August 10, 2011 Lecture

1. F L U I D S AND ELECTROLYTES

2. Water overview *Water comprises about 60% -70% of the total body weight *Varies with age weight gender

3. Factors that Determine the Amount of Water Content Age – the older we get, water content is lesser Sex/Gender – males have more water than females Body size/Weight– thin people have more water than chubby ones

7. Interstitial – between the cells Intravascular – inside the blood vessel Transcellular – CSF, saliva, GIT secretions and tears

8. LOSS of WATER Routes and daily body fluid excretion

9. SENSIBLE - An individual is aware of losing that water.

10. GIT / Feces Water loss through defecation/feces is 200cc

11. KIDNEYS / Urine Water loss through urination is 1,500ml

12. INSENSIBLE - An individual is unaware of losing that water.

13. SKIN / Perspiration Water loss through perspiration is 600ml

14. LUNGS / Respiration Water loss through respiration is about 300ml – 350ml

16. Diarrhea

17. Diaphoresis

18. Vomiting

19. Gastric suctioning

20. Tachypnea

21. Increased sodium intake

22. Increased sodium retention

23. Excessive intake of water

26. Functions of electrolytes -promotes neuromascular irritability -maintenance of body fluid osmolarity -regulation of water balance -distribution of body fluids between compartments -Conduct an electric current that transports energy thoughout the body

31. Physiologic pump that moves from an area of lower concentration to higher concentration with the use of ATP.

33. Types of IV Solutions ISOTONIC – balance osmotic pressure Solute concentration is equal to that of the serum Fluid doesn’t shift because they’re equally concentrated and already in balance Solution has the same osmolality as the extracellular fluid. Examples: D5W ; Normal Saline * Doesn’t cause shrinking or swelling of the cell

34. HYPERTONIC SOLUTION Greater pressure than that of the blood serum Fluids tend to move out of the less concentrated solution into the more concentrated Solutions have a higher concentration of solute and are more concentrated than extracellular fluids. Net movement intracellular to extracellular Examples : 3% saline; 5% saline * Causes the cell to shrink

35. HYPOTONIC SOLUTION Lesser pressure than that of the blood serum Fluid shifts from the hypotonic solution into the more concentrated compartment to equalize the concentrations Solutions have a lower concentration of solutes and is more dilute than extracellular fluid . Net movement extracellular to intracellular Examples : 1/2 Normal Saline; 1/3 Normal Saline * Causes the cell to swell

36. WATER BALANCE THIRST – hypothalamus Hormones a. ADH – posterior pituitary gland - reabsorption of water b. Aldosterone – adrenal gland - Na retention, H2O retention

37. ADH Hypothalamus senses low blood volume  pituitary gland secretes ADH into the bloodstream  ADH causes the kidney to retain water  water retention boosts blood volume

39. Aldosterone causes the kidneys to retain Na and water

41. Renin – angiotensinsystem Angiotensin 2 aldosterone peripheral vasoconstriction increase Na reabsorption increase water reabsorption Increase plasma volume increase blood pressure

42. VOLUME DISTURBANCES

43. FLUID VOLUME DEFICIT

44. Description: Dehydration in which the body’s intake is not sufficient to meet the body’s fluid needs. The goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of the fluid volume deficit.

45. CAUSES Diabetes insipidus Fever Diarrhea Renal failure Lack of fluid intake Malnutrition Vomiting Diaphoresis

46. Poor skin turgor Sunken fontanels Dry mouth Scanty urine No perspiration Sunken eyeballs Weight loss No tears Weak Lethargy Dizziness Extreme thirst Dry skin SIGNS AND SYMPTOMS

47. Encourage increase oral fluid intake Administer IVF (LR or NSS) Monitor I & O Replace fluid loss gradually over 48 hours Monitor Na levels, urine specific gravity MANAGEMENT

48. FLUID VOLUME EXCESS Increase water CAUSES Excess fluid or sodium intake a. IV administration of NSS or LR b. High intake of dietary Na Fluid and Na retention Fluid shift into the intravascular space a. Burn b. use of plasma CHON or albumin

49. Edema Increase in weigHt Puffy eyelids Poor skin turgor Tachypnea Dyspnea Signs and symptoms

50. MANAGEMENT Monitor I & O Limit water Skin care Turn patient every 2 hours O2 Limit Na Monitor electrolyte values

51. ELECTROLYTE IMBALANCES

52. SODIUM (Na+)  135-145 mEq/L -principal cation in ECF -average daily requirements 2-4 grms/day -responsible for: -serum osmolality -water retention -neuromuscular activity “Na pump action” -acid- base balance -foods high in Na -salted foods ex. ham, corned beef, cheese etc. -regulated by the kidneys -influenced by hormone aldosterone -Chloride frequently appears in combination with Na+ion.

53. Hyponatremia: serum sodium level falls below 135 mEq/L. Cells become swollen. Etiology: a. loss of Na b. gains of water c. Disease states associated with ADH (Vasopressin)

54. Clinical manifestations (Hyponatremia) <135mEq/L CNS changes Lethargy, headaches Confusion Seizures Coma nausea/vomiting Hemiparesis Diarrhea, abdominal cramps Pale dry skin

55. Nursing Intervention 1.Evaluate precipitating cause is corrected 2.monitor Na serum level 3.Evaluate clinical manifestations of Na loss 4.Maintain pts. safety 5.Administer prescribed treatment, IV therapy

56. Hypernatremia: Serum sodium is more than 150 mEq/L. Cells shrink. Etiology: Water deprivation Excessive salt ingestion Increased insensible loss Water loss diarrhea Prolong fever or diaphoresis w/o water replacement Na containing parenteral solutions, corticosteroids, some antibiotics Near salt water drowning Diabetes insipidus- polyuria, polydipsia

57. Clinical manifestations (hypernatremia) Serum Na+>145 mEq/L Thirst Nausea and vomiting Flushed, dry skin Fever Dry sticky membranes Rough, dry, swollen tongue CNS effects Restlessness, agitation Muscular twitching, tremor, hyper-reflexia Disorientation, hallucinations Stupor, coma

58. Nursing Interventions 1.Evalute precipitating cause and correct 2.Monitor serum Na level 3.Evaluate clinical manifestations of hypernatremia 4.Administer prescribed treatment 5.Report abnormal findings to MD 6.Patient education for future prevention

61. Skeletal and cardiac muscle activity

62. Intracellular osmolality

64. Hypokalemia:<3 mEq/L Etiology GI loss Diarrhea, GI suction, vomiting, laxatives Renal loss K loss diuretics, aldosterone, steroids Glucocorticoids, sweat, some antibiotic Shift into cells Insulin, alkalosis,TPN Poor intake Anorexia, alcoholism, debilitation, neglect

65. Clinical manifestations ( hypokalemia) Fatigue, weakness Cramps, restless legs Decreased reflexes Quadra-paralysis Respiratory muscle -Renal Impaired conc. Of urine Dilute frequent urination Resistance to ADH, kidney exchange Na for K -CV Sensitivity to digoxin Decreased BP

66. Cont. Clinical manifestation (hypokalemia) -ECG changes Flat T waves U wave Arrhythmias/cardiac arrest -GI Decreased motility, paralytic ileus Anorexia, nausea, vomiting

67. Nursing interventions Be aware of pt.at risk for K excess Assess pt.taking K+P.O. for GI upset Be aware that there are many forms of K+ supplements available. Check physicians order carefully Assess and educate pt.concerning nutrition for adequate K+ intake

68. Hyperkalemia: serum value of >6 mEq/L Etiology: Pseudo hyperkalemia Excess K+ intake Renal excretion Drugs Shift of K+ out of cells

69. Clinical manifestations (hyperkalemia) -ABD cramping, nausea, diarrhea -Lower extremities muscle weakness -Irritability -Paresthesias of face, tongue, feet and hands -Flaccid muscle paralysis -Bradycardia, irregular heart rate, cardiac standstill -ECG changes Tall, peaked T waves, prolonged PR Widened QSR

70. Hyperkalemia: serum value of >6 mEq/L

71. Nursing Interventions Monitor serum K+ report value >5.3 Caution hyperkalemiapts.to avoid foods high in K+ like: Chocolates, coffee, tea, dried fruits and beans, meat and eggs, bananas Monitor for U/O Administer fresh blood as ordered Regulate IV w/ K+ carefully Utilized good phlebotomy techniques

73. Contraction of muscle, relaxation, activation and excitation

74. Maintaining cardiac contraction

75. Cellular strength and permeability

76. Blood coagulation

77. Blocks sodium transport into the cell

79. Clinical manifestations (hypocalcemia) Irritability Decreased memory Delusions, hallucinations Hyperreflexia Parasthesias + Chvostek’s sign + Trousseau’s sign Laryngeal spasm, resp.arrest Tetany, seizures Abd’l. cramps ECG Prolonged QT interval

80. Nursing Interventions Monitor serum Ca, VS, ECG Give PO Ca supp.30 mins.before eating Be aware of safe administration of IV Ca Teach clients to eat food high in Ca, Vit.D, protein Take necessary precautions for confusion, seizure Assess for prolong bleeding

81. Clinical manifestation (Hypercalcemia) Headache, confusion Decreased memory Psychosis, stupor, coma Muscle weaknesses, fatigue Depressed reflexes Anorexia, N/V Bone pain, fractures Polyuria, dehydration Nephrolithiasis ( kidney stones) ECG Shortened QT interval

82. Nursing Interventions Monitor serum Ca, VS, ECG Mobilization and wt. bearing activity Diet low in Ca Dilute urine to prevent renal calculi formation Hydrate w/ isotonic solutions Promote excretion w/loop diuretic Watch for digitalis toxicity

83. DEHYDRATION

84. Dehydration: Definition defined as "the excessive loss of water and electrolytes from the body“ Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both.

85. Dehydration: Definition Infants and children are more susceptible to dehydration than adults because of their smaller body weights and higher turnover of water and electrolytes. So are the elderly and those with illnesses

86. Causes of Dehydration when losses are not replaced adequately, a deficit of water and electrolytes develop. vomiting or diarrhea acute illness where there is loss of appetite and vomiting Excessive urine output ex. diabetes or diuretic use Excessive sweating (sports) Burns

87. Since diarrhea and vomiting are the most common causes of dehydration in children, the volume of fluid loss may vary from 5 ml/kg (normal) to 200 ml/kg Concentration of electrolytes lost also varies NaCl and K are the most common electrolytes lost through stools

88. Dehydration:Checking the main symptoms History taking and do a thorough physical examination classify type of dehydration depending on the amount of water and electrolytes lost These are reflected by the signs and symptoms the child will present

89. Dehydration: Classification Dehydration is classified as no dehydration, some dehydration, or severe dehydration based on how much of the body's fluid is lost or not replenished. When severe, dehydration is a life-threatening emergency DEATH

90. Clinical signs of dehydration

92. Poor Skin Turgor

93. WHO Treatment Plan A Three rules of home treatment: give extra fluids continue feeding advise when to return to the doctor (if the child develops blood in the stool, drinks poorly, becomes sicker, or is not better in three days).

94. WHO Treatment Plan B ORS(ml) the mother slowly gives the recommended amount of ORS by spoonfuls or sips Note: If the child is breastfed, breast-feeding should continue. After 4 hours, reassess and reclassify dehydration, and begin feeding to provide required amounts of potassium and glucose. Wt kg x 75 for 4h

95. WHO Treatment Plan B If there are no more signs of dehydration, do Plan A. If there is still some dehydration, repeat Plan B. If the child now has severe dehydration, do Plan C.

96. WHO Treatment Plan C -Give IV infusion -If IV infusion is not possible, fluids should be given by nasogastric tube. -If none of these are possible and the child can drink, ORS must be given by mouth. Note: In areas where cholera cannot be excluded for patients less than 2 years old with severe dehydration, antibiotics are recommended. Start Cotrimoxazole.

97. WHO Treatment Plan C 100 ml/kg of PLR Normal saline does not correct acidosis or replace potassium losses, but can be used. Plain glucose or dextrose solutions are not acceptable for the treatment of severe dehydration.

98. REMEMBER: Do not give: Very sweet tea, soft drinks, and sweetened fruit drinks. (These are often hyperosmolar (high sugar content). Can cause osmotic diarrhea, worsening dehydration and hyponatremia. Also to be avoided are fluids with purgative action and stimulants (e.g., coffee, some medicinal teas or infusions).

99. Assessment of Dehydration Graded according to the signs and symptoms that reflect the amount of fluid lost. There are usually no signs or symptoms in the early stages As dehydration increases, signs and symptoms develop. Initially, thirst, restlessness, irritability, decreased skin turgor, sunken eyes and sunken fontanelles. As more losses occur, these effects become more pronounced.

100. Signs of hypovolemic shock (SEQUELAE) diminished sensorium (lethargy) Lack of urine output Cool moist extremities A rapid and feeble pulse Decreased BP Peripheral cyanosis DEATH.

101. Summary of Management According to Degree of Dehydration

102. Summary of Management According to Degree of Dehydration

103. Summary of Management According to Degree of Dehydration

104. INTRAVENOUS FLOW RATES

105. IV TUBING

108. 15 drops = 1 ml

110. Macrodrip set is used for routine adult IV administration, depending on the manufacturer and the type of tubing.

111. 10/15, 15/60, 20/60, commonly drop factor.

113. Total number of ml qtts/min= × drop factor Total number of hours 1000ml = × 20gtts/ml 8hours = 41-42gtts/min Doctor’s Order: Start D5LR 1L to infuse over 8 hours the drop factor is 20qtts/ml,compute for the drops/minute.

114. Ex. gtts/min. Doctor’s order: Start 500ml of NS to infuse over 300 minutes. The drop factor is 10 gtts/ml. compute for the gtts/min.? Gtts/min = total no. of ml X drop factor total no. of hour = 500ml X 10gtts/ml 300mins. = 16.66 gtts/min

115. Ex. gtts/min. Doctor’s order: Start 500ml of NS to infuse over 300 minutes. The drop factor is 10 gtts/ml. compute for the gtts/min.? Gtts/min = total no. of ml X drop factor total no. of hour = 500ml X 10gtts/ml 5 hours 60 = 16.66 gtts/min

116. FORMULA ml per hour = Total no. of ml Total no of hours

117. total number of ml Cc /hr= total number of hours 1000ml = 80ml/hour = 12.5hour Doctor’s Order: 1000ml of D5NM to infuse at a rate of 80cc/hour. A nurse determine that it will take, how many hours for 1L to infuse? total number of ml Cc/hour =c

119. Ex. Gtts/min D5NM 1L has been ordered by Dr. Dy for his post-mastectomy patient to be infused at rate of 20gtts/minute. In how many hours will the said IVF last? Gtts/min = _____total no. of ml_____ X drop factor total no. of hour = __1,000ml__ X 15 20 gtts/min 60 = 15,000 1,200 = 12.5 hours

120. Other factors affecting Flow Rate: Gauge of the catheter Viscosity of the infusate Height of the IV stand Condition of the veins Condition of the patient

121. COMPLICATIONS Circulatory Overloadcan occur if an IV is not regulated and IV fluids infuse to rapidly for the patient’s body to handle. Signs of fluid over load: Tachycardia Increase Blood pressure Headache Anxiety Wheezing or signs of respiratory distress Diaphoresis Restlessness Distended neck veins Chest pain

122. - If an IV is running behind schedule-colaborate with the physician to determine the patients ability to tolerate an increased flow rate particularly patients with cardiac, pulmonary and renal problem. A nurse should never arbitrarily speed up an IV to catch up if the IV is running behind the schedule. Whenever an IV rate is increased the nurse should assess the patient for increased heart rate, increase respiration or lung congestion-indication of fluid overload.

123. AFTERCARE Regulating IV fluids is an ongoing process from the time that an IV is started until it is completed. Hourly checks of an IV should include assessing the pt’s response to the IV, the rate of an IV flow, how much fluid has infused, how much fluid remains to be infused, and the condition of the IV insertion site. Adjust the rate if the IV is not flowing at the rate that was ordered.

124. If IV fluid is flowing in slowly, the nurse should check for a kink in the tubing or a position of problem. If an IV is flowing to rapidly, it may be leaking out around the IV insertion site. The whole system from the insertion site to the IV bag should be examined.

125. Thank you very much for listening

126. MAINTENANCE REQUIREMENTS HOLIDAY-SEGAR METHOD BODY SURFACE AREA METHOD

127. HOLIDAY-SEGAR METHOD Estimates caloric expenditure in fixed weight categories Assumption 100 cal metabolized : 100 mL water Not suitable for neonates < 14 days Overestimates fluid needs

128. HOLIDAY-SEGAR METHOD

129. EXAMPLE What is the maintenance fluid rate for a an 8 year old child weighing 25 kg using the Holiday-Segar Method?

130. 100 x 10 = 1000 ml + 50 x 10 = 500 ml + 20 x 5 = 100 ml 1600 ml/day

131. 4 x 10 = 40 ml + 2 x 10 = 20 ml + 1 x 5 = 5 ml 65 ml/hr

132. EXERCISE Using the Holiday-Segar Method, what is the full maintenance requirement and rate for a 10 year old patient who weighs 37 kg?

133. BODY SURFACE AREA METHOD Assumption: caloric expenditure is related to BSA Not used in children < 10 kg

134. BSA METHOD STANDARD VALUES FOR USE IN BODY SURFACE AREA METHOD

136. BSA Formula Surface area (m2) = ht (cm) x wt (kg) 3600

137. EXAMPLE Using the BSA method, what is the maintenance requirement of an 8 year old who weighs 25 kg and is 132 cm tall?

138. BSA Formula 0.92 m2 = 132 cm x 25 kg 3600

139. Water = 1500ml/0.92/day = 1630 ml Na+ = 40 mEq/0.92/day = 43.5 mEq K+ = 30 mEq/0.92/day = 32.6 mEq

140. EXERCISE Using the BSA Method, what is the maintenance requirement of a 12 year old boy who weighs 37 kg and is 142 cm tall?

141. DEFICIT THERAPY Calculated Assessment Clinical Assessment

142. CALCULATED ASSESSMENT Fluid deficit (L) = preillness weight (kg) – illness weight (kg) % Dehydration = (preillness weight – illness weight)/preillness weight x 100%

143. CLINICAL ASSESSMENT

144. FLUID REPLACEMENT

145. ICF & ECF COMPARTMENTS

146. ICF & ECF COMPARTMENTS In dehydration, there are variable losses from the extracellular and intracellular compartments Percentage of deficit is based on total duration of illness

148. BASIC MATH CONCEPTS

149. DECIMALS All figures to the left of the decimal point are whole numbers All figures to the right of the decimal point are decimal fractions . 385 = . 3 8 5 tenths .385 = 385 1000 hundredths thousandths .38 = 38 100 .3 = 3 10

150. CHANGING FRACTIONS TO DECIMALS: Fractions can be changed to decimals by dividing the numerator and the denominator ¾ = 3 ÷ 4 = 0.75

151. PERCENTAGE Percentage ( % ) means hundredths Percent ( % ) is the same as a fraction with denomination as 100. 3% = 3 100 45 100 45% =

152. CHANGING PERCENT TO A DECIMAL & CHANGING DECIMAL TO PERCENT To change percent to a decimal, remove the percent sign and divide the number by 100 or move the decimal point two places to the left. 4% = 4/100 = .04 or 0.04 To change a decimal to a percent, multiply by 100 or move the decimal point two places to the right and place % sign. 0.04 X 100 = 4% or 0.04 = 4%

153. RATIOA Ratio consists of two numbers as separated by a colon ( : ) e.g. 1 : 4 A ratio indicates that there is a relationship between the two numbers. A ratio is an indicated fraction. e.g. ¼ = 1 : 4 The numbers in ratio must be expressed in the same terms. e.g. 3 inches : 2 feet = 3 : 24 (feet changes to inches)

154. PROPORTION It is a statement showing that the two ratios have equivalent values 1 : 50 = 2 : 100 If one value is not known, it can be solved by using the term X. 1 : X = 2 : 100 or means extremes 1 2 X 100 ~

155. THE METRIC SYSTEM It is the international decimal system of weights and measures ¤ In the metric system, fractions are expressed as decimals ¤ In the decimal system, the fraction ½ is written as 0.5 METRIC SYSTEM Liter = vol. of fluids milli = one thousandths Gram = weights of solids centi = one hundredths Meter = measure of length deci = one tenth mcg = one thousandths

156. RULE OF CONVERSION When converting from a larger unit of measure to a smaller unit, multiply the larger unit by (1000, 100, 10) or move the decimal to the right. When converting a smaller unit of measure to a larger unit, divide the smaller unit by (1000, 100, 10) or move the decimal to the left. e.g. 2.5 grams = ___________ mg.

157. APOTHECARIES SYSTEM Grain (gr) Dram Ounce Minims Pounds Approximate Equivalent Value: 1 gr = 60 mg 1 ml = 15 minims (16 minims) 1 ounce = 30 ml 1 ounce = 30 Gm 1 kg = 2.2 pounds e.g. 60 gr = _________ mg. 4 oz = _________ ml.

158. HOUSEHOLD MEASURES 1 teaspoon (tsp) = 4 – 5 ml 1 Tablespoon (Tbsp) = 3 teaspoons (tsp) 1 Tablespoon = 15 ml 1 milliliter = 15 drops (gtts) e.g. 5 ml = ______

159. CONVERSION OF TEMPERATURE Normal Temperature = 37°C = 98°F Conversion of Centigrade (Celsius) to Fahrenheit: Conversion of Fahrenheit to Centigrade (Celsius): °C = 5 ( °F ) – 32 9 °F = 9 ( °C ) + 32 5

160. Interpretation of Doctor’s Order for Drugs The nurse must understand the order perfectly before acting on it > The Drug > The Dose > The Route > The Frequency If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.

161. Example: The order reads : Inderal 2 x4 a. What is the Drug? b. What is the Dose? c. What is the Route? d. What is the Frequency? e. Do es this order need clarification? The order reads : Lasix 10 mg IV 1 ml O.D. a. What is the Drug? b. What is the Dose? c. What is the Route? d. What is the Frequency? e. Does this order need clarification?

162. BASIC MATH CONCEPTS

163. DECIMALS All figures to the left of the decimal point are whole numbers All figures to the right of the decimal point are decimal fractions . 385 = . 3 8 5 .385 = 385 1000 tenths .38 = 38 100 thousandths hundredths .3 = 3 10

164. CHANGING FRACTIONS TO DECIMALS: Fractions can be changed to decimals by dividing the numerator and the denominator ¾ = 3 ÷ 4 = 0.75

165. PERCENTAGE Percentage ( % ) means hundredths Percent ( % ) is the same as a fraction with denomination as 100. 3% = 3 100 45 100 45% =

166. CHANGING PERCENT TO A DECIMAL & CHANGING DECIMAL TO PERCENT To change percent to a decimal, remove the percent sign and divide the number by 100 or move the decimal point two places to the left. 4% = 4/100 = .04 or 0.04 To change a decimal to a percent, multiply by 100 or move the decimal point two places to the right and place % sign. 0.04 X 100 = 4% or 0.04 = 4%

167. RATIOA Ratio consists of two numbers as separated by a colon ( : ) e.g. 1 : 4 A ratio indicates that there is a relationship between the two numbers. A ratio is an indicated fraction. e.g. ¼ = 1 : 4 The numbers in ratio must be expressed in the same terms. e.g. 3 inches : 2 feet = 3 : 24 (feet changes to inches)

168. PROPORTION It is a statement showing that the two ratios have equivalent values 1 : 50 = 2 : 100 If one value is not known, it can be solved by using the term X. 1 : X = 2 : 100 or means extremes 1 2 X 100 ~

169. THE METRIC SYSTEM It is the international decimal system of weights and measures ¤ In the metric system, fractions are expressed as decimals ¤ In the decimal system, the fraction ½ is written as 0.5 METRIC SYSTEM Liter = vol. of fluids milli = one thousandths Gram = weights of solids centi = one hundredths Meter = measure of length deci = one tenth mcg = one thousandths

170. RULE OF CONVERSION When converting from a larger unit of measure to a smaller unit, multiply the larger unit by (1000, 100, 10) or move the decimal to the right. When converting a smaller unit of measure to a larger unit, divide the smaller unit by (1000, 100, 10) or move the decimal to the left. e.g. 2.5 grams = ___________ mg.

171. APOTHECARIES SYSTEM Grain (gr) Dram Ounce Minims Pounds Approximate Equivalent Value: 1 gr = 60 mg 1 ml = 15 minims (16 minims) 1 ounce = 30 ml 1 ounce = 30 Gm 1 kg = 2.2 pounds e.g. 60 gr = _________ mg. 4 oz = _________ ml.

172. HOUSEHOLD MEASURES 1 teaspoon (tsp) = 4 – 5 ml 1 Tablespoon (Tbsp) = 3 teaspoons (tsp) 1 Tablespoon = 15 ml 1 milliliter = 15 drops (gtts) e.g. 5 ml = ______

173. CONVERSION OF TEMPERATURE Normal Temperature = 37°C = 98°F Conversion of Centigrade (Celsius) to Fahrenheit: Conversion of Fahrenheit to Centigrade (Celsius): °C = 5 ( °F ) – 32 9 °F = 9 ( °C ) + 32 5

174. Interpretation of Doctor’s Order for Drugs The nurse must understand the order perfectly before acting on it > The Drug > The Dose > The Route > The Frequency If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.

175. Example: The order reads : Inderal 2 x4 a. What is the Drug? b. What is the Dose? c. What is the Route? d. What is the Frequency? e. Does this order need clarification? The order reads : Lasix 10 mg IV 1 ml O.D. a. What is the Drug? b. What is the Dose? c. What is the Route? d. What is the Frequency? e. Does this order need clarification?

176. GENERAL FORMULA FOR DRUG CALCULATION 1. D x Q S 2. Calculation by Ratio : Proportion 8 mg : x = 16 mg : 1 tab (works for any computation of Dosage if you have a given and a need to determine the unknown). Rule : 1. Units for each ratio must be the same. 2. Units for each ratio must be placed in the same order.

177. Computation of Dosages: When the dose prescribed is in milligram (mg) and the dose available is in Gram (Gm) or vice versa. E.g. The order reads : 0.008 Gm of Morphine Sulfate IV q 4 hours prn for pain. Ampule available is labeled 10 mg/ml. 1. What do you know? 0.008 Gm - 8 mg 10 mg/ml - 2. What do you need to know? Known amount in cc for 0.008 Gm dose 3. Setting up the proportion: a. the units for each ratio must be placed in the same order b. the units for each ratio must be the same ( mg to mg ) 8mg : X = 10 mg : ml

178. 4. solve for the correct dosage 8 mg : X = 10 mg : ml 10 mg X = 8 mg/ml X = 8 mg/ml 10 mg X = .8 ml

179. When the dose is ordered in one system and the dose on hand is in another system. E.g. The order reads : codeine sulfate ¼ gr P.O. q 8 hrs PRN for pain. Tablets on hand are labeled 0.015 Gm tablets. 1. What do you know? Known ¼ gr 1 gr = 60 mg 0.015 Gm / tab 1 Gm = 1000 mg ¼ = .25 2. What do you need to know? # of tablets for ¼ gr dose

180. 3. Setting up the proportion a. the units for each ratio must be the same b. the units for each ratio must be placed in the same order. .25 gm : X = 0.015 gm : 1 tab 15 mg : x = 15 mg : 1 tab 4. Solve for the correct dosage: 15 mg : x = 15 mg : 1 tab 15 mg x = 15 mg / tab x = 15 mg / tab 15 mg x = 1 tab

181. Computation of Correct Insulin Dosage U - 40 means U - 80 means U - 100 means Insulin syringes are calibrated according to the strength of insulin with which it is to be used. U 40 insulin needs a U 40 syringe U 80 insulin needs a U 80 syringe

184. Children’s Doses Clarks’ Rule: weight of child in pounds X A.D. = child’s dose 150 Body Surface Area e.g. Wt = 10 kg BSA X A.D. = child’s dose 1.7 BSA = 4(wt in kg) + 7 = BSA in m² wt in kg + 90 = 4(10 kg) + 7 = 47 10+ 90 = .47 m² Child’s dose = .47 m² X 500 1.7

185. Youngs’ Formula: Age of child in Years X A.D. = Child’s dose Age of child + 12

186. CALCULATION OF FLUID VOLUME(BASED ON BODY WEIGHT) 1. WEIGHT --- 1 – 10 kg. --- 100ml/kg. Eg. Wt = 8 kg. --- 800cc 2. WEIGHT --- 11 – 20 kg.--- 1,000+50ml/excess b.wt. Eg. Wt = 15 kg. 1,000=250ml = 1,250ml 15 50 -10 X 5 5 250 3. WEIGHT > 20 kg. Eg. Wt = 27 kg. 1,500 + 20 ml/excess b.wt. 1,500 + 140 ml = 1640 ml. 27 20 -20 X 7 7 140

187. Calculation of IV Flow Rates Calculation of cc/hr is essential in most IV therapy. Volume # of hrs E.g. 1 L over 8 hrs = 125 cc/hr 50 cc over 20 minutes = 150 cc/hr = cc/hr

188. Calculation of gtt/min (Long Method) STEPS : 1. Need to know cc/hr to calculate 2. Gtt factor = gtt / ml gtt factors : macrodrip 10, 15, 20 gtts/ml microdrip 60 gtt/ml EXAMPLE : LONG METHOD Doctors Order : Run 1L D5W over 8 hours Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr 125 cc x 60 gtt/ml = 125 gtt/ml 60 min 1 10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min 60 min 1 15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min 60 min 1 20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min 60 min 1

189. SHORT METHOD cc / hr ÷ 6 for 10 gtt / min cc / hr ÷ 4 for 15 gtt / min cc / hr ÷ 3 for 20 gtt / min cc / hr = gtt / min for microdrip set

190. Sources Fluids & Electrolytes, Lippincott Williams & Wilkins Fluids & Electrolytes, Walters Kluwer Nelson’s Texbook of Pediatrics WHO department of child and adolescent development (Medline Plus) http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000982.htm