Topic 6:Medication Calculations Putting it together: Some miscellaneous medication questions that require the maths skills looked

at in the previous topics: Example 1 Tom is currently having all his fluid intake monitored. In a day he is taking 6 cups of tea of 180mL, soup 200mL, jelly 0.15L and cordial 1.5L. How many mLs has he taken in during the day? Tea soup jelly cordial 180mL x 6 0.15L 1.5L 1080mL 200mL 150mL 1500mL Total = 2930mL

Example 2 A child weighing 24kg is to have 10mg/kg/day of a drug. Calculate the amount of the drug the child will receive in a day. 10mg/kg/day means that for each kg of weight the child receives 10mg during the day. The child of 24kg requires 24 x 10mg = 240mg/day Example 3 A baby is ordered morphine 0.05mg/kg/hour. If the baby weighs 4.2kg, how many mg of morphine can he receive over the next hour? For each kg of weight the baby can receive 0.05mg each hour
= 4.2 0.05 42 5 = 210 the answer must have 3 dp = 0.210 =0.21mg

The baby can have 0.21mg morphine over the next hour.

Now to look at the calculations involved in delivering medication doses There are three main ways drugs may be administered: by injection, orally or intravenous infusion. We need to look at how to calculate dosages for each. As in the problems worked above we will need to apply the knowledge learned in the previous topics to be able to complete this section competently so look back and revise when you need to. Oral or injected medication calculations: After each calculation, ask yourself if the dosage calculated is a realistic answer, if not then check your calculations. Drug dosages for injections: There is one formula to calculate the Volume Required for an injection:
volume required = Strength Required volume of stock Stock Strength 1

The volumes will be measured in millilitres (mL), the strength required and stock strength in grams (g), milligrams (mg) or micrograms (mcg) You must make sure that the unit of measurement for the stock and strength required match if they dont convert them both to the smaller of the two units. Example Calculate the volume to be injected if a patient required 1mg of bumetanide, and each stock ampoule was 2mg/4mL. Strength Required is 1mg, The Stock Strength is 2mg in 4 mL, The units match so the formula becomes:
volume = 1 4 mL 2 1 4 = mL 2 = 2mL

The Volume to be injected is 2mL Example An infant requires 2000 units of Calciparine. If stock ampoules contain 20000 units in 1mL, how much should you draw up? Strength Required is 2000 units, Stock Strength is 20000units in 1mL So the formula becomes:
volu me

2000 1 = mL 200000 1 20 / 0 / 0 / = mL 20 0 / 0 / 0 / 2 = mL 20 1 = mL 10 0. 1 1 = 10 1. 0 = 0.1mL

The Volume Required is 0.1mL. Example If an adult patient was ordered 85mg of cortisone, and each stock ampoule was 5mL and contained 100mg of cortisone, find the volume required? Strength Required is 85mg, Stock Strength is 100mg in 5mL
volume = 0 4. 2 5 85 5 425 5 85 5 17 mL = mL = mL = mL = 4 11 7.1 0 2 0mL 100 1 100 5 20 5 4

Volume required is 4.25 mL.

Notice in each example covered so far the strength required and the stock strength were in the same units. In this next example we will need to convert the units so that they are the same. Example A patient is ordered 70mg of pethidine, find the volume required if the stock solution contains 10g of pethidine per 200mL. Strength Required is 70mg, Stock Strength is 10g in 200mL First change the g to mg to make the units the same: 10g mg = 10 1000mg = 10000mg Now putting this value into the equation
volume = 70 200 140 /0 /0 / 14 mL = mL = mL =1.4mL 10000 1 100 /0 /0 / 10

So we would inject 1.4mL of stock solution.

Dosage for Oral medication: tablets and mixtures: The formula for oral medication is the same as for injections:
volume required = Strength Required volume of stock Stock Strength 1

Lets look at some examples for mixtures and suspensions (note that there is no real difference with suspensions or mixtures, except suspensions have to be well shaken before use to obtain the correct stock strength): Example A patient who has a sore head from an accidental fall is prescribed 1000mg of a mild painkiller. The stock contains 100mg in 5mL. How much medication should be given to the patient? Strength Required is 1000mg Stock Strength is 100mg in 5mL
volume = 1000 5 500 /0 / 50 mL = mL = mL = 50mL 100 1 10 /0 / 1

So we would measure out 50mL of stock to give to the patient. Example Bill is prescribed 800mg of erythromycin, stock on hand contains 500mg/10mL in suspension. Find the amount of suspension required? Strength Required is 800mg

Stock Strength is 500mg (after shaking) in 10mL

volume = 1 6 800 10 800 /0 / 80 mL = mL = mL =5 8 3 0 =16mL 500 1 50 /0 / 5

Bill would receive 16mL of erythromycin.

Tablets: Things are slightly different when we start using tablets. The rules for tables are that you always try to use a whole tablet, and never use less than half a tablet. Always try to give as few tablets as is possible. Example: A patient is prescribed 50mg of codeine. The three types of codeine tablets on hand contain 5mg, 10mg and 20mg. We could give the patient ten 5mg tablets; however another option with fewer tablets would be preferable. We could give them two and a half 20mg tablets (this would be the least number of tablets); however we want to avoid chopping tablets in half if possible. The better option is to give two 20mg and one 10mg tablets. Check: 20mg + 20mg + 10mg = 50mg.

When a choice of tablet strengths is not available we can use a similar formula as for oral and injected doses to calculate the number of tablets required, however as the stock volume will always be 1 tablet the formula is modified to:
volume required = Strength Required Stock Strength

Example 750mg of ciprofloxacin is prescribed. On hand are 500mg tablets. How many tablets should be given? Strength Required is 750mg Stock Strength is 500mg
volume = 1. 5 750 750 / 75 25 3 tabs = tabs = tabs = tabs = 2 3.1 0 =1.5tabs 500 500 / 50 25 2

1 tablet and a half tablet are required Example How many 20mg tablets of codeine are required for a dose of 0.05g? Strength Required is 0.05g Stock Strength is 20mg

First step is to convert 0.05g to mg 0.05g mg = 0.05 1000mg = 0050. = 50mg

volume = 2. 5 50 50 / 5 tabs = tabs = tabs = 2 5.1 0 = 2.5tabs 20 20 / 2

2 tablets and a half tablet are required Intravenous (IV) infusion When the medication is to be administered intravenously we may need to calculate the drops per minute (dpm) to be delivered by the pump or the flow rate to be delivered in millilitres per hour by a volumetric infusion pump. To calculate the flow rate in millilitres per hour Divide the volume to be delivered in millilitres (mL) by the time in hours (h)
rate = volume(mL) time( h)

Example A patient is to receive 600mL to be infused over 4 hours. Calculate the rate in mL/ hour to be delivered by the pump.
rate = 150 600 300 mL / h = mL / h = 2 31 00 =150mL / h 4 2

Example A patient is to receive 1.5 litres over 8 hours. What is the rate in mL/h? The volume needs to be converted to mL 1.5L mL = 1.5 1000mL = 1500mL
rate = 1 8 7. 5 1500 mL / h =8 11 5 7 0 6 0.4 0 =188mL / h 8

Your answer should be expressed to the nearest whole number so use the usual rounding methods. Example A patient is to receive 100mL of fluid over 20 minutes. Calculate the flow rate in mL/h. The time needs to be converted to hours 20 minutes
rate =
20 1 h= h 60 3

h=

20 60 =

100 1 100 1 100 3 300 h = 100 = = = = 300mL / h 1 3 1 3 1 1 1 3

Remember from the fractions topic: make both numbers into fractions then flip the fraction you are dividing by and multiply

Another way to look at this question Consider how many 20 minute blocks there are in 1 hour So there are 3 blocks in 1 hour Each block = 100mL so 3 blocks = 3 100mL = 300mL

3 20 = 60

To calculate the rate in drops per minute (dpm) To calculate the rate in drops per minute we need to know the volume to be delivered in mL, the time in minutes and the rate of the giving set. Giving sets usually deliver at 20 drops per mL (macrodrip) or 60 drops per mL (microdrip) but can also deliver at 15 drops per mL.
driprate (dpm) = volume(mL) drops / mL time( h) 60

Example 800 mL of fluid is to be given intravenously to a patient over 6 hours. The IV set delivers at 20 drops/mL. Calculate the drip rate?
volume(mL) drops/mL time(h) 60 9 0 4
4

drip rate =

2 2 800 20 16000 / 1600 800 400 = = = = = = 6 60 360 / 36 2 18 2 9

4 0

4 . 4 0 . 4 0 = 44 drops/min

Remember that you can multiply the tops and bottoms and then cancel down (as shown) or else cancel down before any multiplying is done. Use whatever method you feel comfortable with. The advantage in cancelling is to make the numbers that you have to divide, as your last step, easier to work with. Your answer in dpm must be a whole number so use the normal rounding methods to obtain your final answer. Example A patient is to receive 200 mL of fluid over 40 minutes with a giving set of 20 drops/mL. How many dpm will the pump need to be set for? Here the time is given in minutes so the 60 is not required on the bottom line.
driprate = 200 20 4000 / 400 = = = 100dpm 40 40 / 4

Example A teenager who is badly dehydrated is to receive 1.5 L over 10 hours of rehydration fluid by IV infusion. The giving set delivers 20 drops/mL. Calculate the drip rate? Volume to be received = 1.5L = 1500mL

driprate =

1500 20 1500 / 20 / 150 2 2 150 1 150 = = = = = 50dpm 10 60 10 / 60 / 1 6 2 13 3

In this example the cancelling has been completed before any multiplying takes place. Example Calculate the drip rate if a patient is to receive 45 mL/h of fluid through i. a microdrip set. ii. a macrodrip set iii a 15 drops/mL set A flow rate of 45 mL/h equates to a volume of 45 mL over a 1 hour period. i. driprate = ii. driprate =
45 60 45 6 /0 / 45 = = = 45dpm 1 60 1 6 /0 / 1
45 20 45 20 / 45 2 2 45 1 45 = = = = = 15dpm 1 60 1 60 / 1 6 2 1 3 3
11.2 45 15 45 15 15 45 1 45 = = = = 4 45.1 0 =11dpm 1 60 1 60 15 1 4 4

iii.

driprate =

Other calculations involving IV flow rates At times the flow rate may be known but the volume or the time may be unknown. This requires our formula to be re-arranged. To find the volume: To find the time:
volume(mL) = rate(mL / h) time(h)

time(h) =

volume(mL) rate( mL / h)

Example A patient is receiving 100mL/h of a solution for 1.5 hours. How much fluid are they receiving? rate = 100mL/h time = 1.5 h We need to calculate the volume.
volume ( mL) = rate( mL / h) time( h) = 100 1.5 = 150mL

So the patient is receiving 150 mL Example A patient is prescribed 2000mL (2L) of a dextrose saline solution. The flow rate is set at 160mL/h. How long will the infusion take? rate = 160mL/h volume = 2000mL. We need to calculate the time.
time( h) = 1 2. 5 volume( mL) 2000 2000 / 200 2 100 2 50 = = = = = = 4 51 0.2 0 =12.5h rate( mL / h) 160 160 / 16 2 8 2 4

To convert 0.5 hours to minutes, multiply by 60: 0.5 x 60 = 30 minutes Time needed for infusion is 12 hours and 30 minutes

Drug calculations exercises Exercise set 1 1) A patient is ordered an injection of 80mg of pethidine. Each stock ampoule contains 100mg per 1 mL. How much will you draw up for the injection? 2) A child requires 50 milligrams of Phenobarbitone. If stock ampoules contain 200 milligrams in 2mL, how much will you draw up? 3) What volume is required for the injection if a patient is ordered 500mg of capreomycin sulphate, and each stock ampoules contains 300mg/mL,? 4) A patient needs 5000mg of medication. Stock solution contains 1g per 1mL. What volume is required? 5) A teenager is prescribed 1000mg of chloramphenicol, stock on hand contains 250mg/10mL in suspension. Calculate the volume required. 6) A patient is prescribes 3g of sulphadiazine, the stock contains 600mg/5mL. How much stock should be given to the patient? 7) Complete the following table: Strength Required Stock i) 1000U 1000U/2mL ii) 1.25micrograms 2.5micrograms/1mL iii) 20mg 100mg/50mL iv) 1megaunit 1megaunit/10mL v) 4g 1g/5mL Note: 1 megaunit is 1 million units. Volume Required

8) Complete this table: Prescribed amount Stock tablets on hand i) 50mg 2mg, 5mg, 20mg, 40mg ii) 15mg 4mg, 10mg, 20mg iii) 13mg 1mg 5mg 8mg 10mg

Best combination of tablets

9) How many 300mg tablets should be administered for a prescribed dose of 450mg? 10) How many 25mg tablets are required for a prescribed dose of 0.05g? 11) A child weighs 12 kg and is ordered 15mg/kg of medication. If stock strength is 200mg in 5mL, calculate the volume required. 12) Calculate the size of a single dose if a child weighing 20kg is ordered flucloxacillin 100mg/kg/day, 4 doses per day.

Exercise set 2

1) 500ml is to infuse over a 5 hour period. Find the flow rate in mL/h? 2) Mr Smith is to receive 800mL of an antibiotic via an IV infusion over 15 hours. Calculate the flow rate to be set? 3) An infusion is to run for 30 minutes and is to deliver 200mL. What is the rate of the infusion in mL/h? 4) Calculate the flow rate if 1.2L is to be infused over 24 hours? 5) An order states that 500mL albumin 5% is to be given in 4 hours. What is the flow rate that should be set? 6) A young adult has been prescribed 1000mL of 5% Dextrose to be administered over a period of 10 hours, through a set delivering 20 drops/mL. What drip rate in dpm should be established? 7) i) A young child has been prescribed 800mL of Hartmanss solution to be administered over twenty hours, using a set delivering at 20 drops/mL. What should the drip rate be? ii) If the medication is to be delivered over 10 hours what would the drip rate be? 8) A patient is ordered 100mL to be infused over 45 minutes via a 20 drops/mL giving set. What drip rate should be set? 9) A patient is ordered 200mL to be infused over 30 minutes via a microdrop set. What drip rate should be established? 10) What drip rate is required to administer 500mL of whole blood via a blood giving set (15 drops/mL) over a period of 4 hours? 11) A patient is receiving an IV infusion at the rate of 80mL/h. Calculate the drip rate via a 20 drops/mL giving set? 12) Find the drip rate if a patient is receiving fluid at the flow rate of 120mL/h through a 20 drops/mL giving set? Exercise set 3 1) A patient is receiving 260mL/h of a solution for 1.3 hours (1 hour and 18 minutes). How much have they received? 2) A patient is prescribed 1L of a saline solution. The rate is set at 150mL/h. How long will the infusion take? Give your answer to the nearest minute. 3) You are monitoring an IV infusion of 5% Dextrose that has been running at a rate of 40dpm via a 15 drops/mL giving set for 6 hours. What volume of fluid has been administered in this time? (this is a harder question)

Solutions Set 1 1) 0.8 mL 7i) 2 mL 2) 0.5 mL 7ii) 0.5 mL 3) 1.7 mL 7iii) 10 mL 4) 5 mL 7iv) 10 mL 5) 40 mL 7v) 20 mL 6) 25 mL

8i) 1 x 40 mg + 2 x 5 mg 8iii) 1 x 5 mg + 1 x 8 mg 9) 1.5 tabs 10) 2 tabs Set 2 1) 100mL/h 6) 33 dpm 10) 31 dpm 2) 53mL/h 7i) 13 dpm 11) 27 dpm

8ii) 1 x 10 mg + x 10 mg 11) 4.5 mL 3) 400mL/h 7ii) 27 dpm 12) 40 dpm 12) 500mg 4) 50mL/h 8) 44 dpm 5) 125mL/h 9) 400 dpm

Set 3 1) 338 mL 2) 6.7 hours = 6 hours and 42 min 3) volume = 40 x (6 x 60) = 14 400 drops = 14 400/15 = 960mL

Calculating Flow Rate (mL/hr) IV infusion pumps that are set to deliver mL/hr are in wide use today. The nurse needs to be comfortable calculating the number of mL per hour that the patient is to receive. Once the number of mL/hr is determined, the nurse can then adjust the pump to deliver the correct number of mL per hour. Your patients IV orders read: Administer 3000 mL D5W/24 hours.The first factor to determine is how many mL/hr you need the pump to deliver. There are two methods you can use to determine this: Method #1: Ratio and Proportion 3000 mL= x mL 24 hours1 hour24x = 3000 x = 125 mL/hrMethod #2: Formula (based upon the ratio and proportion above) Total volume = mL/hour infusion rate # of hours to infuse 3000 = mL/hr 24 Material protected by copyright 125 = mL/hr For most drug calculation problems, there is more than one method for arriving at the correct

answer. This course demonstrates Ratio & Proportion and the Formula method, but does not demonstrate Dimensional Analysis, as it can be lengthy. Material protected by copyright Practice: Calculating Flow Rate (mL/hr) Perform a similar calculation:Your patients IV orders read: Administer 2.5 L LR/10 hours You will adjust the IV infusion pump to deliver _____mL/hr? Method #1: Ratio and Proportion Method #2: Formula Method

Material protected by copyright Calculating IV Drip Rates The pump does this, I dont have to!Might you be thinking something like that at this point in the course? Although IV infusion pumps are very widely used, nurses are accountable for validating that a pump is functioning properly and delivering IV fluid at a safe and effective rate. Therefore, you must be prepared to calculate the number of drops per minute required to fulfill an IV order. Calculate the number of drops per minute that the pump should be delivering for the setting and validate at intervals that the pump is working properly. There are also occasions when IV infusion pumps may not be available and occasions when patients are disconnected from pumps for transfer or transportation. To practice safely, you must be prepared to calculate IV drip rates.

Commonly Supplied IV Sets: Drip Factor The most commonly supplied IV Sets today have one of the following drip factors: 60 gtts/mL 15 gtts/mL 10 gtts/mL minidrip set regular drip set regular drip set Note that for each set, if you divide the 60-minute hour by the number of drops per mL, you will obtain a whole number of minutes. That is: 60 gtts/mL 15 gtts/mL 10 gtts/mL minidrip set = Sixty 1-minute periods regular drip set = Fifteen 4-minute periods regular drip set = Ten 6minute periods Time Period per Hour Method With these relationships of drip sets to the 60-minute hour, you can readily calculate gtts/hr when you know mL/hr.Simply divide the number of mL/hr by the appropriate number of minutes per time period. 80 mL/hr via 60 gtts/mL set 80 mL/hr via 15 gtts/mL set 80 mL/hr via 10 gtts/mL set = 80 /1 = = 80 /4 = = 80 /6 = 80 gtts/min20 gtts/min13.3 gtts/min, rounded to 13 gtts/min Material protected by copyright Calculating Time Period per Hour To calculate: Divide 60 by the number of gtts/mL Then, divide the number of mL/hr by the result of 60 gtts/mLThe time period per hour method is by far the simplest method of calculating drip rates. 60 gtts/mL minidrip set = Sixty 1-minute periods 15 gtts/mL regular drip set = Fifteen 4-minute periods 10 gtts/mL regular drip set = Ten 6-minute periods Calculating Drops per Minute Although the 60-minute clock method is the simplest way to determine drops per minute, other methods will give the same result. Here are 3 methods for calculating drops per minute. You have an order for 1000 mL D512 NS IV to be infused over 8 hours. You will use a drip set that delivers 15 gtts/min. Calculate for Method 1:Find mL/hr and use the 60-minute clock method

Material protected by copyright Calculate for Method 2: Using Formula Method Calculate for Method 3:Using Ratio and Proportion Method Practice: gtts/min Calculations Practice these gtts/min calculations. Use all of the methods above on at least one problem. How many gtts/min will deliver: 1. 3 L IV fluid over 24 hours, using a 10 gtt/mL set? 21 gtts/min 2. 100 mL IVPB over 1 hour, using a 15 gtt/mL set? 25 gtts/min 3. 50 mL IVPB over 1 hour, using a 60 gtt/mL set? 50 gtts/min 4. 250 mL over 4 hours, using a 60 gtt/mL set? 63 gtts/min

Material protected by copyright Test Yourself

Your patient is receiving 1000 mL D512 NS IV with 20 mEq KCl over 8 hours per IV infusion pump. The drip set delivers 15 gtts/mL. While completing your assessment of the patient, you note that the IV is dripping rapidly you estimate, at approximately 1 gtt/second. The pump is set at 150 mL/hr. Is the pump set correctly? Is the pump malfunctioning? The pump is not set correctly. To deliver 1000 mL in 8 hours, the pump should be set to deliver 125 mL/hr.The pump is also malfunctioning. 150 mL/hr with a 15 gtts/min drip set = 38 gtts/min. To deliver 125 mL/hr with a 15 gtts/min set, the drip rate should be 31gtts/min. Miscellaneous IV Infusion Calculations mL/min = mL/hr 60 mcg/mL = mg/mL X 1000 These two equations or formulae are based on the conversion factors: 1 hour = 60 minutes and 1mg=1,000mcgYou can use these equations, or alternatively you can use ratio and proportion to make same calculations. For example: Your patient has an IV infusing at a rate of 125 mL/hr. How many mL per minute is your patient receiving? Method #1: Ratio and Proportion

Material protected by copyright Method #2: Formula

Practice: Miscellaneous IV Infusion Calculations You have added 1 mg of epinephrine to 500 mL of D5W. How many mcg/mL does this solution contain? Method #1: Ratio and Proportion

Method #2: Formula

Material protected by copyright Infusion Rate Equation for mcg/min When you have an order in mcg/min and have a solution that you have received from pharmacy containing a drug measured in mg, you must calculate mL/hr in order to program the IV infusion pump correctly. You can calculate mL/hr using ratio and proportion, or alternatively, by using a formula (equation). Your patient has an order for Epinephrine 4 mcg/min IV. Pharmacy has supplied a solution labeled Epinephrine 1 mg in D5W 500 mL. You will set the infusion pump for how many mL/min? The first step is to calculate the concentration. Once you know the concentration in mcg/mLs, you can work out the mLs/min by determining the number of mLs needed to deliver 4mcg/min.

Material protected by copyright Infusion Rate Equation for mcg/min Step Two: Calculate the number of mls needed to deliver 4 mcg/min

Method #1:Formula Infusion Rate (mL/hr) = (Target dose in mcg/min) X 60 (Concentration in mg/mL X 1000) mL/hr = (4 mcg/min) X 60 (0.002mg/L X 1000) mL/hr = 240 2 mL/hr = 120 To calculate mL/min:mL/60 min = 120/1 mL/min = 2 2 mcg/mL = x or 0.002 mg/mL = x Infusion Rate Equation for mcg/min Method #2: Ratio and Proportion Step one is to calculate the concentration (in mcg/mL): See Reinforcement Box on screen 20. Step two is to calculate the number of mLs needed to deliver 4 mcg/min: Using 2mcg/mL, use the ratio and proportion method to find the number of mLs needed to deliver 4mcg/min: 2mcg = 4mcg 1 mL x mL 4=2x x = 2 mL 2 is the number of mL per minute needed to deliver a dose of 4 mcg. Since there are 60 minutes in one hour, multiply 2 X 60 to obtain the number of mL/hr. 2X60 = 120mL/hrAs you can see, ratio and proportion is the basis of the formula given in method #1. Using the formula reduces the number of steps in the calculation and thereby reduces error. Material protected by copyright Infusion Rate Equation for mcg/kg/min Since some drugs are ordered in mcg/kg/min (such as Dobutamine and Dopamine), you will need to calculate the infusion rate in mL/hr in order to administer these potent drugs via an IV infusion pump. Compute mL/hr for drugs dosed in mcg/kg/min using any of the two familiar methods: formula or ratio and proportion. You are ordered to administer Dobutamine 5 mcg/kg/min IV. Your patient weighs 152 pounds. You have infusate labeled 250 mg Dobutamine in 500 mL D5W. You will set the IV infusion pump to deliver how many mL/hr?

Infusion Rate Equation for mcg/kg/min Method #1: Ratio and Proportion First find the patients dose: Weight in kilograms = 152 2.2 = 69.0909, which is rounded to 69.1 69.1 X 5 mcg/kg/min = 345.5 mcg/kg/min Next find the amount of drug in mcg/mL of infusate: x mg = 250 mg 1 mL 500 mL 500 = 250 x mgx mg= 0.5 mg/mLmcg/mL = mg/mL X 1000 500 mcg/mL = 0.5 mg/mL Now find the number of mL/min needed for the ordered dose: 500 mcg = 345.5 mcg 1 mL x mL 345.5 = 500 x x = 0.691 mL contains the patients dose per minute, 345.5 mcgNow find the number of mL per hour needed to deliver the patients dose: 60 min X the one-minute dose of 0.691 mL = 41.46 mL/hr, rounded to 42 mL/hr Infusion Rate Equation for mcg/kg/min Method #2: FormulaInfusion Rate (mL/hr) = (Weight in kg ) (Target Dose in mcg/kg/min) X 60 (Infusate concentration in mg/mL) X 1000 NOTE: In a mathematical operation, when 2 quantities appear in parentheses proximate to one another, this means multiply. So (Weight in kg ) (Target Dose in mcg/kg/min) in this formula means the same as (Weight in kg ) X (Target Dose in mcg/kg/min). Material protected by copyright Infusion Rate Equation for mcg/kg/min Inspect the formula on the previous screen and identify the units of measure that you need to obtain in order to use the formula. You need to know: 1. Thepatientsweightinkilograms 2. Theinfusateconcentrationinmg/mL Using the conversion equivalents or ratio and proportion, find these values: 1. Weight in kilograms = 152 2.2 = 69.0909 . . . , rounded to 69.1 2. x mg = 250 mg 1 mL 500 mL 250 = 500 x x = 0.5 mg/mLNow, enter these values into the formula on the previous screen: Infusion Rate (mL/hr) = (69.1 kg ) (5 mcg/kg/min) X 60 (0.5 mg/mL) X 1000 And do the math:Infusion Rate (mL/hr) = 20730 = Infusion Rate (mL/hr) = 41.46, rounded to 42 500 Practice Q1: Infusion Rate Equation for mcg/kg/min

Your patient has an order for ceftriaxone (Rocephin) 1.5 gm in D5W IVPB Q12H. The following information appears on the label of the piggyback bag of ceftriaxone (Rocephin) powder 2 gm: Piggyback Bottle Dosage Size 1 gm 2 gm Amount of Diluent to be Added 10 mL 20 mL

After reconstitution, further dilute to 50 mL or 100 mL volumes with the appropriate IV diluent. Question One: a. Ifyoudiluteto100mL,howmuchofthesolutionwillyouwasteinordertodelivertheordered dose? b. IfyouadministertheIVPBviaadripsetthatdelivers15gtts/mL,athowmanydropsperminute will you regulate the IV infusion rate in order for the solution to infuse over a one hour period? Material protected by copyright Answers to Practice Question 1Part a: The easiest method is the ratio and proportion method: 1000mL= mL 8x=1000 x=125mL/hr 8 hr 1 hr The IVPB bag contains 100 mL, so you will waste 25 mL in order to obtain the dose which is contained in 75 mL. Part b: The easiest alternative is the 60-minute clock method: 15 gtts/mL regular drip set = Fifteen 4-minute periods 75 = 18.75 gtts/min, rounded to 19 gtts/min 4 Using the formula method: IV drip rate (gtts/min) = volume to be infused (mL) X drip factor of tubing time (minutes to be infused) IV drip rate (gtts/min) = 75 mL X 15 gtts/mL = 18.75, rounded to 19 gtts/min 60 min What is the recommended time period over which to administer Verapamil or Dopamine IV push? 2 minutes Practice Q2: Infusion Rate Equation for mcg/kg/min Your patient has an IV order for 1 Liter Lactated Ringers Solution with 20 mEq KCl IV Q8HR. You receive the IV solution premixed from pharmacy. To deliver the ordered dose you will set the IV infusion pump for how many mL/hr? By ratio and proportion: 1000 mL = x mL 8 hr 1 hr 8 x = 1000x = 125 mL/hr

Material protected by copyright Practice Q3: Infusion Rate Equation for mcg/kg/min Your patient has an order for Dopamine (Intropin) 2 mcg/kg/min IV in D5W. Your patient weighs 170 pounds. You have a 500 mL premixed bag containing Dopamine 0.8 mg/mL in D5W. To deliver the ordered dose you will set the IV infusion pump for how many mL/hr? By ratio and proportion: First find the patients dose in mcg/min by finding the patients weight in kg and multiplying by 2 since the patient is to receive 2 mcg/kg/min. Patients dose in mcg/min = 154.545 Next, multiply the patients dose in mcg/min X 60 to obtain the patients dose in mcg/hr = 9272.72 mcg/hr Each mL of the infusate contains 0.8 mg = 800 mcg/mL To find how many mL/hr, you need to find how many mL contain 9273 mcg 1mL =xmL 800mcg 9273mcg 800 x = 9273x = 11.59, rounded to 12 mL/hr By the formula method: Convert 170 lb = 77.3 kgInfusion Rate (mL/hr) = (77.3 kg ) (2 mcg/kg/min) X 60 = 9276 (0.8 mg/mL) X 1000 800 = 11.59, rounded to 12 mL/hr Pediatric Drug Calculations Many of the drug calculation approaches explained earlier in the course apply to both pediatric and adult patients. Certain specific calculations arise only in the pediatric setting. Checking a prescribed dose for safety (Is the dose too high?) and effectiveness (Is the dose too low?): Comparing ordered dose to total recommended daily dose in unit/kg of body weight Comparing ordered dose to body surface area (BSA) Using kg of body weight to calculate IV drip rate for: Packed red blood cells (RBC) Colloids IV fluid maintenance Material protected by copyright Checking the Safety/Effectiveness of a Prescribed Dose: Unit/kg of Body Weight A child who weighs 50 pounds has an order for amoxicillin oral suspension (Amoxil) 250 mg PO Q8H. According to the drug reference on the unit, the recommended pediatric dose is 20 50 mg/kg/day in

divided doses every 8 hours. Does the ordered dose fall within the recommended range of dosage? What questions must you answer before you can answer the question about the safety and effectiveness of the ordered dose? What is the childs weight in kg? The Child's Weight is 50/2.2 = 22.72, rounded to 22.7 kg What are the upper and lower limits of recommended daily dosage for this patient? 22.7 X 20 mg/day = 454 mg/day lower limit 22.7 X 50 mg/day = 1135 mg/day upper limit What are the upper and lower limits of recommended single eight-hourly dose for this patient? How many eight-hour periods are there in a day? (24 hours per day/8 = 3) 454 mg/day lower limit/3 = 151.3 mg1135 mg/day upper limit/3 = 378.3 mg151.3 mg/single 8-hour dose lower limit 378.3 mg/single 8-hour dose upper limit Does the ordered dose lie within or outside of the recommended range? The dose of 250 mg Q8H lies within the recommended range. Material protected by copyright Checking the Safety/Effectiveness of a Prescribed Dose: Body Surface Area (BSA) Body Surface Area (BSA) is calculated using height and weight. The formula appears below. However, BSA is more commonly located on a nomogram rather than by applying the formula. 2 BSA (m ) = OR, using metric measures of height and weight: 2 BSA (m ) = Body Surface Area Nomogram

Material protected by copyright Using a Nomogram Locate the patients height in the scale on the left of the nomogram using the appropriate side of the scale for centimeters or inches. With a ruler or straight edge connect the height with patients weight on the scale at the right side of the nomogram again, using the correct side of the scale for pounds or kilograms. In the example above, the patient is 120 cm tall and weighs 40 kg. The point at which the straight edge intersects the BSA scale indicates the patients BSA in M2 = 1.2 M2. Note that the boxed area indicates BSA for children of normal height for weight, using weight in pounds on the left of the scale to indicate BSA on the right. Application of BSA Formula BSA is used in the following formula to check a dose for safety (Is the dose too high?) and effectiveness (Is the dose 2 2 too low?). Child's BSA in M X adult dosage 1.7 M A child who has a BSA of 0.7 and weighs 37 pounds has an order for cloxacillin (Cloxapen) 0.5 gm oral suspension Q6H. Your drug reference states that the recommended dose for children >20 kg and adults is 250 500 mg Q6H. Does this dose fall within the safe/effective range for this child? Does this child weigh more than 20 kg? 37/2.2 = 16.8 kg...No the child does not weigh > 20 kg, so the adult dose is not appropriate. If the child weighs less than 20 kg, what is the appropriate dose range for this child? LOW: 0.7 X 250 = 175 = 102.9, rounded to 103 mg 1.7 1.7 HIGH: 0.7 X 500 = 350 = 205.8, rounded to 206 mg 1.7 1.7 Since the recommended dose range is in mg and the ordered dose is in gm, how many mg does the ordered dose equal?

0.5 gm = 500 mg...Since the ordered dose is 500 mg and the upper limit of safe is 206, the ordered dose is too high. Material protected by copyright Using kg of Body Weight to Calculate IV Drip Rate for Packed Red Blood Cells (RBC) The Recommended Volume Range for Administering Packed RBCs to a Pediatric Patient is 10 20 mL/kg. For a child who weighs 63 pounds, the recommended volume range for administering packed RBCs is ___________. First find the childs weight in kg: 63/2.2 = 28.6 kgLow end of range = 10 X 28.6 = 286 mLHigh end of range = 20 X 28.6 = 572 mLRecommended volume range for this child = 286 mL to 572 mL Using kg of Body Weight to Calculate IV Drip Rate for Colloids The recommended Dose Range for Administering Colloids to a Pediatric Patient is 10 20 mL/kg For a child who weighs 45 pounds, the recommended volume range for administering albumin is ___________. First find the childs weight in kg: 45/2.2 = 20.5 kgLow end of range = 10 X 20.5 = 205 mLHigh end of range = 20 X 20.5 = 410 mLRecommended volume range for this child = 205 mL to 410 mL Using kg of body weight to calculate IV drip rate for IV fluid maintenance Using kg of body weight to calculate IV drip rate for IV fluid maintenance: For a child who weighs 42 pounds, the correct IV drip rate for fluid maintenance is how many mL/hr? First, find the childs weight: 42/2.2 = 19.09, rounded to 19 kg Childs Weight in Kg 0 10 kg 11 20 kg 21 kg Material protected by copyright Next, identify the correct formula: 11 20 kg 40 mL/hr + 2 mL/kg/hr IV Drip Rate for Fluid Maintenance 4 mL/kg/hr 40 mL/hr + 2 mL/kg/hr 60 mL/hr + 1 mL/kg/hr

Then, multiply 19 X 2 = 38 and add the result to 40 mL = 78 mL/hr Pediatric Infusion Equation Use the Pediatric Infusion Equation to calculate the number of mg of drug to be added to obtain 100 mL of infusate such that 1 mL/hr = 0.1 mcg/kg/min 0.6 mg X weight in kg = drug + fluid = 100 mL of infusate This concentration run at 1 mL/hr will deliver 0.1 mcg/kg/min

Your patient, who weighs 42 pounds, is to receive epinephrine 0.1 mcg/kg/min IV in D5W, 100 mL of infusate. How will you prepare 100 mL of infusate such that you will deliver the ordered dose by running the infusion at 1 mL/hr? First, find the patients weight in kg: 42/2.2 = 19.09, rounded to 19.1Then, use the formula to calculate the number of mg of epinephrine to add to obtain a 100 mL infusate.0.6 mg X weight in kg = drug + fluid = 100 mL of infusate 0.6 X 19.1 = 11.46, rounded to 11.5 mg Pediatric Infusion Equation In some situations, you may find it necessary to adjust your initial calculations by a factor of 10. For example, epinephrine pediatric injection for solution is supplied in the strength of 0.1 mg/mL. In order to obtain 11.5 mg, you would need to use more than 100 mL! Therefore, you can adjust your calculation by using 0.1 X your calculated dose of 11.5 mg = 1.15 or 1.2 mg. To compensate for using 0.1 of the calculated dose, multiply the rate X 10 = 10 mL/hr. Practice Calculations Your patient is a 4-year-old who weighs 48 pounds. His physician orders a daily maintenance dose of digoxin pediatric elixir 250 mcg PO. The drug is supplied in a 60 mL bottle containing 50 mcg/mL. Material protected by copyright Questions: 1. (a). According to your drug reference, the recommended daily maintenance oral dosage for a child age 2 years to age 5 years is 7.5 10 mcg/kg. Is the 250 mcg dose a safe dose using recommended mcg/kg? No, the 250 mcg is not safe by this method. It exceeds the recommended range. The child weighs 21.8 kg (48 lb/2.2).21.8 X 7.5 mcg = 163.5 mcg, lower limit recommended 21.8 X 10 mcg = 218 mcg, upper limit recommended This answer may also be obtained by ratio and proportion . (b). Your unit policy is to determine safe dosage by using BSA. When you refer to the nomogram, you identify this childs BSA as 0.85. The recommended PO adult maintenance dosage is 0.125 0.5 mg. Using the BSA method, is the 250 mcg dose a safe dose? 2 By the BSA method, the dose is at the upper limit of recommended dosage. Child's BSA in M X adult dosage 2 1.7 M Change 0.125 mg to mcg = 125 mcgChange 0.5 mg to mcg = 500 mcg0.85 X 125 = 106.25 = 62.5 mcg, lower limit recommended 1.7 You might alternatively first divide 0.85/1.7 = 0.5 and then multiply 0.85 X 500 = 425 = 250 mcg, upper limit recommended 1.7

0.5 X 125 = 62.5 mcg You might alternatively first divide 0.85/1.7 = 0.5 and then multiply 0.5 X 500 = 250 mcg Note: There is a large discrepancy between these two methods, since the recommended mcg/kg is a range (a range of 2.5 mcg/kg which is the difference between the lower limit of 7.5 mcg/kg and the upper limit of 10 mcg/kg). The BSA method uses the adult dosage and the range for the adult dosage is 125 mcg to 500 mcg a range of 375 mcg. Therefore, the mcg/kg method will give a narrower range. (c). The childs doctor writes a new order for digoxin pediatric elixir 200 mcg PO. Is this dose within safe and effective limits for this child (weight, 48 lb., BSA, 0.85)? Yes, 200 mcg is within the safe and effective range, by either method. Material protected by copyright (d). How many mL of digoxin pediatric elixir containing 50 mcg/mL will you prepare to administer a 200 mcg dose? 200mcgX1mL= 4mL 50 mcg (e). How many 200 mcg doses will you obtain from the 60 mL bottle? 15 doses You can determine this answer either by dividing 60 mL by 4 mL OR by multiplying 60 mL by 50mcg/mL = 3,000 mcg per bottle and then dividing 3,000 by the 200 mcg per dose. Practice Calculations 2. Use the maintenance IV fluid calculation to determine hourly IV fluid rate for a child who weighs 50 lb. 83 mL/hr 3.The childs weight in kg = 22.7 kg. 50/2.2 = 22.7. Therefore the IV drip rate for fluid maintenance is 60 mL/hr plus 22.7 = 82.7, rounded to 83. Childs Weight in Kg 0 10 kg 11 20 kg 21 kg IV Drip Rate for Fluid Maintenance 4 mL/kg/hr 40 mL/hr + 2 mL/kg/hr 60 mL/hr + 1 mL/kg/hr

191 mg to run at 1 mL/hr. OR, 95.4 mg to run at 2 mL/hr. Childs weight in kg = 15.9 kg. 35/2.2 = 15.91 mcg/kg/min6 mg X weight in kg drug + fluid = 100 mL 6 mg X weight in kg = drug + fluid = 100 mL of infusate 6 mg X 15.9 = 95.4 mg for 1 mcg/kg/min. To obtain 2 mcg/kg/min, multiply by 2 = 190.8 mg, rounded to 191 mg. This solution, run at a rate of 1 mL/hr will deliver the ordered dose. Alternatively, add 95.4 mg to obtain 100 mL of solution and run at 2 mL/hr. 6 mg X weight in kg drug + fluid 100 mL of infusate

Material protected by copyright Tips for Calculation Safety The absolute safest approach to administering medications, IV fluids and performing other interventions requiring calculation is to AVOID CALCULATION UNLESS ABSOLUTELY NECESSARY. This is because there is always potential for human error and there is often the potential for distraction while calculating which can lead to error. Ways to avoid calculation include: The use of computer algorithms. Completion of most calculations by the pharmacy. Posting durable (e.g., laminated) references that give the calculated amounts, rates or other answers for frequently used drugs. Tips for Calculation Safety When calculation is unavoidable, the following tips can help assure calculation safety: Always use the same method to approach the same type of problem. Always have your answer verified by an RN colleague and assure that your colleague actually performs the calculation. Assert your need to concentrate by eliminating distractions while performing calculations. Before beginning the calculation procedure, identify some of the parameters of a sensible answer for example, "Should the correct answer be more or less than one mL?" Then, compare the answer you obtain with your common sense parameter. Assure that you have taken into account all of the relevant conversion factors for example, if you have obtained a rate in mL, have you obtained mL per hour or mL per minute?. Validate your calculated answer with an appropriate up-to-date drug reference. That is, does your calculated answer fall within recommended guidelines? Conclusion This course has offered evidence to support the need for nurses to maintain competency in performing selected calculations. The course has presented basic principles of math and algebra. A variety of examples of calculation problems common in nursing practice have been presented and solved. The course has provided the opportunity for practice with at least two methods for solving particular problems.