint.

h. Intraspinal (administration by this route is performed by a physician; however, the nurse is responsible for assisting and monitoring sites and effects): Drug is injected directly into spinal canal.

3. Percutaneous: Medications are applied through or into the skin or mucous membranes. These medications may be used for local or systemic effects; an example would be local anesthetics.

a. Sublingual: Drug is dissolved under tongue and absorbed rapidly through mucous membrane of mouth. It can irritate oral mucosa. The number of drugs given this way is limited; nitroglycerin is primary example.

b. Buccal: Drug is dissolved between cheek and gum and absorbed through mucous membrane of the mouth.

c. Lungs: Drug is inhaled as a gas or aerosol. Route is useful for drugs intended to act directly on the lungs.

d. Vaginal: Drug is inserted into the vagina and absorbed through the mucous membrane.

e. Ophthalmic: Drug is applied to the eye in form of drops or ointments; they must be sterile.

f. Otic or aural: Drug is applied in the ear.

g. Nasal: Drug is applied to the nasal cavity via a dropper or atomizer.

h. Transdermal: Patch applied to skin provides controlled release of medication.

EVALUATION

A Therapeutic goals: evaluate therapeutic effectiveness of drugs

B Diagnostic goals: observe for potential adverse reactions

C Teaching goals: verify patient’s knowledge of drug or ability to perform a skill necessary for administration of the drug

D Patient compliance: evaluates patient adherence to a prescribed plan of treatment; therapeutic blood levels checked with many medications to determine effectiveness

SOURCES OF DRUGS

A Animals

B Plants

C Microorganisms

D Synthetic chemical substances—the major source of drugs

E Food substances

DRUG NAMES

A Generic: the official, established nonproprietary name assigned to a drug; drug licensed under its generic name and often less expensive than brand-name drugs

B Brand (trademark): a name assigned to a drug by its manufacturer; use of this name restricted to the specific manufacturer by the trademark

C Chemical: the exact designation of the chemical structure as determined by the rules of accepted systems of chemical nomenclature

D Prescription drug: a legal prescription is required for the drug to be dispensed; nonprescription or OTC drug may be purchased without a prescription

DRUG LEGISLATION

A Food, Drug, and Cosmetic Act of 1938 (amended 1952, 1962)

1. Contains detailed regulations to ensure that drugs meet standards of safety and effectiveness

2. Requires physician’s prescription for legal drug purchase

B Controlled Substances Act of 1970

1. Defines drug dependency and drug addiction

2. Classifies drugs according to potential abuse and medical usefulness

3. Establishes methods for regulating manufacture, distribution, and sale of controlled substances

4. Establishes education and treatment programs for drug abuse

C Controlled substances schedule

1. Schedule I: drugs that have a high potential for abuse and are not approved for medical use in the United States (e.g., cocaine)

2. Schedule II: drugs that have a high potential for abuse but are currently approved for medical use in the United States; possible severe psychological or physical dependence (e.g., morphine sulfate) with abuse

3. Schedule III: drugs that have a lower potential for abuse than those in Schedules I and II; possible high psychological or low-to-moderate physical dependence with abuse (e.g., aspirin [Empirin] with codeine)

4. Schedule IV: drugs that have some potential for abuse; possible limited psychological or physical dependence (e.g., diazepam [Valium]) with abuse

5. Schedule V: drugs that have the lowest potential for abuse; products that contain moderate amounts of controlled substances; may be dispensed by the pharmacist without a physician’s prescription but with some restrictions such as amount, record keeping, and other safeguards (e.g., Robitussin A-C)

D Drug Regulating Reform Act—shortens the drug investigation process to release drugs sooner to the public

E Orphan Drug Act—encourages drug companies, through grants from the federal government, to investigate rare conditions

F Needle Safety Act of 2000—requires hospitals to have a program regarding needlestick prevention

PRINCIPLES OF DRUG ACTION

A The physiological means by which a drug exerts its desired effects

B Examples: include increasing or decreasing the rate at which a cell or tissue functions or replacing something that is needed by the body

PHARMACOKINETICS

A The study of what actually happens to a drug from the time it enters the body until it leaves the body

B Includes onset, peak, and duration of the drug

MECHANISMS OF DRUG THERAPY

A Dissolution: disintegration of dose form; dissolution of an active substance

B Absorption: the process that occurs between the time a substance enters the body and the time it enters the bloodstream

C Distribution: the transport of drug molecules within the body to receptor sites

D Metabolism: biotransformation—the way in which drugs are inactivated by the body

E Excretion: elimination of a drug from the body

VARIABLES THAT AFFECT DRUG ACTION

A Dosage

B Route of administration

C Drug-diet interactions: Food slows absorption of drugs. Some foods containing certain substances react with certain drugs (e.g., antidepressants can cause adverse reactions if eaten with certain types of food, including cheese and red wine).

D Weight: many antibiotics, particularly IV antibiotics, are ordered based on patient’s weight.

E Drug-drug interactions

1. Additive effect: occurs when two drugs with similar actions are taken together

2. Synergism (potentiation): a total effect of two similar drugs that is greater than the sum of the effects if each is taken separately

3. Interference: when one drug interferes with the metabolism or elimination of a second drug, resulting in intensification of effects of the second drug

4. Displacement: when one drug is displaced from a plasma protein-binding site by a second, causing an increased effect of the displaced drug

5. Antagonism: a decrease in the effects of drugs caused by the action of one on the other

F Age

1. Fetus: metabolism and elimination mechanisms immature

2. Newborn: organ systems not fully developed

3. Children: depends on age and developmental stage

4. Elderly adults: Physiological changes may alter the actions of a drug in the body. Elderly patients often take more than one medication; therefore the chances for interactions are increased.

G Body weight: affects drug action mainly in relation to dosage

H Pregnancy: Many medications cross the placental barrier and can be harmful to the fetus.

I Pathological condition: Disease processes are capable of altering drug mechanisms (e.g., patients with kidney disease have increased risk of drug toxicity because they have difficulty eliminating the medication; patients with liver disease have difficulty metabolizing medications).

J Psychological considerations: Attitudes and expectations influence patient response (e.g., anxiety can decrease effect of analgesics).

Common Responses to Medications

A Desired or therapeutic effect is the reason why a medication is administered.

B Side effects are usually predictable secondary effects produced by the medication; they may be desirable or undesirable.

C Adverse effects are more severe symptoms or problems that arise because of the medication. The nurse must be alert to reports of any adverse effects after the administration of medications.

Adverse Reactions to Drugs

A Idiosyncratic reaction: unusual, unexpected reaction, usually the first time a drug is taken

B Paradoxical effect: reactions opposite of what would be expected

C Allergic reactions: stimulate antibody reactions from immune system of body

1. Urticaria (hives)

2. Anaphylaxis: severe allergic reaction involving cardiovascular and respiratory systems; may be life-threatening

D GI effects

1. Anorexia

2. Nausea, vomiting

3. Constipation

4. Diarrhea

5. Abdominal distention

E Hematological effects

1. Blood dyscrasia

2. Bone marrow depression

3. Blood coagulation disorders

F Hepatotoxicity

1. Hepatitis

2. Biliary tract obstruction or spasms

G Nephrotoxicity: renal insufficiency or failure; kidney stones

H Drug dependence

1. Physiological: physical need to relieve shaking; pain

2. Psychological: need to relieve feeling of anxiety; stress

I Teratogenicity: ability of a drug to cause abnormal fetal development

Tolerance and Cross-Tolerance

A Tolerance: acclimation of the body to a drug over a period of time so larger doses must be given to achieve the same effect

B Cross-tolerance: tolerance to pharmacologically related drugs

SOURCES OF DRUG INFORMATION

Pharmacology changes rapidly. Nurses need to make use of the multiple resources available to stay current.

A Resource people

1. Pharmacists

2. Physicians

3. RNs

B Internet

C Poison control centers

D Published sources of information

1. United States Pharmacopeia (USP) and National Formulary (NF)

a. Official references

b. Establish legally binding standards to which drugs must conform

c. Revised every 5 years, with periodic supplements

2. Package insert: Food and Drug Administration (FDA)–approved label for drug products in the United States

3. Physicians’ Desk Reference (PDR)

a. Published annually, with interim supplements

b. Contains information supplied by manufacturers

c. Is most useful for finding drugs according to brand name

4. American Hospital Formulary Service

a. Contains data on almost every drug available in the United States

b. Kept current by periodic supplements

5. Pharmacology textbooks; drug reference books and cards; online sources often listed from the publisher

6. Nursing journals

7. Online sources, including the American Nurses Association (ANA) and the Centers for Disease Control and Prevention (CDC). Students must consider the site when using online information. There is a great deal of misleading information on the Internet.

NURSING PROCESS

A Assessment: obtain data on patient regarding problems related to:

1. Route of administration

2. Elimination or metabolism (particular attention paid to persons with renal or hepatic disease)

3. Baseline laboratory values

4. Patient teaching needs

B Planning

1. Proper timing of administration of ordered dose

2. Ways to improve the effectiveness of the drug

3. Instruction of patient concerning the drug

C Implementation

1. Proper method of administration

2. Proper timing of administration of ordered dose

3. Instruction of patient concerning the drug

D Evaluation

1. Effectiveness of drug

a. Subjective: questioning the patient for expected response of the drug (e.g., pain relief, reduction in symptoms)

b. Objective: monitoring physical response by the nurse (e.g., decreased blood pressure [BP], increased cardiac regularity, improvement in signs and symptoms of infection)

c. Documentation of assessment of pain and efforts to relieve it: required by TJC

2. Presence of side effects, adverse reactions

3. Effectiveness of patient teaching

4. If therapy is ineffective, examine possible causes, such as drug interactions, and report to RN or medical doctor (MD).

ADMINISTERING MEDICATIONS

CALCULATION OF DOSAGE

A Practical nurse responsibility

1. Abide by the guidelines of the health care agency.

2. Check for accuracy in dosage calculation before preparing and administering drug.

3. Check calculations with another knowledgeable person.

4. Measure doses exactly as prescribed by physician.

B Systems of measurement

1. Household system: measurements commonly used in the home; not as accurate as other systems; examples:

a. 1 teaspoon (tsp or t) = 60 drops (gtt)

b. 3 or 4 tsp = 1 tablespoon (tbsp or T)

2. Apothecary system: an older system, but continues to be used in dosage calculations in several areas of the United States and in several countries outside the United States

a. Common units of measurements

(1) Weight: grain (gr)

(2) Volume

(a) 60 minims = 1 dram (dr or d)

(b) 8 dr = 1 ounce (oz or z)

b. Notations in this system use lowercase Roman numerals; quantities less than 1 are expressed as common factors; exception: one half is written as “ss” in this system only.

3. Metric system: international decimal system

a. Common units of measurement

(1) Weight: unit is expressed in terms of the gram (g).

(a) Prefix kilo indicates 1000.

(b) Prefix milli indicates 1/1000.

(c) 1 g = 1000 milligrams (mg)

(2) Volume: unit is expressed in terms of the liter (L).

(a) Prefix milli indicates 1/1000.

(b) 1 L = 1000 milliliters (mL)

b. Notations in this system use Arabic numbers; fractions are expressed as decimals.

4. Equivalents between systems: a given quantity considered to be of equal value to a quantity expressed in a different system; some common approximate equivalents:

a. 1 kilogram (kg) = 2.2 pounds (lb)

b. 1 g = 15 gr

c. 60 mg = 1 gr

d. 1 cubic centimeter (cc) = 1 mL

e. 1000 mL = 1 quart (qt)

f. 30 mL = 1 oz

g. 1 mL = 15 or 16 gtt

h. 1 tsp = 4 or 5 mL

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