PART I PART I1. PART 111 Reconstituted Medications, 177. PART IV Parenteral Medication Calculations, 233

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1 SECOND EDITION

2 ~~ _/ PART I Essential Math Review tor Medication Calculations, 1 Essential Math Self-Assessment, 2 1 Essential Math Review, 5 2 Dimensional Analysis Calculations, 43 PART I1 Modern Metric System and Medication Calculations, 63 3 Measurement Units and Conversions for Medications, 64 4 Patient Records, Medication Orders, and Labels, 89 5 Solid and Liquid Oral Dose Calculations, 135 PART 111 Reconstituted Medications, Syringe Measurements, Reconstitution of Powders and Liquids, 204 PART IV Parenteral Medication Calculations, Injectable Medication Calculations, Basic Intravenous Calculations, Advanced Intravenous Calculations, 312 PART V Oral and Injectable Hormone Medications, Antidiabetic Agents, Anticoagulant Agents, 392 PART VI Medications tor Intants and Children, Pediatric Medication Calculations, 418 Multiple-Choice Final Review: Chapters 1-13, 456 Comprehensive Final Practice: Chapters 1-13, 461 Answer Keys, 481 Appendix A: Apothecary System Measurements, 583 Appendix B: ISMP's List of High-Alert Medications, 585 Appendix C: 5-Minute Sampie Verbal Communication Hand-off Report, 587 Index, 589 xiii

3 ,Contents PART I Essential Math Review for Medication Calculations, 1 xiv Essential Math Self-Assessment, 2 1 Essential Math Review, 5 Introduction, 5 Directions, 6 Essential Math Vocabulary and Concepts, 6 Whole Numbers, 8 Implied Decimal Points and Trailing Zeros, 8 Sum, 10 Product, 10 Factor,10 Common Fa ctors, 10 Multiple, 11 Factors Versus Multiples, 11 Multiplier, 11 Divisor, Dividend, Quotient, and Remainder, 11 Square, 12 Square Root, 12 Bases and Exponents, 14 Powers of 10 Calculations, 14 Multiplying and Dividing by 10, 100, and 1000, 15 Decimal Fractions, 16 Reading Numbers and Decimals, 17 Decimal Point Spatial Placement, 18 Writing Decimals in Fraction Form, 18 Comparing Decimals to See Which Is Larger, 19 General Rules for Rounding Decimals and Whole Numbers to an Approximate Number, 20 Adding and Subtracting Decimal Numbers, 20 Multiplying Decimals, 21 Dividing Decimals, 21 Fractions, 23 Alternative Fraction Forms, 24 Mixed Fractions, 24 Improper Fractions, 24 Gonverting Mixed and Improper Fractions, 24 Converting an Improper Fraction to a Mixed Fraction, 24 Reducing Fractions, 25 Gommon (Same) Denominator, 26 Lowest Gommon Denominator (LCD), 27 Equivalent Fractions, 27 Comparing Fractions, 28

4 Adding and Subtracting Fractions, 29 Multiplying Fractions, 31 Fraction Multiplication and Canceling Fractions, 31 Multiplication with Mixed Fractions, 32 Dividing Fractions, 33 Percentages, 34 Changing a Fraction to a Percentage, 34 Changing a Percentage to a Fraction, 34 Changing a Decimal to a Percentage, 35 Changing a Percentage to a Decimal, 35 Calculating the Percentage of a Whole Number, 36 Constants, 36 Finding Unit Values and Totals, 37 Finding the Total Value, 37 Equations, 38 2 Dimensional Analysis Calculations, 43 Introduction,43 Three Required Elements of a Dimensional Analysis Equation, 45 Setup of a Simple Equation Using Dimensional Analysis, 45 Conversion Factor Review, 48 Two Kinds of Conversions That Must Be Identified, 50 Problems That Call for More Than One Conversion Factor, 54 PART 11 Modern Metric System and Medication Calculations, 63 3 Measurement Units and Conversions for Medications, 64 Introduction, 64 Metric Measurements: Base Units, 66 Metric Units Number Line, 66 Metric Prefixes and Values, 67 Metric Notation, 68 Equivalent Metric Measurements of Weight or Mass, 71 Equivalent Metric Measurements of VOlume, 72 Equivalent Metric Measurements of Length, 73 Metric Equivalents, 74 Finding Equivalents: Changing Milligrams to Grams and Grams to Milligrams, 75 Examining Micrograms, 78 Milliequivalents (meq), 79 Other Medication Measurement Systems, 80 Key Points About the Measurement Systems, 83 4 Patient Records, Medication Orders, and Labels, 89 Introduction,89 Medication Storage and Security, 92 Medication Forms and Packaging, 94 Solid Drug Forms, 94 Liquid Drug Forms, 96 Medication Routes, 98 Frequency and Times of Medication, 100

5 Ine L4-Hour l,;iock, 106 Medication Orders, 108 Interpreting Labels and Orders, 109 Calculating Dose Based on Label and Order Information, 114 Orders fortwo or More Medications to Be Combined, 119 Telephone and Verbal Orders, 119 Examples of Orders That Must Be Clarified, 119 Medication Administration Records, 121 PRN Medication Administration Record, 124 Patients' Rights, Solid and Liquid Oral Dose Calculations, 135 Introduction, 135 Converting Grams to Micrograms and Micrograms to Grams by Moving Decimal Places, 140 Analyzing Liquid Dose Orders, 145 Setting up DA-Style Equations for Liquid Dose Calculations, 147 Usual Unit Doses, 148 Equipment for Administering Oral Liquid Doses, 151 Measuring Liquids, 151 Reading Syringe Calibrations on the 3-mL and 5-mL Syringe, 151 Safe Dose Ranges, 158 Reconstituted Medications, Syringe Measurements, 178 Introduction, 178 Syringe Sizes, 179 Parts of the Syringe, 181 Total Capacity and Lowest Measurable Dose, 182 Where to Measure the Dose on Syringes, 182 Examining the Calculated Doses for Correct Syringe Selection, 186 Oral Syringes, 188 Oral Syringes Versus Injectable Syringes, 188 Prefilled Injectable Syringes, 189 Prefilled Medication Cartridges for Injection, 189 Needle Sizes, 190 Safety Syringes, 192 Safety Issues and Disposal of Sharps, 193 Recommended Fluid Volume for Selected Sites, Reconstitution of Powders and Liquids, 204 Introduction,204 Reconstituted Medications, 206 Expired Reconstituted Drugs, 208 Reconstituted Parenteral Drugs, 215 Reconstituted Drug Prefilled Containers, 219 Liquid Concentrates: Diluting liquids, 224 Inactive Ingredients Used for Dilutions, 224 Converting Dilution Ratios to Fractions and Percentages, 225 Using a DA Equation to Calculate the Amount of Concentrate, 225

6 PART IV Parenteral Medication Calculations, Injectable Medication Calculations, 234 Introduction, 234 Intradermal Injections, 235 Subcutaneous Injections, 236 Intramuscular Injections, 237 Administering Injections, 237 Parenteral Mixes, 244 Medicines Supplied in Units, Basic Intravenous Calculations, 262 Introduction, 262 Overview of Intravenous Therapy, 265 Basic Intravenous Equipment, 266 Types of Intravenous SOlutions, 267 Tonicity of Intravenous Solutions, 267 Intravenous Solution Volume, 268 Intravenous Solution Orders for Milliliters per Hour, 269 Determining Infusion Durations, 269 Intravenous Flow Rate Entries for Electronic Infusion Devices, 271 Gravity Infusions, 271 Intravenous Administration Sets, 272 Selection of Gravity Infusion Administration Sets, 273 Calculating Flow Rates for Gravity Infusion Devices, 274 Intravenous Piggyback Solutions, 282 Regulating and Positioning Gravity Infusion Devices, 287 Flow Rate Errors, 289 Monitoring the Flow Rate on Infusion Devices, 289 Calculating Milliliters per Hour from Drops per Minute on Gravity Devices at the Bedside, 291 Setting the Alarm for Electronic Intravenous Equipment, 292 Calculating the Volume for a "Volume to Be Infused" Alarm, 293 "To Keep Open" Flow Rates, 298 Calculating Grams of Solute in Intravenous Solutions, 298 A Word about Potassium Chloride, 299 Intravenous Intermittent Solution Delivery Systems, 300 Administration of Blood, Advanced Intravenous Calculations, 312 Introduction, 312 Equation Setups for Advanced Intravenous Calculations, 314 Conversion Factors That May Be Needed for Intravenous Infusion Calculations, 315 Calculating Medicated Intravenous Flow Rates That Require One Conversion Factor, 316 Calculating Intravenous Flow Rates That Require Two Conversion Fa cto rs, 316 Calculating Flow Rates for Weight-Based Doses, 319 Equipment for Medicated intravenous Solutions, 323 Calculating Milligrams per Milliliter (mg per ml) from Available Drug Concentration, 327 Deriving Infusion Dose from Existing Flow Rate and Available Solution, 327 Dilutions: When the Nurse Prepares the Drug for the Intravenous Solution, 329 Intravenous Direct Push Medications, 330 Intravenous Direct Push Calculations, 331 Heralimentation: Parenteral Nutrition, 336

7 Oral and Injectable Hormone Medications, Antidiabetic Agents, 350 Introduction, 350 Oral and Injectable Non-Insulin Antidiabetic Agents, 353 Parenteral Antidiabetic Agents: Insulin Products, 355 Insulin labels, 357 Short- and Rapid-Acting Insulins, 358 Intermediate-Acting Insulins, 361 Short- and Intermediate-Acting Insulins: Insulin Fixed-Combination Mixes, 362 long-acting Insulins, 362 Steps to Prepare Doses for Insulin Syringes, 363 Matching Insulin Concentration and Syringes, 364 Reading Units on Insulin Syringes, 365 Even- and Odd-Numbered Scales on Insulin Syringes, 365 lo-dose Syringes, 366 Sites for Insulin Injection, 369 Sliding-Scale Insulin (SSI), 369 Mixing Insulins: Short Fast-Acting and Siower-Acting Intermediate Mixes, 374 When the Mix Must Be Prepared by the Nurse, 376 Technique for Preparing Insulin Mixes, 376 Intravenous Insulin Infusions, 380 Insulin Administration Devices, Anticoagulant Agents, 392 Introduction, 392 Injectable Anticoagulants, 400 low-dose Heparin Concentrations Used to Maintain Patency of Intravenous Devices (Flushes), 401 Heparin Concentrations Used for Subcutaneous Administration and Bolus Intravenous Doses, 402 Heparin Concentrations Used for Intravenous Infusions, 403 Calculating Heparin Flow Rates in Milliliters per Hour (ml per hr) and Units per Hour Using DA-Style Equations, 405 Determining ml per hr from a Weight-Based Order of Units per kg per hr, 405 Determining Units per hr Being Infused on an Existing Infusion, 406 PART VI Medications for Infants and Children, Pediatric Medicatlon Calculations, 418 Introduction, 418 Comparing Adult and Pediatric Medication Doses and Schedules, 420 Calculating Kilograms to the Nearest Tenth from Pounds and Ounces, 421 Sequence for Calculating Safe Dose Range (SDR), 423 Body Surface Area (BSA), 425 Equipment for Medication Administration to Pediatric Patients and Patients Unable to Chew Tablets and Pills, 428 Injection Sites for Pediatric Patients, 433

8 DETAILED CONTENTS xix Injection Volumes for Pediatric Populations, 434 Fluid Requirements for Pediatric Patients, 438 Intravenous Injections for Infants and Children, 439 Comparing Safe Dose Range and Order, 445 Multiple-Choice Final Review: Chapters 1-13, 456 Comprehensive Final Practice: Chapters 1-13, 461 Answer Keys, 481 Appendix A: Apothecary System Measurements, 583 Appendix B: ISMP's List of High-Alert Medications, 585 Appendix C: 5-Minute Sampie Verbal Communication Hand-off Report, 587 Index, 589

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