F L U I D S AND ELECTROLYTES

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

Normal Composition in Average Man

When a person loses more than 10% of his total body fluids,he can DIE!!!

Functions of Water in the Body

-Transporting nutrients to cells and wastes from cells -Transporting hormones, enzymes, blood platelets, and red and white blood cells -Facilitating cellular metabolism and proper cellular chemical functioning -Facilitating digestion and promoting elimination -Acting as a solvent for electrolytes and non-electrolytes -Acting as a tissue lubricant and cushion -Helping maintain normal body temperature

Two Compartments of Fluid in the Body

Intracellular fluid (ICF) (70%)

fluid within cells - large amounts of K+, PO4--, Mg++

Extracellular fluid (ECF) (30%)

fluid outside cells - large amounts of Na+, Ca+, Cl-, HCO3-- Includes intravascular(15%) and interstitial fluids(5%)

Water Loss
ROUTES OF WATER LOSS -SENSIBLE Urine Feces -INSENSIBLE Lungs Sweat

Causes of Increased Water Loss

Fever Diarrhea Diaphoresis Vomiting Gastric suctioning Tachypnea

Causes of Increased Water Gain

Increased sodium intake Increased sodium retention Excessive intake of water Excess secretion of ADH

Electrolytes
Ions
Cations positive charge Anions negative charge

-An electrolyte is a substance, that when dissolved in water, gives a solution that can conduct electricity (Electrochemistry Dictionary) -Simple inorganic salts -Electrolytes dissociate when dissolved in water to form positively and negatively charged ions (Dissociation and electrolytes) -All inorganic acids, bases, salts, are electrolytes -Also known as Ionic solutes

Importance of electrolytes
-Maintain voltages across cell membranes -Carry electrical impulses to other cells -Found in blood or the human body in the form of acids, bases or salts (Sodium, calcium, potasium, chlorine, magnesium, bicarbonate) -Conduct an electric current that transports energy thoughout the body

Normal Composition in Average Man

Plasma/ Intravascular Cations (mmol per litre) Sodium Potassium Calcium Magnesium Anions (mmol per litre) Chloride Bicarbonate Phosphate Sulphate Protein Organic Anions 102 27 1 0.5 2 3 114 30 1 0.5 0.1 6 5 10 50 10 8 2 140 4 2.5 1 144 4 2 1 10 155 1 15 Interstitial Fluid Intracellular fluid

Effects of Electrolytes
The loss of electrolytes in the body can lead to an unbalance of fluids in the body and the pH, and a damage of the electric potential between the nerve cells that transmit the nerve signals (Encarta)

Major Electrolytes/Chief Function

Sodium controls and regulates volume of body fluids Potassium chief regulator of cellular enzyme activity and water content Calcium nerve impulse, blood clotting, muscle contraction, B12 absorption Magnesium metabolism of carbohydrates and proteins, vital actions involving enzymes Chloride maintains osmotic pressure in blood, produces hydrochloric acid Bicarbonate bodys primary buffer system Phosphate involved in important chemical reactions in body, cell division and hereditary traits

Regulation of Body Fluid Compartments

Osmosis
is the movement of water from an area of lower solute concentration to an area of higher solute concentration. Semi-permeable membrane membrane must be more permeable to water a greater concentration of solutes on one side of the membrane

Facilitated Diffusion
Requires a carrier molecule. Lipid insoluble substances cannot cross the plasma membrane (glucose). ATP is not expended. Movement of the particles is from an area of higher concentration to an area of lower concentration.

Active Transport

movement of a substance across the cell membrane from an area of lower concentration to an area of higher concentration. ATP is expended. The sodium-potassium pump is an example of active transport.

Regulation of Body Fluid Compartments

Regulation of Body Fluid Compartments

Tonicity is the ability of solutes to cause osmotic driving forces

Filtration is the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure Osmolality reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow of water by osmosis

Fluid Volume Deficit

Involves either volume or distribution of water or electrolytes Hypovolemia deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions Dehydration decreased volume of water and electrolyte change Third-space fluid shift distributional shift of body fluids into potential body spaces

Fluid Volume Excess

Hypervolemia excessive retention of water and sodium in ECF Overhydration above normal amounts of water in extracellular spaces Edema excessive ECF accumulates in tissue spaces Interstitial-to-plasma shift movement of fluid from space surrounding cells to blood

Types of IV Solutions
ISOTONIC -solution has the same osmolality as the extracellular fluid. Examples: D5W ; Normal Saline Hypertonic solutions have a higher concentration of solute and are more concentrated than extracellular fluids. Net movement intracellular to extracellular Examples : 3% saline; 5% saline Hypotonic 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

Electrolyte Imbalances
SODIUM (Na+) 135-145 mEq/L Functions
Maintains osmolality Participates in active transport Helps regulate body fluids Participates in the action potential Hyponatremia:serum sodium level falls below 130 mEq/L.Cells become swollen. Neurological Disturbances :cerebral edema,headache, lethargy,depression, confusion,convulsions,coma Cardiovascular Disturbances: postural hypotension,shock Hypernatremia: Serum sodium is more than 150 mEq/L.Cells shrink. Complications:Osmotic Diuresis,cellular dehydration, circulation decreases

Electrolyte Imbalances POTASSIUM (K+): 3.5-5.0 mEq/L

Functions Transmission of nerve impulses Resting membrane potential Acid-base balance Promotes myocardial, skeletal, and smooth muscle contractility Hypokalemia: <3 mEq/L Cardiovascular: dysrhythmias, hypotension, digitalis toxicity, myocardial
damage, cardiac arrest Neurological: lethargy, confusion, depression Gastrointestinal : paralytic ileus Skeletal Muscle: weakness, flaccid paralysis, weakness of respiratory muscles, respiratory arrest Renal System: decreased ability to concentrate urine, water loss, kidney damage Acid-Base Balance: metabolic alkalosis

Hyperkalemia: serum value of >6 mEq/L

Nervous System : Paraesthesia Neuromuscular: Muscle twitching, muscle weakness, paralysis Cardiovascular : Bradycardia, Cardiac arrest

Electrolyte Imbalances
CALCIUM :8.5-10.5 mg/dl or 4.5-5.8 mEq/L
Functions
Formation of bone and teeth Contraction of muscle Blood coagulation Blocks sodium transport into the cell Transmission of nervous impulses

Hypocalcemia
<0.9 mmo/L ionized Calcium

Hypercalcemia
>12 mg/dL total Calcium or >1.5 mmol/L ionized Calcium

-Nervous System Paraesthesia -Muscular System Tetany, Laryngeal spasms -Cardiovascular System congestive heart failure decreased cardiac output cardiac dysrhythmias

-Neurological Manifestation lethargy, confusion, coma -Skeletal Manifestations deep bone pain; fractures -Renal Manifestations:stones
-Gastrointestinal Manifestations Constipation;anorexia Nausea and Vomiting -Cardiovascular Manifestations Shortened QT interval, Bradycardia Cardiac arrest
end

 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.

 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

 dehydration occurs when losses are not replaced adequately and a deficit of water and electrolytes develop. These may occur in Vomiting or diarrhea Presence of an acute illness where there is loss of appetite and vomiting:
Pneumonia DHF Other Acute Ilnesses

Excessive urine output, such as with uncontrolled diabetes or diuretic use Excessive sweating (sports) Burns

 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

 In order to diagnose the type of dehydration, you need to know the History and you must do a thorough physical examination We 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

 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

Assesment 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.

Signs of hypovolemic shock (SEQUELAE) 1. 2. 3. 4. 5. 6. 7. diminished sensorium (lethargy) Lack of urine output Cool moist extremities A rapid and feeble pulse Decreased BP Peripheral cyanosis DEATH.

Look at :condition* Eyes Tears Mouth and tongue Thirst

Well , alert Normal Present Moist Drinks normally,not Thirsty Goes back quickly

*restless,irritable sunken absent dry *thirsty,drinks eagerly

*Lethargic or unconscious;floppy very sunken & dry absent very dry *drinks poorly or not able to drink *

Feel skin pinch

*goes back slowly*

*Goes back very slowly

Decide

The patient has no sign of dehydration

If the patient has 2 or more signs, including at least 1 *signs*, there is Some Dehydration

If the patient has 2 or more signs, including at least 1 *sign* , there is Severe Dehydration

Degree of Dehydration None

Amount of Fluid Vol per vol replacement or after each diarrheic stool: 50-100 ml (1/41/2 cup) if < 2yrs; 100-200 ml (1/2 -1 cup) if 2-10 yrs; ad libitum for older children

Type of Fluid Suitable home fluids (not salty or highly sweetened), ORS, rice water, vegetable or chicken soup

Feeding Usual diet or formula, continue breastfeeding

Degree of Dehydration Mild

Signs Slightly dry mucus memb., increased thirst, slightly reduced urine flow

Fluids ORS, 30-50 ml/kg in 4-6 hrs

Feeding Breastfeeding, full-strength cow milk or lactosecontg. formula, undil. lactosefree formula Same as above

Moderate

Sunken eyes, sunken fontanelle, loss of skin turgor, dry mucus memb.

ORS, 60-90 ml/kg in 4-6 hrs

Degree of Dehydration Severe

Signs Signs of mod. dehydration plus one or more of ff: rapid, thready pulse,cyanosis, rapid breathing, delayed capillary refill time, lethargy, coma

Fluids IV or intraosseus fluids (Ringers lactate or NSS),30/ml/kg in 1/2 hr (1 hr for infants) then 70 ml/kg in 21/2 hrs (5 hrs for infants)

Feeding Begin after clinically improved and ORS has begun

Look at :condition* Eyes Tears Mouth and tongue Thirst

Well , alert Normal Present Moist Drinks normally,not Thirsty Goes back quickly The patient has no sign of dehydration

*restless,irritable sunken absent dry *thirsty,drinks eagerly *goes back slowly* If the patient has 2 or more signs, including at least 1 *signs*, there is Some Dehydration

*Lethargic or unconscious;floppy

very sunken & dry absent very dry *drinks poorly or not able to drink *
*Goes back very slowly If the patient has 2 or more signs, including at least 1 *sign* , there is Severe Dehydration Weigh the patient and use treatment Plan C URGENTLY

Feel skin pinch

Decide

Treat

Use treatment Plan A

Weigh the patient , if possible and use treatment Plan B

Three rules of home treatment: 1. give extra fluids 2. continue feeding 3. 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).

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).

Look at :condition* Eyes Tears Mouth and tongue Thirst Feel skin pinch

Well , alert
Normal Present Moist Drinks normally,not Thirsty Goes back quickly

*restless,irritable
sunken absent dry *thirsty,drinks eagerly *goes back slowly* If the patient has 2 or more signs, including at least 1 *signs*, there is Some Dehydration Weigh the patient , if possible and use treatment Plan B

*Lethargic or unconscious;floppy very sunken & dry absent very dry *drinks poorly or not able to drink * *Goes back very slowly

Decide

The patient has no sign of dehydration

If the patient has 2 or more signs, including at least 1 *sign* , there is Severe Dehydration

Treat

Use treatment Plan A

Weigh the patient and use treatment Plan C URGENTLY

 ORS(ml)

the mother slowly gives the recommended amount of ORS by spoonfuls or sips Note: If the child is breast-fed, breast-feeding should continue. After 4 hours, reassess and reclassify dehydration, and begin feeding to provide required amounts of potassium and glucose.

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.

Look at :condition* Eyes Tears Mouth and tongue Thirst

Well , alert Normal Present Moist Drinks normally,not Thirsty Goes back quickly

*restless,irritable sunken absent dry *thirsty,drinks eagerly *goes back slowly*

*Lethargic or unconscious;floppy very sunken & dry absent very dry *drinks poorly or not able to drink * *Goes back very slowly

Feel skin pinch

Decide

The patient has no sign of dehydration

If the patient has 2 or more signs, including at least 1 *signs*, there is Some Dehydration
Weigh the patient , if possible and use treatment Plan B

If the patient has 2 or more signs, including at least 1 *sign* , there is Severe Dehydration

Treat

Use treatment Plan A

Weigh the patient and use treatment Plan C URGENTLY

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.

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.

MAINTENANCE REQUIREMENTS
HOLIDAY-SEGAR METHOD BODY SURFACE AREA METHOD

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

HOLIDAY-SEGAR METHOD
BODY WEIGHT ml/kg/day ml/kg/hr Electrolytes (mEq/100ml fluid)

First 10 kg Second 10 kg Each additional kg

100 50 20

4 2 1

Na+ 3 Cl- 2 K+ 2

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

+ +

100 x 10 = 50 x 10 = 20 x 5 =

1000 ml 500 ml 100 ml 1600 ml/day

+ +

4 x 10 2 x 10 1x 5

= = =

40 ml 20 ml 5 ml 65 ml/hr

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

BODY SURFACE AREA METHOD

Assumption: caloric expenditure is related to BSA Not used in children < 10 kg

BSA METHOD
STANDARD VALUES FOR USE IN BODY SURFACE AREA METHOD

Component Water Na+ K+

Values 1500 ml/m2/24 hrs 30-50 mEq/m2/24 hrs 20-40 mEq/m2/24 hrs

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

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

BSA Formula
0.92 m2 = 132 cm x 25 kg 3600

Water Na+ K+

= 1500ml/0.92/day= 1630 ml = 40 mEq/0.92/day = 43.5 mEq = 30 mEq/0.92/day = 32.6 mEq

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?

DEFICIT THERAPY
Calculated Assessment Clinical Assessment

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

CLINICAL ASSESSMENT
DEHYDRATION Skin turgor Skin touch Buccal mucosa Eyes MILD Normal Normal Moist Normal MODERATE Tenting Dry Dry Deep set SEVERE None Clammy Parched/cracked Sunken

Tears
Fontanelles CNS Pulse rate Pulse quality

Present
Flat Consolable Normal Normal

Reduced
Soft Irritable Sl increased Weak

None
Sunken Lethargic/obtunde d Increased Peeble

Capillary refill
Urine output

Normal
Normal

~ 2 secs
Decreased

>3 secs
anuric

FLUID REPLACEMENT
Mild Moderate (in 8 hours) (1/4 in 2 hrs then in the next 6 hours) Severe (1/3 in 2 hrs then 2/3 in the next 6 hours)

Infant/< 15 kg Older child/ > 15 kg

50ml/kg 30 ml/kg

100 ml/kg 60 ml/kg

150 ml/kg 90 ml/kg

ICF & ECF COMPARTMENTS

Composition Intracellular (mEq/L) 20 150 Extracellular (mEq/L) 133-145 3-5 98-110

Na K Cl

HCO3
PO4 CHON

10
110-115 75

20-25
5 10

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

BASIC MATH CONCEPTS

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
hundredths tenths

thousandths

.385 =

385 1000

.38 = 38
100 .3 = 3 10

CHANGING FRACTIONS TO DECIMALS:

Fractions can be changed to decimals by dividing the numerator and the denominator

= 3 4 = 0.75

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

100
45

45%

100

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%

A Ratio consists of two numbers as separated by a colon ( : )

RATIO

e.g. 1:4 A ratio indicates that there is a relationship between the two numbers. A ratio is an indicated fraction. e.g.

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)

PROPORTION
It is a statement showing that the two ratios have equivalent values 1 : 50 = 2 : 100
means

If one value is not known, it can be solved by using the term X.

1 : X = 2 : 100 or
1 ~ 2

extremes

100

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 is written as 0.5
METRIC SYSTEM
Liter = vol. of fluids Gram = weights of solids Meter = measure of length milli = one thousandths centi = one hundredths deci = one tenth mcg = one thousandths

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.

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.

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 = ______

CONVERSION OF TEMPERATURE
Normal Temperature = 37C = 98F Conversion of Centigrade (Celsius) to Fahrenheit:

C = 5 ( F ) 32 Conversion of 9 Fahrenheit to Centigrade (Celsius):

F = 9 32

( C ) +

Interpretation of Doctors 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.

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?

BASIC MATH CONCEPTS

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 =

385 1000

hundredths

thousandths

tenths

.38 = 38
100 .3 = 3 10

. 385

.3 8 5

CHANGING FRACTIONS TO DECIMALS:

Fractions can be changed to decimals by dividing the numerator and the denominator

= 3 4 = 0.75

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

100
45

45%

100

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%

A Ratio consists of two numbers as separated by a colon ( : )

RATIO

e.g. 1:4 A ratio indicates that there is a relationship between the two numbers. A ratio is an indicated fraction. e.g.

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)

PROPORTION
It is a statement showing that the two ratios have equivalent values 1 : 50 = 2 : 100
means

If one value is not known, it can be solved by using the term X.

1 : X = 2 : 100 or
1 ~ 2

extremes

100

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 is written as 0.5
METRIC SYSTEM
Liter = vol. of fluids Gram = weights of solids Meter = measure of length milli = one thousandths centi = one hundredths deci = one tenth mcg = one thousandths

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. mg. 2.5 grams = ___________

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.

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 = ______

CONVERSION OF TEMPERATURE
Normal Temperature = 37C = 98F Conversion of Centigrade (Celsius) to Fahrenheit:

C = 5 ( F ) 32 Conversion of 9 Fahrenheit to Centigrade (Celsius):

F = 9 32

( C ) +

Interpretation of Doctors 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.

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?

GENERAL FORMULA FOR DRUG CALCULATION

1. D
xQ

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.

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

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

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

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 = 15 mg : x = 0.015 gm : 1 tab 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

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

If this can not be done, the dose can be converted to milliliters

Dose Required Dose on Hand

X 1 ml = ml needed

Serious error can occur if incorrect syringe or incorrect b calculations are used It is essential that all insulin be checked by a second RN to confirm that errors in dosage are not made and error in the type of insulin were not made.

Fractional Dosages in Infants and Children

Childrens Doses
Clarks Rule: weight of child in pounds X A.D. = childs dose 150 Body Surface Area e.g. Wt = 10 kg BSA X A.D. = childs dose 1.7 BSA = 4(wt in kg) + 7 = BSA in m wt in kg + 90 = 4(10 kg) + 7 = 10+ 90 47

= .47 m
Childs dose = .47 m X 500 1.7

 Youngs Formula:
Age of child in Years X A.D. = Childs dose Age of child + 12

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 Eg. Wt = 27 kg. b.wt. > 20 kg. 1,500 + 20 ml/excess 1,500 + 140 ml = 1640 ml.

27 20 -20 X 7 7 140

Calculation of IV Flow Rates

Calculation of cc/hr is essential in most IV therapy. Volume # of hrs

= cc/hr
E.g. 1 L over 8 hrs = 125 cc/hr
50 cc over 20 minutes = 150 cc/hr

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 min 60 gtt/ml 1 10 gtt/ml 1 15 gtt/ml 1 20 gtt/ml 1 = 125 gtt/ml = = = 20 21 gtt/min 31 gtt/min 41 42 gtt/min

10 gtt/ml set

125cc x 60 min 15 gtt/ml set 125cc x 60 min 20 gtt/ml set 125 cc x 60 min

SHORT METHOD
cc / hr 6 cc / hr 4 cc / hr 3 for for for 10 gtt / min 15 gtt / min 20 gtt / min

cc / hr = gtt / min for microdrip set

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