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  1. 1. Math and Dosage Calculations for Health Care Third Edition Booth & Whaley McGraw-Hill 5- Chapter 5: Drug Orders Edited by B. Holmes MSN/Ed, RN
  2. 2. Learning Outcomes <ul><li>Summarize the Rights of Medication Administration. </li></ul><ul><li>Interpret a written drug order. </li></ul><ul><li>Identify on physicians’ orders and prescriptions the information needed to dispense medication. </li></ul>
  3. 3. Learning Outcomes (cont.) <ul><li>Locate on medication administration records or electronic medication records the information needed to administer medication. </li></ul><ul><li>Recognize drug orders that do not contain all of the necessary information to carry out the orders safely. </li></ul><ul><li>Select appropriate action for confusing, incomplete, or illegible drug orders. </li></ul>
  4. 4. Introduction <ul><li>It is important to be able to read and understand a drug order to correctly calculate medication dosages. </li></ul><ul><li>You can be held responsible for medication errors regardless of the source. </li></ul>
  5. 5. Rights of Medication Administration <ul><li>Basic Rights </li></ul><ul><li>Right patient </li></ul><ul><li>Right drug </li></ul><ul><li>Right dose </li></ul><ul><li>Right route </li></ul><ul><li>Right time </li></ul><ul><li>Right documentation </li></ul><ul><li>Additional Rights </li></ul><ul><li>Right reason </li></ul><ul><li>Right to refuse </li></ul><ul><li>Right to know </li></ul><ul><li>Right technique </li></ul>
  6. 6. Right Patient <ul><li>Before giving a medication to a patient </li></ul><ul><ul><li>Check for two identifiers. </li></ul></ul><ul><ul><ul><li>Patient’s full name </li></ul></ul></ul><ul><ul><ul><li>Another identifier – date of birth, SSN, or medical record number </li></ul></ul></ul><ul><ul><li>Ask the patient state his/her full name and second identifier. </li></ul></ul>
  7. 7. Right Patient (cont.) <ul><ul><li>Check that the name on medication order is exactly the same as the name of the patient. </li></ul></ul><ul><ul><ul><li>Outpatient – photographic identification </li></ul></ul></ul><ul><ul><ul><li>Inpatient – identification number, identification bracelet, bar code scanning </li></ul></ul></ul><ul><ul><li>Check the bed number. </li></ul></ul>
  8. 8. Right Drug <ul><li>To be sure a patient receives the right drug. </li></ul><ul><ul><li>Only give drugs that you prepared yourself </li></ul></ul><ul><ul><li>Check the expiration date. </li></ul></ul><ul><ul><li>Check original order before administration </li></ul></ul><ul><ul><li>If the patient questions a medication, make sure you are able explain the drug, purpose, and side effect </li></ul></ul>
  9. 9. Right Drug (cont.) <ul><ul><li>A patient always has the right to refuse a medication. </li></ul></ul><ul><ul><ul><li>Dispose of refused medications according to facility guidelines. </li></ul></ul></ul>
  10. 10. Right Drug (cont.) <ul><li>Rule 5 – 1 C heck medication three times: </li></ul><ul><ul><li>1. when you take it off the shelf </li></ul></ul><ul><ul><li>2. when you prepare it </li></ul></ul><ul><ul><li>when you replace it on the shelf </li></ul></ul><ul><li>Check it three times even if it is prepackaged, labeled, and ready to be administered. </li></ul>3
  11. 11. Right Dose <ul><li>Preparing and administering the right dose may require calculations. </li></ul><ul><ul><li>Conversion from dosage ordered to desired dose </li></ul></ul><ul><ul><li>Amount to administer </li></ul></ul><ul><li>Use extreme caution when calculating dosages. </li></ul><ul><ul><li>Pay special attention to decimal points </li></ul></ul>
  12. 12. Right Route <ul><li>A drug intended for one route may not be safe if administered via another route. </li></ul><ul><ul><li>Be especially careful between ophthalmic and otic routes. </li></ul></ul>
  13. 13. Right Route (cont.) <ul><li>Some medications are produced in different versions for different routes. </li></ul>Example aspirin is available as tablets or as suppositories <ul><li>Check that route listed on drug label matches route ordered. </li></ul>
  14. 14. Right Time <ul><li>Most often within 30 minutes of schedule </li></ul><ul><ul><li>Absolute time – 9:00 a.m. </li></ul></ul><ul><ul><li>Relative time – before breakfast </li></ul></ul><ul><li>Drug order should identify special timing considerations if needed. </li></ul><ul><li>PRN medications </li></ul><ul><ul><li>Given when needed with a specified time interval. </li></ul></ul><ul><ul><li>Check when previous dose was given. </li></ul></ul>
  15. 15. Right Documentation <ul><li>Sign the medication administration record (MAR) immediately after the patient takes the medication. </li></ul><ul><ul><li>Do not document prior to giving the medication. </li></ul></ul><ul><ul><li>If documentation not done, medication administration is not complete </li></ul></ul><ul><li>Also document if the patient </li></ul><ul><ul><li>Refuses a medication </li></ul></ul><ul><ul><li>Consumes only part of the dose </li></ul></ul><ul><ul><li>Vomits after taking the drug </li></ul></ul>
  16. 16. Right Reason <ul><li>Know why a medication is being given. </li></ul><ul><ul><li>Check medication record </li></ul></ul><ul><ul><li>Check order </li></ul></ul><ul><ul><li>Check with prescribing physician </li></ul></ul>
  17. 17. Right to Know <ul><li>Patients must be educated about their medications, including the </li></ul><ul><ul><li>Reason for taking the medication </li></ul></ul><ul><ul><li>Expected effect of the medication </li></ul></ul><ul><ul><li>Side effects of medications </li></ul></ul>
  18. 18. Right Technique <ul><li>Medications must be given correctly according to the order. </li></ul><ul><ul><li>For example: </li></ul></ul><ul><ul><ul><li>Buccal -- between cheek and gum </li></ul></ul></ul><ul><ul><ul><li>Sublingual -- under the tongue </li></ul></ul></ul><ul><li>If unsure of technique </li></ul><ul><ul><li>Physicians’ Desk Reference (PDR) </li></ul></ul><ul><ul><li>Facility policy or procedure manual </li></ul></ul><ul><ul><li>Valid Internet source </li></ul></ul>
  19. 19. Roman Numerals <ul><li>Are used sometimes in drug orders. </li></ul><ul><li>Calculating dosages may involve changing Roman numerals to Arabic numbers. </li></ul><ul><li>Letters represent numbers. </li></ul><ul><li>Commonly used Roman numerals </li></ul><ul><ul><li>ss = ½ </li></ul></ul><ul><ul><li>I = 1 </li></ul></ul><ul><ul><li>V = 5 </li></ul></ul><ul><ul><li>X = 10 </li></ul></ul>
  20. 20. Combining Roman Numerals <ul><li>Rule 5 – 2 When reading a Roman numeral containing more than 1 letter, follow these two steps: </li></ul><ul><ul><li>1. If any letter with a smaller value appears before a letter with a larger value, subtract the smaller value from the larger value. </li></ul></ul><ul><ul><li>2. Add the value of all the letters not affected by Step 1 to those that were combined. </li></ul></ul>
  21. 21. Combining Roman Numerals (cont.) <ul><li>IX = 10 –1 = 9 </li></ul><ul><li>XIV = 10 + (5-1) = 14 </li></ul><ul><li>XXVIII = 20 + (5+3) = 28 </li></ul><ul><li>Doctor’s orders are most likely to contain Roman numerals from 1 to 30. </li></ul><ul><li>Most common Roman numerals are: V & X </li></ul>Examples
  22. 22. Practice <ul><li>1. Convert the following Roman numerals to Arabic numbers: </li></ul><ul><ul><li>viiss </li></ul></ul><ul><ul><li>XII </li></ul></ul><ul><ul><li>XIX </li></ul></ul><ul><ul><li>ixss </li></ul></ul><ul><li>2. Provide the answers to the following in Arabic numbers: </li></ul><ul><ul><li>V + V </li></ul></ul><ul><ul><li>xxii – vii </li></ul></ul><ul><ul><li>XXXV – XIV </li></ul></ul><ul><ul><li>xvi + xii </li></ul></ul>7½ 12 19 9½ 10 15 21 28
  23. 23. Physician’s Orders and Prescriptions <ul><li>Abbreviations used when writing orders: </li></ul><ul><ul><li>General abbreviations </li></ul></ul><ul><ul><li>Form of medication </li></ul></ul><ul><ul><li>Route </li></ul></ul><ul><ul><li>Frequency </li></ul></ul><ul><li>Approved abbreviations vary among facilities </li></ul><ul><ul><li>Memorize commonly used abbreviations </li></ul></ul><ul><ul><li>Keep facility's approved list available </li></ul></ul>
  24. 24. Commonly Used General Abbreviations
  25. 25. Abbreviations Commonly Used for Form of Medication
  26. 26. Abbreviations Commonly Used for Routes of Administration
  27. 27. Abbreviations Commonly Used for Frequency
  28. 28. Abbreviations <ul><li>Joint Commission on Accreditation of Healthcare Organization (JCAHO) </li></ul><ul><ul><li>“ Do Not Use” abbreviations </li></ul></ul><ul><ul><li>“ Undesirable” abbreviations </li></ul></ul><ul><li>Check abbreviations carefully in drug orders. </li></ul>Q.O.D
  29. 29. “ Do Not Use” Abbreviations
  30. 30. Undesirable Abbreviations
  31. 31. Undesirable Abbreviations (cont.)
  32. 32. Undesirable Abbreviations (cont.) Do Not Use Potential Problem Use Instead > (greater than) < (less than) Misinterpreted as the number “7” (seven) or the letter “L” Confused for one another Write “greater than” Write “less than” Abbreviations for drug names Misinterpreted due to similar abbreviations for multiple drugs Write drug names in full Apothecary units Unfamiliar to many practitioners Confused with metric units Use metric units @ Mistaken for the number “2” (two) Write “at” cc Mistaken for U (units) when poorly written Write &quot;mL&quot; or “milliliters” µg Mistaken for mg (milligrams) resulting in one thousand-fold overdose Write &quot;mcg&quot; or “micrograms”
  33. 33. Physician’s Drug Order <ul><li>Essential elements </li></ul><ul><ul><li>Full name of the patient </li></ul></ul><ul><ul><li>Full name of the drug </li></ul></ul><ul><ul><li>Dosage </li></ul></ul><ul><ul><li>Route </li></ul></ul><ul><ul><li>Time </li></ul></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Signature of prescribing physician </li></ul></ul><ul><ul><li>Date </li></ul></ul><ul><ul><li>PRN order must include the reason </li></ul></ul>
  34. 34. Outpatient Settings <ul><li>Physicians’ orders are given as prescriptions. </li></ul><ul><li>Prescriptions include all the elements of a physician’s order plus </li></ul><ul><ul><li>Physician’s name and prescriber number </li></ul></ul><ul><ul><li>Quantity to be dispensed </li></ul></ul><ul><ul><li>Number of refills </li></ul></ul><ul><ul><li>Instructions for the label </li></ul></ul>
  35. 35. Prescription Form Drug and dose Quantity to dispense Instructions to appear on the label Number of refills permitted Patient’s full name Date Physician name
  36. 36. Inpatient Settings <ul><li>Physicians’ order form </li></ul><ul><ul><li>Multiple orders on one form </li></ul></ul><ul><ul><li>Essential elements of a medication order </li></ul></ul><ul><ul><li>Patient’s name and physician signature appear once </li></ul></ul><ul><li>Orders may be entered into a computer </li></ul>
  37. 37. Physician’s Order Form
  38. 38. Error Alert! <ul><li>Never guess what the prescriber meant! </li></ul><ul><ul><li>If the order is not legible, always contact the prescribing physician to clarify the order. </li></ul></ul>
  39. 39. Verbal Orders <ul><li>Acceptable if the physician is unable to write an order that must be carried out quickly </li></ul><ul><li>Governed by state laws </li></ul><ul><li>If permitted to accept a telephone order </li></ul><ul><ul><li>Write it carefully and legibly as you receive it </li></ul></ul><ul><ul><li>Read the order back to the physician </li></ul></ul><ul><ul><li>Ask for clarification of spelling if unsure </li></ul></ul>
  40. 40. Error Alert! <ul><li>Always be certain that you are dispensing the correct medication. </li></ul><ul><ul><li>Many drugs have names that are similar. </li></ul></ul>Acular—Ocular Benadryl—Bentyl Cafergot—Carafate Darvon—Diovan Digitoxin—Digoxin Eurax—Urex Iodine—Lodine Nicobid—Nitrobid Examples
  41. 41. Practice <ul><li>What, if anything, is wrong with this prescription? </li></ul>Allen Capsella, MD Westtown Medical Clinic 989-555-1234 Name: M Ward Date: 8/15/2008 Address: Rx: Lopressor QUANTITY: SIG: 1 tab BD Refills: 2 MD398475 A Capsella, MD Prescriber ID # Physician Signature
  42. 42. Practice <ul><li>ANSWER </li></ul><ul><ul><li>1. It does not include patient’s full name. </li></ul></ul><ul><ul><li>2. There is no dosage strength for the lopressor. </li></ul></ul><ul><ul><li>3. There is no quantity to be dispensed. </li></ul></ul><ul><ul><li>4. No route is given. </li></ul></ul>Click to return to prescription
  43. 43. Medication Administration Systems <ul><li>Standard schedule for administering medication </li></ul><ul><ul><li>Varies by facility </li></ul></ul><ul><li>Verifier </li></ul><ul><ul><li>Ensures that the times listed for administration are appropriate </li></ul></ul><ul><ul><li>Adjust times as necessary </li></ul></ul><ul><ul><ul><li>Mealtimes </li></ul></ul></ul><ul><ul><ul><li>Conflicting medication schedule </li></ul></ul></ul>
  44. 44. Sample Times for Medication Administration Frequency Ordered Times to Administer qd 0800 bid 0800 – 2000 tid 0800 – 1400 – 2000 qid 0800 – 1200 – 1600 – 2000 q 12 hrs 0800 – 2000 q 8 hrs 2400 – 0800 – 1600 q 6 hrs 2400 – 0600 – 1200 – 1800 Every night at bedtime 2000
  45. 45. Medication Administration Records (MAR) <ul><li>Legal documents that may be handwritten or computerized </li></ul><ul><li>Contain same information as the order form </li></ul><ul><li>Specify the times to administer the medication </li></ul><ul><li>Provide a place to document each medication administration </li></ul>
  46. 46. Medication Administration Records (MAR) (cont.) <ul><li>Rule 5-3 MARs must include the following information: </li></ul><ul><ul><li>1. Name of medication, dose, route, frequency </li></ul></ul><ul><ul><li>2. Times that accurately reflect the frequency specified </li></ul></ul><ul><ul><li>3. Name and identification number of patient </li></ul></ul><ul><ul><li>4. Date order was written (including start and end dates as necessary) </li></ul></ul><ul><ul><li>5. Special instructions or information required by the facility </li></ul></ul>
  47. 47. Practice <ul><li>Is the following MAR complete? If not, what is missing? </li></ul>ANSWER The order is transcribed correctly and all information is complete. Date init. Medication, dose, duration, frequency, route D/C date init Admin time 2/5 CS Vasotec 10 mg po BID hold for systolic BP < 100 0800 x 2000 x
  48. 48. Practice Is the following MAR complete? If not, what is missing? Date init. Medication, dose, duration, frequency, route D/C date init Admin time 2/5 CS Synthroid 50 mcg PO Bid 0800 x x x 2/5 CS Erythromycin tab i po q6h 0800 x 2000 x 2/5 CS Persantine 75 mg po q6h 2400 0800 1600 x 2/5 CS heparin 10,000 units q 8 hr 2400 0800 1600
  49. 49. Practice <ul><li>ANSWER </li></ul><ul><ul><li>1. Order A is correct. </li></ul></ul><ul><ul><li>2. Order B does not include the strength of the medication and there is an error in the times listed. The “hours” reflect only a q 12 hr dosing rather than a q 6 hr dosing. </li></ul></ul><ul><ul><li>3. Order C contains an error in the times listed. There are only 3 times listed and it should be q 6 hours (4 times). </li></ul></ul><ul><ul><li>4. Order D does not include a route. </li></ul></ul>Click to return to MAR
  50. 50. Medication Cards <ul><li>Rarely used </li></ul><ul><li>One drug per card </li></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Easily misplaced </li></ul></ul><ul><ul><li>Increased potential for omitting a medication </li></ul></ul><ul><ul><li>Do not list allergies or diagnoses </li></ul></ul>
  51. 51. Medication Card (cont.) <ul><li>Patient’s name </li></ul><ul><li>Room number </li></ul><ul><li>Full name of drug </li></ul><ul><li>Dose, route, frequency </li></ul><ul><li>Special instructions </li></ul><ul><li>Administration times </li></ul><ul><li>Date ordered </li></ul>
  52. 52. Computerized Medical Records <ul><li>Patient information is entered directly into a computer. </li></ul><ul><li>Information is easily updated and accessible. </li></ul><ul><li>Includes </li></ul><ul><ul><li>Orders </li></ul></ul><ul><ul><li>Lab results </li></ul></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Appointments </li></ul></ul><ul><ul><li>Discharge plans </li></ul></ul>
  53. 53. Computerized Medical Record
  54. 54. Computerized Medical Records (cont.) <ul><li>Electronic Medication Administration Records (eMARs) </li></ul><ul><ul><li>Ongoing working document </li></ul></ul><ul><ul><li>Records medications as they are administered </li></ul></ul><ul><ul><li>Users must log into system using secure passwords </li></ul></ul>
  55. 55. <ul><li>eMAR </li></ul>
  56. 56. Medication Reference Materials <ul><li>To dispense or administer medications </li></ul><ul><ul><li>Know effects of the drugs </li></ul></ul><ul><ul><li>Be familiar with drug information sources </li></ul></ul>
  57. 57. Medication Reference Materials (cont.) <ul><li>Resources </li></ul><ul><ul><li>Package inserts </li></ul></ul><ul><ul><li>Physicians’ Desk Reference (PDR) </li></ul></ul><ul><ul><li>United States Pharmacopeia National Formulary </li></ul></ul><ul><ul><li>Drug handbooks </li></ul></ul><ul><ul><li>Reputable Internet sites </li></ul></ul><ul><ul><li>Software programs used with personal digital assistant (PDA) </li></ul></ul>
  58. 58. Apply Your Knowledge <ul><li>Which of the basic rights of medication administration is not listed? </li></ul><ul><ul><li>Right patient </li></ul></ul><ul><ul><li>Right drug </li></ul></ul><ul><ul><li>Right dose </li></ul></ul><ul><ul><li>Right time </li></ul></ul><ul><ul><li>Right technique </li></ul></ul><ul><ul><li>Right documentation </li></ul></ul>Answer right route
  59. 59. Apply Your Knowledge <ul><li>What do the following abbreviations mean? </li></ul>pc Bid hs supp BP Click for each answer. after meals Twice a day At bedtime suppository blood pressure
  60. 60. Apply Your Knowledge Even though these are inappropriate abbreviation, what do they mean? Qd Au MSO4 cc ug
  61. 61. Apply Your Knowledge <ul><li>Qd = daily </li></ul><ul><li>Au = both ears </li></ul><ul><li>MSO4 = Morphine </li></ul><ul><li>cc = milliliters </li></ul><ul><li>ug = microgram </li></ul>
  62. 62. End of Chapter 5 You must motivate yourself EVERYDAY! ~Matthew Stasior