I have a question about a math question that we just had. the question is....
your client presents in the clinic complaining of fluttering in her chest. she is placed on a cardiac monitor which shows a new onset atrial fibrillation. she has history of COPD and CHF. home medications are digoxin and lasix everyday.
vitals: HR 110-120, RR 22, B/P 100/60
weight: 100 Kg.
she is admitted to the inpatient monitored unit and started on a Cardizem drip. the pharmacy sends you a 50mL bag of 0.25 NS with 250 mg of cardizem added. your order states to start the infusion at 0.5 mg/kg/min.
using nursing judement, would you hang this infusion? why?
my question is...wouldn't you need to check the patients digoxin level before giving this medication? I know that Cardizem will lower the patients BP even lower and can also increase digoxin serum levels.
I was just looking that up too, I didn't see it anywhere! I think she just want to see if we know what to do in this situation. The whole order is messed up!
do you think that the 5/mg/hr is fictitious too? I've never seen it written out like this.
It doesn't fit with any standard writing of numerals and units, no.
The slash (/) means per, so you could try saying or writing out the problem: Five per milligram per hour? Five whats? It's jibberish.
Seriously, this combined with the .25 NS tells me either your instructor is wanting you to point out as many problems with the order as possible or that your instructor is a moron.
I'd hope for the former- our instructors last year set up a mock patient room in which we'd go in and have to spot as many errors as possible for one of our quiz grades.
Wow! Yeah...sometimes I think they like to see us squirm. She had an devilish look when she handed to the test out, you could tell that she was enjoying seeing us trying to figure it out. I don't mind them trying to teach us what to be looking for, but this is going way beyond that. I'm so frustrated right now. This is my last semster of nursing school, and they seem to be making it as confusing as possible.
If it really is supposed to be 5/mg/hr (), I've honestly never seen it written that way.
I would assume that it's supposed to be 5 mg/hr.
I think that the real problem here is that you're trying to actually understand the medication in addition to answering the question. So I'll try to break it down.
First, the way we really do it on our tele unit:
For the sake of simplicity, let's pretend you're dealing with the same 100 kg patient (220 pounds).
If the initial dose is supposed to be 100 X .25, that would be 25 mg in the first hour. If it was followed in 15 minutes by a 35 mg dose, that would make a total of 60 mg in one hour.
Realistically, on our unit, that would mean that we'd give a 10 mg bolus, then run the drip at 15 mg/hr (remembering that our solution works out to a 1:1 ratio of mg/ml when mixed).
I've actually done that. Our population is mostly geriatric patients, so it's not usually followed up with another dose. I would expect that the second dose might be used in an attempt to medically cardiovert the patient. As someone else mentioned earlier, Cardizem will indeed cardiovert and with an elderly population, this method is preferred as cardioversion doesn't always work.
your client presents in the clinic complaining of fluttering in her chest. she is placed on a cardiac monitor which shows a new onset atrial fibrillation. she has history of COPD and CHF. home medications are digoxin and lasix everyday.
vitals: HR 110-120, RR 22, B/P 100/60
weight: 100 Kg.
she is admitted to the inpatient monitored unit and started on a Cardizem drip. the pharmacy sends you a 50mL bag of 0.25 NS with 250 mg of cardizem added. your order states to start the infusion at 0.5 mg/kg/min.
using nursing judement, would you hang this infusion? why?
Strictly looking at the problem as a tele nurse before I look at the drug, I wouldn't want to get all crazy with a lot of medication because the patient's heart rate is not that high and neither is the blood pressure. I prefer parameters from the doc, but generally, if the heart rate sustains below 60 OR the systolic blood pressure is 90 or less, we start thinking about calling the doc and getting the drip DC'd.
But just looking at the patient's vitals and history (sounds like the patient's obese and could be elderly) I would expect this patient to have a Cardizem drip of 1 mg : 1 ml at about a rate of 5-10 mg / hr.
she is admitted to the inpatient monitored unit and started on a Cardizem drip. the pharmacy sends you a 50mL bag of 0.25 NS with 250 mg of cardizem added. your order states to start the infusion at 0.5 mg/kg/min.
First, about the 1/4% NS -- Daytonite, wouldn't that cause edema? Do we really want to do that to a patient who has a CHF hx?
Now on to the concentration:
250 mg divided into 50 ml = 5 mg / ml concentration. Frankly, that's a little too strong for my taste. If you wanted the standard 5 mg/ hour, that'd mean that you get one ml per hour. That's not even enough fluid to keep the IV site open!
But the order wants 0.5 mg/ kg / min.
So 100 kg X 0.5 = 50 mg PER MINUTE. 50 mg X 60 minutes = 300 mg per hour.
Seems like a pretty steep dose to me. So no, I wouldn't give it.
Compared to your drug book, the dose would work out thusly:
0.25 mg / kg = 25 mg , then 0.35 mg/kg = 35 mg 15 minutes later, which totals 60 mg per hour.
Adults, initial: 0.25 mg/kg (average 20 mg) given over 2 min; then, if response is inadequate, a second dose may be given after 15 min. The second bolus dose is 0.35 mg/kg (average 25 mg) given over 2 min. Subsequent doses should be individualized. Some clients may respond to an initial dose of 0.15 mg/kg (duration of action may be shorter).
?IV Infusion Atrial fibrillation/flutter.
Adults: 10 mg/hr following IV bolus dose(s) of 0.25 mg/kg or 0.35 mg/kg. Some clients may require 5 mg/hr while others may require 15 mg/hr. Infusion may be maintained for 24 hr.
I didn't put this in the math problem, but on the first question it ask...your order states to start the infusion (Cardizem) at 0.5mg/kg/min. Which is way too much medication to start out with because the recommended doseage shouldn't exceed 15mg/hr.
then the next question had ask.....if the MD order stated to start the infusion at 5/mg/hr. at what rate would this be?
5mg/Hr x 50mL = 1 mL/hr
250mg
is this correct? and if so, they way the question is written with 5/mg/hr, does that mean it should be increased each time (5mg/hr) not to exceed 15mg/hr?
First of all, Cardizem isn't dosed as mg/kg/min. It is dosed simply as mg/hr with 15mg/hr as the max safe dose according to most drug books. I have seen it run at 20 mg/hr but only rarely.
As for the concentration, it's usually a 1:1 concentration with 125mg/125ml but can be mixed 250mg/300ml which gives you a concentration of 0.83 mg/ml.
If your concentration is 125mg/125ml, 5mg/hr=rate of 5ml/hr.
If your concentration is 250mg/300ml, 5mg/hr=rate of 6ml/hr
And yes, if you are titrating Cardizem for HR & BP, it is generally increased by 5 mg/hr each time not to exceed a rate of 15mg/hr.
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), I've honestly never seen it written that way.
hypocaffeinemia, BSN, RN
1,381 Posts
It doesn't fit with any standard writing of numerals and units, no.
The slash (/) means per, so you could try saying or writing out the problem: Five per milligram per hour? Five whats? It's jibberish.
Seriously, this combined with the .25 NS tells me either your instructor is wanting you to point out as many problems with the order as possible or that your instructor is a moron.
I'd hope for the former- our instructors last year set up a mock patient room in which we'd go in and have to spot as many errors as possible for one of our quiz grades.