# Fundamentals session 3: Intro to dosage calculations

Introduction to dosage calculations

The takeaway here is attention to detail, double check your math and find a comfortable system to do your dosage calculations.

Medications errors happen and nurses or pharmacist need to catch them.

Dose calculations probably do not match what was ordered.

Volume is the amount of fluid

• concentration is the amount of drug per the volume
• concentration may vary widely in the volume.

Always use the smallest unit used

• 60 mg = 1 grain (gr) grain is not too common
• 30 ml = 1 fl. ounce
• 1 mg = 1000 mcg
• 1 Gm = 1000 mg

basic dosage calc

• Order – what the doc wants
• available – what we have

Always write 0.5 Gm not .5 Gm

there are many ways to do a basic dosage calculation

IV Calculations

Using IV pump – Overall volume to be infused/ the time of volume to be infused

• volume in ml
• time in hours
• divide out for rate

Manual drip (gtt) on the NCLEX

• drops per minute (gtt/min)
• drop factor: the amount of drops it takes to make a ml (gtt/ml)
• (solution times drop factor) over (hours times 60)

# Fundamentals session 2: Infections

Fundamentals

Session 2

August 31 2015

Here is session two. It is mainly concerned with infections and specifically

Stopping infection in the hospital

Healthcare associated infections

• five types account for 60% of the reports
• uti, surgical site, bloodstream, pneumonia.

Everyone is a susceptible host.

Infection control – exit versus entry

Overuse of antibiotics is leading to Drug resistant Microbial strains.

• these pt’s tend to have longer hospital stays

MRSA: HA = hospital acquired, CA = Community acquired

• testing upon admission to tell the difference.
• find the location: nose, wound, and be extra careful with that cite

VRE Vancomycin resistant enterococcus – happens in immunocompromised pts,

• ie. cancer, old, steroids

Cdiff – inflammation and irritation of the bowel,

• have to go to the bathroom a lot, distinct smell.

SIRS – systemic inflammatory response syndrome

Standard precaution on all fluids and pts that are considered hazardous

• This can be helped through consciously creating habits

mode of transportation

• direct
• indirect

There is a specific order of operations to apply and remove PPE

Airborne precautions (droplet of <5um)

• Measles, VZV, TB
• Private, negative airflow room
• Rule out tb and an actual tb patient are treated the same.

Contact Precautions

• direct contact transmission
• MRSA, VRE, RSV,
• Accommodations private room
• precautions, gloves and gowns with their own equipment

Droplet Precautions > 5um

• rubella, pertussis

Levels of cleanliness

• Asepsis – no pathogens
• Medical asepsis – “Clean technique”
• Surgical asepsis  – “sterile technique”

• all the time
• a lot
• soap and water if visibly soiled
• C Diff does not die from alcohol gel.

compromise of a sterile package

• get a new sterile package!
• start over

sterile technique

• hands above waist
• edges are contaminated
• liquid contaminates sterile field.

# Fundamentals Class 1

Fundamentals

Class 1

August 31 2015

This is an overview of the first class and is mainly concerned with the improvement of practice over time and what organizations do this.

There was a negative culture in nursing for a long time that created a shame, blame, and shame culture.

• creates fear over not knowing
• hard to learn
• want to cover up mistakes

IOM is the institute of medicine – leader in evidence based practices and learning the new best practices without bias.

• To Err is human – (1999): 44,000- 98,000 people die due to medical errors
• Average is 71,000
• Equivalent to three jumbo jet crashes every other day
• conclusion – not from individual errors but from bad systems, and patterns
• such as stocking full strength toxic drugs
• not mandatory to use some safety equipment ie. gait belt
• Goal is to reduce errors by 50% in 5 years

• Crossing the quality Chasm (2000)

• Safe,
• Timely
• Effective
• Efficient
• Equitable
• patient-centered care
• all healthcare related fields need to be educated in five competencies.
• patient centered care, teamwork, EBP, quality improvement, informatics, safety.
• from a recommendation from the IOM
• Keeping patients safe (2000) – nurses are the best at this due to the time spent with the patient.
• ongoing learning, colaboration, work design to promote safety, stress pt safety.

AHRQ: Agency for Healthcare Research and Quality

• Best Practices are widely accepted and implemented over 17 years after the data is revealed.

The Joint Commission – work to improve systems through accreditation

• tracks sentinel events nationally
• unexpected death,physical or psychological injury, or risk thereof.
• Required to report to the commission.

NQF – The National Quality Forum – Improve practices as well

• they do not work together due to Money \$

IHI Institute for healthcare Improvement – looks at world health

• implementation of these interventions
• RRT, AMI Care reliability, Med reconciliation, Surgical site infection bundle, ventilator bundle, Central venous line bundles.

5 million Lives campaign – avoid 5 million incidences of harm in 24 months.

NSO nursing centered outcomes

conclusion of to Err is Human study: not much has changed and though standardization and checklists it can still improve

Healthcare is a complex and adaptive system and therefore unpredictable

Swiss cheese model (cook 1997): all lines of defence have holes and mistakes can make it through.

• sharp end is at the bedside (nurses)
• blunt end is the Manufacturer end or beginning

HRO – High Reliability Organizations

• Preoccupation with failure
• Reluctance to simplify interpretation
• sensitivity to operations
• commitment to resilience
• deference to expertise

good nurses:

• Anticipate
• proactive monitoring
• strategic delegation
• Individualized paper memory aids
• Stacking or prioritizing

# Nursing interactions with Pharmacology

This is my overview of two early topics in nursing Pharmacology. It is my first real post and I will continue to change the duration of each post and the information density to get you guys the best content possible. If there are any issues or corrections let me know and i will change them. Also i am not a doctor or offering health care advice, these are just my nursing notes here to help you do better in nursing school.

– 5 rights plus many more extras that were added recently.

• Administration, drug, patient, dose, route, time.
• assessment, documentation,evaluation, education, and right to refuse medication or procedure

– Patient care

• Pre-administration – before any interventions are prescribed
• The nurse will go through their assessments finding the patient’s baseline. (basic and focused if needed) ie. Vitals, LOC,
• Know and identify risk factors for the drug and the patient: disease that creates poor metabolism, drug interactions, allergies.
• See if the patient will comply with the treatment and identify reasons that the patient may not beable to follow through with the prescription
• Dose –
• Know the indications and contraindications
• A single drug can have multiple therapeutic ranges depending on the desired effect.
• the dose will change with the route of administration
• Pay extremely close attention to the label!
• Expiration, concentration, and double check your dose calculations with route and concentration.
• Therapeutic response (TPR) – the desired degree of the signs and symptoms a drug is showing
• If there are no signs of the TPR then there is often an issue that needs to be addressed with the administration of the drug immediately
• Things that affect the TPR –
• Non drugs that increase TPR can be diet and exercise and can improve patient outcomes.
• know the s/s of a patient that is falling out of the TPR and what to do if they are experiencing toxicity.
• What to do, and when to do it.
• PRN – as needed,
• The nursing process quick:
• Assessments – basic and focused
• Analysis – what do you think the cause is, what is wrong, s/s,
• Planning – Write care plan with goals, priorities, and interventions recommended.
• Application of plan – Follow through with Care plan,
• reassess and monitor – what was the degree of success of the plan?
• what do we need to do next and how can we deal with issues in the CP that we found in the application?
• Monitor the TPR, interactions, minimize the toxicity and Adverse effects of the drug

Pharmacokinetics

• A drug’s movement through the body
• Membranes-
• Channel pores – these are very small and only allow very small molecules like Na and K to go through
• Transport systems – carry the molecule across a membrane. These can be active which require energy, or passive which do not. These are also very selective in the way that they only transport  specific drugs.
• P- Glycoprotein – this protein crosses the membrane and moves drugs out of the cell. it is also called a multidrug transporter protein, these exist in the liver excreting bile and in the kidneys excreting urine, they also are in the brain, placenta and intestines.
• Direct penetration of the membrane – this is common system of pharmacokinetics. many drugs use this system because they are too large to pass though the other systems or do not have a specific structure to facilitate the transport system. a drug that passes through a membrane this way must be lipid soluble ie. not polar or an ion.
• Polar molecules – uneven distribution of charge but no net charge
• ie. Water
• Ions – Have a net charge and most (except for the smallest) cannot pass through membranes.
• Quaternary Ammonium Compounds – net positive charge and at least one nitrogen.
• pH- dependent – Weak acids give up a proton in basic environments to become ionized and weak bases take a proton in acidic environments to become ionized.
• Ion trapping due to pH imbalances – if one side of a membrane is acidic it will tend to ionize the basic drugs and trap them. If the other side is basic it will tend to ionize and prohibit acidic drugs from crossing.
• Absorption an factors that regulate it.
•  How fast the drug dissolves
• faster is faster
• the amount of receptors or surface area that the drug can absorb through
• More is faster
• Higher blood flow equals more drug to the cite and more absorption
• Lipid soluble drugs absorb faster
• pH differences increase the absorption if the drug ionizes in the plasma
• Enteral route
• oral – (PO) it can be a slow route and must go through the GI tract and the capillaries. This leads to variability in the absorption rates and can be affected by many things: pH, GI absorption, nausea and vomiting , and pt needs to have patient airway.
• Parenteral
• IV – Instant and no barriers to absorption, very precise control of amount, and can push drugs that would irritate patient otherwise.  It is irreversible and a patient cannot do it by themselves.
• Intramuscular and subcutaneous – (IM) (subQ)must absorb through capillary wall, can use poorly soluble drugs, but it can possibly injure the patient.
• Distribution –
• Blood flow – decreases inside a solid tumor, and abscesses, which have no blood flow inside the structure.
• Exiting the blood flow (vasculature)
• – Capillary beds – most common and easy, the drug passes through the pores in the vessel wall.
• Blood brain barrier – less common and hard to get through due to the tight junctions. Only lipid soluble and drugs that can utilize a transport system can pass through.
• The Placenta – not a complete barrier to drug distribution and relatively weak, the same rules that allow drugs to cross a membrane apply to the placenta .
• Metabolism – the enzymatic change of the drug structure, usually happens in the liver.
• changes in metabolism can increase secretion, toxicity, Therapeutic action, decrease toxicity, activation and activation of pro drugs.
• Excretion – removal of drugs from the patient. happens in three steps in the kidneys
• glomerular filtration – the first step from moving the drug from the blood stream into
• passive tubular reabsorption – lipid soluble move out and ionized stay in the
• active tubular secretion – from the blood to the urine using active transport.
• non-renal
• Breast milk
• bile
• small amounts in the sweat and saliva.
• Time related to the drug response
• Plasma drug levels –
• minimum effective concentration, the amount of the drug that brings the effect into the therapeutic range.
• Therapeutic range, enough to get a response but not enough to be toxic.
• Toxic concentration, the highest level of the range were negative or toxic effects occur.
• Half life – the amount of time it takes for 1/2 of the drug to decrease by 50%
• repeated doses will allow for the TP effects to plateau and stay consistent with the drug accumulation.