Lecture 9: Putting it all Together

This lecture isn't really a lecture at all; it is a discussion board and writing assignment project that will give you the opportunity to tie together many of the concepts which we have learned in this class by looking at some theoretical case studies of patients in a hospital. More specifically, this is your final discussion board assignment and your final writing assignment.

You will be given 3 hospital charts for 3 different patients, each containing a variety of medical orders. Your job will be to describe the steps you will need to take before administering each of the ordered medications, including checking the dosages for safety, reconstituting the solutions as needed, diluting any drugs for IV administration as needed, choosing the correct syringe for each dose, calculating the flow rate, dosage rate, infusion and completion times, etc.

Your assignment is to choose 2 of the 3 charts below; for the two charts you choose, you must complete all the questions given.

Discussion Board Assignment:
Your discussion board assignment this week will be to discuss your answers to these questions on the discussion board. You need not post all of your answers to the questions below to the discussion board; all you have to do is to discuss at least two of the questions you choose to answer, and then you must as always respond to two other students' posts with substantive math answers. See the discussion board itself for more details on which problems to discuss there.

Writing Assignment:
After you have discussed the questions as much as you like on this week's discussion board, you should submit a final draft of your answers, written in a clear paragraph essay format, and submit your final essay at Turnitin under the Writing Assignment 3 link. Your writing assignment should narrate clearly what you would do in each step as you treat the patient given in the chart - you should answer all of the questions below, but in a narrative, paragraph format. To get a good grade, be sure to explain everything you will do clearly, and to explain the logic behind each decision clearly and simply. It may help if you think of this paper as an explanation that you would give for someone to follow step-by-step, who does not know how to read a medical chart or how to calculate medication doses.

If you choose to do all 3 charts for this assignment, you may receive extra credit, but in order to receive the extra credit, you must submit your answers to one of the 3 charts separately under the"Extra Credit" link when you turn it in.

Be sure that you show all your work and that you explain each of your answers to the given questions as clearly as possible. I encourage you to reread the lectures as you do these problems. You can discuss these with each other and you can email me with questions, but all of your final answers must be in your own words.

The Charts

Above each chart I will give you important information that you will need to use to complete this assignment. Below each chart I will give you hints as to what you might need to explain during your description of what you would do before dosing each medication. When the charts below belong to a child, we assume that this means the child is below 12 years of age.

Chart #1: An immunocompromised diabetic child with varicella zoster infection

This child weighs 54 lbs and is 46 in tall.

Acyclovir sodium comes in a 1g vial. It should then be diluted with 20 mL of sterile water. Bacteriostatic water for injection which contains benzyl alcohol should not be used for reconsititution.

After reconsititution, if it is to be given intravenously, it must be diluted further with D5W or another compatible diluent. When diluted further for IV use, it should have a concentration of 7mg/mL.

Benadryl comes as an oral suspension with 12.5 mg per 5 mL.

Write out each of the drug orders listed on the chart in words, explaining what every single abbreviation means.
Check the ordered doses of acyclovir sodium and solumedrol for safety. Are the ordered dosages safe? Explain why or why not, backing up your answers with mathematical calculations and information from the labels.
Explain the steps you would take to reconstitute the acylovir sodium and penicillin G potassium and write up labels for each reconstituted solution. (For the penicillin G potassium, assume that you want to obtain a solution with a concentration of 500,000 units/mL.) Be sure to include all the required information on the labels for each of these drugs. If any of the required information is missing from the labels given above, explain which specific pieces of information are missing in each case, and tell me where you would go to look for this missing information.
The Solumedrol must be further diluted to a total volume of 250 mL before it can be infused. How many mL of the reconstituted Solumedrol will you need to obtain 750 mg? Then how many mL of D5W must you add to this in order to obtain a concentration of 750 mg/250 mL?
The acyclovir sodium must also be diluted further before it can be given intravenously. The instructions say that it should be diluted until it reaches a concentration of 7 mg/mL. How many mL would a solution with a concentration of 7 mg/mL have to be in total, in order for it to contain exactly the 450 mg that has been ordered? How many mL of the reconsitituted acyclovir sodium solution will you need in order to get 450 mg to begin with? Based on this answer, how many mL of D5W would you have to add to the reconstituted acyclovir sodium in order to obtain a solution with a concentration of 7 mg/mL? (Remember that the volume of 450 mg of acyclovir sodium adds to the total volume.)
If you use a manual IV with a drop factor of 20 gtt/mL, what will the flow rate be of the acyclovir sodium?
If you use an IV pump to infuse the Solumedrol, what will the flow rate be?
How many mL of penicillin G potassium will you need to withdraw in order to administer the ordered dose? Is the ordered volume safe? Explain why or why not. If it is not safe, explain what you should do.
How many mL of Benadryl will you need to give this child in order to administer the ordered dose?
Which insulin syringe would you use to administer the insulin dosage which is ordered to be given before breakfast? Choose one of the syringes below and correctly mark how you would measure this dosage. Explain which insulin gets drawn up first and why. Explain then how you can correctly measure the second insulin in the same syringe.
Which insulin syringe would you use for the other insulin orders and why? Mark one of the other insulin orders on the correct choice of insulin syringe.

Chart #2: A child with rheumatic fever

This child weighs 36 lbs.

After reconsititution, if it is to be given intravenously, Vancocin must be diluted further with D5NS or another compatible diluent. When diluted further for IV use, any amount up to 500 mg should be diluted to a total of 100 mL solution and any amount between 500 and 1000 mg should be diluted to 200 mL total solution.

When reconsitituting penicillin G potassium for this patient, you want to obtain the weakest possible concentration so that they do not experience irritation when the medication is injected.

Prednisone is available in a 5mg/mL oral syrup. The recommended dose for predisone is 0.5 mg/kg/day.

Diazepam is available in 2, 5, and 10 mg scored tablets.

Digoxin has a recommended dosage of 10 mcg/kg/day in two divided doses. It is available in an oral suspension with the concentration 50 mcg/mL.

Ibuprofen is available in a liquid with concentration 100 mg/5 mL.

Write out each of the drug orders listed on the chart in words, explaining what every single abbreviation means.
Check the ordered doses of Vancocin, prednisone, and digoxin for safety. Are the ordered dosages safe? Explain why or why not, backing up your answers with mathematical calculations and information from the labels.
Explain the steps you would take to reconstitute Vancocin and penicillin G potassium and write up labels for each reconstituted solution. Remember that for the penicillin you want to obtain the weakest possible concentration. What is the weakest possible concentration of penicillin, according to the label? For the Vancocin, do you need to reconsitute the 500 mg vial, or the 1 g vial?
Be sure to include all the required information on the labels for each of these drugs. If any of the required information is missing from the labels given above, explain which specific pieces of information are missing in each case, and tell me where you would go to look for this missing information.
The Vancocin must be further diluted before it can be infused via IV. According to the label, how many mL of diluent must be added to the reconstituted Vancocin to dilute it further for IV use? If you add this amount of D5W to the reconsitituted Vancocin, what will the concentration of this new weaker solution for IV use be in mg/mL? How many mL of this new weaker solution will you need in order to administer the 650 mg of Vancocin prescribed on this patient's chart?
Calculate the flow rate in gtt/min for this Vancocin IV if this is administered using a microdrip.
How many mL of Pfizerpen will you need to withdraw in order to administer the ordered dose? Is this volume safe? Why or why not?
How many tabs, caps or mL of predisone will you need to administer the ordered dose?
How many tabs, caps or mL of diazepam will you need to administer the ordered dose?
How many tabs, caps or mL of digoxin will you need to give this child in order to administer the ordered dose?
How many tabs, caps or mL of of ibuprofen will you need to give this child in order to administer the ordered dose?
If you hang the 500 mL D5LR bag, how long will it take before the bag runs out? If you begin this IV at 11:45am, at what time will this bag finish infusing? Mark the 500 mL bag below with start, completion and progress times.
Since the order is for continuous IV infusion, what will you need to do once this 500 mL bag is empty?
The Vancocin is ordered as IVPB, whereas the D5LR solution is ordered to infuse continuously. What does this mean? How should you hang these two bags on the IV setup? In what order do these two medications infuse? Which is the primary and which is the secondary IV?

Chart #3: An adult with congestive heart failure and pulmonary edema

This adult weighs 54.5 kg.

Furosemide is the generic name for Lasix.

Demerol has the generic name meperidine.

Nitroglycerin comes in a preprepared IV solution of 50 mg in 250 mL D5W.

Nipride comes as 50 mg in 100 mL D5W.

Lasix has a safe range of 0.05-0.5 mg/kg/h.

Write out each of the drug orders listed on the chart in words, explaining what every single abbreviation means.
Check both of the ordered doses of Lasix for safety. Are the ordered dosages safe? Explain why or why not, backing up your answers with mathematical calculations.
To give the stat Lasix order, how many mL of Lasix will you need? Is this a safe amount to administer via IM? Why or why not?
You want to dilute 40 mg of Lasix to a total solution of 50 mL D5W before you administer it via IV. How many mL of Lasix will you need in order to obtain 40 mg? So how many more mL of D5W must you add to obtain a solution of 50 mL total volume?
When you begin the titration, what dosage rate must you begin with? Convert this dosage rate to a flow rate in mL/h.
After adjusting the flow rate over time, the patient's serum level normalizes when the Lasix is infusing at 8 mL/h. What dosage is the patient now receiving per minute?
Compute 75% of the dosage rate the patient was receiving when they stabilized. Now that the patient has stabilized, the doctor has ordered a new dosage of Lasix; it should be this dosage rate (i.e. 75% of the stabilizing rate) given continuously. Record this new drug order on the patient's chart.
What will the total number of mg of Lasix that the patient will receive each day be with this new dosage?
After a few days on the IV Lasix, the doctor gives an order to switch the patient to oral dosage of Lasix. The doctor says that the total daily oral dosage should be approximately 200% of the most recent daily IV dosage. Take the most recent IV dosage and double it. If this is the total daily oral dosage, and it is divided up into two equal doses to be given twice a day, how many mg of Lasix should be given for each dose? Write this new order on the patient's chart for oral dosage of Lasix.
If the Lasix tablets come in 40 mg each, how many tablets should the patient get for each oral dose of Lasix?
How many Slow-K tablets should you give the patient to ensure they receive their ordered dose?
Calculate the flow rate in gtt/min for the nitroglycerin if the drop factor is 15 gtt/mL and you are using a manual IV setup.
What flow rate should the Nipride have in mL/h when you begin the titration? What is the maximum flow rate you may titrate up to while administering the Nipride, according to the order given on the chart?
What should you do if you titrate the patient up to the maximum dosage of 327 mcg/min, but you never reach the goal of the titration (in other words, what if the patient's SBP never goes below 140 mm)?
How many mL of Demerol will you need in order to administer the ordered dose?