Do nurses do med math

direw0lf, BSN · Feb 6, 2016

Well your teacher is wrong. You are responsible for your own practice. If you administer the med despite thinking the order is wrong, it's on you. It absolutely would be on the RN who administered the incorrect dose. In the situation you describe, it behooves the nurse to refuse to administer the medication.

Really so you just refuse to give it? What do you do, tell the physician that you won't give it and why? And if he says "My order is to give it" you don't and document?

But if the patient gets worse because you withheld the medication, isn't that on you also? And if you think the med is wrong in dose, can you give the dose you know it should be?

direw0lf, BSN · Feb 6, 2016

Of course. Sometimes you also have to dilute very low doses of meds into reasonable doses. I.e giving 6.25mg Benadryl iv when your vial is 50mg/ml. You need to dilute in saline to give the proper dose. Because that dose is 0.125ml out the vial. And sadly I've seen a nurse not be able to figure out to dilute it and give 1.25ml and call the md and tell them that the order is ridiculous and they could never give 0.125ml Benadryl (6.25mg)

Are we allowed to dilute without needing an order to?

I wish my nursing teacher taught our pharm class and not this pharmacologist!

Editorial Team / Admin · Feb 6, 2016

Are we allowed to dilute without needing an order to?
I wish my nursing teacher taught our pharm class and not this pharmacologist!

The dose is almost exclusively given in mcg, mg, g, or another common unit. It does not specify the volume. Meds come in different concentrations; you use whatever concentration is available or makes the administration safe.

KelRN215, BSN, RN · Feb 6, 2016

Really so you just refuse to give it? What do you do, tell the physician that you won't give it and why? And if he says "My order is to give it" you don't and document?
But if the patient gets worse because you withheld the medication, isn't that on you also? And if you think the med is wrong in dose, can you give the dose you know it should be?

Yes, if the order is unsafe you refuse to administer the dose. I have never actually seen a case where the pharmacist didn't reject the unsafe order as well but "because the doctor ordered it" will never, ever protect you.

Regarding "the patient getting worse" because the nurse withheld an unsafe dose of a medication, what do you think would happen to the patient if the nurse administered the dose? There must be a reason why the nurse is questioning the order. If it's a matter of giving a toxic dose of a medication vs not giving it, what do you think is worse?

No, you cannot administer a dose that you believe to be correct. You are not a licensed prescriber. If the MD who wrote the unsafe order does not respond to you, you climb the chain of command.

Double-Helix, BSN, RN · Feb 7, 2016

Anyone who says a nurse doesn't do med math has no understanding of what nurses actually do. I'm actually shocked that a nursing instructor would say this.

Purple_roses · Feb 7, 2016

Thanks, Heather. My instructors make it seem that way too (that there are many medication errors) they said it's the number 1 cause of hospital deaths.
I think I just get frustrated and know you're right, I just have such a mental block with these dosage questions. I think I need to just do them repetitiously and it'll get easier.

How are you setting up your problems for dosage calculations? My instructor showed us a few ways. One clicked with me, the other was awful.

Here.I.Stand, BSN, RN · Feb 8, 2016

Well your teacher is wrong. You are responsible for your own practice. If you administer the med despite thinking the order is wrong, it's on you. It absolutely would be on the RN who administered the incorrect dose. In the situation you describe, it behooves the nurse to refuse to administer the medication.
Really so you just refuse to give it? What do you do, tell the physician that you won't give it and why? And if he says "My order is to give it" you don't and document?
But if the patient gets worse because you withheld the medication, isn't that on you also? And if you think the med is wrong in dose, can you give the dose you know it should be?

I may have told this story on AN before, but back in nursing school one of my instructors told a story from the peds unit of one of our clinical sites. A baby had had surgery, and the surgeon ordered a morphine CADD with a higher-than-normal continuous rate. The anesthesiologist agreed with the order, and the pharmacist verified the order. The RN initiated the CADD with the ordered high basal rate, and the baby respiratory arrested and died. The RN ended up getting disciplined because she should have known it was an unsafe dose, but she gave it anyway. In other words, the buck should have stopped with her, but it did not.

In the vast majority of cases, the pharmacist will step in, refuse to verify it, and communicate that to the MD. Some jerk MDs who wouldn't listen to an RN might even be willing to listen to the doctorate-educated pharmacist (not saying that's how it should be, but hey some prescribers are jerks.

Another time where I worked, the chief resident shellacked the G3 and RN both for administering D5W as the MIVF to a critical TBI pt -- the G3 for ordering it in the first place, and the RN for not questioning it. (If you don't know, we don't give hypotonic solutions to people with ICP issues; their MIVF should be isotonic, and in many cases we also have a hypertonic fluid running--usually 2% or 3% NaCl dosed to achieve a high-normal or slightly high serum Na+ goal.)

What I was taught is to call the MD, explain why you feel uncomfortable, and that you will not administer it. If the MD is insistent the pt have the med, they can come and give the pt that med.

Can it come back to bite you, maybe if it turns out the RN was wrong and the order was appropriate...that's part of why it's so important to know your stuff. It's also a good reason to carry Liability Insurance so that if you were truly acting as a prudent nurse, you have some legal help in your corner.

Another example: a young guy (19 or 20 I want to say) is frequently admitted for sickle cell crises. This pt took 20--yes, twenty--mg of IV Dilaudid q 2 hrs, and 50 mg IV Benadryl q 4 or 6 hrs. He was up and around and as conversational as you or I while on these doses. Every RN on the BMT floor knew him well and knew that yes he really was that opioid tolerant, every physician on his service could tell the pharmacist, "Yes we know for a fact that he needs this dose to control his pain, and we know for a fact he can tolerate it, and no I did not mean 0.2 or 2 mg but 20 mg.

Now say an RN who didn't know his history but is advised by many professionals who do, and despite an assessment showing no contraindications refused to give him his meds, that patient would suffer. They might even be mad enough to accuse the RN of pt neglect.

Only one time I was given an order for something I truly felt was unsafe. We were starting a diltiazem drip, and the resident w.rote an order for a really high bolus dose. Her BP was marginal...MAP in low 60s. I don't remember exactly what it was, but my charge RN and I were both like "what the heck??" I gave her 5 mg (documented as a split dose in Epic) with the knowledge that I have more ordered, but she converted to NSR very quickly after the 5. So I just gave the MD an FYI, "I was worried about her BP so tried 5 mg first, and she didn't need any more of the bolus. She went from afib in the 160s to NSR in the 80s in about 1 minute and has sustained." Now keep in mind that titratable drips leave a lot to nursing judgment anyway. Had it been something like an inappropriately high dose of KCl for a renal patient or an oral med in pill form etc., and had the pharmacist done nothing I would have communicated with the MD first. In the case of the KCl, I would have suggested something like "Given her low creatinine clearance, I would be more comfortable giving 10 meq first and then rechecking her K+, vs. giving all 20 meq and praying we didn't overshoot." Every MD I work with would be 110% fine with that, as they are reasonable people and respect our judgment.

BittyBabyGrower, MSN, RN · Feb 9, 2016

Yes yes yes. Case in point: yesterday I had a baby on K+ supplements PO every 3 hours. He should have 0.5ml in the syringe. My syringe had 2mls in it. It scanned correctly, now, if myself and others didn't do the math, that kid would have received a whole heck of a lot of potassium in a day! Moral of the story, follow your 5 rihjts

and always, always calculate your drugs and make sure they are within safe guidelines!

RunBabyRN · Feb 9, 2016

There ARE too many med errors, as ANY med error is one too many. They happen, yes, and we are the last line of defense. ALWAYS do the math. There will also be times you may not have the math done for you (such as giving part of a vial of a medication), and you need to be able to convert X mg into X ml.

CYA.

musingmom · Feb 9, 2016

I gave this last week: 60 mg of solumedrol was the order, and the Pyxis gave me 2 vials of 40mgs in 1 ml. If I call the pharmacist, she will tell me how many mls to give, but since I am ultimately responsible for what the patient actually gets, I should know how to do it myself.

CelticGoddess, BSN, RN · Feb 9, 2016

A pharmacologist teaches our pharmacology class, and I asked her the other day "I know this is important, but I was told that nurses don't actually ever do dosage calculations in the real world nursing, is that true?" and she said yes, the pharm does that for you. I asked what about even checking to make sure an order is correct (because our nursing instructors warned us to always check if an order looks wrong) and she said the pharm always checks that too. But it made me wonder, why are there so many medication errors then? Do nurses do dosage calculations? Thanks.

We do on my floor. I work on Onc and the chemo nurses certainly have to do dosage calculations to ensure that the dose is correct. And there have been a couple of times when the dosage was off and the nurse caught it. Yes, you might have to.

I also have to do dosage calculation for Argatraban and heparin.

direw0lf, BSN · Feb 11, 2016

Thanks again for reminders of med calculation importance and how often nurses do it!

I know I have a math block. Even today the pharm teacher asked me a very simple ratio conversion and I couldn't do it without writing it down, I couldn't visualize it and had the "block", even though right here right now in my home alone I could do it and 100 others like it in my head no problem. So I just ordered Davis Basic Math Review for nurses (I got it used for close to $5 so it's not arriving for about a month). I'm going to do some kind of math every day until my block is gone.