Drug Calculations: Systems of Measurement

Converting Within the Metric System

The metric system is most commonly used for medication administration. Since it
is organized in units of 10, you can easily convert to the different unit of
measurement by multiplying or dividing by 10, or by moving the decimal to the
right or left.
Basic units of measurement include:

Liter: Volume

Gram: Weight

Meter: Length

The following table shows common prefixes for subdivisions or multiples of the
basic unit.
Prefix
Micro(mcg)
Milli(m)
Milli(m)
kilo(k)
Milli(m)
Centi

Common Conversions

Weight
o

1,000 mcg = 1 mg

1,000 mg = 1 g

Volume
o

1,000 g = 1 kg

1,000 mL = 1 L

Length
o

1 cm = 10 mm

Converting From Household to Metric

Converting Pounds to Kilograms
Medications may be ordered based on your clients weight, and doses are
calculated according to the clients weight in kg. Since clients weights are often
recorded in pounds (lb), you must convert pounds to kilograms (kg). To do this,
remember that 1 lb = 2.2 kg.
Therefore, if a client weighs 220 lb, you would divide the weight in lb by 2.2
kg/lb:

Converting Ounces to Milliliters

Since most liquids in the United States are delivered in fluid ounces, ounces (oz)
often must be converted to milliliters (mL) in the clinical arena. To do this,
remember that 1 oz = 30 mL.
Therefore, if a client drank an 8 oz bottle of water, you would multiply the volume
in oz by 30 mL/oz:
8 oz x 30 mL/oz = 240 mL

Drug Calculations: Formula Method

The formula method for calculating drug dosages is simple and easy to
remember.
D = Desired dose (dose ordered)
H = Dose on hand (dose available)
V = Vehicle (form in which the drug is available: tablet, capsule, or liquid)

Therefore, if an order for Acetaminophen is 1,000 mg, and you have 500 mg
tablets on hand, you would divide the order by the mg/tablet to find the correct
dose:

Drug Calculations: Ratio and Proportion Method

The ratio and proportion method is an approach that sets up an equation with
known conditions on the left side and the desired dose and unknown number on
the right.
D = Desired dose (dose ordered)
H = Dose on hand (dose available)
V = Vehicle (form in which the drug is available: tablet, capsule, or liquid)
H : V :: D : X
Once you have the equation set up, multiply the extremes and multiply the
means:
HX= VD
Solve for X
Therefore, if an order for Acetaminophen is 1,000 mg, and you have 500 mg
tablets on hand, you would multiple the means and the extremes:
500 mg : 1 tablet :: 1,000 mg : X
500 mg x X = 1,000 mg x 1 tablet

X = 2 tablets

Drug Calculations: Fractional Equation Method

The fractional equation method is similar to the ratio and proportion method,
except it is set up as a fraction in the equation.

D = Desired dose (dose ordered)

H = Dose on hand (dose available)
V = Vehicle (form in which the drug is available: tablet, capsule, or liquid)

Solve for X by cross-multiplying

HX = DV

Therefore, if an order for Acetaminophen is 1,000 mg, and you have 500 mg
tablets on hand, you would solve for X by cross-multiplying:

X = 2 tablets

Drug Calculations: Dimensional Analysis

Dimensional analysis involves the conversion of a quantity in one unit to a
different unit of measurement by cancelling equal units of measurement. For
instance, if you have a medication ordered in milligrams but it is delivered in
micrograms, the conversion process is within one formula.
D = Desired dose (dose ordered)
H = Dose on hand (dose available)
V = Vehicle (form in which the drug is available: tablet, capsule, or liquid)
C = Conversion factor

Therefore, if an order for Acetaminophen is 1 g (conversion factor: 1 g = 1,000

mg), and you have 500 mg tablets on hand, you would establish the dose by:

X = 2 tablets

Medication Administration: Legal Aspects

As the nurse, you are legally responsible for the administration of medications to
the client. The health care provider (Medical Doctor (MD) or Nurse Practitioner
(NP)) will order the medication, the pharmacist will fill the medication order, and
you will administer the medication. It is your responsibility to determine that the
medication and the dosage are appropriate for the client. If the medication is not
appropriate or the dosage is inaccurate, you as the nurse are most liable for the
administration of the medication. As a nurse, you have the right to refuse to
administer a medication that may be harmful to your client.
You should ask yourself the following questions prior to administering the
medication:

Is this medication appropriate for the clients diagnosis and condition?

Does the clients health status warrant the administration of the

medication?

Is this the correct medication, dosage, and type?

Does the client possess any allergies to the medication?

Medication Administration: Medication Orders

Specific items included in the medication order include:

Clients name

The date and time of the order

Medication to be administered

Drug dosage

Route of administration

Frequency of administration

Signature of prescriber (MD or NP)

Types of medication orders include:

Medication orders are written or computerized.

Written orders are recorded in the clients chart.

Telephone orders are recorded by the nurse and classified as a telephone

order in the clients chart; they must be signed by the prescriber within 24
hr.

Medication orders are written as follows: one time only, prn (as needed),
or routine (according to the prescribers instructions until the order is
cancelled).

Rights of medication administration include:

1. Right medication
2. Right dose
3. Right client
4. Right route
5. Right time
6. Right reason
7. Right documentation

Medication Administration: Oral, Sublingual, and Buccal Routes

Oral medications: Oral medications are administered by mouth with absorption
occurring in the gastrointestinal (GI) tract. Oral forms of medications include
tablets, capsules, and liquids.
Oral medications are also administered through nasogastric and gastrostomy
tubes. The procedure is as follows:

Position the client in semi-Fowlers position and have the client maintain
the position for 30 min after medication administration.

Nasogastric tube: Check tube placement by aspirating stomach contents

(you want to verify that the tube is in the stomach and not the lungs;
check pH (should be 4). Secretions should be green to tan/clear.

Flush the enteral tube with 30 mL of tap water.

Administer medications in elixir form when available; if not, crush tablets

to a fine powder and mix with tap water; do not crush or administer
sustained release or enteric-coated medications.

For clients receiving enteral feeding, be sure the enteral feeding is

compatible with the medications. If not, stop the feeding for 30 to 60 min
before and after administration.

If the tube is connected to intermittent or continuous suction, stop the

suction for 30 min after medication administration.

Flush the enteral tube with 30 mL of tap water following medication

administration.

Sustained release oral medications: These medications are manufactured to

delay absorption. They are used to slow drug absorption in a controlled manner.
When administering these medications, do not crush or break the medication.
This will impair the preparation, its dosage, and the clients response.
Sublingual medications: Sublingual medications are placed under the tongue
and absorbed through the mucous membrane of the mouth into the blood
vessels for rapid onset of action. Sublingual medications bypass the
gastrointestinal tract and the liver to eliminate the first-pass loss when drugs are
metabolized before reaching the site of action.
Buccal medications: Buccal medications are held against the mucous
membrane between the cheek and teeth. They are absorbed through the mucous
membranes of the mouth. The absorption of buccal medications is the same as
sublingual. They bypass the gastrointestinal tract and the liver.

Medication Administration: Topical Medications: Rectal, Irrigations,

Transdermal, and Inhalation
Topical medications are applied to the skin, body cavities, eye, ear, or respiratory
tract and are administered by the following methods: irrigations, transdermal,
inhalation, or instillation (ophthalmic, otic, and nasal medications). The
formulations of the medications are lotions, creams, ointments, solutions,
powders, and patches. They are never ingested.
Rectal
Rectal administration is a convenient and safe method for giving some
medications.
Irrigations
Irrigations are applied to body cavities, such as the urinary bladder or vagina.
Irrigations may instill pharmacologic agents or merely cleanse the orifice.
Transdermal

The application of the medication is designed to provide slow release of the drug,
usually by a patch. Examples of these medications include nitroglycerine,
fentanyl, estrogen, and nicotine.
Inhalation
Inhaled preparations are administered into the respiratory tract using a mist,
spray, or positive pressure.

Medication Administration: Topical Medications: Rectal, Irrigations,

Transdermal, and Inhalation
Other topical medication administration methods include the following:

Ophthalmic: These medications are administered into the eye as drops or

ointments.

Otic: These medications are administered into the ear as drops. The client
is instructed to lie on the unaffected ear for several minutes to ensure the
medication stays in the affected ear.

Nasal: Medications are administered in the nose to produce local or

systemic effects.

Medication Administration: Parenteral Medications

The parenteral routes of medication administration include subcutaneous,
intramuscular, intravenous, and intradermal. Parenteral administration bypasses
absorption in the gastrointestinal tract. The medication is withdrawn from an
ampule or vial.
At times, you may have to mix two medications in the same syringe. It is
important to determine the medications compatibility.
Subcutaneous
The site of administration of the subcutaneous injection is the third layer of tissue
below the skin, known as the subcutaneous tissue. The subcutaneous injection
can be a bolus, or it can be administered as a continuous infusion. An example of
a continuous infusion is the administration of insulin through an insulin pump.
Intramuscular
An intramuscular injection is administered into the muscle for rapid absorption
into the bloodstream. The administration of intramuscular injections is primarily a
bolus dose; however, some drugs contain a substance to delay absorption.
Intradermal

Intradermal injections are administered into the dermal layer of the skin, just
under the

Medication Administration: Parenteral Medications: Intravenous

Intravenous
Intravenous (IV) injections are administered in the clients vein. Medications can
be mixed in intravenous fluids for administration. The onset of action is more
rapid than oral or intramuscular. Various dosage patterns are administered, such
as bolus or continuous infusion. You must monitor the client closely for adverse
effects.
Intermittent IV Infusion
If a client does not require continuous IV infusion of fluids and/or electrolytes, an
intermittent infusion device (commonly referred to as a saline lock) is often used.
This provides the client more freedom because he/she is not tethered to an IV
and provides immediate venous access for drug therapy.
Continuous IV Infusion
Clients who require continuous IV infusions can receive medications via
piggyback.

Nursing Process: Assessment

In the assessment phase of the nursing process, you will assess psychosocial and
biophysical parameters related to the clients medication needs and response to
drug therapy. You should assess the clients:

General health history, allergies, current and past medications, and diet

Perception of health and knowledge of drug reactions

Orientation to time, place, and person to determine the clients ability to

administer the medication safely

Ability to administer the medication due to limitations in mobility

Previous allergic reactions to other medications that could place him/her

at risk for future reactions

Understanding of medication action, use, adverse effects, and implications

related to administration

Vital signs prior to the administration of medications such as

antihypertensives or cardiac medications

Nursing Process: Diagnosis

In the diagnostic phase of the nursing process, you identify any problems the
client has in the administration of medications and reactions to the medication.
The clients needs are based on the physiological and psychosocial effects of
nursing care. The following are examples of diagnoses related to medication
administration:

Need for increased education regarding the action, adverse effects,

contraindications, and implications for medication administration

Physiological and psychosocial results of the medication requiring changes

in the medications to improve response

Nursing Process: Planning

The following are goals and expected outcomes related to medications:

Client and family will understand the medication regime

The client will achieve therapeutic effects from the medication

The client will be without complications related to drug administration

The client will safely administer his/her own medications

Nursing Process: Implementation

In the implementation phase, you will:

Receive the medication order

Correctly transcribe and communicate the order

Accurately calculate the dose if required

Accurately administer the medication

Document the administration of the medication

Determine if the medication is appropriate based on the clients age,

weight, and medical condition

Monitor the administration of any over-the-counter medications

Assess for noncompliance

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Provide teaching to the client regarding medication, including purpose,

dosage, frequency, side effects, and special considerations (factors that
affect medication administration)

Nursing Process: Evaluation

In the evaluation phase of the nursing process, you will evaluate the following:

The clients therapeutic response

The occurrence of adverse effects

Any drugdrug or drugfood interactions

Evaluation measures should include:

Direct observation

Assessment of vital signs

Evaluation of diagnostic testing

Psychosocial responses to the medication

Expected outcomes include:

Client demonstrates therapeutic response to medication.

Correct dose, time, and route of medication is administered.

Client demonstrates correct self-administration of medication as per

teaching.

Unexpected outcomes include:

Medication has undesired affect.

Client experiences a side effect or adverse effect.

Medication error occurs.

Principles of Pharmacology: Drug Nomenclature and Types

When administering medications, it is important that you understand the names
of the medications and instruct your clients on these names. The word drug
and medication can be used interchangeably. Chemical, generic, official, and
trade names can be used to identify a medication.

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Chemical name: identifies the drugs atomic and molecular structure. It

utilizes exact chemical language and terminology.

Generic name: identifies the drugs active ingredient and is the assigned
name from the manufacturer who developed the drug.

Official name: the name used in official publications such as the United
States Pharmacopeia and National Formulary. The official name is often
the generic name.

Trade name: the brand name or proprietary name. The trade name is
selected by the drug company that sells the drug. It is protected by a
trademark.

Types of Drug Preparations

Drugs are administered to the client in different forms. Forms include:

Oral: administered in the mouth and then swallowed or absorbed by

mucous membranes

Topical: placed on the skin or mucous membranes (inhalations,

instillations and irrigations, and dermatologic preparations)

Parenteral: injected (subcutaneous, intramuscular [IM], intradermal [ID],

and intravenous [IV])

Drug Classifications
Drugs are classified based on similar characteristics. One of the most common
ways drugs are classified is according to their effect on various body systems.
Once you are familiar with a class of drugs, you can apply this knowledge to
individual drugs within that class.

Principles of Pharmacology: Drug Effects

Medications can have many effects, both intended and unintended. When
administering medications you will need to assess the client for the following
types of effects:

Therapeutic effect: also called the desired effect. The therapeutic effect
is what the drug has been prescribed to do.

Side effect: unintended secondary effects of the medication that are

usually predictable. They range from harmless to potentially harmful.

Adverse effects: effects that are more severe than side effects and may
require the discontinuation of the medication.

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Toxic effects: harmful effects on the body, usually the result of a drug
overdose, ingestion of a drug intended for external use, or cumulative
effects resulting from impaired excretion or metabolism.

Idiosyncratic effect: an unexpected effect. It is an individual response to

a drug manifested as an underresponse, overresponse, or completely
different response.

Allergic reaction: a clients immunologic reaction to a drug. A client can

react to a drug by producing antibodies, just as it does any other time the
body reacts to a foreign substance. The reaction can range from a mild
rash to an anaphylactic reaction.

Drug interactions: When two drugs are given at the same time, one or
both may alter the effect of the other. The effect may be increased
(potentiating effect) or decreased (inhibiting effect).

Principles of Pharmacology: Pharmacokinetics

Pharmacokinetics is the study of absorption, distribution, biotransformation,
and excretion of drugs.
Absorption

First process of pharmacokinetics whereby the drug passes into the

bloodstream

Drugs are absorbed in the gastrointestinal tract, respiratory tract, or the

skin or mucous membranes.

The rate of absorption depends on the site where the drug is absorbed. For
example, drugs are absorbed more slowly in the stomach than the small
intestine because the small intestine has a greater surface area than the
stomach to absorb the medication. Also, food in the stomach can delay or
enhance absorption.

Drugs administered intravenously immediately enter the bloodstream and

do not need to be absorbed.

Distribution

The movement of the drug from the site of absorption to the site of action.

When the drug enters the vascular system, it is distributed first to the
most vascular organs (liver, brain, and kidneys). Body systems with
limited vasculature receive the drug last.

The chemical and physical properties of the drug determine the area of
the body where the drug is distributed.

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Biotransformation

Also known as metabolism

The drug is changed from its original form to a new form.

The primary organ of biotransformation is the liver. The liver possesses

many drug-metabolizing enzymes.

The products of drug metabolism are active and inactive metabolites. An

active metabolite has a pharmacologic action, and an inactive metabolite
has no pharmacologic action.

Biotransformation is altered with hepatic insufficiency and in young and

older clients. To ensure the drug is metabolized in the body, it is important
to know the clients alanine aminotransferase (ALT) andaspartate
aminotransferase (AST) levels. Elevations in liver enzymes are indicative
of impaired liver function.

Excretion

Drugs and metabolites are excreted primarily in the kidneys and are
eliminated in the urine.

Other sites of excretion include feces, exhaled respirations, perspiration,

saliva, and breast milk.

To ensure that drugs and metabolites will be properly excreted, it is

important to know the clients blood urea nitrogen (BUN) and serum
creatinine levels. Elevated levels indicate impaired renal function.

Principles of Pharmacology: Pharmacodynamics

The pharmacodynamics of a drug describes how the drug alters the cell
physiology and affects body function.

Drugs exert effects by chemically binding with receptors on the cell

membranes or within the cells.

Drug molecules bind to the receptor molecules to form a drugreceptor

complex. This initiates a physiochemical reaction that will stimulate or
inhibit normal cell functions. This binding is usually reversible.

Types of DrugReceptor Interactions

Drugs are categorized by how they exert their effects at the cellular level through
the chemical binding with the receptor.

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Agonist: Drugs that bind to the receptor site and cause the same response
as a physiologic or endogenous substance.

Antagonist: Drugs that bind to the receptor site and inhibit cell function.

Principles of Pharmacology: Plasma Half-Life and Loading Doses

Plasma half-life (t1/2) refers to a drugs duration of action, that is, the amount of
time it takes for the drugs serum concentration to reduce by one-half.

The greater the half-life, the longer it will take for the drug to be excreted
from the body.

The shorter the half-life, the faster the drug will be excreted from the body.

Knowledge of a drugs half-life is important because it helps you understand the

amount of time a drug will have a therapeutic effect on the body. The goal of
drug therapy is to administer drugs at a dose and time interval that will maintain
a therapeutic range, that is, one that provides optimum treatment with minimal
side effects.
In order for some drugs to reach a therapeutic range in a reasonable amount of
time and to sustain a plateau in the therapeutic range, the administration of a
loading dosefollowed by a maintenance dose is required.

Loading dose: a higher dose of the drug given in one or several doses to
boost the plasma level with a sufficient amount of drug to be therapeutic.

Maintenance dose: intermittent doses of the drug given before the plasma
drug concentration drops to keep the concentration at a therapeutic level.

Principles of Pharmacology: Factors Affecting Medication Administration

When administering medications, consider the factors that affect drug action. Not
everyone responds to medication in the same or expected way. As a nurse, you
need to assess these factors and consider how each affects your client.
Consider how each of these factors can affect your client care:

Age
o

Infants

Children

Older adults

Special populations

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Pregnant women

Lactating mothers

Gender

Weight

Genetic and cultural factors

Physiological factors

Timing

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