NURSE REFRESHER COURSE

Author: Alene Burke RN, MSN
80 Contact Hours
Alene Burke & Associates is approved as a provider of Continuing Education by the Florida Board of Nursing, Provider # 50-2502


To take the test:
If you are not registered:

This course can be taken by those who are preparing for the NCLEX exam, for remediation, discipline and as a continuing education course. At the conclusion of this course, you will be able to:

  1. Detail legal and ethical aspects of nursing.
  2. Describe all aspects of medication administration.
  3. Discuss numerous aspects relating to pharmacology.
  4. Relate the roles of the nurse.
  5. Perform a complete physical assessment.
  6. Detail perioperative care, oncology care, geriatric care and a thorough knowledge about the complete care of adults and pediatric patients with respiratory, cardiovascular, neurological, sensory, gastrointestinal, nutritional, renal, genitourinary, reproductive, metabolic, endocrine, hematologic, immunologic, musculoskeletal and integumentary diseases and disorders according to etiology, signs and symptoms, nursing assessment, nursing diagnosis, care, complications, patient/family education, evaluation of care and treatment.
  7. Describe emergency care.
  8. Detail maternal, neonatal and pediatric care and treatment according to etiology, signs and symptoms, nursing assessment, nursing diagnosis, care, complications, patient/family education, evaluation of care and treatment.
  9. Demonstrate a complete and thorough knowledge of psychiatric and mental health nursing.

COURSE REQUIREMENTS

In order to take this course, you must purchase or borrow the Lippincott Manual of Nursing Practice 8th Edition (May 2005). It is available for purchase at Barnes and Noble, Borders Books, Amazon.com and at many college or university bookstores. You may be able to borrow it from a friend or a college or university library.

If you prefer to borrow it from our company, a $75 deposit is necessary to insure its safe and prompt return after using it for 2 months. Contact Alene@AleneBurke.com to borrow the book with this deposit.

  1. Read and study the passages below on Legal and Ethical Issues, Pharmacology and Medication Administration.
     
  2. Read and study the following chapters in The Lippincott Manual of Nursing Practice:

    The Role of the Nurse
    Chapters 1, 2 and 3

    Adult Physical Assessment
    Chapter 5

    IV Therapy
    Chapter 6

    Perioperative Care
    Chapter 7

    Oncology Care
    Chapter 8

    Care of the Older Patient
    Chapter 9

    Respiratory
    Chapters 10 and 11

    Cardiovascular
    Chapters 12, 13 and 14

    Neurological and Sensory
    Chapters 15, 16, 17

    Gastrointestinal and Nutritional
    Chapters 18,19, and 20

    Renal, Genitourinary and Reproductive
    Chapters 21, 22 and 23

    Metabolic and Endocrine
    Chapters 24 and 25

    Hematologic
    Chapters 26 and 27

    Immunologic Disorders
    Chapters 28, 29, 30 and 31

    Musculoskeletal
    Chapter 32

    Integumentary
    Chapters 33 and 34

    Emergencies
    Chapter 35

    Maternal and Neonatal Nursing
    Chapters 36, 37, 38 and 39

    Pediatrics
    Chapters 40 through and including Chapter 56

    Psychiatric and Mental Health Nursing
    Chapter 57
     
  3. Take and pass the post test.

INTRODUCTION TO NURSING LAW

“Ignorance of the law excuses no man; not that all men know the law, but because it is an excuse every man will plead, and no man can tell how to refute him.” (Selden 1584-1654; Bartlett & Dole, 2000).

Nursing is a profession regulated with its own unique body of law. The purpose of these laws and regulations is to protect the consumer of our care and services, that is, the patients, residents and clients that we care for.

Knowledge of and adherence to the law is an imperative professional responsibility. This course will provide you with many aspects of the law and how these laws impact your practice, however, it is up to you to periodically check with the State of Florida in order to know when laws and rules are changed and/or added. Ignorance of the law is not defensible.

THE FLORIDA STATE NURSE PRACTICE ACT

All states throughout the nation have their own nurse practice act. Generally speaking they are quite similar, although there may be some minor differences,. These nurse practice acts, with few exceptions, include some basic definitions and some broad statements about nursing and its role.

Nurse practice acts generally define “professional nursing”, “practical nursing” and “advanced practice”, in addition to some other terms such as “nursing diagnosis” and “assessment”. They differentiate between the roles of the professional nurse, or registered nurse, and that of the practical, or vocational, nurse. They do not list specific tasks or specific roles for each of the two types of nurses, but they do provide the framework with which the roles can be legally executed.

The protection of the public, our consumers of healthcare services, is the primary purpose of nurse practice acts. The protection of the public is also the primary goal of the state boards of nursing throughout our country. Nurse practice acts guide our practice as nurses.

Nurses are protected with their nurse practice act. These acts legally defend what we can and cannot do as a registered professional nurse or a licensed practical, or a vocational nurse. Additionally, it also protects those that delegate aspects of care to others. For example, an RN, who supervises others and delegates patient care to licensed practical nurses and nursing assistants, must apply the principles and guidelines found in the nurse practice act, in addition to other factors such as competency, when they are assigning care. For example, a nursing supervisor, assigning the admission of a new patient, must be aware of the fact that licensed practical nurses and nursing assistants can participate in the admission procedures for this patient, but only the registered professional nurse, or RN, can analyze admission data to decide upon a nursing diagnosis. Legally, nurses must function within the limits of their scope of practice, as defined by their nurse practice act.

The Nurse Practice Act for the State of Florida is, as follows:

FLORIDA STATUTES CHAPTER 464
NURSING
PART I
NURSE PRACTICE ACT (ss. 464.001-464.027)

(3) (a) “Practice of professional nursing” means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:

1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.

2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments.

3. The supervision and teaching of other personnel in the theory and performance of any of the above acts.

(b) “Practice of practical nursing” means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist.

The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.

(c) “Advanced or specialized nursing practice” means, in addition to the practice of professional nursing, the performance of advanced-level nursing acts approved by the board which, by virtue of post basic specialized education, training, and experience, are proper to be performed by an advanced registered nurse practitioner. Within the context of advanced or specialized nursing practice, the advanced registered nurse practitioner may perform acts of nursing diagnosis and nursing treatment of alterations of the health status. The advanced registered nurse practitioner may also perform acts of medical diagnosis and treatment, prescription, and operation which are identified and approved by a joint committee composed of three members appointed by the Board of Nursing, two of whom shall be advanced registered nurse practitioners; three members appointed by the Board of Medicine, two of whom shall have had work experience with advanced registered nurse practitioners; and the secretary of the department or the secretary's designee. Each committee member appointed by a board shall be appointed to a term of 4 years unless a shorter term is required to establish or maintain staggered terms. The Board of Nursing shall adopt rules authorizing the performance of any such acts approved by the joint committee. Unless otherwise specified by the joint committee, such acts shall be performed under the general supervision of a practitioner licensed under chapter 458, chapter 459, or chapter 466 within the framework of standing protocols which identify the medical acts to be performed and the conditions for their performance. The department may, by rule, require that a copy of the protocol be filed with the department along with the notice required by s. 458.348.

(d) “Nursing diagnosis” means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal.

(e) “Nursing treatment” means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health.

4. “Registered nurse” means any person licensed in this state to practice professional nursing.

5. “Licensed practical nurse” means any person licensed in this state to practice practical nursing.

6. “Advanced registered nurse practitioner” means any person licensed in this state to practice professional nursing and certified in advanced or specialized nursing practice.

7. “Approved program” means a nursing program conducted in a school, college, or university which is approved by the board pursuant to s. 464.019 for the education of nurses.”

FLORIDA STATE’S PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES (381.026)

1. SHORT TITLE. This section may be cited as the "Florida Patient's Bill of Rights and Responsibilities."

2. DEFINITIONS. As used in this section and s. 381.0261, the term:

  1. "Department" means the Department of Health.
  2. "Health care facility" means a facility licensed under chapter 395.
  3. "Health care provider" means a physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, or a podiatric physician licensed under chapter 461.
  4. "Responsible provider" means a health care provider who is primarily responsible for patient care in a health care facility or provider's office.

3. PURPOSE. It is the purpose of this section to promote the interests and well-being of the patients of health care providers and health care facilities and to promote better communication between the patient and the health care provider. It is the intent of the Legislature that health care providers understand their responsibility to give their patients a general understanding of the procedures to be performed on them and to provide information pertaining to their health care so that they may make decisions in an informed manner after considering the information relating to their condition, the available treatment alternatives, and substantial risks and hazards inherent in the treatments. It is the intent of the Legislature that patients have a general understanding of their responsibilities toward health care providers and health care facilities. It is the intent of the Legislature that the provision of such information to a patient eliminate potential misunderstandings between patients and health care providers. It is a public policy of the state that the interests of patients be recognized in a patient's bill of rights and responsibilities and that a health care facility or health care provider may not require a patient to waive his or her rights as a condition of treatment. This section shall not be used for any purpose in any civil or administrative action and neither expands nor limits any rights or remedies provided under any other law.

4. RIGHTS OF PATIENTS. Each health care facility or provider shall observe the following standards:

(a) Individual dignity.
  1. The individual dignity of a patient must be respected at all times and upon all occasions.
  2. Every patient who is provided health care services retains certain rights to privacy, which must be respected without regard to the patient's economic status or source of payment for his or her care. The patient's rights to privacy must be respected to the extent consistent with providing adequate medical care to the patient and with the efficient administration of the health care facility or provider's office. However, this subparagraph does not preclude necessary and discreet discussion of a patient's case or examination by appropriate medical personnel.
  3. A patient has the right to a prompt and reasonable response to a question or request. A health care facility shall respond in a reasonable manner to the request of a patient's health care provider for medical services to the patient. The health care facility shall also respond in a reasonable manner to the patient's request for other services customarily rendered by the health care facility to the extent such services do not require the approval of the patient's health care provider or are not inconsistent with the patient's treatment.
  4. A patient in a health care facility has the right to retain and use personal clothing or possessions as space permits, unless for him or her to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons.


(b) Information.
  1. A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services.
  2. A patient in a health care facility has the right to know what patient support services are available in the facility.
  3. A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient's guardian or a person designated as the patient's representative. A patient has the right to refuse this information.
  4. A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law. The responsible provider shall document any such refusal.
  5. A patient in a health care facility has the right to know what facility rules and regulations apply to patient conduct.
  6. A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients' rights. A patient has the right to know the health care provider's or health care facility's procedures for expressing a grievance.
  7. A patient in a health care facility who does not speak English has the right to be provided an interpreter when receiving medical services if the facility has a person readily available who can interpret on behalf of the patient.


(c) Financial information and disclosure.
  1. A patient has the right to be given, upon request, by the responsible provider, his or her designee, or a representative of the health care facility full information and necessary counseling on the availability of known financial resources for the patient's health care.
  2. A health care provider or a health care facility shall, upon request, disclose to each patient who is eligible for Medicare, in advance of treatment, whether the health care provider or the health care facility in which the patient is receiving medical services accepts assignment under Medicare reimbursement as payment in full for medical services and treatment rendered in the health care provider's office or health care facility.
  3. A health care provider or a health care facility shall, upon request, furnish a patient, prior to provision of medical services, a reasonable estimate of charges for such services. Such reasonable estimate shall not preclude the health care provider or health care facility from exceeding the estimate or making additional charges based on changes in the patient's condition or treatment needs.
  4. A patient has the right to receive a copy of an itemized bill upon request. A patient has a right to be given an explanation of charges upon request.


(d) Access to health care.
  1. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.
  2. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide such treatment.
  3. A patient has the right to access any mode of treatment that is, in his or her own judgment and the judgment of his or her health care practitioner, in the best interests of the patient, including complementary or alternative health care treatments, in accordance with the provisions of s. 456.41.


(e) Experimental research. In addition to the provisions of s. 766.103, a patient has the right to know if medical treatment is for purposes of experimental research and to consent prior to participation in such experimental research. For any patient, regardless of ability to pay or source of payment for his or her care, participation must be a voluntary matter; and a patient has the right to refuse to participate. The patient's consent or refusal must be documented in the patient's care record.

(f) Patient's knowledge of rights and responsibilities. In receiving health care, patients have the right to know what their rights and responsibilities are.

5. RESPONSIBILITIES OF PATIENTS. Each patient of a health care provider or health care facility shall respect the health care provider's and health care facility's right to expect behavior on the part of patients which, considering the nature of their illness, is reasonable and responsible. Each patient shall observe the responsibilities described in the following summary.

6. SUMMARY OF RIGHTS AND RESPONSIBILITIES. Any health care provider who treats a patient in an office or any health care facility licensed under chapter 395 that provides emergency services and care or outpatient services and care to a patient, or admits and treats a patient, shall adopt and make available to the patient, in writing, a statement of the rights and responsibilities of patients, including the following:

SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows:

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

A patient has the right to a prompt and reasonable response to questions and requests.

A patient has the right to know who is providing medical services and who is responsible for his or her care.

A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.

A patient has the right to know what rules and regulations apply to his or her conduct.

A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.

A patient has the right to refuse any treatment, except as otherwise provided by law.

A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.

A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.

A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.

A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.

A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.

A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.

A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.

A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.

A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.

A patient is responsible for following the treatment plan recommended by the health care provider.

A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.

A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions.

A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.

A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.”

The Spanish version of the Florida State Patient’s Bill of Rights and Responsibilities (381.026) can and should be accessed at http://www.doh.state.fl.us/mqa/Profiling/billofrights.htm

THE FLORIDA BOARD OF NURSING

According to Florida Statute 464.004:
  1. The Board of Nursing is created within the department and shall consist of 13 members to be appointed by the Governor and confirmed by the Senate.
  2. Seven members of the board must be registered nurses who are residents of this state and who have been engaged in the practice of professional nursing for at least 4 years, including at least one advanced registered nurse practitioner, one nurse educator member of an approved program, and one nurse executive. These seven board members should be representative of the diverse areas of practice within the nursing profession. In addition, three members of the board must be licensed practical nurses who are residents of this state and who have been actively engaged in the practice of practical nursing for at least 4 years prior to their appointment. The remaining three members must be residents of the state who have never been licensed as nurses and who are in no way connected with the practice of nursing. No person may be appointed as a lay member who is in any way connected with, or has any financial interest in, any health care facility, agency, or insurer. At least one member of the board must be 60 years of age or older.
  3. As the terms of the members expire, the Governor shall appoint successors for terms of 4 years, and such members shall serve until their successors are appointed.”

RULES AND RULEMAKING AUTHORITY

There is a distinct difference between administrative rules and statutes, or laws, like the nurse practice act. All Boards, including the Florida Board of Nursing, are given statutory power, by law, to adopt rules according to Florida Statutes 120.536(1) and 120.54.

Rules are found in the Florida Administrative Code. Nurses and nursing practice are addressed Section 64B9. Rules are more specific than statutes. Rules enable the Board of Nursing, and other Boards, to generate regulations about how the laws, or statutes, are implemented. For example, a State of Florida statute require a two hour continuing education course for nurses and all other healthcare professionals. Rules have been generated by the Florida Board of Nursing on what topics, in addition to those already stated in the statute, must be included in a class in order to be sufficient enough for nurses to renew their license with the State of Florida. Other rules, relating to nursing and nursing practice, include the required elements of a practice protocol for a nurse practitioner and the guidelines for IV therapy by a licensed practical nurse.

LICENSURE AND LICENSE RENEWAL

Florida Statutes (464.008,464.009) relate to the application process and the other necessary requirements for a person to become a new licensee in the State of Florida through: Florida Statute 464.013 permits the State to renew licenses on a biennial basis and also to mandate that Florida licensed nurses have up to 30 hours of continuing education per biennium, that is, every 2 years.

LICENSE DENIALS AND DISCIPLINARY ACTIONS

Florida law (464.018) states that:
1. The following acts constitute grounds for denial of a license or disciplinary action, as specified in s. 456.072(2):
(a) Procuring, attempting to procure, or renewing a license to practice nursing by bribery, by knowing misrepresentations, or through an error of the department or the board.

(b) Having a license to practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or country.

(c) Being convicted or found guilty of, or entering a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction which directly relates to the practice of nursing or to the ability to practice nursing.

(d) Being found guilty, regardless of adjudication, of any of the following offenses:
1. A forcible felony as defined in chapter 776.

2. A violation of chapter 812, relating to theft, robbery, and related crimes.

3. A violation of chapter 817, relating to fraudulent practices.

4. A violation of chapter 800, relating to lewdness and indecent exposure.

5. A violation of chapter 784, relating to assault, battery, and culpable negligence.

6. A violation of chapter 827, relating to child abuse.

7. A violation of chapter 415, relating to protection from abuse, neglect, and exploitation.

8. A violation of chapter 39, relating to child abuse, abandonment, and neglect.


(e) Having been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under s. 435.03 or under any similar statute of another jurisdiction; or having committed an act which constitutes domestic violence as defined in s. 741.28.

(f) Making or filing a false report or record, which the licensee knows to be false, intentionally or negligently failing to file a report or record required by state or federal law, willfully impeding or obstructing such filing or inducing another person to do so. Such reports or records shall include only those which are signed in the nurse's capacity as a licensed nurse.

(g) False, misleading, or deceptive advertising.

(h) Unprofessional conduct, as defined by board rule.

(i) Engaging or attempting to engage in the possession, sale, or distribution of controlled substances as set forth in chapter 893, for any other than legitimate purposes authorized by this part.

(j) Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the secretary or the secretary's designee that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such order, the department's order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by the provisions of this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.

(k) Failing to report to the department any person who the licensee knows is in violation of this part or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.

(l) Knowingly violating any provision of this part, a rule of the board or the department, or a lawful order of the board or department previously entered in a disciplinary proceeding or failing to comply with a lawfully issued subpoena of the department.

(m) Failing to report to the department any licensee under chapter 458 or under chapter 459 who the nurse knows has violated the grounds for disciplinary action set out in the law under which that person is licensed and who provides health care services in a facility licensed under chapter 395, or a health maintenance organization certificated under part I of chapter 641, in which the nurse also provides services.

(n) Failing to meet minimal standards of acceptable and prevailing nursing practice, including engaging in acts for which the licensee is not qualified by training or experience.

(o) Violating any provision of this chapter or chapter 456, or any rules adopted pursuant thereto.


2. The board may enter an order denying licensure or imposing any of the penalties in s. 456.072(2) against any applicant for licensure or licensee who is found guilty of violating any provision of subsection (1) of this section or who is found guilty of violating any provision of s. 456.072(1).

3. The board shall not reinstate the license of a nurse, or cause a license to be issued to a person it has deemed unqualified, until such time as it is satisfied that such person has complied with all the terms and conditions set forth in the final order and that such person is capable of safely engaging in the practice of nursing.

4. The board shall not reinstate the license of a nurse who has been found guilty by the board on three separate occasions of violations of this part relating to the use of drugs or narcotics, which offenses involved the diversion of drugs or narcotics from patients to personal use or sale.

5. The board shall by rule establish guidelines for the disposition of disciplinary cases involving specific types of violations. Such guidelines may include minimum and maximum fines, periods of supervision or probation, or conditions of probation or reissuance of a license.”

UNPROFESSIONAL CONDUCT

According to Florida Administrative Code, Section 64B9-8.005, there are several infractions considered unprofessional conduct. Unprofessional conduct subjects the nurse to disciplinary action by the Florida Board of Nursing.

These infractions include:

CERTIFIED NURSING ASSISTANTS

In the State of Florida, certified nursing assistants are regulated under the Florida Board of Nursing and the Council of Certified Nursing Assistants.

Florida Statute 464.2085establishes this Council, its composition and its roles. The Council consists of five members, the chairperson, two registered nurses and one licensed practical nurse. The licensed practical nurse and at least one of the registered nurse members must be currently employed in a licensed nursing home. Additionally, this registered nurse must also supervise CNAs in the nursing home of employment.

The Council addresses areas of concern regarding CNAs in the State and makes the following types of recommendations to the Florida Board of Nursing: A certified nursing assistant has to take 18 hours of inservice training during each calendar year.

FLORIDA BOARD OF NURSING RULES:

Continuing Education

Florida State rule 64B9-5.001 lists the continuing education requirements that are necessary for initial licensure and for the renewal of nursing licenses every two years, that is, each biennium.

All RNs and LPNs must successfully complete at least 24 contact hours of continuing education every two years, unless they are on active duty with the Armed Forces. Each contact hour is equivalent to 50 minutes of classroom, or live instruction, or 50 minutes of reading an independent home study or computer based course.

Of these 24 contact hours, one (1) contact hour must for a domestic violence course, one (1) contact hour must for an AIDS/HIV course and two (2) contact hours must be awarded for a preventing medical errors course. RNs and LPNs can take a one (1) contact hour course in the end of life care to substitute for either the AIDS/HIV requirement or the domestic violence requirements. For those getting their initial license in this State, 3 contact hours of AIDS/HIV must be taken. These mandatory courses must approved by the Florida Board of Nursing.

The content of the State mandated AIDS/HIV course must include: The content of the State mandated preventing medical errors course must include: The content of the State mandated end of life course, when taken in lieu of AIDS/HIV or domestic violence must include at least one of the following content areas:

LPNs and Intravenous Therapy

Continuing Education

Chapter 64B9-12 outlines the limited role of LPNs in intravenous therapy. Some aspects of intravenous therapy are within the scope of practice for the LPN, provided the necessary education and competency validation are accomplished. There are also some aspects of intravenous therapy that are outside of the scope of practice for the LPN.

The educational component of IV therapy consists of 40 contact hours of education with a Florida Board of Nursing approved course and competency assessment and validation by a registered nurse.

LPNs can perform the following aspects of intravenous therapy, under the direct supervision of a registered nurse who is “on the premises and immediately physically available”: Additionally, the following aspects of IV therapy can be done by an LPN under the direction of a registered nurse: The required intravenous therapy class of 40 contact hours must minimally include a wide variety of topics including, but not limited to, the body’s homeostatic and regulatory functions, venipuncture technique, infection control measures, fluids and electrolytes, parenteral nutrition, blood and blood products, local and systemic complications, preventing and treating local and systemic complications, methods of intravenous therapy administration and their advantages and disadvantages, and 4 contact hours of central line management if central lines will be used by the LPN and other content areas.

In addition to the required 40 contact hours of education, competency assessment and validation must be done and documented by a registered nurse qualified to perform this role prior to an LPNs performing aspects of intravenous therapy.

OFFICIAL RECORDS AND DOCUMENTATION

The following documents are considered official records: The falsification of official records is considered unprofessional conduct and, as such, subject to disciplinary action by the State Board of Nursing.

SUPERVISION AND DELEGATION

Although the definitions and provisions of nurse practice acts across the country are broad and non-specific in respect to the scope of practice issues and tasks within and outside of nursing practice, they do offer guidance and direction about nursing practice. As you have probably noticed, certified nursing assistants and other assistive personnel, including non-licensed assistive personnel and "nurse extenders" are not included in the provisions of the Florida Nurse Practice Acts, but they are specific in terms of the roles for registered professional nurses, licensed practical nurses and advanced practice or specialized nursing practice.

The implications of supervision and delegation are loaded with challenges and legal concerns, particularly with the emergence of new classifications of nonlicensed, noncertified assistive personnel who are permitted to perform a role within a particular health care facility, but who are not licensed or certified by the state. These personnel have a wide variety of titles and roles, such as patient care aide, personal care assistant, patient care technician, telemetry aide, etc. These staff members are not regulated by the Florida Board of Nursing in terms of educational preparation, permissible scope of practice, licensure, certification or continuing education.

Some of the above job titles include traditional functions usually assigned to the nursing assistant, such as bathing and hygiene but they may also assume some other responsibilities such as venipuncture, EKGs, and/or the monitoring of telemetry. All of these titles and roles require supervision and delegation by the nurse. As a result, it is the nurse - often the only independent practitioner, who is accountable for all aspects of care delegated to other members of the health care team, including not only unlicensed assistive personnel. This responsibility can lead to significantly disastrous results if supervision and delegation is not done according to provisions of the law.

The most frequently employed nonlicensed nursing staff member is the nursing assistant or CNA. CNAs are regulated by Florida State and the Florida Board of Nursing in terms of educational preparation, permissible scope of practice, and continuing education. They are not licensed but they are certified to practice in a specific role. They are sometimes referred to as unlicensed, assistive personnel (UAP).

Unlicensed personnel, certified and not certified, have appeared on the scene because the cost of health care has skyrocketed to such a degree that is no longer cost-effective to employ an all licensed or registered nursing staff. These healthcare workers cannot work independently. They must be under the supervision of a registered nurse or, under certain conditions, an LPN. Unlicensed, assistive staff assist the nurse. They do NOT replace the nurse. Unlicensed personnel do not perform nursing functions; they perform nursing related functions, as delegated, under the supervision of the nurse.

Among the tasks that these personnel can perform include: The following tasks cannot be delegated to unlicensed assistive personnel (UAP) include aspects of care within the nursing process that require nursing judgment(s), according to Florida State Rules of the Board of Nursing Chapter 64B9-14. Some examples of tasks that cannot be legally delegated to unlicensed assistive personnel include: Registered nurses supervise licensed practical nurses as well. This assignment should be consistent with their scope of practice, as stated in the Florida State Nurse Practice Act, their competencies, the policies and procedures of the facility and the needs of the patient.

Florida State Rules of the Board of Nursing 64B9-14.002 states that “total nursing care responsibility remains with the qualified nurse delegating the task or assignment for supervision.”

Here are some basic rules to follow in reference to the assignment of care and the delegation of patient care responsibilities:
  1. Assign and delegate only those tasks that are permissible according to state and federal regulations and your facility's policies and procedures.
  2. Because the person delegating is still ultimately responsible and accountable, closely supervise and follow up on delegated tasks. If something is done incorrectly or a patient is harmed, it is the license of the person who has delegated that is on the line.
  3. Assign the right person to the right job. Assess patients to ensure that you are delegating the appropriate tasks based on the patient's condition. Base the assignment on the patient's condition and the competency and skill of the staff member.
  4. Monitor the patient for responses to the care provided by others and document those responses in a complete and timely manner.
  5. Regularly follow up and monitor the performance of all those you supervise. Corrective action must be immediately taken if someone is not performing according to established standards.

LEGISLATIVE INITIATIVES: ADVANCING THE NURSING PROFESSION IN FLORIDA and PROTECTING THE PUBLIC

Florida Center for Nursing

Our Florida Legislature is leading the nation in several areas, including the establishment of a Florida Center for Nursing, with the passing of Florida Statute 464.0195.

The goals and challenges before the Florida Center for Nursing consist of:

The Florida Intervention Project for Nurses (IPN)

Intervention Project for Nurses (IPN), begun in 1983, is a nationally recognize program that protects the safety of the public by intervening when a nurse is potentially practicing in an unsafe manner as a result of alcohol and/or drug use or misuse and another physical or psychological impairment that makes them unsafe to practice.

Their objectives include:
  1. “To ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice, due to the use of drugs including alcohol and/or psychiatric, psychological or physical condition (chapter 455.261).
  2. To provide a program for affected nurses to be rehabilitated in a therapeutic, non-punitive, and confidential process.
  3. To provide an opportunity for retention of nurses within the nursing profession.
  4. To facilitate early intervention, thereby decreasing the time between the nurse's acknowledgment of the problem and his/her entry into a recovery program.
  5. To require the nurse to withdraw from practice immediately, and until such time that the IPN is assured that he/she is able to safely return to the practice of nursing.
  6. To provide a cost effective alternative to the traditional disciplinary process.
  7. To develop a statewide resource network for referring nurses to appropriate services.
  8. To provide confidential consultations for Nurse Managers.” (IPN,2004)
The IPN Program has many services, including educating nurses throughout the state about their program and services. To learn more about IPN visit their website at http://www.ipnfl.org

INTRODUCTION TO HEALTHCARE ETHICS

Ethics and ethical practice has, and continues to remain, one of the most important paramount decision-making frameworks in healthcare as well as in other professions. Many professions and professionals are often in a position where they influence the lives of others. This position makes it necessary for them to accept the responsibility of acting ethically and in the interest of those they serve. Ethically, we are held accountable for our acts of omission and commission.

Professions have ethical codes in order to thoroughly, and as parsimoniously as possible, address all possible ethical concerns in the profession. Ethical codes are formal statements about commitments to the good. They contain values and guide the practice(s) of those in the profession or business area.

Accountants, attorneys, real estate brokers, and government employees have codes of ethics that they must adhere to. Accountants are held accountable for honesty and honest accounting practices; real estate brokers are held accountable for disclosures regarding problems and potential problems, such as asbestos, lead and sink hole risks; attorneys are ethically bound to maintain confidentiality and privileged communication regarding some matters; and government employees are ethically bound to avoid any conflicts of interest. Recently, corporate ethics has become a national focus of attention, especially after the Enron Corporation collapse and their faulty accounting systems.

The ultimate purpose of ethical codes in the healthcare industry is to protect the rights and safety of the healthcare consumer. Healthcare professionals must act ethically and adhere to their own professional codes of ethics. (National Council of State Boards of Nursing, 1996)

ETHICS: BASIC PRINCIPLES AND CONCEPTS

Ethics is defined as "the discipline dealing with what is good and bad and with moral duty and obligation; a set of moral principles or values; a theory or system of moral values; the principles of conduct governing an individual or a group <professional ethics>; a guiding philosophy" (Merriam-Webster,2001).

Ethics is a body of knowledge containing values that are held by individuals of groups. Ethics and ethical codes in healthcare reflect four basic ethical principles, or underlying themes, that serve to organize the body of medical ethics and medical ethical decision-making.

These four ethical principles are: Autonomy is "the quality or state of being self-governing; especially : the right of self-government; self-directing freedom and especially moral independence; a self-governing state" (Merriam-Webster, 2001).

Beneficence is defined as "the quality or state of being beneficent" (Merriam-Webster, 2001).

Nonmaleficence is best described as doing no harm. The Hippocratic Oath is an excellent example of how, historically, ethics and ethical principles have been in the healthcare profession throughout the ages. The Hippocratic Oath can be read below in Table 1.

Justice is defined as "the maintenance or administration of what is just especially by the impartial adjustment of conflicting claims or the assignment of merited rewards or punishments; the administration of law; especially: the establishment or determination of rights according to the rules of law or equity; the quality of being just, impartial, or fair; the principle or ideal of just dealing or right action; conformity to this principle or ideal; the quality of conforming to law; conformity to truth, fact, or reason; correctness "(Merriam-Webster,2001).

Autonomy

The word autonomy is derived from the Greek word for self-rule. In reference to healthcare, autonomy is strongly linked to the client's right to decision-making and self-determination. All competent adults have the basic freedom to choose and make choices.

Patients and residents have a right to informed consent and informed refusal. They have the basic right to autonomous, knowledgeable decision-making and the ability to make choices, whether or not the healthcare provider(s) agrees with them or not.

Adults have the right to make decisions when they are of majority age, that is, at least 18 years of age, and they are deemed mentally competent to do so. Minors, on the other hand, are not legally able to make a decision about what care they will or not receive until they reach the age of 18 or they become a legally emancipated minor. Parents generally make legal decisions for minors. In some cases, a court appointed guardian makes these decisions, in the absence of a parent.

The adult consumer of healthcare services, or their surrogate, proxy, decision maker, has the right to consent to care and they also have the right to refuse any aspect of care or a treatment. These autonomous decisions are based on the individual's own unique values and beliefs; they are not based on what the healthcare provider feels is best for them. Self determination and autonomous decision-making must be ethically upheld by all healthcare professionals at all times.

Beneficence

Simply stated, beneficence is doing good. Beneficence is doing the ethically correct thing. It reflects an individual's intentional acts, not errors and mistakes. Beneficence aims to promote the well being of others, not self. These intentional acts take into serious consideration the welfare of others. It is the welfare of others that is of greatest importance.

Beneficence challenges and ethical dilemmas in healthcare occur when it is not totally clear about what is truly good for a particular patient. Patient and resident needs are generally complex and approaches to care are numerous and varied. Many dilemmas arise because of these complexities and other factors.

The multidisciplinary healthcare team sometimes has difficulty arriving at a plan of care that is best for the patient and even then, not all members of the team may be in agreement about what course of treatment or care is best. Additionally, the autonomous decisions of the patient may make the "best" treatment options not feasible because the patient, resident or surrogate, proxy, decision maker has expressed the fact that they do not want a particular treatment or intervention. Lastly, the team and patient or resident may collectively agree to what is best, but this option is not available or accessible to them and/or the option may not be legally permissible. For example, euthanasia is not legally permitted in our country. Any patient requests for euthanasia, therefore, cannot be supported because it is illegal. The healthcare team cannot agree to, or support, this option despite their own personal beliefs that euthanasia should be a legally acceptable and that this is the "best" option, especially when a patient or resident is using their right to self determination by expressing a desire for it.

Nonmaleficence

Nonmaleficence literally means, "do not harm". Maleficence is defined as "doing harm". Nonmaleficence and beneficence are closely related, particularly in healthcare ethics, because many treatments and procedures have both benefits (beneficence) and risks for harm. Some of these risks can cause patient harm and pain (maleficence).

For example, a client under our care may choose to have parenteral nutrition to correct a nutritional deficit. Prior to consenting, the individual was correctly and completely informed about parenteral nutrition, its benefits and its risks, including those associated with infection. Alternatives to parenteral nutrition were also discussed with the patient or proxy decision maker, as appropriate. If this patient chooses to have the parenteral nutrition and gets an infection as a result of it (maleficence), it is not considered unethical because the patient autonomously decided to have the parenteral nutrition after they were advised of the risks associated with this treatment and because the harm, or infection, was not done intentionally by the nurses and other healthcare professionals.

Justice

The principle of justice entails fairness, impartiality, and justness. Challenges in the area of justice are numerous in the healthcare industry, particularly because fair and impartial access to care is sometimes not possible due to the constraints associated with healthcare dollars and the allocation of limited resources. These kinds situations are generally highly complex and difficult to resolve using justice alone as the ethical framework for decision-making.

Other healthcare situations, however, are easily addressed in terms of the principle of justice. Providing the same level of care and the same level of quality for all those in our care, without discrimination, is straightforward and quite simple to ethically accomplish.

THE HIPPOCRATIC OATH



I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art-if they desire to learn it-without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Scarborough, John. "Hippocrates." World Book Online Reference Center. 2005. World Book, Inc. 15 Jan. 2005. www.aolsvc.worldbook.aol.com/wb/Article?id=ar257540.

ETHICS IN HEALTHCARE AND NURSING: HISTORY AND CURRENT STATE

Historically, the first documented sign of ethics in healthcare was the Hippocratic Oath that was discussed above in the context of nonmaleficence. Florence Nightingale continued the development of ethics for nurses as she promoted ethics throughout her practice and within the schools of nursing that she was instrumental in running. The need for ethics and ethical practice in nursing and healthcare continues from these early beginnings to the current day.

At the current time, the International Council of Nurses' Code of Ethics for Nurses, on a global scale, and the American Nurses' Association Code of Ethics, on the national level, ethically drive the majority of nurses and the bulk of nursing practice in our nation. There are, however, other ethical codes that address subspecialties with the profession, for example, nursing research.

International Council of Nurses

The International Council of Nurses (ICN) initially composed an international code for nurses throughout the world in 1953. Their most recent Code of Ethics for Nurses (2000) is organized around four elements, as follows:
  1. nurses and people,
  2. nurses and practice,
  3. nurses and coworkers and
  4. nurses and the profession.
The nurses and people element addresses basic client rights, confidentiality, and the need to uphold these rights, as well as the values and customs of the healthcare consumer.

The nurses and practice element includes guidance regarding competency, education and continuing education, personal health and the need for nursing judgment in respect to accepting and delegating the responsibility of client care.

The third element, nurses and coworkers, underscores the need for cooperation and collaboration as well as the need to take immediate action when a nurse believes that the actions of others jeopardize quality of care.

Finally, the fourth element, nurses and the profession, relates to the need for nurses to abide by their standards of practice and to actively participate in the expansion of their unique body of knowledge.(International Council of Nurses, 2000).

American Nurses Association (ANA)

The most recent American Nurses Association Code of Ethics was published in 2001. Some of the same elements included in the International Council of Nurses' ethical code are also found in the ANA's ethical code. The Code, however, is organized around nine provisions as below:

The nine provisions address:
  1. dignity and the uniqueness of every individual. Respect, compassion and the provision of care to all without any discrimination is emphasized
  2. the need for nurses to accept their responsibility in making a commitment to the client. The client is defined in this ethical code as an individual, group and/or community.
  3. advocacy. The need for nurses and the nursing profession to protect the rights, health and safety of the client is underscored in this provision.
  4. accountability and responsibility for one's own practice. This provision holds the nurse responsible and accountable for their own practice. Additionally, the nurse is held accountable for the delegation of aspects of care to others, According to the American Nurses Association Code of Ethics, delegation must be done using sound professional judgment and taking into consideration what is best for the client(s) receiving nursing care.
  5. responsibilities to one's self-safety, integrity, competence and growth, personal and professional are the responsibilities of the nurse.
  6. the need for nurses to act, on an individual and collective basis, to establish, maintain and improve conditions of employment and the place of employment in order to facilitate the provision of safe, quality care.
  7. contributions that nurses must make in terms of clinical practice, administration and education in order to advance the profession of nursing.
  8. collaboration with the public and other healthcare professionals in order to best meet the needs of the community on a local, national and international level.
  9. the role of the nursing profession in terms of maintaining its own integrity and practice, as well as the responsibility of the profession and its members to shape public policy and articulate nursing values. (American Nurses Association, 2001)

ETHICAL DILEMMAS

An ethical dilemma arises when two or more of the four (autonomy, beneficence, nonmaleficence, and justice) ethical principles are in conflict with one other. For example, when what is good is not justly and fairly distributed or when autonomy is in conflict with beneficence.

Ethical dilemmas disrupt internal and external harmony and homeostasis. They are uncomfortable and often a source of disagreement and debate among members of the healthcare team. For example, an ethical dilemma relating to who gets and who does not get a particular treatment or an organ, can be a source of great consternation and frustration. Allocating limited healthcare resources is an omnipresent challenge in our industry.
Case Study

Arnold is a 53-year-old businessman and a father of 4 children. He is the sole source of family income and is the CEO of a Fortune 500 company. Jane is a 23-year-old developmentally disabled woman without children and without any health insurance. Her medical costs are covered with Medicaid and she is presently living in one of her state's long-term care facilities.

Both individuals are in need of a liver transplant. Both are acceptable candidates. Jane has been waiting for 2 years and Arnold for 1 ½ years.

A young male has died in an automobile accident and his liver has been donated. He is a compatible donor to both Jane, first on the list, and Arnold, 2nd on the list.

Who should get the liver, using the basic ethical principle of justice? Who should get the donated liver, using the basic ethical principle of beneficence?
Ethical dilemmas, although challenging, can be resolved. Ethical dilemmas are best resolved on a case-by-case basis within the context of the unique patient and their unique needs and by using the four basic ethical principles for analysis and decision-making.

The resolution of ethical dilemmas is also best accomplished by a group, rather than one individual. Collective analysis and decision making promotes diverse thinking and often a decision that can be ethically and comfortably accepted by all of those involved in the process.

ETHICS COMMITTEES

Most healthcare facilities now have ethics committees to address ethical dilemmas. Attend a meeting at your facility, especially if you have never attended one before. Ethics committees typically consist of a diverse group of healthcare professionals from different disciplines. Most often there will be representatives from medicine, nursing, pharmacy and nutritional services. Many also have an administrator, a chaplain and a healthcare consumer as members. An ethicist consultant is sometimes added to the group composition when the group is having difficulty resolving a dilemma without the help of an expert ethicist to consult with.

Ethics Committee policies and procedures vary from facility to facility, however, ones that make provisions for the following are the most helpful. Ethics committees are an excellent resource for nurses and all other healthcare professionals.

COMMON ETHICAL ISSUES

Inadequate Staffing

Inadequate staffing and unsafe staffing levels are a matter of grave concern. Some states, for example California and Florida, now have minimum staffing laws to prevent the problems associated with inadequate and unsafe staffing. Although these laws have somewhat helped, they have not eliminated the problem altogether.

What should a nurse, or other healthcare provider, do when they believe that staffing is not adequate enough to safely and effectively meet the needs of the patients that they are caring for? Should they refuse the assignment? Should the nurse accept the assignment but pursue the matter in a formal and prompt manner? Should they just ignore the problem and do the best they can do?

The answers to these questions are not simple and easy. Inadequate staffing is a complex problem without simple solutions. Unsafe staffing can be a sporadic and rare occurrence, one that results from someone calling in sick or it can be an ongoing problem with no apparent efforts underway to correct it.

Ethically, the nurse must address inadequate staffing in order to protect the patients and their rights to safety, freedom from harm and quality care. Ignoring the problem not only places the nurse in a position of legal liability, it is also not ethical. Ethically, the nurse must uphold the principles of beneficence and nonmaleficence. The nurse's duty to promote the well being of others (beneficence) is not being fulfilled and the nurse's duty to do no harm (nonmaleficence) is also not being fulfilled.

Patients suffer harm and a lack of the care they are entitled to as a result of inadequate and unsafe staffing levels. Additionally, according to the American Nurses Association Code of Ethics nurses must act, on an individual and collective basis, in order to establish, maintain and improve workplace conditions that promote the provision of safe, quality care.

Although inadequate staffing is not an ethical dilemma with two or more ethical principles in conflict, it is a frequently occurring ethical issue because one or more of the four principles of ethics are not upheld. Nurses, and other healthcare providers, must report staffing concerns to their supervisor and then up the chain of command until the situation is rectified. Yes, it is true that your actions may lead to some repercussions, nonetheless, it is your ethical responsibility to do so.

Inappropriate Doctor's Orders

Inappropriate doctor's orders are also a frequently occurring ethical issue. What should a nurse, or other healthcare professional, do when they believe that a doctor's order is not appropriate for the patient? Should they just ignore the order? Should they just carry out the order because the doctor ordered it?

Healthcare providers, using profession judgment, should know what doctors' orders are and are not appropriate based on the current condition of the patient. They must question an order when they suspect that it is inappropriate. A questionable order must never be carried out until it is clarified and deemed appropriate by the person carrying it out. To carry out an inappropriate order jeopardizes the ethical principles of beneficence and nonmaleficence. Similar to unsafe staffing levels, this is an ethical issue rather than an ethical dilemma with two or more competing ethical principles. To carry out an inappropriate order is simply unethical.

The first thing that a nurse, or another professional, must do when they are given an order to do something that is inappropriate, illegal or unethical is to NOT follow the order. Communicate with the person giving the order, and document that conversation as well as your rationale for not following the order. Clearly communicate, and document the patient's current condition and why the order is not consistent with the patient's current condition. Communicate with your supervisor and follow further up the chain of command, or the channel of communication, until the inappropriate order is discontinued or it becomes apparent to you that it is indeed appropriate and necessary. To do otherwise is to jeopardize the well being of the patient and perhaps cause harm (maleficence). Yes, your questioning actions and your refusal to follow the order may lead to some repercussions, nonetheless, there are no other options. It is your professional, ethical responsibility to do good and to do no harm.

Euthanasia and Physician Assisted Suicide

Euthanasia and physician assisted suicide are commonly occurring and recent emergent ethical issues, ones with a tremendous amount of lively ethical debate on the international, national and local frontier. These issues are highly complex with religious, legal and cultural implications.

Those that support euthanasia and physician assisted suicide feel that quality of life and the right of an individual to self determination must be addressed with these alternatives, especially when the availability of so many life saving and life supporting interventions tend to prolong a life with little or no quality and when a person chooses to die rather than live. Those who argue against euthanasia and physician assisted suicide believe that they are immoral and equivalent to murder. They also argue that euthanasia and physician assisted suicide can lead to the eradication of people viewed by society as not having a satisfactory quality of life. For example, some believe that euthanasia can lead to the elimination of developmentally disabled people once it is legally acceptable.

Voluntary euthanasia can be defined as the intentional act of ending a life at the request of a competent person who wishes to die. Involuntary euthanasia is defined as the intentional ending of someone's life without the request of a competent person. Euthanasia is also referred to as "mercy killing".

Physician assisted suicide is a similar concept, but it is slightly different. Physician assisted suicide is defined as a person ending their own life with the assistance of a physician. Typically, this assistance consists of the provision of medications, which the person can use to end their life when they decide to do so. Physician assisted suicide involves a physician making the death available but they do not serve as the direct agent, whereas, there is a direct agent, such as a physician or a nurse, that is involved with voluntary and involuntary euthanasia.

In 1994, the American Nurses Association (ANA) published a position paper entitled "Ethics and Human Rights Position Statements: Active Euthanasia, in which it addressed the issue of active euthanasia. The ANA does not consider voluntary or involuntary euthanasia ethical.

Euthanasia is also not permitted by law in the United States even if this action can be viewed as compassionate and supportive of the patient's wishes, either explicit or implicit. It is not legal.

The American Nurses Association (ANA) has, however, addressed some commonly occurring issues of ethical concern at the end of life, including the need to provide comfort even when comfort measures result in the cessation of some basic bodily functions, such as respiration. They also ethically support the cessation of hydration and nutrition, and the withdrawal of and withholding of resuscitation and other life sustaining measures, when chosen by the patient or surrogate decision maker in the absence of the patient's wishes.

The ANA, in support of the patient's need for comfort at the end of life, does encourage the implementation of pain management regimens even if these interventions hasten death. However, such interventions cannot be employed for the sole purpose of ending a life. (American Nurses Association, 1994; American Nurses Association, 2001).

"A nurse's role with regard to a terminally ill patient encompasses promotion of comfort and an optimal dying experience and extends through the continuum of life through death. Careful assessment and management of pain should be the principal goal of a palliative care plan." (American Nurses Association, 2001)

The ANA position statement, Promotion of Comfort and Relief of Pain in Dying Patients (2001), explores the issue of pain control in the terminally ill. The statement makes two important points: "Many factors in a patient's personal profile should be considered when administering potentially lethal doses of medication. These include the existence of a living will, cultural background, family influences, and the patient's desires. The appropriate consideration of these factors necessitates reciprocal relationships among physician, nurse, patient (if able), and family, in which there is open discussion of all parties' concerns and needs.

Pain relief, facilitation of comfort, and an optimal dying experience must be differentiated from two unethical means of ending life, active euthanasia and assisted suicide. These acts stand in conflict with the ANA's Code for Nurses with Interpretive Statements, 1985, which serves as the main ethical resource for the guidance of nursing actions." (American Nurses Association, 2001)

"The Pain Relief Promotion Act (H.R. 2260), introduced in Congress in 1999, includes a troubling provision allowing the Drug Enforcement Agency to investigate the intentions of health care professionals who prescribe medication. The ANA opposes this legislation, believing it would create a barrier to effective palliative care and prevent patients from receiving end-of-life treatment. The ANA has urged Congress to vote against the proposed legislation and to focus more attention on federal support for pain management and palliative care." (American Nurses Association, 2001).

ETHICAL RESOURCES

Websites

The American Society for Bioethics and Humanities www.asbh.org/

American Society of Law, Medicine & Ethics www.asbh.org/

Center for Biomedical Ethics at Case Western Reserve University www.cwru.edu/med/bioethics/bioethics.htm

Center for Biomedical Ethics at Stanford University scbe.stanford.edu/

Center for Ethics and Humanities in the Life Sciences at Michigan State University www.bioethics.msu.edu/

Center for Ethics in Health Care (Oregon Health Sciences University) www.ohsu.edu/ethics/

Center for Medical Ethics and Health Policy at Baylor College www.bcm.edu/ethics/

Do No Harm; The Coalition of Americans for Research Ethics www.stemcellresearch.org

International Bioethics Committee (part of UNESCO) portal.unesco.org/shs/en/ev.php-URL_ID=1372&URL_DO=DO_TOPIC&URL_SECTION=201.html

Kennedy Institute of Ethics kennedyinstitute.georgetown.edu/site/index.htm

National Bioethics Advisory Commission (U.S.) www.bioethics.gov

National Catholic Bioethics Center (U.S.) www.bioethics.gov

Books and Publications

Code of Ethics for Nurses With Interpretive Statements by American Nurses Association

Case Studies in Nursing Ethics by Sara T. Fry, Robert M. Veatch

Nursing Ethics : Across the Curriculum and Into Practice by Janie Butts and Karen Rich

Ethics And Issues In Contemporary Nursing by Margaret A. Burkhardt and Alvita K. Nathaniel

Nursing Ethics through the Life Span (4th Edition) by Elsie Bandman and Bertram Bandman

Sensitive Judgment : Nursing, Moral Philosophy and the Ethics of Care by P. Nortvedt

Concepts and Cases in Nursing Ethics (2nd Edition) by Anne Moorhouse and Michael Yeo (Editors)

Ethics in Nursing Practice: A Guide to Ethical Decision Making by Sara T. Fry and Megan-Jane Johnstone

Nursing Ethics: Communities in Dialogues by Rose Mary Volbrecht

Nursing Concepts: Ethics & Conflicts by Kathleen Ouimet Perrin, et al

ETHICS GLOSSARY

Advance directives. Instructions (usually written) from a competent individual that stipulates the forms of medical treatment to be provided by caregivers and/or designates someone to act as a proxy should the person at some future date lose decision making capacity. Living wills and durable powers of attorney for health care documents are common examples. Legal provisions vary from state to state.

Autonomy. 1) Derived from Greek words meaning "self rule." Referring to the patient's right of self-determination concerning medical care. Autonomy may be used in various senses including freedom of action, effective deliberation, and authenticity. It supports such moral and legal principles as respect for persons and informed consent. 2) Making decisions for oneself, in light of a personal system of values and beliefs.

Beneficence. The state or act of intentionally doing or producing good. The principal of beneficence involves duties to prevent harm, remove harm, and promote the good of another person. The obligation of health care professionals to seek the well-being or benefit of other patients. Duties of beneficence concern the welfare of others.

Competent. A legal concept that describes people who are able to make decisions for themselves. Minors are presumed to be incompetent, except under certain specified conditions. The corollary medical-ethical term is decisional capacity.

Confidentiality. The professional-client promise not to reveal information without consent.

Durable power of attorney for health care. An advance directive that goes into effect in the event that a patient who has completed such a document loses decisional capacity. Allows an individual to name a person(s) who is empowered to make health care decisions when the individual becomes incapacitated.

Emancipated minor. A teenaged minor, who is legally, independent of parental control and who can thus give informed consent to medical treatments.

Ethics committees. An interdisciplinary group that deals with conflicts of values in patient care in acute and long-term settings. Such committees discuss policy issues (e.g., regarding withholding and withdrawing of life-sustaining treatments).

Euthanasia. The act of either permitting a person to die or intentionally ending a person's life, generally rooted in motives of mercy, beneficence, or respect for patient dignity.

Informed consent. The legal and ethical requirement that no significant medical procedure can be performed until the competent patient has been informed of the nature of the procedure, risks and alternatives, as well as the prognosis if the procedure is not done. The patient must freely and voluntarily agree to have the procedure done.

Nonmaleficence. The state of not doing harm or evil; see also beneficence.

Privileged communication. Information communicated to an attorney, physician, spouse, or counselor that may not be revealed, even in court, without the consent of the person who made the statement.

Proxy consent. Voluntary informed consent given on behalf of another who is for some reason incapable of giving it for himself or herself.

(Howard University School of Medicine Program in Clinical Ethics, 2005)
Copyright 2005 Alene Burke & Associates

REFERENCES

American Nurses Association. (1994). "Ethics and Human Rights Position Statements: Active Euthanasia". nursingworld.org/readroom/position/ethics/prteteuth.htm

American Nurses Association (2001). "Code of Ethics for Nurses with Interpretive Statements", Washington, D.C.: American Nurses Publishing. nursingworld.org/ethics/chcode.htm

American Nurses Association (2001). "Dying for Relief: When Pain Relief Could Result in Death" . www.nursingworld.org/AJN/2001/feb/Wrights.htm

Bartlett, John and Nathan Haskell Dole (2000). Familiar Quotations, 10th ed. Boston: Little, Brown, 1919; Bartleby.com, 2000. xix, 1454 p. 23 cm. www.bartleby.com/100/. [January 19, 2005].

Florida State Administrative Rules of the Board of Nursing Chapter 64b9 (2004). Nurse Practice Act.

Florida State Administrative Rules of the Board of Nursing. Chapter 64b9 (2004).

Florida State Administrative Rules of the Board of Nursing. Chapter 64b9-8.005 (2004). Unprofessional Conduct. [January 19, 2005].

Florida State Administrative Rules of the Board of Nursing. Chapter 64b9-5002 (2004). Continuing Education. [January 19, 2005].

Florida State Administrative Rules of the Board of Nursing. Chapter 64b9-12 (2004).LPN and Intravenous Therapy. [January 19, 2005].

Florida State Administrative Rules of the Board of Nursing. Chapter 64b9-14 (2004).Delegation. [January 19, 2005].

Florida State Statutes (2004). Chapter 381.026. Patient's Bill of Rights and Responsibilities. www.doh.state.fl.us/mqa/Profiling/billofrights.htm. [January 19, 2005].

Florida State Statutes (2004). Chapter 464. Nursing. www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0464/ch0464.htm. [January 19, 2005].

Florida State Statutes (2004). Chapter 464. 001- 027 . Florida Nurse Practice Act. www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0464/ch0464.htm. [January 19, 2005].

Florida State Statutes (2004). Chapter 464. 004. Florida Board of Nursing. www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0464/ch0464.htm. [January 19, 2005].

Florida State Statutes (2004). Chapter 464. 0195 . Florida Center for Nursing. www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0464/ch0464.htm. [January 19, 2005].

Florida State Statutes (2004). Chapter 464. 2085. Certified Nursing Assistants. Nursing. www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0464/ch0464.htm. [January 19, 2005].

Howard University School of Medicine Program in Clinical Ethics (2005). "Healthcare Ethics Glossary". www.med.howard.edu/ethics/handouts/health_care_ethics_glossary.htm

International Council of Nurses (2000). "Code of Ethics for Nurses". www.icn.ch/icncode.pdf

Intervention Project for Nurses (IPN). (2004) The Intervention Project for Nurses. www.ipnfl.org

National Council of State Boards of Nursing (1996). "Public Protection or Professional Self-Preservation? The Purpose of Regulation." Chicago, IL: NCSBN. www.ncsbn.org/resources/complimentary_ncsbn_publicpro.asp.

Scarborough, John (2005). "Hippocrates." World Book Online Reference Center. 2005. World Book, Inc. www.aolsvc.worldbook.aol.com/wb/Art

PHARMACOLOGY

INTRODUCTION

Pharmacology is the study of medications and how they work on the body. A thorough and current knowledge of all medications that are given enables us to safely administer them as well as to effectively monitor and assess the patient and their responses to them.

ROUTES AND FORMS OF MEDICATION

Medications are manufactured in different forms and for a specific route of administration. Some medications come in more than one form and some can also be administered via more than one route, provided the correct form of that medication is used.

Complete medication orders specify the route of administration and some may also contain the form that the patient should get.

COMPLETE MEDICATION ORDERS

A doctor or another licensed independent practitioner, such as a nurse practitioner, must write a complete and legible order for a medication before it is administered.

Minimally, a complete medication order must contain the:
All incomplete and/or illegible orders must be questioned with the ordering person before they are administered. The person administering the medication is accountable and responsible for all of the medications that they give.

FORMS OF MEDICATION

Medications come in the following forms:

MEDICATION ADMINISTRATION ROUTES

The routes of administration include:

ROUTE AND FORM CONSIDERATIONS

The oral route of administration is the preferred route of administration for children. When a patient has a swallowing disorder, as is the case with many geriatric patients, the following things can be considered:

AGE SPECIFIC ROUTE AND FORM CONSIDERATIONS

Infants
Toddler
Preschool and School Age Children
Adolescents

ADMINISTERING MEDICATIONS VIA VARIOUS ROUTES

Topical Administration

Do not use topical medications on skin that is not intact unless, of course, the medication is being used to treat broken skin,. The procedure for administering a topical medication is as follows:
  1. Open the tube or container.
  2. Place the top upside down to prevent contamination.
  3. Don gloves.
  4. Place the topical medication on a tongue depressor. Use a cotton tipped applicator or sterile gauze for facial areas.
  5. Apply the medication in long strokes following the direction of hair growth.
Transdermal Administration

The procedure for administering a medication using the transdermal route is as follows:
  1. Remove the old transdermal patch if there is one.
  2. Wash the application site with soap and water. The site should be without hair and on the person's upper arm or chest.
  3. Dry the site.
  4. Don gloves.
  5. Measure the ordered dose onto the patch or strip without allowing the ointment to touch your own skin.
  6. With the medication against the skin gently move the strip over a 3 inch area to spread it out. Do NOT rub.
  7. Secure the site with a plastic wrap or another semipermeable membrane and tape in place.
  8. Note the date, time and your initials on the dressing.
Oral Dosage Administration

Oral medications are administered as below.
  1. Give the patient the medication. Remain with the patient until the medication(s) are swallowed.
Buccal and Sublingual Administration

Buccal medications are placed between the teeth and the inner aspect of the cheek. Sublingual medications are administered under the back of the tongue. The procedure is as follows:
  1. Don gloves.
  2. Place the buccal medication in the buccal pouch and the sublingual medication under the tongue.
  3. Tell the patient to leave the drug in its position so that it can be completely dissolved.
Ophthalmic Medication Administration
  1. Don gloves.
  2. Position the patient in a sitting position or in a supine position.
  3. Have the patient tilt their head back and toward the eye getting the drops or ointment. This prevents the medication from entering the tear duct.
  4. Have the patient look up and away. This helps to prevent touching the eye with the dropper tip or tube tip.
  5. Rest your hand against the person's forehead to steady it.
  6. To administer drops, pull down the lower lid and instill the ordered number of drops into the conjunctival space.
  7. To administer an ointment, pull down the lower lid and squeeze the ointment into the conjuntival space from the inner to the outer canthus of the eye. Do not touch the eye with the tip of the tube.
  8. Ask the person to now close their eyes. Blinking will spread the drops and rolling the closed eyes will spread the ointment over the eye.
  9. Clean excess with a tissue.
Otic Administration
  1. Warm the ear drops to body temperature.
  2. Instruct the person to lie on their side so that the ear to receive the medication is up.
  3. Straighten out the ear canal by pulling the auricle up and back. Straighten out the young child's (less than 3 years of age) ear canal by pulling the auricle down and back.
  4. Instill the ordered drops against the side of the inner ear and hold the auricle in place until the medication is no longer visible. Release the auricle.
  5. Have the person remain in the side lying position for at least 10 minutes.
Inhalation Administration
There are two different types of inhalers that administer medications via the inhalation route. These two types are:
The steps to using a metered dose inhaler are:
  1. Shake the bottle and remove the cap
  2. Ask the person to exhale.
  3. Have the person then firmly place their lips around the mouthpiece.
  4. Compress the bottle against the mouthpiece while the person is taking in a long, slow inhalation
  5. Have the person hold their breath for a couple of seconds and then slowly exhale.
  6. Have the patient rinse their mouth with water and then spit it out. This prevents an fungal infection of the mouth.
The steps to using a turbo inhaler are:
  1. Slide the sleeve away from the mouthpiece.
  2. Turn the mouthpiece counter-clockwise in order to unscrew it.
  3. Place the colored part of the medication into the stem of the mouthpiece.
  4. Rescrew the inhaler.
  5. Slide the sleeve all the way down to puncture the capsule.
  6. Tilt the head backwards and after a full exhalation, tell the patient to deeply inhale and hold their breath for several seconds.
  7. Repeat inhalations until all of the medication has been used.
  8. The patient can then gargle if they like.
Nasogastric Administration
  1. Position the patient in a Fowler's position.
  2. Gently instill about 10 ml of air into the tube while auscultating the abdomen about 3 inches below the sternum to confirm that the nasogastric tube is in the stomach and not in the lung. An air bubble is heard when the tube is in the stomach.
  3. Gently pull back on the syringe to reconfirm that the tube is in the stomach. If gastric contents become visible in the tube, the nasogastric tube is in the stomach where it should be.
  4. Prepare the medication(s) to be administered.
  5. Insert the syringe without the piston into the end of the nasogastric tube.
  6. Pour the medications into the syringe and allow them to flow with gravity.
  7. Follow the administration with about 30 to 50 ml of water for an adult and 15 to 30 ml for children to clear the tube and to maintain its patency.
  8. Leave the person in a Fowler's position for at least 30 minutes after instillation. If the person cannot remain in a Fowler's position, place the patient on the right side with the head elevated.
Vaginal Administration

The procedure for the administration of a vaginal suppository is as follows:
  1. While the patient is in the recumbent position, assist the person into the lithotomy position.
  2. Drape the patient exposing only the perineum.
  3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
  4. Don gloves.
  5. Spread the labia and insert the suppository about 3 to 4 inches into the vagina.
  6. If an applicator was used, discard it if it is for single use or wash it with soap and water.
Rectal Administration

The procedure for the administration of a rectal suppository is as follows:
  1. Position the patient on their left side in the Sim's position.
  2. Drape the patient exposing only the buttocks.
  3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
  4. Don gloves.
  5. Lift the person's upper buttock with the nondominant hand and insert the suppository with the tapered end first about 3 inches into the rectum past the rectal sphincter while the patient is taking deep breaths to relax the sphincter and to decrease anxiety.
  6. Instruct the person to lie still so the suppository can be retained. If the person has the urge to defecate, place a gauze pad over the rectum and press until the urge to defecate passes.
The procedure for the administration of a rectal ointment is as follows:
  1. Drape the patient exposing only the buttocks.
  2. Don gloves.
  3. Place the ointment on a gauze pad and apply to the rectum.
  4. If an applicator is used, follow steps 4 and 5 above.
Subcutaneous Injections

Subcutaneous injections can be given in the abdomen, upper arms and the front of the thighs. The procedure is as follows:
  1. Select the site.
  2. Don gloves and position the patient if necessary.
  3. Clean the injection site with an alcohol swab in an outward circular pattern of about 2 inches.
  4. Gently pinch the site so a 1 inch fat fold appears.
  5. Position the needle with the bevel up and insert at a 45 degree angle unless you CANNOT pinch an inch or more. In this case, use a 90 degree angle. Heparin is always injected at a 90 degree angle.
  6. Release the skin pinch.
  7. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
  8. Slowly inject the medication.
  9. Withdraw the needle and cover the site with an alcohol swab. 10.Gently massage the site, except if you are injecting heparin. Discard the needle and syringe in the proper container. Do NOT recap needles.
Intramuscular Administration
  1. Select and identify the site (deltoid, ventrogluteal, etc.) using bony landmarks.
  2. Don gloves and position the patient if necessary.
  3. Clean the injection site with an alcohol swab.
  4. Position the needle with the bevel up and insert at a 90 degree angle.
  5. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
  6. Slowly inject the medication.
  7. Withdraw the needle and cover the site with an alcohol swab.
  8. Gently massage the site.
  9. Discard the needle and syringe in the proper container. Do NOT recap needles.
If more than 5 mls are needed, split the dose and use two different sites for injection.

Intravenous Bolus Administration (IV Push)

The procedure for IV push without an existing IV line is as follows:
  1. Select the largest vein suitable for the medication.
  2. Don gloves.
  3. Apply a tourniquet, locate the vein, prep the skin and insert the needle at a 30 degree angle with the bevel up.
  4. Lower the angle when you are in the vein.
  5. Check for blood backflow.
  6. Remove the tourniquet and slowly inject the medication at the ordered or recommended rate.
  7. Withdraw the needle, cover the site with a gauze pad and pressure for 3 minutes.
  8. Place a bandage over the site.
The procedure for IV push with an existing IV line is as follows:
  1. Make sure that the medication is compatible with the IV solution and any additives.
  2. Don gloves.
  3. Close the flow clamp on the IV tubing or pinch the tubing just above the injection port.
  4. Prep the injection port with alcohol.
  5. Inject the medication slowly over several minutes.
  6. Open the flow clamp and readjust the flow rate to the ordered rate.
Intravenous Piggy Back or Secondary Line Administration

This procedure is as follows:
  1. Make sure that the medication is compatible with the IV solution and any additives.
  2. Hang the secondary IV set (piggy back).
  3. Clean the injection port with alcohol.
  4. Insert the secondary set needle or needless system into the injection port of the primary IV tubing.
  5. Lower the primary IV using an extension hook to run only the piggy back medication. Keep the primary and the secondary containers at the same level to run both solutions simultaneously.
  6. Remove the secondary set when the medication is completely administered.
Adding Medications to IV Solutions

To add medications to IV solutions:
  1. wipe off the injection port with alcohol,
  2. insert the needle into the injection port and
  3. inject the ordered medication.
Z Track Injections
  1. Pull the skin to the side.
  2. Inject the medication.
  3. Release the skin.
  4. Do NOT massage the site.
Drawing Up Medication From a Vial
  1. Wipe the vial with an alcohol swab.
  2. Remove the cap from the needle.
  3. Pull back on the plunger to draw amount of air into syringe equivalent to volume of medication to be aspirated from vial
  4. Insert the tip of needle, with bevel pointing up, through center of rubber seal and inject the air into the vial.
  5. Let the air pressure in the vial to fill the syringe to the desired dose.
  6. Tap the syringe to rid it of an air bubbles.

THE ACTIONS OF MEDICATIONS

Those that administer and dispense medications must be thoroughly knowledgeable about how medications act on the body. This knowledge enables us to plan patient care and assessments based on the medication's therapeutic effect as well as what the possible side effects and signs of toxicity may be.

Information about the actions of all medications can be found in a drug reference book like the Physicians' Desk Reference (PDR).

INDICATIONS FOR USE

All medications have intended uses. Most of these intended uses are related to the action of the medication, however, some uses are related to a medication's side effects. For example, diphenhydramine, an antihistamine, is used both as an antihistamine and for sleep because one of its side effects is drowsiness.

Approved uses are documented in drug reference books. At times a medication is used for a purpose not specified and approved. This use is referred to as "off label use".

PRECAUTIONS AND CONTRAINDICATIONS

Some medications are contraindicated for certain patients. For example, a medication can be contraindicated, or prohibited, for patients that have severe renal or hepatic disease and those that are pregnant or lactating. Other medications may be permitted with caution under certain circumstances. For example, a medication may be used with caution among the elderly population. When a medication is being used with caution, it is particularly important to monitor and assess the patient's responses to the medication.

The most commonly occurring contraindication is an allergy or sensitivity to a medication. The patient's allergies must be known and researched prior to the administration of any medication.

INTERACTIONS

Medications can interact with:
Information about possible drug-drug, drug-food, drug-herb, drug-lifestyle interactions can be found in a drug reference book like the Physicians' Desk Reference (PDR) for every medication.

SIDE EFFECTS AND ADVERSE REACTIONS

All medications have side effects. Nausea and vomiting are the most commonly encountered side effects. Some side effects are desirable. For example, the side effect of drowsiness associated with diphenhydramine is desirable when this medication is given for sleep. Most side effects, however, are undesirable. For example, the drowsiness associated with diphenhydramine may place the person at risk when they are driving a car.

Some side effects are troublesome; others can be life threatening. Adverse drug reactions are serious and often life threatening side effects. Some medications also have toxic effects. For example, tinnitus is a sign of toxicity associated with aspirin.

A thorough knowledge about side effects, adverse drug reactions and toxic effects is necessary so that the patient can be monitored for not only therapeutic effects but the side effects of medication.

ALLERGIES AND SENSITIVITY

Any allergies or sensitivity to medications must be assessed and documented. All known allergies must be reviewed prior to the administration of medications.

DOSAGES

All medications have approved and recommended dosages and/or dosage ranges for adults and pediatric patients. Some recommended adult dosages may be decreased somewhat among the elderly because the normal physiological changes of the aging process make this age group more susceptible to side effects, adverse drug reactions, toxicity and overdosages.

Pediatric dosages are most often determined as based on the weight of the patient in terms of kilograms. Generally speaking, adolescents can safely take recommended adult dosages.

PHARMACOLOGY ABBREVIATIONS

Abbreviations save time however they can also jeopardize life. The pharmacology abbreviations that we have been using for many, many years are now being highly scrutinized. Some have led to disastrous medication errors.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) offers some guidance and some regulations regarding the use of abbreviations in healthcare organizations. Some of these guidelines and regulations specifically address pharmacology.
Hospitals, nursing homes, assisted living facilities, and all other healthcare settings must now standardize their acceptable abbreviations, acronyms and symbols. JCAHO does not mandate that every facility make a complete list of all the abbreviations, acronyms and symbols that they will accept and use, however, they do mandate that all healthcare facilities make a list of all those that they will NOT use. Additionally, this accreditation body specifies several high risk abbreviations that cannot be used under any circumstances. (Joint Commission on the Accreditation of Healthcare Organizations, 2005).

Commonly used and acceptable abbreviations along with their meaning is found below.

ABBREVIATION MEANING
a.c. Before meals
ad Up to
ad lib Freely
a.m. Morning
amp. Ampule
aq. Water
ASA Aspirin
b.i.d Twice a day
BM Bowel movement
BP Blood pressure
BS Blood sugar
C (with line over it) With
cap Capsule
cc Cubic centimeter
comp. Compound
dil Dilute
disc or D.C. Discontinue
disp. Dispense
div. Divide
DW Distilled water
D5W Dextrose 5% in water
D5LR Dextrose 5% in lactated Ringers solution
elix. Elixir
ext Extract
fl or fld Fluid
g. or Gm. or g Gram
gr Grain
gtt. Drop
h. or hr. Hour
ID Intradermal
IM Intramuscular
inj. Injection
IV Intravenous
IVP Intravenous push
IVBP Intravenous piggy back
kg killogram
L Liter
mEq Milliequivalent
min Minute
mg Milligram
mL Milliliter
NaCl Sodium Chloride
NPO Nothing by mouth
NS Normal saline
1/2 NS Half-strength normal saline
NTG Nitroglycerin
p.c. After meals
p.m. Evening
p.o. By mouth
PR Rectally
prn When needed
q Every
qh Every hour
qid Four times a day
R Rectal
R.L. or R/L Ringer's Lactate
s (with a line over it) Without
SL Sublingual
SOB Shortness of breath
sol Solution
ss. One half
stat Immediately
Sub Q Subcutaneous
sup. Suppository
susp. Suspension
Syr. Syrup
tab. Tablet
tbsp Tablespoonful
tid Three times a day
tinc Tincture
top Topically
tr. Tincture
tsp. Teaspoon
ung. Ointment
w/ With
w/o Without

Prohibited abbreviations, suggested alternatives and the rationale for the prohibition are shown below.

ABBREVIATION Mistaken For: Instead, write
U (unit) zero "unit"
IU (international unit) zero or ten "international unit"
Q.D. (every day) Q.O.D "daily"
Q.O.D.(every other day) Q.D "every other day"
No trailing zero (.Xmg) a whole number "0.Xmg)
MS, MSO4 and MgSO4 eachother "morphine sulfate" or
"magnesium sulfate"

Some not yet prohibited abbreviations that JCAHO encourages us discard are below.

ABBREVIATION Mistaken For: Instead, write
mg (microgram) mg "mcg"
H.S.(half strength & at bedtime) Each other "half strength" or "at bedtime"
T.I.W.(3 times a week) 2 times a week or 3 times a day "3 times a week"
S.C. or S.Q.(subcutaneous) SL (sublingual) "Sub-Q", "subQ", or "subcutaneously"
D/C (discharge) Discontinue meds "discharge"
c.c. (cubic centimeter) U (units) "ml"
A.S, A.D., A.U.(left, right and both ears) OS, OD, OU "left ear, right ear, both ears"

(Joint Commission on the Accreditation of Healthcare Organizations, 2004)

MEDICATION CLASSIFICATIONS

INTRODUCTION

Medications can be classified according to their use or function, the system that they treat and their chemical makeup. For example, they can be classified according to system, as follows: They can also be classified according to their function or use. For example, they can be classified as below: Lastly they can be classified according to their chemical makeup. Examples include: Most of the medications within a classification group, like alpha-adrenergic blockers, are quite similar although they are not identical. Classification systems enable us to readily identify the similarities and differences among a large number of medications within and outside of a particular classification. One of the best and most efficient ways to master pharmacology is to become familiar with the classifications of medications and then to focus on the similarities and differences of medications within the same classification.

MEDICATION CLASSIFICATIONS

ALPHA-ADRENERGIC BLOCKERS

Actions: They bind to α-adrenergic receptors thus leading to the dilation of peripheral blood vessels, lowering of peripheral resistance and the lowering of blood pressure.

Uses: Hypertension and prevention of necrosis secondary to extravasation.

Adverse Reactions and Side Effects: Hypotension, stuffed nasal passages, tachycardia, diarrhea, nausea, and vomiting.

Contraindications: Myocardial infarction (MI) and coronary artery disease, including angina.

Implications: Check K, Na, Cl, CO2, daily weights, I&O, BP standing and lying.

Examples of Medications in This Classification:
ANTACIDS
Actions: They contain magnesium, aluminum, calcium and a combination of these compounds. They slow down the rate of gastric emptying and neutralize gastric acidity.

Uses: Gastritis, peptic ulcer, hiatal hernia and reflux esophagitis.

Adverse Reactions and Side Effects: Constipation, diarrhea, flatus, abdominal distention, alkaluria.

Contraindications: Allergy and sensitivity

Implications: Assess epigastric pain, GI symptoms and renal problems and electrolytes.

Examples of Medications in This Classification:
ANTIANGINALS
This classification is further divided into: Actions:

Nitrates - dilate coronary arteries, decrease preload and afterload.

Calcium channel blockers- also dilate coronary arteries, but they also decrease SA/AV node conduction

β -Adrenergic blockers- slow the heart rate, thus decreasing O2 use.

Uses: Angina. Calcium channel blockers and β-blockers can also be used for hypertension and dysrhythmias.

Adverse Reactions and Side Effects: Postural hypotension, fatigue, dysrhythmias, headache, edema, dizziness.

Contraindications: Increased intracranial pressure, cerebral hemorrhage and sensitivity.

Implications: Monitor for side effects and orthostatic B/P. Continue to assess angina pain.

Examples of Medications in This Classification:
ANTICHOLINERGICS
Actions: Inhibit acetylcholine (autonomic nervous system)

Uses: Many uses- some decrease GI, urinary and billiary motility; others decrease GI secretions, decrease involuntary movement, and relieve nausea, and vomiting.

Adverse Reactions and Side Effects: Dryness of the mouth, paralytic ileus, constipation, urinary problems (retention and hesitancy) dizziness and headache.

Contraindications: GI or urinary obstruction, narrow-angle glaucoma, and myasthenia gravis.

Implications: Monitor urinary and bowel function as well as vital signs. Keep the patient in bed for one hour after parenteral dose.

Examples of Medications in This Classification:
ANTICOAGULANTS
Actions: Prevent clot formation.

Uses: MI, pulmonary embolus, deep vein thrombosis, disseminated intravascular clotting syndrome (DIC), and atrial fibrillation. It is also used with dialysis.

Adverse Reactions and Side Effects: Hemorrhage, diarrhea, fever, rash and blood disorders (leukopenia, thrombocytopenia, etc.) depending on the specific drug.

Contraindications: Bleeding disorders, such as hemophilia and leukemia, ulcers, blood dyscrasias, nephritis, endocarditis and thrombocytopenia purpura.

Implications: Observe for bleeding (oral, black stools, stool occult blood, ecchymosis, etc.). Monitor blood and BP (hypertension may occur).

Examples of Medications in This Classification:
ANTICONVULSANTS
This classification is further divided into: Actions: Act to prevent seizures.

Uses: Depending on the specific drug, they prevent tonic-clonic seizures, psychomotor seizures, status epilepticus, petit mal seizures and cortical focal seizures.

Adverse Reactions and Side Effects: Bone marrow depression, which can be life-threatening, GI problems, CNS effects like confusion, ataxia and slurring of speech.

Contraindications: Sensitivity

Implications: Monitor hepatic and renal function, blood, mental status, blood dyscrasias, and toxicity (ataxia, bone marrow depression, nausea, vomiting, cardiovascular problems, Stevens-Johnson syndrome)

Examples of Medications in This Classification:
ANTIDEPRESSANTS
Antidepressants are further divided into: Actions:

MAOIs- inhibit MAO and thus they increase epinephrine, norepinephrine, serotonin, and dopamine.

Tricyclics- block the reuptake of serotonin and norepinephrine in the nerve endings, thus increasing the actions of both in the nerve cells.

Uses: Depression. Nocturnal enuresis in children.

Adverse Reactions and Side Effects: Orthostatic hypotension, mouth dryness, dizziness, drowsiness, urinary retention, hypertension, renal failure and paralytic ileus.

Contraindications: Hypertrophy of the prostate, seizure disorders, renal, hepatic and cardiac disease.

Implications: Monitor standing and lying BP, blood, mental status, hepatic function. Observe for extrapyramidal symptoms and urinary retention. Withdrawal symptoms occur with abrupt cessation.

Examples of Medications in This Classification:
ANTIDIABETIC MEDICATIONS
Antidiabetics are also subdivided into the following groups: Actions:

Insulin- lowers blood sugar, potassium and phosphate

Oral hypoglycemic agents- stimulate the β -cells of the pancreas to release insulin.

Uses: Diabetes and ketoacidosis

Adverse Reactions and Side Effects: Hypoglycemia, hepatotoxicity, allergic responses

Contraindications: Sensitivity. Oral agents are contraindicated for juvenile diabetes and ketoacidosis.

Implications: Monitor blood glucose, assess for hypoglycemia, rotate insulin injection sites, and use human insulin with pork or beef sensitivity.

Examples of Medications in This Classification:
ANTIDIARRHEALS
Actions: Varying. Come decrease water content of stool, some slow down GI peristalsis.

Uses: Diarrhea

Adverse Reactions and Side Effects: Constipation, paralytic ileus, abdominal pain.

Contraindications: Colitis

Implications: Used for short term therapy (48 hours or less). Monitor electrolytes and bowel response.

Examples of Medications in This Classification:
ANITDYSRHYTHMICS
Antidysrhythmics are subdivided into five groups: Actions:

Class I- decreases any disparity in the refractory period, increases the duration of action potential and effective refractory period

Class II- slows down the rate of SA node discharge and conduction through the AV node. Increases recovery time and decreases the heart rate, thus lowering O2 consumption in the myocardium

Class III- increases effective refractory period as well as the duration of action potential

Class IV- decreases SA node discharge and slows the conduction velocity through the AV node. They also inhibit calcium movement across the cell.

Others- slows conduction through the AV node (adenosine) and increases the refractory period in the AV node and decreases conduction velocity (digoxin)

Uses: Atrial and ventricular arrhythmias (atrial fibrillation, PVCs, and tachycardia), hypertension, and angina

Adverse Reactions and Side Effects: Hypotension, bradycardia, other arrhythmias and various other wide ranging side effects.

Contraindications: Various. Check each medication.

Implications: Monitor rate and rhythm, blood pressure, potassium, dependent edema and I & O

Examples of Medications in This Classification:
ANTIFUNGALS
Actions: Decreases sodium, potassium and nutrients in the cell and increases cell permeability.

Uses: Fungal infections such as cryptococcosis, aspergillosis, histoplasmosis, blastomycosis, coccidiomycosis, , phycomycosis, and candidiasis

Adverse Reactions and Side Effects: Renal, liver damage and failure, gastroenteritis, hypokalemia, anorexia, nausea and vomiting.

Contraindications: Sensitivity and bone marrow depression.

Implications: For IV administration, use a filter, check for extravasation and protect from light (cover with foil). Monitor vital signs, I & O, blood, weight, renal and hepatic function, hypokalemia and ototoxicity.

Examples of Medications in This Classification:
ANTIHISTAMINES
Actions: Antagonists of histamine.

Uses: Allergies, pruritus and rhinitis.

Adverse Reactions and Side Effects: Most cause drowsiness, headache, urinary retention, blood dyscrasias, thickened bronchial secretions and GI effects

Contraindications: Sensitivity, asthma, peptic ulcer, narrow angle glaucoma.

Implications: Monitor urinary, respiratory and cardiac status. Also monitor for blood dyscrasias.

Examples of Medications in This Classification:
ANTIHYPERTENSIVES
This classification is further divided into: Actions:

Angiotensin-converting enzyme inhibitors- dilatation of the arterial and venous systems occur through the suppression of renin-angiotensin I to angiotensin II conversion

Centrally acting adrenergics- inhibit impulses in the CNS and the sympathetic nervous system, decreases cardiac output, blood pressure and pulse rate

Peripherally acting antiadrenergics- inhibit the release of norepinephrine thus decreasing sympathetic vasoconstriction

Vasodilators- reduce blood pressure, cardiac rate and cardiac output because these medications relax and dilate the smooth muscle of the arteries

b-Blockers, calcium channel blockers, and diuretics are discussed in another section below.

Uses: Hypertension, heart failure, angina and some dysrhythmias

Adverse Reactions and Side Effects: Hypotension, tachycardia, bradycardia, nausea, vomiting and headache.

Contraindications: Heart block, hypersensitivity

Implications: Check for edema, monitor renal function, blood and for symptoms of congestive heart failure.

Examples of Medications in This Classification:
ANITIINFECTIVES
Antiinfectives are divided further into the following groups: Actions: Inhibit the growth and/or replication of susceptible bacteria

Uses: Infection

Adverse Reactions and Side Effects: Diarrhea, nausea, vomiting, bone marrow depression and anaphylaxis (life threatening)

Contraindications: Hypersensitivity. Most people allergic to penicillins are also allergic to the cephalosporins.

Implications: Observe bowel pattern and urinary output. Monitor renal function, blood and for signs of a superinfection and bleeding.

Examples of Medications in This Classification:
ANTINEOPLASTICS
This classification is further divided into: Actions: Alkylating agents- interfere with DNA

Antimetabolites - inhibit DNA synthesis

Antibiotic agents- inhibit RNA synthesis by delaying or inhibiting mitosis

Hormones- change the effects of androgens, estrogen, luteinizing hormone, and follicle-stimulating hormone

Uses: Tumors, lymphoma, leukemia and Hodgkin's disease

Adverse Reactions and Side Effects: Anemia, thrombocytopenia, leukopenia, nausea, vomiting, hair loss, hepatotoxicity, cardiotoxicity and hepatotoxicity

Contraindications: Sensitivity, liver and renal damage.

Implications: Monitor blood studies (CBC, platelet count and differential (the drug may have to be held), renal and liver function, I & O. Observe for bleeding, jaundice, dependent edema, breaks in the skin and mucosal inflammation. Check for irritation and phlebitis with IV administration.

Examples of Medications in This Classification:
ANTIPARKINSON AGENTS
This classification is further divided into: Actions:

Cholinergics- block acetylcholine receptors

Dopamine antagonists- activate dopamine receptors

Uses: Parkinson's disease

Adverse Reactions and Side Effects: Involuntary movement, insomnia, nausea, vomiting, orthostatic hypotension, dry mouth, numbness and headache

Contraindications: Sensitivity and narrow angle glaucoma

Implications: Monitor respirations, blood pressure and changes in mental and behavioral status

Examples of Medications in This Classification:
ANTIPSYCHOTIC AND NEUROLEPTIC AGENTS
Again, this classification is subdivided. The groups are: Actions: All of these pharmacological agents block the dopamine receptors in the brain, the area that involves psychotic behavior

Uses: Schizophrenia, mania, paranoia, and anxiety. They are also sometimes used for unrelieved hiccups, nausea, vomiting, and pediatric behavioral problems as well as pre-operative relaxation.

Adverse Reactions and Side Effects: Some symptoms (EPS, dystonia, akathisia and tardive dyskinesia) can be controlled with antiparkinsonian medications. Others side effects include dry mouth, photosensitivity, agranulocytosis, hypotension, and life threatening cardiac problems and laryngospasm.

Contraindications: Coronary disease, severe hypertension, severe depression, bone marrow depression, blood dyscrasias, parkinsonism, cerebral arteriosclerosis, narrow angle glaucoma and children less than 12 years of age. Cautiously used with the elderly.

Implications: Monitor CBC, liver function, I & O, blood pressure lying and standing (orthostatic hypotension), EPS (antiparkinsonian agents should be used for this). Observe for dizziness, palpations, tachycardia, changes in affect, level of consciousness, gait and sleep patterns.

Examples of Medications in This Classification:
ANTITUBERULARS
Actions: Decreases the replication of the offending bacillus through the inhibition of RNA or DNA

Uses: Pulmonary tuberculosis

Adverse Reactions and Side Effects: Anorexia, nausea, vomiting, rash, renal, hepatic and ototoxic effects, which could be severe.

Contraindications: Sensitivity, renal disease. Caution with hepatic disease, pregnancy and lactation

Implications: Check renal and hepatic status and for signs of anemia.

Examples of Medications in This Classification:
ANTITUSSIVES and EXPECTORANTS
Actions:

Antitussives- suppression of the cough reflex

Expectorants- decrease the viscosity of thick, tenacious secretions

Uses: The expectorants are used with a cough associated with bronchitis, TB, pneumonia, cystic fibrosis and COPD. Antitussives are used for nonproductive coughs.

Adverse Reactions and Side Effects: Dizziness, drowsiness and nausea

Contraindications: Iodine sensitivity, pregnancy, lactation and hypothyroidism. Caution with the elderly and those with asthma

Implications: Monitor the cough and the sputum. Increase fluid intake and humidification to thin secretions.

Examples of Medications in This Classification:
ANTIVIRALS
Actions: Interferes with the DNA needed for viral replication

Uses: HIV infections, herpes (herpes simplex virus and herpes genitalis), encephalitis (herpes simplex) and varicella zoster encephomyelitis

Adverse Reactions and Side Effects: Nausea, vomiting, diarrhea, headache, anorexia, vaginitis, moniliasis, blood dyscrasias, renal failure and metabolic encephalopathy which could be fatal

Contraindications: Immunosuppressed patients with herpes zoster and hypersensitivity. Caution with pregnancy, lactation, renal and liver disease and dehydration

Implications: Assess for renal and liver problems. Observe for signs of infection and allergic reactions (itching, rash, urticaria). Monitor the blood for dyscrasias.

Examples of Medications in This Classification:
BARBITURATES
Actions: Decreases impulse transmission to the cerebral cortex

Uses: Epilepsy, sedation, insomnia, anesthesia, cholestasis with some medications in this classification.

Adverse Reactions and Side Effects: Drowsiness, nausea, blood dyscrasias and Stevens-Johnson syndrome

Contraindications: Allergy, poor liver function, porphyria, pregnancy (category D). Caution with the elderly renal or hepatic disease (slowed metabolism)

Implications: Monitor seizure control, blood, hepatic and renal function. Observe for toxicity (insomnia, hallucinations, hypotension, pulmonary constriction; cold, clammy skin; cyanosis of lips, nausea, vomiting, delirium, weakness)

Examples of Medications in This Classification:
BENZODIAZEPINES
Actions: Decreases anxiety by potentiating g-aminobutyric acid and other CNS inhibitory transmitters

Uses: Anxiety secondary to phobic disorders and other conditions, acute alcohol withdrawal and pre-operative relaxation.

Adverse Reactions and Side Effects: Physical dependence and abuse, dizziness, drowsiness, orthostatic hypotension, and blurred vision

Contraindications: Narrow angle glaucoma, infants less than 6 months old, hypersensitivity, lactation (diazepam) and liver disease (clonazepam). Caution with the elderly as well as those with renal and/or hepatic disease

Implications: Monitor lying and standing blood pressure (notify MD if B/P drops 20 mm Hg or more), pulse, hepatic and renal function and signs of dependency. Administer with milk or food to prevent GI symptoms.

Examples of Medications in This Classification:
BETA-ADRENERGIC BLOCKERS
β-Blockers are divided into two categories: Actions:

Selective blockers- block the stimulation of b1-receptors in the cardiac smooth muscle with chronotropic and inotropic effects.

Nonselective blockers- lowers blood pressure (plasma renins are reduced) without a reduction in heart rate or reflex tachycardia.

Uses: Hypertension, angina prophylaxis and ventricular dysrhythmias

Adverse Reactions and Side Effects: Orthostatic hypotension, diarrhea, nausea, vomiting, bradycardia, blood dyscrasias, CHF and bronchospasm

Contraindications: Heart block, cardiogenic shock and CHF. Cautious use with the elderly and those patients with COPD, coronary artery disease, asthma, renal disease, thyroid disease, pregnancy.

Implications: Monitor blood pressure, I&O, daily weights, pulse and renal function. Observe for edema and take the apical and radial pulse before administration in order to determine if significant changes have occurred.

Examples of Medications in This Classification:
BRONCHODILATORS
This classification is further subdivided into: Actions:

Anticholinergics- inhibit the interaction of acetylcholine at receptor sites on bronchial smooth muscle

α/β -adrenergic agonists- increase the diameter of nasal passages and relax bronchial smooth muscle

β-adrenergic agonists- relax the smooth muscle of the bronchii

Phosphodiesterase inhibitors- increased smooth muscle relaxation in the respiratory system

Uses: Asthma, bronchospasm, COPD, emphysema, Cheyne-Stokes respirations

Adverse Reactions and Side Effects: Dyspnea, bronchospasm, anxiety, tremors, throat irritation, nausea and vomiting.

Contraindications: Narrow angle glaucoma, severe cardiac disease, tachydysrhythmias and sensitivity. Cautious use with hypertension, seizure disorders, pregnancy and lactation, hyperthyroidism and prostatic hypertrophy

Implications: Assess for a therapeutic response (absence of dyspnea and/or wheezing) and patient/family education about the use of the inhaler

Examples of Medications in This Classification:
CALCIUM CHANNEL BLOCKERS
Actions: Inhibits the flow of calcium ions across the cell membrane of cardiac and vascular smooth muscle, thus relaxing the coronary vascular smooth muscle, dilating the coronary arteries, slowing SA/AV node conduction, and dilating peripheral arteries.

Uses: Angina, hypertension, and dysrhythmias.

Adverse Reactions and Side Effects: Dysrhythmias, edema, fatigue, headache, and drowsiness.

Contraindications: Systolic blood pressure of less than 90 mm HG, Wolff-Parkinson-White syndrome, 2nd or 3rd degree heart block, sick sinus syndrome, and cardiogenic shock. CHF may get worse in the presence of edema. Cautious use with hepatic and renal disease.

Implications: Monitor blood pressure, pulse and respirations. Administer at bedtime and before meals.

Examples of Medications in This Classification:
CARDIAC GLYCOSIDES
Actions: Cardiac output and cardiac contractility are enhanced by making more calcium available.

Uses: CHF and tachycardia

Adverse Reactions and Side Effects: Cardiac changes, hypotension, GI symptoms, blurred vision, yellowish-green halos and headache.

Contraindications: Hypersensitivity, ventricular fibrillation, ventricular tachycardia and carotid sinus syndrome. Caution among patients with imbalances of potassium, magnesium and/or calcium, acute MI, severe respiratory disease, AV block, renal or liver disease, hypothyroid and the elderly.

Implications: Assess vital signs, check apical rate for one full minute prior to administration (if less than 60, hold the dose and notify the MD), electrolytes (sodium, potassium, chloride and magnesium), renal and hepatic function. Monitor I & O. If K level is less than 3mg/dl, potassium supplements may be ordered.

Examples of Medications in This Classification:
CHOLINERGICS
Actions: These medications prevent the destruction of acetylcholine, thus increasing its concentration, which enhances the transmission of impulses.

Uses: Myasthenia gravis, bladder distention, urinary distention, and postoperative paralytic ileus

Adverse Reactions and Side Effects: Bronchospasm, laryngospasm, respiratory depression, convulsion, paralysis, respiratory arrest, nausea, vomiting and diarrhea

Contraindications: Renal or intestinal obstruction. Cautious use with children, lactation, bradycardia, hypotension, seizure disorders, bronchial asthma, coronary occlusion, and hyperthyroidism

Implications: Monitor vital signs, I & O. Assess for urinary retention, bradycardia, bronchospasm, hypotension, respiratory depression.

Examples of Medications in This Classification:
CHOLINERGIC BLOCKERS
Actions: Blocks the autonomic nervous system's acetylcholine

Uses: Prevention of surgical secretions, to decrease the motility of the urinary, biliary and GI tracts, reverses neuromuscular blockade. Some are used for parkinsonian symptoms secondary to the use of neuroleptic medications

Adverse Reactions and Side Effects: Constipation and dryness of the mouth.

Contraindications: GU or GI obstruction, angle closure glaucoma, myasthenia gravis, and hypersensitivity. Cautious use among the elderly and with patients who have prostatic hypertrophy or tachycardia

Implications: Monitor urinary status and I & O with particular attention to any dysuria, frequency or retention. The medication may be discontinued with these signs. Observe mental status and for constipation. Administer oral doses with milk or food and administer parenteral doses slowly with the person in a recumbent position to prevent postural hypotension

Examples of Medications in This Classification:
CORTICOSTEROIDS
This classification is also subdivided. These groups are: Actions:

Glucocorticoids- increase capillary permeability and suppress the movement of fibroblasts and leukocytes, thereby decreasing inflammation.

Mineralcorticoids- increase potassium and hydrogen excretion in the distal tubule by increasing the resorption of sodium

Uses:

Glucocorticoids- decrease inflammation. Some are used for adrenal insufficiency, allergies and cerebral edema.

Mineralcorticoids- adrenal insufficiency

Adverse Reactions and Side Effects: Insomnia, euphoria, behavioral changes, peptic ulcer (GI irritation), sodium and fluid retention, hypokalemia, hyperglycemia, and carbohydrate intolerance (metabolic reactions)

Contraindications: Fungal infections, amebiasis, hypersensitivity, and lactation. Caution with the elderly, children and pregnant women, diabetes, seizures, peptic ulcers, glaucoma, CHF, hypertension, impaired renal function, myasthenia gravis and ulcerative colitis

Implications: GI symptoms can be prevented when the dose is given with food or milk. Monitor blood sugar, potassium, weight, I & O, plasma cortisol levels, adrenal insufficiency and for any signs of infection. Observe for mood changes, particularly depression

Examples of Medications in This Classification:
DIURETICS
This classification of medications is subdivided into: Actions:

Thiazides and thiazide-like diuretics- slow resorption in the distal tubule, thus increasing the excretion of sodium and water

Loop diuretics- inhibit the resorption of sodium and chloride in the loop of Henle.

Carbonic anhydrase inhibitors- decrease the sodium-hydrogen ion exchange in the tubule, thus increasing sodium excretion

Osmotic diuretics- decrease the absorption of sodium by increasing the osmotic pressure of glomerular filtrate

Potassium-sparing diuretics- decrease potassium excretion by interfering with sodium resorption at the distal tubule

Uses: Hypertension and edema with CHF

Adverse Reactions and Side Effects: Hypokalemia, hyperglycemia and hyperuricemia (mostly with thiazides), blood dyscrasias, aplastic anemia, volume depletion, and dehydration (thiazides, loop diuretics, and carbonic anhydrase inhibitors)

Contraindications: Electrolyte imbalances (K, Cl, Na), anuria, dehydration. Caution among the elderly as well as in the presence of renal or hepatic disease

Implications: A potassium supplement may be needed. Monitor electrolytes, blood sugar, and lying and standing blood pressures. Observe for signs of hypokalemia and metabolic alkalosis. The medication should be given in the morning to prevent the need for frequent nocturnal voiding.

Examples of Medications in This Classification:
HISTAMINE H2 ANTAGONISTS
Actions: Inhibits histamine in the parietal cells, thereby inhibiting the secretion of gastric acid secretion

Uses: Gastric and duodenal ulcers, gastroesophageal reflux disease

Adverse Reactions and Side Effects: Thrombocytopenia, neutropenia agranulocytosis, aplastic anemia, confusion (not ranitidine), diarrhea and headache.

Contraindications: Hypersensitivity. Cautious use with children less than 16 years of age, hepatic or renal disease, organic brain syndrome, lactation and pregnancy

Implications: Monitor I & O, creatinine, BUN and gastric pH. The pH should be maintained above 5. Give slowly IV over 30 minutes to avoid bradycardia and administer oral doses with meals to prolong the effect of the medication

Examples of Medications in This Classification:
IMMUNOSUPPRESSANTS
Action: Inhibits lymphocytes

Uses: Prevention of organ transplant rejection

Adverse Reactions and Side Effects: Proteinuria, renal failure, albuminuria, hematuria, hepatotoxicity, oral Candida, gum hyperplasia, headache and tremors

Contraindications: Hypersensitivity. Caution with severe hepatic or renal disease and pregnancy

Implications: Monitor liver and kidney function, and drug blood levels. Observe for signs of hepatotoxicity, which can include itching, light colored stools, jaundice and dark urine. Administer with meals to avoid GI symptoms

Examples of Medications in This Classification:
LAXATIVES
This group is also subdivided as below: Actions:

Bulk laxatives - absorb water thus adding bulk to the stool

Lubricants- increase water retention in the stool

Stimulants- speed up peristalsis

Saline laxatives- pull water into the intestines

Osmotics- enhance peristalsis and increase distention

Stool softeners- reduce the surface tension of liquids within the bowel.

Uses: Constipation, as a bowel prep and a stool softener

Adverse Reactions and Side Effects: Cramping, diarrhea, and nausea

Contraindications: Megacolon, abdominal pain, nausea, vomiting, impaction, GI obstruction or perforation, gastric retention and colitis. Caution with large hemorrhoids and rectal bleeding

Implications: Monitor blood, I & O, and urine electrolytes. Administer only with water to enhance absorption. Do not administer within one hour of taking an antacid, cimetidine or drinking milk.

Examples of Medications in This Classification:
NEUROMUSCULAR BLOCKING AGENTS
This classification is divided into: Actions: Inhibition of nerve impulse transmission

Uses: The facilitation of endotracheal intubation and skeletal muscle relaxation (surgery, general anesthesia and mechanical ventilation)

Adverse Reactions and Side Effects: Apnea, respiratory depression, bronchospasm, and bradycardia

Contraindications: Hypersensitivity. Cautious use with collagen, thyroid and cardiac disease, lactation, pregnancy, children less than two years of age, dehydration, electrolyte imbalances, and myasthenia gravis

Implications: Monitor potassium and magnesium (imbalances may increase the action of this medication), vital signs every 15 minutes until recovery, and I & O. IV doses must be given over 1 to 2 minutes by a person qualified and competent to do so (usually an anesthesiologist)

Examples of Medications in This Classification:
NONSTEROIDAL ANTIINFLAMATORIES
Actions: Decreases prostaglandin synthesis

Uses: Mild to moderate pain, arthritis and dysmenorrhea

Adverse Reactions and Side Effects: Blood dyscrasias, nephrotoxicity (oliguria, azotemia, hematuria and dysuria), abdominal pain, cholestatic hepatitis, anorexia, dizziness and drowsiness.

Contraindications: Asthma, severe liver and/or renal disease, hypersensitivity. Cautious use with the elderly, children, lactation, pregnancy and for patients with GI, cardiac and/or bleeding disorders.

Implications: Monitor blood, renal and hepatic function. Baseline hearing and eye exams are recommended so that changes can be identified. Toxicity may be signaled with tinnitus and/or blurred vision.

Examples of Medications in This Classification:
OPIOID ANALGESICS
This classification includes: Actions: Depression of the pain impulse transmission at the level of the spinal cord

Uses: Moderate to severe pain

Adverse Reactions and Side Effects: GI (constipation, nausea, vomiting, anorexia, cramps), sedation, respiratory depression, circulatory depression and increased intracranial pressure

Contraindications: Upper airway obstruction, bronchial asthma, hypersensitivity, addiction. Cautious use with renal, hepatic, respiratory and heart disease.

Implications: Monitor respiratory, urinary and mental status, level of consciousness. An antiemetic can be used for nausea and vomiting. Continue to assess level of pain

Examples of Medications in This Classification:
SALICYLATES
Actions: Antipyretic (inhibits the heat regulation center in the hypothalamus), anti-inflammatory (inhibits prostaglandin), analgesic (inhibits prostaglandin)

Uses: Mild to moderate pain, inflammation (arthritis), fever, and thromboembolitic disorders

Adverse Reactions and Side Effects: Rash, GI symptoms, hepatotoxicity, blood dyscrasias, hearing problems and tinnitus (a sign of possible toxicity)

Contraindications: Frequently occurring hypersensitivity. Contraindicated with a vitamin K deficiency, GI bleeding, a bleeding disorder, children with Reye's syndrome. Caution with Hodgkin's disease, hepatic and renal failure, anemia

Implications: Monitor renal and hepatic function, blood. Observe for signs of hepatotoxicity (clay colored stool, dark urine, diarrhea, yellow sclera and skin, itching, fever, abdominal pain) and ototoxicity (ringing or roaring in the ears, tinnitus)

Examples of Medications in This Classification:
THROMBOLYTICS
Actions: These medications convert plasminogen into plasmin which is able to break down the fibrin of clots

Uses: Pulmonary emboli, deep vein and arterial thrombosis, with or after MI, arteriovenous cannula occlusion

Adverse Reactions and Side Effects: Anaphylaxis, GI, GU, intracranial retroperitoneal bleeding, and anaphylaxis. The most common side effects are decreased Hct, urticaria, headache, and nausea.

Contraindications: Hypersensitivity, people with CNS neoplasms, bleeding, renal or hepatic disease, hypertension, COPD, subacute bacterial endocarditis, rheumatic valvular disease, cerebral embolism or thrombosis or hemorrhage, and recent surgery

Implications: Monitor vital signs and neuro signs q 4 hours, be alert for internal bleeding (temperature of more than 104 degrees), arrhythmias, retroperineal bleeding (leg weakness, back pain, and poor pulses), allergic responses (rash, fever, itching, chill), ecchymosis, hematuria, hematemesis, epistaxis. Monitor blood before and during therapy. Thrombolytics are not effective if the thrombi is more than one week old. Use 0.8 mm filter with IV administration

Examples of Medications in This Classification:
THYROID MEDICATIONS
Actions: Increase metabolism cardiac output, blood volume, oxygen consumption, and respiratory rate

Uses: Thyroid replacement

Adverse Reactions and Side Effects: Palpitations, tachycardia, insomnia, tremors, angina, weight loss, dysrhythmias, thyroid storm.

Contraindications: MI, adrenal insufficiency and thyrotoxicosis. Cautious use with the elderly, pregnant and lactating women, and for patients with diabetes, hypertension, angina, and cardiac disease

Implications: Administer at the same time of day. Check the blood pressure before each dose. Monitor I & O, weight, cardiac status and for irritability, excitability and nervousness

Examples of Medications in This Classification:
VASODILATORS
Actions: Various modes for each. Check a drug reference book for specifics

Uses: Hypertension, angina, intermittent claudication, vasospasm, arteriosclerosis

Adverse Reactions and Side Effects: Both hypotension and hypertension, changes in EKG, nausea, headache

Contraindications: Tachycardia, acute MI and thyrotoxicosis. Cautious use with peptic ulcer and uncompensated heart disease

Implications: Administer with meals to reduce any GI symptoms. Check bleeding times and cardiac status

Examples of Medications in This Classification:

ASEPSIS AND INFECTION CONTROL

Standard precautions in healthcare have greatly reduced the risk of occupational exposures to HIV and other blood borne pathogens. Other infection control measures that decrease the risk of spreading infection in our healthcare facilities include:
The greatest occupational risks appear to remain in areas where invasive procedures are done. Sharps, including needles, appear to be the culprits in these high-risk areas.

The following routine infection control measures must be taken when administering medications and providing care, if indicated:
Medical and Surgical Asepsis
The following medication routes are considered clean and, therefore, medical asepsis practices must be adhered to.
The following medication routes are considered sterile and, therefore, surgical asepsis practices must be adhered to.

HOW THE AGING PROCESS AFFECTS MEDICATIONS

The following characteristics of the normal aging process affect medications and how they act in the body of a geriatric patient.

Renal Function
Hepatic Function
Absorption
Distribution
Other Age Related Characteristic of the Elderly That Affect Medications' Actions
The Implications of Aging on Medication Administration
Medications That Pose the Greatest Risk to the Elderly

CALCULATION OF DOSAGES AND SOLUTIONS

Systems of Measurement Used in Pharmacology

Many dosage calculations require knowledge of mathematical conversion equivalents to move from one measurement system to another. We use metric, apothecary, and household measurement systems in pharmacology.

The Metric System of Measurement

Length
The standard unit of length in the metric system is the meter. Other units of length and their equivalents in meters are as follows:
1 millimeter (mm) = 0.001 meter (m)
1 centimeter (cm) = 0.01 meter (m)
1 decimeter (dm) = 0.1 meter (m)
1 kilometer (km) = 1000 meters (m)

Volume
The standard unit of volume in the metric system is the liter. One liter is equal to 1000 cubic centimeters in volume. Other units of volume and their equivalents in liters are as follows:
1 milliliter (mL) = 0.001 liter (l)
1 centiliter (cl) = 0.01 liter (l)
1 deciliter (dl) = 0.1 liter (l)
1 kiloliter (kl) = 1000 liters (l)
1000 mL = 1 liter (l)
1 mL = 1 cubic centimeter (cc) in volume

Weight
The standard unit of mass in the metric system is the gram. Other units of weight or mass and their equivalents in grams are as follows:
1 milligram (mg) = 0.001 gram (g)
1 centigram (cg) = 0.01 gram (g)
1 decigram (dg) = 0.1 gram (g)
1 kilogram (kg) = 1000 grams (g)
1 kilogram (kg) = 2.2 pounds (lbs)

The Apothecary System of Measurement

The grain is the basic unit of measurement in the apothecary system of measurement for weight. The ounce, dram and the minim are the basic units of measurement in the apothecary system of measurement for volume.

The Household System of Measurement

The basic units of measurement in the household system of measurement are drop, teaspoon, and tablespoon.

ABBREVIATIONS FOUND IN OUR SYSTEMS OF MEASUREMENT

gr
g, gm or G
kg
l
mL
cc
dr
gtt
lb
m
mg
mcg
tsp
oz
tbs
U 		grain
gram
kilogram
liter
milliliter
cubic centimeter
dram
drop
pound
minum
milligram
microgram
teaspoon
ounce
tablespoon
unit

COMMONLY USED EQUIVALENTS

It is suggested that you refer to a table of equivalents for the less frequently used mathematical conversion equivalents and memorize the ones that you use most often. Some of the commonly used conversion equivalents are as follows:

1 gr = 60 mg
1 g = 15 gr
1G = 1000 mg
1 mL = 15 m
1 kg = 2.2 lb
1 tsp = 5 mL
1 tbsp = 15 mL
1 oz = 30 mL
1 kg = 2.2 lbs

DIMENSIONAL ANALYSIS

Most schools of nursing and pharmacy teach ratio and proportion and the "desired over have" method of calculation to students. Although these methods give us accurate answers, these methods are difficult to use and remember. They tend to be a source of great confusion and consternation. When two or more conversions are needed in order to perform the calculation these methods pose very real challenges. Additionally, different methods have to be memorized in order to solve each of many types of problems.

Dimensional analysis, on the other hand, uses only one method to calculate all kinds of problems. All problems are set up and solved in the same manner. This consistency not only decreases confusion and the need to memorize many approaches, it will increase your accuracy and confidence.

This course will teach you one simple and consistent method of calculating all dosages using dimensional. There is no longer a need to memorize cumbersome and easy-to-forget rules. Dimensional analysis easily and systematically solves a wide variety of oral, intramuscular, subcutaneous, and intravenous calculations.

Throughout the course you will get practice problems so you can master this simple calculation method. It will also teach you a one- step, no-rules method that rapidly and accurately calculates the number of drops per minute at which an ordered intravenous solution must to be run.

An Introduction to Dimensional Analysis Calculations

In order to calculate dosages using dimensional analysis, you set up an equation that consists of: Once this equation is written, the final step is to cancel out numbers using simple math and then multiply the remaining numbers.

For example, if you want to know how many dimes there are in $3.00, you have to consider: What you want to calculate is the number of dimes in $3.00 if there are 10 dimes in each dollar.

The starting factor always appears first in the equation and The answer unit is the last part of the equation and it is followed by = sign. For example:

Starting Factor X Conversion Factor = Answer Unit

You would set up the dimensional analysis equation in the below manner using the number of dimes in $3.00 example.
Starting factorxConversion factor=Answer unit
3 dollars x 10 dimes = ____ dimes
1 dollar

If you want to find out how many inches there are in 12 feet, you have to consider the starting factor of 12 feet, the number of inches in 1 foot (the conversion factor) and what you are trying to find out, that is, the number of inches (answer unit) in 9 feet.

Below is an example of how to set up a dimensional analysis equation using this starting factor, the conversion factor, and the answer unit. .
Starting factorxConversion factor=Answer unit

12 ft
x
12 inches
=
____ inches
1 ft

The numerator is the number on top of a fraction and the denominator is the number on the bottom of a fraction. When you set up the equation, each numerator label should cancel out a denominator label so that the answer in the conversion factor. Now, only "inches" in the answer unit remains.

As shown below, the unit of feet in the starting factor cancels out the feet unit in the conversion factor. The final answer is then computed by simply multiplying 12 by 12.

12 ft
x
12 inches
=
144 inches
1 ft

In more complex calculations, once all the units of measurement that can be canceled have been struck out, the remaining numerators are multiplied and this product, or answer, is then divided by the product of all the remaining denominators.

If the numerators and denominators can be divided by a common number, or reduced, the multiplication of the numerators and denominators as well as the final division will be somewhat simpler and less mathematically challenging. You will be taught how to reduce in this course.

The conversion factors that are used to calculate dosages and IV flow rates can consist of either established mathematical conversion equivalents or a manufacturer's equivalents.

Some examples of mathematical conversion equivalents are: Manufacturers produce medications of different dosages and IV tubings that deliver different amounts of fluids in each drop. Doctors will also order medications as based on body weight. Manufacturers' and ordered equivalents can include some like these:

Oral Dosages Using Dimensional Analysis

The following sample calculations show you how to compute oral dosage calculations using dimensional analysis.

Sample Calculation 1
Doctor's order: tetracycline syrup 250 mg po
Medication label: tetracycline syrup 50 mg/mL
How many mL should you administer?

In this example, The starting factor is the dosage in the doctor's order, that is, 250 mg. The conversion factor is 50 mg/1 mL, the number of mg that are contained in each mL of the syrup. The answer unit is the number of mL that you would administer to the patient.
Starting factorxConversion factor=Answer unit

250 mg
x
1 mL
=
____ mL
50 mg

All dimensional analysis problems are set up as an equation in the same way and the calculations are performed in the same manner.
  1. Cancel out and reduce the numerators and denominators,
  2. multiply all the remaining numerators and denominators, and
  3. then divide to get the final answer.
Cancel out and reduce these numerators and denominators by dividing each by 50:
5    
250 mg x 1 mL = ____ mL
50 mg
  1  

Multiply the numerators (5 x 1) and the denominators (1), and finally divide the product of the numerators by the denominator to get the final answer:
5 x 1 = 5 mL = 5 mL
1 1

Sample Calculation 2
Doctor's order: Lanoxin 0.250 mg po
Medication label: Lanoxin 0.125 mg per tablet
How many tablets should you give?

The starting factor is 0.5 mg, The conversion factor is 0.25 mg/1 tablet, and The answer unit is the number of tablets you would give.
Starting factorxConversion factor=Answer unit

0.250 mg
x
1 tablet
=
____ tablets
0.125 mg

Cancel out and reduce the numerators and denominators:
0.250 mg x 1 tablet = ____ tablets
0.125 mg

2    
0.250 x 1 tablet = ____ tablets
0.125
    1

Multiply the numerators and the denominators and divide their products to get the final answer:
2 x 1 = 2 = 2 tablets
1 1

Sample Calculation 3
Doctor's order: flucytosine 50 mg/kg/day in four divided doses. The patient weighs 40 kg.
Medication label: flucytosine 250 mg/cap
How many capsules should you give for each of the four doses?

The starting factor is 40 kg. In this example, there are two conversion factors. One of the conversion factors is the number of mg ordered for each kg, or 50 mg/kg, and the other conversion factor is the manufacturer's equivalent, or 250 mg/cap. The answer unit is the number of caps.
Starting factorxConversion factors=Answer unit

40 kg
x
50 mg
x
1 cap
=
______ caps
1 kg 250 mg

Cancel out and reduce the numerators and denominators:
  1    
40 kg x 50 mg x 1 cap = ______ caps
1 kg 250 mg
    5  

Multiply the numerators and the denominators and then divide their products:
40 x 1 x 1 cap = 40 = 8 caps/day
1 5 5

Because the doctor's order read "flucytosine 50 mg/kg/day in four divided doses," it is necessary to divide the total of 8 caps by 4 to determine the number of capsules that would be given for each of the doses:
8 = 2 caps for each dose
4

Now, let's take a few minutes to practice some calculations.

Practice Oral Dosages

Grab your pencil and paper and do these problems.

Practice Problem 1
Doctor's order: KCl 20 meq po
Medication label: KCl 15 meq/11.25 mL
How many mL would you administer?

Practice Problem 2
Doctor's order: Gantrisin 250 mg po
Medication label: Gantrisin 0.5 g/tab
How many tabs would you administer?

Practice Problem 3
Doctor's order: trimethoprim 5 mg/kg po. The patient weighs 80 kg.
Medication label: trimethoprim 160 mg/tab. The tabs are scored in half.
How many tabs would you administer?

Practice Problem 4
Doctor's order: nystatin 3 mg/kg po. The patient weighs 115 lb.
Medication label: nystatin 100 mg/tab
How many tabs would you administer?

Answers
  1. 15 mL
  2. ½ tab
  3. 2½ tabs
  4. 1½ tabs
Here is how each of the problems was set up and solved:

Practice Problem 1
The starting factor is 20 meq
The conversion factor is 15 meq/11.25 mL
The answer unit is ____ mL
4      
20 meq x 11.25 mL x 45 = 15 mL
15 meq 3
  3    


Practice Problem 2
The starting factor is 250 mg
The conversion factors are: The answer unit is ____ tabs
1        
250 mg x 1 g x 1 tab = 1 = ½ tab
1,000 mg 0.5 g 2
  4      


Practice Problem 3
The starting factor is 80 kg
The conversion factors are: The answer unit is ____ tabs
  1      
80 kg x 5 mg x 1 tab = 80 = 2 ½ tabs
1 kg 160 mg 32
    32    


Practice Problem 4
The starting factor is 115 lb
The conversion factors are: The answer unit is ____ tabs.
23          
115 lb x 1 kg x 3 mg x 1 tab = 69 = 1.56 tabs (1 ½ tabs)
2.2 lb 1 kg 100 mg 44
      20    

Intramuscular and Subcutaneous Dosages Using Dimensional Analysis

Intramuscular and subcutaneous dosages are calculated in the same manner as oral dosages when you are using dimensional analysis, however, there are some addition things that you must remember. These special considerations include:
  1. It is often necessary to round off when calculating intramuscular and subcutaneous dosages. The dosage is rounded off to the nearest hundredth (0.01) of a mL or cc when you are using a regular syringe or a tuberculin syringe. Your arithmetic must be carried out to the thousandths place (the third decimal place) in order to round off to the hundredths place. If the number in the third decimal place, or thousandths place, is 5 or higher, you round up one number in the hundredths place to determine the dosage. For example, if you are calculating a dosage for a tuberculin syringe and your mathematical calculation gives you 0.187 mL, you would round it off to 0.19 mL because the 7 in thousandths place is greater than or more than 5.
  2. Heparin is given in a tuberculin syringe using the subcutaneous route of administration.
  3. Insulin is also administered via the subcutaneous route of administration. Most often the insulin is Units 100 insulin and the syringe that is used is also a Units 100 syringe. A 1cc Units 100 syringe can hold up to 100 Units of insulin; a ½cc Units 100 syringe can hold only half of that amount, that is, it can hold up to 50 Units of insulin. At times you may encounter Units 80, Units 60, etc. insulin. There are 80 Units of Units 80 insulin per cc and 60 Units of Units 60 insulin in one cc. A matching syringe (Units 80 and Units 60 syringe) can be used to administer these kinds of insulin, however, calculation using dimensional analysis can also be done.
  4. An additional consideration for intramuscular injections is that many calculations, particularly those necessary to determine an antibiotic dosage, require a conversion factor that reflects the amount of the drug per mL after a powder is reconstituted with sterile water or normal saline solution for injection.
Below are some sample problems involving intramuscular and subcutaneous dosages. These calculations are set up and performed using dimensional analysis procedures in the same manner as that used above for the oral dosage calculations.

Sample Calculation 1
Doctor's order: meperidine 30 mg IM q4h prn for pain
Medication label: 50 mg/mL
How many mL or cc would you give?

The starting factor is 30 mg
The conversion factoris 50 mg/1 mL
The answer unit is ____ mL or cc
Starting factorxConversion factor=Answer unit 

30 mg
x
1 mL
=
_____ mL
50 mg

30 mg
x
1 mL
=
3
=
0.6 mL
50 mg 5

Sample Calculation 2
Doctor's order: amikacin 5 mg/kg IM tid. The patient weighs 130 lb.
Medication label: amikacin 500 mg/2 mL
How many mL would you administer?

The starting factor is 130 lb
The conversion factors are: The answer unit is ____ mL
Starting factorxConversion factors=Answer unit

130 lb
x
1 kg
x
5 mg
x
2 mL
=
_____ mL
2.2 lb 1 kg 500 mg

 
 
 
 
1
 
1
 
 
 
 
130 lb x 1 kg x 5 mg x 2 mL = 130 mL = 1.18 mL
2.2 lb 1 kg 500 mg 110
1.1 100

Rounded Off to: 1.2 mL

Sample Calculation 3
Doctor's order: heparin 3,000 Units subcutaneously
Medication label: 5,000 Units/mL
How many mL would you administer?

The starting factor is 3000 Units
The conversion factor is 5,000 Units/mL
The answer unit is ____ mL
Starting factorxConversion factor=Answer unit

3,000 Units
x
1 mL
=
_____ mL
5,000 Units

3		  
3,000 Units x 1 mL = 3 = 0.6 mL
5,000 Units 5
5


Sample Calculation 4
Doctor's order: ticarcillin 600 mg IM
Medication label: ticarcillin reconstituted with 2 mL of sterile water to yield 1 g of ticarcillin in 2.6 mL of solution.
How many mL would you administer?

The starting factor is 600 mg

The conversion factors are: The answer unit is ____ mL
Starting factorxConversion factors=Answer unit

600 mg
x
1 g
x
2.6 mL
=
_____ mL
1,000 mg 1 g

6
 
600 mg x 1 g x 2.6 mL = 15.6 = 1.56 mL
1,000 mg 1 g 10
10

Rounded Off to: 1.6 mL

Sample Calculation 5
Doctor's order: neomycin 30 mg/kg/day IM in three divided doses. The patient weighs 140 lb.
Medication label: neomycin 250 mg/mL
How many mL would you administer for each of the three doses?

The starting factor is 140 lb

The conversion factors are: The answer unit is ____ mL The starting factor is 120 lb. The conversion factors are, , and. The answer unit is the number of mL.
Starting factorxConversion factors=Answer unit

140 lb
x
1 kg
x
30 mg
x
1 mL
=
_____ mL
2.2 lb 1 kg 250 mg

70
 
6
 
140 lb x 1 kg x 30 mg x 1 mL = ____ mL
2.2 lb 1 kg 250 mg
1.1 50

70
x
1
x
6
x
1
=
42
=
7. 63 mL
2.2 lb 1 kg 250 mg
1.1 1 50 5.5

Because the doctor ordered 30 mg/kg over one day in three divided doses, it is necessary to divide the 7.63 mL for the day by 3 to determine how many mL would be given in each of the doses:

7.63
=
2.54, or 2.5 mL per dose
3

Practice Intramuscular and Subcutaneous Dosages

Now try these intramuscular and subcutaneous dosage calculations:

Practice Problem 1

Doctor's order: heparin 3,000 Units subcutaneously
Medication label: 4,500 Units/ mL
How many mL would you administer?

Practice Problem 2 Doctor's order: cefuroxime 500 mg IM
Medication label: The addition of 3.2 mL of sterile water yields a suspension of 750 mg in 4.2 mL
How many mL would you administer?

Practice Problem 3

Doctor's order: cephalothin 400 mg IM
Medication label: The addition of 4 mL of sterile water yields 0.5 g in 2.2 mL of suspension.
How many mL would you administer?

Practice Problem 4

Doctor's order: neomycin 20 mg/kg/day IM in three divided doses. The patient weighs 120 lb.
Medication label: neomycin 250 mg/mL
How many mL would you administer for each of the three doses?

Practice Problem 5

Doctor's order: 450,000 Units of ampicillin
Medication label: 250,000 Units/mL
How many mL would you administer?

Now, check your answers. The answers are:

Answers
  1. 0.7 mL
  2. 2.8 mL
  3. 1.8 mL
  4. 1.4 mL
  5. 1.8 mL
Here is how each of the problems is set up and solved:

Practice Problem 1

The starting factor is 3,000 Units
The conversion factor is 1mL/4,500 Units
The answer unit is ____ mL

6
3,000 Units x 1 mL = 6 = 0.66 mL
4,500 Units 9
9

Rounded Off to: 0.7 mL

Practice Problem 2

The starting factor is 500 mg

The conversion factor is 750 mg/4.2 mL

The answer unit is ____ mL

2
500 mg x 4.2 mL = 8.4 = 2.8 mL or with more cancellations:
750 mg 3
3


2 1.4
500 mg x 4.2 mL = 2.8 = 2.8 mL
750 mg 1
3
1


Practice Problem 3

The starting factor is 400 mg

The conversion factors are:
The answer unit is ____ mL

2
400mg x 1 g x 2.2 mL = 4.4 mL = 1.76 mL
1,000 mg 0.5 g 2.5
5

Rounded Off to: 1.8 mL

Practice Problem 4

The starting factor is 120 lb
The conversion factors are:
The answer unit is ____

60 4
120 lb x 1 kg x 20 mg x 1 mL = 24 mL = 4.36 mL
2.2 lb 1 kg 250 mg 5.5
1.1 50

Because the doctor ordered 20 mg/kg over one day in three divided doses, it is necessary to divide the 4.36 mL for the day by 3 to determine how many mL would be given in each of the doses:

4.36 mL = 1.45 mL rounded off to: 1.4 mL
3

Practice Problem 5

The starting factor is 450,000 Units
The conversion factor is 250,000 Units/1 mL
The answer unit is ____ mL

9
450,000 U x 1 mL = 9 = 1.8 mL
250,000 Units 5
5

Calculating IV Flow Rates Using Dimensional Analysis and the One-Step, No-Rules Method

This final portion of this course will teach you: IV Flow Rates Using Dimensional Analysis

As you probably know, IV tubing is manufactured by a number of different companies. Each tubing set has a drop factor that indicates whether it delivers 10, 15, 20, or 60 drops (gtt) per mL of solution. The 60 gtt per mL tubing, which is often referred to as microdrop tubing or pediatric tubing, delivers the smallest drops of all the sets. The 10 gtt/mL tubing delivers the largest drops of solution.

When calculating the number of drops per minutes, the number of drops is rounded off to the nearest whole drop.

The IV flow rate calculations immediately below are set up and performed using dimensional analysis.

Sample Calculation 1

Doctor's order: 0.9% NaCl solution at 100 mL per hour
How many gtt per minute would you give if the tubing delivered 20 gtt/mL?

The starting factor is 1 minute
The conversion factors are: The answer unit is ____ gtts/min

Starting factor x Conversion factors = Answer unit
1 min x 1 h x 100 mL x 20 gtt = ____ gtt
60 min 1 h 1 mL

5
10
1 min x 1 h x 100 mL x 20 gtt = 100 = 33.3 gtt
60 min 1 h 1 mL 3
6
3

Rounded Off to: 33 gtt/min

Sample Calculation 2

Doctor's order: 1,000 mL of 5% D 0.45 normal saline solution to infuse over 4 hours
How many gtt per minute would you give if the tubing delivers 10 gtt/mL?

The starting factor is 1 minute

The conversion factors are: The answer unit is ____ gtts/min

Starting factor x Conversion factors = Answer unit
1 min x 1 h x 1,000 mL x 10 gtt = ____ gtt
60 min 4 h 1 mL

250 1
1 min x 1 h x 1000 mL x 10 gtt = 250 = 41.6 or 42 gtt
60 min 4 h 1 mL 6
6 1

Sample Calculation 3

Doctor's order: 30 mL/h of 5% D 0.45 normal saline solution

How many gtt per minute would you give if the tubing delivered 60 gtt/mL?

The starting factor is 1 minute
The conversion factors are:
The answer unit is ____ gtts/min

Starting factor x Conversion factors = Answer unit
1 min x 1 h x 30 mL x 60 gtt = ____ gtt
60 min 1 h 1 mL

1
1 min x 1 h x 30 mL x 60 gtt = 30 gtt
60 min 1 h 1 mL
1


Sample Calculation 4

Doctor's order: 25 mL/h of 5% D 0.45 normal saline solution
How many gtt per minute would you give if the tubing delivered 60 gtt/mL?

The starting factor is 1 minute

The conversion factors are: The answer unit is ____ gtts/min

Starting factor x Conversion factors = Answer unit
1 min x 1 h x 25 mL x 60 gtt = ____ gtt
60 min 1 h 1 mL

1
1 min x 1 h x 25 mL x 60 gtt = 25 gtt
60 min 1 h 1 mL
1

Did you notice that the last two calculations, which use the microdrop or 60 gtt/mL IV tubing, yielded the same number of gtt per minute as the number of mL per hour that was ordered? Good observation!

Specifically, the first doctor's order was for 30 mL per hour. You would have to run the IV solution at 30 gtt per minute to deliver 30 mL per hour. The second doctor's order called for 25 mL per hour. You would have to run the IV solution at 25 gtt per minute in order to deliver 25 mL an hour.

If you look closely at these two calculations, you will see that the conversion factor of 60 min = 1 h cancels out the conversion factor of 60 gtt per mL. We will now move one step further with this observation.

IV Flow Rates Using the One-Step, No-Rules Method

In order to calculate using the one-step, no-rules method, you need to know the number of mL per hour ordered. Occasionally, the doctor's order clearly states the number of mL per hour, which is the easiest scenario. If the doctor's order specifies the number of mL per 8 hours, 12 hours, or any other number of hours rather than the number of mL for each hour, it is necessary to first determine the number of mL to be administered per hour.

For example, if the doctor orders 1,000 mL in 8 hours, you must divide 1,000 mL by 8 to determine the number of mL per hour. The answer is 125 mL/h.

Likewise, if the doctor orders 2 liters of IV fluid over 12 hours, the calculation to determine the number of mL per hour is as follows: 2,000 mL/12 = 166.6 mL, which rounds off to 167 mL/h.

Once you have observed that the number of mL/h is identical to the number of gtt/min, something that never changes when you are using a 60 gtt/mL tubing, it soon becomes apparent that for tubing with other drop factors (10 gtt/mL, 15 gtt/mL, and 20 gtt/mL), you must simply look at the relationship of the drop factor to the ever-present 60, the never-changing number of minutes in an hour.

For example, if you are using IV tubing with a 20 gtt/mL drop factor, you have to look at the relationship between the 20 in the tubing drop factor and the ever-present 60, the number of minutes in an hour. The relationship between 60 and 20 is 3; in other words, 60/20 = 3.

Similarly, if you are using IV tubing with a 10 gtt/mL drop factor, you have to look at the relationship between the 10 in the tubing drop factor and the number 60. The relationship between 60 and 10 is 6: 60/10 = 6. Finally, if you are using IV tubing that delivers 15 gtt/min, the relationship of 60 to 15, or 4, requires you to divide the number of mL an hour by 4.

Now that you know all the possible relationships, it is only necessary to divide the number of mL an hour: All you have to do is one step. There are no rules to forget, no complicated formulas, and no unnecessary steps!

Here are some examples:

If you are using a 10 gtt/mL set, the number of drops per minute will always be the number of mL an hour divided by 6.

100 mL/h: 100/6 = 16.6 = 17 gtt/min rounded off

125 mL/h: 125/6 = 20.8 = 21 gtt/min rounded off

150 mL/h: 150/6 = 25 gtt/min

If you are using 20 gtt/mL IV tubing, the number of drops per minute will always be the number of mL an hour divided by 3.

100 mL/h: 100/3 = 33.3 = 33 gtt/min rounded off

125 mL/h: 125/3 = 41.6 = 42 gtt/min rounded off

150 mL/h: 150/3 = 50 gtt/min

And, finally, if you are using 15 gtt/mL tubing, the number of drops per minute will be the number of mL an hour divided by 4.

100 mL/h: 100/4 = 25 gtt/min

125 mL/h: 125/4 = 31.2 = 31 gtt/min rounded off

150 mL/h: 150/4 = 37.5 = 38 gtt/min

This one-step, no-rules method of calculating the number of IV drops per minute works all the time because there are always 60 minutes in an hour. The one step involved in calculating the number of drops per minute consists of dividing the relationship number for the specific IV tubing set into the number of mL per hour ordered by the doctor. Pediatric (60 gtt/mL) tubing has an identity relationship; therefore, the number of drops per minute will always exactly match the number of mL per hour.

This one-step method is particularly useful because nurses caring for patients with IV infusions should count and verify the number of drops per minute at the bedside with each patient contact. Volumetric controllers and pumps are not always accurate and do not always function properly.

Other IV Calculations Using Dimensional Analysis

Calculating the number of drops per minute, or the flow rate, is probably the most frequently used IV calculation in nursing, however, there are other IV computations that you will also have to know. These include calculating the following: Calculating Total Infusion Time

When you have adjusted an IV solution to run at a certain number of drops per minute, you will always want to know when the solution is should finish infusing so that you can anticipate the need to hang another bag of solution, if so ordered. Additionally, even when you are using a controller the accuracy of the flow rate is not always fail proof. Machines fail. You must, therefore, be able to calculate the total infusion time for the presently infusing bag.

Following is an example of how this type of calculation is accomplished using dimensional analysis.

Total volume of IV fluid: 800 mL

Infusion rate: 23 gtt/min

Drop factor: 10 gtt/mL

When will the liter of fluid run out?

The starting factor is 800 mL
The conversion factors are:
Starting factor x Conversion factors = Answer unit
800 mL x 10 gtt x 1 min x 1 h = _____ h
1 mL 23 gtt 60 min

1
800 mL x 10 gtt x 1 min x 1 h = 800 = 5.79 h (5 h 47 min)
1 mL 23 gtt 60 min 138
6


Calculating the Concentration of a Medication in an IV Solution

On some occasions, a physician may order an hourly dosage of a medication that has been diluted in an IV fluid.

For example, the doctor may order an hourly dosage of 1,400 units of heparin that has 20,000 units of heparin diluted in 1,000 mL of normal saline solution. The nurse must then be able to calculate the flow rate of the fluid based not on the volume of the fluid ordered, but instead, on the dosage of the medication.

The starting factor is 1 h

The conversion factors are: The answer unit is ____ mL

The starting factor is 1 h; The conversion factors are 1,200 Units/1 h and; and The answer unit is the number of mL.

Starting factor x Conversion factors = Answer unit
1 h x 1,400 Units x 1,000 mL = _____ mL
1 h 20,000 Units

70 1
1 h x 1,400 Units x 1,000 mL = 70 mL
1 h 20,000 Units
20
1


Calculating IV Flow Rates Based on Body Weight

When a doctor's order specifies a volume of fluid or a dosage of a diluted medication over a period of time based on body weight, the calculation is similar to those described above with the addition of a conversion factor that allows for body weight.

For example, if you are caring for a patient that weighs 250 lb and the doctor orders 5 mcg/kg/min of a medication intravenously infused via 500 mL of an IV fluid that contains 250 mg of the medication, you would perform the following computation to determine the number of mL per minute or hour that the patient will receive.

The starting factor is 250 lb

The conversion factors are: The answer unit is ____ mL

Starting factor x Conversion factors = Answer unit
250 lb x 1 kg x 5 mcg x 1 mg x 500 mL = _____ mL
2.2 lb 1 kg 1,000 mcg 250 mg

1 1
250 lb x 1 kg x 5 mcg x 1 mg x 500 mL = 5 = 1.136 mL
2.2 lb 1 kg 1,000 mcg 250 mg 4.4
2 1


The number of mL to be administered per hour = 1.136 . 60 = 68.16 mL

Rounded Off to: 68.2 mL

Practice Problem 1

Total volume of IV fluid at the beginning of your shift: 350 mL

Infusion rate: 21 gtt/min

Drop factor: 15 gtt/mL

When will this fluid run out?

Practice Problem 2
How many mL/h would you administer if the doctor orders 30 Units/h of a medication that has been diluted in a solution with a total of 250 Units in 1,000 mL?

Practice Problem 3

If your patient weighs 100 lb and the doctor orders 5 mcg/kg/min of a medication intravenously infused via 500 mL of an IV fluid that contains 250 mg of the medication, how many mL/min and mL/h would you administer?

Here are the Answers 1. 4 h 10 min 2. 120 mL/h 3. 0.45 mL/h and 27 mL/h Practice Problem 1

The starting factor is 350 mL

The conversion factors are: The answer unit is ____ h or min

350 mL x 15 gtt x 1 min x 1 h = _____ h
1 mL 21 gtt 60 min

1
350 mL x 15 gtt x 1 min x 1 h = 350 = 4.16 h (4 h 10 min)
1 mL 21 gtt 60 min 84
4


Practice Problem 2

The starting factor is 30 Units

The conversion factor is 250 Units/1,000 mL

The answer unit is ____ mL/h

30 Units x 1,000 mL = _____ mL
250 U

3
30 Units x 1,000 mL = 3,000 = 120 mL/h
250 Units 25
25


Practice Problem 3 The starting factor is 100 lb

The conversion factors are: The answer unit is ____ mL/min and mL/h

100 lb x 1 kg x 5 mcg x 1 mg x 500 mL = _____ mL
2.2 lb 1 kg 1,000 mcg 250 mg

1
1 1 10
100 lb x 1 kg x 5 mcg x 1 mg x 500 mL = 1 = 0.45 mL
2.2 lb 1 kg 1,000 mcg 50 mg 2.2
10 50
1 1

Per hour:
0.45 . 60 = 27 mL/h

Summary

Dimensional analysis is a highly useful way to calculate dosage and solution problems of all types. It is an orderly and systematic mathematical process that results in consistent accuracy, provided the equation is set up correctly and careless mathematical errors are avoided.


RATIO AND PROPORTION

This portion of this course teaches the ratio and proportion method of calculating dosages. It provides the learner with an opportunity to use ratio and proportion calculations for a wide variety of oral, intramuscular, subcutaneous, and intravenous calculations as well as many practice calculations.

WHAT IS RATIO?

Ratio

Ratio is a relationship in terms of size, amount, or quantity of two or more things. They are pairs of numbers that are used to make comparisons between the numbers.

For example, the ratio of men compared to women included in a pharmacological research study may be 3 to 1. There are 3 times as many men in the study as there are women.

Ratios can be written in 3 different ways, as below: Comparing Ratios

Write the ratios as fractions when you want to compare them. All ratios must be equal or they are not a ratio.

For example, the ratios 1/4 and 2/8 are equal. When you set up these ratios and criss cross multiple the numerators and denominators you end up with the same number, that is 8. These ratios are equal.

1
=
2
4 8

1 x 8 = 8 and
2 x 4 = 8

WHAT IS PROPORTION ?

Proportion

Proportion is the relationship of one part to another or to the whole in respect to size, size, amount or quantity. A proportion is an equation with a ratio on each side of the equal sign. Solving proportions involves criss cross multiplying and then finding out what the missing number is using division.

For example:

2
=
?
8 24


2 x 24
=
48
=
6
8 8

OR
1  
2 x 24 = 24 = 6
8 4
4

Calculating Oral Dosages Using Ratio and Proportion

The doctor orders: 250 mg of a medication
The label on the medication states: 1 tablet = 125 mg
How many tablets will you administer?
250 mg: x tabs :: 125 mg: 1 tab
OR
250 mg: x tabs = 125 mg: 1 tab
OR
250 mg = 125 mg
x tabs 1 tab

The immediately above setup allows us to more simply reduce numerators and denominators by dividing each by the same number and to more easily avoid errors as we criss cross multiply.

250 mg = 125 mg = 125 x = 250 =
x tabs 1 tab

x = 250 = 2 tablets
125


Doctor's order: tetracycline syrup 250 mg po
Medication label: tetracycline syrup 50 mg/mL
How many mL should you administer?

250 mg = 50 mg = 50 x = 250
x mL 1 mL

x = 250 = 5 mL
50


Grab your pencil and paper and do these problems.

Practice Problem 1
Doctor's order: KCl 20 meq po
Medication label: KCl 15 meq/11.25 mL
How many mL would you administer?

Practice Problem 2
Doctor's order: Gantrisin 250 mg po
Medication label: Gantrisin 0.5 g/tab
How many tabs would you administer?

Practice Problem 3
Doctor's order: trimethoprim 5 mg/kg po. The patient weighs 80 kg.
Medication label: trimethoprim 160 mg/tab. The tabs are scored in half.
How many tabs would you administer?

Practice Problem 4
Doctor's order: nystatin 3 mg/kg po. The patient weighs 115 lb.
Medication label: nystatin 100 mg/tab
How many tabs would you administer?

Answers
  1. 15 mL
  2. ¼ tab
  3. 2 ½ tabs
  4. 1 ½ tabs


Practice Problem 1

20 meq = 15 meq = 15 x = 20 X 11.25
x mL 11.25 mL


15 x = 225


45
x = 225 = 15 mL
15
3


Practice Problem 2

250 mg = 1000 mg = 1000 x = 250
x g 1g

1
x = 250 = 0.25 g
1000
4


This problem is a two step problem. Above we calculated the number of g for the 250 mg dose because the drug label is in g and not mg. Next we will calculate the dose to be administered in terms of g.

0.25 g = 0.5 g = 0.5 x = 0.25
x tabs 1 tab

x = 0.25 = 0.5 or ½ tab
0.5


Practice Problem 3

80 kg = 1 kg = x = 80 X 5 = 400 mg
x mg 5 mg

This problem is also a two step problem. Above we calculated the number of mg to be administered as per the patient's body weight. Next we will calculate the dose to be administered in terms of tablets as based on the patient's weight and the fact that the doctor has ordered 5 mg for each kg of body weight.

400 mg = 160 mg = 160 x = 400
x tabs 1 tab

x = 400 = 2 ½ tablets
160


Practice Problem 4

115 lb = 2.2 lb = 2.2 x = 115
x kg 1 kg

x = 115 = 52.27 kg
2.2


This problem is a three step problem. Above we calculated the number of kg a patient weighs as based on the patient's body weight in pounds. The patient weighs 115 pounds or 52.27 kg. This can be rounded off to 52 kg.

Next we will calculate the dose to be administered in terms of mg as based on the patient's weight in kg.

52 kg = 1 kg = x = 156 mg
x mg 3 mg

Finally, we will calculate how many tablets will be administered in terms of body weight when each tablet has 100 mg.

x tabs = 1 tab = 100 x = 156
156 mg 100 mg

x = 156 = 1.56 tabs rounded off to 1 ½ tabs
100

Calculating Intramuscular and Subcutaneous Dosages Using Ratio and Proportion

Sample Calculation 1
Doctor's order: meperidine 30 mg IM q4h prn for pain
Medication label: 50 mg/mL
How many mL or cc would you give?

30 mg = 50 mg = 50 x = 30 mL

x = 30 = 0.6 mL
50


Sample Calculation 2
Doctor's order: amikacin 5 mg/kg IM tid. The patient weighs 130 lb.
Medication label: amikacin 500 mg/2 mL
How many mL would you administer?
Again, there are multiple steps in this problem. First, we will calculate how many kg the patient weighs. Next, we will determine how many mg the patient will get in each tid dose. Lastly, we will calculate how may mL we will have to administer for the ordered number of mg.
130 lb = 2.2 lb = 2.2 x = 130
x kg 1kg

x = 130 = 65 kg
2.2

5 mg = x mg = 1 x = 65 X 5 = 325 mg
1 kg 65 kg

500 mg = 325 mg = 500 x = 325 X 2
2 mL x mL

x = 650 = 1.3 mL
500


Sample Calculation 3
Doctor's order: heparin 3,000 Units subcutaneously
Medication label: 5,000 Units/mL
How many mL would you administer?

x mL = 1 mL = 5,000 x = 3,000
3,000 Units 5,000 Units

x = 3,000 = 0.6 mL
5,000


Sample Calculation 4
Doctor's order: ticarcillin 600 mg IM
Medication label: ticarcillin reconstituted with 2 mL of sterile water to yield 1 g of ticarcillin in 2.6 mL of solution.
How many mL would you administer?

600 mg = 1,000 mg = 1,000 x = 600
x g 1 g

x = 600 = 0.6 g
1000

0.6 g = 1 g = x = 0.6 X 2.6 = 1.56 m:
x mL 2.6 mL

Rounded Off to: 1.6 mL

Sample Calculation 5
Doctor's order: neomycin 30 mg/kg/day IM in three divided doses. The patient weighs 140 lb.
Medication label: neomycin 250 mg/mL
How many mL would you administer for each of the three doses?

140 lb = 2.2 lb = 2.2 x = 140
x kg 1 kg

x = 140 = 63.63 or 64 kg
2.2

30 mg = x mg = x = 64 x 30 = 1902 mg
1 kg 64 kg

1902 mg = 250 mg = 250 x = 1902
x mL 1 mL

x = 1902 = 7.6 mL
250

Because the doctor ordered 30 mg/kg over one day in three divided doses, it is necessary to divide the 7.6 mL for the day by 3 to determine how many mL would be given in each of the doses:
7.6 divided by 3 is 2.5 mL per dose
Now try these intramuscular and subcutaneous dosage calculations:

Practice Problem 1
Doctor's order: heparin 3,000 Units subcutaneously
Medication label: 4,500 Units/ mL
How many mL would you administer?

Practice Problem 2
Doctor's order: cefuroxime 500 mg IM
Medication label: The addition of 3.2 mL of sterile water yields a suspension of 750 mg in 4.2 mL
How many mL would you administer?

Practice Problem 3
Doctor's order: cephalothin 400 mg IM
Medication label: The addition of 4 mL of sterile water yields 0.5 g in 2.2 mL of suspension.
How many mL would you administer?

Practice Problem 4
Doctor's order: neomycin 20 mg/kg/day IM in three divided doses. The patient weighs 120 lb.
Medication label: neomycin 250 mg/mL
How many mL would you administer for each of the three doses?

Practice Problem 5
Doctor's order: 450,000 Units of ampicillin
Medication label: 250,000 Units/mL
How many mL would you administer?

Now, check your answers. The answers are:

Answers
  1. 0.7 mL
  2. 2.8 mL
  3. 1.8 mL
  4. 1.4 mL
  5. 1.8 mL
Here is how each of the problems is set up and solved:

Practice Problem 1

3,000 Units = 4,500 Units = 4,500 x = 3,000
x mL 1 mL

x = 3,000 = 0.66 mL
4,500

Rounded Off to: 0.7 mL

Practice Problem 2

500 mg = 750 mg = 750 x = 500 X 4.2
x mL 4.2 mL

x = 2100 = 2.8 mL
750


Practice Problem 3
400 mg = 1,000 mg = 1000 x = 400
x g 1 g

x = 400 = 0.4 g
1000

0.4 g = 0.5 g = 0.5 x = 0.4 X 2.2
x mL 2.2 mL

x = .88 = 1.76 mL
0.5

Rounded Off to: 1.8 mL

Practice Problem 4
120 lb = 2.2 lb = 2.2 x = 120
x kg 1 kg

x = 120 = 54.5 kg
2.2

54.5 = 1 kg = x = 54.5 X 20 = 1090 mg
x mg 20 mg 1

1090 mg = 250 mg = 250 x = 1090
x mL 1 mL

x = 1090 = 4.36 mL
250

Because the doctor ordered 20 mg/kg over one day in three divided doses, it is necessary to divide the 4.36 mL for the day by 3 to determine how many mL would be given in each of the doses:

4.36 divided by 3 is 1.45 mL This is rounded off to 1.4 mL

Practice Problem 5
450,000 Units = 250,000 Units = 250,000 x = 450,000
x mL 5 mL

x = 450,000 = 1.8 mL
250,000

Calculating Intravenous Flow Rates

The rule for calculating intravenous flow rates is as below.
gtts/min = Total number of mL x Drip or drop factor
Total number of minutes


Sample Calculation 1

Doctor's order: 0.9% NaCl solution at 100 mL per hour

How many gtt per minute would you give if the tubing delivered 20 gtt/mL?

x gtts per minute = 100 x 20 = 2000 = 33.3 gtt
60 60

Rounded Off to: 33 gtt/min

Sample Calculation 2

Doctor's order: 1,000 mL of 5% D 0.45 normal saline solution to infuse over 4 hours

How many gtt per minute would you give if the tubing delivers 10 gtt/mL?

x gtts per minute = 1000 x 10 = 10,000 = 41.6 gtt
240 240

Rounded off to 42 gtt per minute

Sample Calculation 3

Doctor's order: 30 mL/h of 5% D 0.45 normal saline solution

How many gtt per minute would you give if the tubing delivered 60 gtt/mL?
x gtts per minute = 30 x 60 = 1800 = 30 gtt
60 60


Sample Calculation 4

Doctor's order: 25 mL/h of 5% D 0.45 normal saline solution

How many gtt per minute would you give if the tubing delivered 60 gtt/mL?
x gtts per minute = 25 x 60 = 1,500 = 25gtt
60 60

Now, do these practice problems.

Practice Problem 1

Doctor's order: 75 mL/h

How many gtt per minute would you give if the tubing delivered 60 gtt/mL?

Practice Problem 2

Doctor's order: 125 mL/h

How many gtt per minute would you give if the tubing delivered 15 gtt/mL?

Practice Problem 3

Doctor's order: 150 mL/h

How many gtt per minute would you give if the tubing delivered 20 gtt/mL?

Practice Problem 4

Doctor's order: 80 mL/h

How many gtt per minute would you give if the tubing delivered 10 gtt/mL?

Practice Problem 5 Doctor's order: 150 mL/h

How many gtt per minute would you give if the tubing delivered 15 gtt/mL?

Now, check your answers. The answers are:

Answers
  1. 75 gtt
  2. 31 gtt
  3. 50 gtt
  4. 13 gtt
  5. 37 gtt
Here is how each of the problems is set up and solved:

Practice Problem 1
x gtts per minute = 75 x 60 = 75 gtt
60


Practice Problem 2
1
x gtts per minute = 125 x 15 = 31.2 or 31 gtt
60
4


Practice Problem 3
1
x gtts per minute = 150 x 20 = 50 gtt
60
3


Practice Problem 4
x gtts per minute = 80 x 10 = 13.3 or 13 gtt
60
6


Practice Problem 5
1
x gtts per minute = 150 x 15 = 37.5 or 37 gtt
60
4

Ratio and proportion is useful way to calculate dosage and solution problems of all types. It is an orderly and systematic mathematical process that results in consistent accuracy, provided the equation is set up correctly and careless mathematical errors are avoided.

PHARMACOLOGY RESOURCES

Because of the complexities of pharmacology, the vast and ever increasing number of available medications on the market, and the fact that several medications are pulled from the market ever year, it is imperative that you are able to use current and reliable pharmacological resources, such as a formulary, the PDR or another drug reference book.

Referring to any reliable pharmacology resource book, answer the following questions.

  1. What is the trade name of busulfan?
  2. What is the generic name for Neoral?
  3. What other medications have the same generic name as Neoral?
  4. What classifications of medication does propantheline bromide belong to?
  5. What is ifosfamide used for?
  6. What is the recommended adult initial oral dosage of phenytoin for grand mal seizures?
  7. What is the recommended adult loading IV dosage of phenytoin for status epilepticus?
  8. What is hyaluronidase indicated for?
  9. What are the contraindications for cyclobenzaprine hydrochloride?
  10. What are some of the side effects and adverse drug reactions associated with menotropins?
  11. What medications interact with pemoline?
  12. What foods interact with ramipril?
  13. What lifestyle components interact with chlorpheniramine maleate?
  14. What forms and routes is metronidazole supplied in?
  15. Which bodily systems and functions must be assessed prior to and during Parlodel therapy?

Answers

  1. Myleran
  2. cyclosporine or cyclosporin
  3. Sandimmune and Sandimmun
  4. anticholinergic and GI antispasmodic and antimuscarinic
  5. testicular cancer
  6. 100 mg tid
  7. 10 to 15 mg/kg
  8. It is used as an adjunct to increase the absorption and dispersion of other injected medications; hypodermoclysis and urography when a contrast medium is given subcutaneously
  9. Hypersensitivity; post acute MI; heart block; patients who have taken MAO inhibitors within 14 days; conduction disturbances; arrhythmias and heart failure.
  10. Nausea, vomiting, multiple births, ovarian enlargement, CVA, tachycardia, atelectasis, acute respiratory distress, pulmonary emboli, arterial occlusion, hypersensitivity, and anaphylaxis.
  11. Insulin and oral hypoglycemic medications
  12. Salt substitutes with potassium
  13. Alcohol use
  14. The forms are capsules, tablets, oral suspension, liquid for injection and powder to injection. The routes are oral and intravenous.
  15. Hepatic, renal and cardiac systems; hematopoietic function

Care has been taken to confirm the accuracy of the information presented in this course and to describe generally accepted practices and drug information. However, the author and publisher are not responsible for errors or omissions or for any consequences from application of the information and make no warranty, express or implied, with respect to the contents of the publication.

Copyright 2005 Alene Burke & Associates

REFERENCES

Joint Commission on Accreditation of Healthcare Organizations (2004)." 2004 National Patient Safety Goals - FAQs"
http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm

Skidmore-Roth, Linda (2004). Mosby's Rapid Reference Library. CD-ROM

MEDICATION ADMINISTRATION


TRANSCRIPTION OF ORDERS

Medications are often transcribed by hand onto a medication administration record (MAR) or Medex, however, a large number of hospitals, health care agencies and healthcare corporations are now using computerized order entry, which decreases the possibility of a transcription error.

If you are still hand transcribing medications onto an MAR or medex, the following procedures must be followed:

If you are using computerized order entry, the above procedures must be followed, except that legibility is not a concern with computerized order entry.

THE SEVEN "RIGHTS" OF MEDICATION ADMINISTRATION

The safe administration of medication necessitates that we strictly adhere to the seven "rights", which include:

LEGAL ISSUES: ADMINISTRATION, OBSERVATION, DOCUMENTATION AND RECORD KEEPING

We are legally and ethically responsible and accountable for accurate and complete medication administration, observation, documentation and record keeping.

Administration: Legal Aspects

Controlled substances must be immediately recoded on the narcotic record upon their removal from their secure and double locked cabinet. They are documented into the patient's medication record as soon as they are administered. If a controlled substance is wasted, either in its entirety or partially, this waste must be witnessed by the wasting nurse and another nurse. Both nurses document this wasting.

All medications, including non controlled ones, must be securely maintained at all times. This security maintains the safety of children, cognitively impaired patients and those at risk for taking medications that are not administered to them by the nurse.

A medication that is administered, omitted, held or refused by the patient must be documented in the patient's medication record and/or progress note, according to the facility's specific policy and procedure. Other pertinent information such as vital signs, apical rate, PT and/or PTT must be documented as indicated. For example, before administering digoxin to a patient, the apical rate for a full minute must be taken and documented. If the rate is 54 or more, the administration of the dose is documented. If the rate is less than 54, the dose must be held and the doctor must be notified. This holding and notification must also be documented.

Complete and acceptable medication administration records must minimally include:
Identification of the patient is essential to the safe administration of medications.

One area that must consistently be addressed, whether or not the person is in a high risk for medical errors population of not, is patient/resident/client identification. Accurate identification is necessary for all aspects of diagnosis and treatment, including medication administration. JCAHO requires that at least two (2) unique identifiers, other than room number, are used prior to the administration of medications, blood and blood products, blood and other laboratory specimens and other treatments and procedures. Some examples of unique identifiers include the person's: Other measures that can be used to prevent medical errors among populations at high risk for medical errors are described below.

Decreased level of consciousness. Patients that are not alert, awake and oriented to time, place and person are at high risk for medical errors. Levels of consciousness can be altered by a number of factors including anesthesia, medications, delirium, head injuries and other forces. Patient identification is absolutely necessary when providing care to a person with a diminished, or compromised, level of consciousness. At times, a family member or friend who is visiting this patient/resident/client can assist with this identification process and also serve as a person to question you about questionable treatments and to ask questions of you. All of these things will help to avoid medical errors among the members of this high-risk group.

Cognitive impairments. Lower levels of cognition place a person at risk for medical errors. Clients that are confused, disoriented, demented or with delirium are at risk for all sentinel events because of the challenges associated with accurate patient identification and the hazards of impaired cognition. Some of these hazards include the risk for medication errors, falls, elopement, death or injury as a result of restraint use, transfusion errors, fire and infection. Again, patient identification is highly important. It is also helpful, depending on the person's level of cognition, to communicate with the affected person in a way that is understandable to them and to listen to them carefully, especially if they cue you to an impending error, either verbally or nonverbally. The use of pictures and drawings may help you to communicate with a person that is affected with a cognitive disorder, or impairment. The elderly population is most often affected by cognitive impairment.

Language barriers. One of our best defenses against medical errors is an alert, oriented, mentally competent person who is well educated and informed about their disease process, all of their diagnostic tests and all of treatments that they are, or will be, getting. These "ideal" patients are not frequently encountered. More often, our patients pose challenges, including a language barrier. A person with a language barrier can be as challenging as a person with a cognitive impairment. People with language barriers and cognitive impairments may not understand what you are saying or asking, and, you do not understand them. You may not know what they are saying or asking. The use of interpreters, family or friends, pictures and drawings should be maximized to overcome a language barrier. Additionally, it is very wise to learn some basic medical terminology and useful foreign language phrases for the populations you frequently care for.

Sensory disorders. Auditory and visual impairments can also lead to medical errors. A patient that is visually impaired, or even blind, may not be able to detect that an erroneous medication is about to be given or an incorrect treatment is about to be done. Additionally, patients with a visual impairment are at greater risk for falls than those without such an impairment.

Patients with auditory impairments may not hear the healthcare provider's explanation about what they are about to do and why they doing it. They may not even be able to hear the nurse, pharmacist or laboratory technician call them be the incorrect name. All of these issues lead to medical errors.

Assistive devices, such as eyeglasses, hearing aids, must be consistently provided to the impaired person in order to protect their safety. Additionally, the use of large print or Braille reading materials and magnifying glasses may be helpful for the visually impaired; and speaking loudly while facing the patient with an auditory impairment may offer some protection against medical errors.

Infants and children.

For natural and obvious reasons, infants and children are not cognitively or developmentally able to participate in care and decision making. They are usually unaware of what medications, treatments and procedures they should and should not be getting. They are unable to verbalize questions and concerns regarding erroneous medications, treatments or surgeries. Until they reach a certain age, they are not even able to state their name. Infants and children are at risk for virtually all types of sentinel events, especially abduction, placing the infant with the wrong parents, poisoning, falls and other physical injuries. Eliciting the support and presence of the family is one way to prevent medical errors among this high risk population.

Developmental disorders.

The same concerns and interventions described above for infants and children apply to those with developmental disorders, as specific to the degree of their developmental delay.

Psychiatric disorders.

Lastly, patients/residents/clients with a psychiatric disorder are at risk for sentinel events for a variety of reasons including medications and the nature of their illness. Some psychotrophic medications have sedating effects, thus posing some of the same challenges that those with decreased levels of consciousness have. Also, depressed patients may be at risk for suicide, the most frequently occurring sentinel event according to JCAHO. Additionally, patients with a psychiatric disorder may also be aggressive and violent, thus causing harm to self or others.

This population is also at risk because they may be delusional and out of touch with reality. They may not be able to reliably even state their correct name; they may not be legally, mentally competent enough to accept or reject care or to ask questions.

Observation: Legal Aspects

Additional legal responsibilities include the observation and assessment of the patient prior to the administration of a medication and the observation and evaluation of the patient's responses (therapeutic, side effects and adverse drug reactions) to a medication. Generally speaking, this information is documented in the progress notes.

We are also required to assess the patient for allergies to medications and their knowledge about the medications being given.

MEDICATION ERRORS AND HOW TO PREVENT THEM

Some medication errors occur at the point of entry, that is, when the medication is manually transcribed onto a medication administration record. Others occur when they are dispensed. Bar coding helps to prevent dispensing errors.

Still more medication errors occur when they are being administered. We you administer medications, you must follow the Seven "Rights" and you must carefully validate the person's identity. Examples of administration errors include:
You can be certain of the right patient by checking the patient's identity using unique identifiers and paying special attention to those patients that are at risk for medical errors. Patient education is also important. Teach your patients to protect themselves against medication errors.

You can protect yourself from errors of relating to the wrong time, medication, dosage and route by checking the medication record against the original order and making sure that the transcription was correct and by checking every medication, the dosage and the route against the medication administration record before you administer it.

You can protect yourself against incorrect infusion rates by accurately calculating flow rates and checking the flow. Volumetric controllers do malfunction and fail so be careful.

Unit dosing and automated bedside dispensing systems have significantly decreased medication administration errors, however, they have not completely disappeared. One study indicates that unit dose systems have a 15.9% error rate and automated dispensing systems have an error rate of 10.6%. Dosages given at the incorrect time are the most frequently occurring errors. (Auriche & Loupi, 1993)

HOW PATIENTS CAN PROTECT THEMSELVES AGAINST MEDICATION ERRORS

Below are guidelines for your patients. They, too, can prevent medication errors.

"1. The single most important way you can help to prevent errors is to be an active member of your health care team.

That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

Medicines
2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.

At least once a year, bring all of your medicines and supplements with you to your doctor. "Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help you get better quality care.

3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.

This can help you avoid getting a medicine that can harm you.

4. When your doctor writes you a prescription, make sure you can read it.

If you can't read your doctor's handwriting, your pharmacist might not be able to either.

5. Ask for information about your medicines in terms you can understand-both when your medicines are prescribed and when you receive them.

6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?

A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.

7. If you have any questions about the directions on your medicine labels, ask.

Medicine labels can be hard to understand. For example, ask if "four doses daily" means taking a dose every 6 hours around the clock or just during regular waking hours.

8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it.

Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.

9. Ask for written information about the side effects your medicine could cause.

If you know what might happen, you will be better prepared if it does-or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

(Agency for Healthcare Research and Quality, 2000)
Copyright 2005 Alene Burke & Associates

REFERENCES

Agency for Healthcare Research and Quality (2000). 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38. Rockville, MD. http://www.ahrq.gov/consumer/20tips.htm Auriche, M and E. Loupi (1993). "Does Proof of Casualty Ever Exist in Pharmaco-Vigilence?". Drug Safety. (9). pgs. 230-235.

Joint Commission on Accreditation of Healthcare Organizations (2004)."2004 National Patient Safety Goals - FAQs" http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm

Skidmore-Roth, Linda (2004). Mosby’s Rapid Reference Library. CD-ROM

Contact Hours: 80
Price: $199.00
Course Title: NURSE REFRESHER COURSE
Course Number: 20-67022

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